Salma Abdul1 was born and grew up in Bangladesh. Her children left for the US to study, then settled in the country as permanent residents. When her husband died, she found herself alone. Her children, unable to leave their lives in the US, but worried about her aging alone, asked her to come and join them in America. When Abdul arrived in the USA at 69 years of age, she had to find her feet in a brand new country and culture. Her adopted country was technologically more advanced and spoke a language she didn’t understand. Its culture was completely different from hers. Its systems were complex and, because she couldn’t speak fluent English, harder to navigate.
With the numbers of immigrant elderly surging in cities like NYC, cultural competency on the part of service providers like hospitals becomes ever more important.
“I feel tension in my mind,”: Being ill and unable to communicate
Abdul’s real troubles began when she became ill with kidney disease and had to visit a city hospital on her own. Her children were pre-occupied with work and demands from their young families, and couldn’t spare the time. The hospital had few interpreters. Intake staff at the hospital couldn’t speak Bengali and instead made her access the Translation Hotline and tell the disembodied voice at the other of the phone her symptoms. Doctors ignored what she was struggling to say in her broken English, or dismissed her after a cursory examination.
Discrimination as a barrier to care
According to a study in the Journal of General Internal Medicine, researchers analyzed data from 6,017 Americans older than 50 who took part in a Health and Retirement Study and found that one out of five of these adults experience discrimination in healthcare settings, and one in 17 experiences it frequently. “Ageism in healthcare is very common and experienced by many older adults,” says lead author Stephanie Rogers, MD, MPAS, MPH, a clinical geriatric fellow at University of California San Francisco. There have also been several studies that prove that immigrants in particular report more discrimination in healthcare settings (Derose et al., 2009).
In Abdul’s case, she “found it difficult to understand the instructions the doctors gave her or the questions he asked her,” said Afroditi Panna, India Home’s Case Manager. Abdul’s daughter also spoke to Panna. Abdul’s daughter felt her mother, was being ignored and treatment options were left unexplained, perhaps because she was older immigrant woman of color who spoke hardly any English. The doctors and nurses would explain things to her when she accompanied her mother, Abdul’s daughter reported, however, when her mother went alone, they would be unresponsive and “not nice”.
“That’s when we decided to start accompanying Salma to the hospital because, as with so many of our immigrant elders, she didn’t know what questions to ask her doctor, how to fill forms, or even where to go, or how to get to different specialists,” Panna said.
Case managers and cultural Interpreters
In her experience with Care Management, Panna said, older adults need help with much more than just paperwork. Sometimes, she and her team are called upon to become interlocutors between cultures.
For instance, when a doctor asks a Bangladeshi senior, how she feels emotionally or mentally she’ll invariably answer, “amar onek tension,” or “I have a lot of tension in my mind.” In Bengali culture, the English word tension is often used as a catch all term for anxiety or depression or worry, and other distressing mental issues. Most American doctors don’t understand this culturally specific term, unless someone with cultural competence (like an accompanying case worker) can explain what the elder means.
Salma Abdul’s case highlights an important point that often gets lost in the scramble to deliver aging services: with the numbers of immigrant elderly surging in cities like NYC, cultural competency on the part of service providers becomes ever more important.
The fact that her team speaks Bengali and understands South Asian ways has made a huge difference in her clients lives, says Afroditi Panna, the Case Manager at India Home.
How to deliver Culturally Responsive Care
At India Home, where we have culturally competent and multi-lingual staff like Panna, working with our South Asian elder population, we have found that the culture from which our elders come affects all aspects of their behavior. For example, it affects whether they seek help, the kind of help they seek, the symptoms and concerns they bring to their doctor or their family’s attention. Here are some of the guidelines that our case workers and managers follow in order to become more cuturally responsive:
Maintaining the tradition of respecting elders: A focus on engaging clients in a manner that is consistent with their cultural values and adapting communication to be consistent with the client’s traditions. For example, in Asian and South Asian culture this would entail addressing our elders with a honorific and never by their name. It would also mean case workers listen respectfully (and patiently) so that the elder feels understood and establishes rapport before rushing into the business at hand. It would mean being respectful of cultural norms around touch, personal space and so on.
