preparing students for culturally competent practice among ethnic minority elders

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Preparing Students forCulturally Competent PracticeAmong Ethnic Minority EldersColette V. Browne a & Noreen Mokuau aa School of Social Work, University of Hawaii ,Honolulu, HawaiiPublished online: 21 Mar 2008.

To cite this article: Colette V. Browne & Noreen Mokuau (2008) Preparing Students forCulturally Competent Practice Among Ethnic Minority Elders, Educational Gerontology,34:4, 306-327, DOI: 10.1080/03601270701834018

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PREPARING STUDENTS FOR CULTURALLY COMPETENTPRACTICE AMONG ETHNIC MINORITY ELDERS

Colette V. BrowneNoreen Mokuau

School of Social Work, University of Hawaii, Honolulu, Hawaii

The increase in the nation’s present and projected multicultural agedpopulation is both dramatic and well documented. One result of thisgrowth is a sharpened focus on racial and ethnic disparities in health,health care access, and utilization of services that impact aging adults.This paper presents work conducted by a university-community colla-borative project in gerontology. The thrust of the project is that culturalcompetency is a key ingredient for preparing social work students forwork with ethnic minority elders and for potentially improving servicesto older minority populations. A brief description of the project ispresented with highlights of the standards of cultural competencies thatwere developed for three specific populations: Japanese, Filipino, andNative Hawaiians. In general, standards organized around knowledge,values and skills consistently reflect the importance of the family systemin caring for older adults.

Nearly one of every four persons is identified as a racial=ethnic min-ority in 2000. Demographers predict that by 2050 nearly one of everytwo persons will be of ethnic minority descent (U.S. Census Bureau,2000; 2001). Inherent in the growth rate of minority populations is an

This project was funded in part by the Hawai‘i Medical Service Association Foundation, the

Hawai‘i Community Foundation, and the Hartford Foundation. The assistance of the following

project Consortium Council members and support staff is also gratefully acknowledged:

Roberta Onzuka Anderson, Susan Atkinson, Jamie Fukui Chang, Charlotte Kuwanoe, Pua Iuli,

Christine Langworthy, Leilani Lidstone, Lois Lee, John McDermott, Dr. Linda McLaughlin,

Janelle Young Ogata, Sara Wong Tompkison, Ralph Uyeoka, Heidi Wong, and Vicki Woolfard.

Thanks, too, to Dr. Rowena Fong at the University of Texas and Dr. Anita Rosen, formerly with

the Council on Social Work Education, for their ideas.

Address correspondence to Colette V. Browne, University of Hawai‘i, School of Social Work,

1800 East-West Road, Henke Hall, Honolulu, Hawai‘i 96822. E-mail: [email protected]

Educational Gerontology, 34: 306–327, 2008

Copyright # Taylor & Francis Group, LLC

ISSN: 0360-1277 print=1521-0472 online

DOI: 10.1080/03601270701834018

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increase in the older minority population. In 1999, 16% of America’solder population—persons 65 years and older—were those fromethnic minority backgrounds, in comparison with approximately13% of the overall older population (Administration on Aging,2003). There are projections of significant growth rates, as much asby three times, anticipated for minority elders between the years2010 and 2030 when the ‘‘baby boom’’ generation reaches age 65(Angel & Hogan, 2004).

The increase in minority elders argues for a greater societalresponsibility to develop and deliver services that are acceptableand utilized. This responsibility is amplified when viewed in contextof the health disparities that exist for older minority populationsin regards to health care access, utilization, and health outcomes(Federal Interagency Forum on Aging-related Statistics, 2004;Kosloski, Montgomery, & Karner, 1999; Williams, 2004). To accom-modate the changing needs of an increasingly older ethnic minoritypopulation that exhibits disparities in health, it is important to designservices that respond to diversity. One national agenda as reflectedin the Healthy People 2010 report identifies goals and strategies that‘‘bring focus to the disparities among racial and ethnic minorities . . .and the elderly . . .’’ (Brooks, 1998, p. 1). The following is a statementby Dr. Clay Simpson Jr., former Deputy Assistant Secretary forMinority Health:

We cannot improve the health of all Americans unless we bring up

those who lag behind . . . closing the gap in illness and death betweenminorities and other U.S. populations, and improving access to health

care. Services must be accessible and acceptable to all Americans,

regardless of their racial or ethnic background, language, education

level or financial situation. Cultural competence is critical (Simpson,

l998a; 1998b, pp. 1–2).

