Adaptive Communication Activities with Minority Elderly Consumers

1. Adaptive Communication Activities with Minority Elderly Consumers Christine R. Boone, DSW

2. 2 Adaptive Communication Activities with Minority Elderly Consumers Purposes of Module To present unique linguistic patterns and communication styles of minority groups, including elderly to prepare health care providers for a more effective helping relationship with this population. To provide health care providers with a working knowledge of communication styles and the interactive tools needed to become more effective health care practitioners with minority elderly clients.

3. 3 Adaptive Communication Activities with Minority Elderly Consumers Objectives To understand and appreciate the unique linguistic patterns and communication styles of minority elderly and to view these styles as reflective of culture. To examine Black English as a unique communication pattern for African American elderly and their families. Purposes of Module To present unique linguistic patterns and communication styles of minority groups, including elderly to prepare health care providers for a more effective helping relationship with this population. To provide health care providers with a working knowledge of communication styles and the interactive tools needed to become more effective health care practitioners with minority elderly clients. Purposes of Module To present unique linguistic patterns and communication styles of minority groups, including elderly to prepare health care providers for a more effective helping relationship with this population. To provide health care providers with a working knowledge of communication styles and the interactive tools needed to become more effective health care practitioners with minority elderly clients.

4. 4 Adaptive Communication Activities with Minority Elderly Consumers Objectives continued To examine some of the barriers to effective communication with minority elderly clients. To teach strategies that will enhance the ability of the health care providers to communicate effectively with ethnic elders. Learner Outcomes List specific ethnic styles of communication that differ from mainstream communication patterns. Identify at least one specific communication pattern. Identify three barriers to effective communication with minority elders. Describe how Black English as a distinctive pattern is an effective communication style of African Americans. Design health care treatment plans for minority elderly clients that are sensitive to all issues of diversity, including communication. Learner Outcomes List specific ethnic styles of communication that differ from mainstream communication patterns. Identify at least one specific communication pattern. Identify three barriers to effective communication with minority elders. Describe how Black English as a distinctive pattern is an effective communication style of African Americans. Design health care treatment plans for minority elderly clients that are sensitive to all issues of diversity, including communication.

5. 5 Supplemental Word Documents Activities and Pre-Post Test, Answers, and References are in a separate MS Word Document

6. 6 Adaptive Communication Patterns of Ethnic Elderly Effective communication is essential in the delivery of health services to minority elders and their families. Communication, especially as related to ethnic minorities, has different styles than does mainstream U.S. culture. This places ethnic minority elders at a disadvantage because many mainstream providers place negative values on linguistic patterns and styles of communicating. Effective communication is essential in the delivery of health services to minority elders and their families. This appears to be an area which very little attention has been focused, especially when one looks at the health disparities in minority communities. Communication, especially as related to ethnic minorities, has different styles than does mainstream United States culture. This fact often places ethnic minority elders at a disadvantage because many mainstream providers place negative values on their linguistic patterns and styles of communicating. This can potentially lead to misinterpretation of the minority elder�s needs. Elderly consumer�s response is often to withdraw from services or to view the provider as being insensitive to their needs. Effective communication is essential in the delivery of health services to minority elders and their families. This appears to be an area which very little attention has been focused, especially when one looks at the health disparities in minority communities. Communication, especially as related to ethnic minorities, has different styles than does mainstream United States culture. This fact often places ethnic minority elders at a disadvantage because many mainstream providers place negative values on their linguistic patterns and styles of communicating. This can potentially lead to misinterpretation of the minority elder�s needs. Elderly consumer�s response is often to withdraw from services or to view the provider as being insensitive to their needs.

7. 7 Adaptive Communication Patterns of Ethnic Elderly Barriers to effective communication with ethnic elders can contribute to communication failure. Verbal Non-verbal Paralanguage aspects Barriers to effective communication with ethnic elders can contribute to communication failure. Barriers include: both verbal and non-verbal obstacles such as language differences, slang usage jargon and paralanguage aspects like volume, tone and speech patternsBarriers to effective communication with ethnic elders can contribute to communication failure. Barriers include: both verbal and non-verbal obstacles such as language differences, slang usage jargon and paralanguage aspects like volume, tone and speech patterns

8. 8 Understanding Linguistic patterns and Communication styles of Minority Elders1 Assessing communication between health care providers and culturally and linguistically diverse clients is a critical need. Communication styles of ethnic elders and their families differ from that of the majority culture. Assessing communication between health care providers and culturally and linguistically diverse clients is a critical need The culturally and linguistically ethnic population in the United States is steadily growing and the need for competent health care providers is essential (Kader & Yawley, 2002). Communication styles of ethnic elders and their families differ from that of the majority culture. For some groups (Hispanic, African, and Native Americans) the primary mode of communication is non-verbal. Nonverbal communication is no doubt a more accurate gauge of one�s true feelings and the beliefs. Assessing communication between health care providers and culturally and linguistically diverse clients is a critical need The culturally and linguistically ethnic population in the United States is steadily growing and the need for competent health care providers is essential (Kader & Yawley, 2002). Communication styles of ethnic elders and their families differ from that of the majority culture. For some groups (Hispanic, African, and Native Americans) the primary mode of communication is non-verbal. Nonverbal communication is no doubt a more accurate gauge of one�s true feelings and the beliefs.

