in Practice
Cross-Cultural Health Care for Older Adults: Strategies for Pharmacists Cynthia X. Pan, Wing Fun Leo-To
The United States population not only is aging, but also becoming more ethnically diverse. Approximately half of elders who take medications find adherence challenging, and cultural diversity is one of the variables that may affect adherence. By better understanding patients’ cultural perspectives, senior care pharmacists can more effectively address their medication management needs; failure to recognize these differences may contribute to misunderstanding or miscommunication that may affect treatment. When a patient does not adhere to prescribed medications, explore reasons and feelings. Different ethnic groups have varying communication styles and also seek different degrees of family involvement in diagnosis and treatment. Some mistrust in Western health care, choose to use herbs and nonpharmacologic agents, and have different time orientation that may affect adherence. Senior pharmacists have an active role in screening, evaluation, and counseling elderly, ethnically diverse patients. Applying general trends of cultural values should not be mistaken for stereotyping. KEY WORDS: Communication, Cross-cultural, Cultural competency, Ethnic diversity, Nonadherence.
T
he United States population not only is aging, but also becoming more ethnically diverse. In 2030, when all the Baby Boomers will be 65 years of age or older, nearly one in five U.S. residents is expected to be in this age group. This cohort is projected to increase to 88.5 million in 2050, more than doubling the number in 2008. Concurrently, the minority older population will triple during the same period, with one quarter of the elderly population belonging to a minority racial or ethnic group.1
Approximately 50% of elders who take at least one medication find adherence challenging.2 Nonadherence in the elderly is multifactorial, and one factor—the influence of patients’ cultural background and its influence on adherence—has not been systematically explored. Many cultural fundamentals are practiced by the older generation and should be taken into consideration during patient encounter and treatment. By better understanding the patient’s cultural perspectives, senior care pharmacists can more effectively address the patient’s
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medication-management needs. Failure to recognize these differences may contribute to misunderstanding or miscommunication, which in turn may affect treatment. Cultural assumptions are commonly made with patients. As health care professionals, we must take the time to listen to and engage our patients, establish a relationship, and ask them about their fears, worries, and hopes. In a study of 72 minority members representing African-Americans, Hispanics, Native Americans, Sudanese, and Vietnamese, and eight whites, the respondents indicated that the health care provider’s lack of knowledge regarding their cultural background may have affected the care they received. Minority respondents felt the health care provider “spoke down to them” and used too many “big words,” and they recommended that the provider should have used visual aids, simpler language, and/or included gestures. In addition, the respondents thought their illnesses could be better treated by someone of the same ethnic or racial group since he or she may have a better understanding of their cultural backgrounds.3
Case Vignette 1 An 80-year-old Chinese female who had undergone surgery was never asked by nurses whether she had pain following the operation. She was not interviewed or provided pain medication by the nurses because it was assumed she did not speak English and had a high tolerance to pain. It turned out this patient did not have a language barrier and was in moderate-to-severe pain.4 She hesitated to take “strong” pain medications because of the fear of addiction, but also wanted her pain to be controlled so that she could walk.
Approach to Ethnically Diverse Elderly Patients When evaluating how to approach older adults from diverse ethnocultural backgrounds, pharmacists should consider cultural experiences and values in communicating with different ethnic groups (Table 1). Although these reflect broad generalizations, they should not be used to stereotype individuals.4
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Tip 1: Applying general trends of cultural values is not the same as stereotyping. Generalizations indicate common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual. Generalizations may be inaccurate when applied to specific individuals, but when applied broadly, can indicate common behaviors and shared beliefs.4
Case Vignette 2 A 73-year-old African-American male presented at the outpatient unit to receive eculizumab to treat his paroxysmal nocturnal hemoglobinuria (PNH), an extremely rare, life-threatening blood disorder. The patient had previously consented to receive the medication. However, prior to administration, the patient refused the medication based on his perception that in the past he was being used as a ‘”laboratory experiment.” He believed he could only be cured by herbal medication and feared he would experience the side effects of diarrhea and dizziness from eculizumab. After further exploring his feelings with openended questions and counseling using the “repeat-back” method, the patient agreed to receive the drug. Tip 2: Make sure reasons for compliance are explained and stressed. Use open-ended questions and the “repeatback” method.7 Avoid asking questions requiring a “yes” or “no” response (see box). While there are cultures (Asian and Middle-Eastern) in which direct eye contact is thought to be disrespectful to the elderly, brief eye contact is important while taking patient cues when it may not be appropriate.4 To put the elder patient at ease, take the time to “talk story” before interventions.8 (Talk story is an Hawaiian expression for having an informal chat, thus establishing a therapeutic relationship.) For the vast majority of diverse older adults, addressing them in the respectful formal voice (Mr. or Mrs. or Dr. or Rev.) is preferred.
Involvement of Family in Diagnosis and Treatment In many non-Anglo-Saxon cultures, when caring for the elderly, decisions about diagnosis and plan of care are made by the family. This practice is a form of respect
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Table 1. Considerations in Communicating with Various Ethnic Groups
Ethnic Group
Communication Style
African-American
Style: Patients may not trust hospitals and may be sensitive to discrimination, even when it is not intended. This is a result of their historical experiences with cultural insensitivity and deeply rooted prejudices. Advice: Rather than addressing the patient by his/her first name, greet him/her as Mr. or Mrs. or by professional title and last name.
Asian (i.e., China, Korea, Japan)
Style: Chinese patients may appear to agree (by nodding) to what health care providers say, out of politeness, without meaningful understanding or having intentions of following through. Husbands and sons may be valued more than wives and daughters as decision makers. Advice: Offer things such as medications, treatments, or even basic necessities such as tea or water, several times; patients may refuse at first to be polite. Ask about preferences for decision making.