This article presents work conducted by a university-communitycollaborative project in gerontology. The project considers culturalcompetency as a key ingredient in preparing social work studentsfor work with ethnic minority elders and for potentially improvingservices to these populations. The older minority population in thiscommunity is comprised primarily of Asian Americans, NativeHawaiians, and other Pacific Islanders. Specifically, this articleexamines four areas: (a) a profile of Asian Americans and NativeHawaiians, (b) a review of the scope and parameters of culturalcompetence, (c) a brief description of a project which trains social

Students and Culturally Competent Practice 307

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work providers and graduate social work students in cultural compe-tency with older minority adults, and (d) development of practicestandards for cultural competence for older minority adults. Thelong-term intent is to evaluate such standards. There is also an intentto develop educational programs that focus on cultural competenceas a mechanism that may influence the reduction of health disparitiesfor older minority populations while providing recommendations forthe continuing education of practitioners and students in work withthese populations.

ASIAN AMERICANS, NATIVE HAWAIIANS,AND OTHER PACIFIC ISLANDERS

The U.S. census in 2000 notes that Asian Americans, NativeHawaiians, and other Pacific Islanders (AAPI) in the past decadehave had an explosive growth rate reflecting a 43% increase in popu-lation size nationwide (U.S. Census, 2003). Such growth is primarilyattributable to high rates of immigration and high birth rates. Inaddition, Asian and Pacific Islander minority elders are expected toincrease by 302%, in comparison with 77% for Whites by 2030(Administration on Aging, 2003). Asian Americans are the third lar-gest and fastest growing minority group in the U.S. (Yee-Melichar,2004).

Asian Americans and Pacific Islanders are extremely hetero-geneous in terms of their country of origin, with the largest Asiangroups being Chinese, Filipino, Japanese, Asian Indian, and Korean;the largest Pacific Islander groups are composed of Native Hawaiian,Samoan, and Chamorro=Guamanian. Because of such diversity, theU.S. census in 2000 separated Asian Americans from Native Hawai-ians and other Pacific lslanders as two distinct racial categories(Braun, Yee, Browne, & Mokuau, 2004). Emerging reports havebegun to disaggregate information, although much of what was writ-ten prior to 2000 presents combined information. The interchangingof such categorical designations in this paper reflects this.

As with other minority elders, health disparities in regards tohealth care access, utilization, and health outcomes challenge thewell-being of Asian Americans and Native Hawaiians and otherPacific lslanders. As noted by former U.S. Department of Healthand Human Services (DHHS) Secretary Tommy G. Thompson,‘‘Asian Americans, Native Hawaiians and other Pacific Islander(AAPI) communities are affected disproportionately by cardiovascu-lar disease, cancer, hepatitis B, tuberculosis and other diseases’’(Office of Minority Health, 2003, p. 7). Poor health and poor access

308 C. V. Browne and N. Mokuau

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to health care are typically associated with poverty, and for Asiansand Pacific Islanders 65 years and older, the poverty rate in 1998was 12% compared with non-Hispanic Whites in this age group at8% (Humes & McKinnon, 2000).

Utilization data are limited, but what are available suggest thatAAPI populations have low health care utilization in regards toknowledge of services, preventive care, and hospitalization rates(Federal Interagency Forum on Aging-related Statistics, 2004; Officeof Minority Health, 1999; 2000a, 2000b; Shibusawa, Ishikawa, &Maeda, 2001). Some barriers to utilization may be universal for allAmericans such as the fragmentation of health care services and ris-ing costs; however, other barriers such as linguistic differences arecommon among specific certain Asian and Pacific Islander groups,and they exacerbate utilization trends. For example, newly arrivedimmigrant groups such as the Cambodian and Hmong with limitedEnglish-speaking skills and low literacy may be less likely to seekneeded health care or adhere appropriately to treatment plans.

