Barbara Zapatocky, DC, MA, a Palmer College alumna (1979), has a masters in gerontology from the University of Northern Colorado. She is a consultant to the Palmer research dept. on a federal grant from the U.S. Health Resources and Services Administration to assess geriatric education nationally in the chiropractic profession. She is also consulting Palmer College in creating and teaching a chiropractic gerontology diplomate course.
Multicultural Literacy and Gerontology
Have you ever noticed how the "one size fits all" approach to health care doesn't work? While whites made up the vast majority (89.9 percent) of the older population in 1990, demographic projections show the non-white portion of the elderly population is expected to double to 1 in 5 adults by 2040.1 In addition, the minority portion of the 65-plus population is expected to grow rapidly from the 14 percent in 1985 to 33 percent in 2050.2 The Western region of the United States is home to about 21 percent of the total population and most of that population resides in California. Consistently since 1983-1984, 30 percent or more of all new refugees have settled in California (in 1988, 46 percent).3 What does all this mean for the chiropractor of today and the future? It means we all must become more multiculturally literate.
Here are some things to consider. Research published, relative to orthopedics, neurology, etc., may not necessarily include minority populations, nor account for intra-minority diversity. For example, African American women are not usually predisposed to osteoporosis due to their genetically dense bone structure, while white and Asian women are. The U.S. government only mandates targeting for four groups: Hispanics, Blacks, Native Americans/Native Alaskans and Asian/Pacific Islanders.4 A common assumption that minority groups hold uniform beliefs and behavioral norms5 may be incorrect. Let's take the category "Hispanic" as an example. This category varies widely demographically and geographically. It includes people from Europe, Central and South America, the Caribbean, Cuba, Mexico, and Puerto Rico. Certainly it would be foolish to think there was no variation among these people in religion, education, rural vs. urban location, income, occupation, gender roles, cohort historical events, socioeconomic class, length of time in America, level of English language skills and acculturation process. These vary significantly.
The chiropractor-patient relationship requires that personal information be disclosed in a health history. However, cultures vary on perspectives, appropriate methods of inquiry and action towards healing. Consider the following items that may affect treatment effectiveness with patients from other backgrounds. Cultural beliefs, behaviors and values provide an underlying structure for decision making during illness or injury with regards to etiology, course and timing of symptoms, reasons for becoming sick or injured, diagnosis, methods of treatment, and roles and expectations of the sick individual.6 As an example, in certain Hispanic speaking cultures, prestige among female peers emphasizes a "long-suffering sisterhood" that both fosters and glorifies the length of time a woman suffers, and that longevity places her in a female social hierarchy that denotes status.7 How effective would your treatment and care be in trying to get her to "improve"?
In some cultures, particular "folk illnesses" may require the plurality of providers, with patients seeking help from both Western medicine and traditional healers. If you are knowledgeable about the "folk illness" or have interest in learning about it, your inquiry into understanding the specifics of the illness, and nonjudgmental acceptance of the patient's beliefs, will improve the quality of the interaction with the patient. It is not so important that you accept the logic of the belief, but that you acknowledge and respect it.
Occasionally, a staff member or another family member may be asked to be an interpreter for a patient since they are bilingual. While this may be a frustratingly dependent position for a chiropractor it can serve its purpose if certain principles are kept in mind. First, it is extremely difficult for an interpreter to be neutral. Interpreters may paraphrase your question differently, thus eliciting incorrect information; they may interpret the answer for you according to their own values or judgment, and they may omit critical information the patient offers that they discount as irrelevant. In addition, in certain cultures there is a lack of linguistic equivalency,8 that is, there is no equivalent word or concept in the culture to describe what is asked. The interpreter may struggle to describe what she thinks is wanted with words and concepts that are difficult if not impossible for the patient to understand.
As general guidelines, when using interpreters, here are some suggestions: avoid using family members if possible; address the patient directly; ask the interpreter to go back to an issue where hesitation occurred; read back the answer and ask the patient about corrections or further explanations; follow-up on seemingly unconnected points that the patient offers; use short questions the interpreter can handle; allow a patient to bring their own interpreter if they feel uncomfortable about some personal information, but clarify what is needed from the interpreter. Lastly, ask the interpreter to comment afterwards about the use of specific words or emotions by the patient. This may help you understand the answers more fully.
An understanding of multicultural literacy and gerontology are critical skills for the future chiropractor. While barriers do exist in communication, the attempts of practitioners at recognition of different perspectives, acknowledgment of traditional approaches, and sincerity of understanding another's beliefs and practices will greatly advance health care for those of different cultures.
References
1. The Gerontological Society of America. (1994). Minority elders: Five goals toward building a public policy base. Washington, D.C.
2. National Council on the Aging. (1994). Mexican American aging and social policy. Perspective on Aging. Vol. 23(3). Washington, D.C.
3. Barker JC. Cultural diversity-Changing the context of medical practice. Western Journal of Medicine. September, 1992. Vol. 157., pp. 248-254.
4. Kramer BJ and Barker J (1991). Ethnic diversity in aging and aging services in the US. Journal of Cross Cultural Gerontology, 6 pp. 127-133. Netherlands: Kluwer Academic Publishers.
5. Barker JC. Cultural diversity-Changing the context of medical practice. Western Journal of Medicine. September, 1992. Vol. 157., pp. 248-254.
6. Pachter L (1994). Culture and clinical care: Folk illness beliefs and behaviors and their implications for health care delivery. JAMA, March 2, 1994. Vol. 271(9). pp. 690-694.
7. Mitchell W (1994). Women's hierarchies of age and suffering in an Andean community. Journal of Cross-Cultural Gerontology, 9 pp. 179-191. Netherlands: Kluwer Academic Publishers.
8. Putsch R (1985). Cross-cultural communication: The special case of interpreters in health care. JAMA, December 20, 1985. Vol. 254(23) pp. 3344-3348.
Barbara Zapatocky, DC, MA
Lakeside, Montana
