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Disclaimer
Information within this resource may be freely used provided the
source is acknowledged. Every effort has been made to ensure that
the information in this resource is correct. Waitemata District Health
Board and the authors will not accept any responsibility for
information which is incorrect and where action has been taken as a
result of the information in this resource.
This resource is commissioned by the Northern Regional Alliance
Limited Agency as part of the Asian, Refugee and Migrant Health
programme.
This was oriignally published in 2014.
It has been reviewed, updated and republished in March 2017,
by Waitemata District Health Board, eCALD® Services.
Authors: Dr Annette Mortensen and Sue Lim
ISBN 978-0-473-37506-5 (Paperback)
ISBN 978-0-473-37507-2 (PDF)
ISBN 978-0-473-37508-9 (HTML)
Website: www.eCALD.com
Suggested citation:
Waitemata DHB, eCALD® Services (2017). CALD Older People
Resource for Health Providers: Working with Asian, Middle Eastern
and African Older People. Auckland: WDHB, eCALD® Services.
Retrieved from:
http://www.ecald.com/Resources/Cross-Cultural-Resources/ToolkitsManager/type/View/ID/1867.
Copyrights © Waitemata District Health Board (WDHB).
This resource is available in limited paperback edition and also
available in PDF version, as well as a HTML online tool accessible via
www.eCALD.com. NB: the HTML online version has additional video
case scenarios not available in the paperback and the PDF versions.
Updated: 27 March 2017
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Table of Contents
Welcome ........................................................................................................................ 1
Who this resource is for ........................................................................................................ 1
What this resource aims to do .............................................................................................. 2
What this resource does not include .................................................................................... 3
How this resource is organised ............................................................................................. 3
Background .................................................................................................................... 5
Introduction .......................................................................................................................... 5
CALD older populations......................................................................................................... 6
Asian older population .......................................................................................................... 6
Middle Eastern and African older population ....................................................................... 7
Assessment, Treatment & Rehabilitation (AT&R) ......................................................... 9
AT&R services for Chinese older people ............................................................................... 9
AT&R services for South Asian older people....................................................................... 11
AT&R services for Middle Eastern/African older people .................................................... 14
CALD Older People Assessment Tool .................................................................................. 16
Case study ........................................................................................................................... 17
Key considerations .............................................................................................................. 18
Dementia...................................................................................................................... 21
Introduction ........................................................................................................................ 21
Family perceptions of dementia ......................................................................................... 21
Accessing dementia services ............................................................................................... 22
Carers of CALD people with dementia ................................................................................ 22
Stigma and shame ............................................................................................................... 23
Cognitive screening tools .................................................................................................... 24
Culturally appropriate cognitive screening tools ................................................................ 24
Day care services ................................................................................................................. 25
Cultural Considerations ....................................................................................................... 26
Summary of Best Practice Guidelines ................................................................................. 29
Case studies......................................................................................................................... 30
Key considerations .............................................................................................................. 34
Stroke ........................................................................................................................... 35
Overview ............................................................................................................................. 35
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Case studies......................................................................................................................... 36
Key Considerations.............................................................................................................. 39
Mental health............................................................................................................... 40
Acculturation stressors ....................................................................................................... 40
Utilisation of mental health services .................................................................................. 40
Case studies......................................................................................................................... 41
Key considerations .............................................................................................................. 46
Needs Assessment and Co-ordination (NASC) Service ................................................ 47
NASC for CALD over 65s ...................................................................................................... 47
Attitudes towards Home Based Support Service (HBSS) and Residential Aged Care (RAC) 47
Home health services in the Auckland Region .................................................................... 48
Case study ........................................................................................................................... 49
Key considerations .............................................................................................................. 50
Residential aged care ...................................................................................................51
Emotional support .............................................................................................................. 51
Case study ........................................................................................................................... 51
Key considerations .............................................................................................................. 54
Elder Abuse and Neglect .............................................................................................. 55
What is elder abuse and neglect? ....................................................................................... 55
CALD communities and elder abuse ................................................................................... 56
Culturally appropriate screening and assessment .............................................................. 57
Elder abuse and neglect – social work intervention ........................................................... 58
Case studies......................................................................................................................... 59
Case study 3: Elder abuse in the family: Mrs Jang’s story .................................................. 60
Key considerations .............................................................................................................. 63
Advance Care Plan and Advance Directive ..................................................................64
Advance Care Plan (ACP) ..................................................................................................... 64
Advance Directive (AD) ....................................................................................................... 64
Enduring Power of Attorney (EPA) ...................................................................................... 64
Cultural perspectives........................................................................................................... 65
Culturally appropriate ACP.................................................................................................. 67
Case study ........................................................................................................................... 70
Key considerations .............................................................................................................. 72
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End-of-life care............................................................................................................. 74
Decision making .................................................................................................................. 74
Communicating bad news................................................................................................... 76
Hospices .............................................................................................................................. 77
Death and dying .................................................................................................................. 77
Culturally appropriate end-of-life care ............................................................................... 81
Case studies......................................................................................................................... 85
Key considerations .............................................................................................................. 90
Resources ..................................................................................................................... 92
Day care programmes for CALD groups .............................................................................. 92
Hospices .............................................................................................................................. 96
Translated information flyer: A Guide for Carers ................................................................ 96
The SuperGold Card ............................................................................................................ 97
Primary Health Interpreting Service ................................................................................... 97
Enduring Power of Attorney ............................................................................................... 98
Services for CALD older people - elder abuse and neglect ................................................. 99
Tools and Guidelines ..................................................................................................100
CALD Older People Assessment Tool ................................................................................ 100
CALD End-of-Life Care Assessment Tool ........................................................................... 104
Culturally appropriate dementia assessment tools .......................................................... 106
Guidelines for developing trust and rapport .................................................................... 106
Guidelines for improving communication ........................................................................ 107
Guidelines for working effectively with interpreters ........................................................ 107
Terms Used and Glossary...........................................................................................109
Summary of terms and definitions used in this resource ................................................. 109
Glossary ............................................................................................................................. 110
Acknowledgements....................................................................................................111
References .................................................................................................................112
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Welcome
This culturally and linguistically diverse (CALD) older people resource is the first of its kind in
New Zealand. It has been written because Asian groups now comprise 22% of the Auckland
region population and Middle Eastern and African peoples are increasing in number
(Statistics New Zealand (SNZ), 2013).
Many CALD families experience confusion and stress when trying to navigate care and
support services for their older relatives. As just one example, the Ministry of Health (2013)
New Zealand Framework for Dementia Care, together with the health and social support
sector, recognises that dementia care needs to be improved nationwide in a way that is
inclusive of Asian and other ethnic minority groups. In 2011, 1838 (3.7 percent) of the
estimated 48,182 people with dementia were Asian. By 2026, of the estimated 78,267
people with dementia in New Zealand, 6568 (8.4 percent) are expected to be Asian
(Alzheimers New Zealand, 2012).
There are many cultural reasons that may prevent families from seeking support for older
family members. In Asian, Middle Eastern and African cultures, it is important for elders to
be looked after by their own family. Cultural factors may delay families from seeking
support, leading to increased stress for both the carers and the older person. Language
barriers are significant for non-English speaking older people (Ministry of Health, 2013). The
CALD Older People Resource for Health Providers is intended to support the health and
disability workforce to provide culturally competent care for older peoples from Asian,
Middle Eastern and African backgrounds and their families.
Who this resource is for
The purpose of this resource is to enable health providers
to gain understanding around what is required to provide culturally
appropriate care to CALD older people.
This resource is for health providers working with CALD older people and their families in
primary, community, mental health, secondary care, home-based support services (HBSS)
and residential aged care (RAC) settings. The resource serves as a reference for the online
CALD older people resource and complements the CALD Cultural Competency Training
Programme.
It is expected that viewers of this resource will:
1. Have completed CALD 1: Culture and Cultural Competency.
2. Be familiar with Ministry of Health and DHB protocols on interventions in suspected
cases of Elder Abuse and Neglect.
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Additionally it is highly recommended that the viewers of this resource will:
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Have completed CALD 2: Working with Migrants (Asian) clients course.
Have completed CALD 3: Working with Refugee clients course.
Have completed CALD 4: Working with Interpreters course.
Additional valuable information on working in a culturally competent way with migrants,
refugees and interpreters can be found in the following courses and supplementary
resources:
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CALD 5: Working with Asian mental health clients.
CALD 7: Working with religious diversity.
CALD 9: Working in a mental health context with CALD clients.
Supplementary resources:
1. Working with Asian clients in mental health.
2. Working with Middle Eastern and African clients in mental health.
The resource is aligned to relevant competency standards and professional development
frameworks, such as the Ministry of Health (2008) National professional development
framework for palliative care nursing in Aotearoa New Zealand; the New Zealand
Framework for Dementia Care (MoH, 2013); and the Age Concern New Zealand (2012)
protocols for elder abuse screening and intervention.
The University of Auckland (2016) CALD Guidelines for Dementia Patients in Aged Residential
Care is also recommended to be read in conjunction with this resource for working with
Dementia patients.
What this resource aims to do
The purpose of this resource is to provide:
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Information about Asian, Middle Eastern and African older adult populations.
General cultural perspectives for CALD communities including working with families,
decision-making, religious and cultural practices and its implication for practice.
Cultural perspectives, cultural approaches and case scenarios for health
practitioners in the following areas and services:
 Assessment, Treatment and Rehabilitation.
 Dementia.
 Stroke.
 Mental Health.
 Needs Assessment and Coordination (NASC).
 Residential Aged Care (RAC).
 Elder Abuse and Neglect.
 Advance Care Plan and Advance Directive.
 End-of-life Care.
Resources.
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What this resource does not include
This resource assumes that health practitioners are familiar with Health of Older People
Health Service Providers and agencies, for example: Needs Assessment and Co-ordination
Service (NASC), Assessment, Treatment and Rehabilitation services (AT&R), and Age
Concern; older people’s entitlements (e.g., Age Concern taxi chits, meals on wheels, free
shuttle transport, etc.); and when and how to refer older people to such entitlements and
agencies and services appropriately. Information about support services for older people is
available on the Ministry of Health website: http://www.health.govt.nz/yourhealth/services-and-support/health-care-services/services-older-people/support-servicesolder-people.
How this resource is organised
Welcome: This provides an overview of what this resource is designed to achieve and its
scope.
Background: This section provides an introduction to the topic, including a summary of
definitions and terms, and some broad considerations for service providers working with
older CALD clients. It includes an overview of Asian, Middle Eastern and African (Asian/MEA)
populations the health status of Asian/MEA older people.
Assessment Treatment and Rehabilitation (AT&R): This section provides cultural
information and tips for working with CALD clients.
Dementia: This section looks at cultural viewpoints on dementia and caring for older people
with dementia. It also provides recommended tools for assessing CALD clients.
Stroke: This section looks at cultural perspectives about care giving and the impact of stroke
on clients and their families with recommended approaches for service providers.
Mental Health: This section provides information about service barriers and the utilisation
of services by CALD older people; and includes assessment tools and key considerations.
Needs Assessment and Co-ordination (NASC): This section provides an overview of the
responses of CALD clients and their families towards home-based support services (HBSS)
and Residential Aged Care (RAC) and recommends approaches for NASC services.
Residential Aged Care: This section gives an overview of what is required for culturally
competent care.
Elder Abuse and Neglect: This section provides cultural contexts for the neglect and abuse
of older people and offers culturally appropriate approaches.
Advance Care Plan and Advance Directives: This section provides information about the
impact of a client’s cultural background on their willingness to participate in Advance Care
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Plans and Advance Directives; and culturally appropriate approaches to addressing these
issues with CALD clients.
End-of-life Care: Cultural perspectives ont end-of-life care and the role of the family are
provided. Considerations around culturally appropriate end-of-life care and guidelines are
also included.
Resources for CALD people over 65: This contains information about the services available
for this group.
Tools and guidelines: This contains tools and guidelines for your use.
4
Background
Introduction
This CALD resource provides research materials and guidelines for health providers working
with CALD older people from Asian/South Asian, Middle Eastern and African older age
groups settled in the Auckland region.
The resource discusses specific health issues and common health and cultural beliefs and
practices for the care of older age groups. Culturally appropriate communication strategies
including the use of interpreters are described. Culturally appropriate health screening and
assessment tools are included. The resource informs health providers about best practice for
CALD older people and their families, using practical tips and case scenarios.
Topics in this resource include:
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Family systems and care giving in CALD communities.
Assessment, Treatment and Rehabilitation (AT&R) services.
Dementia and culturally appropriate assessment tools.
Stroke.
Mental health.
Residential Aged Care (RAC).
Screening for elder abuse and neglect.
Advance Care Plans and Advance Directives.
End-of-life care.
Services and resources for CALD older people.
The first step in the provision of culturally appropriate health and personal care for CALD
older people is to address issues around language and communication (Centre for Cultural
Diversity in Ageing, 2010).
The cultural and religious needs of older people must also be identified and incorporated in
health and personal care service provision. Culture and religion influence the way CALD
older people respond to illness, ageing and health care. Understanding cultural and religious
practices and expectations will assist in the provision of culturally appropriate health and
personal care for older people and their families (Mhlanga, 2008).
Health providers caring for older people also need to understand the impact of migration
and the refugee experience and social isolation in new societies; as well as of role changes
and intergenerational conflict in the family (Hokoyeda & Tanabe, 2010; Ho, Lewin & Muntz,
2010; Ip, Lui &Chui, 2007; Jang, Kim & Chiriboga, 2005).
5
It is recommended that health providers:

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Have broad understandings of the impact of migration; and the refugee experiences
of CALD older people.
Do not assume that CALD older people have extended family and community
support networks.
Use professional interpreters.
Understand the role of family and communities in CALD older people’s lives.
Develop knowledge of culturally appropriate referral agencies where available.
CALD older populations
CALD older populations in this document refer to people from Asian, and Middle Eastern
and African (MEA) backgrounds who are culturally and linguistically diverse.
Asian older population
Demography
The term ‘Asian’ refers to people originating from countries in West Asia (Afghanistan and
Nepal); South Asia (covering the Indian sub-continent); East Asia (covering China, North and
South Korea, Taiwan, Hong Kong and Japan); and South East Asia (Singapore, Malaysia, the
Philippines, Vietnam, Thailand, Myanmar, Laos and Cambodia).
Asian groups are diverse in their cultures, languages, religions, educational status and
migration or refugee experiences. However, they do share certain collective cultural values
and orientations. It is important to note that some Asian communities have settled in New
Zealand for three or more generations and that not all Asian older people are newcomers.
Asian groups now comprise 22% of the region’s population (SNZ, 2013). In 2010, around
310,000 Asian people resided in the Auckland region, comprising 127,000 Chinese, 100,000
Indians and 84,000 Other Asian people. Asian groups were the second largest ethnic group
in Auckland DHB, Waitemata DHB and across the Auckland region and the third largest
group in Counties Manukau DHB after European/Other and Pacific peoples (Mehta, 2012).
One third of all Asian migrants have been in New Zealand fewer than five years.
People aged 65 years or older, comprise around 10% of the Auckland population. Census
2013 show significant growth in the Asian over 75 years age group compared to Census 2006
(SNZ, 2013).
Asian older people population characteristics
Greater cultural diversity in Auckland region populations and an increase in Asian older
adults, has led to an increased awareness of the cultural needs of Asian older people and
their families. The migrant experience for Asian older people can be particularly stressful
6
due to factors such as limited or no English language proficiency; limited incomes; loneliness
and isolation.
Asian older people’s adjustment to New Zealand society is affected by their: pre-migration
history; countries of origin; cultural backgrounds; socioeconomic status in their country of
origin; prior history of living in an urban versus a rural environment; and reasons for
migration (political, economic, familial). Successful integration in New Zealand society is
influenced by: the proximity of other older people who speak the same language;
participation in cultural and religious communities and ethnic social clubs. Asian people who
migrate at an older age may find themselves isolated in their new surroundings. As
newcomers, they must adapt to a new and alien culture and language. For these reasons,
daily life in a new environment may become stressful for older people (Kalavar & Willigan,
2005).
Chinese and Korean older people who have migrated to join their children often arrive to
help care for their grandchildren. Older migrants in Chinese and Korean communities may
speak little English. Chinese and Korean older people tend to hold on to traditional values
of gender expectation, age hierarchy, filial piety and collectivity (Stokes-Chen & Pan, 2010).
In traditional South Asian societies, extended family members usually live together as a
single family unit. When families migrate, often, the husband’s parents will join them,
particularly when help is needed with child-rearing. Grandparents’ roles in raising children is
highly respected, and provides an important link to cultural and religious heritages. Parents
who have migrated to join family are often financially dependent on their children. They
face the challenges of being in a culturally alien society, may face language barriers, role
reversal, a loss of status and a restricted lifestyle (Periyakoil & Dara, 2010; Sohn, 2010).
Health status of Asian older people
The healthy migrant effect abates over time as acculturation occurs. The health needs
assessment of Asian people living in the Auckland region shows that CVD mortality rates are
rising among Indians, and the burden of diabetes is increasing in other Asian communities
and, to a lesser extent, among Chinese people in Auckland (Mehta, 2012).
The Health needs assessment of Asian people living in the Auckland region (Mehta, 2012)
provides further information about the health status of Asian peoples.
Middle Eastern and African older population
Demography
Census 2013 data shows that Middle Eastern, Latin American and African (MELAA) groups
living in the Auckland region have increased since the 2006 Census from 1.3% to 1.7% of the
Auckland region population (SNZ 2013). Approximately 80% of MELAA peoples are born
overseas (Perumal, 2011).
7
The Health needs assessment of Middle Eastern, Latin American and African people living in
the Auckland region shows significant deprivation in Middle Eastern and African groups
(Perumal, 2011). Most people in the Middle Eastern and African groups live in rental
accommodation and many in crowded accommodation. Almost 60% of Africans and 55% of
Middle Eastern people were on the unemployment benefit (Perumal, 2011).
The effects of the refugee experience
It is important to recognise that those who have arrived in New Zealand as refugees and
asylum seekers, or as the family members of refugees, may be in poorer health than
‘voluntary’ migrants.
Refugees have faced significant periods of civil war, loss of family and community, flight to
countries of asylum, and years in dangerous refugee camps. Refugees may experience
significant mental and emotional distress as a result of their refugee experiences, and
further being resettled in an alien society. Like migrant groups, refugees may experience a
loss of status and respect once settled in New Zealand. Many refugees face discrimination in
employment and rates of unemployment are high in refugee communities. Older people
from refugee backgrounds face the problems of loneliness and isolation in New Zealand;
along with intergenerational issues, which impacts on their mental health and wellbeing.
Health status of Middle Eastern and African older people
Middle Eastern people in the Auckland Region have a higher estimated prevalence of
cardiovascular disease (CVD) than Europeans and Pacific people (Perumal, 2011). In males,
Africans have a marked rise in CVD prevalence from age 55 years onwards, becoming the
ethnicity with the highest prevalence in the 75+ year age group, compared with all other
ethnicities. In women, Middle Eastern people appeared to have a similar trend in the
prevalence of CVD as that of Pacific people, which was higher than European women until
74 years of age. Middle Eastern people have higher rates of hospitalisations from angina
and chest pain than ‘Others’ and Maori and Pacific peoples.
All three MELAA ethnicities have approximately double the prevalence of diabetes
compared with Europeans in Auckland, with Middle Eastern people having the highest
prevalence (Perumal, 2011). All MELAA ethnicities have a markedly higher prevalence of
diabetes than Europeans from age 35 years onward. In men, African people had a higher
rate of hospitalisation from diabetes than ’Others’ and Maori. Both Middle Eastern men and
women have higher rates of hospitalisations from diabetes than their counterparts in
‘Others’. The mortality rate and cancer registration rate in adults from cancer from all
causes appears highest in Middle Eastern people compared with all other ethnicities
(Perumal, 2011).
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Assessment, Treatment & Rehabilitation (AT&R)
AT&R services provide specialist inpatient services for older people and are dedicated to
improving and maintaining their health and independence. Services are a mix of geriatric
medicine and rehabilitation for older clients who often have multiple or complex needs.
AT&R services receive referrals for clients from the community/primary care sector and
from acute hospital services. They provide care and rehabilitation for older people including
those recovering from an injury, illness or age-related conditions such as stroke or
Parkinson’s disease.
These services help older people tackle the problems associated with disability or ageing
that are affecting their day to day living. Practitioners work with the client and their family
to plan care and to help the client achieve their healthcare goals. The AT&R team may
include doctors, nurses, physiotherapists, occupational therapists, speech language
therapists, social workers and needs assessors depending on the client’s issues and goals.
A CALD Older Person Assessment Tool is available under Tools and Guidelines at the end of
this resource book. This provides tips for practitioners who are assessing the health and
social status of older people from diverse cultural backgrounds.
The following section provides specific cultural information which is useful for the
assessment, treatment and rehabilitation of Chinese, South Asian and Middle Eastern older
people.
AT&R services for Chinese older people
Assessment

Formalistic conformity/deference to authority
Clients may not verbalise anxiety or doubts regarding their medical care in front of
clinicians, but they may not follow through with treatments. This can be misinterpreted
as client non-compliance.
This deference to authority can also be misconstrued as a lack of interest in
participating in medical decision making. It is a good idea to briefly summarise the plan
of care, and to ask questions so that client’s concerns can be addressed.