Common health outcomes are life expectancy and mortality rates.Life expectancy has increased dramatically and people who reach theage of 65 can expect to live into their eighties. Within the AsianAmericans, Native Hawaiians, and Pacific Islander populations thereis great diversity regarding health prospects. Those born in the Uni-ted States and established here for generations are indistinguishablefrom the general population in terms of health prospects; yet, PacificIslander populations and recent refugee groups from Southeast Asiashow health inequities (Braun, Yang, Onaka, & Horiuchi, 1996).Another indicator of health is the prevalence of chronic diseases andpoor health practices. In one study, the health of Native Hawaiianswas compared to that of the nation, and Native Hawaiians werefound to have higher rates of tobacco use, poorer nutrition, and werethe most overweight and least insured of all ethnic populations inthe state (Aiu, 2000).

In the U.S., the largest percentage of Native Hawaiian and otherPacific Islanders reside in Hawaii. Of the 1.2 million state population,approximately 25% are White, 42% are Asians, 9% are NativeHawaiian and other Pacific Islander, 3% are of other minorityextraction, and 21% are of mixed race (Pang, 2001a). The nationwideincrease in the older minority population is also observed in Hawaii,with the 65 years and over category representing 13% of the overallpopulation in 2000 (in comparison with 11% in 1990). The twofastest growing age categories in Hawaii are the 75–84 and the 85and over groups (Pang, 2001b). Among the older adult populationin Hawaii, nearly 70% are Asian American, Hawaiian, and other


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Pacific Islander (State of Hawaii, Executive Office on Aging, 2003).The requisite consequence of these demographic increases is thedesign of services that address the unique needs and circumstancesof a multiculturally diverse aging population.

SCOPE AND PARAMETERS OF CULTURAL COMPETENCE

In the last 10 years, there has been pronounced attention to theimportance of cultural competence in a nation that is increasinglymultiethnic and multicultural. A number of researchers have theo-rized that cultural competence may be viewed as a strategy in whichto combat health disparities (Brach & Fraser, 2000). An additionaland compelling justification for a cultural competence perspectivein the human services is the promotion of social justice. Social justiceis the condition in which there is a respect for human dignity, a con-cern for self-determination, and the assurance that all members ofsociety have the same basic rights and opportunities. Advocatingfor culturally competent services for older minorities is equatedwith the promotion of equitable access, the promotion of serviceutilization, and the promise of improved health for all Americans.

There are multiple definitions of cultural competence; however,they all capture several common denominators: (a) knowledge andskills that are compatible with culturally diverse peoples, (b) atti-tudes and values that honor diversity, and (c) a dual focus on theresponsibilities of the provider and institution to improve practice,policy, and research related to the culturally diverse (Fong &Furuto, 2001). Implicit in these denominators is the importance ofthe provider to continually engage in self-reflective activities thatassess his=her world views and values regarding oppression, dis-crimination, and working with the culturally diverse (Mokuau,1991). The Office of Minority Health (OMH) in the Bureau ofPrimary Health Care provides the following definitions of cultureand competence:

Culture refers to integrated patterns of human behavior that include

the language, thoughts, communications, actions, customs, beliefs,

values and institutions of racial, ethnic, religious or social groups.

Competence implies having the capacity to function effectively as

an individual and an organization within the context of the cultural

beliefs, behaviors, and needs presented by consumers and their

communities’’ (Meadows, 2000, pp. 1–2).


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In addition, the OMH has published standards for cultural andlinguistic competence that emphasizes culturally competent care(i.e., providers showing respectful care of diverse clients), languageaccess services (i.e., provide bilingual staff), and organizationalsupports (i.e., maintain demographic, cultural, and epidemiologicalprofile of the community) (Office of Minority Health, 2001).

Literature related to cultural competence with older minoritypopulations is limited (Aranda, 2006; Chadiha, Brown, & Aranda,2006; Delgado & Tennstedt, 1997; Kosloski et al., 1999; Min &Moon, 2006). This literature, reflecting a combination of conceptualand empirical research, broadly describes ways to change health andsocial services to be more culturally appropriate for minority elders.The information that is specific to Asian Americans, Native Hawaiians,and other Pacific islanders elders is even more limited, but what is avail-able is primarily descriptive of the population and suggestive of strate-gies to improve social services (Braun et al., 2004; Min & Moon, 2006;Tanjasiri, Wallace, & Shibata, 1995; Yee, 1999). A growing number ofresearchers are aiming for more evidence-based interventions that maybe effective with these populations (Braun, Mokuau, Hunt, Ka’ano’i, &Gotay, 2002; Braun, Takamura, Forman, Sasaki, & Meininger, 1995;Choi, 2001; Hikoyeda & Wallace, 2001).

