Select one published article from any of the University online databases listed under the Library tab, or from the Recommended Websites listed for this course, addressing the current issue of the aging adult. The aging population has issues such as being a parenting grandparent, aging, and levels of care, what constitutes successful aging, non-traditional retirement, healthcare costs, financial exploitation of a vulnerable adult, and substance abuse in aging. Examine how human service professionals are addressing these issues with the aging population in the article. Write a paper that includes a brief summary of the article, the service delivery explored in the article, information about how human service professionals are addressing the issues identified in the article, and your analysis of the recommendations for service delivery as outlined in the article. Your paper should be 1,500 words in length and be based on an article from 2011 to present. You are required to use APA (6th ed.) formatting for in-text citations and references.
Collins, W. L. (2011). Culturally Competent Practices: Working with Older African Americans in Rural Communities. Social Work & Christianity, 38(2), 201–217. Retrieved from http://search.ebscohost.com.proxy-library.ashford.edu/login.aspx?direct=true&db=a9h&AN=63899136&site=eds-live&scope=site
Culturally Competent Practices: Working with Older African Americans in Rural Communities Wanda Lott Collins This article discusses why culturally competent skills are important for agency administrators, human service providers, and social work practitioners to work effectively with African American elders living in rural communities. Education in cultural competence can enable practitioners to adopt culturally sensitive practices and solutions to clients’ problems and avoid stereotypes and biases that can undermine their efforts in addressing the specific needs of rural African American elders. Several culturally competent practices, including acknowledging spirituality and religion, are shared from the author’s professional experience as a service provider. As the U. S. population ages, the Bureau of the Census data indicates the face of aging is changing dramatically (National Institute on Aging, 2006). The older population (65 +) is projected to double from 36 million in 2003 to 72 million in 2030. In 2003, there were 35.9 million people age 65 and older (12 percent of the total population). Ages 65 to 74 represented 18.3 million of the older population, 12.9 million were aged 75 to 84, and 4.7 million were 85 and older (U.S. Census, 2005). According to the U. S. Census Bureau projections, a substantial increase in the number of older people will occur when the Baby Boom generation (people born between 1946 and 1964) begins to turn 65 in PRACTICE NOTES Social Work & Christianity, Vol. 38, No. 2 (2011), 201-217 Journal of the North American Association of Christians in Social Work 202 SOCIAL WORK & CHRISTIANITY 2011. Likewise, the 85 and older age group is projected to grow rapidly after 2030, when the Baby Boomers begin to move into this age group (U. S. Census, 2005). By 2050, those aged 85 and older are projected to double—from 4.7 million in 2003 to 9.6 million in 2030—and to double again to 20.9 million in 2050 (U.S. Census , 2005). The 65 and over population is not only increasing in size, but also in diversity. In 2003, non-Hispanic Whites accounted for nearly 83 percent of the 65 and over population, Blacks represented 8 percent, Hispanics, 6 percent, and Asians, 3 percent. It is projected by 2050 that the elderly population (over age 65), will be represented by 61 percent non-Hispanic Whites, almost 18 percent Hispanics, 8 percent Asians, and 11 percent Blacks (U.S. Administration on Aging, 2009; U. S. Census, 2005). Furthermore, at least one-fifth of the growing older population lives in rural areas, presenting the social work profession with a variety of challenges (Coburn & Bolda, 2001). In general, compared to urban elders, rural elders are more likely to have lower incomes, face disparities in health-care services, and have less access to transportation and social services providers (Coburn & Bolda, 2001; NACRHHS Report, 2004; Rogers, 2000). When these rural older adults are then also African American, they are especially burdened. Income. Many elderly individuals are faced with the reality that a lifetime of work does not guarantee retirement years free of poverty. The National Institute on Aging (2006), revealed that 3.5 percent of older, non-Hispanic, White, married-couple families lived in poverty, compared with 10.7 percent of older, non-Hispanic, White men living alone and 16.9 percent of older, non-Hispanic, White women living alone. In comparison, among older Blacks, 12.4 percent of those in married-couple families lived in poverty. The poverty data covering 2003 showed that 26.4 percent of older Black men living alone lived in poverty and 40.3 percent of older Black women who lived alone lived in poverty. African American elders are therefore in a disadvantaged position in terms of poverty rates (National Institute on Aging, 2006). The Administration on Aging (2009) indicates that in 2007, households containing families headed by Black persons aged 65+ reported a median income of $32,025. The comparable figure for all older households was $41,851. The median personal income for Black men was $16,074 and $11,578 