KIRSTEN AVLUND, MIKE LUCK AND ROB TINSLEY
CULTURAL DIFFERENCES IN FUNCTIONAL ABILITY AMONG ELDERLY PEOPLE IN BIRMINGHAM, ENGLAND, AND GLOSTRUP, DENMARK
ABSTRACT. The purpose of this article is to compare patterns of functional ability among four groups of elderly people with different cultural backgrounds. The data originates from (1) a study of 369 65 to 74 year old people in Birmingham, born in England, the West Indies, and Asia, and (2) a study of 734 rather homogeneous 70 year old people in Glostrup, Denmark. In both surveys functional ability was measured by interviews about Physical and Instrumental Activities of Daily Living (PADL and IADL). With regard to PADL there were only a few differences between the four study populations, whereas larger differences were found in IADL. The general pattern was that the Glostrup population had better functional ability than the other study populations and that Asians had the poorest functional ability. The reasons for these differences may arise from different patterns of disease, variations in life style, and differing access to and response from social and health services in the four cultural groups. KEY WORDS: Functional ability, Activities of daily living, Cross-cultural, Population study, Social and health services, Household situation INTRODUCTION Many of the problems from which the elderly suffer tend to be chronic rather than acute. It is therefore important to discriminate between morbidity and functional ability associated with morbidity. For this reason, the assessment of functional ability has become an essential part of health studies among elderly individuals. It is usually approached by measures of activities of daily living (ADL) which can be grouped into Physical and Instrumental ADL (PADL and IADL). PADL are concerned with basic self-care (e.g. bathing, eating, dressing, grooming). IADL are concerned with domestic tasks (shopping, cooking, cleaning) and activities required to be a functioning member of society (e.g., handling personal finances) (Fillenbaum 1984). There are few studies comparing measures of functional ability among the elderly in different cultures. This has been done by comparing elderly in different countries (Shanas 1974; Heikkinen, Waters & Brzezinski 1983; Waters, Heikkinen & Dontas 1989; Fillenbaum 1990; Teresi, Cross & Golden 1989) and in different ethnic minorities within the same country (Kunitz & Levy 1989; Lindblad & M01gaard 1993; Lewinter, Kesmez & Gezgin 1993). Those studies reveal evidence of variations in people's own perception of health between different cultural groups. However, in relation to measures of functional ability, the knowledge of differences is based mostly on measures that combine very basic activities (PADL) with more complex activities such as IADL. As measures of Journal of Cross-Cultural Gerontology 11:1-16 (March 1996) © 1996Kluwer Academic Publishers. Printed in the Netherlands.
K. AVLUND,M. LUCKAND R. TINSLEY functional ability in daily life are sometimes used for deciding whether elderly people can live in their home or not, it is very important to be able to distinguish between activities that are performed by everybody, and activities that are dependent on sex and culture. The study of patterns of functional ability in different cultures is important as increasing knowledge about cultural variation in aging gives better understanding of the process of normal aging. For several years gerontological researchers have tried to distinguish between pathological and normal aging without real success. Perhaps the concept of normal aging cannot be separated from culture. Culture can be described as a set of understandings, shared by members of a group, about how things should be done, and what is desirable and good (Mosey 1986). Thus, culture leads a person to a characteristic way of perceiving and acting in the world (Fisher, Liu, Velozo & Pan 1992). Cultural differences may influence elderly people's functional ability in several ways. There may be different perceptions of the severity of certain experiences. Attitudes toward elderly people and gender roles may vary between cultures. Their housing conditions may be different. Problems with mobility are more serious if you live on the fifth floor with no elevator and if there is no public transportation close by. Elderly people in different cultures may vary in disease patterns and/or actual biological/physiological function related to different life styles. Expectations of function in old age may vary in different groups, and may actually influence functional ability. It has been shown, for example, that Chinese-Americans die significantly earlier than