PROJECT OVERVIEW

One tenet that is pervasive in the literature on health disparities andcultural competence with older adults is the need for the ongoingeducation and training of professionals in gerontology (Behrman,Mancini, Briar-Lawson, Rizzo, Baskind, & Valentine, 2006; Damron-Rodriguez & Lubben, 1994) and culturally appropriate services (Fong& Furuto, 2001; Office of Minority Health, 2003). A conference report,Out of many one: A multicultural action plan to achieve health parity(Ulmar, 2003), identifies a number of barriers to improving healthand reducing health disparities among minority populations: lack ofaccess, resources, political power, and policies. Emphasized throughoutthis report is the importance of, and institutionalization of, culturalcompetency training.

Social workers are key professionals who work with the nations’growing aging population. The education and training of social workprofessionals and students that address the unique characteristics andneeds of specific multicultural elders are important in potentiallyinfluencing the health disparities that exist. In response to this needfor education and training, this university-community model projectwas developed that emphasizes geriatric=gerontology social work


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education in Hawaii. Located within a school of social work andfunded by both local and national private foundations, this colla-borative project aimed to increase the numbers of gerontologicallytrained social workers. It was also designed to provide support forthe continuing education needs of professional social workers andstudents with emphases in diversity and cultural competence. Accord-ingly, the project has a dual focus on both the education and trainingof professionals and students and the development of curricula incultural competence (see Browne, Braun, Mokuau, & McLaughlin,2002, for a more complete description of the project).

PARTICIPANTS

As a collaborative university-community endeavor, the universityserves as the central locus for planning and implementation. Six com-munity organizations (chosen for their commitment to, and expertisein, aging) provide the infrastructure for education and trainingopportunities. Social workers from these six agencies, who are skilledpracticum instructors, compose the project’s Consortium Counciland are full collaborators in all aspects of the project. The first yearof project operations reflected a ‘‘train-the-trainer’’ approach inwhich the development of social work field instructors and otherinterested professionals in gerontology was emphasized. Continuingeducation workshops and seminars were sponsored with experts ingeriatric health care and cultural competence. Intrinsic to thesesessions was the culling of participants’ expertise. There was alsothe development of standardized competencies relevant for work withminority elders and, in particular, for select Asian Americans andPacific Islander groups. While the second year continued to providetraining opportunities for social workers, the education of graduatesocial work students at community sites was emphasized. Standar-dized learning competencies developed in the first year were incorpor-ated into the gerontology social work curriculum and implemented infield practicum at the community sites.

DEVELOPMENT OF STANDARDS FOR CULTURALCOMPETENCE

The following section highlights the activities associated with thecultural competence dimension of the project. Previous work of theproject had reemphasized the need for cultural competency educationand training by Consortium Council members. To address thisneed, one seminar and two workshops on cultural competency were


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conducted with social work field instructors and other professionalsin the field of gerontology. The goal of these sessions was to improvecare and services to culturally diverse older adults and their families.It was recognized that reaching health parity will require a number ofcommunity and policy changes, not the least of which is increasedhealth insurance coverage and greater funding for research on min-ority populations. Nevertheless, these sessions focused on issues ofspecific import that were voiced and requested by the practice com-munity participants. These issues included a focus on (a) a conceptualframework for cultural competence comprising definitions, assump-tions, and a functional imperative for practice with diverse olderpopulations, and (b) building on the standardized competenciesdeveloped earlier: the identification of specific practice standardsfor select Asian and Pacific Islander elders. Workshop facilitatorsprovided the conceptual framework, whereas the competencieswere participant-driven and developed in small and large group dis-cussions. The participants, all professional social workers, reflectedthe ethnic and racial makeup of the state.