Decision makers
Decision makers are traditionally expected to be the husband or oldest son. However,
this may change depending on the degree of acculturation. Thus, it is a good idea to ask
the client whether they would want to make their own decisions about health care, or
defer to other family representatives. It is also important to clarify that the doctor
cannot act as the surrogate decision maker for the client.
9

“Saving face”
The concept of “keeping one’s good reputation” may make it harder for older people to
admit to having problems, especially mental health and family problems. Clients who
do not want to lose face with the doctor may not want to question or disagree with
them directly, resulting in the client not coming back for follow up, or not taking
medications as prescribed.

Concepts of yin/yang and “chi” or “qi” (vital energy)
Traditional Chinese Medicine (TCM) is the most common form of healthcare among first
generation migrants. TCM is mainly guided by a holistic concept of health that
emphasises achieving balance and harmony throughout the bodily systems. Many older
Chinese people use TCM and allopathic medicine in a complementary fashion (StokesChen & Pan, 2010).
Treatment

Role of the health provider
In order to put the client at ease, it is important to take a little time to chat before
beginning the clinical interview, to address clients with respect (Mr or Mrs) and to try to
pronounce names correctly. It is appropriate to ask the client how to pronounce his/her
name. The basic concept of treating clients with respect, compassion and honesty is
regarded as paramount, regardless of the client’s cultural/ethnic background (StokesChen & Pan, 2010).
Other considerations:
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There may be a conflict with the Western concept of the client-doctor relationship
of partnership versus the doctor as authority.
Doctors are expected to make decisions and give instructions.
The doctor must be viewed as trustworthy, caring and willing to help.
Clients may hesitate to make direct eye contact, or may hesitate to ask questions or
voice opinions so as not to inconvenience others or appear disrespectful.
Some older people may feel uncomfortable with physical contact during
conversations.
Integration/awareness of Traditional Chinese Medical (TCM) treatments/beliefs
Many Chinese older people use TCM treatments. Therefore, a physician’s disregard or
lack of respect for these beliefs may lead to distrust. Open discussion and flexibility may
go a long way to achieving the best treatment outcome for the client.
10

Advance directive/end-of-life issues
Many Chinese older people may be reluctant to discuss these issues. However,
attitudes can change according to the degree of acculturation.
Clinicians need to take care and be aware of their clients’ beliefs when approaching
these issues with Chinese older people and their families. It is important to ask about
whether there is an accepted family decision maker.

Medications
Many less acculturated Chinese older people believe that Western medications are too
strong and may not take prescribed doses. Older Chinese people may be at risk for drug
interactions due to metabolic factors which alter the metabolism of drugs, and the
concurrent use of herbs and other Chinese medications (Chan et al., 2008).
Rehabilitation
It is a traditional Asian belief that resting is an important part of recovery especially
after major surgery. Some Asian older people may be reluctant to do exercise or help
themselves in daily activities. There may be a dilemma between western expectations
of gaining independence and client and family expectations of interdependence.
Increasing health professional efforts to explain the process and consequences of
rehabilitation will assist.
AT&R services for South Asian older people
Assessment

Formality of address
The concept of respect is an important one for traditional South Asian older people.
Providers should address clients with warmth and respect and use a formal mode of
address until given permission to use first names, if ever. Old age is often synonymous
with wisdom, and the concepts of filial piety are central, consequently older adults
expect deferential treatment as their due. Older South Asian people often treat the
doctor with the same level of respect and deference.

Role of the doctor
Older South Asian people may be more accustomed to a paternalistic medical system in
which the doctor determines the care plan and makes the decisions.

Gender issues
Older women may prefer to be examined by same-gender health practitioners. Having a
female relative available when examining an older woman is highly recommended as it
facilitates a frank interaction (e.g., questions concerning incontinence).
11
Married Hindu/Buddhist women may wear a sacred thread/gold chain with pendants
and beads around their necks. These should not be removed during examination or
surgery without the client’s approval. Sensitivity should be taken to protect the client’s
modesty (e.g., avoid short examination gowns). In addition, direct eye contact from
women to men may be limited.

Traditional beliefs
Although the biological causes of illness are understood, there is often believed that
illness and disability is caused by karma.
Treatment

Approaches to decision making
Many South Asian families have a hierarchy of decision makers, usually beginning with
the oldest son as the primary contact and disseminator of information.
Families may consult the GP often to get as much information as possible but may be
reluctant to discuss personal, emotional and financial issues with health providers.

Effective care plans
Most South Asian clients prefer a family-centred approach. Older adults and their
children often prefer not to disclose negative information to clients because they may
worry that the truth may take away hope and increase suffering.

Disclosure and consent
Older adults who are ill may practice “closed awareness”, i.e., although they may be
fully aware of the gravity of their illness, they may be unwilling to discuss the illness and
prognosis openly with their family. Family members may request that the physician
withhold information from their loved one.
The client may expect doctors to have all the answers and to make all the decisions for
the client. As a result, the client takes a passive role, answering but not asking
questions, and waiting for the doctor to give their diagnosis and recommendations.
Most of the time medical advice is accepted without question.

Value of assertiveness
A doctor who takes charge and gives prescriptions for medications may be preferred.
Doctors may be perceived as incompetent if they sound unsure.
For example, a less optimal way of communicating information to the client is:
Dr Murray: “Mrs Sharma, I am not sure if what you have is late onset lupus or
Sjogren’s Syndrome. Your test results are inconclusive. I am going to start you on a
medicine called hydroxychloroquin and see how you respond. What do you think?”
12
Mrs Sharma’s interpretation of the statement: “This doctor does not know what
disease I have. He wants to start me on a new medication and he is asking me what I
think? I am not a doctor? What can I say?”
Using Assertive Communication (adapted from Periyakoil & Dara, 2010) is a more
optimal way of stating the same information:
Dr Murray: “Mrs Sharma, there are two diseases that can mimic each other and
cause the symptoms you have. One is called lupus and the other is called Sjogren’s.
Your test results are not helping us identify the exact disease you have. Your
situation is not uncommon. I am going to start you on a medication which will help
your symptoms. I am also going to monitor your symptoms and blood work very
carefully to see how you respond to the medication. I need you to take the medicines
regularly and keep a log of your symptoms. I want you to come back to the clinic in
four weeks.”
Inpatient care

Hospital food
Many South Asian older adults observe religious dietary restrictions, e.g., many Hindus
are vegetarians or vegans. Older Hindus will consume milk and butter but not cheese
and eggs. Other considerations:




Beef is forbidden for Hindus who eat meat.
Muslim people require a halal diet.
Foods containing pork and pork products (gelatine, etc.) are prohibited for Muslims
and Hindus.
Hospital dress code
Some clients decline to wear hospital gowns and pyjamas as these have been used by
others, even when reassured that these have been washed and sterilised.
When a client in hospital has a sacred thread across their chest (in men, this is a
upanayanam) and around the neck in women (a mangalsutra), it should not be
removed or cut without the permission of the client or family.

Surgery and procedures
Some South Asian older adults may prefer to have surgery only on some auspicious
days and times of the day. This is less important during emergency procedures, but is a
challenge during elective procedures. It is important to explore this with the client and
their family when scheduling procedures and surgery, to negotiate a solution.

Medications
Many older South Asian clients may not adhere to the prescribed out-patient
medication regime. Many Hindu older people may be using Ayurvedic (pronounced:
13
Are-yer–ved–ic) medications (this is a form of traditional medicine and an alternative
treatment). It is important to elicit and document this in client notes.

Body care
Modesty is a strong South Asian value, especially for women. Older adults are averse to
being touched and examined, by a practitioner who is of the opposite gender, including
such procedures as ECGs enemas and catheterisation. Women are wary about breast
and cervical screening.
Clients strongly prefer care from a practitioner of the same gender if feasible. Family
members may want to help in providing intimate body care to avoid care being
provided from a care-giver of the opposite gender.

Communication
Communication with people with limited English is challenging. Family members may
insist on serving as interpreters. Using professional interpreters is strongly
recommended.

Visiting hours
Family and friends will often want to stay with a hospitalised person and be included in
performing personal care. This can result in a high volume of visitors. Visitors are
expected to spend a significant time with the client at the bedside.

Home health care
For many South Asian older adults, the activities of social workers and home-based
support services are unfamiliar and are often not welcomed. Family may seek help from
family and friends and are unlikely to place an older adult in residential aged care.
Rehabilitation
Some South Asian cultures may believe that resting is an important part of recovery
especially after a major surgery. If client’s are not willing to participate in exercise or
help in daily activities, it may be due to the client’s expectation of dependence on
family members for activities of daily living during recovery and rehabilitation.
Increasing health professional efforts to explain the process and consequences of
rehabilitation will assist.
AT&R services for Middle Eastern/African older people
Assessment

Formality of address
The concept of respect for older people is important in Middle Eastern/African
communities. Providers should address clients using formal modes of address, until or
unless clients give permission to use their first names.
14

Body Care
Modesty is a strong value for Middle Eastern and African communities, especially for
women. Older adults are averse to being touched and examined. This is also true for
procedures such as ECG, enemas and catheterisation. Women are wary about breast
and cervical screening. Clients will strongly prefer care from the same gender if
feasible. Family members may want to help in providing intimate body care to avoid
care from the opposite gender.

Religion and religious practices
Many but not all Middle Eastern older adults are Muslim. The client should be asked
their religion rather than making an assumption, and religious beliefs should be
respected.
Older people may wear religious articles and clothing (e.g., amulets, hijab or religious
caps). These should not be removed without the permission of the owner. The prayer
rug and the Koran must not be touched by anyone ritually unclean (e.g., with blood or
urine on the hands). It is preferable that nothing should be placed on top of these
sacred objects.
Hand washing is considered essential before and after eating. Water for washing is
needed in the same room as the toilet. Middle Eastern clients should be provided with
bowls or jugs of water in the toilet. If a bedpan has to be used, bowls or jugs of water
should also be provided at the bedside.

Sensitive issues
Questions about sexuality are considered to be extremely delicate and personal and
therefore must be asked with extreme sensitivity. Asking widowed and divorced
women about their sex life would be viewed as extremely insulting. It may be difficult
to elicit intimate details such as bodily functions and sexual history when the health
provider interviews the female client.

Residential aged care
Middle Eastern/African families do not consider this is a good option for older family
members. It is expected that adult children are responsible for the care of ageing
parents and will care for them at home. Women are customarily designated the
primary caregivers. This can result in a high degree of burden when caregivers feel the
traditional pressure of providing all elder care personally within the home setting.

Communication
Older adults (women in particular) may not speak English. Using a professional
interpreter acceptable to the client will need to be arranged. Providing a gendermatched interpreter is important.
15
Treatment

Approaches to decision making
Middle Eastern families are close-knit and the family unit often makes important
decisions.
Inpatient care

Hospital food
Halal and other religious dietary preferences must be provided. Foods containing pork
and pork products (gelatine, etc.) are prohibited for Muslims.

Hospital dress code
Older women prefer not to change into a gown even with a same sex chaperone unless
absolutely necessary.

Surgery and procedures
Some Middle Eastern older people may prefer not to have surgery during the fasting
month. This is less important during emergency procedures, but is a challenge during
elective procedures. It is important to explore this with the client and their family when
scheduling procedures and surgery, to negotiate a solution.

Body care
Modesty is a strong Middle Eastern value, especially for women. Unnecessary touching
between non-related people of the opposite sex should be avoided. Muslim clients,
particularly women, may need a special gown to cover the whole body in order to avoid
unnecessary exposure during physical examination.

Communication
Communication with people with limited English is challenging. Family members may
insist on serving as interpreters. Using professional interpreters is strongly
recommended.
CALD Older People Assessment Tool
The CALD Older People Assessment Tool is designed to assist health practitioners to deliver
culturally-competent care for older people from culturally diverse backgrounds.
The assessment tool is adapted from the Stanford School of Medicine’s Ethnogeriatric
Assessment (Periyakoil, 2013) and includes: health and social history taking; conducting a
physical examination; assessing cognitive, affective and functional status; home, family,
community and neighbourhood assessment; and talking about end of life preferences if
appropriate. Additionally, eliciting problem specific data; intervention specific data and
outcomes specific data are included.
16
The CALD Older People Assessment Tool is available under the “Tools and Guidelines”
section.
Case study
Mrs Xie
Mrs Xie is an 85 year old woman from mainland China. She has lived independently in her
own unit since her husband passed away five years ago. Her son and family moved to
Australia a year ago. Her osteoarthritis has progressively limited her ability to shop, cook and
clean her apartment.
Her concerned GP refers her to the AT&R service at the local hospital. The needs assessor on
the assessment team arranges for home-based support services on her return home to help
with shopping and cleaning.
Mrs Xie does not speak English. The caregiver, a European New Zealander, does not speak
Mandarin. After the first two visits, a Chinese neighbour comes over and tells the caregiver
that she can take a break because the unit is clean and Mrs Xie can manage the shopping.
When Mrs Xie next visits her GP, he notices that she is weak and exhausted. She has lost
weight and is disoriented.
Question:
How will you make sure that the assessment for Mrs Xie is culturally and linguistically
appropriate?
Discussion:
It is essential that health practitioners know how to assess language fluency, spoken
language and the need for an interpreter. They should also know how to access and arrange
a qualified interpreter for the assessment process.
The assessment team needs to be trained in cultural competency (eg be aware of how to
address and communicate with the client appropriately; be aware of the nuances of crosscultural interactions; know how to accommodate different cultural/religious
practices/beliefs/attitudes; know how to work with interpreters effectively; know what
behaviours are appropriate when entering a client’s home, etc).
Question: What will you need to consider in arranging Home Based Support Services?
Discussion:
If possible, it is important to provide a carer who can speak the client’s language. Carers
need to be culturally competent (eg how to address and communicate with the client
appropriately; be aware of the nuances of cross-cultural interactions; know how to
accommodate different cultural and religious practices, beliefs and attitudes; know how to
work with interpreters effectively; know what to observe when entering client’s home, etc).
17
Question: What particular considerations will the AT&R team need to address in the care
plan for Mrs Xie?
Discussion:






An interpreter will be needed for all interviews and interactions with Mrs Xie. Mrs Xie
will need an explanation of the roles of respective team members (eg
physiotherapists, occupational therapists, needs assessors, etc).
It will be important to Mrs Xie to have female health practitioners providing assistance
if needed with activities such as showering and dressing.
Mrs Xie may need assistance with food preparation. It will be necessary to understand
her preferred foods, cooking methods, and her understanding of a “balanced” diet will
need to be explored.
Mrs Xie has no family in New Zealand. It is possible that she may have family overseas
and it is good to attempt to contact them. Failing that, referral to a Chinese older
person’s support group will be important for ongoing support.
When eliciting information from Mrs Xie about her mental health status, it is
important to use culturally acceptable words and language to describe depression and
other psychiatric conditions.
It is usually important to involve family members when doing an assessment to help
confirm/clarify information and to help gather accurate family history. In this instance,
Mrs Xie has no family in New Zealand and therefore this is not possible.
Key considerations
Key considerations: AT&R
Role of the health provider






Formality of address


Older people may be more accustomed to a paternalistic medical
system in which the doctor determines the care plan and makes the
decisions.
A doctor who takes charge and gives prescriptions for medications may
be preferred.
Doctors are expected to make decisions and give instructions.
Doctors may be perceived as incompetent if they sound unsure.
The doctor must be viewed as trustworthy, caring and willing to help.
Some older people may feel uncomfortable with physical contact during
conversations.
To put the client at ease, it is important to take a little time to chat
before beginning the clinical interview; to address clients with respect
(Mr or Mrs) and to try to pronounce names correctly. It is appropriate
to ask the client how to pronounce his/her name.
Older adults should be treated with the utmost courtesy and respect.
During the assessment interview with the older adult it is important not
to forget that formality and respectfulness must be conveyed during the
meeting. Providers should use a formal mode of address until given
18
Key considerations: AT&R

Formalistic
conformity/deference to
authority
Decision makers and
approach to decision making





Gender issues




Effective care plans
Specific cultural
considerations


permission to use first names, if ever.
Clients may hesitate to make direct eye contact, or may hesitate to ask
questions or voice opinions so as not to inconvenience others or appear
disrespectful. In conversation, extended direct eye contact can be
considered rude.
Clients may not verbalise anxiety or doubts regarding their medical care
in front of clinicians, but they may not follow through with treatments.
This can be misinterpreted as client non-compliance.
It is a good idea to briefly summarise the plan of care, and to ask
questions so that their concerns can be addressed.
Many families have a hierarchy of decision makers in place, usually
beginning with the oldest son as the primary contact and disseminator
of information. However, this may change depending on the degree of
acculturation.
It is a good idea to ask the client whether they would want to make
their own decisions about health care, or defer to other family
representatives. It is also important to clarify that the doctor cannot act
as the surrogate decision maker for the client.
Families may be reluctant to discuss personal, emotional and financial
issues with health providers.
Same-gender care providers are usually preferred. If a same-gender
provider is not available, then examine a female client in the presence
of another female chaperone.
Care providers should respect older women’s modesty and privacy.
Unnecessary touching between non-related people of the opposite sex
should be avoided.
Muslim clients, particularly women, may need a special gown to cover
the whole body in order to avoid unnecessary exposure during physical
examination.
Most clients will prefer a family-centred approach.
Older adults and their children often prefer not to disclose negative
information to clients because they may worry that the truth may take
away hope and increase suffering.
Chinese older people