Involving the Family: Mostofour immigrant elders live with their families and are dependent on them. Individualistic Western methods where the patient is solely responsible for their own welfare may need to be modified for aging South Asian elders. Other family members may have to be made familiar with the treatment process and involved actively in their care. To take Abdul’s case as representative: our case workers engaged with her family members and took the time to talk to them and explain her treatment.
Framing issues in culturally relevant ways: For example, music and art therapy is used in Western practice to reduce tension and stress, but some South Asians older adults may have restrictions based on their religious beliefs on the kind of music or they are allowed to listen to or the art they may practice. A culturally competent case worker may have to advise the Western doctor to come up with alternate methods to help her client to cope.
Facilitatingcollaboration: Many older adults have learned important ways of coping with life’s stress and have developed impressive resilience that is informed not only by their experiences but also by specific cultural beliefs and values. Our case workers learn a lot by showing cultural humility and listening and learning from our clients. These are some of the ways in which India Home’s case management department is developing client-agency interactions. It’s an evolving art Ms. Panna says and her team learns something new every day. But for her, she says:
“cultural competent case management means that for every one of our 75 active cases, our clients feel that we understand their concerns, and that we are treating them with respect. We want them to feel that we hear them.”
Join India Home and the Diverse Elders Coalition for a Twitter chat about cultural competence in aging services on Wednesday, March 21st at 3pm EST. Follow the hashtag #CultCompMatters to join in.
1 Names have been changed to protect privacy of the client.
By Nibras Karim, Hunter College Asian American Studies Program Intern
The Captain Tilly Park in Jamaica, is named after Captain George H. Tilly who was a local son of a prominent Jamaica family who was killed while fighting in the American war in the Philippines in 1899. The park is a local destination for Jamaica residents to relax and enjoy public space and greenery in their neighborhood. Situated on nine acres, the park is in the heart of Jamaica and a peaceful getaway from the hustle and bustle of the city.
On September 21, 2017, as part of our effort to help with the health, fitness, and mental wellbeing of the seniors of our Desi Senior Center, we took them out for a change of environment and had them try some new activities they hadn’t done before. The seniors really enjoyed the scenery that the Captain Tilly Park had to offer such as the ducks and Canadian geese swimming about. They also enjoyed the picnic we had brought. They did their exercises outside and enjoyed the fresh air.
One highlight of the day was when they played games like carrom board and ludu. Carrom is a “strike and pocket” table game similar to billiards. Instead of using cue sticks and billiard balls, carrom is played by using different sized and colored pieces called carrom men. Some of the seniors were very passionate about winning the carrom board games. Prizes were given out to the winners of the games.
After they ate their picnic, they sang Bengali folk songs, solo and in chorus with others. Everyone was very supportive of each other regardless of their singing abilities. In the end of the picnic, all the seniors thanked the director of our Desi Senior Center Dilafroz Nargis Ahmed for making this wonderful picnic a possibility.
Last year, Narendra Butala, a long time member of India Home, was facing a health crisis. He had been feeling breathless for a while. His blood pressure would drop suddenly and he would sweat profusely.
Still, he was afraid to go to the cardiologist because his brother had got a pacemaker in 2004 and had passed away shortly after. Even as he worried about the condition of his heart, he heard from one of his relatives. Pacemaker technology had changed, she said, and urged him to get a check-up. Finally, in July, a few months after his 78th birthday, Butala, took the plunge and went to Mount Sinai Hospital in New York City, and got a pacemaker inserted. “I was home after two hours,” he said. “They monitor my heart from the hospital, remotely.”
South Asian seniors like Mr. Narendra Butala (left) will benefit from a new bill introduced by Rep. Pramila Jayapal that targets heart health in the community
Mr. Butala, who emigrated from India 20 years ago, lives an active lifestyle, and is a life-long vegetarian who doesn’t smoke. At first glance, he would not appear to be a typical candidate for heart disease. However, there is one indicator that increases his risk exponentially – his South Asian descent. Several recent studies have found that all over the world, individuals of South Asian descent account for 60 percent of heart disease patients. A study conducted by the University of California San Francisco found that in the United States, South Asians have the highest death rate from heart disease compared to other ethnic groups. Other research published in the Annals of Internal Medicine, discovered an even more troubling trend. Among people of normal BMI (Body Mass Index), South Asians were twice as likely as whites to have risk factors for heart disease.
