The Journal of Primary Prevention, Vol. 17, No. 2, 1996
Promoting Older Ethnic Minorities Health Behaviors: Primary and Secondary Prevention Considerations Marianne Maynard, Ph.D., OTR/C, NCC 1,2
This article examines elderly ethnic minorities health care utilization patterns and health behaviors and their need for primary and secondary preventive care. Assessment issues are discussed along with ways to involve minority clients in identifying resources that could promote their own self care management. Suggestions are also made on ways health care practitioners can encourage minority clients to be active team players in our health care system. KEY WORDS: minority elderly health care utilization and behaviors; primary and secondary prevention.
In recent years, the elderly population has been growing faster among persons of color than among our majority population. This trend is expected to continue in the future. The non-white population, 65 years and older, is projected to be 25 percent of the U.S. population by year 2025 and 35 percent by the year 2050 (American Association for Retired Persons, 1992). However, data on the health needs of elderly ethnic minorities still remain limited, with even less information on their participation patterns in the health care delivery system. Local and state health facilities have been remiss in tracking the patterns of elderly minorities seeking and receiving health care services.
1Retired Professor, Department of Occupational Therapy, Virginia Commonwealth University/ Medical College of Virginia, Program Director for Holistic Wellness Associates, San Diego, California. 2Address correspondence and reprint requests to Marianne Maynard, 11828 Rancho Bernardo Rd., Suite 123-71, San Diego, CA 92128. 219
@ 1996HumanSciencesPress,Inc.
Maynard
220
According to Dorfman, 1990, common health problems found among most older ethnic minorities are high blood pressure, diabetes, heart disease, and cancer as illustrated in Fig. 1. All of these conditions require long term care management and are the leading causes of death of older persons for these minority groups. Poor health maintenance contributes to many life threatening conditions. For example, a long history of alcohol abuse contributes directly to cirrhosis of the liver in Native American and African American groups, especially among males. The stress of minority status, low socio-economic conditions, lifestyle behaviors and competition in a majority society can contribute to hypertension, a condition common in ethnic minority groups. Diabetes, cancer, and other serious conditions are often not detected until later stages when treatability is more difficult. Infrequent health exams, poor health maintenance and lack of health information are major contributors to complications of illness and disease. For a variety of reasons, many older minorities will postpone seeking medical care until their condition interferes with their daily functional capacity. The reliance on folk remedies for cures, based on health beliefs and economic reasons, may be the first line of defense against illness. Only recently have health promotion programs targeted ethnic minority groups to encourage better health prac-
Health Risks
African American
American Indian Alaska Native
AsianAmerican Pacific American
Hispanic
Accidents Cancer Cirrhasis af Liver Diabetes Heart Disease High Blood Pressure Pneumonia/Influenza ~ R P Hea;Ih~ Aging, Washmfit~, OC. Publicati~ DI 4 ; 74
Fig. 1. Health risks among older persons of color.
Promoting Older Ethnic Minorities Health Behaviors
221
tices. There are some indications that these programs can be successful in reducing the high health risk behaviors in these cultural groups when a personalized and consistent effort is made to inform, instruct and involve participants in planning their own health program activities.
HEALTH SERVICE UTILIZATION Watson (1982) reported that visits to private physicians' offices, hospital care, and long-term institutional care were the major categories of services consumed by older minorities. Except for physician visits, data suggest that the utilization of health and long-term care services are based on information about the availability of health services and how to access services. Older minorities often are less informed about the nature of disease or the seriousness of certain diseases/impairments and therefore may not seek care until experiencing major limitation in physical function and daily activities. Moreover those on limited income and without health insurance coverage will find it extremely difficult to purchase prescribed medication and health care services. When a medical crisis occurs the likely entrance into the medical care system is generally by way of a hospital emergency room or an ambulatory care drop-in-center. The problem with this route is the general lack of proper follow-up care after the initial medical crisis is treated, especially for those who do not have a primary care physician. Older ethnic minorities are more likely to utilize health care services when they: 1. Are conveniently located on a direct transportation route with convenient hours of operation and short waiting time to see practitioners. 2. Affordable with reasonable pre-payment requirements. 3. Have a good reputation for being sensitive to the needs of clients and have a diversity of personnel and clientele. 4. Use intervention strategies appropriate to client's cultural orientation, needs and values. YeaRs, Thomas, and Folts (1992) suggest that predisposing factors such as race, gender, education, age, marital status, beliefs/attitudes and religion play an important part in whether a person understands the importance of good health care and takes the necessary steps to care management. For example, minority older women are more likely than minority older men to seek early medical care and the higher the educational or information level, the more likely these older adults will seek care early from a primary care physician. Marital status and family situation can also hinder or be a
Ma~a~
2~