9. 9 Understanding Linguistic Patterns and Communication styles of Minority Elders2 Understanding eye contact is especially challenging. Communication styles often differ dramatically across cultural groups. Knowledge specific cultural norms will enhance health care provider�s ability to communicate effectively and influence behavior. Understanding eye contact is especially challenging because it has different meanings in different cultures (Sue & Sue, 2003). These communication styles often differ dramatically across cultural groups. If practitioners are to be effective in their work with minority elderly clients, they will need to enhance their appreciation and understanding of ethnic verbal patterns as well as nonverbal behavior interpretations. Knowledge and use of cultural expressions idioms and differences associated with the modes of the expressions used by a particular ethnic group will enhance the ability of the health care provider to communicate effectively and influence behavior. Understanding eye contact is especially challenging because it has different meanings in different cultures (Sue & Sue, 2003). These communication styles often differ dramatically across cultural groups. If practitioners are to be effective in their work with minority elderly clients, they will need to enhance their appreciation and understanding of ethnic verbal patterns as well as nonverbal behavior interpretations. Knowledge and use of cultural expressions idioms and differences associated with the modes of the expressions used by a particular ethnic group will enhance the ability of the health care provider to communicate effectively and influence behavior.

10. 10 Understanding Linguistic Patterns and Communication styles of Minority Elders2-4 Minority group members often define issues and concerns differently than their White counterparts. Blacks and Whites have very different styles of communication. Training in vocabulary adjustment is needed. Minority group members often define issues and concerns differently than their White counterparts. Sometimes these issues and concerns are expressed in a way that may be misinterpreted by the health care provider. For instance, it is easy for mainstream health providers to ignore the impact of the wider environmental systems (physical and sociopolitical) on the well-being of minority clients. These clients are often concerned about meeting basic survival and coping needs than dealing with social and bureaucratic procedures. Some of their health needs may be communicated in a fatalistic manner (it�s God�s will) and it may appear to the practitioner that the clients are unconcerned and unmotivated. Grammar usage, voice pitch, body language, street talk, etc. may be misinterpreted by a majority health care provider, and negative assumptions may be made about the clients behavior to the point sometimes of seeing it as pathological. Hence, these elders� communication styles may trigger preconceived notions and stereotypes held by the majority culture health care providers that can potentially impact the practitioner-minority client relationship negatively (Sue & Sue, 2003). According to Green (1999) and Sue & Sue (2003), Blacks and Whites have very different styles of communication. For instance: Mainstream culture�s mode of acceptable communication is considered low-key, impersonal, and issue-oriented. Black�s mode of acceptable communication is interpersonal, high-key, passionate, and animated. These differences in communication styles often can reveal a value judgment and even lead to misinterpretation. Training in vocabulary adjustment is needed to enhance practitioner understanding of what elderly minority clients may be trying to communicate about their health care needs is needed (Vacc, DeVaney, & Wittmer, 2000). This can often be facilitated by the practitioner willingness to ask clients what they mean without judgment, and to accept their interpretation of their needs as valid. All diverse cultural groups have elements of speech that are easily interpreted in their own cultural groups, but more difficult in mainstream culture. This means that language must be interpreted in the context of the particular group. Minority group members often define issues and concerns differently than their White counterparts. Sometimes these issues and concerns are expressed in a way that may be misinterpreted by the health care provider. For instance, it is easy for mainstream health providers to ignore the impact of the wider environmental systems (physical and sociopolitical) on the well-being of minority clients. These clients are often concerned about meeting basic survival and coping needs than dealing with social and bureaucratic procedures. Some of their health needs may be communicated in a fatalistic manner (it�s God�s will) and it may appear to the practitioner that the clients are unconcerned and unmotivated. Grammar usage, voice pitch, body language, street talk, etc. may be misinterpreted by a majority health care provider, and negative assumptions may be made about the clients behavior to the point sometimes of seeing it as pathological. Hence, these elders� communication styles may trigger preconceived notions and stereotypes held by the majority culture health care providers that can potentially impact the practitioner-minority client relationship negatively (Sue & Sue, 2003). According to Green (1999) and Sue & Sue (2003), Blacks and Whites have very different styles of communication. For instance: Mainstream culture�s mode of acceptable communication is considered low-key, impersonal, and issue-oriented. Black�s mode of acceptable communication is interpersonal, high-key, passionate, and animated. These differences in communication styles often can reveal a value judgment and even lead to misinterpretation. Training in vocabulary adjustment is needed to enhance practitioner understanding of what elderly minority clients may be trying to communicate about their health care needs is needed (Vacc, DeVaney, & Wittmer, 2000). This can often be facilitated by the practitioner willingness to ask clients what they mean without judgment, and to accept their interpretation of their needs as valid. All diverse cultural groups have elements of speech that are easily interpreted in their own cultural groups, but more difficult in mainstream culture. This means that language must be interpreted in the context of the particular group.

