This article discusses the intersection of culture, cultural competence, cultural humility, and implicit bias, and how they impact the diversity spectrum of older adults including people of color, members of the LGBTQIA population, those with differing abilities, rural, tribal, and immigrant communities.
culture, cultural competence, cultural humility
Just as services to older adults have changed over the years to meet the requirements of a changing older adult population, so has the need to deliver culturally competent services with cultural humility. This requires continuous self-examination by care managers to ensure they are providing services that are driven by the needs of the older consumer and not based upon personal values, beliefs, and implicit bias.
Definition of Cultural Competence/Cultural Humility
It is important to talk about issues related to culture because of the increased diversity of our society, our interconnectedness due to globalization, and to foster understanding. It is not what we have in common that creates tension and misunderstanding, but our differences.
The National Association of Social Workers (NASW) defines cultural competence as a “process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each” (NASW, 2001, p. 11).
The diversity factors in the definition should be expanded to include, but not be limited to, sexual orientation, sexual identity, gender, and ability. This definition implies that at both the individual and systems level our behaviors and policies should result in a service delivery system that responds to the needs of all older adults requiring services. The word competence implies mastery of a subject area. However, as culture evolves over time and place, so should health and social service practitioners continue to change how services are planned, structured, and delivered in response to evolutionary changes. Competence implies a checkbox; but the capacity to support elders from diverse cultural backgrounds is not a box to be checked.
Cultural humility, on the other hand, was defined in an article by Tervalon and Murray-García (1998) as a lifelong commitment to critical self-evaluation, critique, and learning, to recognizing and challenging imbalances of power, the development of respectful partnerships with client systems and populations and to being open to different world views. While the discussion continues concerning the use of terminology, the goal is that we deliver services that meet the needs of an increasingly diverse older adult population (Green-Moton and Minkler, 2020).
Generalizations in Cross-cultural Care Across Older Adult Communities of Color
It is important to establish a baseline understanding of what is meant by culture. Essentially culture influences our psychological, physiological, and sociological responses to our internal and external environment. It encompasses our beliefs, values, attitudes, mental maps, and worldview. It is learned and shared, cross-generational, and ensures the survival of a people (Lum, 2003). Culture is even more important as people age, because as losses increase, this is one aspect of self that does not go away. This is reflected in older adults with Alzheimer’s Disease who react to reminders of who they are as cultural beings by reverting to an original language, or singing songs passed down through the generations, which their children may never have heard previously.
With elders who are people of color, some cultural characteristics are shared across groups. One characteristic finds its form in the distrust of formal systems, which include healthcare and social services. This is due to historical discrimination, differential treatment, and abuse by the medical system such as was seen in the Tuskegee Experiments (Heintzelman, 2003). Racism is a key factor, which some providers want to downplay, however medicalized racism as an extension of institutional racism has been documented in differential treatment by medical providers when it comes to care (Gollust, et al., 2018; Smedley, et al., 2003 ).
In U.S. culture, informality is viewed as being friendly toward someone, and the use of first names often is seen as acceptable. However, for older adults of color, it is important to ask them, and any person for that matter, what they would like to be called. We should not ask consumers if it is okay to call them by their first name because even if they do not find it acceptable, the consumer will probably say yes due to the power difference between practitioner and consumer. Also, it is important to ask for preferred pronouns in order to not make assumptions about how they express their gender identities.
Western practices typically emphasize the rights of the individual and self-determination. However, for elders of color, decisions are often made by the group or family (Pinderhughes, 1994). This directly conflicts with the code of ethics for many professions, as well as current HIPPA (Health Insurance Portability and Accountability Act) regulations, which family members sometimes do not understand. This cultural disconnect may place the practitioner in an ethical dilemma, which requires the ability to balance legal and organizational requirements against the relationship with the consumer and his or her family. Empathetic listening and determining if there is congruence between the family and the client go a long way in being inclusive and developing a good working relationship.
