Cultural and Gender Diversity in Health

General Overview

After decades of research in gerontology, researchers have come to a clear consensus that older adults are characterized by their heterogeneity rather than their homogeneity. As people age, their life experiences contribute to their uniqueness physically, psychologically and culturally. This diversity makes it inappropriate to talk about “the aged” as a single social category, without stereotypical oversimplification (Fry, 1990). Cultural and ethnic variations in health have been known for some time, and strict medical or biological models have not been able to explain more than a fraction of variations in health. The remainder must be attributed, at least in part, to environmental, societal, and cultural factors (Zola, 1979).

Studying the health of the elderly in a multicultural context is timely because of the rapid demographic changes in the Canadian society. While the overall population is aging, it is also becoming more culturally diverse. Additionally, the increasing heterogeneity of Canada’s population is largely a result of changing immigration patterns, which have been changing over the last century. Prior to the 1960s, immigrants were primarily European, but by the late 1980s, substantial numbers came from South Asia, Southeast Asia, Central and South America, Africa and China (Masi, Mensah & McLeod, 1993), with the Asian population projected to be the fastest growing among cultural minorities. The number of European immigrants dropped from 687,780 in 1961, to 172,060 in 1996 (an almost 75% decrease), whereas Asian immigrants increased from 32,580 in 1961, to 592,710 in 1996, a near 20 fold increase (Statistics Canada, 2003). Although ethnicity is a factor in the health and aging patterns of all ethnic groups, because of the prevalence and the impact of Asian immigration, this article focuses on the range of health challenges in this group, particularly among elderly Asian women population – one of the fastest growing segments.

Variations in Health

Variations in health are often the result of complex interactions among biological, psychological, social and cultural factors. Health cannot be defined without reference to history or culture, or in absolute terms, because the perception, interpretation, and expression of health and illness are culturally based (Danesi, 1993). The experience and manifestation of pain is a good example. In one study, fewer Chinese, Japanese and Filipinos made demands on health care staff, cried or requested medication than did the Caucasians and Hawaiians in response to pain (Lister, 1977), and it was suggested that special attention be paid to the management of pain for these patients.

Physical Health and Morbidity Rate

Epidemiological evidence shows clear patterns of cross-cultural variations in health problems that are explained, at least in part, by underlying biological differences. A higher prevalence for certain genetically inherited traits are present in some cultural groups (e.g. sickle cell anemia in black communities, thalassaemia among the Mediterranean area [Masi, 1993] ), and Southeast Asian people are more prone to lactose intolerance. Further, height, weight, and rate of metabolism are different in Southeast Asians than other groups and these affect the medications’ pharmacodynamics (the mechanism of drug action based on physiological, chemical and molecular observation) and pharmacokinetics (the study of drug absorption, distribution and excretion in the body), and subsequently should be considered during medication prescription (see, for example, Morioka-Douglas and Yeo, 1990).

Different populations may also have dissimilar morbidity rates. Certain cancers (i.e., ear, nose and throat, nasopharynx, esophagus, liver, and stomach), hepatitis, tuberculosis, intestinal parasites, and renal stones are more prevalent in the Chinese population (Lai and Yue, 1990), while Filipino women over 50 have a 65.2% prevalence rate of hypertension compared with 46.8% in white American women (Rubenstein, Calkins & Greenfield, 1989). Jenkins & Kagawa-Singer (1994) reported that cancer incidence rate of Chinese, Japanese, and Filipinos, for all anatomic sites combined, is lower than that of whites.

The incidence of breast cancer in Chinese-American women is substantially higher than in Chinese women in Asia, with similar trends with colon and rectal cancers. A higher prevalence of diabetes exists among Japanese-Americans than among both the white population and the native population in Japan. The prevalence rate of multi-infarct dementia and osteoporosis may be higher for Japanese Americans than white Americans (Lum, 1995).