for Black women. The comparable figures for all elderly were $24,323 for men and $14,021 for women. The poverty rate in 2007 for Black elderly (65 and older) was 23%, which was more 203 than twice the rate for all elderly (9.7%). Other findings show elderly rural residents are also less likely to have sources of retirement income, financial savings, ownership of supplemental insurance policies, and other assets (Rogers, 2000; Coburn & Bolda, 2001). Health care. The increasing number of older persons and their need for health care services is another area of concern. Only about 10 percent of physicians practice in rural America, despite the fact 204 SOCIAL WORK & CHRISTIANITY Overall, social and economic barriers are likely to impact the general well-being of elderly African Americans living in rural areas and impede their access to goods, services, and information. Therefore, as the population of elders grows, it is important for professional helpers to provide appropriate services and gain an understanding about rural adults who could be different from themselves relative to service needs, culture, class or ethnic background, religion, or racial experience. Education in cultural competence can enable practitioners to adopt sensitive practices and solutions to clients’ problems and avoid stereotypes and biases that can undermine their efforts in addressing the specific needs of rural African American elders. Why Cultural Competence is Important The National Association of Social Workers (2001) operationally defined cultural competency as a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals and enable the system, agency, or professionals to work effectively in cross-cultural situations (p. 11). Cultural competence is a multifaceted construct that embodies cultural and specific knowledge of minority communities, general skills, challenges regarding cultural assumptions, and the development of approaches to learning that cross cultures (Eiser & Ellis, 2007). Practitioner cultural competence in rural areas involves recognition and acceptance of the role of natural helpers (e.g., friends, and immediate and extended family) and informal care networks (e.g., churches, lay persons, and community), and communicating with minority elders in culturally and linguistically appropriate ways. It also includes understanding culturally specific behaviors and worldviews. Learning and relearning is an important component of competency awareness. Workers are encouraged to expand their cultural knowledge and expertise by understanding the impact of culture on behavior, attitudes, and values, the help seeking behaviors of diverse clients groups, the specific cultural customs, the role of language, speech patterns, and communication styles of various client groups in the communities served, and the informal helping networks that can be used on behalf of diverse client groups (NASW, 2001; Min, 2005). 205 Case Illustration The following case was observed as the author visited the home of an elderly family friend of thirty plus years. Due to the close relationship, I was invited to stay during his visit with the social worker. His contact with the practitioner illustrates the value of cultural competency awareness in working with an eighty-one year old, southern, African American widower with diabetes. His diabetic history included erratic, as well as escalating, blood sugar levels. A twenty-four year old Caucasian, rural-based social worker scheduled a first time home visit to monitor the patient’s adherence to a dietary and health maintenance plan established by his physician, an endocrinologist (diabetic specialist). The patient schedules periodic visits with his local physician but because the physician has a high patient load he usually has long waits for check-ups related to high blood pressure, respiratory disease, and the A1C blood test. The A1C is an important test that provides the doctor with an average of the patient’s blood glucose levels over a period of three months. When the blood glucose levels stay too high, individuals can suffer from kidney damage, eye problems (diabetic retinopathy), nerve damage, (diabetic neuropathy) or sores and skin infection that can lead to amputations (American Diabetes Association, 2009). However, the results of the A1C test are generally not available to the doctor’s patient for four days since blood tests are outsourced to a lab in another county. The endocrinologist specializes in advances in diabetic care and has a registered dietitian and a certified diabetes educator on his clinical staff. The endocrinologist’s office is thirty miles from the patient’s rural home. Often, the patient’s extended family or a retired neighbor will drive him to his medical appointments. Because he has several chronic diseases, the patient stretches his meager monthly income to pay for gas or gives courtesy tips to those who accompany him to his appointments. Due to the distance and the small monthly income from social security, he schedules his appointments with the endocrinologist six to seven months apart. Upon arrival at the client’s home, the social worker saw the elderly gentleman at his carport and greeted him by saying, “Hi Hon.” Mr. John Sams (client’s named changed) acknowledged her greeting with a low grunt and a look of displeasure. The elderly client was in the process of replacing windshield wipers on his Chevy truck and intermittently