facilitating factor in seeking prompt health care, depending on the knowledge and support of spouse, adult children or significant others. Furthermore beliefs and attitudes about illness and aging can also deter or promote care-seeking behaviors. Richardson (1992) examined the service used by 186 urban elderly African Americans and found the majority of respondents interviewed were aware of the services in their area. During the preceding six months the author reported that 61% of the respondents had seen a physician, 45% had used public transportation to a health care facility, 40% used hospital services, 37% used health clinics, 31% use assistance from churches and 30% from senior centers. The majority rated a high satisfaction with these services. These findings suggest that older persons will more likely utilize health care and support services when they are aware of the availability of these services and when satisfaction is good. Further example of service utilization was based on a sample of 151 Korean elders living in the New York area (Koh & Bell, 1987). The major problems cited by this sample of respondents were the lack of proficiency in the English language, loneliness, limited transportation, income, and available housing. The major health problems of this sample were high blood pressure, body aches/pain and digestive problems. Over 67% had seen a doctor during the last year and more than 11% were hospitalized during the same period. Sixty-six percent of this sample group visited Korean speaking doctors or Korean herb doctors (28%). Some visited American medical doctors (18%) and only 1% had used hospital emergency rooms. Koh and Belle also found that over 75% of the sample groups had no private health insurance, were not eligible for Medicare benefits for reasons of immigrant status and therefore used Medicaid sponsored health services. Primary Prevention Considerations Primary prevention emphasizes health seeking behaviors and lifestyle changes for the prevention of disease prior to the occurrence of symptoms. For the older ethnic minority this means taking appropriate action in health maintenance and disease prevention. Health practitioners, serving as health promotion change agents, can foster primary prevention by collaborating with older persons in: 1. Identifying health risk factors and providing education and support services for reducing risk factors and behaviors. 2. Promoting adherence to health recommendations, such as lifestyle changes, avoidance of environmental risk factors that contribute
Promoting Older Ethnic Minorities Health Behaviors
223
to illness, annual physicals and seeking prompt care when symptoms arise. 3. Coping with threats to health, including stressors of everyday life. (Albino, 1983). Primary prevention must also address the living environment that exposes a person to disease causing agents or injuries. In the area of healthy lifestyle, emphasis should be placed on educating the older person about proper nutrition, stress management, the importance of exercise, and early detection of illness and symptoms or signs of diseases. The fear and denial of illnesses deters many elderly from seeking prompt care, which can be costly in time, money and health outcomes. Teaching older ethnic minorities the importance of self-examinations to detect signs of cancer, or to identified symptoms of diabetes, hypertension, heart problems and other illnesses can enhance their awareness as to when to seek health care or information about a health problem. The use of home remedies may reduce the symptoms for a time, but generally will not cure the condition. Educating older adults to the seriousness of certain diseases and conditions is an important focus of primary prevention.
Secondary Prevention Secondary prevention is required at the earliest sign of a problem along with the prevention of secondary impairments. The delay in seeking medical care for acute problems, such as cancer or heart condition, usually results in the need for intensive medical action. In the case of chronic conditions such as kidney disease, high blood pressure or diabetes, the prevention of further decline in function becomes paramount. The health maintenance and care management needs of older adults generally includes facilitating adaptation to disabling condition, modification of living environment to enhance functional and safety needs, and informing and educating the older person and family members about the benefits of self-care management and health maintenance. Therefore, careful assessment of the older persons' environmental situation, social-cultural-spiritual beliefs and practices, and support networks must be performed, along with an examination of their health status.
ASSESSMENT ISSUES The appropriateness of functioning assessment instruments also must be examined before using them with older minority adults. Most Activity
2~
Ma~a~
of Daily Living Scales (ADL) evaluations are standardized on North American majority samples (Fisher, Liu, Velozo, & Pan, 1992) and therefore do not reflect diverse population groups norms, role behaviors, belief system or cultural standards for performing certain life tasks. When possible, it is better to observe an older person participating at home in their daily activities. Better results are often obtained when incorporating the same labeling terms used by older persons when instructing them during the assessment process and teaching self care management skills. Differences in word meaning, even when the language is English, can lead to misinterpretation of the evaluator's instructions and client's performance outcomes (Fisher et al., 1992). Practitioners often observed this phenomena occurring when assessing individuals from lower social economic backgrounds, rural vs urban residents and those from other regions of the country where word meaning may be different from those used by the practitioner. In addition, practitioners must be extremely careful not to bias their ratings of clients' performance by basing it on their own cultural norms rather than clients' norms for role behaviors and levels of acceptable functional performance. It is also critical that the practitioners explore clients' social-economic environment and support networks (family, kinship networks, ethnic and religious associations, and self-help groups). A comprehensive assessment should include clients' functional status, ability to perform activities that are important to the fulfillment of their socio-cultural group norms for roles in addition to the expectation of the majority society. In addition, the role of spirituality, an important supportive and empowering source in life, should also be explored during the interview and assessment process as a guide towards assisting clients in their over-all feelings of well-being.
