Social Determinants of Health & Cultural Humility PDF

Social Determinants of Health & Cultural Humility JULIA VAN LIEW, PH.D. DEPARTMENT OF BEHAVIORAL MEDICINE, MEDICAL HUMANITIES, & BIOETHICS DES MOINES UNIVERSITY Select slides originally developed by: Jeritt Tucker, Ph.D. Lecture Objectives 2 1. Consider ways aging is experienced differently across d...

Social Determinants of Health & Cultural Humility JULIA VAN LIEW, PH.D. DEPARTMENT OF BEHAVIORAL MEDICINE, MEDICAL HUMANITIES, & BIOETHICS DES MOINES UNIVERSITY Select slides originally developed by: Jeritt Tucker, Ph.D. Lecture Objectives 2 1. Consider ways aging is experienced differently across diverse, intersectional cultural identities 2. Recognize social determinants of health and health disparities facing older adults 3. Understand approaches for incorporating cultural humility in clinical encounters with older adults 3 Today’s Older Adults Older Adults in the U.S. u 4 Living longer, staying in communities longer, and living alone u Among age 80+, more than 75% live in their own homes u Of these, approximately 60% live alone u Generations (and age cohorts within generations) each face unique historical circumstances u In 2020, 1st cohort of “Baby Boomers” reached age 65 u More comfortable with technology u Have experienced both economic prosperity & challenge u More diverse family structures & cultural backgrounds The Growing Diversity of those 65+ in US 350% 300% 328% 285% 250% 200% 150% 100% 147% 131% 50% 0% African American Asian American Indian 1990-2030 Projected Increase, US Census Bureau, 2000 Latino 5 Adapted from Debra Allwardt, MSW & Debra Anderson, PhD; UNO School of Social Work Sociocultural Identity: the ADDRESSING model u Age and generational influence u Developmental or other Disability u Religious/spiritual orientation u Ethnicity & Race u Socioeconomic status u Sexual orientation u Indigenous heritage u National origin u Gender (Hays, 2016; Bitzel, 2013) Aging in the LGBTQ Community https://www.youtube.com/watch?v=lkPJxQorieo&fe ature=emb_logo 7 Aging in the LGBTQ Community u By 2030, 2-6 million LGBTQ+ adults age 65+ u u Homosexuality as mental disorder (removed 1973), AIDS epidemic, Don’t Ask Don’t Tell (1993), legalization of same-sex marriage by US Supreme Court (2015) Aging alone: 2x more likely to live alone, less likely to have children, may have strained relationships with family of origin, loss of partners and friends u u “invisible,” “hidden” Generation Silent History of discrimination, stigmatization, victimization, with few legal protections across most of their lives u u 8 Lateral caregiving from peers/“chosen family” Shifting identities across lifespan u LGB: In the closetàoutà”back in the closet” due to stigma in long-term care, home health u Transgender adults over age 65: 97% transitioned at age 55 or later See Gen Silent trailer at end of lecture for more 9 World Health Organization Social Determinants of Health Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and qualityof-life outcomes and risks. -healthypeople.gov More information at https://www.cdc.gov/socialdeterminants/index.htm Social Determinants of Health in Older Adults 11 Socioeconomic status (SES) Social connection Education/Health Literacy Stress Geographic region: urban, rural Food Transportation Physical environment: exposures, safety, neighborhood 12 Health Disparities in Older Adults Health Disparities 13 Health Disparity: A higher burden of illness, injury, disability, or mortality experienced by one population group relative to another group. u This burden is and not the result of natural causes. u Disparities align with patterns of social exclusion, blocked opportunities, or unequal returns on equal effort. Healthy People 2020; Wallace, 2012 Disparities in Older Adults 14 u Existing identity-based disparities (e.g., by gender, sexual orientation, religion, and ethnicity/race) tend to be exacerbated in old age u Aspects of identity intersect with social determinants of health and factors such as ageism, disenfranchisement, discrimination history, resilience Select examples: u SES u Social connection: loneliness and isolation u Race and ethnicity u Geographic region SES u SES reflects a combination of educational, occupational, and income factors u SES differences are the largest cause of health disparities United States, 2021: The gap in life expectancy between the richest 1% and poorest 1% of individuals was 15.51 years. u u Health disparities between rich and poor are increasing Older adults in U.S.: nearly 15% live below the poverty line u IA poverty rate for 65+: 8.4%; median