hummed excerpts of a church hymn. As he walked around the vehicle, WORKING WITH OLDER AFRICAN AMERICANS IN RURAL COMMUNITIES 206 SOCIAL WORK & CHRISTIANITY occupying himself with the task at hand, he talked to the social worker about topics ranging from the weather to his thoughts about a younger grandson. As the elderly client worked and talked he mentioned his grandson had called a few days earlier. He said to the worker, “I had to give that boy some advice and let him know that ‘It’s a poor frog that doesn’t have his own lily pad.’” Wishing to get to the reason for the visit, the worker interrupted the client and proceeded to inquire about his diabetes. As the worker gathered health information she corrected the client to use the term “diabetes” each time he talked about his condition as “a little touch of sugar.” As this practitioner observed, the worker seemed rushed for time and appeared to dismiss the client’s rambling conversation about his grandson. Before concluding her visit, the worker complimented the client on the changes he had made in reducing his intake of southern fried chicken and expressed satisfaction that he enjoyed cooking turnip greens from his small backyard garden. Unfortunately, the worker did not comprehend that her lack of cultural exposure to southern traditions meant she was encouraging the client to continue consuming pork products with unhealthy fats and significant sodium intake based on his traditional way of preparing turnip greens. As the social worker departed, Mr. Sams’ retired neighbor sought her out as she was entering her vehicle. He proceeded to inform the worker that Mr. Sams’ grandson had lost several jobs and was seeking to move in with his grandfather because he had been evicted twice. The neighbor further revealed to the worker that the grandson also abused alcohol. Confidentiality was not an issue in this case. Mr. Sams had given written permission for his neighbor to assist him with various medical and social service matters due to his limited education. Culturally Competent Practices for Service Providers This section will focus on culturally sensitive practices that can enhance cultural competency for social workers, service providers, mental health care professionals, and practitioners in providing a range of services to rural African American elders in rural communities. Individuals or agencies must be willing to grasp certain aspects of the experiences of older rural African Americans. This population may have faced barriers in receiving services, limited interactions or biases from service providers who lacked knowledge of the client’s culture, chal- 207 lenges related to poverty and lack of access, or difficulty with service professionals’ styles of communication. Furthermore, considering the differences that can arise from ethnicity, culture, class, religion, and individual experiences, a lack of proficiency in cultural competency can create difficulties in the helping process for both clients and providers. The following culturally competent practices are gleaned from my professional experience as a service provider. 1. Address elders by their surname. Addressing older adults formally (i.e., using Mrs./Miss/Ms. /Mr.), unless they invite the practitioner to call them by their first name, is a way to show respect toward any older adult. However, modes of address for African American families have historical, cultural, and psychological significance (Collins & Moore, 2004). The use of surnames by African Americans when referencing one another, particularly the elderly, has its roots in a history of being marginalized and purposefully humiliated by members of the dominant culture. The perpetuation of language and protocols that addressed Blacks by their first names as a sign of disrespect created feelings of invisibility against a backdrop of racism and discrimination (Parker, 2002; Collins & Moore, 2004). Using the last name and an appropriate title such as Mr., Ms., Rev., Dr., or a title combined with the use of the first name, such as Ms. Catherine or Mr. James, is an empowering gesture that signifies respect and value for the humanity of the individual (Collins, & Moore, 2004). Whether the professional uses the first, last, nickname, or name with title should be evaluated in relation to the impact of establishing a positive professional relationship with the service recipient. In the case illustration, greeting the client with the very informal term of endearment, “hon” instead of Mr. Sams probably minimized the social worker’s ability to connect with him in a meaningful fashion. Perhaps the practitioner casually addressed Mr. Sams as “hon” to show a sense of warmth or friendliness. However, since she had no previous contact with the elderly man, failing to initially address him formally could hamper her ability to traverse challenging cultural barriers in building trust and a positive working relationship. Worker lack of attention to this gesture of respect may lead the client to have negative perceptions about the professional helper and trigger unwillingness to enter into a helping relationship. WORKING WITH OLDER AFRICAN AMERICANS IN RURAL COMMUNITIES 208 SOCIAL WORK & CHRISTIANITY 2. Understand that some older adults speak in stories, one-liners, idioms, or parables. Knowing the language and culture of minority elders is critical for the success of communicating with older African