SOCIAL SUPPORT Important social support networks for most minority older adults are family members, friends, religious institution and community organizations, in this order. According to Lubben and Becerra (1987) "social networks are an individual's social contacts from which social support may be given. . . . supports include the nature and extent of social exchanges between an individual and his or her social networks" (p. 131). Studies suggest that many older ethnic minorities tend to live with an adult child either for economic or health reasons and those living alone tend to have frequent contact with one or more of their children. Those who have never married or are divorced, rely more on siblings, friends and social institutions for assistance, when needed.
Promoting Older Ethnic Minorities Health Behaviors
225
Exploring the need for assistance in activities of daily living (ADL) suggest that Mexican Americans tended to receive ADL assistance from an adult child, while African Americans more often received ADL assistance from formal support systems, such as home health aides, homemakers, and visiting nurse services. However, having a spouse seemed to enable the elder to receive more assistance with function from informal sources (Lubben & Becerra). Older African American men are more likely to receive assistance from immediate family members rather than relatives and friends (Chatters, Taylor & Jackson, 1985). Further investigation of African American elders suggest that family members often provide informal assistance to their elders in areas of basic living activities such as walking, bathing, dressing, eating, grooming, housekeeping, transportation, food preparation, grocery shopping, and personal affairs (Sangle, 1983; Keith, 1985). The church is also a strong source for informal support for African Americans. Church members are second only to family members in providing support and aid in times of illness (Krause & Van Tran, 1989). Barresi (1990) summary of support for older African Americans found that most tend to receive good levels of care through their informal networks, such as extended family structure and involvement with voluntary association. In addition, many were found to prefer informal support because of the difficulty in dealing with formal systems of support. One example of informal support for African Americans is what is called "church spiritual families" where kin terms are assigned to church members such as "church mothers," who function as lay therapists and confident to church members. These church mothers provide help when members are ill and needed resources to family members (Johnson & Barer, 1990).
ENVIRONMENTAL MAPPING PROCESS Environmental mapping can enable the health practitioner to obtain information about the social-cultural-economic situations of older minorities and identify their health care and social support needs. The Environmental mapping process gives older persons an opportunity to involve practitioners in their socio-cultural environment, by collaborating on exploring patterns of participation in community life, social and family activities, assessing neighborhood quality and the availability of community resources. Health practitioners are participant observers in mapping resources (people, programs, and other support networks) in the community that are available and beneficial to their clients. Barriers in accessing resources are identified along with resources needed but not available. Shar-
Maynard
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ing these observations with the client for verification and exploring ways to integrate cultural considerations in treatment planning can lead to a suecessful intervention plan. For example, the practitioner and client, working together as a team, can identify the reasonable and helpful pharmacies for prescriptions and resources for spiritual comfort and leisure pursuits. The client becomes the teacher during the mapping process, helping the practitioner to become aware of the uniqueness of the community including communication style, types of foods consumed, important rituals and ceremonies, gender roles expectations, life style habits, and what is important to people in this community (Maynard, 1984). Home health practitioners and some family practice physicians who make home visits do a perfunctory neighborhood mapping in order to identify resources helpful for their clients. Social workers and public health nurses also use a mapping process to find support services for their clients. Neighborhood health centers, mental health drop-in-centers, and senior centers are all part of the neighborhood support network and can provide information to the health practitioner during the community mapping process. The mapping process engages the clients in their own problem identification and solution finding by identifying possible resources that can aid in their own self-management. Thus, the practitioner, client and family members together can develop realistic and attainable treatment goals compatible with client's socio-cultural needs, supportive networks, and environmental resources.