11. 11 Understanding Linguistic Patterns and Communication styles of Minority Elders It is important to realize that misunderstandings can be triggered by preconceived stereotypes and beliefs about certain groups of people. Eye contact also varies within ethnic cultures. In the U.S., emphasis is placed on one�s facial expressions. Health care practitioners need to be aware of these dialectical patterns and subtleties. It is important to realize that misunderstandings can be triggered by preconceived stereotypes and beliefs about certain groups of people. When this is the case, it is not possible for the practitioner to listen attentively to what the elderly minority client is saying or in some situations to be even interested in what the person is trying to communicate. Eye contact also varies within ethnic cultures. For example, African Americans use of eye contact is similar to Caucasian. Both groups place importance on maintaining eye contact with the person with whom you are communicating. However, even here there is one major difference, Caucasians tend to maintain eye contact more when listening to another person than when talking; African Americans tend to maintain eye contact more when they are talking than when they are listening. Asian American and Native Americans believe that is impolite and a sign of disrespect to look a speaker directly in the eye, especially persons who are viewed as authority figures. In the U.S., emphasis is placed on one�s facial expressions. This too can be misleading. Health care practitioners need to be aware of these dialectical patterns and subtleties in order to enhance their ability to understand what elderly minority clients may be communicating and to demonstrate acceptance of the language differences that exist. It is important to realize that misunderstandings can be triggered by preconceived stereotypes and beliefs about certain groups of people. When this is the case, it is not possible for the practitioner to listen attentively to what the elderly minority client is saying or in some situations to be even interested in what the person is trying to communicate. Eye contact also varies within ethnic cultures. For example, African Americans use of eye contact is similar to Caucasian. Both groups place importance on maintaining eye contact with the person with whom you are communicating. However, even here there is one major difference, Caucasians tend to maintain eye contact more when listening to another person than when talking; African Americans tend to maintain eye contact more when they are talking than when they are listening. Asian American and Native Americans believe that is impolite and a sign of disrespect to look a speaker directly in the eye, especially persons who are viewed as authority figures. In the U.S., emphasis is placed on one�s facial expressions. This too can be misleading. Health care practitioners need to be aware of these dialectical patterns and subtleties in order to enhance their ability to understand what elderly minority clients may be communicating and to demonstrate acceptance of the language differences that exist.

12. 12 Use of Interpreters and translators:A caution2,5 Guidelines for effective communication with Minority elders include: Find out which language the consumers communicate best. Be sensitive to the possibility that in a crisis situation it may be difficult for the elderly client or his/her family to communicate because of emotions. Use trained people as interpreters or translators. Despite the fact that everyday communication with Hispanic consumers is in English (Mexican Americans 63%, Puerto Ricans 50%, Cuban Americans 31%), there are guidelines that must be used to effectively communicate with these elders. Ewalt, Freeman, Kirk & Poole (1999) Suggest: Find out which language the consumers communicates best in. Be sensitive to the possibility that when in a crisis situation it may be difficult for the elderly client or his/her family to communicate because of the emotions. Use trained people as interpreters or translators. Sue and Sue (2003) point out that if relatives/friends of the client are the only available translator it is important for the practitioner to be aware of problems that may result, such as misinterpretation of client�s message, alterations of the message and when the translator is not familiar with health and medical aspects of the health care needs of the client. Despite the fact that everyday communication with Hispanic consumers is in English (Mexican Americans 63%, Puerto Ricans 50%, Cuban Americans 31%), there are guidelines that must be used to effectively communicate with these elders. Ewalt, Freeman, Kirk & Poole (1999) Suggest: Find out which language the consumers communicates best in. Be sensitive to the possibility that when in a crisis situation it may be difficult for the elderly client or his/her family to communicate because of the emotions. Use trained people as interpreters or translators. Sue and Sue (2003) point out that if relatives/friends of the client are the only available translator it is important for the practitioner to be aware of problems that may result, such as misinterpretation of client�s message, alterations of the message and when the translator is not familiar with health and medical aspects of the health care needs of the client.