Body language is another important consideration. As human beings, most of our communication is non-verbal. Eye contact, spatial distance, touch, and non-touch are all important considerations when working across cultural and racial groups. For example, practitioners are trained to look clients directly in the eye, but many ethnocultural groups see this as impolite.
With spatial issues, there are groups who are uncomfortable with closeness and touching, while others communicate at closer distances and are most comfortable when being greeted with a hug versus a handshake (when we’re not in a pandemic). Seating arrangements in an office are important, too, as is asking where to sit if an interview is conducted in the home.
It is critical that practitioners learn to observe patterns of behavior in the room and adopt those that are authentic to one's own culture, while also connecting to the observed cultural patterns in a community. This might be enacted by learning to ask questions internally and aloud like, “How do I see respect offered within this situation between the client and their community? What questions can I ask to know how I am expected to behave while providing care and resources?”
For example, a human service provider might notice that clients address their needs through storytelling rather than through direct requests. In that instance, it might be best not to run an initial visit guided by a checklist. Rather the practitioner should listen deeply and reflect back to the client gratitude for sharing their story, in addition to using ideas revealed in that story as possible appropriate resources that can be provided to support them.
Another practice might be to take stock of a room upon entering and follow a similar pattern of nonverbal behavior. If, upon arriving at a home, one were to notice that shoes are positioned at the front door and that the residents of the home do not wear shoes or wear house shoes, it would be appropriate to also leave one's shoes at the front door with no expectation of an explanation as to why this practice is followed.
‘Healthcare professionals need to be mindful of how to communicate in ways that address individual cultures, values, beliefs, and biases.’
Across several ethnocultural groups, there is the circular notion of time that connects the past to the present. Ancestors are held in reverence and the elders are respected for their wisdom; they are resourceful and can adapt to difficult challenges with a strong spirit that serves as a source of resilience (Randall-David, 1989). To that end, care managers may find a dissonance between the implementation of linear questions or checklists and the client’s circular storytelling that addresses the questions asked through multilayered meaning-making exchanges. This may be addressed by the care manager learning how best to listen to stories and associate the narrative with posed questions, repeating back to the client key aspects of their story in connection with the necessary questions to confirm that the care manager and client have reached a shared understanding.
Approximately 2.4 percent of the older adult population (older than age 50) or 2.4 million people, identify as members of the LGBTQ population, a number that will more than double by 2030 (Fredriksen-Goldsen and Emlet, et al., 2013; Fredriksen-Goldsen and Kim, 2014). For members of the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, agender, asexual, and two-spirit) population, the stressors of lifelong discrimination and victimization, external and internalized stigma, and lack of access to quality physical and emotional support can lead to poor outcomes for older members of the community (Fredriksen-Goldsen and Kim, et al., 2013). This is a diverse population group, which is often studied in terms of sexual orientation and not gender identity, so more information is needed.
Due to the stigma of the AIDS epidemic and fear of discrimination, older adults who were once open about their sexual orientation and/or gender identity may feel the need to hide again to avoid housing discrimination, which impacts long-term care service delivery. However, questions about sexual orientation and/or gender identity are as important as questions about finances, health status, and functional disability. Feelings of acceptance go a long way in providing emotional well-being (Barbara, et al., 2007).
Sexuality and sexual orientation are important to all people regardless of age. Older people who are members of the LGBTQIA+ population may have faced discrimination in their lives due to their sexual orientation or gender identification. As a result, the person may find it difficult to be open about his or her partner or family. Showing respect and acceptance of a person's sexual orientation and/or gender identification shows respect for them as a person. Often the assumption is that an older adult is heterosexual, which then translates into a lack of assessment training on asking questions concerning sexual orientation or gender identity.
Older members of this community face issues such as increased social isolation and limited health and mental health access, often caused by mistrust of these systems in terms of their sensitivity, a lack of expanded caregiver support, financial issues because of employment discrimination, and legal issues connected to partner status and decision making (Choi and Meyer, 2016).