Americans. Storytelling, one-liners, idioms, and speaking in parables have been around long before television and technology. In the African American culture, these tools served slave communities with a conduit to share values, beliefs, and other forms of expression that they were denied. Additionally, speaking in parables, telling fables, or sharing stories served as a therapeutic function of psychic health (Pershing, 1996). In explaining the use of stories by rural elderly African Americans to teach the next generation of social workers and practitioners, LaNey (2003) states, “Stories allow the listener or reader to have a better understanding of what services might be needed and accepted and to identify strengths upon which services, programs, and policies can be hinged” (p.1). The African American community continues to utilize these mechanisms, in various forms, as a way to share culture and traditions from generation to generation. Embedded in these one-liners or stories are moral lessons or philosophies reflecting worldviews about life and living. Listen to how some elderly women in my family speak in one-liners. An elderly grandmother was noted for saying, “Common sense ain’t so common.” Doesn’t everybody have common sense? Her use of this clever remark was usually when people with degrees would demonstrate poor decision making skills. Implied in this jibe was the idea that educated people should consider sensible and levelheaded solutions to day-to-day problems. Another grandmother’s way of expressing the same concept was to state, “The school owes that person a refund.” She, too, meant that being educated was not an indication that the person would balance “book learning” with practical knowledge during problem solving. To communicate self-worth and appreciation for individual gifts and abilities, Grandmother Frankie would casually remark, “You don’t have to put somebody else’s light out in order for yours to shine.” However, her dual purpose was to also discourage gossiping and disparaging other people’s accomplishments. Another quip was “A leopard’s spots won’t change.” Rather than engage in sermonic diatribe regarding the people involved in our lives, Grandmother Frankie’s aphorism taught loved ones how to guard against being deceived about a person’s integrity and trustworthiness. In the case illustration, Mr. Sams mentioned, “a frog needs its own lily pad.” In other words, each person should have his 209 or her own place to live. Had the worker understood Mr. Sam’s earlier colloquial statement she would have most likely been privy to some important family information. Older African Americans can often use various forms of communication to encapsulate their views about many issues or concerns in their lives. Talking to a New York Times reporter, Brenda Dixon-Gottschild, a dance professor at Temple University, had this to say: ‘’Stories are such an important aspect of so much African-American expression. AfricanAmericans never tell stories in a linear way, but as associative narratives, an often bracing collage of ideas, moods and dramatic expression” (Murphy, 2000). Speaking to the wide array of communication forms used, Tom McArthur (1998) writes that African American vernacular English (AAVE) used by a majority of U.S. citizens of Black African background consists of a range of socially stratified urban and rural dialects. The variation is pervasive, occurring with phonology, intonation, morphology, syntax, African-American slang, idioms, and ritualized verbal confrontations. While some phrases or forms of speech are used on a regular basis, others have fallen out of use (Carpenter, 2009; Wolfram, 2003). These communication practices can vary from region to region and across socioeconomic status. Carpenter (2009) conducted an analysis on a series of 100 tape-recorded oral history interviews that were conducted between 1994 and 1997 in Birmingham, Memphis, and New Orleans with individuals born before 1942. These data were used for intergenerational analyses, cross-gender analyses, analyses of socioeconomic factors and overall interpretation between different sites. The study indicated that individuals with greater prestige jobs, such as educators and professionals, generally showed the lowest rates of AAVE. Those with the lowest socioeconomic positions and with the least social prestige, blue-collar work and service industries, showed the highest rates of vernacular English use across the Southern cities. The report suggests that patterns of grammatical complexity can occur over a life time (Carpenter, 2009). Inevitably, older rural African Americans have shared expressions, idioms, and colloquial speech with those from whom it is learned and with those to whom it is taught, most likely incorporating habit and spoken rituals central to their lives. The social worker corrected Mr. Sams to use the term “diabetes” each time he talked about his condition as “a little touch of sugar.” Appearing irritated, the client became quieter and superficially answered the worker’s remaining questions. Her interruptions and lack of skill WORKING WITH OLDER AFRICAN AMERICANS IN RURAL COMMUNITIES 210 SOCIAL WORK & CHRISTIANITY in asking follow-up questions likely curtailed the senior gentleman’s desire to share full information about how he was managing his diabetes. The client never bothered to mention that he routinely used a variety of home remedies and