Addressing Health Disparities Among Older Adults

Transcript:

Amanda Moore McBride:

Welcome to episode eight of the Brave Ideas for Social Change podcast series, produced by the University of Denver Graduate School of Social Work, which is celebrating its 90th anniversary this academic year. This series draws on GSSW faculty expertise for fast-moving discussions on emerging research, practice, and policy innovations to spur social change.

Today's guest is Assistant Professor Kaipeng Wang, whose research aims to understand how social determinants such as discrimination, acculturation, and food insecurity contribute to health and mental health disparities among ethnic minorities and immigrants, particularly older adults. His work informs the development, evaluation, and implementation of culturally sensitive interventions to improve mental health outcomes for older adults.

Amanda Moore McBride:

Dr. Wang, thank you so much for being here to share more about your important work.

Kaipeng Wang:

Thank you so much, Dean McBride. It's such a pleasure to be here.

Amanda Moore McBride:

So the pandemic has magnified many disparities across society and what we're hearing is that ethnic minorities, immigrant communities, older adults, they're all disproportionately affected. What are some of the health and mental health disparities experienced by these individuals and how have these changed or grown as a result of the pandemic?

Kaipeng Wang:

So, during the COVID-19 pandemic, we certainly see many disparity related factors being significantly amplified. Older Americans who are minority or immigrants have reported the lowest rate of access to telehealth and telemedicine, which deprives them of essential medical and mental health care, especially during the peak of the pandemic. Age itself is a risk factor for poor outcomes from COVID-19, and older age is often actively correlated with an individual's self-efficacy in using technologies. In addition, older Asian Americans, especially women, are increasingly experiencing physical harassment. For example, security videos have shown older Asians being pushed to the ground, kicked in the body, or stomped in the head by assailants yelling racial slurs and telling them that they do not belong to this country.

In New York City for example, harassment incidents reported to the police department have decreased overall since 2019, but if we look more closely we see that incidents of harassment actually increased when the victim was Asian. These incidents are still happening, causing a lot of anxiety and fear among older Asian Americans, and preventing them from even trying to get food, not to mention mental health services.

Amanda Moore McBride:

This is simply disgusting. It's heartbreaking, uh, to consider that even today risk of harassment could prevent people from meeting their most basic needs. For older adult immigrants then that are in the US, what other health related barriers do they face? What are some of the social determinants that you found most affect their physical and mental health?

Kaipeng Wang:

In addition to common determinants among older Americans in general, such as age and social economic status, for older immigrants in the US particularly Asians, family relationships and acculturation have a profound impact on physical and mental health, including their health behaviors, health service use, and health outcomes. For instance, my studies found out acculturation is significantly associated with food insecurity, advanced care planning, depression, and self-rated health among older Chinese Americans and Puerto Ricans living in the Continental US.

Amanda Moore McBride:

I so appreciate what your research is revealing. I think that in common parlance, when we talk about social determinants of health for immigrant communities, often it focuses on access to care and how language may be a barrier. We may not recognize the many complex ways that culture and acculturation are involved in how systems are experienced by diverse populations. I'd love for you to share with our listeners more about how the populations you study experience the health and mental health systems here in the US.

Kaipeng Wang:

Sure. So when we think about language barriers, many equate that with translation services alone. However the disparity of mental health service use includes not only language barriers, but also lack of culturally responsive services. For example, even though the US is one of the most advanced mental health systems in the world, older generations of immigrants are still associating mental health service with simply taking medication or being locked up in a inpatient psychiatric unit. So from a language perspective, many older adults who need mental health services know very well that they're not going to everybody admitted to an inpatient treatment facility, but they still have negative thoughts about mental health services. Without culturally responsive services, mental heath-related stigma can be perpetuated, leading to disengagement from mental health services which remains a significant mental health gap among older Asian Americans.

Amanda Moore McBride:

You recently published a study on end-of-life care planning among older Chinese Americans. End-of-life planning has been associated with improved quality of care, fewer unnecessary medical treatments, lower medical treatment cost, and reduced anxiety and distress among patients and their family members. And yet, only about 20% of older Chinese Americans have even heard about advanced directives. What have you learned and what do you recommend?

