Services for Latino Family Dementia Caregivers: Is the Workforce Prepared?

The American healthcare system is ill-fitted to meet the needs of the growing population with Alzheimer's and Related Dementias (ADRD) and their caregivers, which disproportionately affects Latinos. This paper describes the caregiving process for Latino patients with ADRD from the perspective of caregivers and service providers to reveal service areas in need of improvement. Ten providers and 24 Latino caregivers were interviewed through the Miami-Dade County Aging Network. Interviews were analyzed using a grounded theory approach. Five themes emerged: lack of social service connectivity, case management challenges, unmet mental health needs, language barriers, and the need for alternative service models. Our analysis indicates insufficient training and the need to improve dementia competencies, support strategies, and understanding of cultural nuances among service providers. These findings can help inform the development of a required ADRD provider education curriculum that incorporates cultural competency training to improve the quality and effectiveness of care.

Care v. Caring: Obligation, Duty, and Love Among Latino Alzheimer's Family Caregivers.

The number of Latinos living with Alzheimer's disease is projected to grow. Latinos currently make one-fifth of U.S. family caregivers. In this paper, we explore the cultural scripts and gendered practice of care in Latino families in relation to the underutilization of services to persons with Alzheimer's disease and related dementias. We conducted interviews with 24 Latino caregivers in Miami-Dade, Florida representing six Latin American countries of origin. Interviews were analyzed using a grounded theory approach. We critically examined the concept of familism in order to better understand in-depth experiences of diverse Latino caregivers and concluded that an ethics of care model better elucidates the complexities of the care experience. Our analysis illustrates the ambivalence, contradictions, and changes in the beliefs and practice of care. These findings can help advance understanding among researchers and providers to develop a formal support system that is responsive to Latino caregiver needs.

The Experience of Alzheimer's Disease Family Caregivers in a Latino Community: Expectations and Incongruences in Support Services.

OBJECTIVES: Current theoretical constructs on the utilization of formal support for Latino caregivers focus on familism and exclude the cultural values represented in the service system. The purpose of this paper is to highlight the experience of care for Latino family caregivers to persons with Alzheimer's disease and related dementias (ADRD). We also examine the cultural congruence between provider perspectives with the expectations of Latino ADRD caregivers. METHOD: We conducted extended interviews with 24 Latino ADRD caregivers and 10 service providers. Interview transcripts were coded and analyzed using a grounded theory approach. RESULTS: Our study provides a deeper understanding of Latino caregiving experiences and highlights some of the structural and systematic issues in current systems of caregiver support. While Latino families have very specific notions of care, by upholding notions of familism, there is a tendency to not look deeper into how they may be better supported in caregiving and fall into the "culture trap." The assumption that family should be the natural support network for older adults may lead to health and social systems of care to ignore the specific needs of the Latino population. DISCUSSION: Services are being provided under a model that was established four decades ago and may not reflect current realities. The concept of "an ethics of care" allows us to move beyond familism and explain that underutilization of services may also be due in part to the cultural incongruence between what service providers offer and the perceived needs of Latino caregivers.

Empowering the Latino Community Related to Palliative Care and Chronic Disease Management through Promotores de Salud (Community Health Workers).

Background: Latinos are the largest minority group in the United States and when compared with non-Latino whites suffer from higher rates of certain chronic diseases. Latino community health workers (promotores de salud) are successful in improving the health of their communities. However, evidence of their effectiveness in increasing awareness of palliative care (PC) is limited. Objective: To evaluate the feasibility of applying a promotores de salud model to improve PC awareness among Latinos within the context of chronic disease management. Methods: Bilingual promotores from Familias en Acción trained 76 southern California promotores on PC and chronic disease management. Promotores agreed to disseminate the information learned to 10+ Latino community members. The strengths of the curriculum and the community's needs were identified during phone interviews six months post-training. Results: In 406 diverse settings, 69 promotores trained 2734 community members. Interviews with promotores at follow-up established four themes: (1) holistic health in chronic disease management; (2) communication with doctors; (3) shared decision making, patients' rights, and control; and (4) need for PC information (awareness, access, and support groups). Conclusion:Promotores proved effective at disseminating information related to PC within chronic disease management to Latino community members. Future training should include information on support groups and where caregivers can seek help while caring for those with a terminal disease.