normal, if they have a combination of disease and birthyear which Chinese astrology and medicine consider ill-fated, and the more strongly a group is attached to Chinese tradition, the more years of life are lost (Phillips, Ruth & Wagner 1993). Finally, the value of health and functional ability may vary in different cultures. When elderly Danes were asked about the best and worst that could happen to them, nearly half of them mentioned that the worst would be to become dependent on help from others, while only a fourth mentioned loss of contact with other people as the worst that could happen (SCrensen & Pedersen 1988). These answers underline the importance of independence for Western people, in contrast to other cultures, as for example the Asians which emphasize inter-relatedness and interdependence (Kim 1994). When people migrate from one culture to another, these cultural differences become more evident and maybe also more problematic - at least when growing old in a foreign community. This has lead to the theory of the double jeopardy hypothesis that an older person who comes from a cultural background significantly different from that of the majority is extra vulnerable, being old as well as belonging to a minority (Lindblad & Molg~d 1993). Furthermore, ethnic minority groups often live in poor social conditions and with problems of prejudice and racism. Immigrant elderly may suffer the disadvantages of a lack of cultural awareness on the part of those health care professionals upon whom they must rely. Difficulties also arise in communication in understanding the bureacratic
CULTURALDIFFERENCESAMONGELDERLYPEOPLE processes of obtaining health care services and in cultural taboos applied to various aspects of medical practice by certain ethnic groups (Ehtisham et al. 1991). During the past 20 to 30 years there has been considerable immigration of people from non-Western cultures to the North-West European countries (Castles, Booth & Wallace 1984; Fryer 1984). These immigrants are now beginning to get old. In Denmark the immigration since the 1970s from mainly former Yugoslavia, Turkey, and Pakistan will cause the amount of elderly with other cultural backgrounds to increase in the coming years (Leeson 1989). Thus health and social services in Great Britain and Denmark have had little experience of providing services for elderly people of non-Western background (Department of Health 1992). With data from the West Birmingham Survey of Health Needs of Elderly People in the Inner City and from the Glostrup Survey of 70-year-olds in 1984, it is possible to compare functional ability among four groups of elderly men and women with different cultural backgrounds - and with a measure that distinguishes between PADL and IADL. The purpose of this article is thus to compare patterns of functional ability among elderly people in three different cultural groups in Birmingham, England, and one in Glostrnp, Denmark. MATERIALAND METHODS The data analysed in this article originates from two studies of elderly people in Birmingham, England and in Glostrup, Denmark.
The two populations Description of the Birmingham population. Birmingham is one of the largest cities in Great Britain with 20% of its population from ethnic minorities at the 1991 Census (Healthy Birmingham 2000 Information Group 1994). After World War II, as in most Western European countries, the post-war reconstruction boom drew in large numbers of migrants to Britain. At first these migrants were from Eastern European countries; then migrants started to come from the former British colonies, mainly from the Caribbean countries and the Indian sub-continent (Castles, Booth & Wallace 1984). The economy of Birmingham was largely based on manufacturing and heavy engineering which declined rapidly in the 1970s, and the ethnic minorities suffered unequally because of direct and indirect discrimination. Thus they, particularly the elderly, have become trapped in the inner city with a population characterized by high unemployment, poor housing and facilities, and racism (Cashmore 1987).
Description of the Glostrup population. Glostrup is west of Copenhagen, the capital of Denmark. The change in character of the area from the 1960s reflects the change in the Danish society from an agricultural to an industrial country. In
K. AVLUND,M. LUCKAND R. TINSLEY 1964 the area was similar to the Danish population with respect to age and sex as well as occupation and social class. Since then the area has developed into a more typical suburban district (SchroU 1982). The population used to be rather homogeneous, and very few old people living in Glostrup were born outside Denmark.