13. 13 Five problems areas in communication6,7 Language differences Interpreter changes Interpreter�s own cultural norms and values Psychological perspective Confidentiality issues Lee (1999) lists five problems that practitioners must be aware of: One language may lack the words to fully correspond to the meaning of a word in another language. The interpreter may unintentionally change, embellish, or distort information. The interpreter�s own cultural norms and values may interfere. The interpreter may lack an understanding of what is important from a psychological perspective. Confidentiality issues may cause the client to provide more limited information when the interpreter is a friend or a family member. Winkleman (1999) suggested the following guidelines when translators or interpreters are used: try to use a person of the same racial/ethnic background; avoid technical terms as much as possible; consider the possible effect of the translator/interpreter on the interpretation of the information; consider the level of acculturation of the translator; avoid, if possible, the use of relatives and friends; avoid using children.Lee (1999) lists five problems that practitioners must be aware of: One language may lack the words to fully correspond to the meaning of a word in another language. The interpreter may unintentionally change, embellish, or distort information. The interpreter�s own cultural norms and values may interfere. The interpreter may lack an understanding of what is important from a psychological perspective. Confidentiality issues may cause the client to provide more limited information when the interpreter is a friend or a family member. Winkleman (1999) suggested the following guidelines when translators or interpreters are used: try to use a person of the same racial/ethnic background; avoid technical terms as much as possible; consider the possible effect of the translator/interpreter on the interpretation of the information; consider the level of acculturation of the translator; avoid, if possible, the use of relatives and friends; avoid using children.

14. 14 Understanding language and cultural nuances There�s a great difference between how minority elders view their role and the role of the health provider in helping relationships. For the minority consumer, it is more important that he/she establishes a personal relationship with the health care provider. For practitioners it is more important to evaluate the quality of tangible services he/she can provide to the client. There�s a great difference between how minority elders view their role and the role of the health provider in helping relationships. For the minority consumer, it is more important that he/she establishes a personal relationship with the health care provider. This involves more time and self-disclosure by the provider. This is contrary to mainstream practitioners who may evaluate their effectiveness to provide services to minority elderly clients based on the quality of tangible services he/she can provide to the client rather than the quality of services. There�s a great difference between how minority elders view their role and the role of the health provider in helping relationships. For the minority consumer, it is more important that he/she establishes a personal relationship with the health care provider. This involves more time and self-disclosure by the provider. This is contrary to mainstream practitioners who may evaluate their effectiveness to provide services to minority elderly clients based on the quality of tangible services he/she can provide to the client rather than the quality of services.

15. 15 Black English as a Communication Pattern of African Americans2,7,8 Language is both a part of a group�s culture and a means of encoding and transmitting cultural information. Many blacks do not communicate the same way as other Americans. Health care practitioners must examine language styles in the African American family so that they respond more appropriately to these clients. Language is both a part of a group�s culture and a means of encoding and transmitting cultural information. Many blacks do not communicate the same way as other Americans. Health care practitioners must examine language styles in the African American family so that they respond more appropriately to these clients. Black English has a very interesting and colorful history. Its origin is uniquely African, but it has been influenced by other groups as well as Portuguese. Referred to pidgin English first used by American Indians (Dillard, 1973). Some African American, rural less educated elderly persons, do not speak the same as other Americans. This is troublesome to some, especially Whites. Dillard (1973), Sue and Sue (2003), and Winkleman (1999) give some good examples of how African Americans speak. For instance in terms in grammar there is a tendency to use the same verb root across tenses. The question �have they gone there?� (Standard American English) might be replaced by �is they gone there?� in Black English. In a similar example, a mother might report that �my child is sick� (Standard American English), this may be replaced by �my child be sick� in Black English. Rapping (using language in a rhythmic fashion) is a lively, fluid, and fluent style of speech used to convince another person. This is seem a lot in African American teen communication. A Call and Response communication style is evident. An example is what occurs often in religious services or group meetings where the speaker calls out to the audience, which then responds in unison. To understand Black English, one has to listen to it and learn to recognize not only the basic linguistic features, but also such elements as talking and speaking. Health care professionals must be comfortable in asking for clarification of what is being said rather than making assumptions. Language is both a part of a group�s culture and a means of encoding and transmitting cultural information. Many blacks do not communicate the same way as other Americans. Health care practitioners must examine language styles in the African American family so that they respond more appropriately to these clients. Black English has a very interesting and colorful history. Its origin is uniquely African, but it has been influenced by other groups as well as Portuguese. Referred to pidgin English first used by American Indians (Dillard, 1973). Some African American, rural less educated elderly persons, do not speak the same as other Americans. This is troublesome to some, especially Whites. Dillard (1973), Sue and Sue (2003), and Winkleman (1999) give some good examples of how African Americans speak. For instance in terms in grammar there is a tendency to use the same verb root across tenses. The question �have they gone there?� (Standard American English) might be replaced by �is they gone there?� in Black English. In a similar example, a mother might report that �my child is sick� (Standard American English), this may be replaced by �my child be sick� in Black English. Rapping (using language in a rhythmic fashion) is a lively, fluid, and fluent style of speech used to convince another person. This is seem a lot in African American teen communication. A Call and Response communication style is evident. An example is what occurs often in religious services or group meetings where the speaker calls out to the audience, which then responds in unison. To understand Black English, one has to listen to it and learn to recognize not only the basic linguistic features, but also such elements as talking and speaking. Health care professionals must be comfortable in asking for clarification of what is being said rather than making assumptions.

