The document Healthy People has served as a guide for the promotion of health and the prevention of disease and disability since it was first published in 1979 and updated in 2000. It is in the process of revision in 2010 (U.S. Department of Health and Human Services [USDHHS], 2009a). In the past, one of the goals was to decrease health disparities. At present one of the new overarching goals goes much further: “Achieve health equity, eliminate disparities, and improve the health of all groups” (USDHHS, 2009b) (Box 5-5). This goal and its associated objectives have significant implications for the consideration of culture, gender, and aging and for the practice of gerontological nursing. Addressing health disparities begins with providing culturally competent and proficient care.

BOX 5-5

Healthy People 2020

Overarching Goals

• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

• Achieve health equity, eliminate disparities, and improve the health of all groups.

• Create social and physical environments that promote good health for all.

• Promote quality of life, healthy development, and healthy behaviors across all life stages.

From U.S. Department of Health and Human Services: Healthy people 2020 framework (2009b). Available at http://www.healthypeople.gov/hp2020/Objectives/framework.aspx. Accessed December 2010.

Health Disparities

The term health disparity refers both to differences in the state of health and in health outcomes between groups of persons. An associated term is health inequity, which refers to the excess burden of illness, or the difference between the expected incidence and prevalence and that which actually occurs in excess, in a comparison population group. Those found to be especially vulnerable to health disparities and inequities include older women, men and women of color, and the poor. Among older poor adults, women of all races and ethnicities predominate.

In 2002 the Institute of Medicine (Washington DC) prepared an analysis of the state of the science on health disparities. It began with the acknowledgment that persons of color had difficulty accessing the same care as their white counterparts. The researchers were to determine the state of care while controlling for access issues.

The result of the study was that, even when controlling for unequal access, health care treatment in and of itself was unequal (Smedley et al., 2002). The barriers to quality care were found to be wide, ranging from those related to geographical location to age, gender, race, ethnicity, and sexual orientation. Disparities were consistently found across a wide range of disease areas and clinical services. Among the findings were the following:

• Disparities were found even when clinical factors, such as stage of disease presentation, comorbidities, age, and severity of disease, were taken into account.

• Disparities were found across a range of clinical settings, including public and private hospitals and teaching and nonteaching hospitals.

• Disparities in care were associated with higher mortality among minorities.

In the years since then, the Agency for Healthcare Research and Quality (Rockville, MD) has produced national healthcare quality reports and national healthcare disparities reports to track the prevailing trends in health care quality and access for vulnerable populations, including the elderly and those from minority populations. Each year another aspect of care is highlighted. Most of the information available consists of comparisons between the white and black populations. There is still inadequate data available about other groups, e.g., Native Alaskans for an adequate assessment of their health care status (Table 5-1 and Figure 5-2). None-the-less older adults of color have been described as facing “double jeopardy” for health disparities because of two risk factors for vulnerability (age and ethnicity). For black women, the risk becomes “triple jeopardy,” and poverty adds a fourth factor.

TABLE 5-1

BLACKS COMPARED WITH WHITES ON MEASURES OF QUALITY AND ACCESS FOR MOST CURRENT DATA YEAR: SPECIFIC MEASURES, 2009 *

TOPIC	BETTER THAN WHITES	WORSE THAN WHITES
Cancer		Colorectal cancer diagnosed at advanced stage Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test Colorectal cancer deaths per 100,000 population Breast cancer diagnosed at advanced stage Cancer deaths per 100,000 female population due to breast cancer
Heart disease	Deaths per 1000 admissions with acute myocardial infarction as principal diagnosis, age 18 and over Hospital patients who received recommended care for heart failure
HIV and AIDS		New AIDS cases per 100,000 population age 13 and over
Respiratory diseases		Adults age 65 and over who ever received pneumococcal vaccination Hospital patients with pneumonia who received recommended care
Functional status preservation and rehabilitation		Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis
Supportive and palliative care	Long-stay nursing home residents who were physically restrained	High-risk long-stay nursing home residents with pressure sores Short-stay nursing home residents with pressure sores Home health care patients who were admitted to the hospital
Timeliness		Emergency department visits in which patients left without being seen
Access	People without a usual source of care due to a financial or insurance reason	People who have a usual primary care provider

AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.