Hispanic/Latino
Style: These patients value personal relationships. Patients may not discuss emotional problems outside the family. Advice: Rapport and trust may increase if patient is asked about his/her family and interests before discussing health care issues.
Jewish
Style: Knowledge is highly valued. Patients may ask many questions, and health is a great concern. Advice: Explore patients’ concerns and questions; keep them informed at their own level of health literacy. Assure you are doing your best to meet their needs.
Middle Eastern
Style: These patients may appreciate health care providers sharing information about themselves; then ask them to share their own information. Advice: Effective communication will often be a two-way approach . For example, personalize your approach: “I once had a patient from your country who was afraid to take this medicine. We discussed all her questions, then she felt better about taking it. What concerns do you have?”
Russian
Style: These patients usually expect health care workers to be warm, friendly, and caring. They may speak loudly and appear abrasive. Some Russian patients may ask for brand name medications only. Advice: Treat these patients in a warm and friendly manner, and do not take it personally if patients speak loudly. Patients and family members also appreciate frequent updates. But if you feel the patient is taking advantage of the situation, gently set limits. May need to counsel patients regarding brand vs. generic medications.
Southeast Asian (i.e., Phillipines, Malaysia, Singapore, Vietnam, Thailand)
Style: Patients from these countries are rarely told the name of their illnesses and medication or types of procedures performed. Blood is venerated as strength and health. Advice: Keep in mind that accurate health records may be difficult to obtain. Address their concerns regarding blood loss during blood drawing and surgery. Some patients may decline blood draws to preserve their blood. Evaluate whether routine blood draws are truly necessary.
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Methods of Communication An open-ended question is a way to engage people in a
conversation. Because it cannot be answered by just “yes” or “no,” it requires a person to think and respond. (A closedended question can be answered with a simple yes or no.) Teach-back is a strategy in which providers ask patients to repeat, in their own words, what they have just learned about their medical condition and treatment to confirm that the patients understand what has been said. Talk story is a Hawaiian expression for having an informal chat, thus establishing a therapeutic relationship.
Tip 3: During medication management, find out if the patient prefers involvement of the family. Uncover potential nonadherence by asking the patient to bring in all medications or a list, and “teach back” to the pharmacist about what they are taking or not taking (see box). In the course of this conversation, the pharmacist can assess the patient’s level of functional health literacy and impact of ethnic or cultural background that could affect medication management. At the same time, explore specific barriers, such as cost, regimen complexity, side effects, and other concerns.
Use of Herbs and Nonpharmacologic Agents for the elderly.9 In addition, in Hispanic/Latino culture, some older, more traditional wives, defer to husbands in decision-making, both for their own health and that of their children.4 There are also spiritual/religious beliefs that time of death is in God’s control. The family would avoid discussing death with their elder since they believe this will make it become a reality. In some Asian and African-American cultures, elders are traditionally venerated as one step removed from a spiritual union with their ancestors.
Ethnocentrism and cultural relativism are two key anthropological concepts. Ethnocentrism is the view that one’s culture’s way of doing things is superior to all others, while cultural relativism is the attitude that other ways of doing things are different, but equally valid.4 Most cultures are ethnocentric. The goal of all systems of healing is the same—to help people get well. One study concluded that if all cultures could study each other’s techniques with a culturally relativistic perspective, the cause of modern medicine would be greatly advanced.4
Table 2. General Trends in Cross-Cultural Characteristics of the Elderly Patient
Ethnic Group
Involvement of Family In Diagnosis and Treatment
Mistrust in Western Health Care
Use of Herbs/ Nonpharmacologic Agents
Time Orientation: Past, Present, or Future
African-American
Yes
Yes
Yes
Present
Asian
Yes
Yes
Yes
Past
Hispanic/Latino
Yes
No
Yes
Present
Jewish
Yes
No
N/A
Future
Middle Eastern
Yes
Yes
N/A
N/A
Russian
Yes
No
Yes
N/A
Southeast Asian
Yes
No
Yes
Past and present
Note: The table reflects broad generalizations and should not be used to stereotype individuals. Abbreviation: N/A = Not available. Source: Adapted from Reference 5.
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Cross-Cultural Health Care: Strategies for Pharmacists
Some cultural groups use herbs and nonpharmacologic modalities because of mistrust in Western health care. For example, many older Korean immigrants purchase traditional Korean medicine because they do not trust patent medications; this can be a problematic since these traditional medications are aimed at relieving symptoms rather than treating underlying conditions.10 African elders may feel Western health care providers show “cultural insensitivity and deeply rooted prejudices,” based on their historical experience of segregation and discrimination.11 Many cultures traditionally use herbs and nonpharmacologic agents to treat their ailments. Pakistani elders, especially women, may try traditional folk medicine initially when illness strikes and seek allopathic medical help only when the suffering as a result of the disease becomes intolerable.12 In some cultures, decreasing drug doses are practiced because it is believed that Western medicine is “stronger, faster, and curative,” while folk medicine is “weaker, slower, but preventive.”13 This belief has been presented in studies where Chinese elders are more likely to develop angiotensin-converting enzyme inhibitor-induced dry cough and are also two times more sensitive to propranolol effects on changes of blood pressure and heart rates when compared with whites.14-17 Elder Chinese-Americans may be at risk for drug interactions because of metabolic factors and concurrent use of herbs and other Chinese medication.18 Based on these studies, senior pharmacists should consider the possibility that some Chinese patients may want or need lower medication doses.