Concepts of yin/yang and “chi” or “qi” (vital energy).
Traditional Chinese Medicine (TCM) is the most common form of
healthcare among first generation migrants. TCM is mainly guided by a
holistic concept of health that emphasises achieving balance and
harmony throughout the bodily systems. Many older Chinese people
use TCM and allopathic medicine in a complementary fashion (StokesChen & Pan, 2010). A physician’s disregard or lack of respect for these
19
Key considerations: AT&R
beliefs may lead to distrust. Open discussion and flexibility may go a
long way to achieving the best treatment outcome for the client.
South Asian older people


Despite complete understanding of biological causes of illness, it is
often believed that illness and disability is caused by karma.
Many Hindu older people may be using Ayurvedic medications and it is
important to elicit and document this.
Middle Eastern older people

Religious Background. Many but not all Middle Eastern older adults are
Muslim. The client should be asked their religion rather than making an
assumption and religious beliefs should be respected.
20
Dementia
Introduction
Dementia is the term used when a person experiences a gradual loss of brain function and
cognitive abilities due to physical changes in the structure of their brain. Dementia is a
neurodegenerative condition and is not part of normal ageing. Although it is a diagnosis
more common for people over the age of 65, dementia can affect people in their 40s and
50s.
There are many types of dementia, but the most common is Alzheimer’s disease. Other
types include vascular dementia, dementia with Lewy bodies and fronto-temporal dementia.
A person can have a combination of types of dementia. In general, each type of dementia
affects particular areas of the brain (although with vascular dementia, any part of the brain
can be affected) causing changes in behaviour, cognition, personality and mood (Ministry of
Health, 2013).
The differential diagnosis of dementia, in the presence of depression and/or delirium can be
particularly complicated in patients from culturally and linguistically diverse backgrounds
(Johnson, Sims & Gottlieb, 1994).
People with dementia from culturally diverse backgrounds and their carers face difficulties
accessing services and being able to choose care and support in the forms that they would
like (SCIE, 2011). These difficulties arise from lower levels of awareness about dementia and
greater levels of stigma in some communities (Sun, Gao & Coon, 2013; SCIE, 2011). These
factors influence the ways in which families seek support.
Asian communities may consider dementia a normal part of ageing, a form of mental illness,
a source of shame, or even the result of fate and are less likely to seek services during the
early stages of the disease (Alzheimer’s Association, 2009; Punchihewa & Lou, 2013).
Family’s perceptions of the causes of dementia influence the time to presentation to
medical and psychiatric care (Trinh & Ahmed, 2009). As Punchihewa and Lou’s (2013, p.11)
state, “as symptoms progress and become more severe, dementia is also often viewed by
families as a form of insanity”.
The literal translation of the term “dementia” can also perpetuate the stigma, for example,
in Chinese, dementia commonly translates as “crazy catatonic“. Family members may ignore
memory difficulties to “save face” for their elderly relatives. Caregivers may not seek outside
support and interventions out of respect for and duty towards their older relative.
Family perceptions of dementia
Caregivers of Asian older people may have an understanding of dementia that reflects more
traditional views of ageing. In a study of adult family caregivers, Asian American caregivers
were the most likely to adhere to ‘folk models’ of dementia, which attribute dementia-
21
related changes as a result of psychosocial stress in combination with ‘normal’ ageing
processes (Hinton et al., 2005). This difference in the family’s perception of the aetiology of
the illness may influence the time to presentation to medical and psychiatric care. In
addition, the family may not recognise their ailing relative’s difficulties.
In a study of Japanese older people , family members failed to notice problems with
memory, and the majority of subjects with dementia had not received medical evaluation
for their illness (Ross et al., 1997). Participant’s lack of access to information about dementia
was the main factor in their inability to recognise dementia in their elderly relatives. In
addition, out of respect, family members reported trying to ignore memory difficulties to
‘‘save face’’ for their elderly relatives.
The idea that caregivers would not seek outside support and interventions out of respect for
and duty toward elders is a theme that recurs in the cross-cultural literature on the care of
older people (Dilworth-Anderson & Gibson, 2002).
Accessing dementia services
There is evidence that culturally diverse people with dementia access services at a later
stage than European populations, when they may find it harder to set out their preferences
for their current and future care needs (Mukadam et al., 2011; Sayegh & Knight, 2013).
Additionally, many CALD families may not know about the dementia services available.
CALD people with dementia and their carers need support aimed at improving access to
early diagnosis services. This will help them make greater use of early intervention dementia
services and support them in planning their future care.
CALD carers have highlighted the need for respite and advocacy services. Day care may be
more acceptable than other types of respite, such as home-based respite or short stays in
residential aged care homes.
Please note the CALD Guidelines for Demential Patients in Aged Residential Care (Peri &
Cheung (2016), could be used in conjunction with the CALD Older People resource for health
providers working with Asian, Middle Eastern and African People. The guidelines is
downloadable from:
http://www.ecald.com/Portals/49/Docs/Toolkits/CALD%20Guidelines%20Dementia.pdf.
Carers of CALD people with dementia
While carers for CALD people with dementia face similar issues to other population groups,
factors such as differing expectations about care from family and community, and a lack of
services that are culturally acceptable can mean that families face additional pressures.
Asian family members are the primary source of support for older people with dementia.
Care giving in Asian communities may involve multiple caregivers who each serve a specific
care giving role (Wong, 2013). During the assessment process it is important that
professionals establish who in the family provides care giving roles. In traditional Asian
22
cultures, the younger generation customarily cares for the older generation but caregivers
frequently underestimate the physical and emotional tolls of care giving.
CALD family carers of older people with dementia may have strong expectations about the
role of women and adult children in care giving. Carers may be reluctant to ask for help and
this may be the result of one or more of the following:



They may not be familiar with, or identify themselves with, terms such as ‘carer’,
‘caregiver’ or ‘respite’. This is not simply about terminology – CALD carers may find it
difficult to distinguish between tasks deriving from an illness or disability and kinship
obligations.
They may feel that family care is preferable and that services will not meet the
standards they want.
They may fear that others in their community will criticise them for using services.
However, there is evidence of some convergence between the issues faced by CALD carers
and other population groups as more CALD carers are now combining caring responsibilities
with paid employment, particularly adult daughters or daughters-in-law (Wong, 2013).
Traditional CALD carers have highlighted the need to have time off from caring. Additionally,
some would value the opportunity to attend carer support groups if they were available in
their own language.
Non-traditional carers want help in maintaining their paid employment. They also want
support that takes account of their relationship with the person with dementia − for
example, helping them to deal with feelings that are a “bad person” because they find
caring difficult.
It is important to find ways of supporting CALD people with dementia and their carers that
affirms and enhances their sense of self-identity and is not based on stereotypical
assumptions.
Stigma and shame
Stigma and cultural expectations can influence the willingness of CALD older people and
their carers to access health services and supports.
Stigma may lead to a reluctance to use health of older people services in case this results in
a person’s dementia becoming public. Carers may find that they experience stigma because
of their association with the person with dementia. In communities where there are
arranged marriages, the knowledge that a family includes a person with dementia may
jeopardise children’s marriage prospects (SCIE, 2011).
CALD families may be reluctant to seek external help out of fear that the discovery of an
illness might bring “shame” to the family; and from the need to protect family and friends
from the burden of the older person’s health problems (Lai & Chau, 2007).
23
Cognitive screening tools
The lack of suitable dementia assessment instruments is noted in a number of studies
(Alzheimer’s Association, 2009; CSIE, 2011; Trinh & Ahmed, 2009). However, assessment
tools are merely one part of a comprehensive assessment, and diagnosis is more likely to be
made based on the history of presenting problems and clinical examination.
Some instruments may be culturally biased and overestimate the severity of dementia in
people with lower levels of education or among people who are not proficient in English. For
CALD people with dementia who have learned English as a second or additional language,
their ability to speak English may be lost as their dementia progresses.
The M.I.N.I. is an appropriate translated tool for non-English speaking background older
people. It is designed as a brief structured interview for the major Axis 1 Psychiatric
Disorders in DSM-IV and ICD-10. The M.I.N.I. International Neuropsychiatric Interview
Tool, translated into more than 30 languages, is available free through the Medical
Outcome Systems, Inc website: http://www.medical-outcomes.com/index/mini
There is an expanding literature discussing the cross-cultural validity of tests and interviews
used in medical assessments (Basic et al., 2009; Nasreddine, 2006; Paniagua, 2000).
However, little attention has been paid to cultural bias in the use of social care assessments
and reviews of CALD people with dementia and their carers. Good cross-cultural
communication and using interpreters when needed, is essential. It is also important to
remember that:



Conducting an assessment or review in a culturally sensitive way is critical to making
an accurate assessment.
Where interpreters are being used, they should ideally be briefed beforehand.
Reassuring CALD clients and families about interpreter confidentiality is important.
Culturally appropriate cognitive screening tools
Early dementia can be difficult to diagnose in CALD older people. The Folstein Mini-Mental
State Examination (MMSE), the General Practitioner Assessment of Cognition (GPCOG) and
the Rowland Universal Dementia Assessment Scale (RUDAS) were compared in 151 older,
community-dwelling persons (Basic et al., 2009). All three instruments were equally accurate
in predicting dementia. All three instruments were influenced by concomitant depression.
Whereas the MMSE was influenced by CALD status, the RUDAS and GPCOG were not. While
the GPCOG combines participant and informant data, the RUDAS is a stand-alone measure
specifically designed for, and validated in, multicultural populations (Basic et al., 2009).
24
The Folstein Mini-Mental State Examination (MMSE)
The Mini Mental State Examination (MMSE) is the most commonly used test for complaints
of memory problems. It can be used by clinicians to help diagnose dementia and to help
assess its progression and severity. The MMSE has been translated into many languages but
there is criticism about its psychometric properties in CALD people, people with low
education and people with very mild cognitive difficulties.
Rowland Universal Dementia Assessment Scale
The Rowland Universal Dementia Assessment Scale (RUDAS) is the preferred tool. It is a
short cognitive screening instrument designed to minimise the effects of cultural learning
and language diversity on the assessment of baseline cognitive performance. All resources
associated with this assessment tool are available via the Rowland Universal Dementia
Assessment Scale (RUDAS) information page. The RUDAS can easily be administered with an
interpreter and has good psychometric properties.
Montreal Cognitive Assessment (MoCA)
The Montreal Cognitive Assessment (MOCA) is available in 36 languages and dialects. The
MOCA is used for the detection of cognitive impairment in multiple conditions including
Mild Cognitive Impairment (MCI), Alzheimer's disease, Vascular Dementia, Parkinson’s
disease Dementia and Fronto-temporal dementia. The tool has been validated in 21
languages/dialects. It is also available in parallel versions in English. See website for more
information at www.mocatest.org.
Additionally, the Alzheimer's Australia website www.fightdementia.org.au/understandingdementia/culturally-appropriate-dementia-assessment-tools-1.aspx offers a range of
dementia assessment scales and tools which are appropriate for CALD older people (Basic et
al., 2009).
Addenbrooke’s Cognitive Examination – Version III (ACE-III)
The ACE-III is a brief cognitive screening that assesses five cognitive domains, namely
attention/ orientation, memory, verbal fluency, language and visuospatial abilities.
Translated versions of ACE-III are available for download from the website:
https://www.neura.edu.au/download-form/?redirect_to=2100.
Day care services
Adult day care services not only benefit individuals with dementia, but these programmes
also provide respite to caregivers. CALD families often look to programmes that offer
25
culturally appropriate activities and have staff that they can communicate with in their own
language. Examples of these programmes are available in the Resources Section.
Cultural Considerations
History taking
A comprehensive history forms the foundation of the assessment process. It is essential that
a history is obtained from a family member who knows the older person well. This usually
involves a separate interview without the client. The same information should be sought
from a client from a non-English speaking background as would be sought from older people
from an English speaking background.
Additionally, the assessment needs to be culturally appropriate and sensitive. To do this
effectively the practitioner needs to establish an understanding of culturally relevant issues
for each person, for example, for an older person from a refugee background particular
attention and sensitivity needs to be given to issues of trauma, war experiences, migration,
family separation and the disappearance of relatives, etc.
Effective communication
Practitioners working with people with dementia need to pay particular attention to their
communication style. These issues are equally relevant whether working with an older
person who speaks fluent English, or working through an interpreter.
The following points are key considerations when screening or assessing a CALD client for
dementia:











Check and use the client’s preferred mode of address (for example, Mrs Wong, or
Kim, for Mrs Kim Wong).
Obtain a personal profile, including showing an interest in the clients past and
current activities.
Provide support for their sense of identity and self-worth.
Be attentive to non-verbal cues (e.g., agitation, frustration).
Not raising your voice to try to enhance the older person’s understanding.
Talking in a calm and reassuring manner.
Providing clear information in a caring, sensitive manner.
Ensuring you directly face the older person while speaking to them; for people with
hearing impairment, this is particularly important. (Note: for some cultures, eye
contact is not the norm – the practitioner needs to determine this prior to or at the
commencement of the assessment).
Use short, easily comprehensible sentences.
Ensure that the person’s dignity is preserved at all times.
Ensure that the client has maximal sensory input available, that is, appropriate
glasses are worn; hearing aids (if required) are worn and turned on; and dentures
are in place so they can communicate.
26



Rephrase questions or statements if they do not appear to have been understood.
Ensure that the views of the older person are sought, and that the interaction is not
merely between the practitioner and the carer.
Ensure adequate engagement and time for the interaction, questions and discussion
between the practitioner, client and their family.
It is recognised that as people age, it is not unusual to lose proficiency in speaking a second
language. As a result older people with conditions affecting memory tend to revert to their
first language. When working with people from a CALD background who do not speak
English well, health providers should use a qualified interpreter (McGrath et al., 2001).
Using competent and appropriate assessors
The most effective strategy for effective assessment is to have a language matched assessor
or a qualified interpreter if a competent practitioner who speaks the older person’s
language is not available.
Efforts should be made to establish and promote a model of care whereby a referral
network of competent bi- and multi-lingual practitioners can be supported and readily
accessed to undertake appropriate screening and assessment.
Use of professional interpreters to assist with interpreting
Where possible, aim to match the interpreter to the client by age and gender, region/dialect
and cultural group.
The assessing practitioner should remain vigilant in observing the interaction between the
older person, their family, the interpreter and themselves to ensure the process progresses
smoothly.
Interpreter phone services are also available (for example in urgent situations where an
interpreter is not able to be accessed quickly), although this is a less satisfactory
arrangement than having an interpreter in the room with the older person, their family and
the practitioner.
Use of bi/multi-lingual staff to assist with interpreting
The bi/multi-lingual staff available, will need to have sufficient skills, sensitivity and
understanding to manage the complexities of the dementia screening process.
Use of family members to assist with interpreting
Family members provide important background information and they should be actively
engaged in the assessment process where possible. However, professional interpreters are
needed, as family members may lack objectivity, and may be unfamiliar with medical and
cognitive assessment terminology.
27
Creating optimal environments
Providing an optimal physical and social environment for CALD older people with dementia
supports their unique needs and improves the quality of care for the client and their family.
The care-setting environment can support or hinder the social connectedness and sense of
self for CALD older people with dementia.
Approaches to care and support should be in line with the older person’s social, cultural and
religious activities, needs and capabilities.
Involving family
Involve the family in providing an optimal care setting for the CALD older person
(Department of Health, State of Victoria, 2010c). For example:

Ask family members to attend a care planning meeting and develop a partnership with
them. Explicitly contact family members to encourage participation, questions and
comments.

Share information about a person’s daily experiences and special activities and discuss
how family members might help in care routines or activities and provide opportunities
for them to do so.

Encourage involvement in activities that keep family connectedness:

Invite family and friends to play a part in special events, for example birthdays, Sunday
lunch and religious celebrations.

Be attuned to cultural events and occasions friends and family members can share, for
example Diwali celebrations for Indian families, New Year celebrations for Chinese
people, and Eid celebrations for Muslim families.

Be honest, approachable and open with family members and ask about what matters to
them.
Spirituality and religion
Spirituality and religion are important to many CALD older people and their families and are
strong predictors of quality of life. They are part of the person’s identity, their life story and
sense of belonging.
Aged care services have a responsibility to provide spiritual support and to promote a
quality of life (Ministry of Health, 2008; DHB Shared Services, 2013; Department of Health,
State of Victoria, 2010c). Spiritual and religious involvement helps people to cope with many
issues as they age, and as their health declines. Providing for people’s spiritual and religious
needs can reduce the psychological morbidity related to chronic and terminal illness.
It is important that dementia care facilities and services have a policy of finding out people’s
spiritual and religious needs and that staff understand the importance of this and are
trained in how to address the religious needs of their clients. Providing prayer rooms is
important.
28
Spiritual needs
To ensure clients’ spiritual needs are met:

Find out people’s spiritual preferences when they first enter a facility, not just as they
near death, and use experienced and knowledgeable spiritual and religious leaders and
pastoral care workers.

Find out whether a person practises particular beliefs, but word your enquiries about
spiritual and religious beliefs carefully.

Hold any discussion of spiritual needs in a safe environment with someone whose
interpersonal skills allow information to be gathered using a conversational style.

Respect the privacy of those who either publicly or privately practise their beliefs, and
support opportunities for these practices, such as providing a place for prayer.