The Birmingham survey The Birmingham survey was carried out in four inner city wards in 1987. Twelve G.P.s whose surgeries were located in this area agreed to provide lists of patients aged 65 and over. The sample was selected by taking every second person on each list. Contact was made with 736 people of whom 91% agreed to participate in the survey. Thus, 669 65+year old persons were interviewed in their home in their own language about social and health characteristics by four trained interviewers from various ethnic backgrounds. The main interviewer was a multi-lingual Asian woman (Ehtisham et al. 1991). The study population was similar to the general population of the four inner city wards in terms of age and house hold size, but it was not representative in terms of gender, place of birth and marital status. These differences are due to the sampling procedure which deliberately included higher proportions of those in ethnic minorities (Luck et al. 1991). For comparative purposes the analyses in this work comprise data only about the 65 to 74 year olds in the study population. Thus the Birmingham study population described here includes 369 participants of which 50% were English-born, 21% were born in West Indies, and 29% in Asia. In Britain, it is currently common practice to use the term 'Asian' to refer only to people from India, Pakistan, and Bangladesh but not from China, Vietnam, and other Asian countries. The Glostrup survey This investigation is part of the 1984 study of 70 year old men and women in Glostrup, Denmark, in which data were obtained from two different groups of 70 year old people born in 1914: (1) Survivors (736 persons) from a Glostrup cohort study of 50 year olds initially investigated in 1964 and (2) 383 additional individuals born in 1914 drawn from the National Person Register in 1984 to supplement the survivors. Groups 1 and 2 of the 1914 cohort have been compared regarding social situational variables, biological functions, chronic disease and behavioural variables. No statistically significant differences were found. We have concluded that the two groups of 70 year old people born in 1914 can be combined for subsequent analysis (Avlund & Schultz-Larsen 1991). Thus, the study sample consisted of 1,119 men and women of whom 804 agreed to participate in a comprehensive medical survey at the Copenhagen County Hospital in Glostrup in the period April 1984 to March 1985. One to two weeks after the medical survey, 734 of the participants were visited in their own homes by an occupational therapist (participation rate 91%) who interviewed them about functional ability and social situation.
CULTURALDIFFERENCESAMONGELDERLYPEOPLE The non-participants (1,119-734 = 385 persons) did not differ significantly from those who participated with regard to social and demographic characteristics or to days spent in hospital for all causes (Avlund & Schultz-Larsen 1991). The variables
The comparison of data in the two localities is necessarily limited to data that have been collected with identical questions and categories. The following variables are used in the comparative analysis: - F u n c t i o n a l ability: was measured by ability to manage PADL (washing, dress-
ing, feeding) and IADL (public transportation, shopping, cooking, housework) with or without help. Need of help with at least one PADL activity was categorized as dependent on help with PADL. Need of help with at least one IADL activity was categorized as dependent on help with IADL. - H o u s i n g type: 1. House; 2. Flat; 3. Other. H o m e ownership: 1. Own home; 2. Rented home. - H o u s i n g facilities: were measured by presence or absence of toilet, bath/shower, hot water, and type of heating. - H o u s e h o l d composition: 1. Live alone; 2. Live with one person; 3. Live with more than one person. M a r i t a l status: Married/not married. - Utilization o f health and social services: was measured by visits to general practitioner, receiving homehelp, and meals on wheels within the last year. - Religion: 1. No religion; 2. Christian; 3. Other religions. The inferential statistics of differences between the populations are based on Pearson's Chi-square tests.
RESULTS The dislribution of background variables among men and women in the four study populations is shown in Table 1. More of the study population in Birmingham lived in their own house compared to the study population in Glostrup. More English-born and West-Indian men and women lived alone and/or were not married whereas more Asian men and women lived with others/were married compared to the Glostrup study population. More English-born men and Englishborn and Asian women lived with other than spouse compared to any of the other groups. Regarding utilization of health and social services, more of the West-Indian and Asian study population in Birmingham had seen their general practitioner during the last year compared to both the English-bom in Birmingham and the Glostrup-group. None of the Asian men and women had home help. More English-born and West-Indian men had home help compared to Danish men.