Service-Learning through conference-based, interdisciplinary workshops on Age-Friendly design.

For three consecutive years, the Age-Friendly Design Committee (AFDC) of the Academy for Gerontology in Higher Education (AGHE) used AGHE's annual meeting as a platform to conduct community-based service-learning workshops focusing on age-friendly design. These workshops assembled local stakeholders, conference attendees from multiple disciplines, and landscape and architectural designers to discuss age-friendly design issues and solutions for local environments. Each workshop provided hands-on design experience and the opportunity for AGHE participants to contribute to conference host communities by using their gerontological expertise to translate knowledge into practice. Local stakeholders learned the value of gerontological input when considering design issues. We describe the process of incorporating service-learning into the conference experience through age-friendly design workshops and how these bring together students, faculty, and design professionals from different backgrounds and disciplines to address local age-friendly design issues.

Balance and Gait of Frail, Pre-Frail, and Robust Older Hispanics.

Older Hispanics are an understudied minority group in the US, and further understanding of the association between frailty, gait and balance impairments in disadvantaged older Hispanics is needed. The objectives of this study were to compare the balance and gait of older Hispanics by their frailty status. Sixty-three older Hispanics (21 men, 42 women, mean age 75 ± 7 years) attending senior centers in disadvantaged neighborhoods were grouped by their frailty status and completed balance and walking tests at a preferred speed and during street crossing simulations. Sixteen percent (n = 10) of the participants were frail, 71% (n = 45) were pre-frail, and 13% (n = 8) were robust. Frail participants had poorer balance than robust participants (F = 3.5, p = 0.042). The preferred walking speed of frail and pre-frail participants was lower (F = 6.3, p < 0.011) and they took shorter steps (F > 3.5, p = 0.002) than robust participants. During street crossing conditions, frail participants had wider steps (F = 3.3, p = 0.040), while pre-frail participants walked slower (F = 3.6, p = 0.032), and both took shorter steps than robust participants (F > 3.5, p < 0.043). Frailty and pre-frailty were prevalent and associated with gait and balance impairments in disadvantaged older Hispanics. The findings can inform the development of programs and interventions targeting this vulnerable underserved population.

Increasing Awareness on Health Care Access in Florida: A Community-Based Medical-Legal Practicum Project.

PROBLEM: Service learning and experiential coursework has become a requirement for medical students and law students. Advocacy for the underinsured and uninsured is of ethical importance to both the practice of law and medicine, however engaging professional students in meaningful advocacy work with community partners can be challenging. PURPOSE: The article describes a partnership between medical and law students in a community-based service learning project to promote health care access. KEY POINTS: Law and medical students at Florida International University partnered with community members and Florida Legal Services to collect patient narratives, disseminate information on Medicaid expansion to community members, and present patient stories to state lawmakers. CONCLUSIONS: The medical and law students learned about each other's professional roles and gained skills in interviewing, and legislative and policy advocacy through this service learning project by providing legislative testimony to key stakeholders and community education on Medicaid expansion.

Breast Health Disparities: A Primer for Medical Students.

INTRODUCTION: While breast cancer incidence rates have remained stable and mortality rates have declined for white women, breast cancer mortality has steadily increased for African American women since the 1950s. It has often been assumed that genetic risks linked to African ancestry are the cause for these disparities. However, a better understanding of the role of stress and social and environmental factors in health lends evidence to the social determinants behind the increasing gaps in breast health outcomes. This resource's goal is to raise awareness among undergraduate medical students about breast cancer disparities, particularly the late-stage diagnoses and the higher mortality rate for African American women. METHODS: Our educational session included a lecture on basic epidemiological data and information on breast cancer etiology followed by a case study, which was created with the founder of a local cancer support and resource center serving mainly African American women diagnosed with breast cancer. As part of the case exercise, we utilized concept mapping as a tool to apply learning. RESULTS: Pre-/postquizzes showed significant improvements in knowledge and confidence in working with patients. Narrative reflections from students indicated an improvement in targeting at-risk populations, educating patients about their risk and options, and understanding the complex role that socioeconomic factors may play in patient outcomes. DISCUSSION: By raising awareness and exposing medical students to the socioeconomic and cultural aspects of breast health, we hope to improve medical students' knowledge of risk factors and preventive strategies, as well as their abilities to guide patients through appropriate screening and follow-up.

