Health Disparities in Late Adulthood
May L. Wykle, PhD, RN, FAAN, FGSADean and Florence Cellar Professor
Cleveland, Ohio
University of Washington School of Nursing February 21, 2007
Program Outline
• Vulnerable Populations
• Overview of an Aging Society
• Nursing Leadership
• Self Care in Minority and Ethnic Populations
• Factors That Influence Our Health
• Health Literacy
• Conclusions
“The cumulative effects of poverty, segregation, discrimination, racism, official neglect, and exclusionary immigration laws, experienced over a lifetime, sometimes for generations, have left their mark on the older members of minority groups now living in the United States. Generally poorer physical health and greater disability, compared to that of White persons of the same age and gender, give mute evidence of disadvantages endured.”
Amasa B. Ford
Vulnerable Populations
• Elderly Persons• Minorities
Cultural AttitudesHealth Beliefs
• Persons with Chronic Diseases
• Caregivers
Increased Life Expectancy
Source: Centers for Disease Control and Prevention (http://www.cdc.gov/)
Increased Life Expectancy
Projections
• From 1990-2020 the elderly population is projected to increase to 54 million persons
• Beginning in 2011 the first members of the Baby-Boom will reach age 65
• In 2020, about 1 in 6 Americans will be elderly
• The population of persons 85+ will increase from 4.3 million in 1990 to over 7 million by 2020
Ration of Elderly to Working-Age Population
020406080
100
1990
2010
2030
2050
ElderlyYouth
Source: U.S. Bureau of the Census
Population Increase among Ethnic Minority Elderly 65+: 1990 to 2020
150%
358%
300%
102%
58%
American Indian, Eskimo and Aleut
Asian and Pacific Islander
Hispanic
Black
White
Nursing Leadership:Challenging Unequal Health Care
Among Older Adults
80 Percent of Older Adults Living at Home Suffer from at Least One Chronic Disease
Home Care
Percent with Difficulty and Receiving Help with Selected Activities by Age
Selected Chronic Health Conditions Causing Limitation of Activity Among Working-Age Adults by Age: 2000-2002
Mental Illness
Fractures/joint injury
Lung
Diabetes
Heart/other circulatory
Arthritis/other musculoskeletal
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High Risks for Minority Elders
Heart diseaseStroke
High blood pressureDiabetesCancer
Cirrhosis of the liver
African Americans
Heart diseaseMalignant neoplasm
DiabetesChronic liver disease
CirrhosisPneumonia / influenza
American Indians/Alaskan Natives
High blood pressureDiabetes
Hispanics
Heart diseaseHigh blood pressure
DiabetesCancer
Pacific Islanders/Asian Americans
Source: Burggraf, 2000
Co-Morbidity
• Chronic Illness Effects over 100 million people Over 65 may have 5-6 80% of older adults needing care are cared
for in the home Care often provided by family members for
both ADL and IADL
Co-Morbidity (cont.)
• Caregiving Process beginning with identification of chronic health
problem and the need for someone to provide care
• Family Caregiving Unpaid informal care of an individual in need of illness
care Often a misnomer, in many cases only one individual
family member assumes the major caregiving role
Co-Morbidity (cont.)
• Family Caregiving (continued) Most informal caregiving is associated with older
adults, but family caregiving spans all ages due to chronic illness
More focus on elders due to shift from acute care to chronic care
Problems exist for families• Family structures are changing• Often parents and children share adulthood
Co-Morbidity (cont.)
• Family Caregiving (continued) Pool of family caregivers shrinking—families are
smaller and live at great distances In addition, caregivers work and with delayed
childbearing have school aged children Caregiving can be burdensome and have negative
outcomes---with support can be positive and last longer
Other Societal Trends
• Smaller Families• More Working Women• Adult Children Living at Greater Distances• Changing Marital Structures (Divorces and
Remarriage)
Caregiving as a Career Transition in Caregiving over Time
Caregiving Is Often a Continuous Long-Term Investment
Stage 1: Role AcquisitionRecognition of needAssumption of responsibilities
Stage 2: Role EnactmentPerforming Caregiving tasksAdopting caregiver concerns
Stage 3: Role DisengagementBereavement Social readjustment
Positive Impacts of Family Caregiving
• Strengthen family ties
• Fulfill sense of duty
• Personal growth
• Appreciation from others
• Reciprocity
• Finding meaning
• Prevent placement
Negative Impacts of Family Caregiving
• Exhaustion• Sense of inadequacy• Limited social life• Financial strain• Poor health• Family conflicts• Guilt-NH placement• Depression• Burden
Outcomes
POSITIVE:
• Personal gain
• Satisfaction
NEGATIVE:
• Depression
• Emotional distress
• Poor physical health
Minority Caregivers
1. Often Work Full Time2. Low Decision Making Status Jobs - Can’t Take
Time Off3. Arrange for Care During Work Hours4. No Time for Support Groups
Minority Elders
Minority Elders• “Minorities have poorer health and higher death rates
than whites at all age levels until very old age, when genetics are presumed to dominate longevity outcomes” (Wykle & Kaskel, 1991)
• Minority elders (over 65) include:• Blacks
• Hispanics
• Asians and Pacific Islanders
• American Indians
• Particularly affected by the process of aging, which inflicts psychosocial changes that influence health experiences and perception of control of everyday lives
Health Care for Minority Elders
• Minority elders face jeopardy situations in: Age Racial and/or ethnic discrimination Income and poverty Gender (for women) Dependence on government programs Other barriers (language, culture, access to
health care services, etc.)