^*Modified for those most relevant to older adults.

From Agency for Healthcare Quality and Research: Priority populations: older adults. In: National healthcare quality report, 2009. Available at http://www.ahrq.gov/qual/nhdr09/Chap4.htm. Accessed December 2010.

FIGURE 5-2 Medicare Beneficiaries Age 65 and Over Who Had an Influenza Vaccination in the Last Winter, by Race and Ethnicity, 2002-2005.
AI/AN, American Indian or Alaska Native; API, Asian or Pacific Islander. (From Agency for Healthcare Quality and Research: Older adults: prevention, influenza vaccination. In: *National healthcare quality report, 2009*. Available at http://www.ahrq.gov/qual/nhdr09/Chap4d.htm#older_adults. Accessed December 2010.)

Cultural Proficiency

To address health disparities and inequities, it is necessary not just to become competent but to become culturally proficient health care providers and organizations, that is, able to move smoothly between the world of the nurse and the world of the patient (and in this case, the world of the elder). Nurses should become aware of and understand the considerable problems that many older women in general, and men and women from ethnically distinct groups, encounter in the pursuit and receipt of health care and the considerable disparities in health outcomes. Through this awareness, more compassionate and relevant care can be provided.

By increasing awareness, nurses learn of their personal biases, prejudices, attitudes, and behaviors toward persons different from themselves in age, gender, sexual orientation, social class, economic situations, and many other factors. Through increased knowledge, nurses can better assess the strengths and challenges of the older adult and know when and how to effectively intervene to support rather than hinder cultural strengths. Skills in cultural competence include putting cultural knowledge to use in assessment, communication, negotiation, and intervention.

Cultural Awareness

The development of cultural proficiency begins with increased awareness of our own beliefs and attitudes and those commonly seen in the community at large and in the community of health care (Box 5-6). Increased awareness requires openness and self-reflection. Consider the following:

BOX 5-6 Moving Toward Cultural Sensitivity and Healthy Aging

• Become familiar with your own cultural perspectives, including beliefs about disease etiology, treatments, and factors leading to outcomes.

• Examine your personal and professional behavior for signs of bias and the use of negative stereotypes.

• Remain open to viewpoints and behaviors that are different from your expectations.

• Appreciate the inherent worth of all persons from all groups.

• Develop the skill of listening to both nonverbal and verbal communication.

• Develop sensitivity to the clues given by others, indicating the paradigm from which they face illness and aging.

• Learn to negotiate, rather than impose, strategies to promote healthy aging consistent with the beliefs of the persons to whom we provide care.

A gerontological nurse responded to a call from an older patient’s room. For some unknown reason, he repeatedly and without comment dropped his watch on the floor while talking to the nurse. She calmly picked it up, handed it back to him, and continued talking. During one of the droppings, an aide walked in the room, picked up the watch, and attempted to hand it back to him. The patient immediately started yelling and cursing at the aide for attempting to steal his watch. When telling this story, the nurse thought the whole situation odd, but not too remarkable. It was not until she learned about subtle racism in health care settings that she realized the more harmful, racist behavior of the man—he was white, and so was she; the aide was black.

If the nurse is white, it is realizing that whiteness alone often means special privilege and freedoms. Older adults of color may not have had the same advantages or experiences as the nurse (McIntosh, 1989). Cultural awareness means recognizing the presence of the “isms” (e.g., racism, social classism, ageism) and how these have the potential to impact not only health care but also the quality of life for older adults (Smedley et al., 2002). Awareness includes considering how the nurse feels about gender. For example, is sexuality accepted in the same way in older men as in older women?

An awareness of one’s thoughts and feelings about others who are culturally different from oneself is necessary. These thoughts and feelings can be hidden from oneself but may be evident to clients. To be aware of these thoughts and feelings about others, one can begin to share or write down personal memories of those first experiences of cultural differences. Questions such as “When did I first provide care for someone I thought was different from me? How did I feel? How did I act? How did they react to me providing them with care?” are a good starting point for the process of cultural self-discovery.

