primary language of the patientIncludes pictures and illustrationsPresents a small amount of information Auditory materialDelivered slowlyIs delivered one‐on‐oneIs delivered by a trusted providerIs in the patient’s primary language
Table 8.4 Cultural factors that affect health care.
| AgeGenderEthnicityAssimilationGeneration cohortThe ever‐changing nature of culture |
Cultural sensitivity in geriatrics
The need for cultural sensitivity
Developing strategies to increase awareness of cultural differences and address them appropriately in the context of providing good health care is difficult because of the various influences on culture (Table 8.4). Reaching this goal is further complicated by the fact that culture is fluid and constantly changing. These changes compound misunderstandings between members of different cultural groups. A further complication is the fact that there are cultural differences between different generations26 who share the same cultural background. Also, cultural differences often seem to be insurmountable between men and women of the same cultural background. Gender differences across cultures can be even more complicated. These differences highlight the complicated and constantly changing nature of culture. Providing geriatrics care often requires that health care providers interact with multiple generations of the same family. Therefore, any strategies employed to address cultural differences in the clinical setting need to be general and flexible in approach.
When cultures clash
Culture surrounds and defines everyone. Both providers and patients have their own national and ethnic cultures. These include their culture of origin and the cultural values, beliefs, language, and local culture (acculturation) skills they have adopted. The patients’ cultures will influence when they seek treatment, their expectation of care, and whether they will comply with the providers’ recommendations.27 Health care providers have the culture of biomedicine and their specific profession (e.g. medicine, nursing, and pharmacy) and speciality (e.g. surgery, geriatrics, and rheumatology). In addition, both providers and patients have cultural ideas and values that relate to their social culture28‐30 age,31,32 gender,33,34 and gender identity.35,36 Finally, health care providers for older adults are almost always younger than their patients. This age difference also has ramifications for compliance based on trust and respect.37
Finding a way to communicate effectively is critical to good patient care. Patient satisfaction and the likelihood of compliance with medical instructions38,39 are linked to patient–provider communication. If cultural differences are not addressed, then poor health outcomes and limited quality of medical decision‐making may result.40 Patient satisfaction with health care is affected by age, race, and literacy level. In low‐income populations, communication satisfaction may be lower for groups that are traditionally active in doctor–patient interactions (e.g. younger patients, patients with higher literacy skills). Health care providers should be aware that older, non‐white, optimistic, and literacy‐deficient patients report greater communication satisfaction than their younger, white, pessimistic, and functionally literate peers. Furthermore, they are more likely to cope with their illnesses by withdrawing rather than by actively pushing for a higher standard of care.41 Therefore, health care providers should continuously seek ways to facilitate dialogue with patients who are older and non‐white and have poor literacy skills. Thus, cultural sensitivity can help providers improve health care delivery in the clinical encounter. It can lead to better provider–patient communication, more accurate diagnoses, more effective treatment, higher patient satisfaction/compliance, and efficient use of medical resources.
For most adults who are not health care providers themselves, navigating the culture of biomedicine is challenging. These challenges are even greater for older adults who are handicapped with physical, mental, and/or social limitations. Most older adults have chronic diseases in addition to acute diseases. Health care providers often underappreciate the physical burdens of these chronic diseases. For example, community‐dwelling Korean older adults with low health literacy often have been reported to have significantly higher rates of arthritis and hypertension. After adjusting for age, education, and income, older individuals with low health literacy had more significant activity limitations and lower subjective health. Older adults with low health literacy were more likely to report lower levels of physical function and subjective health and higher levels of limitations in activity and pain.25
Nor are older adults the only ones with challenges. Providers have their own challenges when applying their biomedical culture to an ageing population. They were taught ‘Primum non nocere’ (or ‘First, do no harm’, the origins of which are discussed elsewhere42), but many cures are harsh. This is because so many cures are designed for younger, robust patients who are experiencing an acute illness and whose natural reserves allow them to overcome any debilitating effects of the ‘cure’. This is not true for the frail elderly. For them, multiple pharmaceuticals increase the possibility of lethal drug interactions and/or side effects. Surgery is dangerous, and the subsequent recovery can be debilitating. Medical care is often too costly. Sometimes care is available but not in a timely manner. This waiting period can be particularly problematic for an older person, especially if they lack a cultural understanding of the need for haste or confrontation. Finally, the culture of medicine often emphasises the quantity of life over the quality of life. However, older patients may insist on more autonomy than the culture of biomedicine encourages.43 They do not always follow instructions, especially if they feel that quality of life is preferred over quantity of life. It is not uncommon for family members to decide that an older patient should not be treated for a serious disease such as depression26 or cancer.44,45 This makes treatment difficult, if not impossible.
These differences in the approach to the culture of medicine affect care. Being aware of the potential for culture‐related problems in the clinical encounter is the first step in developing strategies to deal with those problems when they arise. To address these differences, providers must learn to communicate effectively, provide evidence‐based medicine in a timely manner, be prepared continually to develop new health services that target older adults’ changing medical needs, and consult with the older patient and family as to their preferences for care. The delivery of optimal health care depends on understanding across all cultures.
Barriers to cultural understanding
There are several barriers to developing successful strategies for the delivery of health care (Table 8.5). First, it is impossible to learn about every cultural or ethnic group that might seek health care. Second, relying on cultural stereotypes for guidance can result in conflict with those patients who show within‐culture variations or who have acculturated to the local norms. Third, if culture is viewed as an obstacle to overcome, rather than incorporated into the care plan, conflicts cannot be resolved. Finally, if the impact of the culture of biomedicine on provider–patient communication46 is ignored, then problems with health literacy arise. Any of these barriers may lead to a failure either in compliance or in applying the best clinical approach.
Table 8.5 Barriers to successful, culturally appropriate health care delivery.
| Large variety of culturesEffects of acculturationNegative effects of stereotypesComplexity of the culture of biomedicine |
Cultural sensitivity is more a process than an outcome. It is as much about acceptance of differences as it is about knowledge of differences. The following section lists a number of common problems that may arise in clinical encounters