Mistrust in Western Health Care Drug adherence in older adults is linked to having trust in their health care provider. In Japan, physicians are considered as authoritarian figures, and patients usually prefer to depend on them to make treatment-related decisions rather than doing so on their own.19 Conversely, in African-American older adults, patients may have a lower adherence rate as a result of suspicious beliefs and negativity toward their physicians.20 Some older adults also take less of the prescribed dosage to save money and make the medications last longer.
The United States population not only is aging, but also becoming more ethnically diverse. It is evident from the above discussion that medication management in culturally and ethnically diverse older populations is complex. There is an interplay of genetic/ biologic, environmental, and cultural factors that contribute to variability in drug response.21 Tip 4: Westerners are beginning to acknowledge the effectiveness of complementary and alternative therapies. Acupuncture, herbals, and nonpharmacologic agents may be accepted to relieve side effects from Western medications or disease states. Senior care pharmacists should practice cultural relativism since the goal is to help people get well and collaborate with practitioners of complementary and alternative medicine. Monitor for use of herbs or traditional medicines, drug-drug duplications and interactions, and drug-herb interactions. There is a need for collaboration between practitioners of complementary/ alternative medicine and Western health care providers. Ask the patient how he or she is taking the medication. Find out whether doses are decreased because of beliefs, side effects, or financial reasons. Also, in some ethnic groups, it is common to share medications among family and friends.18 Conducting a brown-bag review also may help reveal a broader picture of what the patient may be currently taking. Pharmacists can play a critical role in medication adherence and reconciliation.
Time Orientation: Past, Present, or Future Time orientation is a person’s focus on time. No individual or culture will look exclusively to the past, present, or future, but many will tend to emphasize one over the others.4 Hispanics and African-Americans tend to have a present time orientation. This does not mean that they do not recognize the past or the future, but living in the present is more important to them. Tip 5: Cultures that tend toward a present-time orientation are less likely to take advantage of preventive medicine and follow-up care. Pharmacists should
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Table 3. Screening/Evaluation: 4 Cs of Culture (Call, Cause, Cope, Concerns)
Identify Challenges and Solutions
Getting to Know Your Patient
What do you call your problem? (What do you
1. Cognitive challenges: dementia, Alzheimer’s. Involve family in decision-making. Give directives to caregiver. 2. Language barrier or health literacy? Draw pictures to explain, matching diagrams, visual aids, bilingual translators. Use “teach-back” method (see box, page 648). 3. Physical impairment? Hand dexterity? Tools to assist medication delivery. Swallowing, vision, hearing, and mobility loss? Consider referring to occupational therapy. Communicate with primary physician. 4. Socioeconomic status? Affordability of medications, adequacy of health insurance. Consider substituting less- costly medications.
think is wrong?) 1. Understand your patient’s mindset. 2. What does your patient think his or her disease and conditions are?
What do you think caused your problem? 1. Reveals patient’s understanding of what precipitated the problem. 2. Some cultures believe their disease was caused by cold/hot, yin-yang imbalances while others believe it was caused by personal sins.
How do you cope with your condition? 1. Are there side effects to the medication? 2. Are caregivers/family involved in decision- making process? What are your concerns regarding the condition? 1. Why do they resist certain medications? 2. Fear of addiction to pain medications? 3. Misconceptions of Western medications?
1. Asking this question can help measure the patient’s health literacy. 2. Screen patients for cross-cultural beliefs, nonadherence/ compliance issues caused by polypharmacy, side effects. 3. Perform medication reconciliation. 4. Monitor for interactions with drugs, herbs, and food. 5. If the patient is taking herbs, foreign prescriptions/over- the-counter medications, conduct brown bag review. Assess the use of nonpharmacological agents. 1. For patients who focus on past or present time orientation, promote disease prevention. 2. Encourage the practice of future-time: orientation, thinking ahead and planning ahead.
1. Eliminate unnecessary medications or duplications. 2. Help reduce costs. 3. Simplify medication regimen by curtailing dosing schedule or switching to convenient dosing formulations. 4. Use the Beers criteria to counsel patients about medications to avoid in the elderly. 5. Identify and minimize drug interactions. 6. Empower, organize, and follow up with patients/ caregiver to reinforce adherence.
Source: Adapted from Reference 4.
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focus on the need for preventive medication (such as for hypertension) and to finish antibiotics, even after symptoms have dissipated. Also, pharmacists should address adverse effects from medications, and teach patients to anticipate potential problems.4 Time orientation can also refer to degree of adherence to clock time. In countries with economies based on agriculture, people tend to be more relaxed about time: Many people in traditional agricultural villages do not own a clock since the pace is slower and their lifestyle is more attuned to nature’s rhythms. In contrast, industrialized nations must pay attention to clock-time. There are large numbers of people to organize, and each must complete his or her task according to schedule for the next person to begin. Without clock time, chaos would reign.4 Past-time orientation is practiced by the Chinese, British, and Austrian populations. They tend to stick with old traditions and believe in doing things the way they have always been done.4
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Middle-class white American culture tends to be future-oriented. That is reflected in its medical system’s stress on preventive medicine, advance-care planning, and enthusiasm for each new medical technique or drug. In contrast to past-oriented cultures, progress and change are highly valued. China is shifting to a future orientation, as evidenced by the long-term plan to reduce the country’s population by limiting family size. Tip 6: Pay attention to the time orientation of your elderly patients from diverse backgrounds. Those patients who adhere to a present-time orientation may not realize the importance of taking medications on a clock-time schedule. For patients with a past-time orientation, introduce the patient to new concepts and importance of medication adherence.