INTERVENTION CONSIDERATIONS Many older adults feel more comfortable if they have the opportunity to choose the type of intervention. Often their beliefs about health and illness are more in line with homeopathic or naturopathic medicine than with allopathic medicine, which generally ignores the importance of spiritual beliefs, attitude about well-being and emotional stress of illness (Shealy & Myss, 1988). Other complementary therapies that have proven beneficial to older adults with acute and chronic conditions are spinal manipulation by a chiropractor or physical therapist, massage therapy, therapeutic touch and other forms of "laying on of hands" that person's of color especially African Americans, Hispanic and Native Americans acknowledge as part of their spiritual and emotional healing practices. For older Asians, the use of acupressure and acupuncture is well accepted as a means for curing and relief of pain. In addition, the use of prayer and prayer groups for healing, are important to African Americans, Native Americans and Hispanics as
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are various forms of meditation with older Asians. In addition, nutritional counseling, exercises, and various types of psychotherapies have valuable components that relate to older persons of color health beliefs and can be successfully used in collaboration with allopathic practice. There are several intervention models that can be used to enhance self-maintenance and health care. One proposed by Satsuki (1986) is an educational helping intervention model. Helping interventions found to be most acceptable to elderly clients is an educational-problem-solving model because of their expressed need for information regarding various aspects of aging and practical solutions to difficult problems (Satsuki). The educational helping intervention encourages the client, family members and practitioner(s) to identify pressing problem areas to self-maintenance and health care. In this model the counselor/practitioner may conduct individual counseling sessions in the older person's home, which permits a more natural assessment of the person's needs, and allows for an informal, less threatening interaction. These counseling sessions can also take place in the person's hospital/or nursing home room or home of a family member or friend. During the counseling session the person's personality characteristics, life style, habits and family roles are discussed in order to match appropriate solutions to specific areas of need. Another model is a holistic medical model in which health care practitioners would address the mental and spiritual as well as the physical aspects of the client in care planning; tailor treatment to each client's unique characteristics; promote health as a positive state of well-being, not merely the absence of disease; encourage personal responsibility for own health care; use therapeutics approaches that mobilize the individual's capacity for self-healing; and appreciate and nurture the person's quality of life (Romano, 1992). When using a holistic medical model Gross (1980) suggests that the health care counselors/practitioners should focus their attention on the following: 1. The whole person, an integration of body, mind, feelings, spirit, and life style as well as the physical and social environment of the individual--and on the interdependence of these factors in growth and change. 2. The goal being the positive wellness of the person, a sense of heightened well-being and fitness. 3. The intervention should elicit from the client (older adult) self-responsibility for their situations and what can they do (Action needed). Maximizing the client participation in self-care without blaming the client for the problem...(Gross, 1980, pp. 99-100).
228
Maynard
In summary, the following suggestions can empower ethnic minorities responsible action for health care. 1. Provide choices and altematives to the management of a chronic condition. If one approach is not to the liking of the person, explore other alternatives that fit into client's daily habits, lifestyle and cultural orientation. 2. In cooperation with the client and/or family design a culturally specific serf-care management plan that takes into consideration the client's own support networks and needs, e.g., family members, minister, other significant relationship and even elements of folk medicine, if used. 3. Provide health care information in the person's native language, when possible, or in simple, clear English. Use illustrations and drawings to reinforce teaching. Demonstrate how to perform certain health tasks and have the client practice these tasks with you in order to correct and reinforce performance. 4. Support client's and family member's positive coping methods. 5. Encourage the client or family member to take responsibility in mapping home and neighborhood environment for protection against environmental health risks, emotional stressors, household accidents and to identify appropriate resources to facilitate self care needs. 6. Use a problem-solving approach rather than a directive approach in promoting health enhancing behavior. 7. Foster self-confidence and positive self-regard in self care management skills. 8. become an advocate for needed services for the client. 9. Monitor care plan, frequently evaluate outcomes, follow-up and reassess the client's progress as needed. The Interventions presented here provide a framework for practitioners to empower the older person to become an active participant in their own self care management and also a team member with the health care practitioner. By choosing to collaborate with the practitioner the client becomes more respons~le for his/her own health enhancing behaviors. In addition, finding a primary care physician that the older person feels at ease with, can eventually foster mutual trusting relationships, good support and open communication between physician and client. This is generally the first major step to successful secondary prevention and health care outcomes.
