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 between people with different cultural experiences. The subsequent section provides general strategies for addressing these problem areas.
Common areas of conflict or misunderstanding in the clinical encounter
There are several areas in which misunderstandings commonly occur during a clinical visit (Table 8.6). Each of these is described here, along with suggestions for improvement.
Prior experiences
Both the provider and the older adult bring certain expectations to the clinical encounter based on prior experience. Both may be unaware that their own ethnic or professional culture influences the interaction. Problems often arise due to the knowledge and power differential between the older adult and the health care provider.
Older adults may distrust their providers based on their own or others’ previous encounters with biomedicine, such as the American experience with the Tuskegee Syphilis Study. This research study exemplifies several factors that have influenced African Americans’ attitudes toward the biomedical community in the United States,47 although more recent research indicates that these attitudes may have ameliorated over the past two decades.48 This may be due to acculturation by the younger generation, rather than forgiveness on the part of those who were directly affected.
Providers may view the patients’ ethnic cultures as an obstacle. For example, because Afghani Muslim women do not seek health care from male practitioners,34 the woman receives care by proxy. Her husband describes her symptoms to the male practitioner, who then instructs the husband in the recommended treatment plan. Not all practitioners are comfortable practising medicine in this manner.
Identifying the patient
In general, Western biomedical culture focuses on the adult individual as the patient. As such, information is gathered from the patient and the patient alone (this is different from practising Western paediatrics, where the mother and child are often considered to be the ‘patient’). In many cultures, however, the family, or even the entire community, plays a major part in managing illness. In cases such as this, it is often best to include the entire family in decision‐making,49 including spouses and/or adult children.
Table 8.6 Common areas of cultural conflict.
| Mistrust garnered during prior contactsCultural differences in defining who the patient isVerbal and non‐verbal communicationPrior misconceptions about cultural normsAgeism by both patient and provider |
Communication
Communication may be verbal or non‐verbal, and both are important. When communication is hindered by a lack of a common language, health suffers. Patients not proficient in the local language are unable to take advantage of health promotion programmes.50,51 The clinician’s misunderstanding of the patient’s language can lead to inappropriate treatment,52 ranging from misdiagnosis to ineffective pain control.31
Although professional translators may be employed, providers must remember that misinterpretations may occur even when the same language is spoken. Providers tend to mix medical jargon and everyday language when they speak to patients, but a word may mean something different than intended to the patient. For example, a patient may refer to a stomach ache, which is duly interpreted to be a pain in the stomach. The patient may actually mean a pain in the abdominal area. The clinician should be careful when interpreting the symptoms as they are reported. This is particularly true when the interpreter is a child who may not have insight into how important it is to have an accurate description of the symptoms, even if the patient is uncomfortable sharing that information with either the clinician or the child.
A surprising amount of information can be communicated through non‐verbal cues. This has led to the successful development of pain assessment tools for demented patients.53 Research on such tools provides information about which