People receiving care commonly ask staff members about spiritual matters. Address
such questions in an open, non-judgemental manner.
Summary of Best Practice Guidelines
The following are best practice points for providing culturally appropriate dementia care for
residents (Peri & Cheung, 2016).
 Ensure dementia assessments including the InterRAI-LTCF are: culturally appropriate;
have been reviewed for cultural bias; and recognise the impact of culture and the
migration experience on individual behaviour. Comprehensive assessments must take a
multidimensional interdisciplinary approach to understanding a client and their family
and carer needs.
 Use professional interpreters who are familiar with aged care settings; dementia
assessments, and the development and review of care plans if required.
 Identify and support the cultural, linguistic and spiritual needs of people with dementia
to ensure care plans are person centred.
 Consider the different cultural representations and perceptions of dementia when
discussing the residents and their families.
 Provide residents and their families with dementia information in their preferred
language if available.
 Ensure that culturally competent care is provided across all care delivery services.
 Implement a culturally appropriate activities program with therapies that are designed
to promote and enhance the quality of life for people with dementia – e.g. culturally
appropriate music therapy and reminiscence therapy.
 Ensure the physical environment is culturally appropriate and supports people with
dementia by providing a safe, comfortable, familiar and orientating environment.
 Ensure that all staff have received dementia training that is person centred in approach,
and training in communication.
29



Ensure that all staff have received cultural awareness training such as CALD 1 Culture
and Cultural Competency, CALD 2 Working with Migrant Patients, CALD 3 Working with
Refugee Patients, CALD 4 Working with Interpreters as well as have viewed the CALD
Older People Resource for Health Providers available via www.eCALD.com.
Ensure all managers have access to “Managing Culturally Diverse Teams” training.
Ensure all staff have access to “Working in Culturally Diverse Teams” training.
Case studies
Case study 1: Care for an older Chinese man with dementia and diabetes
Mr Lam is an 80-year-old Chinese man who suffers from dementia. He has a Mini Mental
State Examination (MMSE) score of 11/30 which along with his presenting history indicates
moderate disease. He is considered to lack the capacity to make decisions regarding his
general welfare.
He has a wife, a son and two daughters.
His condition has progressed to the stage where he is at serious risk of injury as he wanders
away from home and gets lost. Mr Lam has poorly controlled diabetes, which further
complicates his diagnosis of dementia, as he becomes confused and disoriented.
Mr Lam lives with his family. They are unable to manage his care and to provide a protected
environment. Mr Lam refuses any intervention, including hospitalisation to stabilise his
diabetic condition. He does not have an Enduring Power of Attorney in place for his future
care. The Mental Health Services for Older People (MHSOP) team consults with the head of
the family (the client’s son) and other family members about how best to proceed with
getting the appropriate care for their father.
Unfortunately, despite discussions, no definite decisions are made in the best interests of
the client. Mr Lam’s son refuses to allow his father to go to hospital or into residential aged
care, as his belief is that it will upset his father greatly and that it would be culturally
shameful. The team seek a second opinion from a geriatrician who recommends that a
palliative approach is reasonable in order to respect the wishes of the client and his family.
The physician also recommends treatment of diabetes at home with oral medication. The
geriatric team attempts to follow this recommendation and consults the family.
To reduce the risk further, they suggest that the son move in with his father to reduce the
burden of care on his wife and to increase his father’s safety. However, to the team’s
surprise, all the women in the family support involuntary admission and the son has to
change his mind about hospitalisation.
Interestingly, Mr Lam does not object to hospital admission. Whilst in hospital, his diabetes
is stabilised and after six weeks he is transferred to a residential aged care facility with
medical facilities.
30
Issues for consideration:
 The Mental Health Services for Older People (MHSOP) team’s understanding of
culturally competent care for Mr Lam including the power of filial piety.
 There is intense cultural shame attached to admitting elders to residential aged care
facilities in Chinese cultures.
 Addressing the son’s guilt about hospitalising his father.
 Consider the decision-making preferences of the client and family.
Case study 2: Supporting Mrs Chang to care for her husband
Mrs Chang and her husband have been in New Zealand for 21 years. They were married in
China in 1966.
Background
Mrs Chang cares for her husband, who was diagnosed with dementia nine months ago. Mr
Chang’s memory problems started a few years ago, initially he would forget small things.
This has escalated to accusations that Mrs Chang is stealing things. Up until now Mrs Chang
has believed that her husband is mildly confused but as he is now accusing her of stealing
things, she now thinks that there is something seriously wrong with him. Mrs Chang states
that her husband has always been grumpy by nature but his character has recently changed
significantly and he has become very aggressive. Mrs Chang is embarrassed by his
behaviour. She says: “To be honest it’s getting worse and worse but we have been a couple
for many years”.
The diagnosis
Nine months ago, Mrs Chang took her husband to the general practitioner. He assessed Mr
Chang and suggested a referral to a psychiatrist at North Shore Hospital. Initially, Mr Chang
was diagnosed with psychosis and was hospitalised for two months. He was started on
medications to “calm him down and to help him sleep and another medication”. Mrs Chang
says she doesn’t know what the third medication is for. Mrs Chang stopped the sleeping
tablets after her husband was discharged, as he was very sleepy all the time.
The current situation
Since Mr Chang was returned home Mrs Chang has to watch him all the time. She is
constantly worried that her husband will walk out of the house and get lost. Mr Chang has
disappeared twice and it has taken hours for the family to find him. It is very frightening for
Mrs Chang as her husband doesn’t know what he is doing and cannot find his way home.
She worries constantly about his safety. She doesn’t like to bother the police, so family go
and search for him when he goes missing.
Mr Chang is “getting much worse” and Mrs Chang is not sure how she will cope in the
future. Her husband’s behaviour can be very aggressive and Mrs Chang worries that she will
not be able to calm him down or manage his behaviour. Mrs Chang has talked to the GP
about her husband’s change in behaviour. His response was that she should carry on with
31
the medications at the same dose. She says: “I just have to listen to instructions and carry
on”. The only support person the family has is a Mandarin-speaking social worker from the
local hospital who they find very helpful.
Mrs Chang feels a strong obligation to look after her husband. She feels he needs somebody
who understands him although his behaviour is very disruptive and difficult to deal with at
times, e.g., switching channels on the TV all the time, constantly on the go, and waking three
to four times in the night. Mr Chang is often incontinent in the bed. Mrs Chang is on
“standby all the time, even at 3am in case of disaster”. Mrs Chang finds it very tiring and
stressful. She never knows what is going to happen next.
The son runs a takeaway business and works long hours. He is not available to offer help, the
grandchildren are at school, and friends are no longer involved because Mr Chang’s
behaviour has become so disruptive. Mrs Chang says: “I begin to wonder what kind of life I
have”. The social worker is looking for a suitable rest home but Mrs Chang doesn’t feel that
it is right for somebody else to have to look after her husband. Mrs Chang admits she lives
day to day, she also has a real fear about the safety of rest homes and worries about
burglars –although the social worker has reassured her that resthomes are safe places.
Reflective question:
Consider what support services Mr Chang needs and how you might approach Mrs Chang’s
feelings of guilt about needing assistance to manage the sole care of her husband.
Discussion:
Mrs Chang needs time off from caring. She needs support that takes account of her strong
sense of obligation to her husband and to help deal with her feelings that she is a “bad
person” because she finds caring difficult.
Day care may be more acceptable than other types of respite. Day care options which are
culturally appropriate will need to be found.
32
Case study 3: Helping Mr and Mrs Lee decide on care for Mrs Lee’s mother.
Background
Mr and Mrs Lee live with Mrs Lee’s mother and have done so for the past 18 years. The
family are Chinese and speak Cantonese. They migrated to New Zealand from Hong Kong
twenty years ago. Mr Lee’s mother-in-law (Mrs Cheung), aged 77 years, has had memory
problems for about the last four years. Initially she was forgetful but her mental state has
deteriorated, for example, she has started hanging clean washing on the line; is unable to
recognise her grandson; and has set fire to the kitchen so that the fire brigade had to be
called to extinguish the fire.
The diagnosis
Mrs Lee takes her mother to see the general practitioner. The GP accepts straight away that
there is a problem and refers Mrs Cheung to a specialist. The specialist is a junior doctor who
gives the family information but provides nothing in writing and no translated information.
The family are not told about an Enduring Power of Attorney or Advance Directives.
The current situation
The Lee family recognise that their mother is unsafe at home but they have had no
professional advice regarding the options available to them for the care of Mrs Cheung.
Reflective Questions:
1. If Mr and Mrs Lee are not opposed to rest home care for Mrs Cheung what factors will
be important to them in their choice of rest home care?
2. What factors are important in communication with the Lee family?
Discussion:
1. In discussion with Mr and Mrs Lee about options for care, you find that they are not
opposed to rest home care. They say that Chinese people are more accepting of
dementia now so that the stigma is not an issue any more – people “are very liberal”.
However, the rest home needs to provide Chinese foods and television channels.
2. Mr and Mrs Lee and Mrs Cheung need a rest home with staff who speak Cantonese. In
addition, they need written information in Chinese (check to see if they read Traditional
or Simplified Chinese).
33
Key considerations
Key considerations: Working with dementia clients
Ensure effective
communication
Address cultural
diversity
Accessing services

The first step in the provision of culturally appropriate dementia care is to
address issues around language and communication (Centre for Cultural
Diversity in Ageing, 2010).

Communication issues can be even more significant for people from CALD
backgrounds, who may not be able to communicate with staff or other
patients in their preferred language. Difficulties in communication are
commonly misinterpreted as 'problem' behaviour by staff when the needs of
older people are not being met due to language issues (Goldsmith, 1996).

The availability of interpreters is essential for non-English speaking clients.

Ensure dementia assessments are culturally appropriate, have been reviewed
for cultural bias and recognise the impact of culture and the migration
experience, in understanding individual behaviour.

Identify and support the cultural, linguistic and spiritual needs of people with
dementia in all care plans and reviews; and consider the different cultural
representations and perceptions of dementia when discussing the subject
with older people and their families.

Ensure that cultural diversity is addressed across all care services, including
health and personal care and food services.

Ensure that staff have received dementia training, as well as training in CALD
cultural competencies and appropriate communication.

Provide people with dementia and their families with dementia information
in their preferred language where available.

Ensure that people with dementia and their families are aware of the
dementia support services available through Alzheimer’s New Zealand.

Ensure that people with dementia have access to culturally appropriate
emotional support and spiritual support.

Establish culturally specific services for carers to reflect the populations
served, e.g., Alzheimer’s Auckland run carer education and support groups for
Chinese families.
34
Stroke
Overview
The average age of stroke onset in Auckland in 2012 in Asian/other ethnic groups was 67.5
years (down from 72.1 years) (Fink, 2016). By comparison, the age of stroke onset is
increasing in most ethnic groups in New Zealand (Fink, 2016). The results of a study of 30day case fatality rates (CFR) of ischaemic stroke in New Zealand from 2000-2004 to 20102014 showed that CFR in Asian people rose in Asian people but fell in Europeans (Sandiford,
Selak and Ghafel, 2016). This may be due to differences in severity at presentation, or in
access and utilisation of the increasingly effective acute and hyper-acute stroke
interventions (Sandiford et al., 2016).
The findings of a Rapid Improvement Event (RIE) study conducted to reduce the burden of
stroke and to improve services to stroke clients showed that the average age of an Asian
client with a stroke at WDHB was almost 10 years less than for European and other ethnic
groups (Ratnasabapathy, 2010). Close to half of the Asian stroke clients (44%) were aged less
than 65 years of age (compared to European/Other groups –21%). There were
proportionately more Asian males with strokes than European and other ethnicities.
Asian groups have higher proportional rates of haemorrhagic strokes than Europeans and
other ethnic groups. However, fewer Asian clients have had rehabilitation in AT&R services
(over 65 years old) compared to European and other ethnicities. The average length of stay
for Asian stroke clients is lower than for European and other ethnic groups. More Asian
clients return to their own homes compared to European and other ethnicities. None of the
Asian clients received thrombolysis1. Asian communities need information and education on
the need to reach hospital as soon as the onset of stroke symptoms occur, to benefit from
thrombolytic treatments (Ratnasabapathy, 2010).
Asian patients who present later to hospital after a stroke miss the opportunity for acute
stroke treatments, stroke unit care to avoid complications and the provision of early
rehabilitation (Fink, 2016).
In a study of Chinese stroke victims in Auckland, traditional Chinese family values,
particularly filial piety by the younger generation was emphasised (Wong, 2013). Adult
children rather than the spouse were identified as predominantly responsible for the
ongoing care of an older person who had suffered a stroke. Chinese families generally
preferred sharing care giving among extended family members (Wong, 2013). Although
migration to New Zealand reduced the extended family network and limited the support
available, Chinese families preferred to to manage care on their own rather than to seek
1
Thrombolysis is recommended as first-line treatment for ischaemic stroke for people who meet
specific criteria. Similar to acute MI there is a small window where thrombolysis is of benefit for
ischaemic stroke – up to 4.5 hours, but ideally within three hours (Hacke et al., 2004). The sooner the
treatment is given, the greater the chance of a successful outcome.
35
external support. Communication between health providers and the stroke client or the key
family member, excluded the extended family, thus undermining their collective model for
family decision making. Many Chinese carers did not seek support services although they
were needed, because the services did not meet their cultural needs (Wong, 2013).
Migrant families in the study were unaware of the health and social support services
available to them and many did not know what financial assistance they were entitled to.
Many Chinese families had never received Home Based Support Services (HBSS) and they
were less likely to be part of a carer support group (Wong, 2013, p 123):
I don’t know… part of our problem is that we come from a
background where there are no social services you know. You make
do with whatever you have or how you do it. So I am not very good
at trying to access any funding or anything like that (Chinese family
carer). Perhaps they thought we were living with our children so
they don’t give us that service. But at the moment, I don’t think we
really have the needs. It’s not just the two of us old people you
know there are our children and grandchildren. So whatever I can
do I will try to do (Chinese family carer).
Case studies
Case study 1: Stroke Care for Mrs Li
Background
Mrs Li is a 70-year-old Chinese woman who had a stroke six months ago.
She came to New Zealand from China five years ago to join her son and his family. Mrs Li
speaks Mandarin but not English. After a period of rehabilitation, Mrs Li was discharged to
the care of her son’s family. Mrs Li’s son John and daughter-in-law Jenny have three children
aged 20, 15 and 12 years of age. Jenny works full time in the family business. Mrs Li is being
visited by the District Nurse. She wants to do as much as possible for herself.
While in the stroke unit, the family emphasised their need to be included in their mother’s
rehabilitation plan. The stroke team recognised the need to include all the family carers (ie
whoever could be present at the rehabilitation sessions) as active participants in Mrs Li’s
therapy. All family carers learned how to provide the best support and care for Mrs Li to
assist her to achieve her goals on the rehabilitation journey.
When Mrs Li returned home she was contacted by the DHB interpreting service for followup appointments. The Interpreting Service provided Mrs Li with a phone number she could
contact for help or information at any time of the day or night. The allied health team
prepared Mrs Li and her family for ongoing rehabilitation in her home. This is proving
successful as Mrs Li continues to work towards maximising her capabilities. She wants to do
as much as she can for herself.
36
Reflection
Stroke survivors, such as Mrs Li, are very dependent on their family for practical,
psychological and social support. Migrant families who are coping with settlement stressors
are placed under even more pressure when supporting a family member with a stroke. The
support provided by the allied health team, not only for Mrs Li but for her family, is critical
to the successful outcome of rehabilitation and to her achieving her maximum capacity.
In China, Mrs Li could expect the full support and availability of her extended family and she
will expect this level of family support in New Zealand, although she has fewer family
members here. As well, her son and daughter-in-law have demanding work commitments
and they are not familiar with the New Zealand health and disability system.
Mrs Li will have great difficulty managing all her appointments. To support her adequately,
she will need multiple services in place. It is essential to involve Mrs Li’s family members in
managing her appointments so they can incorporate her appointments and activities into
their schedules. The Li family as a whole needs to be informed about which services to
contact for different types of assistance. Importantly, they will need to use their general
practitioner as their liaison person for many services, and to assist them to manage Mrs Li’s
changing needs for services over time.
Mrs Li’s care demonstrates how effective services can be when they are culturally and
linguistically responsive to the needs of the client, for example through:



Communication:
 Mrs Li received phone calls in her own language.
 She and her family received a phone number to ring for help and
information at any time during the day and after hours.
 The communication with the family was provided in clear, simple English
with translated information provided where possible.
Therapy:
 Mrs Li felt respected, dignified and in control.
 Met Mrs Li’s cultural needs, and enabled her to do as much as she was able
to do.
 District Nursing and Allied Health services were culturally sensitive and
aware of Mrs Li’s needs.
 Family members were educated about the health and disability services and
support available (including financial support, respite services, community
support services (Stroke Foundation), psychological services and additional
rehabilitation services).
 Mrs Li and her family felt informed and empowered.
Referral appointments:
 These were received in Mrs Li’s own language.
 She was cared for by a CALD culturally competent health workforce.
 She had access to interpreters, or cultural caseworkers.
 The services provided were responsive.
37
Case Study 2: Stroke Care for Dr Rajandram
Dr Rajandram is a 64-year-old Sri Lankan man. He is recovering from a stroke which has left
him partially paralysed and aphasic.
He was a GP in a busy practice. He lives with his wife and has three adult children. Mrs
Rajandram explains that her husband is frustrated because he can only speak a few words of
English since the stroke. Dr Rajandram’s mother tongue is Tamil. His wife explains that he
still speaks Tamil and uses this when he speaks with family but he wants to be able to speak
English again so that he can be independent.
He was in hospital for several months and was helped to mobilise and was assisted with
speech therapy. He is very keen to remain independent and has refused help from carers. He
attends a day centre once a week. He also attends a support group for people with aphasia
and finds it helpful to communicate with others with similar speech difficulties.
Dr Rajandram is assigned a speech language therapist (SLT) as his key worker. The following
points outline culturally appropriate approaches to speech, language therapy:



The designated SLT meets with the client to provide written and pictorial information
explaining the family meeting process.
The SLT then works with the client to identify goals for the meeting, the level of
support required, which family members they want present, and any other issues the
client wishes to raise.
Cultural and linguistic considerations are included in planning for and facilitating the
meeting with Dr Rajandram and his family (WDHB, Medicine & Health of Older People
Service Allied Health/ Speech Language Therapy, 2012).
Family meeting
When addressing Dr Rajandram and his family ask about what names and titles should be
used as forms of address.
Speech language therapy




Tune into multilingual abilities. The nature of language deficits in multilingual adults is
complex and not a matter of tuning into the use of each language as a separate ability.
Talk to the client and their family about language use - the use and importance of
each language will vary from person to person. Find out from the client and family
which is the most important language to them (Ardila, 1998).
Seek help in differentiating premorbid and current levels of expressive and receptive
competence in each of the client’s languages.
Be careful to consider dialectic variations. Even when an individual is proficient in
English, his or her English may differ from New Zealand English in terms of phonology,
vocabulary, grammar, idioms, and pragmatics. What might be considered an ‘error’ or
‘deficit’ on the part of the clinician may actually be due to cultural variations.
Extensive variations may also occur in the individual’s first language.
38

Be careful to also consider different forms of showing respect and being formal/
informal (both verbal and non-verbal) and differences in aspects such as eye contact,
body language and facial expression.
Rehabilitation



Allow Rajandram’s wife to come in each day to bathe and feed her husband.
Hospital staff can encourage Mrs Rajandram to let her husband do as much as
possible for himself.
Once home, Dr Rajandram attends a support group for people with aphasia and
finds it helpful to communicate with other people with similar speech difficulties.
Cultural support agencies and community groups could be involved in providing
support and social opportunities for Dr Rajandram and his family. Community
therapy staff can liaise to provide advice around communication, mobility and other
aspects that will help Dr Rajandram to access these opportunities and events.
Key Considerations
Key considerations: Working with stroke clients
Support for care givers
Use interpreting services
Day care services

Family caregivers of stroke clients are in need of support in terms of
information, training and services, including access to benefits and HBSS
(Woo et al., 2011).

Inform all residents of their right to access professional interpreting
services at any time, and of the availability of telephone interpreting
services.

Use professional interpreting services:
- as requested by residents and/or their families;
- when care plans are developed and reviewed; and
- whenever informed consent is required.

Beware of the ethical implications, privacy issues and the potential for
misunderstandings in using bilingual staff, family members or friends to
communicate on behalf of residents.

