US Pharm. 2013;38(9):20-22.
The United States population is not only aging, but it is
also increasing in diversity. Approximately 13.3 % of the population is
now 65 years of age or older, and approximately 42% of the general
population identifies as African American, Hispanic, Asian, American
Indian, Alaskan Native, being of another race that is not White, or as
coming from two or more races.1
As the age and diversity of our population increases, so
does the potential for patients, including older adults, to experience
barriers to health care access. Therefore, pharmacists and other
clinicians must continue to strive for effective communication with
sensitivity toward cultural, socioeconomic, and sociodemographic
factors. Furthermore, seniors who do achieve access to care need to be
fully engaged in the clinician-patient encounter so they are able to
follow instructions and adhere to medication regimens; engaging an aging
and diverse population requires that pharmacists and other health care
providers be culturally competent.
Factors Influencing Access to Health Care in Seniors
Among nonelderly Americans, disparities in access to
health care have been well documented, with the primary reason being
lack of health insurance (i.e., either employer-sponsored or public).2-6 Some sociodemographic factors such as race and income are highly correlated with a lack of insurance in younger populations.7-9
Sociodemographic factors, socioeconomic status, and type
of insurance coverage have a substantial impact on the elderly
population’s access to health care.10 Among seniors, psychological and physical barriers affect access to care and may be influenced by poverty more than by race.11
The issue of adequate access to health care has attracted the attention
of the U.S. Government, professional associations, and health care
In one study supporting this concern,
Fitzpatrick et al. evaluated self-perceived access to health care from
self-administered questionnaires in a cohort of Medicare beneficiaries
with a mean age of 76 years.11 The researchers identified
patterns of use and barriers to health care and found the most common
barriers to seeing a physician were the doctor’s lack of responsiveness
to patient concerns, medical bills, transportation, and street safety.
Independently related to perceptions of barriers to access to health
care were low income, no supplemental insurance, older age, and female
gender; race was not significant after adjustment for other factors.11
Interestingly, there is a perception of greater equality
regarding access to health care in U.S. seniors due to their eligibility
for Medicare; however, conclusions from recent studies show otherwise.
Even for Medicare recipients, cost appears to be one of the significant
factors associated with lack of access to care.13-18 Since
the greatest financial burden for Medicare recipients involves
out-of-pocket expenses, issues of cost in the elderly are primarily
related to insurance coverage that is supplemental to Medicare coverage.16 This type of insurance has been reported to be independently related to both the use of health services and medical outcomes.14,17
Lack of complementary health insurance may affect the health care
services received by individuals aged 65 years and older, in addition to
race, education, age, and gender.13,15-18
Striving for Cultural Competence
Numerous studies indicate that satisfaction with provider
services may impact perceptions of access to health care, in addition to
clinical outcomes.19-22 As noted above, lack of
responsiveness to patient concerns is commonly perceived as a barrier to
access to care among older adults.11 A factor in patients’
perceptions of clinicians’ responsiveness may be their ability to make
patients feel respected and understood regardless of cultural
differences between them.
We, as individuals, are defined by our culture.23 Further,
a variety of factors that mold behavior and values have the potential
to influence cultural values and beliefs toward health care (TABLE 1).24
The ultimate goal of a health care provider is to improve patient
outcomes; achieving this goal includes understanding the culture and
language of patients.24 To provide quality care to patients
who come from a variety of cultures and backgrounds, health care
providers, including pharmacists, should strive toward cultural
competence. Cultural competence is the ability of individuals and
systems to respond respectfully and effectively to people of all
cultures, classes, races, ethnic backgrounds, sexual orientations, and
faiths or religions in a manner that recognizes, affirms, and values the
worth of individuals, families, tribes, and communities and protects
and preserves the dignity of each.23
The underlying reasons for emphasizing cultural competence
in the health care arena are the change in demographics in the U.S.,
disparities in health, and patient safety.24 It is important
for clinical practitioners and their students alike to recognize that
patients, including seniors, may enter a health care setting describing
their illness with a different explanation than that found in the U.S.
medical model. Clinicians need not only to be able to truly listen to a
patient’s own perception of health, but also to acknowledge difference
and negotiate treatment options, all while being respectful.
Standards for Cultural Competence
Understanding and interpreting
accreditation standards for health care organizations and Title VI of
the Civil Rights Act are some of the regulatory and legal issues
surrounding cultural competence.24 On April 24, 2013, the
U.S. Department of Health & Human Services released enhanced
National Standards for Culturally and Linguistically Appropriate
Services (CLAS) in Health and Health Care—a comprehensive update of the
2000 CLAS Standards—to ensure an even stronger platform for health
equity.25 Considered a blueprint to help organizations
improve health care quality in serving diverse communities, these
enhanced standards are grounded in a broad definition of culture in
which health is recognized as being influenced by a range of factors
from race and ethnicity to language, spirituality, disability status,
sexual orientation, gender identity, and geography.25 These
standards can be used by stakeholders including policymakers,
purchasers, patients, advocates, educators, and the health care
community in general to advance health and health care in the U.S.25
There is support for CLAS standards by
the primary national accrediting body for health care organizations and
programs, the Joint Commission, which requires effective communication,
cultural competence, and patient-oriented care (see RESOURCES).