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REFERENCES Albino, J. (1983). Health psychology and primary prevention: Natural allies. In R. Felner, L Jason, J. Moritsugu and S. Father (Eds.), Preventive Psychology: Therapy, Research and Practice. New York: Pergamon Press, 221-233. American Association of Retired Persons. (1992). A Portrait of Older Minorities. Washington, D.C., Minority Affairs Publication NO MA 3668 (1993). D12404. Chatters, L., Taylor, R., & Jackson, J. (1985). Size and composition of the informal helper networks of elderly blacks. Journal of Gerontology, 40 (5), 605-614. Dorfman, S. (1990). Health Promotion for Older Minority Adults. National Resource Center on Health Promotion and Aging. Washington, D.C., AARP Publication NO P4722 (99D14493). Fisher, A., Liu, Y., Velozo, C., & Pan, A. W. (1992). Cross-cultural assessment of process skills. The American Journal of Occupational Therapy, 46 (10), 867-885. Gross, S. (1980). The holistic health movement. The Personal and Guidance Journal, 59 (2), 96-10. Johnson, C., & Barer, B. (1990). Families and networks among older inner-city blacks. The Gerontologist, 30 (6), 726-733. Keith, J. (1985). Age in anthropological research. In R. Binstock and E. Shanes (Eds.), Handbook of Aging and Social Sciences. N.Y.: Van Nostrand Reinhold, 231-263. Koh, J., and Bell, W. (1987). Korean elders in the United States: Intergenerational relations and living arrangements. The Gerontologist, 27, 1, 66-71. Krause, N., & Van Tran, T. (1989). Stress and religious involvement among older blacks. Journal of Gerontology: Social Sciences, 44 (1), 4-13. Lubben, J., & Becerra, R. (1987). Social support among Black, Mexican, and Chinese Elderly. In D. Gelfrand and C. Barresi (Eds.), Ethnic Dimensions of Aging. N.Y.: Springer. Maynard, M., & Pizzorno, J. (1992). The Neuropathic Revolution. Venture Inward, 8 (4), 12-18. Richardson, V. (1992). Service use among urban African American elderly people. Social Work, 37 (1), 47-54. Roman, J. (1992). Psychoeducationat intervention for stress management and well-being. Journal of Counseling and Development, 71 (2), 199-209. Satsuki, T. (1986). Private practice in gerontological counseling. Journal of Counseling and Development, 64, 406-409. Sangle, J. (1983). The family support system of elderly. In IL Vogue and H. C. Palmer (Eds.), Long Term Care. Washington, D.C.: Health Care Finance Administration. Shealy, N. C., & Myss, C. M. (1988). The Creation of Health: Merging Traditional Medicine with Intensive Diagnosis. Walpole, NH, Stillpoint Publishing. Watson, W. (1982). Aging and Social Behaviors: An Introduction to Social Gerontology. Monterey, CA: Wadsworth (Health Sciences Division).
Promoting Older Ethnic Minorities Health Behaviors: Primary and Secondary Prevention Considerations Marianne Maynard, Ph.D., OTR/C, NCC 1,2
This article examines elderly ethnic minorities health care utilization patterns and health behaviors and their need for primary and secondary preventive care. Assessment issues are discussed along with ways to involve minority clients in identifying resources that could promote their own self care management. Suggestions are also made on ways health care practitioners can encourage minority clients to be active team players in our health care system. KEY WORDS: minority elderly health care utilization and behaviors; primary and secondary prevention.
In recent years, the elderly population has been growing faster among persons of color than among our majority population. This trend is expected to continue in the future. The non-white population, 65 years and older, is projected to be 25 percent of the U.S. population by year 2025 and 35 percent by the year 2050 (American Association for Retired Persons, 1992). However, data on the health needs of elderly ethnic minorities still remain limited, with even less information on their participation patterns in the health care delivery system. Local and state health facilities have been remiss in tracking the patterns of elderly minorities seeking and receiving health care services.
1Retired Professor, Department of Occupational Therapy, Virginia Commonwealth University/ Medical College of Virginia, Program Director for Holistic Wellness Associates, San Diego, California. 2Address correspondence and reprint requests to Marianne Maynard, 11828 Rancho Bernardo Rd., Suite 123-71, San Diego, CA 92128. 219
@ 1996HumanSciencesPress,Inc.
Maynard
220
According to Dorfman, 1990, common health problems found among most older ethnic minorities are high blood pressure, diabetes, heart disease, and cancer as illustrated in Fig. 1. All of these conditions require long term care management and are the leading causes of death of older persons for these minority groups. Poor health maintenance contributes to many life threatening conditions. For example, a long history of alcohol abuse contributes directly to cirrhosis of the liver in Native American and African American groups, especially among males. The stress of minority status, low socio-economic conditions, lifestyle behaviors and competition in a majority society can contribute to hypertension, a condition common in ethnic minority groups. Diabetes, cancer, and other serious conditions are often not detected until later stages when treatability is more difficult. Infrequent health exams, poor health maintenance and lack of health information are major contributors to complications of illness and disease. For a variety of reasons, many older minorities will postpone seeking medical care until their condition interferes with their daily functional capacity. The reliance on folk remedies for cures, based on health beliefs and economic reasons, may be the first line of defense against illness. Only recently have health promotion programs targeted ethnic minority groups to encourage better health prac-
Health Risks
African American
American Indian Alaska Native
AsianAmerican Pacific American
Hispanic
Accidents Cancer Cirrhasis af Liver Diabetes Heart Disease High Blood Pressure Pneumonia/Influenza ~ R P Hea;Ih~ Aging, Washmfit~, OC. Publicati~ DI 4 ; 74
Fig. 1. Health risks among older persons of color.
Promoting Older Ethnic Minorities Health Behaviors
221
tices. There are some indications that these programs can be successful in reducing the high health risk behaviors in these cultural groups when a personalized and consistent effort is made to inform, instruct and involve participants in planning their own health program activities.