89 1 10
76 12 5
60
26 14 60
93 97 97 96
42 58
83 17
98 0 2
98 14 0
65
28 7 65
96 100 100 96
55 45
80 20
WI (47)
3 97 0
98 0 0
90
5 5 90
100 98 95 100
59 41
93 5 2
AS (61)
Men
95 1 4
84 7 1
82
16 2 82
99 97 97 96
46 54
51 44 5
GLO (366)
***
*** *
***
** *** ***
***
p
94 1 5
88 10 5
37
42 21 37
99 99 99 97
45 55
81 19
UK (112)
Women
100 0 0
97 7 0
65
28 7 65
100 100 100 94
53 47
80 20
WI (32)
4 96 0
98 0 0
64
11 25 64
100 98 96 100
50 50
87 11 2
AS (46)
0
97
82 10 2
48
45 7 48
99 97 98 94
45 55
46 52 2
GLO (368)
***
**
***
*** *** ***
***
P
p describes statistical significant differences between the four study populations for men and women separately. *p
CULTURAL DIFFERENCES IN FUNCTIONAL ABILITY AMONG ELDERLY PEOPLE IN BIRMINGHAM, ENGLAND, AND GLOSTRUP, DENMARK
ABSTRACT. The purpose of this article is to compare patterns of functional ability among four groups of elderly people with different cultural backgrounds. The data originates from (1) a study of 369 65 to 74 year old people in Birmingham, born in England, the West Indies, and Asia, and (2) a study of 734 rather homogeneous 70 year old people in Glostrup, Denmark. In both surveys functional ability was measured by interviews about Physical and Instrumental Activities of Daily Living (PADL and IADL). With regard to PADL there were only a few differences between the four study populations, whereas larger differences were found in IADL. The general pattern was that the Glostrup population had better functional ability than the other study populations and that Asians had the poorest functional ability. The reasons for these differences may arise from different patterns of disease, variations in life style, and differing access to and response from social and health services in the four cultural groups. KEY WORDS: Functional ability, Activities of daily living, Cross-cultural, Population study, Social and health services, Household situation INTRODUCTION Many of the problems from which the elderly suffer tend to be chronic rather than acute. It is therefore important to discriminate between morbidity and functional ability associated with morbidity. For this reason, the assessment of functional ability has become an essential part of health studies among elderly individuals. It is usually approached by measures of activities of daily living (ADL) which can be grouped into Physical and Instrumental ADL (PADL and IADL). PADL are concerned with basic self-care (e.g. bathing, eating, dressing, grooming). IADL are concerned with domestic tasks (shopping, cooking, cleaning) and activities required to be a functioning member of society (e.g., handling personal finances) (Fillenbaum 1984). There are few studies comparing measures of functional ability among the elderly in different cultures. This has been done by comparing elderly in different countries (Shanas 1974; Heikkinen, Waters & Brzezinski 1983; Waters, Heikkinen & Dontas 1989; Fillenbaum 1990; Teresi, Cross & Golden 1989) and in different ethnic minorities within the same country (Kunitz & Levy 1989; Lindblad & M01gaard 1993; Lewinter, Kesmez & Gezgin 1993). Those studies reveal evidence of variations in people's own perception of health between different cultural groups. However, in relation to measures of functional ability, the knowledge of differences is based mostly on measures that combine very basic activities (PADL) with more complex activities such as IADL. As measures of Journal of Cross-Cultural Gerontology 11:1-16 (March 1996) © 1996Kluwer Academic Publishers. Printed in the Netherlands.
K. AVLUND,M. LUCKAND R. TINSLEY functional ability in daily life are sometimes used for deciding whether elderly people can live in their home or not, it is very important to be able to distinguish between activities that are performed by everybody, and activities that are dependent on sex and culture. The study of patterns of functional ability in different cultures is important as increasing knowledge about cultural variation in aging gives better understanding of the process of normal aging. For several years gerontological researchers have tried to distinguish between pathological and normal aging without real success. Perhaps the concept of normal aging cannot be separated from culture. Culture can be described as a set of understandings, shared by members of a group, about how things should be done, and what is desirable and good (Mosey 1986). Thus, culture leads a person to a characteristic way of perceiving and acting in the world (Fisher, Liu, Velozo & Pan 1992). Cultural differences may influence elderly people's functional ability in several ways. There may be different perceptions of the severity of certain experiences. Attitudes toward elderly people and gender roles may vary between cultures. Their housing conditions may be different. Problems with mobility are more serious if you live on the fifth floor with no elevator and if there is no public transportation close by. Elderly people in different cultures