The project had previously established the following standard forall students: ‘‘Students will be knowledgeable of and appreciate diversecultural norms, issues, and values and demonstrate this knowledge intheir assessment and interventions with culturally diverse aged popula-tions.’’ The following definition of cultural competence was adoptedby the group: ‘‘the mastery and demonstration of knowledge and skillsby organizations and providers to compassionately respond to thevalues, traditions, and lifestyle experiences of older minority personsand their families.’’ The following are assumptions supporting such adefinition: (a) there is inherent worth in all older minority persons, (b)minority elders and their families deserve conditions that honor self-determination and informed choice, (c) heterogeneity can exist betweenelders from different cultural groups as well as with elders within specificcultural groups, and (d) it is the responsibility of society to developavenues for equitable access and utilization of health care in order toreduce disparities among the increasingly aging minority population.

We continued this focus on culturally competent standardsbecause of the difficulties students appeared to be having with theconcept. Students had no trouble defining cultural competence, andthey could easily provide a few examples of culturally competent pro-grams and services. However, they struggled with whether or nottheir own practice skills were sensitive to their ethnic minority clients,especially when they worked with clients who came from differentcultural backgrounds than their own. To address these concerns,we worked with members of the consortium council to develop more


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specific practice competency areas. These would guide the formationof culturally competent strategies and techniques uniquely suited forAsian American and Pacific Islander elders. Building on the strengthsperspective that emphasizes mobilizing clients’ assets (i.e., talents,knowledge, capabilities, resources) in the service of their achievinga better quality of life (Saleebey, 1997), we stressed the need for cul-tural values and practices that reflect cultural strengths to be utilizedin assessment and intervention. Also acknowledged is the resiliencyin the human condition, indicating that a role for social workers isto assist Asian American and Pacific Islander elders and their familiesto continue growth even through the challenges and tribulationsof crises and change associated with being a minority member ofsociety. It further acknowledges that this resiliency, in large part,can come from a source of cultural identity, cultural values, andcultural practices.

CULTURAL COMPETENCIES FOR ASIAN AMERICANAND NATIVE HAWAIIAN ELDERS: KNOWLEDGE,VALUES AND SKILLS

Japanese, Native Hawaiians, and Filipinos are groups with increas-ingly larger segments of older adults who experience disparities inhealth access, utilization, and health outcomes (Braun et al., 2004;Office of Minority Health, 2003; Tanjasiri, Wallace, & Shibata,1995; Yee-Melichar, 2004). Nonetheless, it must be emphasized thatgreat disparities exist among these populations. There are more than24 Asian American groups, each with its own language, culturalvalues, cohort influences, acculturation patterns, and history (Min &Moon, 2006). Although certain values may be shared, many vari-ables—gender, socioeconomic status (SES), nativity, to name afew—lead to numerous variations among these groups. There arealso critical differences between ‘‘full-blooded’’ Native Hawaiiansand those who are ‘‘part Hawaiian’’ (Braun et al., 2004). Standardsfor cultural competence for these three groups must, therefore, beused as guidelines rather than prescriptive strategies.

Organized around information on knowledge, values, and skills,these standards have practice as their focus. Each of these standardsrelate to the acquisition of knowledge essential to understandingdifferent ethnic and cultural groups, the delineation of values thatare central to ethnic and cultural group identification, and the trans-position of this knowledge and these values into skills that can beapplied by human service workers (see Table 1). This kind of culturalinformation provides the social worker with a context from which


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to assess the minority elder’s and his or her family’s degree of sub-scription to, and identification with, cultural values and behaviorsand, thereby, guide prescriptions for interventions. While all threeareas are deemed important for improving care for culturally diverseAsian American and Pacific Islander elders, the available literaturehas tended to focus on the ‘‘knowledge base’’ and, to some extent,cultural values; but the literature has paid less attention to specificskills and techniques. The discussion that follows highlights all areaswith the intent of drawing linkages between knowledge and valueswith skills. Although we acknowledge that understanding culturalvalues alone will not by itself reduce health disparities, the literaturedoes suggest an association between programs that reflect the culturalvalues of the community they serve and utilization of services (Braunet al., 1995, Kuo & Torres-Gil, 2001). Understanding and respectingcultural values does not ignore the importance of addressing keyinstitutional and sociostructural barriers to service utilization (Min& Moon, 2006).