HEALTH SERVICE UTILIZATION Watson (1982) reported that visits to private physicians' offices, hospital care, and long-term institutional care were the major categories of services consumed by older minorities. Except for physician visits, data suggest that the utilization of health and long-term care services are based on information about the availability of health services and how to access services. Older minorities often are less informed about the nature of disease or the seriousness of certain diseases/impairments and therefore may not seek care until experiencing major limitation in physical function and daily activities. Moreover those on limited income and without health insurance coverage will find it extremely difficult to purchase prescribed medication and health care services. When a medical crisis occurs the likely entrance into the medical care system is generally by way of a hospital emergency room or an ambulatory care drop-in-center. The problem with this route is the general lack of proper follow-up care after the initial medical crisis is treated, especially for those who do not have a primary care physician. Older ethnic minorities are more likely to utilize health care services when they: 1. Are conveniently located on a direct transportation route with convenient hours of operation and short waiting time to see practitioners. 2. Affordable with reasonable pre-payment requirements. 3. Have a good reputation for being sensitive to the needs of clients and have a diversity of personnel and clientele. 4. Use intervention strategies appropriate to client's cultural orientation, needs and values. YeaRs, Thomas, and Folts (1992) suggest that predisposing factors such as race, gender, education, age, marital status, beliefs/attitudes and religion play an important part in whether a person understands the importance of good health care and takes the necessary steps to care management. For example, minority older women are more likely than minority older men to seek early medical care and the higher the educational or information level, the more likely these older adults will seek care early from a primary care physician. Marital status and family situation can also hinder or be a
Ma~a~
2~
facilitating factor in seeking prompt health care, depending on the knowledge and support of spouse, adult children or significant others. Furthermore beliefs and attitudes about illness and aging can also deter or promote care-seeking behaviors. Richardson (1992) examined the service used by 186 urban elderly African Americans and found the majority of respondents interviewed were aware of the services in their area. During the preceding six months the author reported that 61% of the respondents had seen a physician, 45% had used public transportation to a health care facility, 40% used hospital services, 37% used health clinics, 31% use assistance from churches and 30% from senior centers. The majority rated a high satisfaction with these services. These findings suggest that older persons will more likely utilize health care and support services when they are aware of the availability of these services and when satisfaction is good. Further example of service utilization was based on a sample of 151 Korean elders living in the New York area (Koh & Bell, 1987). The major problems cited by this sample of respondents were the lack of proficiency in the English language, loneliness, limited transportation, income, and available housing. The major health problems of this sample were high blood pressure, body aches/pain and digestive problems. Over 67% had seen a doctor during the last year and more than 11% were hospitalized during the same period. Sixty-six percent of this sample group visited Korean speaking doctors or Korean herb doctors (28%). Some visited American medical doctors (18%) and only 1% had used hospital emergency rooms. Koh and Belle also found that over 75% of the sample groups had no private health insurance, were not eligible for Medicare benefits for reasons of immigrant status and therefore used Medicaid sponsored health services. Primary Prevention Considerations Primary prevention emphasizes health seeking behaviors and lifestyle changes for the prevention of disease prior to the occurrence of symptoms. For the older ethnic minority this means taking appropriate action in health maintenance and disease prevention. Health practitioners, serving as health promotion change agents, can foster primary prevention by collaborating with older persons in: 1. Identifying health risk factors and providing education and support services for reducing risk factors and behaviors. 2. Promoting adherence to health recommendations, such as lifestyle changes, avoidance of environmental risk factors that contribute
Promoting Older Ethnic Minorities Health Behaviors
223
to illness, annual physicals and seeking prompt care when symptoms arise. 3. Coping with threats to health, including stressors of everyday life. (Albino, 1983). Primary prevention must also address the living environment that exposes a person to disease causing agents or injuries. In the area of healthy lifestyle, emphasis should be placed on educating the older person about proper nutrition, stress management, the importance of exercise, and early detection of illness and symptoms or signs of diseases. The fear and denial of illnesses deters many elderly from seeking prompt care, which can be costly in time, money and health outcomes. Teaching older ethnic minorities the importance of self-examinations to detect signs of cancer, or to identified symptoms of diabetes, hypertension, heart problems and other illnesses can enhance their awareness as to when to seek health care or information about a health problem. The use of home remedies may reduce the symptoms for a time, but generally will not cure the condition. Educating older adults to the seriousness of certain diseases and conditions is an important focus of primary prevention.
Secondary Prevention Secondary prevention is required at the earliest sign of a problem along with the prevention of secondary impairments. The delay in seeking medical care for acute problems, such as cancer or heart condition, usually results in the need for intensive medical action. In the case of chronic conditions such as kidney disease, high blood pressure or diabetes, the prevention of further decline in function becomes paramount. The health maintenance and care management needs of older adults generally includes facilitating adaptation to disabling condition, modification of living environment to enhance functional and safety needs, and informing and educating the older person and family members about the benefits of self-care management and health maintenance. Therefore, careful assessment of the older persons' environmental situation, social-cultural-spiritual beliefs and practices, and support networks must be performed, along with an examination of their health status.