Cultural awareness has several levels. The first is the self-level, requiring self-understanding of one’s experiences and values. The second level involves the ability to work with and build relationships with a member from another cultural group. The third level is the recognition of factors beyond culture, such as health, safety, and poverty, that affect members of a cultural group. On the fourth level, it is important to understand how one’s own community history affects how others are viewed. On the last level, one must be able to step outside of cultural bias and accept that other cultures have different ways of perceiving the world that are equal to our own.

Cultural Knowledge

Cross-cultural knowledge can minimize frustration and cultural conflict among older adult patients, nurses, and other health care providers. It will allow the nurse to more appropriately and effectively improve client health outcomes. However, cultural knowledge should never yield to assumptions—only an avenue of essential communication—about the beliefs and practices that are unique to those persons living within a culture, a family, and a community.

Cultural knowledge is both what the nurse brings to the caring situation and what the nurse learns about older adults, their families, their communities, their behaviors, and their expectations. Essential knowledge includes the elder’s way of life (ways of thinking, believing, and acting). This knowledge is obtained formally or informally through the professional experience of nursing and caring. Over time, the nurse builds up a reservoir of information about the beliefs of his or her clients and how they behave.

Some nurses prefer to use what can be called an “encyclopedic” approach to details of a particular culture or ethnic group, such as proper name usage, greeting, eye contact, gender roles, foods, and beliefs about relevant topics (e.g., the meaning of aging, the appropriate expression of pain, death practices, caregiving). Another approach involves increasing knowledge with more global application to nursing care and the ethnic elder rather than specific details about any one culture group.

Definitions of Terms

Cultural knowledge includes the appropriate use of terms, especially race, culture, and ethnicity. Often used interchangeably, each actually has a separate meaning. Race is defined in terms of phenotype as expressed in traits, such as eye color, facial structure, hair texture, and especially skin tones. In a genomic analysis of persons identified as member of a racial group there is little difference. The term “race” is best used as a proxy for geographic origins and lineage with implications for pharmacogenomics more than anything else (see Chapter 9). However, the relative usefulness of race is diminishing because of widespread mixing of the gene pool, making it increasingly uncommon for any one person to be genetically homogeneous (Gelfand, 2003). Acknowledgment of this heterogeneity was demonstrated when a new racial category of “mixed” was added to the 2000 U.S. Census forms.

Culture is the shared and learned beliefs, expectations, and behaviors of a group of people. Style of dress, food preferences, language, and social behavior are reflections of culture. Culture guides thinking, decision-making, and action. Beliefs about aging may be relatively consistent within one culture group (Jett, 2003). Cultural beliefs about aging are often portrayed in the media, both in print and on the screen. For example, the 2005 movie In Her Shoes portrays a number of white stereotypes about aging, both positive and negative. A particular characteristic of culture is that it is transmitted from one member to another through a process called enculturation. Culture provides directions for individuals as they interact with family and friends within the same group. Culture allows members of the group to predict each other’s behavior and respond in ways that are considered appropriate (Spector, 2008).

Acculturation is the process by which a person from a minority or marginalized culture adopts that of the dominant or majority culture in which they find themselves. There has been much concern about aging immigrants and how culture facilitates or hinders the adjustments needed in late life in the United States. Pierce and colleagues (1978/1979) and Spector (2008) wrote that various types of acculturation were more critical to functional adaptation than others. For example, outward adaptation that incorporates language, dress, and behavior was seen as superficially important. On a deeper level, traditional personal value orientations, including concepts of time, and personal relationships to others and nature, were more likely to remain in the original cultural context. These have been a source of conflict between parents and children when caregiving is needed. The parents may expect the children to provide all the care that is needed. The more acculturated children may feel significant conflict as their “American” lives do not reflect or support their filial duties.

Ethnicity refers to a culture group with which one self-identifies. Persons from a specific ethnic group may share common nationality, migratory status, race, language or dialect, or religion. Traditions, symbols, literature, folklore, food preferences, and dress are often expressions of ethnicity. Persons from a specific ethnic group may not share a common race. For example, persons who identify themselves as “Hispanic” may be from any race and from any one of a number of countries. However, most Hispanic persons share the Catholic religion and the Spanish language. It is more accurate to ask an elder to self-identify ethnicity rather than make assumptions.