Twelve tips for teaching social determinants of health in medicine.

BACKGROUND: There has been a recent movement towards social accountability in medical schools, which includes integrating the social, economic, and cultural determinants of health into the curriculum. Medical schools and their guiding bodies have met this challenge of educating future physicians to provide effective care to diverse populations with varying response and successes. Because these topics have not been systematically taught in most medical school curricula, strategies are needed to teach them alongside clinical sciences. AIM AND METHOD: We provide 12 tips on how to teach social determinants of health and cultural competency to undergraduate medical students. These recommendations are based on a review of the literature and our experience in developing and delivering a longitudinal course over the last five years. CONCLUSION: Medical students must be taught to think critically about the social and cultural issues impacting health, and the intersection with the basic biology and clinical skills. Teaching social determinants of health in medicine requires keeping the material concrete and applicable. Educators must engage students in active learning strategies, reflection, and focus on how to make the material relevant to the clinical care of patients.

Examining functional and social determinants of depression in community-dwelling older adults: implications for practice.

Coping with declining health, physical illnesses and complex medical regimens, which are all too common among many older adults, requires significant lifestyle changes and causes increasing self-management demands. Depression occurs in community-dwelling older adults as both demands and losses increase, but this problem is drastically underestimated and under-recognized. Depressive symptoms are often attributed to physical illnesses and thus overlooked, resulting in lack of appropriate treatment and diminished quality of life. The purpose of this study is to assess prevalence of depressive symptoms in community-dwelling older adults with high levels of co-morbidity and to identify correlates of depression. In this sample of 533 homebound older adults screened (76.1% female, 71.8% white, mean age 78.5 years) who were screened using the Geriatric Depression Scale (SF), 35.9% scored greater than 5. Decreased satisfaction with family support (p << 0.001) and functional status (p ≤ 0.001) and increased loneliness (p < 0.001) were significant independent predictors of depression status in this sample; thus, these factors should be considered when planning care.

Impact of an academic-community partnership in medical education on community health: evaluation of a novel student-based home visitation program.

OBJECTIVES: Current US healthcare delivery systems do not adequately address healthcare demands. Physicians are integral but rarely emphasize prevention as a primary tool to change health outcomes. Home visitation is an effective method for changing health outcomes in some populations. The Florida International University Herbert Wertheim College of Medicine Green Family Foundation NeighborhoodHELP service-learning program assigns medical students to be members of interprofessional teams that conduct household visits to determine their healthcare needs. METHODS: We performed a prospective evaluation of 330 households randomly assigned to one of two groups: visitation from a student team (intervention group) or limited intervention (control group). The program design allowed randomly selected control households to replace intervention-group households that left the program of their own volition. All of the households were surveyed at baseline and after 1 year of participation in the study. RESULTS: After 1 year in the program and after adjustment for confounders, intervention group households proved more likely (P ≤ 0.05) than control households to have undergone physical examinations, blood pressure monitoring, and cervical cytology screenings. Cholesterol screenings and mammograms were borderline significant (P = 0.05 and P = 0.06, respectively). CONCLUSIONS: This study supports the value of home visitation by interprofessional student teams as an effective way to increase the use of preventive health measures. The study underscores the important role interprofessional student teams may play in improving the health of US communities, while students concurrently learn about primary prevention and primary care.

A community-based approach for integrating geriatrics and gerontology into undergraduate medical education.