ASSESSMENT ISSUES The appropriateness of functioning assessment instruments also must be examined before using them with older minority adults. Most Activity
2~
Ma~a~
of Daily Living Scales (ADL) evaluations are standardized on North American majority samples (Fisher, Liu, Velozo, & Pan, 1992) and therefore do not reflect diverse population groups norms, role behaviors, belief system or cultural standards for performing certain life tasks. When possible, it is better to observe an older person participating at home in their daily activities. Better results are often obtained when incorporating the same labeling terms used by older persons when instructing them during the assessment process and teaching self care management skills. Differences in word meaning, even when the language is English, can lead to misinterpretation of the evaluator's instructions and client's performance outcomes (Fisher et al., 1992). Practitioners often observed this phenomena occurring when assessing individuals from lower social economic backgrounds, rural vs urban residents and those from other regions of the country where word meaning may be different from those used by the practitioner. In addition, practitioners must be extremely careful not to bias their ratings of clients' performance by basing it on their own cultural norms rather than clients' norms for role behaviors and levels of acceptable functional performance. It is also critical that the practitioners explore clients' social-economic environment and support networks (family, kinship networks, ethnic and religious associations, and self-help groups). A comprehensive assessment should include clients' functional status, ability to perform activities that are important to the fulfillment of their socio-cultural group norms for roles in addition to the expectation of the majority society. In addition, the role of spirituality, an important supportive and empowering source in life, should also be explored during the interview and assessment process as a guide towards assisting clients in their over-all feelings of well-being.
SOCIAL SUPPORT Important social support networks for most minority older adults are family members, friends, religious institution and community organizations, in this order. According to Lubben and Becerra (1987) "social networks are an individual's social contacts from which social support may be given. . . . supports include the nature and extent of social exchanges between an individual and his or her social networks" (p. 131). Studies suggest that many older ethnic minorities tend to live with an adult child either for economic or health reasons and those living alone tend to have frequent contact with one or more of their children. Those who have never married or are divorced, rely more on siblings, friends and social institutions for assistance, when needed.
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Exploring the need for assistance in activities of daily living (ADL) suggest that Mexican Americans tended to receive ADL assistance from an adult child, while African Americans more often received ADL assistance from formal support systems, such as home health aides, homemakers, and visiting nurse services. However, having a spouse seemed to enable the elder to receive more assistance with function from informal sources (Lubben & Becerra). Older African American men are more likely to receive assistance from immediate family members rather than relatives and friends (Chatters, Taylor & Jackson, 1985). Further investigation of African American elders suggest that family members often provide informal assistance to their elders in areas of basic living activities such as walking, bathing, dressing, eating, grooming, housekeeping, transportation, food preparation, grocery shopping, and personal affairs (Sangle, 1983; Keith, 1985). The church is also a strong source for informal support for African Americans. Church members are second only to family members in providing support and aid in times of illness (Krause & Van Tran, 1989). Barresi (1990) summary of support for older African Americans found that most tend to receive good levels of care through their informal networks, such as extended family structure and involvement with voluntary association. In addition, many were found to prefer informal support because of the difficulty in dealing with formal systems of support. One example of informal support for African Americans is what is called "church spiritual families" where kin terms are assigned to church members such as "church mothers," who function as lay therapists and confident to church members. These church mothers provide help when members are ill and needed resources to family members (Johnson & Barer, 1990).
ENVIRONMENTAL MAPPING PROCESS Environmental mapping can enable the health practitioner to obtain information about the social-cultural-economic situations of older minorities and identify their health care and social support needs. The Environmental mapping process gives older persons an opportunity to involve practitioners in their socio-cultural environment, by collaborating on exploring patterns of participation in community life, social and family activities, assessing neighborhood quality and the availability of community resources. Health practitioners are participant observers in mapping resources (people, programs, and other support networks) in the community that are available and beneficial to their clients. Barriers in accessing resources are identified along with resources needed but not available. Shar-
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ing these observations with the client for verification and exploring ways to integrate cultural considerations in treatment planning can lead to a suecessful intervention plan. For example, the practitioner and client, working together as a team, can identify the reasonable and helpful pharmacies for prescriptions and resources for spiritual comfort and leisure pursuits. The client becomes the teacher during the mapping process, helping the practitioner to become aware of the uniqueness of the community including communication style, types of foods consumed, important rituals and ceremonies, gender roles expectations, life style habits, and what is important to people in this community (Maynard, 1984). Home health practitioners and some family practice physicians who make home visits do a perfunctory neighborhood mapping in order to identify resources helpful for their clients. Social workers and public health nurses also use a mapping process to find support services for their clients. Neighborhood health centers, mental health drop-in-centers, and senior centers are all part of the neighborhood support network and can provide information to the health practitioner during the community mapping process. The mapping process engages the clients in their own problem identification and solution finding by identifying possible resources that can aid in their own self-management. Thus, the practitioner, client and family members together can develop realistic and attainable treatment goals compatible with client's socio-cultural needs, supportive networks, and environmental resources.