may vary in disease patterns and/or actual biological/physiological function related to different life styles. Expectations of function in old age may vary in different groups, and may actually influence functional ability. It has been shown, for example, that Chinese-Americans die significantly earlier than normal, if they have a combination of disease and birthyear which Chinese astrology and medicine consider ill-fated, and the more strongly a group is attached to Chinese tradition, the more years of life are lost (Phillips, Ruth & Wagner 1993). Finally, the value of health and functional ability may vary in different cultures. When elderly Danes were asked about the best and worst that could happen to them, nearly half of them mentioned that the worst would be to become dependent on help from others, while only a fourth mentioned loss of contact with other people as the worst that could happen (SCrensen & Pedersen 1988). These answers underline the importance of independence for Western people, in contrast to other cultures, as for example the Asians which emphasize inter-relatedness and interdependence (Kim 1994). When people migrate from one culture to another, these cultural differences become more evident and maybe also more problematic - at least when growing old in a foreign community. This has lead to the theory of the double jeopardy hypothesis that an older person who comes from a cultural background significantly different from that of the majority is extra vulnerable, being old as well as belonging to a minority (Lindblad & Molg~d 1993). Furthermore, ethnic minority groups often live in poor social conditions and with problems of prejudice and racism. Immigrant elderly may suffer the disadvantages of a lack of cultural awareness on the part of those health care professionals upon whom they must rely. Difficulties also arise in communication in understanding the bureacratic
CULTURALDIFFERENCESAMONGELDERLYPEOPLE processes of obtaining health care services and in cultural taboos applied to various aspects of medical practice by certain ethnic groups (Ehtisham et al. 1991). During the past 20 to 30 years there has been considerable immigration of people from non-Western cultures to the North-West European countries (Castles, Booth & Wallace 1984; Fryer 1984). These immigrants are now beginning to get old. In Denmark the immigration since the 1970s from mainly former Yugoslavia, Turkey, and Pakistan will cause the amount of elderly with other cultural backgrounds to increase in the coming years (Leeson 1989). Thus health and social services in Great Britain and Denmark have had little experience of providing services for elderly people of non-Western background (Department of Health 1992). With data from the West Birmingham Survey of Health Needs of Elderly People in the Inner City and from the Glostrup Survey of 70-year-olds in 1984, it is possible to compare functional ability among four groups of elderly men and women with different cultural backgrounds - and with a measure that distinguishes between PADL and IADL. The purpose of this article is thus to compare patterns of functional ability among elderly people in three different cultural groups in Birmingham, England, and one in Glostrnp, Denmark. MATERIALAND METHODS The data analysed in this article originates from two studies of elderly people in Birmingham, England and in Glostrup, Denmark.
The two populations Description of the Birmingham population. Birmingham is one of the largest cities in Great Britain with 20% of its population from ethnic minorities at the 1991 Census (Healthy Birmingham 2000 Information Group 1994). After World War II, as in most Western European countries, the post-war reconstruction boom drew in large numbers of migrants to Britain. At first these migrants were from Eastern European countries; then migrants started to come from the former British colonies, mainly from the Caribbean countries and the Indian sub-continent (Castles, Booth & Wallace 1984). The economy of Birmingham was largely based on manufacturing and heavy engineering which declined rapidly in the 1970s, and the ethnic minorities suffered unequally because of direct and indirect discrimination. Thus they, particularly the elderly, have become trapped in the inner city with a population characterized by high unemployment, poor housing and facilities, and racism (Cashmore 1987).
Description of the Glostrup population. Glostrup is west of Copenhagen, the capital of Denmark. The change in character of the area from the 1960s reflects the change in the Danish society from an agricultural to an industrial country. In
K. AVLUND,M. LUCKAND R. TINSLEY 1964 the area was similar to the Danish population with respect to age and sex as well as occupation and social class. Since then the area has developed into a more typical suburban district (SchroU 1982). The population used to be rather homogeneous, and very few old people living in Glostrup were born outside Denmark.