BMI, a height-to-weight ratio, is used to determine whether someone is overweight or obese. Body Mass Index and weight are often the first numbers doctors consider. Many doctors may not screen for heart disease and Type 2 diabetes if they are within normal range, but what the study indicated was that when it came to South Asians, even patients of normal weight were showing risk factors for heart disease.
Fortunately, someone in the federal government has been paying attention to these concerning numbers. Representative Pramila Jayapal (D-Washington) introduced in the House in late July a bill aimed at the issue of high levels of heart disease in the South Asian American community. Called the “South Asian Heart Health Awareness and Research Act,” the bill garnered bipartisan support and was co-sponsored by 18 other members of Congress, including Rep. Joe Wilson (R-South Carolina).
In an email to NBC News, Jayapal said that she introduced the bill because she thinks the US, needs, “to take action by expanding funding for research and spreading awareness targeting [these] communities. We’ll save lives and reach a better understanding of heart health that will benefit all Americans.”
Rep. Pramila Jayapal (D-Washington) sponsored the “South Asian Heart Health Awareness and Research Act,” in the House of Representatives.
NBC News reported that the bill would “establish grants at the Centers for Disease Control and the National Institutes of Health to provide information about heart health to South Asian-American communities and fund medical research on cardiovascular disease in South Asians in the U.S. The bill would also fund grants through the U.S. Department of Agriculture for the promotion of better South Asian heart health nutrition.”
India Home, which runs the largest South Asian senior center in the North-East, has made its own modest contribution to improve heart health among the older South Asian adults it serves. Regular yoga, meditation and Ayurveda is taught at its centers along with holistic and healthful ways to exercise and maintain their physical and mental wellness. Moreover, in partnership with NYU Langone’s Center for the Study of Asian American Health (CSAAH), India Home has introduced its members to a number of educational projects like Keep On Track / REACH FAR.
Eighty seniors from India Home took part in Reach Far, a project in collaboration with NYU Langone, which taught community volunteers to monitor blood pressure for better heart health.
This project trained 26 volunteers at India Home to monitor blood pressure as part of a Community Health Assessment. Over 80 Bengali seniors from India Home’s Desi Senior Center participated in the project. Another project helped to disseminate nutrition information with culturally and linguistically adapted brochures in Bengali and Hindi and taught seniors how to measure their food portions and try new nutrition strategies.
As for Mr. Butala, he’s back at India Home’s Sunnyside center, being the first to volunteer to push the lunch cart, as usual. “I’m feeling fine,” he said the other day. “The doctor said I can do all activities.”
We are collaborating with a sister organization, Sapna NYC, on the Tiffin Project. The project is named after the “Tiffin,” a stainless-steel three-tiered utensil that is used to transport lunch in South Asia. In the city of Mumbai for instance, home cooked meals are delivered to workers in offices and factories by an army of delivery men or “Tiffin Walas” on bicycles, rickshaws and motorbikes.
The Tiffin Project, helmed by Michelin-starred, Chef Surbhi Sahni, brings the familiar tastes of a home-cooked meal to our elders. On Thursdays, the congregate meal we serve at our Queens Community House program in Kew Gardens is a healthy, culturally appropriate 6-item vegetarian lunch from Sapna NYC.
The Tiffin Project also helps in the “economic empowerment of low income South Asian women,” who lack “job seeking skills, work experience and English language proficiency, ” according to Sapna NYC.
India Home collaborates with Sapna NYC to help underserved women bring culturally appropriate meals to our elders
India Home recently undertook a Needs Assessment Survey of the Bangladeshi elders we serve in order to gain an objective and honest understanding of their needs. In the tradition of our partnerships with universities, the survey was conducted by graduate students from Hunter College Urban Policy & Leadership Graduate Research. The findings from the survey were published in a report titled “Migrating from Bangladesh to New York: Needs of Seniors.” Working closely with India Home’s staff, graduate students, Katherine Elston, Marc Fernandes Oriade, Tanik Harbor and Jormary Melo co-authored the report.
The 2010 US Census reported that the New York metropolitan area is home to the largest concentration of South Asians in the United States. Bangladeshi seniors were the fastest growing group among all seniors in New York City, increasing at a rate of over 600% between 2000 and 2014, according to the Asian American Federation’s 2016 American Community Survey.
Moreover, 52% of the respondents in Jamaica had arrived in the US only within the last five years, and an additional 15% within the last ten. As a result, 77% of Bangladeshi seniors have limited English proficiency–a fact that points to an even greater need for immediate support.