Care Management in Urban Versus Rural Areas
Statistically, rural areas have higher proportions of older adults in their population (Institute of Medicine, 2006). Therefore, it is important to understand that some differences in the aging experience are based upon place of residence. Because rural and urban communities differ dependent upon region of the country, community demographics, and context, it is difficult to discuss attributes that are specific to residents in one area versus another. However, the literature provides some general concepts. First, in rural communities there is a personal closeness that is based on proximity, relationships, and reliance upon one another. In urban areas, these same characteristics may exist but more in a neighborhood area versus a small town or farm community.
In rural areas, there is a general mistrust of outsiders and formal service delivery systems; there may be a cultural expectation of a high level of self-reliance, because of a historical and perceived (sometimes based upon a valid assessment) lack of available services. Churches and schools are two of the most trusted institutions in rural communities and places from which to engage in outreach and education. They also are places to disseminate resource information to older adults. For older adults in rural and urban areas, religious institutions can be a source of informal support.
Families in rural areas spend a great deal of time together, provide emotional, service, and financial support, and are more likely to live in multigenerational households. There are generational ties to the land and thus even more of a desire to age in place. In urban and rural areas, delivering community-based services means that the care manager must build relationships at the local level so that they are not viewed as an outsider (Daley, 2015). Some literature suggests that quality of life may be diminished for those in rural versus urban communities, especially for older veterans, African Americans, and Latinx people (Baernholdt et.al., 2012; Weeks et al., 2004).
Care Management and Religiosity Versus Spirituality
Spirituality is the belief in a power or force outside of oneself that can provide emotional support and comfort. Religion is seen as an organized system of worship of whatever we are calling that higher sacred power. Older adults have greater participation rates in religious institutions than any other age group, which provides high levels of social support outside of family (Kaplan and Berkman, 2019; The Pew Forum on Religion & Public Life, 2008). African Americans are the most likely ethnic and racial group to report religious affiliation (The Pew Forum on Religion & Public Life, 2008).
‘Care managers need to understand the community in which their clients reside.’
Questions to consider when assessing for religiosity and spirituality include: Does the person practice an organized religion? Is there a belief in a sacred power, and if so what role does that belief play in the older adult’s decision making? Are there customs or rituals related to their religion of which the care manager should be aware?
In African American and Latinx cultures, spirituality is often intertwined with a mind, body, and spirt connection and provides a centering for positive mental health and self-esteem, can be a source of healing, and influences healthcare practices (Musgrave, Allen, and Allen, 2002).
Immigrants and Indigenous Elders
Immigrants represent another vulnerable population of older adults. Approximately 16 percent of older adult immigrants live below the poverty line, 40 percent are members of low-income families, and older immigrants tend to have less than a high school education. Immigrants with limited English proficiency tend to be healthier than their native counterparts upon arrival into the United States, but lose that health advantage over time (Ayon, 2019). As they age, they tend to develop chronic diseases, cognitive disorders, and physical injuries.
Older undocumented immigrants face severe barriers to obtaining healthcare as they do not qualify for Medicaid or Social Security benefits even though many pay taxes. In general, they are unable to afford private insurance, thus rely upon emergency rooms or community health centers for healthcare, which is a temporary solution that drives up overall healthcare costs (Ayon, 2019).
Because there is limited access to healthcare, these populations often turn to self-medication. For many older immigrants, their health is placed at greater risk as they do not have access to prevention services such as regular checkups and may delay accessing care or needed treatment, ultimately debilitating their health (Ayon, 2019). Healthcare professionals need to be mindful of how to communicate in ways that address individual cultures, values, beliefs, and biases. Health systems also need tools to work with people who may not be native English-speakers or who may have difficulties with health literacy (Periyakoil, 2017).
Indigenous elders also face difficult outcomes as they age. In 1978, Title VI Grants for Tribal Organizations to the Older Americans Act were amended to include nutrition, supportive, and caregiver services to older American Indians, Alaska Natives, and Native Hawaiians. Care managers should be mindful that, while indigenous communities are enriched with generations of community cultural wealth (Yosso, 2005), colonialization had and continues to have devastating effects on this population, particularly in undermining traditional spirituality, belief sets, education, cultural pride, food practices, networks of support, and intergenerational interconnectedness.