16. 16 Barriers to Effective Communication with Minority Elders Importance of understanding specific barriers that impede effective communication with ethnic elders. Barriers are a result of long standing prejudice, stereotypes and discrimination against minority groups. Challenge for health care providers is to acknowledge and internalize the concept of diversity-competent intervention. Given the impact of cultural diversity, it is important to understand specific barriers that impede effective communication with ethnic elders. These barriers are brought about as a result of long standing prejudice, stereotypes and discrimination against minority groups in the United States. The challenge for health care providers is to acknowledge, and internalize the concept of diversity-competent intervention that sees ethnic styles as empowering and valid. Given the impact of cultural diversity, it is important to understand specific barriers that impede effective communication with ethnic elders. These barriers are brought about as a result of long standing prejudice, stereotypes and discrimination against minority groups in the United States. The challenge for health care providers is to acknowledge, and internalize the concept of diversity-competent intervention that sees ethnic styles as empowering and valid.

17. 17 Barriers To Effective Communication with Minority Elders2,7 Many barriers to communication have been identified by a number of researchers. While these are important, some take on special significance when relating to minority elders. Sue and Sue (2003), Winkleman (1999) and Robinson and Howard-Hamilton) are among several researchers who have identified barriers to effective communication with minority ethnic people. Each agree that health care professionals must accept communication differences and not see these necessarily as deficits. Getting in tune to the client�s communication style will go a long way to enhancing relationship building. These differences in communication style and patterns are significant to building a therapeutic system of health care. For example, understanding that the directness of conversation and degree of frankness viewed as imperative in mainstream United states society may be seen by ethnic minority elders as immature and rude. On the other hand speaking loudly (African Americans) does not always indicate anger and hostility any more than speaking in a soft voice (Native and Asian Americans) indicates being a sign of weakness or shyness.Sue and Sue (2003), Winkleman (1999) and Robinson and Howard-Hamilton) are among several researchers who have identified barriers to effective communication with minority ethnic people. Each agree that health care professionals must accept communication differences and not see these necessarily as deficits. Getting in tune to the client�s communication style will go a long way to enhancing relationship building. These differences in communication style and patterns are significant to building a therapeutic system of health care. For example, understanding that the directness of conversation and degree of frankness viewed as imperative in mainstream United states society may be seen by ethnic minority elders as immature and rude. On the other hand speaking loudly (African Americans) does not always indicate anger and hostility any more than speaking in a soft voice (Native and Asian Americans) indicates being a sign of weakness or shyness.

18. 18 Barriers To Effective Communication with Minority Elders2 Barriers can be broken into six finite areas: Cultural Physical Linguistic Lack of understanding of non-verbal behavior Inactive listening skills Mode of communication Many barriers to communication have been identified by a number of researchers. While they are all important, some take on special significance when relating to minority elderly consumers. Sue & Sue (2003) broke these down into finite areas to include: 1. Physical, relating to time, needs and physical medium 2. Cultural barriers including ethnic, religious, and social ceremonies 3. Linguistic differences and varied uses of vocabulary 4. Lack of understanding of non-verbal behavior 5. Inactive listening skills 6. Mode of communication Many barriers to communication have been identified by a number of researchers. While they are all important, some take on special significance when relating to minority elderly consumers. Sue & Sue (2003) broke these down into finite areas to include: 1. Physical, relating to time, needs and physical medium 2. Cultural barriers including ethnic, religious, and social ceremonies 3. Linguistic differences and varied uses of vocabulary 4. Lack of understanding of non-verbal behavior 5. Inactive listening skills 6. Mode of communication

19. 19 Barriers To Effective Communication with Minority Elders2 The mode of communication can differ when working with elderly minority clients including: American Indians Asians & Hispanics Caucasian Americans African Americans The mode of communication can be extremely significant when working with elderly minority clients, particularly African American elderly clients. Sue & Sue (2003) proposed specific strategies for enhancing communication with the cultural groups mentioned above. The mode of communication can be extremely significant when working with elderly minority clients, particularly African American elderly clients. Sue & Sue (2003) proposed specific strategies for enhancing communication with the cultural groups mentioned above.

20. 20 The mode of communication for American Indians: Speak softly/slower Interject less; seldom offer encouraging communication Delayed auditory (silence) Manner of expression low-keyed, indirect Barriers To Effective Communication with Minority Elders2 Sue & Sue (2003) proposed a specific schematic assessing communication styles of American Indians. Remember that there is much diversity in language, tradition and life style among American Indian tribes. Their communication style is characterized by a more indirect, softer speech pattern than some other groups. American Indians are less likely to initiate conversation and tend to use longer periods of silence than most other groups. They consider direct eye contact rude and intimidating and see not staring directly at others as a sign of showing respect. Remember, as other minority elderly groups, American Indian elderly will not share sensitive issues and may test the practitioner�s sincerity before trusting him/her.Sue & Sue (2003) proposed a specific schematic assessing communication styles of American Indians. Remember that there is much diversity in language, tradition and life style among American Indian tribes. Their communication style is characterized by a more indirect, softer speech pattern than some other groups. American Indians are less likely to initiate conversation and tend to use longer periods of silence than most other groups. They consider direct eye contact rude and intimidating and see not staring directly at others as a sign of showing respect. Remember, as other minority elderly groups, American Indian elderly will not share sensitive issues and may test the practitioner�s sincerity before trusting him/her.