The Role of Senior Pharmacists: Screening and Evaluation The “4 Cs of Culture” (“Call, Cause, Cope, Concerns”) were developed to help achieve cultural competence by
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asking the right questions to elicit an understanding of the patient’s point of view (Table 3).4 By performing a good medication review, discrepancies between the patient’s understanding of what he or she should be taking, what has actually been taken, and what physicians have documented in their medical chart will be clarified.22,23 This 4 Cs approach, outlining the screening/evaluation process and suggesting ways to solve problems, can help pharmacists in addressing the challenges of providing medication therapy in the diverse older population.
Conclusion Prescribing for diverse older adults and ensuring adherence can be a complex task. Understanding the patient’s point of view can help the health care provider deal with potential barriers to compliance.4 The Department of Health and Human Services’ Office of Minority Health has published a set of National Standards for Culturally and Linguistically Appropriate Services (CLAS) to guide the care of diverse populations, both from a systems perspective as well as from health care providers’ perspectives. Health care providers are encouraged to use the standards to make their practices more culturally and linguistically accessible. The 14 standards are organized by three themes: culturally competent care, language access services, and organizational supports for cultural competence.24 To perform a proficient medication therapy management with a diverse senior population, pharmacists must first focus on connecting to the patient and building a trusting, therapeutic relationship by using knowledge of cultural fundamentals. By creating an effective patient-provider relationship, pharmacists can sort out the common discrepancies stemming from the patients’ understanding of what they should be taking, what they actually are taking, and what physicians record on their medication lists.21,22 Pharmacists are key providers in patient counseling, correcting nonadherence, and simplifying and improving drug regimens. Pharmacists are also great resources for patients to seek help because of their availability in the community.
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Prescribing for diverse older adults and ensuring adherence can be a complex task. Understanding the patient’s point of view can help the health care provider deal with potential barriers to compliance.4 n Cynthia X. Pan, MD, is chief, Division of Geriatrics & Palliative Care Medicine, New York Hospital Queens, Queens, New York, and associate professor, clinical medicine, Weill Cornell Medical College, Flushing, New York. Wing Fun Leo-To, BS, PharmD, is clinical pharmacist, New York Hospital Queens, Flushing, New York. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. Consult Pharm 2014;29:645-57. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.645.
References 1. Bernstein R, Edwards T. An Older and More Diverse Nation by Midcentury. The U.S. Census Bureau Newsroom, August 14, 2008. Available at http://www.census.gov/newsroom/releases/archives/ population/cb08-123.html. Accessed May 12, 2014. 2. Wick J. Adherence issues in elderly patients. Pharmacy Times January 2011. Available at http://www.pharmacytimes.com/ publications/issue/2011/January2011/RxFocus-0111. Accessed May 12, 2014. 3. Cook CT, Kosoko-Lasaki O, O’Brien R. Satisfaction with and perceived cultural competency of healthcare providers: the minority experience. J Natl Med Assoc 2005;97:1078-87. 4. Galanti GA. Cultural Sensitivity: A Pocket Guide for Health Care Professionals. Oakbrook Terrace, IL: Joint Commission Resources; 2012. 5. Doorway Thoughts: Cross Cultural Health Care for Older Adults. Volumes 1, 2, 3. Boston, MA: Jones and Bartlett Publishers; 2004, 2006, 2009. 6. App: iGeriatrics. Geriatrics Cultural Navigator. Retrieved from http://itunes.apple.com. 7. Hughes A. Pain Management in Diverse Older Adults. 2012 Webinar Series Part II: Tackling the Tough Topics in Ethnogeriatrics. Stanford University. Available at http://sgec.stanford.edu/ webinar/2012Handouts/Jul/Pain_Management_Handout.pdf. Accessed July 17, 2012. 8. Elliot KS, DiMinno M, Lam D et al. Working with Chinese families in the context of dementia. In Yeo G, Gallagher-Thompson D, eds. Ethnicity and the Dementias. Washington, DC: Taylor & Francis; 1996. 9. Culturally Appropriate Geriatric Care: Health Care Interventions, Access and Utilization. Curriculum in Ethnogeriatrics Second Edition, Ethnogeriatric Curriculum: Module Five. Available at http:// www.stanford.edu/group/ethnoger/.
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10. Shin KR, Shin C, Blanchette PL. Health and Health Care of Korean-American Elders, 1-16. Stanford Ethnogeriatrics Curriculum module. 2nd ed. Core Curriculum and Ethnic Specific Modules. October 1, 2001. Available at http://www.stanford.edu/group/ ethnoger/. 11. Gordon S, Hargreaves M, Lieto J et al. Health and Health Care of African American Elders. Stanford Ethnogeriatrics Curriculum module. 2nd ed. Core Curriculum and Ethnic Specific Modules. October 1, 2001. 12. Periyakoil VS, Mendez JC, Buttar AB. Health and Health Care for Pakistani American Elders, 1-13. Stanford Ethnogeriatrics Curriculum module. 2nd ed. Core Curriculum and Ethnic Specific Modules. October 1, 2001. Availabe at http://www.stanford.edu/ group/ethnoger/. 13. Pham CT, McPhee SJ. Knowledge, attitudes, and practices of breast and cervical cancer screening among Vietnamese women. J Cancer Educ 1992;7:305-10. 14. Ding P, Hu OY-P, Liao WC. Does Chinese ethnicity affect the pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors? J Hum Hypertens 2000;14:163-70. 15. Lu J, Li LM, Cao WH et al. Post-marketing surveillance of benazepril-related cough and related risk factors analysis on hypertension. Zhonghua Liu Xing Bing Xue Za Zhi 2003;24:401-5. 16. Tomlinson B, Woo J, Thomas N et al. Randomized, controlled, parallel-group comparison of ambulatory and clinic blood pressure responses to amlodipine or enalapril during and after treatment in adult Chinese patient with hypertension. Clin Ther 2004;26:1292-304.