It is evident that cancer and other disease occurrences in immigrants suggest important information on the roles of heredity and environment in the development of cancer. Epidemiological findings stress the importance of environmental factors in cancer etiology, but they do not provide a means of identifying the risk or health determinants on their own. These determinants may include factors like air pollution and solar radiation, which may have an immediate effect. Others determinants like changes in occupation, socioeconomic status, diet and personal habits, may happen more gradually. Jenkins & Kagawa-Singer (1994) argue that the majority of cancers are believed to be caused in part by behavioral, cultural, and dietary factors, suggesting that at least some cancers are preventable through the modification of these factors. Definitive conclusions can not be made based on these data because of factors such as selective migration, which could affect equivalence of groups, and the comparability of data from the country of origin with that of host, as it may be compromised by differences in medical care, for example.

Mental Health

There are a number of mental health issues associated with aging, with depression and suicide being two of the more significant. A common explanation for mood disturbances in later life is that aging is accompanied by role losses through widowhood and retirement, as well as by losses of meaningful relationships through the death of significant others. These stressors clearly affect women more than men. Members of cultural minorities also experience additional stressful events such as migration, discrimination, cultural and language changes, and they may have fewer resources for dealing with stress (Markides and Mindel, 1987).

Asian Americans have been targets of severe prejudice and discrimination for some time. Ujimoto et al (1994) explained that both Chinese and Korean women are “captive immigrants” which means that they came to Canada because of a felt responsibility towards their family. Their role in the Canadian society is often limited to childcare and household chores. This greatly reduces their opportunity to becoming integrated into the new society and compounds their sense of anxiety and depression. Kuo (1984) found higher rates of depression among Asians compared to whites, and Ying (1988) found levels of depressive symptoms were higher in the Chinese than whites. Lum (1995) reported that, for elderly 65 to 74 years old, the suicide rate is three times higher for Chinese-American women than white women; in those 75-80 years old, it is seven times higher. The suicide rate of Chinese in San Francisco between 1952 and 1968 was 27.9 per 100,000 population compared with 10.0 for the nation. The suicide rate among Japanese-American women aged 75 and older and among Issei men 85 years and older are significantly higher than non-Asian rates in the US. However, Markides and Mindel (1987) found no evidence suggesting that Asian Americans experience greater rates of mental illness.

Mortality and Life Expectancy

The crude and age-adjusted death rates of Asian Americans in comparison with other American ethnic groups showed that Japanese Americans have the lowest death rate, followed by Chinese Americans, American Indians and Alaskan Natives, Whites, and finally Blacks (Markides & Mindel, 1987). Other studies showed similar findings (Gardner, 1994). Trovato (1994) reported the first mortality and life expectancy data between native born and foreign born people in Canada. It was argued that the better survivorship of immigrants in their earlier years might be attributed to a healthier lifestyle, the immigration selection process and mandatory health screening.

However, among the elderly, the foreign born had worse survival patterns, perhaps because of the accumulated stresses, trauma during the working years, and psychological problems. It was suggested that the selection process is most intensive within the working ages, but reduces its “protection” effect in old age. It may also be the case that the reversal of mortality rates is a reflection of fewer restrictions in health standards at the time when immigrants presently aged 70 years and older immigrated.

As for causes of death, Asian American death rates were lowest in comparison with white rates for accidents, pulmonary disease, liver diseases, atherosclerosis, cancer, cerebrovascular disease, pneumonia and influenza, and diabetes (Gardner, 1994). In term of leading causes of death (heart disease, cancer, cerebrovascular disease and accident), Chinese, Japanese, Filipino and White have identical rankings. Chinese males experience excess mortality of cancers of oral cavity, pharynx, nasopharynx, esophagus, stomach, and liver; Chinese females experience excess cancer mortality at the same sites, with the exception of esophagus and the addition of cervix uteri. Japanese males experience excess deaths from cancer of the nasopharynx, stomach, liver and gallbladder; Japanese females, from cancers of the stomach and liver. Filipino males experience excess mortality from cancers of the nasopharynx and liver; Filipino females, from cancer of the nasopharynx (Jenkins & Kagawa-Singer, 1994). These differences may be attributed to both health behaviors and health beliefs (Jenkins & Kagawa-Singer, 1994).