21. 21 The mode of communication for Asians & Hispanics: Avoidance of eye contact when speaking to high status persons Similar rules Mild delay Low-keyed, indirect Barriers To Effective Communication with Minority Elders2 Sue & Sue (2003) proposed a specific schematic for assessing communication styles of Asians & Hispanics. Asian and Hispanic communication patterns have a very strong nonverbal tradition. This means that the health care provider must be alert to facial expressions and body language as these provide better clues to how elderly from these groups are feeling than do verbal comments. Both groups place a strong emphasis on being personal and informal. Hence, the health care practitioner must build a relationship first before any real work can be accomplished. Remember that for these groups the Anglo emphasis on individualism is at odds with the family centered approach in these groups. Therefore, even illness and health care becomes a family affair.Sue & Sue (2003) proposed a specific schematic for assessing communication styles of Asians & Hispanics. Asian and Hispanic communication patterns have a very strong nonverbal tradition. This means that the health care provider must be alert to facial expressions and body language as these provide better clues to how elderly from these groups are feeling than do verbal comments. Both groups place a strong emphasis on being personal and informal. Hence, the health care practitioner must build a relationship first before any real work can be accomplished. Remember that for these groups the Anglo emphasis on individualism is at odds with the family centered approach in these groups. Therefore, even illness and health care becomes a family affair.

22. 22 The mode of communication for Caucasian Americans: Greater eye contact when listening Head nods, non-verbal Quick responding Objective, task-oriented Barriers To Effective Communication with Minority Elders2 Sue & Sue (2003) proposed a specific schema for assessing communication styles of Caucasian Americans. Direct eye contact is important and assumptions are made about persons who �cannot look you in the eye.� Less eye contact when talking than when listening. Tend to speak loud and fast in order to control the listener. Verbal expressions of feelings are common and expected. Non verbal head nods, facial expressions and body positioning are examples used to indicate listening. Priority on efficiency and impersonality. Caucasian Americans� emphasis on directness of speech, i.e. get to the point, is often at odds with the indirect manner of ethnic minority groups. This preference for �direct communication� may lead them to miss significant parts of the communication interaction with minority ethnic clients.Sue & Sue (2003) proposed a specific schema for assessing communication styles of Caucasian Americans. Direct eye contact is important and assumptions are made about persons who �cannot look you in the eye.� Less eye contact when talking than when listening. Tend to speak loud and fast in order to control the listener. Verbal expressions of feelings are common and expected. Non verbal head nods, facial expressions and body positioning are examples used to indicate listening. Priority on efficiency and impersonality. Caucasian Americans� emphasis on directness of speech, i.e. get to the point, is often at odds with the indirect manner of ethnic minority groups. This preference for �direct communication� may lead them to miss significant parts of the communication interaction with minority ethnic clients.

23. 23 The mode of communication for African Americans: Direct eye contact speaking, less listening Interrupt turn taking when able Quicker responding Affective, emotional, interpersonal Barriers To Effective Communication with Minority Elders2,7 Sue & Sue (2003) proposed a specific schematic for assessing the communication styles of African Americans. African Americans tend to be uncomfortable with direct eye contact in situations where they are communicating with a person in authority. More direct eye contact when talking than when listening. Feelings, especially anger feelings, may be demonstrated in a forceful manner through highly aggressive and threatening verbal forms. However, Winkleman (1999) points out that this manner of behaving are generally not followed by the actions threatened. Are often impatient to get their position across and will often interrupt in order to be heard. This may be misinterpreted as aggression rather than communication style. Emphasis is on a personal, personable, oral and relational style. Therefore will Seek helping relationships that are based on mutual respect and sharing of information (often personal information) instead of a superior-inferior hierarchy that characterizes many professional relationships.Sue & Sue (2003) proposed a specific schematic for assessing the communication styles of African Americans. African Americans tend to be uncomfortable with direct eye contact in situations where they are communicating with a person in authority. More direct eye contact when talking than when listening. Feelings, especially anger feelings, may be demonstrated in a forceful manner through highly aggressive and threatening verbal forms. However, Winkleman (1999) points out that this manner of behaving are generally not followed by the actions threatened. Are often impatient to get their position across and will often interrupt in order to be heard. This may be misinterpreted as aggression rather than communication style. Emphasis is on a personal, personable, oral and relational style. Therefore will Seek helping relationships that are based on mutual respect and sharing of information (often personal information) instead of a superior-inferior hierarchy that characterizes many professional relationships.

