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