Where appropriate and available, stroke clients need to be referred to
culturally appropriate day care services.
39
Mental health
Acculturation stressors
Older migrants encounter many settlement stressors in new societies and are at risk for
depression, anxiety and suicide if they are unsupported (Trinh & Ahmed, 2009). The process
of acculturation is multi-dimensional including: physical, psychological, financial, spiritual,
social, language and family adjustments (Lai & Chau, 2007; Mehta, 2012; Trinh & Ahmed,
2009).
Asian societies value the family group, filial piety, humility, restraint of emotional expression
and a sense of obligation toward elders. Whereas western societies value more
individualistic, competitive, achievement-oriented, assertive and independent behaviours.
Older migrants face challenges integrating into New Zealand society because:

They may have fewer resources, such as income support, social networks and English
language proficiency to assist them to adapt to their new life situation (Ip et al., 2007).
They may find it difficult to adjust to a new way of life in their families; as their children
and grandchildren acculturate, cultural discontinuity increases in the home. The
differences in acculturation among the different generations can lead to
intergenerational conflict. These differences may need to be negotiated within the
extended family to restore harmony.
Role reversals may occur when children and grandchildren become translators and
interpreters of the new society for seniors, or when limitations on financial resources
translate into a reversal of authority and power in the family.


Utilisation of mental health services
A study of older Chinese migrants in New Zealand showed that significant numbers of older
people (26%) appear to be depressed or at risk for depression (Abbott et al., 2003). Older
Chinese migrants with mental health issues face a number of barriers accessing culturally
appropriate services (Abbott et al., 2003; Cheung, 2010). In Cheung’s (2010) study of
characteristics of Chinese service users in an old age psychiatry services in New Zealand,
older Chinese people were found to have lower referral rates and to under utilise Mental
Health Services for Older Adults (MHSOA), compared to non-Chinese users. In the study all
MHSOA service users had been in New Zealand for more than three years, and dementia
(36.4%) and depression (31.8%) were the most common diagnoses for those referred to
MHSOA.
Other key findings in the study showed that (Cheung, 2010):

Mental illness is conceived as supernatural punishment for wrong doing and is
associated with intense shame and stigma. Family support is a key protective factor
and source of emotional support in the Chinese communities.
40

Families can encourage help-seeking behaviour. A typical pathway to care for Chinese
people with mental illness starts with seeking medical help accompanied by the
family.
General practitioners play a pivotal role in referring older Chinese clients and their
families to appropriate services and supports.
Greater use of services and better clinical outcomes can be achieved when
bilingual/bicultural clinicians are available.


Case studies
Case Study 1: Mr Nguyen (adapted from Tran & Hinton, 2010).
Mr Nguyen is a 74-year-old South Vietnamese former army officer who was imprisoned by
the Socialist Republic of Vietnam. He was physically and emotionally tortured with stories of
family members being killed or imprisoned in other re-education camps2.
Mr Nguyen felt lucky to be alive as so many people died in Vietnam’s re-education camps.
He came to New Zealand in 1989 and had nightmares every night for the first couple of
years. He felt estranged from his family as he was imprisoned for 12 years and his family had
since become westernised strangers to him. His doctor said that he suffered Post-Traumatic
Stress Disorder from his long imprisonment and from the torture he suffered.
Mr Nguyen still has nightmares when he feels stressed. He deals with his stress by smoking
four packs of cigarettes a day and drinking beer. He has a hoarse cough and sometimes
coughs up blood. His family has brought him the see the GP because his herbal medicines do
not work on his cough anymore and he cannot get to sleep at night.
Question 1:
What would be the key issues for the clinician to consider?
Discussion:


Providing an interpreter who is acceptable to Mr Nguyen.
Providing culturally appropriate assessment for mental health, CVD risk assessment,
smoking cessation, a drug and alcohol assessment and cancer screening.
2
The Reeducation camps were the prison camps operated by the Government of Vietnam following
the end of the Vietnam War. In such "reeducation camps" the government imprisoned several
hundred thousand former military officers and government workers from the former regime of South
Vietnam. Reeducation was seen as a means of repression and indoctrination which developed for
several years in the North and was extended to the South following the 1975 Fall of Saigon. An
estimated 1-2.5 million people were imprisoned with no formal charges or trials. Approximately,
165,000 people died in the Socialist Republic of Vietnam's re-education camps. Thousands were
tortured or abused. Prisoners were incarcerated for as long as 17 years, with most terms ranging from
three to 10 years.
41
Question 2:
How could an understanding of Mr Nguyen’s cultural health beliefs and practices and his
refugee experiences assist health providers in providing effective care?
Discussion:
Understanding the impact of the refugee experience on mental health is important for the
care of refugee clients. Mr Nguyen has been through horrific life events during the Vietnam
War and its aftermath. These have led to depression, loss and trauma expressed as posttraumatic stress syndrome. Vietnamese and other South East Asian refugees, and
particularly older people may suffer from poor mental health due to their refugee
experiences. Additionally, Mr Nguyen spent many years being held as a political detainee in
a prison in Vietnam (Mollica, McInnes, Pham, et al., 1998). As well, adaptation to Western
life brings multiple stressors. Vietnamese older people are at higher risk of psychological
distress than younger community members because they have fewer buffers and coping
strategies to deal with their distress.
Understanding the client’s cultural practices and health beliefs and in particular the use of
traditional herbal remedies will improve the intervention for Mr Nguyen. The use of herbal
remedies is widespread among traditional Southeast Asian elders. When prescribing it is
important to take into consideration ethnopharmacological responses to the therapeutic
agents prescribed (Chen, Chen & Lin, 2008; Lin & Poland, 2000). Vietnamese people believe
that Western medicine is “stronger, faster, and curative” while folk medicine is “weaker,
slower, but preventive” (Pham, Rosenthal & Diamond, 1999). These beliefs have major
implications for Southeast Asian older people’s adherence to medical regimens. Decreasing
drug doses is a cultural response to the client’s perceptions about the strength of Western
medications. It is important to give clear explanations about what the medication is for, its
side effects, and to gain an understanding of the client’s concerns about the powerful
effects of Western medicines and Vietnamese beliefs about pharmacokinetics.
People from non-Western backgrounds may not have experience of psychotropic
medication or understand its purpose or effects. Clients may initially say that they
understand treatment regimes when they do not. It is important to give extra time and
attention to the client to make sure that all the information is understood and internalised.
The client will need careful and accurate interpretation of information including the purpose
of the medication and the details of their medication regime.
Question 3:
What kind of treatment, management, or referrals might the GP consider?
Discussion:


Referral to a community mental health service may be indicated.
Referral to a culturally appropriate smoking cessation programme may be indicated.
42
Case Study 2: Mrs Mansoor
Mrs Mansoor is a 70-year-old Iraqi woman from Bhagdad. She was sponsored by her son to
come to New Zealand in 2007.
In 2012, Mrs Mansoor’s son moved to Australia because he had a good job offer. He initially
took his mother with him but realised she was ineligible for social support so sent her back
to New Zealand alone. Mrs Mansoor does not speak any English. She has no relatives in New
Zealand. An Iraqi family who have limited means and four children give Mrs Mansoor a room
in the basement of the house they rent. They are kind to Mrs Mansoor but have little
knowledge of the services available and few resources as they are newcomers themselves.
Mrs Mansoor is sleeping on a mattress on the floor and the basement is cold and dark. Mrs
Mansoor is frail, confused and extremely distressed. She eats very little and has an ongoing
chest infection. The family contact a local Muslim women’s support group who make a
referral for pensioner housing for Mrs Mansoor. They also refer Mrs Mansoor to an Arabic
speaking female GP who admits Mrs Mansoor for bilateral pneumonia.
Mrs Mansoor makes a good physical recovery but remains confused and distressed. She is
referred by the medical team to the Mental Health Services for Older Adults (MHSOA)
service as an inpatient for assessment, treatment and support.
Question:
What cultural and language factors and aspects of care need to be considered when
conducting an assessment with Mrs Mansoor?
Discussion:
Addressing language and communication issues and having an understanding of a person’s
cultural/religious beliefs can improve the relationship between the client and the provider
and compliance with treatment.
Language competency
If the referral form indicates that the client is a non-English speaker and gives the client’s
spoken language /dialect:



The most effective approach is to have the assessment, including the history taking,
undertaken by a practitioner who is fluent in the client’s language, and is confident
in practicing their profession in that language. An effective assessment requires not
merely literal translation of the spoken words, but also the cultural context of what
is said, and the relevance of non-spoken communication as well.
If this is not possible, a professional interpreter should be used and preferably a
female interpreter for Mrs Mansoor.
It is important to match the language of the interpreter to the client’s language.
Rapport and trust (Engagement)
It is important to build rapport with your client:
43




Address the client with respect and greet her using her title and surname, e.g.
Mrs Mansoor.
Check with the client to ensure that her name is pronounced correctly.
Start with a chat with the client to explore her cultural identity/orientation. This
helps to develop rapport at the beginning of the clinical interview.
Be aware that the client may:
 Prefer doctors to make decisions/give instructions /provide practical
solutions.
 Prefer doctors to be assertive and not ask the client’s views.
 Prefer no physical contact/touch.
 Not make direct eye contact, or may hesitate to ask questions or hesitate to
voice opinions to a higher authority such as a doctor, e.g. there may be a
conflict with the Western concept of the client-doctor relationship based on
partnership versus the doctor as an authority model which is expected in
traditional societies.
Culturally appropriate assessment
Cultural factors related to the client’s psychosocial environment need to be considered such
as the client’s cultural/religious/social support and networks (or absence of these).
Use the following cultural assessment tools found in the “Tools and Guidelines” section to
guide clinical assessment.
1) CALD Older People Assessment Tool.
2) Culturally Appropriate Dementia Assessment Tools.
Assessment with the assistance of a professional interpreter
It is important to pre-brief the interpreter before starting the assessment, explaining that:



3
The general nature of the session is to conduct a cognitive assessment (NB: It is
important to ensure that the client’s hearing and vision are at a functional level
prior to making a cognitive assessment).
The clinician needs to find out from the client (or from family or friends)
information about the client’s level of education and their previous occupation as
this is important for interpreting the results of the assessment. It is recommended
that clinicians should use the RUDAS3 test for this client.
All instructions and the test taker’s responses must be interpreted as exactly as
possible.
Rowland Universal Dementia Assessment Scale (RUDAS)
The Rowland Universal Dementia Assessment Scale (RUDAS) is the preferred tool. It is a short cognitive screening
instrument designed to minimise the effects of cultural learning and language diversity on the assessment of
baseline cognitive performance. All resources associated with this assessment tool are available via the Rowland
Universal Dementia Assessment Scale (RUDAS) information page.
44


The interpreter needs to take note of any instances during the assessment, where
the client’s performance may have been affected by subtle or unintended changes
to the meaning of the test instructions, due to language or cultural factors.
It may be necessary for you to clarify any concepts covered in the assessment
after the test, to check the distinction between the client’s actual cognitive
capacity and potential cultural bias, which could have arisen as a result of the
interpreting process.
Session structuring
It is important to structure the session and set the ground rules, that is to:

Introduce the interpreter to the client and explain to her that the interpreter is
the facilitator and that you will be asking the questions. This may help to avoid
confusion during the assessment. It is also important to:
 Assure the client that the rule of confidentiality applies to all parties
including the interpreter.
 Reassure the client that everything said must be interpreted.
In addition to the above:




Make sure that the client’s hearing and vision are at a functional level prior to
cognitive assessment. It is important to find out from the client or from family and
friends information on the client’s education level and previous occupation which
is important for interpreting the results. Again, it is recommended that clinicians
should use RUDAS test for this client.
A consultation liaison case will require obtaining as much information as possible
prior to the actual assessment, eg information from the medical and nursing team
(eg treatment of pneumonia, any signs of symptoms of delirium and general
observations), information from the Iraqi family, her son and GP (eg level of
functioning prior to this hospital admission, the progression of cognitive decline, if
any).
It may be good to postpone the cognitive assessment if there is any suggestion of
delirium. It is still possible to build rapport in the meantime by being with the
client and offering her practical support such as meals, drinks and making sure
that her basic needs are met.
It is most important for the clinician to check for pain and that the client is not in
any discomfort (eg from her facial expression). Pain is often overlooked in a busy
medical ward and when the client cannot communicate pain due to language
barriers and confusion, the risk is increased. The clinician can advocate for the
client and liaise with the medical team for analgesics. Again, postpone a cognitive
assessment if there is pain.
45
Key considerations
Key considerations: Mental health
Trinh and Ahmed (2009) highlight the following as useful practices when
working with older CALD clients.
Assessment Tools
Family engagement
Use the following cultural assessment tools (see “Tools and Guidelines”
section) to guide clinical assessment.
 CALD Older People Assessment Tool.
 Culturally Appropriate Dementia Assessment Tools.
Invite family members to assist with:




Medical history


Physical needs, negotiating a new environment.
Confirmation or clarification of information.
Interpretation in the event that a qualified interpreter is not available,
or to clarify expressions for the client in the event of poor English
and/or poor hearing.
Providing an accurate family history.
It is important to assess chronic health conditions (cancer, heart
disease, stroke, etc) as these are known to affect the mental health of
older people. Rates of depression can be two to three times higher in
older clients with chronic health issues (Black et al 1992).
Encourage clients to bring all medication to the interview to avoid
confusion and difficulty recalling names and the dosages of medication
(combinations of medications can cause confusion). Check what the
older person is actually taking not just what they were prescribed.
Functional status

The level of functioning of older people is often understated by their
children. It may be necessary to refer for an over 65 assessment for
HBSS or mental health day stay as the pressure on families of a
dependent older person is considerable.
Elder abuse

It is important to assess for elder abuse (see Mehta, 2012). Apart from
assessing for physical, sexual and psychological abuse, it is also
important to be aware of possible improper use of funds and other
resources, and/or exploitation.
Older people often experience neglect and CALD clients can be more
vulnerable because of acculturation issues, as well as isolation if no
family is available.

Educational history


This must be assessed prior to making treatment plans and arranging
for further assessment. Be aware that literacy influences test outcomes.
Employment history will also be an important indicator of pre-morbid
functioning.
46
Needs Assessment and Co-ordination (NASC) Service
NASC for CALD over 65s
NASC helps older people and their care givers access support services, such as home based
support, residential aged care, or respite services in the community. They work with patients
and their families to assess and plan their support needs. NASC then coordinates support
services for as long as they are applicable. Needs assessors will determine:



Whether respite care is appropriate by identifying carer stress.
Whether or not the person can live safely in the community with the available
supports.
If the person needs long-term residential care indefinitely and what level of care is
needed in a residential aged care facility.
Respite care is a service that can be arranged by the NASC for planned and regular breaks, or
for emergency situations such as main carer illness. The respite service can be used at home
or in an age related residential care facility. There is no means testing for older people who
require respite care.
Information about NASC for older adults and their caregivers to access support and services
can be found on the Health Point website for Waitemata DHB, Auckland DHB and Counties
Manukau DHB districts (http://www.healthpoint.co.nz/specialists/older-peoples-health/).
A CALD Older Person Assessment Tool is available under the Tools and Guidelines Section in
this document. It provides tips for NASC assessors who are assessing and coordinating care
for older people from culturally and linguistically diverse backgrounds.
Attitudes towards Home Based Support Service (HBSS) and Residential Aged
Care (RAC)
Asian families
There may be a reluctance to place parents in long-term care facilities out of respect and
filial piety. Daughters and daughters-in-law bear the burden of care (Wong, 2013). Often
decisions regarding placement occur at a stage when caring for an older person becomes
extremely stressful.
South Asian families
For many older adults, the activities of social workers and home care health providers are
unfamiliar and may not be welcome or acceptable. Older people generally will seek help
from family and friends. Some families are unlikely to place an older adult in residential
aged care except as a last resort.
47
Middle Eastern families
It is expected that adult children assume responsibility for the care of ageing parents and
care for them at home. Women are customarily designated as the primary caregivers. This
can result in a high degree of burden when caregivers feel the traditional pressure of
providing all elder care personally within the home setting.
Home health services in the Auckland Region
CMDHB, WDHB and ADHB offer Needs Assessment Coordination Services, which provide
publically funded community support services for:





People over 65 years who have a disability that will last longer than six months and
results in a reduction of independent function to the extent that ongoing support is
required.
People who have a need for short term personal health support, i.e., following an
admission to hospital.
People requiring Meals on Wheels.
People requiring home-based services who have palliative care needs.
People aged less than 65 years who have a chronic health condition long term
disability and very high support needs as a result of chronic disease and who meet
the eligibility for the Chronic Health Conditions Long Term Support Service (CHC
LTS). This service was previously known as the Interim Funding Pool (IFP).
NASC has a range of professional clinical needs assessors and a wide cultural mix. The
assessments can be carried out for people living in their homes or when they are in hospital
or residential care, either at rest home or hospital level, to evaluate the needs, strengths
and preference of the older person. The assessment tool used is interRAI - an
internationally validated needs assessment tool.
The NASC service will link clients to services to meet their identified needs. These may
include but are not limited to the following:








Domestic assistance / household management.
Personal care (showering, grooming, etc.), both short term and long term.
Meals on Wheels.
Day care.
Carer support.
Palliative and respite care.
Social worker referrals.
Residential aged care (NASC will give clients subsidy forms to complete if they need
to apply for the Government Residential Care subsidy).
48
Case study
Case study: Mrs Kim (adapted from Sohn, 2010)
Mrs Kim is a 79 year old Korean woman who was brought to the GP by her daughter-in-law.
The daughter-in-law states that her mother-in-law has been very withdrawn, lost weight and
is concerned that she is becoming demented. On history taking (provided by the daughterin-law as interpreter) you find out that Mrs Kim and her family migrated to New Zealand 12
years ago with her son and his family who she lives with. Mrs Kim until recently worked in
the families catering business.
Since Mrs Kim has become unwell, she has lost contact with her friends. Her son who is not
religious does not take her to the Korean church she used to attend. During the day Mrs Kim
is alone. She rarely spends time with her grandchildren who are busy with school, friends
and after school tutorials.
Mrs Kim’s daughter-in-law tells you at a subsequent appointment that she is exhausted
working in the family business, taking care of her husband, children and mother-in-law. She
is stressed, tearful and fatigued.
Reflective Questions
1. What are the stressors in Mrs Kim’s life?
Discussion:
 Social isolation: loss of social networks.
 Loss of cultural and religious support.
 Loss of independence.
2. What support/services does Mrs Kim need and who will you refer her to? How will you
address her social isolation?
Discussion:
Referrals for Mrs Kim may include:
 The AT&R team.
 Aged concern, regarding assessment for the Total Mobility Scheme: (for people
with a disability and provision of a Total Mobility card for discount taxi fares). NB:
Age Concern Auckland can access Primary Health Interpreting Services (see
Resources).
 The Korean Positive Ageing Charitable Trust (see Resources).
 Contacting the pastor of the Korean Church Mrs Kim used to attend to provide
support.
3. How will you provide support for her daughter-in-law?
Discussion:
 The NASC assessment could consider offering a period of cultural and language
appropriate respite care to Mrs Kim to give her daughter-in-law a break.
 NASC assessment could consider providing cultural and language appropriate
Home-Based Support services that could support her daughter-in-law to care for
her mother-in-law.
49
Key considerations
Key considerations: NASC for CALD over 65s
Assessment
Decision making

A CALD Older Person Assessment Tool provides tips for NASC needs
assessors who are assessing and coordinating care for older people
from culturally and linguistically diverse backgrounds.