24. 24 Impact of Health Provider Style and Perception on Communication The key to effective health care intervention with elderly minority is the practitioner�s ability to examine his or her own biases and prejudices. The practitioners must understand the potential impact of racism and discrimination. Biases and prejudices may impact the assessment and intervention planning. The key to any effective health care intervention with elderly minority clients rests initially with the practitioner�s ability to examine his or her own biases and prejudices prior to engaging in an evaluation of minority clients who do not share the same race and ethnicity as the practitioner. The practitioners must understand the potential impact of racism and discrimination on the helping relationship with minority elderly clients. Since biases and prejudices may impact the assessment and intervention planning, an effective practitioner will do a self-evaluation to gauge what may negatively impact his/her ability to make appropriate assessments. Assessing one�s assumptions about ethnics communication becomes a challenge particularly for majority health care providers. Requires an awareness and assessment of one�s stereotypical beliefs and prejudices; also requires some alteration in how one communicates with minority elders.The key to any effective health care intervention with elderly minority clients rests initially with the practitioner�s ability to examine his or her own biases and prejudices prior to engaging in an evaluation of minority clients who do not share the same race and ethnicity as the practitioner. The practitioners must understand the potential impact of racism and discrimination on the helping relationship with minority elderly clients. Since biases and prejudices may impact the assessment and intervention planning, an effective practitioner will do a self-evaluation to gauge what may negatively impact his/her ability to make appropriate assessments. Assessing one�s assumptions about ethnics communication becomes a challenge particularly for majority health care providers. Requires an awareness and assessment of one�s stereotypical beliefs and prejudices; also requires some alteration in how one communicates with minority elders.

25. 25 Impact of Health Provider Style and Perception on Communication2,5 Assessment of minority�s health care needs must include an acceptance of cultural beliefs and traditions. Techniques have been designed to reduce language barriers. Knowing how minority elderly view health and illness, the health provider can more easily incorporate this knowledge into the intervention. Assessment of the minority consumer�s health care needs must include an acceptance of cultural beliefs and traditions, even when these do not fit into the practitioner�s frame of reference. Majority practitioners� dependence on standard English as the only mode of communication hampers an effective relationship. In some ways it may be viewed as ethnocentric (Ewalt et al. 1999: Sue & Sue, 2003). Reducing language barriers is critical to the effectiveness of intervention. Remember, many ethnic elders utilize health care services when practitioners are able to speak their native language or when the office environment reflects a cross-cultural sensitivity by the use of music, decorations, and available literature. Unless these elements are present, ethnic minority elders are less likely to feel welcome or to utilize services. Encouraging minority elders to utilize existing health care services and identifying health care needs will result in better understanding between health care practitioner and the minority elderly client. Techniques have been designed to reduce language barriers (Sue & Sue, 2003; Ewalt et al., 1999) Knowing how minority elderly view health and illness, the health provider can more easily incorporate this knowledge into the intervention. Assessment of the minority consumer�s health care needs must include an acceptance of cultural beliefs and traditions, even when these do not fit into the practitioner�s frame of reference. Majority practitioners� dependence on standard English as the only mode of communication hampers an effective relationship. In some ways it may be viewed as ethnocentric (Ewalt et al. 1999: Sue & Sue, 2003). Reducing language barriers is critical to the effectiveness of intervention. Remember, many ethnic elders utilize health care services when practitioners are able to speak their native language or when the office environment reflects a cross-cultural sensitivity by the use of music, decorations, and available literature. Unless these elements are present, ethnic minority elders are less likely to feel welcome or to utilize services. Encouraging minority elders to utilize existing health care services and identifying health care needs will result in better understanding between health care practitioner and the minority elderly client. Techniques have been designed to reduce language barriers (Sue & Sue, 2003; Ewalt et al., 1999) Knowing how minority elderly view health and illness, the health provider can more easily incorporate this knowledge into the intervention.

26. 26 Elements of Health Provider Style and Perception on Communication Key words Family members as translators Beliefs and values Key ethnic customs Preconceived stereotypes Natural support systems Learn key words in the language of ethnic elders. It has been documented that language and communication barriers are primary deterrents to the utilization of health care services by ethnic elders. Avoid using family members, especially children, as translators. It is best to use trained persons, if possible. If family member is the only available person, make sure he/she only translates and does not interpret what the elder is saying. Become familiar with the beliefs and values regarding respect, health and illness. Although minority elderly clients are impacted by certain diseases, they traditionally have not sought health services. Learn key ethnic customs and rituals of the ethnic elders that you serve. This can potentially facilitate quality health services. Suspend any preconceived stereotypes and prejudice. Prejudice, negative attitudes and a distant personality can interfere with communication. Use the natural support systems of ethnic elders in assessment and intervention. Remember, many ethnic minority elders believe that fold medicine can be effective in the treatment of their medical problems. If illness has a physical cause the belief is that it can be cured with herbs, teas, and other natural substances, If illness is thought to be the result of occult or spiritual factors (including evil spirits) fold healers may be consulted.Learn key words in the language of ethnic elders. It has been documented that language and communication barriers are primary deterrents to the utilization of health care services by ethnic elders. Avoid using family members, especially children, as translators. It is best to use trained persons, if possible. If family member is the only available person, make sure he/she only translates and does not interpret what the elder is saying. Become familiar with the beliefs and values regarding respect, health and illness. Although minority elderly clients are impacted by certain diseases, they traditionally have not sought health services. Learn key ethnic customs and rituals of the ethnic elders that you serve. This can potentially facilitate quality health services. Suspend any preconceived stereotypes and prejudice. Prejudice, negative attitudes and a distant personality can interfere with communication. Use the natural support systems of ethnic elders in assessment and intervention. Remember, many ethnic minority elders believe that fold medicine can be effective in the treatment of their medical problems. If illness has a physical cause the belief is that it can be cured with herbs, teas, and other natural substances, If illness is thought to be the result of occult or spiritual factors (including evil spirits) fold healers may be consulted.