household income $48,171 u SES affects physical, mental, and functional health outcomes u SES is often intertwined with other health determinants Schwandt et al (2022) SES 16 The impact of one’s SES accumulates over the lifespan SES operates on a gradient from greater to less health With age, survival gap between incomes increase (Chetty et al., 2016) Social Connection u u Older adults: Socioemotional selectivity theory u Strategically choose social networks to maximize social and emotional gains u # of social contacts decreases and become more selective about who to spend time with— familiar social partners Social networks begin getting smaller but deeper when people are in their 30s and 40s – pruning 17 Social Connection u Older adults spend over half of waking hours alone (on average, ~7 hrs/day) u u 44.4% of Iowans 65+ live alone Loneliness: “subjective” experience of lacking relationships u u 18 43% of US adults > age 60 Social isolation: “objective” measure of connections u 1 in 5 older adults u At risk: women, lower SES, LGBTQ, marginalized populations Pew Research Center, 2019 Social Connection 19 Harvard Study of Adult* Development (1938-2013) 1. Social connection is a better predictor of well-being than SES, IQ, or genetic loading 2. Loneliness is toxic: 45% increased risk of mortality for lonely vs. not lonely older adults 3. Quality of relationships matters more than quantity *male See TED Talk for more: https://www.ted.com/talks/robert_waldinger_what_makes_a_good_life_lessons_from_the_longest_study_on_happiness?language=en Social Connection Holt-Lunstad et al., 2017 20 Social Connection u Most conclusively linked to blood pressure, cortisol, and systemic inflammation u These biological outcomes are linked to increased morbidity and mortality and higher healthcare costs u 21 45% increased risk of death Holt-Lunstad et al. (2015); Perissinotto et al. (2012); Uchino et al. (2018) Social Connection Protective effects from social support networks: u Family systems u Friends u Religious communities u Community programs (e.g., Senior Centers) u Residential communities (e.g., assisted living) u Health care team: in-home supports u Informal supports: employees at frequently visited businesses 22 Race and Ethnicity u 23 Chronic illness has earlier age of onset for marginalized groups u premature aging u Accelerated brain aging, with disparities in small vessel cerebrovascular disease beginning in midlife u Underreported health problems u Delay in receiving health-related treatments u Often limited representation in research u Systemic effects of chronically elevated stress u Worse mental health: contributory factors may include higher rates of poverty, history of discrimination, healthcare access Commonwealth Fund, 2001; Turney et al (2022) 24 Farrell et al. (2022). Exploring the intersection of structural racism and ageism in healthcare. Journal of the American Geriatrics Society. Race and Ethnicity Examples: u Higher mortality & chronic health conditions among Native American/Alaskan Native & African American populations u Mortality rates are lower in Latinx, yet disability rates are higher u Mortality and disability rates are lower for Asian Americans u African American adults in US have higher rates of diabetes and hypertension u African American adults are almost twice as likely as White adults to develop Alzheimer’s disease 25 Geographic Region o o Increasingly, rural areas have a higher proportion of older adults o Among US counties with > 20% population 65+, 85% are rural o 1 in 5 older adults live in rural areas in US, many concentrated in states where more than 50% of their older populations are in rural areas Rural areas have more adverse health outcomes; often have: o Reduced access to medical care, support services to age in place o Limited resources in critical access centers o E.g., poorer COVID-19 and myocardial infarction outcomes Huang et al. (2021); Sunil et al. (2021); US Census, USDA 27 Working with older adults across cultures CULTURAL HUMILITY Culturally responsive care 28 u Rather than using knowledge about groups to make generalizations… u ALWAYS assess individual preferences and contextual factors u Be aware of your own multifaceted cultural worldview (personal and professional) u Right to know u Secularism u Prolongation of life u Superiority of biomedicine in “conquering” death u Aspects of your sociocultural identity (i.e., ADDRESSING model) History of Health Care Experiences u u 29 Marginalized groups’ historical experiences in health care often influence individuals’ current comfort accessing health