In many Asian, South Asian and Middle Eastern cultures, the eldest son
or family, rather than the older person, are assumed to be the decision
makers concerning the care and support of the older person. Assess
family patterns of decision making (eg individual vs. collective) to know
who the key decision maker is in the family.
Use gender appropriate carers.
Explore preferred interaction patterns, that is:
 What is the client’s preferred language?
 Is a direct or indirect form of communication most appropriate
for this client?
 What is the client’s preferred form of address (formal or
informal)?
 Are there other considerations in interactions with the client,
such as language matching/gender of service provider/carer/
support worker?


Home assessment



Family assessment


Culturally appropriate social
services

Living patterns: Who lives in the home, relationship to the older person
and what is the level of support from the people who live with the older
person?
Safety, comfort and convenience of the home for the older person’s
health and well being.
Financial stability and adequacy of housing.
Composition and structure, including kinship patterns and social
support: expectations of and for family members (who care for the
older person).
Stereotypes that CALD families "take care of their own" can be very
misleading since some CALD older people are not part of strong family
networks and accordingly are vulnerable to loneliness and isolation.
Develop a knowledge of culturally appropriate social services to refer to
for social support, eg Shanti Niwas; Chinese Positive Ageing Charitable
Trust; Korean Positive Ageing Charitable Trust (refer to information
under the “Resources” section).
50
Residential aged care
It is important to conduct the entry and orientation programme to a residential aged care
facility in the preferred language of residents and their families (Centre for Cultural Diversity
and Ageing, 2010). Professional translators should be used to translate all documents
requiring the consent of residents, such as care plans, as well as other documents as
required. Information about services, including health and personal care procedures should
be provided in the preferred language of residents.
It is important to ensure that residents and their representatives have access to internal and
external complaint mechanisms and the Health & Disability Code of Rights
(http://www.hdc.org.nz/the-act--code/the-code-of-rights) in their preferred language
(Health & Disability Commissioner, 1996). The language needs of residents in residential
aged care facilities need to be considered, that is using trained interpreters and signage in
preferred languages.
Emotional support
Older people face major life changes, often within a short period of time. Ongoing emotional
support is required to assist them to cope with the experiences of bereavement and illness,
and in adjusting to life in a residential care facility.
Entering an aged care facility is an enormous change for a person. People may undergo
feelings of loss, anxiety, frustration, anger or grief. This change may also cause some people
to relive past trauma. The experience can be even more emotionally overwhelming for
people from CALD backgrounds, who may find many aspects of their new life and care
services completely unfamiliar and who may be at greater risk of isolation due to language
issues.
Addressing a resident’s culture, language and religious needs will assist them by providing
culturally appropriate emotional support.
Case study
Case study: Mrs Khan
Mrs Khan is a 78-year-old Fiji Indian Muslim woman.
She has been admitted to a rest home as her husband is no longer able to manage her care
at home following a number of strokes and a deterioration in her condition. Mrs Khan has
developed severe bilateral pneumonia.
A speech therapy evaluation reveals a swallowing dysfunction. A pureed diet is ordered and
the nurse offers the client a choice of several jellies. However the client refuses this,
although she stated earlier that she was hungry.
51
Question:
How will you make sure that Mrs Khan’s nutritional needs are met with consideration to
her religious requirements?
Discussion:

Muslims eat halal foods. Halal meats are slaughtered according to Islamic rites.
Mrs Khan will not eat jelly because it is made with gelatine. A list of foods that are
acceptable (Halal) to Mrs Khan and not acceptable (Haram) are listed below.

It is also important to note that for Muslim people self care practices involving
eating or drinking are ideally performed with the right hand. Health care providers
should be aware that where a client has lost the ability to use their right hand,
sensitivity may be required. Similarly, a loss of function in the left hand may affect
the client’s comfort with their bathing and washing habits.
Health Care Providers Handbook on Muslim Clients (Islamic Council of Queensland, 1996).
Approved (Halal)
Forbidden (Haram)
Meat and substitutes:




Chicken, beef, lamb killed by Muslim
slaughtermen.
All seafood.
Eggs cooked in water, butter, vegetable
margarine or vegetable oil.
Dried beans and lentils, baked beans.

Pork and all pig products (bacon, ham,
salami, gelatine, etc.).

Ice cream made with animal fat.

Any fruit or vegetables fried or roasted in
lard or dripping.
Milk and milk products

Milk, yoghurt, cheese, ice cream made
without animal fat, e.g., tofu ice cream,
gelatine or sherbet.
Fruit and vegetables

All fruit or vegetables raw, dried, dripping,
canned or cooked using water, vegetable fats
or butter.
Bread and cereals



All breakfast cereals. Bread, cakes and
biscuits prepared without animal fat other
than butter (read labels).
Rice cooked without animal fat.
Pasta.
52
Approved (Halal)
Forbidden (Haram)
Fats and oils
Butter, vegetable margarine, olive oil, peanut oil,
vegetable oils.

Lard, dripping, suet, other animal fats
(except butter) and any other foods made
with or cooked in them.

Alcohol and foods cooked with alcohol, e.g.,
trifles, puddings, sauces.

Any with ham bone stock.

Any with alcohol, lard, suet or suet
dripping, gelatine, ice cream with animal.


Gelatine (pork product).
Vanilla essence (alcohol base).
Beverages

Tea, coffee, water, fruit juices, soft drinks,
mineral and soda water, cordials.
Soups

Any made without pork, ham or animal fats.
Desserts


Any without alcohol, lard, dripping or suet,
e.g., fruit-based, custards, tofu, ice cream,
gelatine or sherbet, fat.
puddings made with butter or vegetable
margarine, egg dishes, rice dishes.
Miscellaneous

Coconut milk, spices, including chilli, curry
powder. Pickles, chutneys.
53
Key considerations
Key considerations: Residential aged care
Engagement







Food services





Identify, address and regularly review the emotional support needs of
your residents.
Consult family members regarding the emotional support your residents
may require and provide emotional support services in the preferred
language of your care recipients. Encourage families to visit and support
their family member.
Consider establishing support groups for families in different languages.
Assist your residents to maintain community and other support
networks and explore the availability of volunteers to provide
recreational visits to isolated residents in their preferred language.
Ensure that CALD cultural competency is addressed across all services,
including health and personal care, food services and leisure activities.
Ensure your residents have access to culturally appropriate spiritual
support.
Ensure that staff are trained in CALD culturally competent care and
appropriate communication.
Respecting the dietary needs and preferences of your CALD residents
will enable them to maintain significant practices, a meaningful
connection to the past, and an enjoyable relationship to food (Centre
for Cultural Diversity and Ageing, 2010).
Present menu choices in the preferred language of your residents and
involve them in menu planning and food preparation (where
appropriate).
Regularly include your residents' favourite meals in menu plans - ask
residents and/or family members for recipes and instructions on the
correct way of preparing these dishes. Obtain specific items and meals
from external sources, where necessary.
Celebrate special occasions with a culturally appropriate dish, and invite
families, friends and community members.
Ensure that any staff responsible for food preparation or assessment of
dietary requirements are familiar with dietary preferences and the
culturally determined dietary restrictions of your residents, and provide
training as required.
54
Elder Abuse and Neglect
What is elder abuse and neglect?
Elder abuse and neglect includes psychological, financial, physical, sexual abuse and neglect.
The agreed official definition of elder abuse is that of the Toronto Declaration on the Global
Prevention of Elder Abuse (WHO, 2002).
“Elder Abuse and Neglect is a single or repeated act, or lack of appropriate action, occurring
within any relationship where there is an expectation of trust, which causes harm or
distress to an older person. It can be of various forms: physical, psychological/ emotional,
sexual, or financial/material abuse, and/or intentional or unintentional neglect”.
Summary of definitions
Psychological abuse
Behaviour causing mental anguish, stress or fear. For example:




Financial abuse
Illegal or improper use of money, property or other resources. For example:




Physical abuse
Misuse of power of attorney.
Failing to repay loans.
Use of home and/or utilities without contributing to costs.
Hitting, pushing, rough handling.
Over-medication.
Inappropriate use of restraints or confinement.
Not providing for physical, emotional or social needs. For example:



Sexual abuse
Unauthorised taking of money or possessions.
Infliction of pain, injury or use of force. For example:



Neglect
Ridicule or threats.
Harassment or humiliation.
Preventing choice or decision making.
Withholding affection.
Inadequate food, fluids, clothing, shelter.
Lack of social contact, support, human contact.
Health needs not attended to, such as not changing position in bed.
Non-consensual sexual acts or exploitive behaviour. For example:


Inappropriate touching
Sexual acts with someone unable to give consent.
55
The Ministry of Health (2007) ‘Family Violence Intervention Guidelines, Elder Abuse and
Neglect’ can be found on: http://www.health.govt.nz/publication/family-violenceintervention-guidelines-elder-abuse-and-neglect.
CALD communities and elder abuse
The traditional CALD family is characterised by extended family systems with an emphasis
on the interdependence of family members, continuity between generations and familial
duty. Older people in traditional ‘age-honouring’ cultures hold a position of prestige within
the family, and obligation to older members is emphasised.
However, it is important to acknowledge that generalisations across cultures are risky and
issues for ethnic communities are complex. Increased numbers of nuclear families and
higher participation by women in the workforce can compromise traditional care giving
practices and may contribute to intergenerational conflict.
Elder abuse and neglect: Chinese, Korean and Indian perspectives
New Zealand research highlights some of the forms of elder abuse and neglect among CALD
older people in our population (Park & Kim, 2013; Peri et al., 2008). The common forms of
abuse identified were financial abuse, neglect, abusive and neglectful role modelling by
adults and the isolation of the older people. A common theme was the exploitation of older
people to help with domestic duties and the care of children, financial abuse, and abuse
associated with inappropriate living arrangements (Park & Kim, 2013; Peri et al., 2008). The
research also highlighted the following (Peri et al., 2008).





Intergenerational relationships between older migrants and younger family
members became complex and difficult in transnational families.
In Chinese communities, the breakdown of the reciprocal roles of older people and
the younger generations was reported. Older Chinese people were said to have a
dream of following and supporting their child, of selling everything in China and
coming to New Zealand to look after their grandchildren. But having done so they
often had no one to talk to and no control over their finances. Adult children
treated the older persons money as family money. Son’s in particular considered it
their right to use their mother’s money. Mothers sometimes were left to live alone
in poor housing, or in residential care, if businesses failed and homes were lost.
The Indian community preferred the term ‘neglect’ rather than ‘abuse’, and
identified the common problems of exclusion of older people, disrespect and
isolation, which they attributed to financial stress and a lack of time.
The costs of family members’ addiction to gambling and smoking were specifically
mentioned, with older people pressured to fund these activities; for example, by
threats of loss of family contact if they did not comply.
There is stigma attached to placing an older person in residential care but
nevertheless older Chinese and Indian people are living in these facilities. They may
be subject to an increased risk of isolation.
56


A lack of social and community networks make older people more vulnerable. This is
a factor in the continuing abuse, as under these circumstances abuse is more easily
hidden and the older person does not have the knowledge, language or means to
seek support.
Strong cultural norms requiring family members to support and protect each other
actually appeared to increase abuse when it did occur, because of the fear of
community disapproval and the reluctance of older people to disclose abuse and
seek help, thus stigmatising the family.
Culturally appropriate screening and assessment
People experiencing abuse are likely to be physically, emotionally and spiritually vulnerable.
The first point of contact is important in building trust, together with an atmosphere that
conveys openness, caring and a non-judgmental attitude. It is important to provide sufficient
time to respond and to explore options. A positive encounter for the person includes being
asked what plan of action they would like to take as well as being offered resources, support
and guidance (Glasgow & Fanslow, 2006).
You will find the Ministry of Health (2007) Family Violence Intervention Guidelines: Elder
Abuse and Neglect on: http://www.health.govt.nz/publication/family-violence-interventionguidelines-elder-abuse-and-neglect.
Interviewing older people where abuse is suspected
When working with CALD older people, be mindful that there may be cultural
variations in definitions and in ways of addressing abuse. Cultural differences in
communication styles also need to be considered. When conducting elder abuse and neglect
screening interviews with older people it is important to:
 Make sure that assessment and intervention are part of a face-to-face health care
encounter.
 Use open-ended and non-judgmental questions.
 Use professional interpreters where required, rather than a person’s friend or family
member.
 Ensure that privacy is considered. Unless the older person specifically requests the
presence of a friend or family member for support, the person should be
interviewed away from relatives or caregivers. If feasible talk to the person in their
own home, as most older people feel safer in familiar surroundings, and the living
situation can also be observed.
 If there is a suspicion of abuse or neglect, ensure that the older person’s caregivers
are interviewed separately from the older person.
 Be alert to financial abuse of the older person. Examples of this include the older
person not being allowed to buy what they need; their bank accounts being
57

accessed without consent; and Enduring Power of Attorney (EPA) being used for the
personal gain of the person holding the EPA (Age Concern New Zealand, 2009).
Comply with organisational policies for elder abuse and neglect screening interviews
when cognitive impairment is suspected or when the older person does not have
mental capacity.
Issues to consider when asking about possible abuse and/or neglect
The health provider’s ability to engage the older person in the questioning process is a
critical factor for obtaining accurate and relevant information. Consider the following:





Does the older person have sensory deficits? Ensure glasses and hearing aids are
used and eliminate background noises. Ensure the area is well lit. Arrange seating
face-to-face, use familiar words and repeat questions.
Are reactions slowed? Allow extra time for responding and pace questions. Where
English is a second language offer the use of professional interpreters. Ensure that
you speak clearly and avoid jargon.
It is common for people who have been abused to deny that abuse has taken place.
Talking about abuse can be very difficult.
Maintaining privacy about what goes on in the home can be highly valued, while a
sense of duty or desire to protect their carer or family members can deter the
person from speaking out against their abuser.
The abused person may feel ashamed, frightened or intimidated, or may fear being
placed into care or being labelled with dementia. The person being abused may be
resigned to or accepting of long-standing abuse and may blame themselves or feel it
is their duty not to complain and to accept what life deals out. There may also be a
concern that revealing the abuse could result in losing contact with an abuser who is
a vital source of social contact or care.
Elder abuse and neglect – social work intervention
In older people from CALD backgrounds, risk factors for abuse may include:






Lower levels of acculturation.
Living with non-family members or in an intergenerational household.
Dependence on other adults to move about.
Lack of ability to use simple technology (e.g. telephone).
Lack of English proficiency.
A degraded physical appearance such as self-neglect (Lewis, Sullivan & McBride, 2000).
Health practitioners should also look for other physical signs of abuse, and for other types of
abuse (e.g., emotional abuse, sexual abuse, neglect by caregivers, self-neglect, financial
exploitation or health care fraud and abuse). District Health Board staff should refer to DHB
policies on Elder Abuse and Neglect Screening and Intervention.
58
Case studies
Case Study 1: Elder abuse in the community: Mayada Assad’s story
Mayada Assad is 69 years of age. She is a refugee from Bhagdad who speaks little
English. She arrived in New Zealand with her husband, who died a year after arriving,
leaving her alone with no family support. Mrs Assad was being harassed by her neighbour in
a Housing NZ pensioner flat because she was a Muslim. Her neighbour, an older male was
often drunk and used rude and threatening language towards Mrs Assad, so that she was
afraid to go outside alone.
Another resident in the pensioner flats contacted Age Concern about the situation, and she
went with the Elder Abuse and Neglect Coordinator to visit Mrs Assad. It became apparent
that Mrs Assad has poor mobility and possibly other health concerns.
Question:
What would be considered a culturally responsive approach for this case?
Discussion:
A culturally responsive approach for this case would include:











Starting with some general conversation. Avoid an overly clinical/business-like
approach.
Responding with sensitivity to gender, and the dynamics of status in ethnic
communities.
Selecting interpreters with care and ensuring the role of the interpreter is clearly
defined and confidentiality is assured.
Having an understanding of the effects of migration, refugee resettlement, and
religious or cultural conditioning.
Providing advice on the resources available and legal protection and prevention
systems.
Offering referral to ethnic-specific agencies.
Assessing with the assistance of a professional interpreter. Referring Mrs Assad
for a gerontology nurse specialist assessment to assess her health status.
Referring Mrs Assad to the community mental health service closest to her
residential area to assess for any mental health issues (e.g., any post-traumatic
stress disorder).
If there are signs of post-traumatic stress disorder, Mrs Assad should be referred
to a mental health practitioner (clinical psychologist) who specialises in this type
of disorder and a professional interpreter used.
If needed, Mrs Assad could be referred to a Muslim women’s support group to
help her gain confidence, gain skills and to reduce her isolation.
Referring to the local Age Concern Elderly Abuse case worker, to explain to the
neighbour (the bully) that Mrs Assad has had a traumatic time in Iraq and that
59
he needs to understand that she needs support to readjust to living in a New
Zealand neighbourhood.
Case study 2: Elder abuse in the family: Mr Patel’s story
Mr Patel, an older Indian man, lives with his son, two grandchildren and his son’s new
partner. The son’s partner does not like Mr Patel living with them and has made his life
unbearable.
Mr Patel is expected to do the housework, prepare all meals, receive visitors only when
other members of the household are not at home, and to be in his room by 7pm at night.
Mr Patel wants to return to India. However, he does not have the financial resources to do
this. After suffering a heart attack Mr Patel is admitted to hospital.
Question: How do you make it safe for Mr Patel to disclose the abusive situation in his
home and what assistance and support will you make available to him?
Discussion:
Prior to being discharged Mr Patel discloses to a social worker that he is being abused by his
family, and that he does not want to return to live with them. Mr Patel consents to a referral
being made to Age Concern to assist him to find an alternate living arrangement. With the
support of Age Concern and friends, Mr Patel is now living independently, and in a safer and
friendlier environment.
Case study 3: Elder abuse in the family: Mrs Jang’s story
(Adapted from Park, 2013)
Mrs Jang is 80-years-old. She came to New Zealand with her son and his family 20 years ago.
She has been referred by her GP to the cardiologist for chest pain. Test results show no
abnormalities. Mrs Jang is seen by a hospital social worker who is Korean.
She tells the social worker that she has been financially exploited and emotionally
mistreated. She feels “endless unfairness" about being betrayed by her own children. She
says that she experiences symptoms of “extreme pressure on her chest” from time to time
with “a feeling of tightness and heaviness in her chest”, in addition to serious sleeping
problems. She tells the doctor that “my pain here [her chest] is really bad, so painful. . . you
know, and I often have hard time breathing . . . however, my Kiwi [New Zealand] doctor
always said that I am healthy and [there are] no problems in my chest”. She says that she is
seized by “Hwa-byung”.
Mrs Jang tells the social worker that she would often pray for “not waking up in the next
morning” before falling asleep at night. Mrs Jang is isolated in her home and has little social
contact with others from her community.
60
Questions:
1. What does ‘Hwa-byung’ mean, which Mrs Jang refers to?
2. What action will you take to address the elder abuse in this family?
3. What steps will you take to address Mrs Jang’s mental health status including
suicide risk and wellbeing?
4. What support and resources will you offer Mrs Jang?
Discussion:
1. What is Hwa-Byung?

Korean older people in situations of family abuse may present with the somatised
symptoms of emotional and psychological distress. In a New Zealand study, Korean
older people in situations of mistreatment identified Hwa-byung (literally anger
disease), a Korean culture-bound syndrome as a health issue associated with
suppressed emotions of anger, demoralisation, heat sensation and other somatised
symptoms (American Psychiatric Association, 2000; Park, 2013).