The Birmingham survey The Birmingham survey was carried out in four inner city wards in 1987. Twelve G.P.s whose surgeries were located in this area agreed to provide lists of patients aged 65 and over. The sample was selected by taking every second person on each list. Contact was made with 736 people of whom 91% agreed to participate in the survey. Thus, 669 65+year old persons were interviewed in their home in their own language about social and health characteristics by four trained interviewers from various ethnic backgrounds. The main interviewer was a multi-lingual Asian woman (Ehtisham et al. 1991). The study population was similar to the general population of the four inner city wards in terms of age and house hold size, but it was not representative in terms of gender, place of birth and marital status. These differences are due to the sampling procedure which deliberately included higher proportions of those in ethnic minorities (Luck et al. 1991). For comparative purposes the analyses in this work comprise data only about the 65 to 74 year olds in the study population. Thus the Birmingham study population described here includes 369 participants of which 50% were English-born, 21% were born in West Indies, and 29% in Asia. In Britain, it is currently common practice to use the term 'Asian' to refer only to people from India, Pakistan, and Bangladesh but not from China, Vietnam, and other Asian countries. The Glostrup survey This investigation is part of the 1984 study of 70 year old men and women in Glostrup, Denmark, in which data were obtained from two different groups of 70 year old people born in 1914: (1) Survivors (736 persons) from a Glostrup cohort study of 50 year olds initially investigated in 1964 and (2) 383 additional individuals born in 1914 drawn from the National Person Register in 1984 to supplement the survivors. Groups 1 and 2 of the 1914 cohort have been compared regarding social situational variables, biological functions, chronic disease and behavioural variables. No statistically significant differences were found. We have concluded that the two groups of 70 year old people born in 1914 can be combined for subsequent analysis (Avlund & Schultz-Larsen 1991). Thus, the study sample consisted of 1,119 men and women of whom 804 agreed to participate in a comprehensive medical survey at the Copenhagen County Hospital in Glostrup in the period April 1984 to March 1985. One to two weeks after the medical survey, 734 of the participants were visited in their own homes by an occupational therapist (participation rate 91%) who interviewed them about functional ability and social situation.
CULTURALDIFFERENCESAMONGELDERLYPEOPLE The non-participants (1,119-734 = 385 persons) did not differ significantly from those who participated with regard to social and demographic characteristics or to days spent in hospital for all causes (Avlund & Schultz-Larsen 1991). The variables
The comparison of data in the two localities is necessarily limited to data that have been collected with identical questions and categories. The following variables are used in the comparative analysis: - F u n c t i o n a l ability: was measured by ability to manage PADL (washing, dress-
ing, feeding) and IADL (public transportation, shopping, cooking, housework) with or without help. Need of help with at least one PADL activity was categorized as dependent on help with PADL. Need of help with at least one IADL activity was categorized as dependent on help with IADL. - H o u s i n g type: 1. House; 2. Flat; 3. Other. H o m e ownership: 1. Own home; 2. Rented home. - H o u s i n g facilities: were measured by presence or absence of toilet, bath/shower, hot water, and type of heating. - H o u s e h o l d composition: 1. Live alone; 2. Live with one person; 3. Live with more than one person. M a r i t a l status: Married/not married. - Utilization o f health and social services: was measured by visits to general practitioner, receiving homehelp, and meals on wheels within the last year. - Religion: 1. No religion; 2. Christian; 3. Other religions. The inferential statistics of differences between the populations are based on Pearson's Chi-square tests.
RESULTS The dislribution of background variables among men and women in the four study populations is shown in Table 1. More of the study population in Birmingham lived in their own house compared to the study population in Glostrup. More English-born and West-Indian men and women lived alone and/or were not married whereas more Asian men and women lived with others/were married compared to the Glostrup study population. More English-born men and Englishborn and Asian women lived with other than spouse compared to any of the other groups. Regarding utilization of health and social services, more of the West-Indian and Asian study population in Birmingham had seen their general practitioner during the last year compared to both the English-bom in Birmingham and the Glostrup-group. None of the Asian men and women had home help. More English-born and West-Indian men had home help compared to Danish men.
89 1 10
76 12 5
60
26 14 60
93 97 97 96
42 58
83 17
98 0 2
98 14 0
65
28 7 65
96 100 100 96
55 45
80 20
WI (47)
3 97 0
98 0 0
90
5 5 90
100 98 95 100
59 41
93 5 2
AS (61)
Men
95 1 4
84 7 1
82
16 2 82
99 97 97 96
46 54
51 44 5
GLO (366)
***
*** *
***
** *** ***
***
p
94 1 5
88 10 5
37
42 21 37
99 99 99 97
45 55
81 19
UK (112)
Women
100 0 0
97 7 0
65
28 7 65
100 100 100 94
53 47
80 20
WI (32)
4 96 0
98 0 0
64
11 25 64
100 98 96 100
50 50
87 11 2
AS (46)
0
97
82 10 2
48
45 7 48
99 97 98 94
45 55
46 52 2
GLO (368)
***
**
***
*** *** ***
***
P
p describes statistical significant differences between the four study populations for men and women separately. *p