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17. Zhou HH, Koshakji RP, Siberstein DJ et al. Racial differences in drug response: altered sensitivity to and clearance of propranolol in men of Chinese descent as compared with American whites. N Engl J Med 1989;320:565-70. 18. Tom LA. Health and Health Care for Chinese-American Elders, 1-17. Stanford Ethnogeriatrics Curriculum module. 2nd ed. Core Curriculum and Ethnic Specific Modules. October 1, 2001. Available at http://www.stanford.edu/group/ethnoger/. 19. Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging 2006;23:191-202. 20. Siegel K, Karus D, Schrimshaw EW. Racial differences in attitudes toward protease inhibitors among older HIV-infected men. AIDS Care 2000;12:423-34. 21. Burroughs VJ, Maxey RW, Levy RA . Racial and ethnic differences in response to medicine: towards individualized pharmaceutical treatment. J Natl Med Assoc 2002;94:1-26. 22. Kaboli PJ, McClimon BJ, Hoth AB et al. Assessing the accuracy of computerized medication histories. Am J Manag Care 2004;10 11 Pt 2:872-7. 23. Bedell SE, Jabbour S, Goldberg R et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med 2000;160:2129-34. 24. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Executive Summary. Department of Health and Human Services. Washington, DC: Office of Minority Health; March 2001. Available at http://minorityhealth.hhs.gov/assets/pdf/ checked/executive.pdf. Accessed May 12, 2014.
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Cross-Cultural Health Care for Older Adults: Strategies for Pharmacists Cynthia X. Pan, Wing Fun Leo-To
The United States population not only is aging, but also becoming more ethnically diverse. Approximately half of elders who take medications find adherence challenging, and cultural diversity is one of the variables that may affect adherence. By better understanding patients’ cultural perspectives, senior care pharmacists can more effectively address their medication management needs; failure to recognize these differences may contribute to misunderstanding or miscommunication that may affect treatment. When a patient does not adhere to prescribed medications, explore reasons and feelings. Different ethnic groups have varying communication styles and also seek different degrees of family involvement in diagnosis and treatment. Some mistrust in Western health care, choose to use herbs and nonpharmacologic agents, and have different time orientation that may affect adherence. Senior pharmacists have an active role in screening, evaluation, and counseling elderly, ethnically diverse patients. Applying general trends of cultural values should not be mistaken for stereotyping. KEY WORDS: Communication, Cross-cultural, Cultural competency, Ethnic diversity, Nonadherence.
T
he United States population not only is aging, but also becoming more ethnically diverse. In 2030, when all the Baby Boomers will be 65 years of age or older, nearly one in five U.S. residents is expected to be in this age group. This cohort is projected to increase to 88.5 million in 2050, more than doubling the number in 2008. Concurrently, the minority older population will triple during the same period, with one quarter of the elderly population belonging to a minority racial or ethnic group.1
Approximately 50% of elders who take at least one medication find adherence challenging.2 Nonadherence in the elderly is multifactorial, and one factor—the influence of patients’ cultural background and its influence on adherence—has not been systematically explored. Many cultural fundamentals are practiced by the older generation and should be taken into consideration during patient encounter and treatment. By better understanding the patient’s cultural perspectives, senior care pharmacists can more effectively address the patient’s
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Cross-Cultural Health Care: Strategies for Pharmacists
medication-management needs. Failure to recognize these differences may contribute to misunderstanding or miscommunication, which in turn may affect treatment. Cultural assumptions are commonly made with patients. As health care professionals, we must take the time to listen to and engage our patients, establish a relationship, and ask them about their fears, worries, and hopes. In a study of 72 minority members representing African-Americans, Hispanics, Native Americans, Sudanese, and Vietnamese, and eight whites, the respondents indicated that the health care provider’s lack of knowledge regarding their cultural background may have affected the care they received. Minority respondents felt the health care provider “spoke down to them” and used too many “big words,” and they recommended that the provider should have used visual aids, simpler language, and/or included gestures. In addition, the respondents thought their illnesses could be better treated by someone of the same ethnic or racial group since he or she may have a better understanding of their cultural backgrounds.3
Case Vignette 1 An 80-year-old Chinese female who had undergone surgery was never asked by nurses whether she had pain following the operation. She was not interviewed or provided pain medication by the nurses because it was assumed she did not speak English and had a high tolerance to pain. It turned out this patient did not have a language barrier and was in moderate-to-severe pain.4 She hesitated to take “strong” pain medications because of the fear of addiction, but also wanted her pain to be controlled so that she could walk.