The elders were asked 4 questions:
What are the current housing needs for Bangladeshi seniors in regards to being both affordable as well as culturally-specific?
What physical and mental health issues are impacting these seniors?
Is access to quality health care available in their community?
How does transportation (or lack of) impact their daily lives?
A robust survey tool and interview template was used to get answers from the elders at India Home’s Desi Senior Center. The survey was administered to 106 survey respondents and to nine key informants chosen from among other non-profits and leaders serving the community. The responses yielded a rich trove of data which was then analyzed to provide findings and make recommendations for the future.
Community Gaps and How to Move Forward
The research provided strong evidence of need for Bangladeshi seniors in Jamaica. The research team identified key findings within housing, mental and physical health, and transportation. In addition, the data revealed two important underlying concerns that should be addressed immediately.
1. Bangladeshi seniors face the highest rates of poverty and low income status across New York City.
2. As one of the newest senior immigrant populations in the region, their English language skills are low. This lack of proficiency makes it extremely hard for these seniors to navigate the community and the social service resources they need for support.
Furthermore, the findings from this needs assessment in Jamaica show even higher rates of lack of income and limited English proficiency than previously collected data from other city-wide research efforts.
Elders fill out the surveys created by Hunter College Urban Policy and Leadership Graduate Research
A few of the key findings to the initial four questions include:
Lack of affordable culturally-specific independent senior housing in Jamaica
high levels of social isolation and the stigma seniors face in regard to talking about their state of mental health
the absence of chronic disease management and the negative impact of poor diet and limited exercise on their quality of life
the underutilization of the public transit system due to cost, language barriers, and discomfort in navigating the system.
The research teams recommended that all needs identified within the report be integrated into India Home’s long-term strategic plan and the specific recommendations provided be taken up for implementation.
expanding daily services at the center
creating innovative programs for seniors and their families
strengthening existing community partnerships as well as building new ones, and
continuing to collect data to gain a deeper understanding of the community.
The report felt that by incorporating the report’s recommendations, India Home can further its mission to address the inequities that impact the most vulnerable community member, and help transform Jamaica’s Bangladeshi senior population from one with great needs to one with greater assets.
Everett Lo leads the Regional Network for the White House Initiative of Asian American Pacific Islander that has over 33 agencies under it’s purview.
Jan 11, 2017, Jamaica– India Home hosted a Listening Session with the White House Initiative on Asian and Pacific Islander Americans at the Desi Senior Center in Jamaica, Queens, NY. Everett Lo, as the lead for the Regional Network for WHIAAPI, helped India Home put together the Listening Session which brought together an unprecedented number of representatives of federal, state, and local government. These agencies included the Administration for Community Living (ACL), the Centers for Medicare and Medicaid Services (CMS), US Customs and Immigration Services (USCIS), the US Department of Labor (USDOL), the Substance Abuse and Mental Health Services Administration (SAMHSA) and more. The aim of the Listening Session was two-fold: on the one hand it was to inform our Bangladeshi elders about the range of government services available to them. On the other, it allowed the representatives on the panel to hear directly from our elders and understand their unique concerns. An interpreter translated their remarks into Bengali so the elders could follow along.
Each representative spoke about the scope of their agency and its abilities to meet the needs of our elders: for instance, Shyconia Burden of USCIS talked about waivers that are available to elders taking the citizenship test and warned them about the dangers of handing original documents to unauthorized agents. Dennis Romero of SHAMSA discussed the support services available to combat addictions to prescription medicines.
Elders Get Answers
The representatives spent the second hour answering questions from the 70+ elders gathered in the room. A large majority of questions had to do with immigration and citizenship. Our clients wanted to know more about the citizenship test, the rules for affidavits of support and so on. Medicaid and the ACA was another topic that gave rise to a lot of questions. Some common themes emerged. Our elders were concerned with access across the board: whether it was access to language, health care, information in a way they could understand or transportation and metro cards.
India Home’s Desi Senior Center provides congregate meals, ESL and exercise classes, cultural activities and social connection to over 150 elders a day, three times a week. The elders we serve face unique challenges: 74% of all Bangladeshis in New York City were born outside the USA and 53% have limited English proficiency. Anecdotal and case management evidence tells us that some of them are unfamiliar with American systems. Many elders struggle to understand how health insurance or the subway works.