Kaipeng Wang:

For those who are unfamiliar with the term, an advanced directive is the legal document that allows your healthcare team and loved ones to know what kind of health you want and who you want to make decisions for you when you can't. Advanced directives are one important component of end-of-life care planning, which can also include things like drafting a will. My colleagues and I have found that the advanced directive completion rate among Chinese Americans aged 50 or above is only 14%, which is much lower than noticed by white, Hispanic, and African American counterparts. To effectively promote end-of-life care planning for Chinese Americans, it is critical to understand the facilitators of and barriers to advanced directive completion.

One might assume that health status would be the most deciding predictor of advanced care planning for older adults, however we have found that for Asian or Chinese Americans, social and cultural factors play even stronger roles in advanced care planning. More specifically, Chinese Americans who had US citizenship were three times more likely to complete advanced directives than those who don't, even after controlling for health means factors such as depression and self-rated health.

Higher acculturation level indicated by things like speaking more English than Chinese, or attending American events more often than Chinese events is also significantly associated with higher chances of advanced directive completion. We also found that a better family relationship was associated with higher self-efficacy and a better attitude towards advanced care planning. Those findings highlight that advanced care planning is not just a personal matter, but a family matter for Chinese Americans. Those factors important to consider when we engage older Chinese Americans in culturally appropriate and family-centered and applied care planning.

Amanda Moore McBride:

What can and, and should social workers be doing to better engage older Chinese Americans and other older adults around end-of-life care?

Kaipeng Wang:

It's important to recognize the continuum of health prevention assessment and intervention in engaging older adults. From a direct practice standpoint, our conversations should be guided by a better understand of where the clients are in their life journey. When people are seeking mental healthcare, these topics are often overlooked. Given the empirical evidence, it is critical to assess cultural and social factors such as family relationships and death attitudes. When it comes to intervention, culturally sensitive psycho-education is often the first option for raising awareness of healthcare related issues. And for Chinese Americans, including family members in these conversations, it's highly recommended.

Social works have the responsibility, qualities and training to engage people in difficult conversations, taking end of life care as an example, I'm currently working with a Chinese American Coalition for Compassionate Care. We know that for many Chinese Americans initiating conversation about end of life care causes a lot of discomfort. To minimize comfort, the coalition developed the Heart to Heart Café where they printed a variety of end-of-life care related issues on a standard card deck and categorized them into physical, social, psychological and financial needs using four different suits.

By the way, many Chinese Americans love playing cards, so when you this culturally sensitive tool and combine that with excellent focus group facilitators, who are often social workers, to guide folks to play the game, you can find a lot of older Chinese Americans enjoying this advanced care planning conversation even with people they don't even know yet. One thing, therefore, I can never over-emphasize is the empathy, creativity, and innovation us social work possess to engage participants in these conversations.

Amanda Moore McBride:

I love the emphasis on creativity and innovation. These are things I just, we don't talk enough about in social work. This conversation is such a powerful reminder to me of their importance and it underscores the need for social work to be even more culturally appropriate and responsive. There are lives at stake in all of this. How do we move the needle, uh, more in both education and practice? What are your suggestions?

Kaipeng Wang:

I think this really speaks to the importance of the social work profession in general to continue its focus on diversity, equity, and inclusion. GSSW's a leader in the profession, evidenced by our commitment to advancing social justice and emphasis on community engagement. But beyond that, it's important to recognize that Asian Americans are still underrepresented in the social work workforce. In a 2020 census, 6% of respondents identified as Asian American, up from 4.85% a decade earlier. But in 2016, only 3% of masters and 1.9% bachelors degree graduates in social work were Asian.

Kaipeng Wang:

I believe that partially explained why many Asian Americans, particularly older folks, can't even find a licensed social worker who can speak their language and provide culturally responsive services in their community. It's important first to further incorporate the life and perspectives of the Asian American community in our curriculum, promote experiential learning for our current students in their internships and practice with Asian American communities and recruit a more diverse MSW student body, which will in turn help to develop diverse and inclusive services for people from different backgrounds.

Amanda Moore McBride:

Thank you so much for this discussion. Your work is incredibly relevant to today's world.

Kaipeng Wang:

Thank you. It's my great honor to contribute to social change at GSSW.

Amanda Moore McBride:

Listeners, please subscribe to our Brave Ideas for Social Change podcast for more conversations like this. Learn more at socialwork.du.edu/change.

For more information on the history of GSSW and what the next 90 years have in store for this school and the profession of social work, visit socialwork.du.edu/next90. Thank you for joining us.