Cultural competence, therefore, can be demonstrated by an organization
when that entity has a defined set of values and principles (i.e.,
mission), policies, and the necessary structures for the delivery of
services that incorporate community input and enable persons in the
organization to effectively perform within cultures and
cross-culturally.26,27 Although barriers exist for
cross-cultural communication, they can be overcome if clinicians
understand verbal and nonverbal cues in communication.24
Pharmacists and other clinicians should also recognize and embrace the
fact that it is essential to have quality interpretation in the patient
Access to health care has been viewed as a
primary concern, particularly among the elderly population. Ineffective
communication may contribute to this concern, in addition to negatively
affecting medication adherence, therapeutic outcomes, and patient
safety. Navigating across cultures requires tools such as learning how
to listen, empathize, and negotiate a treatment and pharmaceutical plan
with patients. Without cultural competence, effective communication
regarding these issues may be compromised.
1. U.S. Census Bureau. 2011 American
Community Survey 1-year Estimates and 2009-2011 American Community
Survey 3-Year Estimates - United States.
Accessed August 19, 2013.
2. McCormick MC, Weinick RM, Elixhauser
A, et al. Annual report on access to and utilization of health care for
children and youth in the United States–2000. Ambul Pediatr. 2001;1:3-15.
3. Reed MC, Tu HT. Triple jeopardy: low income, chronically ill and uninsured in America. Issue Brief Cent Stud Health Syst Change. 2002;49:1-4.
4. Broyles RW, Narine L, Brandt EN Jr. The temporarily and chronically uninsured: does their use of primary care differ? J Health Care Poor Underserved. 2002;13:95-111.
5. Cunningham PJ. Declining employer-sponsored coverage: the role of public programs and implications for access to care. Med Care Res Rev. 2002;59:79-98.
6. Guyer J, Broaddus M, Dude A. Millions
of mothers lack health insurance coverage in the United States: most
uninsured mothers lack access both to employer-based coverage and to
publicly subsidized health insurance. Int J Health Serv. 2002;32:89-106.
7. Keruly JC, Conviser R, Moore RD. Association of medical insurance and other factors with receipt of anti-retroviral therapy. Am J Public Health. 2002;92:852-857.
8. Ruiz P. Hispanic access to health/mental health services. Psychiatr Q. 2002;73:85-91.
9. Strzelczyk JJ, Dignan MB. Disparities
in adherence to recommended followup on screening mammography:
interaction of sociodemographic factors. Ethn Dis. 2002;12:77-86.
10 Shi L, Stevens G. Vulnerable Populations in the United States. San Francisco, CA: Jossey-Bass, 2005.
11. Fitzpatrick AL, Powe NR, Cooper LS, et al. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004; 94(10):1788-1794.
12. Smith MA. Access to health care among the elderly. NP World News. 2010;15(11/12):18-19.
13. Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002;287:1288-1294.
14. Porell FW, Miltiades HB. Access to care and functional status change among aged Medicare beneficiaries. J Gerontol B Psychol Sci Soc Sci. 2001;56:S69-S83.
15. Gornick ME. The association of
race/socioeconomic status and use of Medicare services: a little-known
failure in access to care. Ann N Y Acad Sci. 1999;896:497-500.
16. Janes GR, Blackman DK, Bolen JC, et al. Surveillance for use of preventive health-care services by older adults, 1995–1997. MMWR CDC Surveill Summ. 1999;48:51-88.
17. Hsia J, Kemper E, Sofaer S, et al. Is
insurance a more important determinant of healthcare access than
perceived health? Evidence from the Women’s Health Initiative. J Womens Health Gend Based Med. 2000;9:881–889.
18. Escarce JJ, Epstein KR, Colby DC,
Schwartz JS. Racial differences in the elderly’s use of medical
procedures and diagnostic tests. Am J Public Health. 1993;83:948-954.
19. Akinci F, Sinay T. Perceived access in a managed care environment: determinants of satisfaction. Health Serv Manage Res. 2003;16:85-95.
20. Meng YY, Jatulis DE, McDonald JP, Legorreta AP. Satisfaction with access to and quality of health care among Medicare enrollees in a health maintenance organization. West J Med. 1997;166:242-247.
21. Harris LE, Luft FC, Rudy DW, Tierney
WM. Correlates of health care satisfaction in inner-city patients with
hypertension and chronic renal insufficiency. Soc Sci Med. 1995;41:1639-1645.
22. Alazri MH, Neal RD. The association
between satisfaction with services provided in primary care and outcomes
in type 2 diabetes mellitus. Diabet Med. 2003;20:486-490.
23. Child Welfare League of America. CWLA
National Advisory Committee on Cultural Competence and Racial
Disproportionality and Disparity of Outcomes. Cultural competence: about
this area of focus.
August 18, 2013.
24. Sias JJ, Loya AM, Rivera JO, et al. Cultural competency. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. Chapter 4. www.accesspharmacy.com/content.aspx?aID=7965864. Accessed August 11, 2013.
25. HHS releases blueprint to advance
culturally and linguistically appropriate services in health and health
care. U.S. Department of Health & Human Services. April 24, 2013.
Revised August 5, 2013.
www.hhs.gov/news/press/2013pres/04/20130424b.html. Accessed August 26,
26. AgingStats.gov. Federal Interagency
Forum on Aging-Related Statistics. Number of older Americans.
Accessed August 16, 2013.
27. National Healthcare Disparities
Report, 2007. Agency for Healthcare Research and Quality.
http://archive.ahrq.gov/qual/qrdr07.htm. Accessed August 16, 2013.
28. Moyerman DR, Forman BD. Acculturation and adjustment: a meta-analytic study. Hisp J Behav Sci. 1992;14(2):163-200.
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