Approach to Ethnically Diverse Elderly Patients When evaluating how to approach older adults from diverse ethnocultural backgrounds, pharmacists should consider cultural experiences and values in communicating with different ethnic groups (Table 1). Although these reflect broad generalizations, they should not be used to stereotype individuals.4
646
Tip 1: Applying general trends of cultural values is not the same as stereotyping. Generalizations indicate common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual. Generalizations may be inaccurate when applied to specific individuals, but when applied broadly, can indicate common behaviors and shared beliefs.4
Case Vignette 2 A 73-year-old African-American male presented at the outpatient unit to receive eculizumab to treat his paroxysmal nocturnal hemoglobinuria (PNH), an extremely rare, life-threatening blood disorder. The patient had previously consented to receive the medication. However, prior to administration, the patient refused the medication based on his perception that in the past he was being used as a ‘”laboratory experiment.” He believed he could only be cured by herbal medication and feared he would experience the side effects of diarrhea and dizziness from eculizumab. After further exploring his feelings with openended questions and counseling using the “repeat-back” method, the patient agreed to receive the drug. Tip 2: Make sure reasons for compliance are explained and stressed. Use open-ended questions and the “repeatback” method.7 Avoid asking questions requiring a “yes” or “no” response (see box). While there are cultures (Asian and Middle-Eastern) in which direct eye contact is thought to be disrespectful to the elderly, brief eye contact is important while taking patient cues when it may not be appropriate.4 To put the elder patient at ease, take the time to “talk story” before interventions.8 (Talk story is an Hawaiian expression for having an informal chat, thus establishing a therapeutic relationship.) For the vast majority of diverse older adults, addressing them in the respectful formal voice (Mr. or Mrs. or Dr. or Rev.) is preferred.
Involvement of Family in Diagnosis and Treatment In many non-Anglo-Saxon cultures, when caring for the elderly, decisions about diagnosis and plan of care are made by the family. This practice is a form of respect
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Table 1. Considerations in Communicating with Various Ethnic Groups
Ethnic Group
Communication Style
African-American
Style: Patients may not trust hospitals and may be sensitive to discrimination, even when it is not intended. This is a result of their historical experiences with cultural insensitivity and deeply rooted prejudices. Advice: Rather than addressing the patient by his/her first name, greet him/her as Mr. or Mrs. or by professional title and last name.
Asian (i.e., China, Korea, Japan)
Style: Chinese patients may appear to agree (by nodding) to what health care providers say, out of politeness, without meaningful understanding or having intentions of following through. Husbands and sons may be valued more than wives and daughters as decision makers. Advice: Offer things such as medications, treatments, or even basic necessities such as tea or water, several times; patients may refuse at first to be polite. Ask about preferences for decision making.
Hispanic/Latino
Style: These patients value personal relationships. Patients may not discuss emotional problems outside the family. Advice: Rapport and trust may increase if patient is asked about his/her family and interests before discussing health care issues.
Jewish
Style: Knowledge is highly valued. Patients may ask many questions, and health is a great concern. Advice: Explore patients’ concerns and questions; keep them informed at their own level of health literacy. Assure you are doing your best to meet their needs.
Middle Eastern
Style: These patients may appreciate health care providers sharing information about themselves; then ask them to share their own information. Advice: Effective communication will often be a two-way approach . For example, personalize your approach: “I once had a patient from your country who was afraid to take this medicine. We discussed all her questions, then she felt better about taking it. What concerns do you have?”
Russian
Style: These patients usually expect health care workers to be warm, friendly, and caring. They may speak loudly and appear abrasive. Some Russian patients may ask for brand name medications only. Advice: Treat these patients in a warm and friendly manner, and do not take it personally if patients speak loudly. Patients and family members also appreciate frequent updates. But if you feel the patient is taking advantage of the situation, gently set limits. May need to counsel patients regarding brand vs. generic medications.
Southeast Asian (i.e., Phillipines, Malaysia, Singapore, Vietnam, Thailand)
Style: Patients from these countries are rarely told the name of their illnesses and medication or types of procedures performed. Blood is venerated as strength and health. Advice: Keep in mind that accurate health records may be difficult to obtain. Address their concerns regarding blood loss during blood drawing and surgery. Some patients may decline blood draws to preserve their blood. Evaluate whether routine blood draws are truly necessary.
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Methods of Communication An open-ended question is a way to engage people in a
conversation. Because it cannot be answered by just “yes” or “no,” it requires a person to think and respond. (A closedended question can be answered with a simple yes or no.) Teach-back is a strategy in which providers ask patients to repeat, in their own words, what they have just learned about their medical condition and treatment to confirm that the patients understand what has been said. Talk story is a Hawaiian expression for having an informal chat, thus establishing a therapeutic relationship.
Tip 3: During medication management, find out if the patient prefers involvement of the family. Uncover potential nonadherence by asking the patient to bring in all medications or a list, and “teach back” to the pharmacist about what they are taking or not taking (see box). In the course of this conversation, the pharmacist can assess the patient’s level of functional health literacy and impact of ethnic or cultural background that could affect medication management. At the same time, explore specific barriers, such as cost, regimen complexity, side effects, and other concerns.
Use of Herbs and Nonpharmacologic Agents for the elderly.9 In addition, in Hispanic/Latino culture, some older, more traditional wives, defer to husbands in decision-making, both for their own health and that of their children.4 There are also spiritual/religious beliefs that time of death is in God’s control. The family would avoid discussing death with their elder since they believe this will make it become a reality. In some Asian and African-American cultures, elders are traditionally venerated as one step removed from a spiritual union with their ancestors.