Although women and men die of some of the same diseases, women have advantages over men with regard to mortality for most major diseases such as cardiovascular, respiratory, and chronic liver disease . The advantage may be explained by differences in lifestyle (e.g. smoking, drinking, driving, and violent behavior) or to biological differences. Strong genderspecific behavioral taboos exist, which lead many women from ethnic minorities to shun some negative lifestyles (see, for example, CIHI 2003). However, some unhealthy behaviors increase with acculturation, as evidenced by rising lung cancer due to smoking among women.

In other cases, certain cultures engage in inappropriate health behaviors, such as inappropriate mammography practices. For example, Hispanic, Native American, Asian and African American women are least likely to report or engage in mammography (Anderson & May, 1995; Calle, Flanders, Thun & Martin; Burns et al., 1996; Caplan, Wells, & Haynes, 1992; Fox, Siu & Stein, 1994; Rimer; 1993; Tang, Solomon & McCracken, 2000) . Other evidence of disparities in screening between cultures also exists with cervical screening (CIHI 2003).

With regards to life expectancy at birth, Trovato (1994) found that immigrant males can expect to live 2.7 years longer than Canadian born males. For females, this difference is 1.7 years longer for immigrant women.

Health Beliefs and Health Seeking /Management Behaviors

Concepts about health and illness, as well as care and treatment, are an integral part of ethnic identity that can be traced to cultural beliefs. Women traditionally retain the role of the transmission of such health concepts, with older women acting as repositories for traditional beliefs and practices. Understanding culturally based beliefs of health and illness is critical in effective care of elderly women from cultural minorities (Hopper, 1993). Health beliefs across the globe may be categorized as the following: those concerning “nature” (natural causation); those related to the individual (the “self”); and those associated with forces beyond ordinary human control (supernatural), such as religion, spirits and magic (Masi, 1988bc).

Using Asians as an example, the belief systems of Asians have a common heritage tracing back to the traditional Chinese culture. The belief relates to a state of equilibrium among individual, society, and the cosmic forces of the universe (Lum, 1995). The concepts of “yin” and “yang”, and “hot” and “cold” are common in most Asian groups. Health requires “yin” and “yang” to be in dynamic equilibrium. Illness, on the other hand, represents a disequilibrium of the forces. Chinese people usually think of themselves as ill only when symptoms are obvious. Since the primary goal is to get rid of these symptoms, the concepts of chronic illness, where symptoms persist for a long time with no absolute cure, and of prevention are not clearly understood and appreciated (Lai and Yue, 1990).

Also, as immediate results are expected from medications, prolonged Western treatment regimes are often viewed with skepticism, which leads to premature discontinuation of Western prescriptions (Lai & Yue, 1990). Many Asians also believe that the Western medicines are too strong and may cause side effects not evident in traditional medicines. They may alter the dosage or treatment period for fear of undesired side effects (Lai & Yue, 1990; Okabe, Takahashi, and Richardson, 1990; Dinh, Ganesan, and Waxler-Morrison, 1990). Evans and Cunningham (1996), and Montbriand (1995) reported that at times of stress and severe illness, patients often retreat to their cultural roots, and rely on earlylearned ideas and beliefs for treatment. At the same time, they might turn to these traditional approaches because they find Western medicine ineffective (Hamilton, 1996). Hamilton (1996) also pointed out that most Western physicians are trained in basic sciences like biochemistry and anatomy, which assume that human bodies are the same and standardized approaches are taken. Consequently, cultural and social factors are neglected and “the person” is lost in this approach. Patients in turn are reluctant to communicate their alternate treatment methods as evident in Montbriand’s study (1993) that 75% of cancer patients did not tell the doctors that they are using an alternate therapy.

Self-medication is a common practice for Chinese and other Asian ethnic groups. When Western culture meets traditional ethnic cultural, the treatment approaches to illness is not constant. Many Chinese people use both Western and traditional Chinese medicines to treat an illness. Singh and Kinsey (1993) pointed out that 65% of the Philippine elderly use home remedies compared with only 9% their white counterpart. Driedger and Chappell (1987) reported that self care, rather than professional care, makes up the majority of personal health care. Most elderly persons, especially ethnic elderly, treat themselves before seeking formal services. Even after seeking formal care, many forms of self care continue. Chappell (1993) also reported that between 75% to 85% of all personal care received by seniors come from the informal network. Family and friends are the first resort for care to elders. They provide the vast majority of that care, and it is the lack of informal support, not ill health, that is the main predictor of long-term institutionalization (Chappell, 1993).