Japanese Elders

Among those in the Asian alone census category of those 65 years ofage and over, 20.8% are Japanese (Ruggles et al., 2004). Immigratingin the 1880 s, Japanese are one of the earliest Asian groups to arrivein the United States (Kitano, 1993). Approximately two-thirds ofJapanese Americans today are U.S.-born, and many are of third(sansei), fourth (yonsei), and fifth (gosei) generations (Braun &Browne, 1998). Despite their longevity in the United States, accul-turation continues to be an important area of examination becauseof the heterogeneity of Japanese Americans and the variations intheir subscription to traditional values. Assessing the degree of accul-turation expressed by individuals and their families is complex andcan only be fully understood after reviewing multiple factors in afamily’s background (i.e., socioeconomic status, education, healthstatus, strengths, psychosocial stressors, and presenting problems)(Yee-Melichar, 2004).

While the degree of subscription to traditional cultural valuesmay vary for Japanese Americans, common values continue toemphasize the importance of interpersonal relationships. Specificvalues of reciprocity, respect, filial piety (oyakoko), and notbringing shame to one’s family (haji), maintain the importanceof all social relationships—in particular, family relationships. Inaddition, caregiving of elders in many Japanese American families


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is contoured by values related to gender. Similar to other ethnicgroups, the majority of caregivers in Japanese culture are women,primarily wives and daughters. This is reinforced in someJapanese families that uphold values of male dominance (taisho)in which the men are viewed as the leaders=representatives ofthe family system and the women are seen as the nurturers forthe family.

In line with such standards on knowledge and values, severalskills were identified for improving care to Japanese elders. Theimportance of family relationships and gender roles suggests thatproviders identify and work with a family representative on issuesof eldercare. The family representative is the individual who hasthe authority to make decisions on caring for the older adultand who can convene the family for important discussions. Thisfamily representative may appear to be a male, possibly an olderson, but the family member who actually provides the day-to-day care will probably be a daughter or daughter-in-law. Herinclusion in all family meetings is very important. A significantaspect of working with Japanese-American families is the provisionof outreach services in which the worker visits the home setting todiscuss with the family ways to address eldercare and arrangesdirect services to support caregivers in the home (i.e., bathingservices for elderly, respite care). In working with families, workersalso want to utilize questions or comments that accentuatestrengths such as a family’s willingness to seek help for caregivingor the existence of a family network to provide care. Workers alsoneed to engage in dialogue that demonstrates an understanding ofthe interdependence (amae) of family members in caring for theirelderly. Communication patterns within some Japanese Americanfamilies may be indirect and subtle (Fugita, Ito, Abe, & Takeuchi,1991), and the worker will need to verify messages through mul-tiple sources. Individualistic decision-making styles that character-ize many Western families may not be congruent with Japanesefamilies, leaving discomfort around discussions about advancedirectives, end-of-life care planning, and rules of confidentiality(Min & Moon, 2006). Furthermore, feelings of shame associatedwith having a family member suffer from Alzheimer’s disease ordepression are common (Braun & Browne, 1998) and call for moreintensive caregiver education and support. The provision of specificresources such as brochures listing support groups for caregiversor identifying sources of financial assistance are always valuable.For new immigrant groups, bilingual staff and language-specificinformation is required.


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Filipino Elders

Filipino elderly also compose nearly 21% of the Asian-alone categoryof those 65 years of age and over (U.S. Census Bureau, 2002). Andsimilar to the Japanese, immigration history provides the necessarycontext for understanding Filipinos’ acculturation experiences inthe United States. Beginning in 1906, Filipino laborers, predomi-nantly male, were recruited to work in the agricultural industry(Anderson, Coller, & Pestano, 1984). One result of the highlyunbalanced sex ratio in which there were as many as five males toone female in the 1930s was the restricted development of families(Okamura & Agbayani, 1991; Yee-Melichar, 2004). Without childrenand families, early groups of male immigrants were often isolated, didnot have the impetus for interactions across the broader community(i.e., school systems), and did not sustain traditions and celebrationsthat would have fostered family cohesion. More recent waves ofimmigration, post-1965, differ from the earlier group in that theyhave greater educational and professional qualifications, and theyare joining families already in the United States. Filipino-Americansare comprised of three main groups: former plantation and farmlaborers, the American-born, and post-1965 immigrants. Today, theyare diverse in their level of acculturation, socioeconomic status, edu-cational position, health status, and religious beliefs (Okamura &Agbayani, 1991).