Medical school accreditation requirements require educational opportunities in geriatrics. Twenty-six minimum graduating competencies in geriatrics have recently been identified for medical students. The authors describe how these competencies are being integrated into a new medical curriculum through coursework and community-based experiences. This approach is intended to expose students to older adults from diverse communities and adequately prepare students to address the complex and individual needs of these patients. Initial results indicate proficiency in the minimum geriatric competencies covered. The growth and diversity of the older adult population makes it important to integrate and evaluate geriatrics education in undergraduate medical education.

Perspectives on Latino lay health promoter programs: Maryland, 2009.

OBJECTIVES: We examined common barriers and best practices in the design, implementation, monitoring, and evaluation of Latino lay health promoter programs. METHODS: Ten lay health promoter program coordinators serving Maryland Latinos were recruited in 2009 through snowball sampling for in-depth semistructured interviews with a bilingual and bicultural researcher. Program coordinators were asked about recruitment, selection, training, and supervision; key program elements; and evaluation. Analyses were conducted to identify common themes. RESULTS: Respondents had worked up to 13 years in programs focused on such areas as awareness of healthy lifestyles and reducing risk of illness. Coordinators looked for Latino leaders with team-building skills and a desire to help the community. Six programs compensated promoters with stipends; 4 paid an hourly wage. Promoters were usually trained in monthly meetings that actively engaged them. Most programs conducted site visits, practice sessions, and performance evaluations. CONCLUSIONS: Our findings indicate that successful health promoter programs require needs assessments, formation of a target population advisory board, identification of appropriate promoters, and a significant amount of training. These findings can be used to guide future programs in the identification, recruitment, and training of health promoters as well as in program monitoring.

Invisible civic engagement among older adults: valuing the contributions of informal volunteering.

There is a growing call for civic engagement, largely in the form of formal volunteering, among older adults in America. This call is a response to the aging of the baby boom population, believed to be the healthiest and wealthiest cohort of older adults to date. It also coincides with the devolution of welfare programs. We argue that current discussions of civic engagement are too narrow and may exclude important informal contributions that older adults make to civic society, and put undue stress on, and devalue those who may not contribute to society due to poor health, poverty or other barriers. We draw on data collected from older adults of lower socio-economic status and diverse ethnic backgrounds in Baltimore City using focus groups to explore their definitions of volunteering and barriers which they face. Through a discussion of existing barriers and motivators for engagement, we critically assess the use of these terms and advance discussions on how to facilitate and value contributions of all older adults. We conclude that civic engagement includes more than formal volunteering and that significant barriers need to be removed to facilitate greater participation of all elders in both formal and informal activities.

Engaging older adults in high impact volunteering that enhances health: recruitment and retention in The Experience Corps Baltimore.

Engagement in social and generative activities has benefits for the well-being of older adults; hence, methods for broadly engaging them in such activities are desired. Experience Corps Baltimore, a social model for health promotion for older adult volunteers in public schools, offers insight to such successful recruitment and retention. We report on data over a 4-year period in Baltimore City, Maryland, and describe a five-stage screening process implemented to recruit a diverse group of senior volunteers who would remain in the program for at least 1 year. The sample consisted of 443 older adults expressing an interest in and screened for volunteering. Comparisons were made with Chi-square and Fisher's t-test between those who entered the program and those who did not and those who were retained in the program. Gender, race, age group, and prior volunteering were significant in ultimate volunteer service in the schools. Overall, 38% of 443 persons recruited entered the schools; 94% of participants were over 60 years (p = 0.05) with a mean age of 69 years; 90% were women (p = 0.03), and 93% African-American (p = 0.005); 57% had not volunteered in the past year (p = 0.004). Ninety-two percent were retained in the first year; 80% returned a second year. Among the latter, 83% had <12 years of education (p = 0.001). Participants remained in the program for a second year of volunteering regardless of baseline MMSE score, self-reported health, and motivation for volunteering. In conclusion, it is possible to recruit and retain a diverse pool of older adults to participate in a high-intensity volunteer program, including non-traditional volunteers. Of special note is the success in recruiting African-American women and those with lower education, who may particularly benefit from health promotion.