‘Hwa’ (fire) refers to anger, resentment or a strong feeling of frustration, while
‘byung’ means disease or illness. Min (2009) argues that this syndrome is unique in
the Korean culture because “suppression and control have been strong social codes
of behaviour in the traditionally familial, collective and Confucian culture of Korea.”

Hwa-byung can be a major cause of mental and physical health issues for abused or
neglected older people over a long period.

This culture related anger syndrome prevents older people from seeking help for
protection from elder abuse.
2. What action will you take to address the elder abuse in this family?

Offer reassurance to Mrs Jang that there are services that can help her with the
issues she describes.
3. What steps will you take to address Mrs Jang’s mental health status including suicide
risk and well-being?

Make a referral to the mental health team for an assessment to assess her mental
health status, suicide risk, and her overall social wellbeing.

Ensure the provision of a culturally appropriate assessment to understand her
background, health and social history relating to elder abuse, cognitive and affective
61
status, functional status, home situation, family system, explanatory models of
illness; and to gain some outcomes-specific information (refer to the CALD Older
People Assessment Tool under the “Tools and Guidelines”).
4. What support and resources will you offer Mrs Jang?

If there is a Korean speaking cultural case worker in a local Age Concern service, to
follow up with the client’s issues concerning abuse and neglect that would be most
appropriate.

If language is a barrier, using a professional interpreter to communicate is better
than family members.

Link Mrs Jang to a local Korean community group if available, to ensure that she has
access to culturally and linguistically appropriate activities.
62
Key considerations
Key considerations: Elder abuse and neglect

Providing a service that is safe
and respectful for CALD older 
people (Glasgow & Fanslow, 
2006).


Ensuring CALD older people
are not only supported but
also empowered




Assessment


Safety planning


Referrals

Where required, provide professional interpreters.
Where possible, use gender-appropriate practitioners.
Recognise that relationship building is a process that takes time and
ensure a non-judgmental and respectful communication style, tone and
language.
Record the ethnicity and the primary language of the older person and
your inclusion of cultural/religious considerations. Where physical
evidence and photographs are required, provide adequate support and
explanation, and ensure that processes are sensitive to
cultural/religious considerations.
Develop your knowledge and understanding of the dynamics of abuse in
Asian/MELAA communities.
Select interpreters with care and ensure the role of the interpreter is
clearly defined and confidentiality is assured. Have persons available
who can speak the same language as the older person.
Provide support based on an understanding of the context for CALD
older people, including the effects of migration, refugee resettlement
and religious or cultural conditioning.
Recognise that for solutions to be meaningful to CALD older people,
other sectors may need to be involved (e.g., Work & Income; Housing
New Zealand; Immigration New Zealand).
Provide advice on the resources available and legal protection and
prevention systems.
Offer reassurance to older people that there are services that can help,
and offer referral.
Recognise the diversity of definitions and experiences of violence, and
the barriers to asking for and receiving support.
Know your local community referral agencies with expertise in abuse
and offer the choice of an ethnic-specific elder abuse advocate, where
available.
Do not assume the family, religious or ethnic community leaders should
be involved – ask the older person what plan of action they want.
Ensure contact details are available for people and community groups
with the necessary knowledge and skills for working with older people
in CALD communities.
63
Advance Care Plan and Advance Directive
Advance Care Plan (ACP)
ACP is a voluntary process of discussion and shared planning for future health care. It
involves an individual, his/her family and health providers. ACP gives people the opportunity
to develop and express their preferences for future care based on:



Their values, beliefs, concerns, hopes and goals.
A better understanding of their current and likely future health.
The treatment and care options available.
An Advance Care Plan can be a written document or a verbal statement/s.
During the process of an ACP discussion a person may express specific wishes with regard to
a treatment option that might be offered in the future. This could constitute an Advance
Directive.
Advance Directive (AD)
An Advance Directive is consent or refusal to specific treatment(s) offered in the future
when the person does not have capacity to make a decision. To be valid, an AD must meet
the following criteria:




The person must have been competent when the AD was written or stated.
They must have been adequately informed.
Their decision must have been made voluntarily and be free from any undue
influence.
The AD must have been intended to apply in the current circumstances.
In the absence of reasonable grounds to doubt validity, an AD should ordinarily be
honoured. An AD can be a written document or a verbal statement.
Note: A client or family cannot demand in advance any medical treatment that would not
ordinarily be offered. Each clinician makes a decision regarding the type of treatment, which
is likely to be beneficial to a client. If a treatment is not medically indicated it should not be
offered. This position is supported by the New Zealand Medical Council.
Enduring Power of Attorney (EPA)
People aged 18 years or over can formally appoint a person or people to act on their behalf.
The person who acts on the appointee’s behalf is known as an ‘attorney’. The form
/document used to appoint the attorney is known as ‘power of attorney’ (EPA).
The two main forms of attorney in use in New Zealand are:


The enduring power of attorney in relation to property, and
The enduring power of attorney in relation to personal care and welfare. The aim of
this EPA is to give the attorney the right to act in relation to personal care or welfare
if the appointee becomes mentally incapable.
64
The attorney can make decisions in relation to consent for treatment. However the attorney
cannot refuse consent to any standard medical treatment or procedure intended to save the
person’s life or prevent serious damage to a person’s health.
Cultural perspectives
The following section outlines the cultural influences on CALD patients’ willingness to
participate in ACP and AD. While aspects of culture are described, it is important to avoid
stereotyping patients as having the same worldviews. The patient’s degree of acculturation
and the strength of their ties with traditional beliefs will be important factors in patient and
family responses to ACP and AD.
This section also provides culturally appropriate approaches to addressing ACP and AD with
CALD clients, including additional guidelines on how to communicate and engage with
clients and their families. Knowing how to assess the need for an interpreter and how to
work with interpreters effectively is essential for working with patients with low or no
English language ability.
Chinese
Some families may not be familiar with the concept of ACP and AD. Some may value length
of life more than quality of life and may make every attempt to prevent someone from dying
and may even ask for cardiopulmonary resuscitation (CPR) to be attempted at the last
minute or in the ACP or AD plan. This is usually because they do not want to feel guilty at not
doing enough for the loved one during the end-of-life period (Con, 2007; Htut, 2007; Lip,
2009; Tse, 2003). It is important to be aware that some families are not aware that in New
Zealand treatment that is considered not effective for ameliorating or correcting serious or
life-threatening conditions, will not be offered. This needs to be explained in a culturally
appropriate manner.
Families’ protection of elders may result in not informing their family member of a serious
diagnosis, and there may be a reluctance to place the older person in long-term care. For the
same reasons, families are unlikely to want to discuss ACP with their older family member.
Traditional Chinese families do not like discussing taboo subjects such as death, dying and
cancer. They believe that discussing death and dying may lead to something bad happening.
Health professionals need to be sensitive and aware of these possible beliefs when
approaching such issues when discussing ACP.
Decision making is traditionally expected of the husband or the eldest son. Caring for the
sick and dying is the duty of the family. It is also important to ask about whether there is an
accepted family decision-maker (Yeo, 1995). Physician and family-based decision making is
preferred over patient autonomy.
There may be resistance towards organ donation. This may result from a wish to keep the
body whole for the afterlife, and out of respect for the deceased person. However, attitudes
can change in families depending on their level of acculturation.
65
Korean
Traditional Korean families consider family-based medical decisions as a function of filial
piety. Illness is considered a family event, rather than an individual occurrence (Searight,
2005). It is also expected that family leaders be the decision makers, eg husband or oldest
son.
In Korean families, it is expected that a parent will make decisions in the best interests of
their children, and children will make decisions in the best interests of their parents to meet
filial piety obligations. This may conflict with practical decisions. Parents and children may
assume that they know what is best and may not discuss issues with each other. It is
important for health professionals to understand why Koreans may not make clear decisions
about ACP or end of life care, and why they often change their minds.
South Asian
Traditional South Asian families value physician and family-based decision making over
patient autonomy. Caring for the sick and dying is the duty of the family. There are social
taboos against using words such as cancer, and death and dying when talking to a family
member with a serious diagnosis. The avoidance of contemplating serious ill-health and
death presents a barrier to the discussion of ACP in Asian families (Lip, 2009).
It is important to note that due to religious beliefs and practices post mortems or organ
donation is generally unacceptable to people from South Asian backgrounds, unless it is
necessary.
Muslim
Family support is seen as integral to the process of recovery. If a family member is sick the
whole family may feel a responsibility to look after the one in need (Con, 2007; Shah, 2012).
Seeking any form of treatment is allowed whether traditional or Western, as long as it is a
recommended and legal form of treatment.
Some families could urge that “everything needs to be done” for the dying patient because
they want to prolong life for as long as possible. Sometimes there is family disagreement
about what is best for the dying patient. It is important to be aware of this and explain that
treatment cannot be offered to the patient if it is not medically indicated.
Many Muslim families may not be familiar with advance directives or advance planning.
Some think that if they give an AD they will not be treated and that by appointing a healthcare representative they are giving up control of their health-care decisions. There should be
a discussion on AD with members of the family and expressed wishes should be recorded.
There are also misconception amongst Muslims (a) that an advance directive is a permanent
document and that it cannot be changed; (b) verbal wishes are not legal; (c) that physicians
do not have to follow one’s wishes because they are “gods;” they will do whatever they
want (Athar, 2011).
66
Culturally appropriate ACP
The provision of culturally appropriate ACP involves clinicians eliciting and complying with
the patient’s preferences and values about an ACP and their decision-making processes. For
information and eLearning modules in ACP and communication skill development, refer to
the ACP website at www.advancecareplanning.org.nz.
For cultural and religious reasons it may be more challenging to discuss ACP with patients
from CALD backgrounds.
The following points are approaches to consider when discussing ACP with CALD patients
and families, in order to provide and open and supportive environment:

Ideally, discussions on ACP should be performed well before an impending health care
crisis and should become part of the patient’s routine care. It should also be a
continuing discussion as patient’s views change, they grow older or their health status
declines and their perspective on their health care preferences change. Incorporating
an ACP discussion on a yearly basis is advisable.

Patients who are competent to make decisions should be asked if they wish to discuss
ACP on their own or with the support of their family member(s). If they nominate
family member(s) as the designated decision maker on health care issues any ACP
discussion should include the family. It is also important to determine the patient’s
preference for being present at the discussion and to remind patients that their
decision will be recorded in the notes and that they can change their mind at any
time. This is important as there is a common misconception that once completed an
ACP cannot be changed.

Sufficient time must be allocated for the discussion. Setting up a separate time allows
for a more thorough discussion and question and answer sessions. Also the patient
may need to make arrangements for family members to attend. ACP discussions
should be completed over a series of meetings as it is a process of thinking about,
talking about and if people wish, documenting future health care preferences.

The discussion should be in private. The health provider should encourage the patient
and their family to ask questions. The health provider should reassure the patient and
the family that the ACP will be shared with those who are on the patient’s health care
team ensuring that there is a shared understanding of what is important to the
patient and/or family.

Provide detailed information including the natural course of the disease, the
prognosis, and the chances of survival. Many family members will pursue less
aggressive treatment if the chance of survival is poor. Help the patient and family
understand that “doing everything” may also bring about additional pain and
suffering. However, recognise that for some people, even in the face of a low survival
67
rate, aggressive treatment is expected and supporting those decisions is
important. When the patient or family wants “everything possible done,” an
exploration of what that means can provide a greater understanding of what’s behind
the request. Underlying concerns may include: denial of the illness or the progression
of the illness; unrealistic goals; fear of dying, and loss of self-control; false hope; or a
sense of familial duty (Braun, et al., 2010).

Patients and family members need to be assured that an ACP that excludes curative
treatment does not mean the patient will be abandoned by the health care
system. The health provider must provide reassurance that stopping curative or lifesupporting treatment does not mean no treatment, but the focus of the patient’s
treatment will be the provision of the expert management of symptoms the person
may experience.

For some cultures, the concept of present orientation is to “take each day as it
comes”. The health provider may suggest having a trial intervention to help with the
decision-making process. A trial intervention is time limited and takes the approach
of “Let’s see what happens to your mother’s condition in the next few days and we can
then revisit the discussion on life-sustaining treatment. Meanwhile if you have any
questions for me, please feel free to ask them.”

A religious leader can play an important role in facilitating the discussion and decisionmaking process in ACP through clarification of how certain aspects of a religion’s
principles or beliefs may influence the decision on providing life support
measures. The religious leader can also act as a crucial intermediary in helping the
patient connect with his or her faith or spiritual life.

When the discussion of death and dying is a taboo subject, the health provider might
suggest that the patient do a life review. Xiao et al.’s (2011) study on Chinese patients
with advanced cancer found that encouraging patients to do a life review prepared
them for death. Encouraging the patient to review and value his or her life
experiences and complete unfinished business may enable the patient to work on an
ACP.

More subtle, indirect and implicit non-verbal communication may be preferred when
discussing an ACP. Non-verbal communication includes active listening with pauses
between sentences, silence and where appropriate physical contact such as holding
the patient’s hand.
68
The following are examples of scripts for the discussion on ACP. Adjust the script if the
discussion is with the family.
Ask permission to have
the discussion. This
shows respect.
“I would like to talk to you about what kind of care you (your mother)
would like if you (she) got really sick. Is that ok?”
“If you get really sick, I am concerned that we do not know what you
want or how you would like to be cared for. Could we talk about it
now?”
“What kind of medical care would you want if you were too ill or hurt to
let someone know your wishes?”
“There is a way to let your family, friends, and health providers know
what your wishes are and to avoid any confusion later. This is called an
ACP. This is where you think about, talk about and if you would like to,
document your preferences for your future health care needs. This helps
make it clear what you want and do not want if you are very seriously ill.”
If the patient is
seriously ill and does
not have an ACP.
“I realise these are hard questions for you to think about, but because
you are so seriously ill, if your heart stopped or you stopped breathing
what would you like to have done?”
Some patients avoid
discussions because of
a belief around “hope
or a miracle cure.” Be
open and honest, and
refocus on the
possibility of different
types of hope and
miracles.
“I believe (or I know you believe) in hope and miracles, but sometimes a
cure doesn’t happen. However, there may be other types of hope and
miracles to consider, such as a good death, a peaceful death having all
your family around you, or for the relief from pain and suffering. What
do you think?”
Developing trust and rapport with CALD clients and their families, improving communication
and working with interpreters effectively, are all important aspects cross-cultural
interactions with CALD clients. Guidelines on the following topics can be found in the ‘Tools
and guidelines’ section of this document:



Guidelines for Developing Trust and Rapport.
Guidelines for Improving Communication.
Guidelines to Work with Interpreters Effectively.
69
Case study
Case study: Advanced directives - GP and residential age care case
Mr Yu is a 90 year old Chinese man admitted to a Residential Aged Care (RAC) facility for
respite care under the care of his own GP.
He rapidly deteriorates post admission. The residential care staff call Mr Yu’s GP to come
and assess the client. The GP is on holiday and the locum advises that (1) he would prefer
not to make a visit to the patient and (2) he does not know the patient, Mr Yu.
Staff are worried about Mr Yu’s medical condition and asked the RAC-contracted GP to
review the patient. The RAC-GP does so and advises that the client has an acute lobar
pneumonia and on the basis of the local Community Acquired Pneumonia Pathway, the
patient needs admission to hospital for intravenous antibiotics. Mr Yu is seriously unwell
with marked shortness of breath and a high risk of dying.
Mr Yu does not speak English and there is no Enduring Power of Attorney. His son who is the
next of kin and the first contact for the client is available and interprets the RAC-GPs findings
and recommendations. Mr Yu clearly declines admission and his son tells staff that this is
consistent with his father’s wishes. Further, he explains that his father understands the
severity of his illness and the likely outcome. The RAC-GP feels confident with the patient’s
direction based on the interactions between father and son, the clarity of the patient’s
speech. Mr Yu’s repeated English insistence “no hospital”, and the son’s acknowledgement
of his father’s understanding.
The RAC-GP agrees with Mr Yu’s decision and communicates this to him. Mr Yu thanks the
RAC-GP. The RAC-GP spends time with the son explaining the likely outcomes and gets his
agreement to this process.
The father deteriorates as expected; the RAC-GP reviews the case the next day but now the
son is not available and two new family members are present. They are less in agreement
with this process. Discussion occurs but they are clearly not as convinced as to the outcomes
of the discussion with the son the previous day. Mr Yu has now deteriorated to the point
that his wishes are not able to be expressed clearly and his mental capacity would make any
directive invalid. The two new family members want Mr Yu to be transferred to hospital.
Question:
Was best practice applied in this scenario to obtain advance directives from Mr Yu?
Discussion:
An Advance Directive must be made by a person who is competent at the time the decision
is made, informed, free from undue influence and it should apply to the current
circumstances.
In this case, it could be argued that the GP made the assumption that Mr Yu was mentally
competent, informed and free from any undue influence in the decision not to go to
70
hospital. However this could not be safely assumed when a family member was interpreting
for the patient.
While this patient may have been best supported by his own GP, if his own GP was
unavailable then it was appropriate to involve the RAC-GP.
Good practice in this situation would have been:

To arrange an urgent family meeting involving all the key family members while
Mr Yu was still able to express his wishes;

To use a qualified independent interpreter during this meeting to ensure that
information is conveyed correctly between both parties and there is no undue
influence or misinterpretation from family members. It is important that Mr Yu’s
wishes (which were that he was ready to accept his life’s end and preferred not
to go to hospital) are understood by the RAC-GP and the family without any
ambiguity; and

To document all ACP and AD conversations including the clinical decision to
allow the patient to stay in the RAC facility rather than transferring him to
hospital based on the patient’s wishes. It is worth noting that if the regular GP
had documented any previous ACP conversations he had had with Mr Yu and his
family, the RAC-GP would have been better informed and aware of the situation.
The case highlights the importance of involving all key family members, using a qualified
interpreter when communicating with patients with limited English speaking ability and
the need for documenting all ACP conversations.
71
Key considerations
Key considerations: ACP and AD
ACP and AD



ACP is a voluntary process of discussion and shared planning for future health care.
An AD is consent or refusal of specific treatment(s) offered in the future when the
person does not have capacity.
EPA - People aged 18 or over can formally appoint a person or people to act on their
behalf. The person who acts on the appointee’s behalf is known as an ‘attorney’. The
form /document used to appoint the attorney is known as ‘power of attorney’ (EPA).
Cultural
perspectives

It is important to avoid stereotyping Asian, Middle Eastern or African patients as
having the same worldviews.
Chinese
perspectives

Chinese families may have difficulty conceptualising ACP. Longevity is more
important than the quality of life.
Families’ protection of elders may result in their not informing their family member
of a serious diagnosis to protect them; which means that they are unlikely to want to
discuss ACP with their older family member.
Traditional Chinese families do not like discussing taboo subjects such as death,
dying and cancer.
Physician- and family-based decision making is preferred over patient autonomy.
Chinese people may not necessarily see “home” as the place of care at the end-oflife. Hospitals can be seen as places with appropriate competent professional care.
The use of community hospices can also be encouraged.
There may be resistance towards organ donation. This may result from a wish to
keep the body whole for the afterlife, and out of respect.