homeopathic medicines for his “touch of sugar” and other physical ailments. Were the home remedies interfering with his prescribed medication and contributing to the spikes in his blood sugar? A conversation that more deeply explored how the client incorporated the traditional medicine and his knowledge of folk medicine could have yielded invaluable cultural knowledge and necessary information to the worker. She could have gained insight to share later with the endocrinologist regarding why the client might have experienced difficulty in managing this metabolic disorder. Or, she could have discovered ways to incorporate and complement his efforts from a strengths perspective. Because the interview was conducted in the correct and formal language of the worker, it hampered her ability to effectively communicate with the client. Therefore, it is incumbent on the practitioner to take the time to understand the meaning behind phrases older individuals may use and to avoid judging language that may appear difficult to understand. What might be correct speech or expressions in professional circles or urban settings may be expressed differently in rural areas. Workers who are culturally unaware can easily misinterpret difference as deviance or as a deficiency, and fail to recognize the strengths coming from practices that individuals adopt (Marsiglia & Kulis, 2009). Understanding African American stories, one-liners, idioms, or parables is essential for understanding elements of the culture. A display of cultural competence during the social worker’s visit would have involved actively listening for important information about challenges and strengths that were embedded in the older man’s story about the grandson and his use of informal language. Remembering to show tact and respect will create a strong anchor point for engaging in gerontological service delivery. 3. Form partnerships with community caregivers. As the social worker in the vignette departed from Mr. Sams’ home she was approached by a neighbor who was knowledgeable about Mr. Sams’ well-being and his personal affairs. Seemingly, the worker’s schedule precluded her from talking with the neighbor. Considering the grandson’s lack of employment and his misuse of alcohol, an assessment of these factors could assist the worker in determining whether the 211 elderly client was possibly at risk for financial exploitation or physical abuse. As referenced earlier, the social worker did not violate worker client confidentiality. It is not known if she had future contact with the neighbor or Mr. Sams for follow-up information. Mr. Sams relies on this neighbor to transport him to medical appointments and he is also someone that Mr. Sams trusts as a confidant. The elderly neighbor volunteers to drive Mr. Sams’ truck because Mr. Sams has vision problems. Often, it is expensive for Mr. Sams to keep his old vehicle in a safe drivable condition due to his meager monthly income. Culturally competent practices that engage clients and their neighbors in organizing free or low-cost transportation services can provide an acceptable alternative to empowering older adults to gain access to quality care that is sensitive to their economic and health needs (North Carolina Rural Health Research and Policy Analysis Center, 2001). Such an approach helps to minimize overtaxing the goodwill of neighbors, whose schedules are sometimes inconvenient or unworkable for those needing transportation, and who sometimes expect “gas fare.” What is critical is that there are great disparities in the physical and mental health status, service availability, service access, and socioeconomic factors between elderly African Americans and elderly Whites. These disparities are even more evident with older African Americans in rural communities (Rasheed & Rasheed, 2003; Schoenberg, 2000, 1997). Rural elderly could benefit from a variety of community supports that include people from their own community in partnership with professionals who live outside their localities and environment. Cultural competence is enhanced among workers when they understand that community caregivers, such as Mr. Sams’ neighbor, have visibility and credibility in their social networks, understand the cultural contexts, and can comprehend their community norms. This level of awareness can aid practitioners toward finding ways to engage clients and their neighbors with each other, thereby empowering older adults to successfully utilize formal (e.g., social workers or other professional helpers) and informal supports (e.g., family, friends, or neighbors) to their advantage. 4. Understand that spirituality and religion are strong sources of emotional support. Historically, the Black church has looked upon African American families as having resources, wisdom, knowledge, and skills (Collins, 2008, 2006). It has been the one institution that serves as a commuWORKING WITH OLDER AFRICAN AMERICANS IN RURAL COMMUNITIES 212 SOCIAL WORK & CHRISTIANITY nity icon and offers a physical and spiritual foundation of hope and strength (Lincoln & Mamiya, 1999). The importance of religion in the lives of many African Americans persists today, making the church an important source of support in the African American community and a moral adhesive that holds the African American community together and fosters strong socialization networks (Boddie, 2002). One way practitioners can implement culturally