Steps To Improving Service Delivery
It is easy to concentrate on the physical or psychological abilities of an older adult and how that affects functional ability. However, a complete assessment of an older adult is dependent upon the information shared by the consumer and their informal network. Without first establishing trust and understanding the person as a cultural being, this information will be incomplete. To establish that trust, a care manager should engage in the following steps:
Step One: Have an open mind. Training time is often spent learning about the people who are different from ourselves. While this is important, what is paramount is that we be open to a worldview that is not like our own. It is essential that we understand our values and beliefs and not impose them upon others, but are open to learning from others. There are no universal truths.
Step Two: You cannot walk in someone else’s shoes until you learn to walk in your own. It is important that while we are learning to work with other cultural groups, we learn as much as possible about our own. We transmit unconscious messages about ourselves and our cultural values because they are embedded in the unconscious. As care managers, it is important that we spend time learning about ourselves so that we are open to how cultural factors affect assessment and service delivery. Self-awareness is critical to assess one’s implicit biases that may impact service delivery and any explicit biases that would cause one to not provide the services needed by a group of people (Pritlove, et.al., 2019).
Step Three: Engage in continuous learning. Care managers are direct service providers but also managers of agency resources. Effective fulfillment of both roles requires the care manager to learn as much as possible about a group that is different from themselves before engaging with that group. There is a great deal of information on the Internet that can help with the initial engagement with a client and or client system to establish a helping relationship. If possible, seek input from a cultural guide before engaging in assessment, care management, and/or community work. It is also important to allow the consumer and their family to provide education. Care managers must engage in continuous learning and be willing to change their practices as new information evolves. Cultural groups evolve, and that can mean a change in what they would like to be called, how they want to be treated, and what is considered acceptable behavior. Care managers need to keep up with these evolutionary changes. Additional research is needed on how issues of cultural and ethnicity impact care (Periyakoil, 2017).
Step Four: Do a community mapping to discover assets that might assist you in outreach and service provision. Care managers need to understand the community in which their clients reside. This means not only knowing about formal resources, but also the informal systems in the community that could help their clients. This requires care managers to learn about services available through the informal support system at the local level. This is important when operating from a cross-cultural perspective and can legitimize the care manager as a person that can be trusted. Care managers must track information about ethnicity, preferred language, education, and other cultural factors so that outreach, programs and services can be tailored to specific needs, improve health outcomes, and curb inefficiencies (Periyakoil, 2017).
Step Five: If conflicts arise, seek guidance. Cross-cultural work can be rewarding but misunderstandings can arise. These should be brought to the attention of supervisors to work through difficulties and learn from mistakes. Transparency and taking ownership of errors to grow from them is part of the work of being in a relationship with the community. Additionally, care managers might seek to implement a restorative justice–type process to rebuild trust with the consumer and the community, which allows for all parties to be open about harm and steps to take to heal from that harm.
Step Six: Work from a strength versus deficit perspective. Because care managers control resources, this can result in a power differential between the worker and the consumer. Instead of always viewing the professional as the one who brings expertise, skills, and knowledge to the interaction, the care manager and consumer should be equals. In this way, the care manager builds their effectiveness as a professional helper, while the consumer is empowered to build upon their abilities to handle crises and overcome obstacles (Levine, 2009; Saleeby, 1994).
Norma D. Thomas, DSW, MSW, is a retired full professor from California University of Pennsylvania, Department of Social Work, and teaches part-time for Widener University, Center for Social Work Education, in Chester, Pennsylvania. She may be contacted at firstname.lastname@example.org. Raina León, PhD, MFA, MA (Educational Leadership), MA (Teaching of English), is a full professor in the Department of Education at St. Mary’s College, in Moraga, California. She may be contacted at Raina.email@example.com.
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