Panel of speakers brought in by the White House Initiative for Asian American Pacific Islanders
Shyconia Burden of USCIS got a lot of questions from our speakers. (right) Ms. Mahbooba Kabita, interpreted remarks into Bengali
Putting a Face to the Issues
The panel was an opportunity for our immigrant elders to see American democracy in action and understand that the government is not some remote entity, but made up of people who, in theory at least, work for them. Our elders got an opportunity to meet the agencies which make the decisions that directly impact their lives. For the representatives at the table it was a chance to put faces to and connect with the clients they make critical decisions about, and understand their unique culture and circumstances.
New York University’s Center for the Study of Asian American Health (CSAAH) held a community health forum at our Desi Senior Center on Tuesday, September 26th. The forum celebrated the advances in the health of our seniors thanks to our partnership with CSAAH. MD Taher is the Project Coordinator for NYU’s Department of Population Health and a Community Health Worker with CSAAH. He has, for the past several months, helped to coordinate impactful health projects at the Desi Senior Center in Jamaica. “We wanted to share our results with the community, celebrate their health,” he said. Also being celebrated was our successful partnership with New York University’s Center for the Study of Asian American Health (CSAAH), which is the leading institute in the US set up to study Asian American health. Our collaboration with the institute has helped facilitate and advance several health projects.
We wanted to tell the community what our findings were, and thank the seniors from India Home, MD Taher, Project Coordinator, NYU Department of Population Health, said.
These projects fill a necessary void in care because as MD Taher said: “There are serious health concerns in the community.” One in four Bangladeshis have diabetes. One in five suffer from hypertension.
One of these projects, titled Keep On Track / Reach Far trained 26 volunteers at India Home to monitor blood pressure as part of a Community Health Assessment. Over 80 seniors from Desi Senior Center participated in the project.
Other projects too have had a direct impact on the health of our seniors. One helped to disseminate nutrition information with culturally and linguistically adapted brochures in Bengali and Hindi. “They came many, many times to the center to teach our seniors about nutrition. They gave them a cup and a spoon, taught them how to measure their food portions, ” Nargis Ahmed, the Site Director for Desi Senior Center said. Nargis worked closely with the NYU team to get seniors to try these new nutrition strategies.
The team from CSAAH shared the finding from various projects with the seniors at India Home’s Desi Senior Center.
Another important innovation has been CSAAH’s partnership with five area pharmacies to create linguistically adapted health materials in Hindi and Bengali, the languages spoken by our seniors. CSAAH also launched a nutrition strategy by working with area restaurants like Star Kabab in Jamaica to replace ingredients in common dishes so as to make them healthier. For example, switching white rice with brown in kitchurie ( a Bengali rice and lentil dish) increased its nutrition content. CSAAH has also partnered with local mosques to serve healthier foods for the iftar meal that breaks the Ramadan fast.
Other CSAAH projects like the DREAM (Diabetes Research, Education, and Action for Minorities) project, a five-year community based participatory research study, have also had success in improving attitudes toward health in the Bangladeshi community. The DREAM project aims to develop, implement, and test a Community Health Worker (CHW) Program designed to improve diabetes control and diabetes-related health complications in the Bangladeshi community in New York City. As a result of this effort at diabetes management, over 400 patients who participated across the city lost weight, became more active physically, managed their medications better and saw their doctors regularly.
The community health forum was held in the spirit of transparency and partnership and sought to update the seniors who participated in the projects and create ongoing dialogue. “We wanted to tell the community what our findings were,” MD Taher said. “And thank them.” The forum was well attended by community leaders, partners, local businesses, policy makers, and media partners.
Dr. Nadia Islam, PhD, the Deputy Director and co-investigator of the Center for the Study of Asian American Health presents findings on the DREAM Project.
The response from the community of seniors has been excellent. Even with all the barriers like work, taking care of grandchildren and busy lives, participants have been able to maintain the lifestyle changes they made as a result of the projects. India Home is happy to have done its part in improving the lives of our seniors. In the face of the rapidly growing older adult population of Bengali seniors in New York City, India Home’s vision is to continue to be a leading resource to our seniors and agencies and institutions that are working to respond to their changing and emerging needs. “Our seniors were very happy that they learned new things and I plan to continue to remind them,” Nargis Ahmed said.