Ethnocentrism and cultural relativism are two key anthropological concepts. Ethnocentrism is the view that one’s culture’s way of doing things is superior to all others, while cultural relativism is the attitude that other ways of doing things are different, but equally valid.4 Most cultures are ethnocentric. The goal of all systems of healing is the same—to help people get well. One study concluded that if all cultures could study each other’s techniques with a culturally relativistic perspective, the cause of modern medicine would be greatly advanced.4
Table 2. General Trends in Cross-Cultural Characteristics of the Elderly Patient
Ethnic Group
Involvement of Family In Diagnosis and Treatment
Mistrust in Western Health Care
Use of Herbs/ Nonpharmacologic Agents
Time Orientation: Past, Present, or Future
African-American
Yes
Yes
Yes
Present
Asian
Yes
Yes
Yes
Past
Hispanic/Latino
Yes
No
Yes
Present
Jewish
Yes
No
N/A
Future
Middle Eastern
Yes
Yes
N/A
N/A
Russian
Yes
No
Yes
N/A
Southeast Asian
Yes
No
Yes
Past and present
Note: The table reflects broad generalizations and should not be used to stereotype individuals. Abbreviation: N/A = Not available. Source: Adapted from Reference 5.
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Some cultural groups use herbs and nonpharmacologic modalities because of mistrust in Western health care. For example, many older Korean immigrants purchase traditional Korean medicine because they do not trust patent medications; this can be a problematic since these traditional medications are aimed at relieving symptoms rather than treating underlying conditions.10 African elders may feel Western health care providers show “cultural insensitivity and deeply rooted prejudices,” based on their historical experience of segregation and discrimination.11 Many cultures traditionally use herbs and nonpharmacologic agents to treat their ailments. Pakistani elders, especially women, may try traditional folk medicine initially when illness strikes and seek allopathic medical help only when the suffering as a result of the disease becomes intolerable.12 In some cultures, decreasing drug doses are practiced because it is believed that Western medicine is “stronger, faster, and curative,” while folk medicine is “weaker, slower, but preventive.”13 This belief has been presented in studies where Chinese elders are more likely to develop angiotensin-converting enzyme inhibitor-induced dry cough and are also two times more sensitive to propranolol effects on changes of blood pressure and heart rates when compared with whites.14-17 Elder Chinese-Americans may be at risk for drug interactions because of metabolic factors and concurrent use of herbs and other Chinese medication.18 Based on these studies, senior pharmacists should consider the possibility that some Chinese patients may want or need lower medication doses.
Mistrust in Western Health Care Drug adherence in older adults is linked to having trust in their health care provider. In Japan, physicians are considered as authoritarian figures, and patients usually prefer to depend on them to make treatment-related decisions rather than doing so on their own.19 Conversely, in African-American older adults, patients may have a lower adherence rate as a result of suspicious beliefs and negativity toward their physicians.20 Some older adults also take less of the prescribed dosage to save money and make the medications last longer.
The United States population not only is aging, but also becoming more ethnically diverse. It is evident from the above discussion that medication management in culturally and ethnically diverse older populations is complex. There is an interplay of genetic/ biologic, environmental, and cultural factors that contribute to variability in drug response.21 Tip 4: Westerners are beginning to acknowledge the effectiveness of complementary and alternative therapies. Acupuncture, herbals, and nonpharmacologic agents may be accepted to relieve side effects from Western medications or disease states. Senior care pharmacists should practice cultural relativism since the goal is to help people get well and collaborate with practitioners of complementary and alternative medicine. Monitor for use of herbs or traditional medicines, drug-drug duplications and interactions, and drug-herb interactions. There is a need for collaboration between practitioners of complementary/ alternative medicine and Western health care providers. Ask the patient how he or she is taking the medication. Find out whether doses are decreased because of beliefs, side effects, or financial reasons. Also, in some ethnic groups, it is common to share medications among family and friends.18 Conducting a brown-bag review also may help reveal a broader picture of what the patient may be currently taking. Pharmacists can play a critical role in medication adherence and reconciliation.
Time Orientation: Past, Present, or Future Time orientation is a person’s focus on time. No individual or culture will look exclusively to the past, present, or future, but many will tend to emphasize one over the others.4 Hispanics and African-Americans tend to have a present time orientation. This does not mean that they do not recognize the past or the future, but living in the present is more important to them. Tip 5: Cultures that tend toward a present-time orientation are less likely to take advantage of preventive medicine and follow-up care. Pharmacists should
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Table 3. Screening/Evaluation: 4 Cs of Culture (Call, Cause, Cope, Concerns)
Identify Challenges and Solutions
Getting to Know Your Patient
What do you call your problem? (What do you
1. Cognitive challenges: dementia, Alzheimer’s. Involve family in decision-making. Give directives to caregiver. 2. Language barrier or health literacy? Draw pictures to explain, matching diagrams, visual aids, bilingual translators. Use “teach-back” method (see box, page 648). 3. Physical impairment? Hand dexterity? Tools to assist medication delivery. Swallowing, vision, hearing, and mobility loss? Consider referring to occupational therapy. Communicate with primary physician. 4. Socioeconomic status? Affordability of medications, adequacy of health insurance. Consider substituting less- costly medications.
think is wrong?) 1. Understand your patient’s mindset. 2. What does your patient think his or her disease and conditions are?
What do you think caused your problem? 1. Reveals patient’s understanding of what precipitated the problem. 2. Some cultures believe their disease was caused by cold/hot, yin-yang imbalances while others believe it was caused by personal sins.
How do you cope with your condition? 1. Are there side effects to the medication? 2. Are caregivers/family involved in decision- making process? What are your concerns regarding the condition? 1. Why do they resist certain medications? 2. Fear of addiction to pain medications? 3. Misconceptions of Western medications?
1. Asking this question can help measure the patient’s health literacy. 2. Screen patients for cross-cultural beliefs, nonadherence/ compliance issues caused by polypharmacy, side effects. 3. Perform medication reconciliation. 4. Monitor for interactions with drugs, herbs, and food. 5. If the patient is taking herbs, foreign prescriptions/over- the-counter medications, conduct brown bag review. Assess the use of nonpharmacological agents. 1. For patients who focus on past or present time orientation, promote disease prevention. 2. Encourage the practice of future-time: orientation, thinking ahead and planning ahead.