care: u Experience with racism, ableism, discrimination, and mistreatment (including in health care) u Experiences challenging trust of healthcare providers Despite being generation/s removed from historical events, you will likely still experience their impact. Cultural Identity Assessment u Illness experience of the individual and family u Family and interpersonal dynamics u Patient-identified salient aspects of identity u Stigmatized dimensions of patient’s identity (current AND historical/generational; inside AND outside of health care) u Communication style: direct vs. indirect u Barriers to health engagement: insight, health literacy, trust, stimulus value of health care setting u Patient’s resiliencies, strengths 30 Important Beliefs & Practices to Consider u Respect u Family Communication and DecisionMaking u End-of-Life Care 31 Respect for Elders Across Cultures 32 u Whether older adults live alone or with family varies drastically across the world u Aging is often associated with appreciation of wisdom and respect for elders u Tips: u Generally, assume formality through use of title & surname until corrected u Address eldest family member first, avoid interrupting u Ask for preferences in how they would like to be addressed u Allow informality to develop naturally as rapport is established Family Communication and Decision-Making u Assess patient and family preferences for degree of patient vs. family involvement in health care communication and decision-making u Right “not to know,” desire to protect older family members from end-of-life prognosis u u Can challenge providers’ value of patient autonomy u Ex: The “right to not know” Tips u Ask patient’s preferences in private u Consider your own professional values and assumptions 33 End-of-Life Care 34 u Anticipatory decision-making about end-of-life care is historically a North American concept u Standard advance directive forms fail to capture individual preferences for values and beliefs at end of life Willingness to use hospice & palliative care, advance directives, removal of life support u u u Can be perceived as not fulfilling values of filial piety, “duty” u Can be perceived as showing lack of faith in God/Allah or challenging religious will u Low faith in healthcare due to experiences of mistreatment can lead to reduced trust at end-of-life Tips: u Thoroughly discuss what terms and forms do and do not mean, repeatedly assess family and patient beliefs, assess patient beliefs in private u Emphasize hospice meant to assist, not replace, family--involve family in cares u Emphasize that choices can be updated u Involve religious leaders or hospital chaplain Take Homes 35 1. Older adults are far from homogenous, with the population continuing to diversify 2. Health disparities that exist across sociocultural groups are compounded in old age 3. Social connection and SES are primary social determinants of health in older age 4. To best treat diverse older adults’ needs, you must consider how your own assumptions and cultural values inform your beliefs Selected References 36 Berk, Laura E. "Development through the lifespan, 4/E." Pearson, Boston, MA, ISBN: 0-205-49125-1 24 (2007): 25. Charles ST, Carstensen LL. Social and Emotional Aging. Ann Rev Psychol. 2009;61:383-409. Golden, R. (2016). Addressing Older Adults’ Social Determinants of Health. Rusch University Medical Center. Hill, R. & Smith, D.J. (2015). Positive Aging: At the Crossroads of Positive Psychology & Geriatric Medicine. Joint Center for Housing Studies of Harvard University. 2014. Housing America’s Older Adults. President & Fellows of Harvard College. Mutchler, J. E., Shih, Y. C., Lyu, J., Bruce, E. A., & Gottlieb, A. (2015). The elder economic security standard index™: A new indicator for evaluating economic security in later life. Social Indicators Research, 120(1), 97-116. NCMHA and Coalition to End Social Isolation & Loneliness. (2020, May 20). Social isolation & loneliness among older Americans during COVID-19: Evidence, policy, and advocacy. Web event. The Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates from April 2001 to November 2002. Press Release, March 6, 2002. Simon NM. Treating complicated grief. JAMA. 2013;310(4):416-423. Wallace, S.P. (2019). Equity and Social Determinants of Health Among Older Adults. American Society on Aging. Wang M, Shi S. Psychological Research of Retirement. Ann Rev Psychol. 2014;65:209-33. World Health Organization (WHO). 2007. Global Age-Friendly Cities. Geneva, Switzerland: WHO. Aging in the LGBTQ Community: Gen Silent https://www.youtube.com/watch?v=fV3O8qz6Y5g 37