Post-1965 Filipino immigrants are credited with revitalizingFilipino culture in regards to renewing the practice of the language,norms, and social activities of the culture. Several values that are coreto Filipino culture emphasize the importance of relationships and thefamily, a respect for others, hard work, filial piety, and cooperation.For Filipinos, the family is the primary source of identity, and it is thefocus of one’s primary duty and commitment. Valuing relationshipsand, in particular, family relationships, is intertwined with the valueof hard work: members may hold multiple jobs in order to secure thewell-being and advancement of the family unit. Filial piety can reflectthe obligation or the debt of gratitude that exists within relationships(utang na loob).

Gratitude is also related to the value of cooperation. Cooperationis synonymous with harmony, the avoidance of conflict, and thedesire to comply with family members on important issues.Cooperation with human service providers on prescribed interven-tions and treatments is also important (Braun & Browne, 1998).A final value that is significant in Filipino culture pertains to reli-giousness and faith. Filipino faith (bahala na) is associated with


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the belief that God is in control of all things and contributes to astrength to persevere during crises and hard times (Okamura &Agbayani, 1991).

Information on the background and values of Filipino Americansis relevant to enhancing services to Filipino elders. As with JapaneseAmericans, linkage with the family is important and working with afamily representative can facilitate collective decisions on services forthe elder family member. An interpreter or cultural guide may benecessary if the family representative is not fluent in the English lan-guage. Several examples illustrate the relevance of cultural values inthe human services. An appreciation of a cultural value such as hardwork can be demonstrated with the use of flexible scheduling ofappointments should family members hold multiple jobs. The valueof cooperation among Filipino family members may manifest inverbal statements and, sometimes, behaviors of agreement and com-pliance that may not fully reflect the desires and wishes of the family.Thus, the worker may need to verify the messages of communicationby either checking with multiple sources—including other familymembers or human service providers—or engaging in open-endeddiscussions in which the family collaborates on the goals and inter-ventions to support the elderly family member. Providing tangibleservices that support the familial care of the aging parent or grand-parent (i.e., transportation services) and opportunities for familymembers to learn new ways to interact with their elder family memberwill, in the end, demonstrate an appreciation of cultural values andbehaviors.

Native Hawaiian Elders

Pacific Islanders refer to those individuals whose origins are from theindigenous or original people of Hawaii, Guam, Samoa, or otherPacific Islands (Browne & Richardson, 2006). Native Hawaiiansare indigenous to the islands known as Hawaii. As such, their histori-cal relationship to the United States is not based on immigrationexperiences but on changes imposed by American society on a nativehost culture. In 1893, the United States participated in an illegaloverthrow of the Hawaiian monarchy (Apology Resolution, 1993).A territory since 1898 and a state since 1959, Hawaii was initiallysought by the United States because of its strategic militarylocation in the Pacific and rich geographical resources. Influencesfrom American culture altered the nature of Native Hawaiiansociety such that traditional institutions of religion, education, poli-tics and economics were replaced with Western democratic systems


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(Daws, 1968). In 1993, the U.S. issued a formal apology to the nativepeople of Hawaii for its role in the overthrow of the Kingdom ofHawaii in 1893, and it made a commitment to facilitate reconciliationefforts (Apology Resolution, 1993). Part of its reconciliation efforts isto explore sovereign nation status for Native Hawaiians.

Historical changes wrought by the United States as well as bymany other Asian, Pacific Islander and European groups that havemigrated to Hawaii have contributed to a Native Hawaiian identitythat is influenced by multiple cultural influences. While there is greatdiversity reflected in the ethnic=cultural identification among NativeHawaiians, several core values can be delineated. As with Japaneseand Filipinos, all of the values revolve around and accentuate theimportance of relationships. Relationships include linkages with thefamily, community, land, and a spiritual realm in a manner thatemphasizes harmony (lokahi) or interconnectedness and reciprocity(Pukui, Haertig, Lee, & McDermott, 1979). For example, the NativeHawaiian is a steward who cares for the land and who also benefitsfrom the harvest from the land. In a similar manner, the elders carefor and teach younger generations who are then responsible for pro-viding for their welfare as they grow older. Inherent in these values ofharmony and reciprocity is the value of ‘‘aloha.’’ Aloha refers to mul-tiple values including love, affection, compassion, charity, and arespect and regard for all things (Pukui & Elbert, 1981). These corevalues reflect a cosmography in which spirituality is recognized as adefining feature of Native Hawaiian culture (Kame‘eleihiwa, 1992).The expression of spirituality may vary for Native Hawaiians, butit generally connotes beliefs and patterns of behavior that emphasizeconnections in relationships (Mokuau, Lukela, Obra, & Voeller,1997).