• Minority elder women have higher poverty rate (12.8%) than their male counterparts (7.2%)
• Only 7% of practicing physicians are African American, Hispanic, or American/Alaskan Native
Factors Influencing Minority Health Status and Use of Health Care
3. Reliance on kinship networks
4. Preference for traditional medicines and faith healing
5. Reliance on religious beliefs over health care system
6. Lack of understanding and denial of illness symptoms
7. Unwillingness to adopt the “sick role”
1. Experience of racial segregation
2. Suspicion of dominant culture and its institutions
(Edmonds, 1990)
Factors Influencing Minority Health Status and Use of Health Care (cont.)
8. Inadequate health care information
9. Unrealistic perception of health status
10. Poverty leading to inadequate health insurance, transportation, and nutrition
11. Insensitivity of health care planners and policy makers
12. Inadequate number of trustworthy health care practitioners
13. Perceived or real unequal treatment in health care system
(Edmonds, 1990)
Double Jeopardy
• Faced by African Americans as they reach elder status
• Indicates “the accumulation of specific disadvantages, due to old age on the one hand and minority status on the other” and is based on “greater stresses, including a long history of racism, endured by this group” (Kahana et.al., 1999)
• Alternatively, cultural traditions of African American elders may provide valuable coping skills
Successful Aging
• Stress-Theory-Based Model of Successful Aging• Defined as proactive, preventive, and corrective
adaptations by elders to enhance their well-being despite stressful life events
• Social factors such as race and culture have influence on successful aging
(B. Kahana & E. Kahana, 1998)
• Major stressors include illness, social losses, and person-environment incongruence
Factors That Influence Health
Factors That Influence Health
• Anger
• Ability to cope
• Behavior
• Stress Failing health key stressor
in elderly difficulties of daily activities bring stress
•Environment
•Education
Factors That Influence Health
• Attitudes/Self-ConceptJudgment of self
“Elders who believe their health is good are less likely to interpret their symptoms as threatening and have more confidence in their own resilience.” (Davis & Wykle, 1993)
Factors That Influence Health
• Feelings of hopelessness/loss of control
• Family/Spouse Situation Importance of relationships linked to
meaning and purpose in life among elderly
“Meaningful relationships are important in self-care education because ‘Meaning in life is ultimately linked to health’”
Factors Associated with the Self Care of Home-Dwelling Elderly
Self-Care ofHome Dwelling
Elderly
Life Satisfaction
Functional Capacity Self-Esteem
Health Literacy:
The Hidden Key to Wellbeing and Quality of Life
Defining What We Mean
• Definitions of health literacy: The ability to read, understand, and act
on health care information “The degree to which individuals have
the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Healthy People 2010)
• Improves quality of life of African Americans
• Ensures survival of families and communities
Functional Literacy: Definition and Scope
• The ability to read, write, speak, and compute and solve problems at levels of proficiency necessary to: function on the job and in societyachieve one’s goalsdevelop one’s knowledge and potential
Source: National Literacy Act of 1991
Health Literacy and African Americans
• Health literacy is key factor to minorities’ well-being and quality of life
• Health information improvements that would benefit African Americans: Be more clear Include culturally sensitive text Use simple visuals Be more relevant Pay special attention to health/social needs of
elders
Literacy Related Tasks for Disease Management
• Give information for assessments and diagnosis
• Monitor and describe signs and symptoms• Measure and calibrate medicine• Schedule and time medicines and other
treatments• Recognize and describe changes• Understand disease, symptoms, and chronicity• Understand and negotiate treatment options
A National Concern
• Health materials must: Be clear Display accurate information Be easy to read
• In the U.S.: 1 in 5 adults read at 5th grade level 2 in 5 older adults read between 1st and 5th
grades Average adult reads at 8th grade level
Health Literacy Findings to Date
• Most health materials have been assessed at above high school level
• A variety of health related outcomes are linked to patients’ reading skills Knowledge Screening Following regimen Hospitalization Glucose measures in diabetes patients
Importance of Minority Health Literacy to Survival of the Family
• Health literacy is essential to family survival Family caregivers with low literacy skills tend to:
• Make more errors with medication• Fail to comply with medication treatments and regimens• Delay help seeking behaviors
• Miss opportunities for self-empowerment and decision-making in the healthcare system
Patients with low literacy skills are:• At higher risk for hospitalization• Less able to manage their self-care
when at home
Example: Asthma & Health Literacy Among African Americans
• Some important findings:*
Limited knowledge leads to low self-care Those with low skills in using inhalers were at more risk
for health complications Patients with low literacy had more ER visits Poor knowledge leads to higher use of health care
services Low literacy patients without asthma symptoms did not
know to continue seeking care Low literacy patients had low self-esteem Low quality of life led to higher mortality/morbidity Health disparities were experienced in this group
* SOURCE: Williams, Baker, Honig, Lee, & Nowlan, 1998
Conclusions
• More research is needed to determine how self-care practices differ between and among different ethnic/cultural groups
• Social, economic and policy reform are critical due to the dramatic growth in of the elder population
Address barriers that prevent vulnerable populations from access to formal health care
The promotion of self-care practices will be an important solution in the overall provision of health care services