27. 27 Further Techniques that Facilitate Cross-Cultural Communication2,5 Strategies that providers should use to positively impact communication include: Accept Address Introduce Don�t rush Rules for acceptable attentiveness Understand personal positioning In order for health care professionals to be effective in their work with minority elderly they must communicate effectively. Putting aside their notions about speech patterns and non-verbal gestures. Strategies proposed by Ewalt and colleagues (1999) and Sue & Sue (2003) that providers should use to positively impact communication include: Accept the elderly consumer unconditionally. It�s important that ethnic elders are treated with warmth, dignity and respect. Address the ethnic elderly client by his/her last name. Avoid condescending terms as � dear�, �honey�, �grandma�, �grandpa�, �auntie�, or any other label. Introduce yourself clearly to the consumer. Prepare to become personal, i.e., the practitioner may need to self-disclose. Minority elders need to feel that they know the person and can trust him/her. Do not rush the consumer. Maintain an unhurried pace; many older consumers require a longer time to formulate their thoughts and to respond. Understand the rules for levels of acceptable attentiveness in one-on-one conversation. Maintaining eye contact in mainstream culture is desirable and suggests that one is listening and is alert. Constant eye contact is considered disrespectful and rude among African, Hispanic, and Native Americans cultures. Understand personal positioning. In some cultures, standing close to the speaker is considered disrespectful, while health care providers from the dominant culture might find this uncomfortable.In order for health care professionals to be effective in their work with minority elderly they must communicate effectively. Putting aside their notions about speech patterns and non-verbal gestures. Strategies proposed by Ewalt and colleagues (1999) and Sue & Sue (2003) that providers should use to positively impact communication include: Accept the elderly consumer unconditionally. It�s important that ethnic elders are treated with warmth, dignity and respect. Address the ethnic elderly client by his/her last name. Avoid condescending terms as � dear�, �honey�, �grandma�, �grandpa�, �auntie�, or any other label. Introduce yourself clearly to the consumer. Prepare to become personal, i.e., the practitioner may need to self-disclose. Minority elders need to feel that they know the person and can trust him/her. Do not rush the consumer. Maintain an unhurried pace; many older consumers require a longer time to formulate their thoughts and to respond. Understand the rules for levels of acceptable attentiveness in one-on-one conversation. Maintaining eye contact in mainstream culture is desirable and suggests that one is listening and is alert. Constant eye contact is considered disrespectful and rude among African, Hispanic, and Native Americans cultures. Understand personal positioning. In some cultures, standing close to the speaker is considered disrespectful, while health care providers from the dominant culture might find this uncomfortable.

28. 28 Conclusions Communication exchanges between minority elderly clients and health care practitioners is an essential element in the health care process. Effective communication can be particularly difficult when the minority elderly clients uses words, sentences and phonology that is not part of the language of the health care practitioner. Practitioners are encouraged to seek out ways to better understand these clients and employ strategies that will facilitate better communication that will result in more effective health care delivery to these clients. Specifically needed is that specific intervention strategies and models of health care treatment that guide professional education and training are a must. Likewise, incorporating strategies for routinely assessing the quality of health care services to these disenfranchasized ethnic minority elderly groups is an essential requirement of any health care provider.Specifically needed is that specific intervention strategies and models of health care treatment that guide professional education and training are a must. Likewise, incorporating strategies for routinely assessing the quality of health care services to these disenfranchasized ethnic minority elderly groups is an essential requirement of any health care provider.

29. 29 Conclusions Perhaps the first step in this process is for the practitioner to better understand their own biases and stereotypes about diverse cultural groups and to seek ways to grow in acceptance and respect for group differences. This will require adapting one�s intervention style to the culture of the client. These changes must occur at the practitioner level as well as the organizational and societal levels if meaning health care is to reach these groups. See supplemental Word documents to use Activity V. See supplemental Word documents to use Activity V.

30. 30 Author Biography Christine R. Boone is Professor and Chairperson of the Department of Human Services at South Carolina State University in Orangeburg, SC and has taught in social work programs in North Carolina and Africa. She received her undergraduate degree at North Carolina College, the MSW at Rutgers University and the DSW at Howard University.