Service Utilization Patterns

A review of service utilization by Damron-Rodriguez, Wallace, & Kingston (1994) found that there are clear ethnic differences in utilization rates for many health care services. For example, Liu and Yu (1985) found that Asian-American elders visit physicians half as often as white Americans (see also Boult & Boult, 1995), while Singh and Kinsey (1993) reported that the Philippine elderly spent more days in hospital compared with their white counterparts. Yeo (1992) noted that despite greater evidence of disability, ethnic elders are significantly under represented in nursing homes compared with whites. Additionally, significantly fewer Asian-American elders used social services than Latino and black elders (Damron-Rodriguez et al., 1994).

Among the very few Canadian studies, Majumdar, Browne, and Roberts (1995) reported that although ethnic groups make up 24% of the population in the Hamilton-Wentworth region, only 11.7% of those are receiving formal health care. This could be related to many perceived service barriers such as lack of knowledge regarding available resources, cost, lack of transportation, fear of contact with unfamiliar cultures and language, and that service use could lead to loss of independence (Evans and Cunningham, 1996). Language barriers could lead to poor health provider and patient communication, which subsequently could affect diagnosis, treatment, and adherence.

Emergency room care is one of the few services where ethnic elders have a relatively high rate of inappropriate use compared with the general population. Liu & Yu (1985) reported that Asian/Pacific Americans have the highest rate of use of emergency room services. Inappropriate emergency room use may be an indicator of problems with access to other types of health care. Maxwell, Bancej and Snider (2001) reported that for females, being born in Asia was a significant predictor of never having had a mammogram. Women born in Asia were significantly less likely than those born elsewhere to have had a mammogram. Choudhry, Srivastava and Fitch (1998) also reported that 47% of South Asian women age 40 and over had never had a mammogram compared to 43.6% of Canadian women age 49- 50, and 20.9% age 50-69 (Maxwell et al., 2001). Ibrahim et al (2003) examined whether physician recommendations for cardiac revascularization vary according to patient race and found that African American patients were less likely than Whites to be recommended for revascularization at the public hospital.

This brief overview of service utilization of ethnic elders showed ethnic differences in service use patterns across most geriatric services. Among immigrant women, their prior experience with immigration quotas and immigrant status may negatively affect their attitude towards the use of formal health services in older age (Hopper, 1993). To reduce the implied inequities, it is important that practitioners, researchers, and policy makers understand the variety of barriers to service utilization.

Concluding Remarks

An aging, multicultural society must deal with many issues for health care delivery (Majumdar et al. 1995). As the Canadian population is increasingly becoming multicultural and heterogeneous, the interaction between culturally related health issues and the modern medical health care system will continue to gain importance. One must recognize and understand these health issues to avoid any “cultural misunderstandings” (Ujimoto, 1988). Cross-cultural research at the national level which takes into account population size and location is needed in order to understand the effects of culture and their relationship to older people’s health (Kramer & Barker, 1991). The lack of longitudinal national surveys, insufficient data to examine specific ethnic groups, and a shortage of international comparisons are the primary barriers to performing comparative studies between ethnic groups.

There have been reports that many health care providers believe their own professional health care practices are superior (Fong, 1985); hence, they overlook other culturally important alternative approaches. Other studies continue to indicate that women of an ethnic origin are less likely to engage in positive preventive health behaviours. These studies also demonstrated the importance of cultural beliefs and attitudes about disease risks and prevention as barriers to preventative care (Maxwell et al., 2001; Bottorff et al., 1998; Choudhry et al., 1998). Considerable evidence suggests that variations in health and alternative health care use exists, Canadian health care providers therefore need to find ways to meet the needs of these individuals. It should be realized that treatment is most effective when the patient, family and health care providers work together to incorporate the patient’s perception and beliefs into the care plan.