1. Eliminate unnecessary medications or duplications. 2. Help reduce costs. 3. Simplify medication regimen by curtailing dosing schedule or switching to convenient dosing formulations. 4. Use the Beers criteria to counsel patients about medications to avoid in the elderly. 5. Identify and minimize drug interactions. 6. Empower, organize, and follow up with patients/ caregiver to reinforce adherence.
Source: Adapted from Reference 4.
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focus on the need for preventive medication (such as for hypertension) and to finish antibiotics, even after symptoms have dissipated. Also, pharmacists should address adverse effects from medications, and teach patients to anticipate potential problems.4 Time orientation can also refer to degree of adherence to clock time. In countries with economies based on agriculture, people tend to be more relaxed about time: Many people in traditional agricultural villages do not own a clock since the pace is slower and their lifestyle is more attuned to nature’s rhythms. In contrast, industrialized nations must pay attention to clock-time. There are large numbers of people to organize, and each must complete his or her task according to schedule for the next person to begin. Without clock time, chaos would reign.4 Past-time orientation is practiced by the Chinese, British, and Austrian populations. They tend to stick with old traditions and believe in doing things the way they have always been done.4
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Middle-class white American culture tends to be future-oriented. That is reflected in its medical system’s stress on preventive medicine, advance-care planning, and enthusiasm for each new medical technique or drug. In contrast to past-oriented cultures, progress and change are highly valued. China is shifting to a future orientation, as evidenced by the long-term plan to reduce the country’s population by limiting family size. Tip 6: Pay attention to the time orientation of your elderly patients from diverse backgrounds. Those patients who adhere to a present-time orientation may not realize the importance of taking medications on a clock-time schedule. For patients with a past-time orientation, introduce the patient to new concepts and importance of medication adherence.
The Role of Senior Pharmacists: Screening and Evaluation The “4 Cs of Culture” (“Call, Cause, Cope, Concerns”) were developed to help achieve cultural competence by
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asking the right questions to elicit an understanding of the patient’s point of view (Table 3).4 By performing a good medication review, discrepancies between the patient’s understanding of what he or she should be taking, what has actually been taken, and what physicians have documented in their medical chart will be clarified.22,23 This 4 Cs approach, outlining the screening/evaluation process and suggesting ways to solve problems, can help pharmacists in addressing the challenges of providing medication therapy in the diverse older population.
Conclusion Prescribing for diverse older adults and ensuring adherence can be a complex task. Understanding the patient’s point of view can help the health care provider deal with potential barriers to compliance.4 The Department of Health and Human Services’ Office of Minority Health has published a set of National Standards for Culturally and Linguistically Appropriate Services (CLAS) to guide the care of diverse populations, both from a systems perspective as well as from health care providers’ perspectives. Health care providers are encouraged to use the standards to make their practices more culturally and linguistically accessible. The 14 standards are organized by three themes: culturally competent care, language access services, and organizational supports for cultural competence.24 To perform a proficient medication therapy management with a diverse senior population, pharmacists must first focus on connecting to the patient and building a trusting, therapeutic relationship by using knowledge of cultural fundamentals. By creating an effective patient-provider relationship, pharmacists can sort out the common discrepancies stemming from the patients’ understanding of what they should be taking, what they actually are taking, and what physicians record on their medication lists.21,22 Pharmacists are key providers in patient counseling, correcting nonadherence, and simplifying and improving drug regimens. Pharmacists are also great resources for patients to seek help because of their availability in the community.
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Prescribing for diverse older adults and ensuring adherence can be a complex task. Understanding the patient’s point of view can help the health care provider deal with potential barriers to compliance.4 n Cynthia X. Pan, MD, is chief, Division of Geriatrics & Palliative Care Medicine, New York Hospital Queens, Queens, New York, and associate professor, clinical medicine, Weill Cornell Medical College, Flushing, New York. Wing Fun Leo-To, BS, PharmD, is clinical pharmacist, New York Hospital Queens, Flushing, New York. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. Consult Pharm 2014;29:645-57. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.645.
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17. Zhou HH, Koshakji RP, Siberstein DJ et al. Racial differences in drug response: altered sensitivity to and clearance of propranolol in men of Chinese descent as compared with American whites. N Engl J Med 1989;320:565-70. 18. Tom LA. Health and Health Care for Chinese-American Elders, 1-17. Stanford Ethnogeriatrics Curriculum module. 2nd ed. Core Curriculum and Ethnic Specific Modules. October 1, 2001. Available at http://www.stanford.edu/group/ethnoger/. 19. Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging 2006;23:191-202. 20. Siegel K, Karus D, Schrimshaw EW. Racial differences in attitudes toward protease inhibitors among older HIV-infected men. AIDS Care 2000;12:423-34. 21. Burroughs VJ, Maxey RW, Levy RA . Racial and ethnic differences in response to medicine: towards individualized pharmaceutical treatment. J Natl Med Assoc 2002;94:1-26. 22. Kaboli PJ, McClimon BJ, Hoth AB et al. Assessing the accuracy of computerized medication histories. Am J Manag Care 2004;10 11 Pt 2:872-7. 23. Bedell SE, Jabbour S, Goldberg R et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med 2000;160:2129-34. 24. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Executive Summary. Department of Health and Human Services. Washington, DC: Office of Minority Health; March 2001. Available at http://minorityhealth.hhs.gov/assets/pdf/ checked/executive.pdf. Accessed May 12, 2014.
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