Understanding cultural values has implications for services for theaged. With the emphasis on relationships and connections, theworker may want to develop a relationship with the family thatdemonstrates a willingness to establish ‘‘binders:’’ the disclosure ofpersonal information. (i.e., schools attended) that illustrates sharedexperiences and, ideally, builds trust. In this regard, it is also impor-tant to use language that reflects a ‘‘talk story’’ approach. Achievinga talk story means communication is rendered in an informal andopen manner and there is a greater emphasis on the broader contextof life rather than just the issues confronting the elderly family mem-ber (Braun et al., 2004). This type of relationship can be furtherenhanced if cultural practices are incorporated into family meetings.For example, in some Native Hawaiian families, the recognition ofspiritual importance may be observed with prayers, typically


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given by family elders, at the beginning and end of sessions. Despitevarying degrees of acculturation, many older Native Hawaiiansmaintain leadership functions within their families, churches, andcommunities. Nonetheless, such strengths do not negate the negativeinfluences of a lifetime of poverty, discrimination, and poor healththat persist in some members of these communities (Braun et al.,2004).

PROJECT EVALUATION

To date, the training and the preparation of students in culturalcompetence have yielded tentative positive results. We say so becausethe path toward cultural competence is, in our view, a developmentaland unfinished journey. The evaluative efforts of our curricularfocused on whether or not gerontology students had increased theirknowledge and were better prepared for the delivery of culturallycompetent practice. We sought to answer this question in three ways.First, student knowledge and skills were evaluated by gathering datafrom the 24 students over a 2-year period. Students completed a self-reported pretest on the first day of class and an identical posttest onthe last day of class nine months later. The questionnaire included 39items tapping mastery of content and skills in aging. In questionsspecific to cultural competence, 100% of students in the first cohortand 95% of students in the second cohort felt competent interveningwith Asian American and Pacific Islander elders and believed thattheir style of practice was culturally competent with these popula-tions. Second, we met with practicum instructors and found thatthe renewed focus on cultural competence in the curriculum increasedtheir own focus with student preparation in this area. Finally, classcourse work validated student preparation with a final case presen-tation-format assignment. The assignment specifically focused onan ethnic minority elder and the use of culturally competent practices.At this time, faculty are reviewing a number of measures of culturalcompetence as additional methods for student evaluation (Office ofMinority Health, 2003). Moreover, faculty are discussing areas forfurther study that may help to quantify potential outcomes (results)of culturally competent practice, i.e., increased client satisfaction withservices, increased utilization of services, and improved health status(Brach & Fraser, 2000). We acknowledge this evaluation is only astart. We will continue our efforts to evaluate such competencieswhile broadening our knowledge of different populations andaddressing those community-based and policy interventions thatcan and do promote the well-being of elders.


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SUMMARY

This article describes the need for and the development of beginningstandards for preparing students for culturally competent practicewith older minority populations. In particular, standards for culturalcompetency were developed for three Asian American and PacificIslander groups: Japanese, Filipinos, and Native Hawaiians. Thediversity in these populations suggests that these efforts to ‘‘define’’and ‘‘refine’’ cultural competence is a continuing need in gerontologi-cal education (Min & Moon, 2004). One common and dominanttheme reflected in the standards for all three groups relates to theinvolvement of the family in providing care and support to olderadults. Standards on knowledge, values, and skills consistently reflectthe importance of the family system. Such standards provide thebroad context for guiding cultural assessments and interventionsthat are appropriate for specific populations. While recognizing themultiple barriers to good health that exist, the potential of culturalcompetency to improve services and reduce health disparities amongminority elders can be further supported. Such support shouldinclude the preparation of students in cultural competency and thedevelopment and revisions of standards that enhance care for specificpopulations.

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preparing students for culturally competent practice among ethnic minority elders

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