grounded approaches is to explore the client’s spiritual beliefs and practices as a possible source of strength when engaged one-on-one with clients (Marsiglia & Kulis, 2009). Mr. Sams intermittently hummed excerpts of a church hymn as he talked with the social worker. During the initial intake and assessment phase the practitioner could have interviewed him regarding his spiritual beliefs and practices. Considering the impact of Mr. Sams’ religious beliefs would have revealed that regular attendance and worship in his rural church is a cornerstone in his life. This information would have provided the worker with a key element to examine in determining whether his religious or spiritual beliefs may shape his point of view about his diabetes. For example, religious fatalism, the belief that health outcomes are inevitable determined by God, may inhibit healthy behaviors for African Americans who report the importance of religious practices. In addition, a religious belief that God or some “higher power” is ultimately in control of one’s health can also spur apathy about health prevention, detection, and cure (Brown, 2000; Plowden, 2003; Powe, 1997; Powe, Ntekop, & Barron, 2004; Powe & Johnson, 1995). On the other hand, spiritual beliefs can support positive health behaviors by reinforcing a sense of responsibility and good stewardship of the body (Collins & Antle, 2010; Antle & Collins, 2009). There are several ways of implementing culturally relevant approaches that could allow the worker to incorporate the spiritual beliefs and practices of the client from the beginning (Marsiglia & Kulis, 2009). Professional helpers and practitioners can secure fundamental knowledge regarding religion and spirituality as it pertains to minority populations by reading articles or books, engaging in intentional listening, and by honoring others’ histories of survival that may be different from their own. Another strategy is to become familiar with how African American families use religion and spirituality in an adaptive role to manage entrenched and deep-rooted historical stressors. Professionals could also examine how their own personal faith practices, religious choices, beliefs, and spirituality shape their values, attitudes, 213 and worldview. However, since rural churches are not homogeneous, workers should take into consideration that religious participation and the structure of rural churches may differ (Gesler, Arcury, & Koenig, 2000) based on denominational affiliation, the socioeconomic status of the congregation, or the geographic location. It is prudent for culturally sensitive practitioners not to make sweeping generalizations about rural black churches in spite of their uniqueness, location, or size. Given the historical relevance of religion, religious and spiritual activity can be viewed as a protective factor that is often of special importance to African American elders living in rural communities (Collins, 2008). However, in a broader culturally competent context, it is imperative for workers to examine the vestiges of systematic discrimination, oppression, and racism in society and seek to understand how those ills may have impacted the personal narratives of clients and their perceptions in order to suspend judgment and opinions about rural clients’ faith practices. Summary Service providers and gerontological helpers need to be culturally competent to work effectively with older African American clients living in rural areas. They must be knowledgeable about the vestiges of discrimination and adversity that have impeded minority clients’ ability to access many types of services. It is also important that they focus on delivering services that embrace cultural customs, traditions, and history and commit to building cultural competencies that address issues facing older African American elders. A lack of sensitivity to these areas can result in service recipients who terminate services prematurely or under use services and social benefits. In some instances, service providers may be unfamiliar with many of the cultural nuances that they might encounter when serving clients and can feel less than confident in providing services. This issue can be resolved in a number of ways. Workers could improve their cultural capabilities by adapting services to the cultural context of families, which would help to integrate culturally competent knowledge in the service delivery system. Others could opt to read appropriate reference materials concerning cultural, historical, and regional differences in places where they work. Another approach could be to shadow more seasoned personnel who have been successful in working with various WORKING WITH OLDER AFRICAN AMERICANS IN RURAL COMMUNITIES 214 SOCIAL WORK & CHRISTIANITY ethnic groups or to seek regular and on-going feedback relative to the worker’s level of inclusive practices or possible alienating behaviors. An additional way to increase cultural competence is to participate in community social events at which food, music, and entertainment is featured in neighborhoods where social workers deliver services. These beginning steps could initially assist social work staff in enhancing their communication with a diverse range of clients and improve the confidence of the providers of service. Ultimately, culturally competent care for clients is an ongoing process consisting of awareness, knowledge, skill, and desire. v