INTERVENTION CONSIDERATIONS Many older adults feel more comfortable if they have the opportunity to choose the type of intervention. Often their beliefs about health and illness are more in line with homeopathic or naturopathic medicine than with allopathic medicine, which generally ignores the importance of spiritual beliefs, attitude about well-being and emotional stress of illness (Shealy & Myss, 1988). Other complementary therapies that have proven beneficial to older adults with acute and chronic conditions are spinal manipulation by a chiropractor or physical therapist, massage therapy, therapeutic touch and other forms of "laying on of hands" that person's of color especially African Americans, Hispanic and Native Americans acknowledge as part of their spiritual and emotional healing practices. For older Asians, the use of acupressure and acupuncture is well accepted as a means for curing and relief of pain. In addition, the use of prayer and prayer groups for healing, are important to African Americans, Native Americans and Hispanics as
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are various forms of meditation with older Asians. In addition, nutritional counseling, exercises, and various types of psychotherapies have valuable components that relate to older persons of color health beliefs and can be successfully used in collaboration with allopathic practice. There are several intervention models that can be used to enhance self-maintenance and health care. One proposed by Satsuki (1986) is an educational helping intervention model. Helping interventions found to be most acceptable to elderly clients is an educational-problem-solving model because of their expressed need for information regarding various aspects of aging and practical solutions to difficult problems (Satsuki). The educational helping intervention encourages the client, family members and practitioner(s) to identify pressing problem areas to self-maintenance and health care. In this model the counselor/practitioner may conduct individual counseling sessions in the older person's home, which permits a more natural assessment of the person's needs, and allows for an informal, less threatening interaction. These counseling sessions can also take place in the person's hospital/or nursing home room or home of a family member or friend. During the counseling session the person's personality characteristics, life style, habits and family roles are discussed in order to match appropriate solutions to specific areas of need. Another model is a holistic medical model in which health care practitioners would address the mental and spiritual as well as the physical aspects of the client in care planning; tailor treatment to each client's unique characteristics; promote health as a positive state of well-being, not merely the absence of disease; encourage personal responsibility for own health care; use therapeutics approaches that mobilize the individual's capacity for self-healing; and appreciate and nurture the person's quality of life (Romano, 1992). When using a holistic medical model Gross (1980) suggests that the health care counselors/practitioners should focus their attention on the following: 1. The whole person, an integration of body, mind, feelings, spirit, and life style as well as the physical and social environment of the individual--and on the interdependence of these factors in growth and change. 2. The goal being the positive wellness of the person, a sense of heightened well-being and fitness. 3. The intervention should elicit from the client (older adult) self-responsibility for their situations and what can they do (Action needed). Maximizing the client participation in self-care without blaming the client for the problem...(Gross, 1980, pp. 99-100).
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In summary, the following suggestions can empower ethnic minorities responsible action for health care. 1. Provide choices and altematives to the management of a chronic condition. If one approach is not to the liking of the person, explore other alternatives that fit into client's daily habits, lifestyle and cultural orientation. 2. In cooperation with the client and/or family design a culturally specific serf-care management plan that takes into consideration the client's own support networks and needs, e.g., family members, minister, other significant relationship and even elements of folk medicine, if used. 3. Provide health care information in the person's native language, when possible, or in simple, clear English. Use illustrations and drawings to reinforce teaching. Demonstrate how to perform certain health tasks and have the client practice these tasks with you in order to correct and reinforce performance. 4. Support client's and family member's positive coping methods. 5. Encourage the client or family member to take responsibility in mapping home and neighborhood environment for protection against environmental health risks, emotional stressors, household accidents and to identify appropriate resources to facilitate self care needs. 6. Use a problem-solving approach rather than a directive approach in promoting health enhancing behavior. 7. Foster self-confidence and positive self-regard in self care management skills. 8. become an advocate for needed services for the client. 9. Monitor care plan, frequently evaluate outcomes, follow-up and reassess the client's progress as needed. The Interventions presented here provide a framework for practitioners to empower the older person to become an active participant in their own self care management and also a team member with the health care practitioner. By choosing to collaborate with the practitioner the client becomes more respons~le for his/her own health enhancing behaviors. In addition, finding a primary care physician that the older person feels at ease with, can eventually foster mutual trusting relationships, good support and open communication between physician and client. This is generally the first major step to successful secondary prevention and health care outcomes.
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