Korean
perspectives



South Asian
perspectives


Muslim
perspectives

Culturally

appropriate ACP

Traditional Korean families consider family-based medical decisions as a function of
filial piety. Illness is considered a family event, rather than an individual occurrence
(Searight, 2005).
Family leaders are traditionally expected to be the decision makers, e.g. the husband
or the eldest son. There tends to be an orientation toward the extended family as
opposed to individual patient self interest.
It is important for health professionals to understand why Koreans may not make
clear decisions about ACP or end of life care, and why they often change their minds.
Traditional South Asian families value physician- and family-based decision making
over autonomy. Caring for the sick and dying is the duty of the family.
The avoidance of contemplating serious ill health and death presents a barrier to the
discussion of ACP in Asian families (Lip, 2009).
Not all Muslim families are familiar with advance directives or advance planning.
There should be a discussion on AD with members of the family and expressed
wishes should be recorded.
When the family has been nominated by the patient as the designated decision
maker on health care issues, any ACP discussion should include the family.
Sufficient time must be allocated for discussion, which must be in private.
72
Key considerations: ACP and AD





Determine if the client and family understand the purpose of an ACP.
Provide detailed information including the natural course of the disease, the
prognosis, and the chance of survival. When the client or family wants “everything
possible done”, an exploration of what that means can provide a greater
understanding of what is behind the request.
Clients and family members need to be assured that an ACP that excludes curative
treatment does not mean the client will be abandoned by the health care system.
A religious leader can play an important role in facilitating the discussion and
decision-making process in ACP through clarification of how certain aspects of a
religion’s principles or beliefs may influence the decision on providing life support
measures.
More subtle, indirect and implicit non-verbal communication may be preferred when
discussing ACP. Non-verbal communication includes active listening with pauses
between sentences, silence, and where appropriate physical contact such as holding
the patient’s hand.
73
End-of-life care
The following definitions are taken from the New Zealand Palliative Care Glossary (Palliative
Care Council of New Zealand et al., 2012).
End of life: The end of life phase begins when a judgement is made that death is
imminent. It may be the judgement of the health/social care professional or team
responsible for the care of the patient, but it is often the patient and the family who
first recognises its beginning.
End-of-life care: End-of-life care is the provision of supportive and palliative care in
response to the assessed needs of the patient and family during the end of life
phase. It focuses on preparing for an anticipated death and managing the end stage
of a life-limiting or life-threatening condition. This includes care during and around
the death and immediately afterwards. It enables the supportive and palliative care
needs of both the person and the family to be identified and met throughout the
last phase of life and into bereavement. It includes management of pain and other
symptoms and the provision of psychological, social, spiritual and practical support
and support for the family.
Decision making
Asian, South Asian, Middle Eastern and African cultures are collective cultures. Accordingly
the individual is part of the family unit in which decisions are made collectively.
The cultural expectations about who should be making health care decisions and who should
be told about a patients’ serious diagnosis may conflict with the patients’ rights in New
Zealand to information from health providers. An awareness of family expectations, and
their underlying reasons for such expectations, will help the practitioner better understand
and negotiate with distressed family members when end-of-life care issues need to be
approached in a culturally sensitive manner.
There are differing cultural perspectives on the full disclosure of health information such as
a diagnosis with a poor prognosis or the giving of bad news to patients from a CALD
background (Hasan & Periyakoil, 2010; Searight, 2005; Windsor, 2008). Reviewing general
perspectives on models of decision-making can be helpful.

Patient Autonomy Model
The rights of the individual are considered paramount in Western culture and are
reflected in the patient autonomy model. Following this model, bad news is
communicated directly and honestly to the patient, who is then able to choose
whether or not to be actively involved in all aspects of decision-making about the
management of his or her illness (Windsor et al., 2008). The concept of patient
autonomy is so powerful in Western cultures that people can safeguard their right
to make future decisions about their own health by providing living wills and
advance directives in the event of the loss of their ability to make such decisions.
74

Non-maleficence Model
The non-maleficence model is at the opposite end of the spectrum to the patient
autonomy model in that the patient is not told of a poor prognosis in the belief that
this will protect them against unnecessary physical and emotional harm (Windsor et
al., 2008). Following this model, diagnostic and prognostic information is given to
the patient’s immediate family members who then make treatment decisions on
behalf of the patient. This approach is more common in families from Middle
Eastern and African backgrounds.

Beneficence Model
In the middle of the spectrum is the model of beneficence in which decisions about
health care and treatment tend to be made jointly by family members (who are
often the main caregivers) and the patient, rather than by the patient alone. In this
setting the family rather than the patient are the first to be informed of the
diagnosis and/or the suggested management plan. This approach is common in
Asian countries including: China, India, Korea, Singapore and Thailand (Windsor et
al., 2008).
Chinese perspectives
In traditional Chinese families, physician and family-based decision making is preferred over
client autonomy. Decision making is traditionally expected of the husband or the eldest son.
Caring for the sick and dying is the duty of the family. It is also important to ask about
whether there is an accepted family decision maker (Yeo, 1995).
Traditional Chinese families expect that information will be conveyed to the family first.
Sensitivity and subtleness is important because the family believes that the loved one may
lose the will to live or may be upset and unhappy for their remaining time. Chinese people
do not like discussing taboo subjects such as death, dying and cancer issues. They would
prefer indirect nuances over truth telling. They believe that discussing death and dying may
lead to something bad happening.
Korean perspectives
Collective decision making in traditional Korean families is expected. Respect for one’s
parents and ancestors are a feature of filial piety. Illness is considered a family event, rather
than an individual occurrence (Searight, 2005). Traditionally, the husband or the eldest son
is expected to be the decision maker in the family.
The relationship between parents and children is very important in Korean culture. There is
a subtle understanding that a parent will make decisions in the best interests of their
children, and children will make decisions in the best interests of their parents. This may
conflict with practical decisions. Parents and children may assume that they know what is
best and may not discuss the issue with each other. For example, there may be a conflict of
views between health practitioners and family members about the quality of life of the
75
dying person. The older person’s children may wish to prolong life, believing that they are
doing their best (both emotionally and financially) to support their parent who is dying. In all
likelihood children will not want to make a decision about stopping treatment if it is
available and free.
Middle Eastern perspectives
It is expected in traditional Muslim families that the patient is not given bad news and that
the patient’s diagnosis and prognosis is given to their immediate family members who then
make treatment decisions on behalf of the patient (Windsor et al., 2008).
In Middle Eastern families, elders will often involve family members in decision making, and
will commonly involve a son or a daughter (Hasan & Periyakoil, 2010). When an older person
becomes ill, it is the family who expect to be fully involved in all aspects of treatment and
care rather than the client. Even in the case of a conscious client, the family expect that
they and the physician will generally protect the client from the anxiety and distress
associated with the knowledge of a terminal illness.
Muslim perspectives
An essential aspect of health care for Muslim families is the health providers' role in:
understanding the concerns of the client and family and communicating these concerns to
all those involved in the decision-making process; consoling and comforting the older person
and their family so that they can accept their or their loved one's health status; and, if
possible, taking care of the family's needs beyond the medical aspects.
Traditional Muslim families tend to symbolically and formally introduce the doctor into the
family. The doctor/specialist is expected to direct rather than just facilitate medical
management (Hasan & Periyakoil, 2010).
Communicating bad news
Determining how much and how best to communicate bad news to CALD patients is
challenging.
It is clear that giving a patient’s serious diagnosis to their relatives before telling the patient
is in breach of the New Zealand Code of Health and Disability Services Consumers’ Rights
(1996). However, it is important to take note of the CALD patients level of acculturation. A
first generation migrant with limited English proficiency living in New Zealand may have
limited exposure to Western culture and may still fully retain their traditional beliefs and
preferences. Conversely, a second or third generation New Zealand-born ethnic person
whose parents were migrants may have developed a mixture of Eastern and Western beliefs
or may be fully assimilated to Western cultural attitudies towards healthcare.
It is important to offer patients a choice about whether they or nominated family members
should be told bad news first, although offering the patient the choice may not be in
accordance with their cultural expectations (Windsor, 2008). Although a New Zealand study
by Windsor et al. (2008) has developed a useful questionnaire to assess a patient’s
76
preference regarding how bad news should be conveyed, this has yet to be implemented.
The recommendation is to ensure that communication between patients, families and staff
in hospital settings is culturally sensitive and appropriate (Windsor, 2008).
Tse et al’s (2003) study of breaking bad news to terminal cancer patients in a Chinese family
context recommends that giving bad news should depend on what the client wants to know
and is prepared to know, and not on what the family wants to disclose. Tse et al. (2003)
recommend the standard palliative care approach to breaking bad news be adopted, with
modifications to address the ‘family determination’ and ‘death as taboo’ issues.
Hospices
Asian clients and their families are less likely to take advantage of hospice services, such as
home visiting, day stay and rest-home facilities. In Asian communities there is a general lack
of awareness about what hospices provide and their philosophy of care. The general
perception is that when a hospice becomes involved, death is certain and imminent. It is
important to educate clients and their families about what services hospices can offer.
In New Zealand, with appropriate cultural support in place more Chinese people are
choosing specialist hospice units for their end-of-life care, rather than home or residential
aged care. However, many families do not understand that a ‘referral to hospice’ also means
the option of community support by a palliative care team in their own homes (personal
communication Catherine Chiu 28/08/13).
It is useful to note that some hospices in the Auckland region cater to the spiritual needs of
religiously diverse clients, for example, the Amitabha Hospice Service in Auckland (2013) is
based on and practices Buddhist principles.
Death and dying
Traditional families from Asian, Middle Eastern and African cultures do not like discussing
taboo subjects such as death and dying. They believe that discussing death and dying may
lead to something bad happening. An awareness of family expectations and views around
death and dying beliefs and practices will help health professionals to approach such issues
with distressed family members, in a culturally sensitive manner.
77
Chinese perspectives
The Chinese traditional view about “a good ending” is that, when facing death, the dying
person feels comfortable, peaceful and surrounded by children/family.
Some families consider quantity of life more important than the quality of life and may insist
that cardiopulmonary resuscitation (CPR) be provided until the last minute. This is because
they want to do the best for their loved one (Con, 2007; Htut, 2007; Lip, 2009; Tse, 2003).
They may not be aware that in New Zealand treatment that is not medically indicated will
not be offered. Being aware of this will help health practitioners negotiate with the
distressed families appropriately.
Religious views about death and dying include:
Religion
Belief
Confucian
‘Willingness to die to preserve virtue’: One should not be afraid of death. If a
non-virtuous act is needed to preserve life, one would rather die.
Taoist
‘Life and death unified’: Life and death are natural processes. One becomes
part of nature upon death, and one need not grieve when facing death.
Buddhist
‘Belief in new life after death’: Death is part of the process of the wheel of
rebirth. Death is a way to Nirvana.
Christianity
A belief in resurrection.
Islam
A belief in after life and the day of judgment.
Korean perspectives
Beliefs about life after death differ according to a person’s age, religion, education and life
experiences.
Korean people’s religious backgrounds affect their beliefs about the afterlife. The majority of
Koreans in New Zealand are Christians. However, while Christians in general accept death
because there is a positive outlook on death and the afterlife, there are other Korean
Christians whose death and afterlife beliefs are deeply influenced by Confucian thought,
particularly neo-Confucian (a term commonly applied to the revival of the various strands of
Confucian philosophy and political culture). There are also Buddhist and Shamanistic
influences in Korean traditional funeral rites.
78
South Asian perspectives
In South Asian families, the family plays a central role at the time of terminal illness or
death. Many South Asian people prefer to die at home. From a traditional perspective it is
very important for family members to be at the bedside of the terminally-ill client praying,
chanting hymns and bringing in pictures of religious figures/gods/goddesses (Periyakoil &
Dara, 2010).
Some families may be hesitant to allow health providers to give a dying person sedating
medications (because it may be important to the family that they be as awake as possible
during the dying process). These traditions reflect a belief that dying individuals should be
thinking of God as they go through the dying process, because it is believed that the nature
of one’s own thoughts at the time of death determines the destination of the departing soul.
However, if the clinician identifies that the client is suffering pain, dyspnoea or other
symptoms, and the client is requesting relief of symptoms, sedation of the person and
gentle education of the family members will likely result in consent to the needed palliative
care measures.
Hindu families may request that the body be placed on the ground (as a mark of respect to
mother earth). Hindu families may also request that health providers allow them to place a
Tulsi leaf or drops of water from the Ganges River on a client’s lips. They may want to chant
the Bhagavad Gita or other Vedic hymns at the time of death. This allows a client to focus on
God as their soul leaves the body.
After death, it may be important for family members (of the same gender) to be allowed to
perform ritual washing of the body and prepare it for burial (in the case of Muslim families)
or cremation (in the case of Hindu families). This should ideally be done within 24 hours of
the death. Christians may opt for burial or cremation. Most South Asian families will not
request an autopsy but may not be opposed if there are clear reasons for it. This topic
should be approached with great sensitivity.
The mourning family may prefer to have a priest perform a prayer and blessing. It is very
important to provide privacy to the family after the death of a family member to allow
religious rites to be performed. It is an accepted practice for family members and others to
openly express grief. For Hindu families, after cremation, there is a mourning period that
lasts for 10 to 40 days.
Religious views about death and dying include:
Religion
Belief
Hinduism
Belief in karma and rebirth
Islam
Belief in after life and day of judgment
Christianity
Belief in resurrection
79
Buddhism
Belief in “eight fold path” for Moksha
Sikhism arose from Hinduism and these religions share a culture and world view that
includes ideas of karma and rebirth; collective versus individual identity; a strong emphasis
on purity; and a lifestyle based on ‘Ayurvedic’ medicine (a system of traditional medicine
native to the Indian subcontinent, a form of alternative medicine) (Con, 2007). These
religions affect end-of-life decisions and care in a number of ways:





There is a perception that talking about death may make it occur and therefore the
family are often reluctant to let their loved one know about a terminal illness.
There is a preference to die at home or in a hospital but not in a palliative care unit
as the latter are seen as places for dying people and may be seen as tainted.
Withdrawal of food and water at the end-of-life is not likely to occur because it is
believed that both are needed for a good death.
There may be a reluctance to use pain killers as pain must be endured (to help reach
a higher state of mind).
Withdrawal of treatment is acceptable if it is futile.
Muslim perspectives
Death is believed to have its set times for every human being and is expected to come at any
time, therefore it is well accepted. Muslims believe in the afterlife and the Day of Judgment.
They regard death as a transition from one phase of existence to the next. It is preferred
that Muslim people die at home. Care of the dying is a regular and essential responsibility of
the immediate and extended family and has historically been managed at home. With more
young Muslims becoming professionals and moving away from their family homes, this is
slowly eroding.
During illness, Muslims are expected to seek God's help with patience and prayer, increase
the remembrance of God to obtain peace, ask for forgiveness, give more in charity, and read
or listen to more of the Qur'an.
Muslim clients do not consider illness to be a punishment from God. They also believe that
dying is a part of living and an entrance to the next life; a transformation from one life to
another, a part of a journey, and a contract and part of their faith in God.
Muslim traditional practices believe that maintaining a terminal client on artificial life
support for a prolonged period in a vegetative state is not encouraged. Although there is a
belief that autopsy is not to be encouraged, it is permitted if required by law. Individual
Muslim practices may vary.
NB: Information about end-of-life care for: Cambodian, Chinese, Indian, Japanese and
Vietnamese cultures; and for Buddhist, Hindu, Sikh and Muslim faiths is available from
Waitemata DHB eCALD® Services (2016) See “Death and Dying: Information from Different
Asian Cultures and Religions”
http://www.ecald.com/Portals/49/Docs/Publications/ACP%20Asian.pdf.
80
Palliative care for Muslim clients
The aim of end-of-life care is to reduce anxiety. Optimism and hope are regarded as some of
the fruits of faith in Islam. Illness and disease is a test from Allah and illness should be
received with patience, meditation and prayer. Palliative care services are valued and
effective but Muslim families need to be informed that such services exist.
Important aspects for consideration include:








In matters of terminal care, the attending physician should always consult the client
and involve the family, before making a final decision.
Health providers should comfort the terminally ill person, making sure they are painfree and that their relatives and friends are able to be with them.
The family should be given access to an Imam who can read the Qur'an and make
special prayers.
Muslim families may want to chant the Qur’an at the bedside.
At the time of death, family members may request that the body be positioned in
specific directions (for Muslims the dying person’s face is turned towards Mecca).
It is important that funeral and burial arrangements be made in advance, in
consultation with the family and according to the wishes of the dying or deceased
person if possible.
With minimum delay, the body is to be removed to the funeral home because
Muslims prefer an expeditious burial. Provide routine post-mortem care. The body
should be gowned and shrouded.
Allow the family and Imam to follow Islamic guidelines for preparing the dead body
for an Islamic funeral.
Culturally appropriate end-of-life care
The provision of culturally appropriate end-of-life care involves clinicians eliciting and
complying with the older person’s preferences and values about disclosure and decisionmaking processes.
The power imbalance in clinician-client interactions may make it difficult for some CALD
people to request their cultural/religious care preferences (Hofstede, 2002). Clinicians need
to offer autonomy to clients while respecting and acknowledging different cultural norms
such as preferences for non-maleficence, non-disclosure and rights to independent decisionmaking.
CALD older people may prefer family-based decision making processes and may refuse to
make decisions in regard to their medical investigations or diagnostic procedures. In these
cases clients must be provided with clear and voluntary choices. Some cultures prefer to
communicate information about serious illness and death subtly instead of explicitly, by
using facial expressions, voice tone and other nonverbal cues. However, it is important not
to stereotype or make assumptions about a CALD person’s cultural beliefs, preferences and
values, but to always ask.
81
Assessing the clients’ ability to speak and understand English or their ability to read written
information in English or any other language is essential to the provision of quality health
care. Ensuring that the older person has a professional interpreter (if needed) is not only
important for clear communication but also to ensure that decisions made by and for them
are legal and without any undue influence. It is highly inappropriate to use a family member
to interpret, especially when giving bad news to an older person.
Developing trust and rapport, improving communication and working with interpreters
effectively are all important aspects in dealing with CALD clients. Guidelines on the following
topics can be found in the ‘Tools and guidelines’ section of this document:



Guidelines for Developing Trust and Rapport;
Guidelines for Improving Communication; and
Guidelines to Work with Interpreters Effectively.
The following is a CALD End-of-Life Care Assessment Tool (adapted from ‘Cultural Relevance
in End-of-Life Care’ (http://ethnomed.org/clinical/end-of-life/cultural -relevance-in-end-oflife-care) (Giger et al, 2006; Kagawa-Singer & Blackhall, 2001; Huff &Kline, 2007) with
suggested questions and strategies for health practitioners to consider when assessing CALD
clients and their family.
82
CALD End-of-Life Care Assessment Tool
Relevant information
Attitudes of client and family:



What attitudes do this client and
family have about truth telling with
regard to diagnosis and prognosis?
What is their general attitude
towards death and dying?
Do they have positive or negative
attitudes about particular aspects of
care?
Beliefs:

What are the client’s and family’s
religious and spiritual beliefs,
especially relating to the meaning of
death and dying, the afterlife, and
miracles?
Questions and strategies for health provider
Determine the client and family’s perception of an illness:
 What does your illness/sickness mean to you?
 Are there traditional healing or herbal remedies used when
someone is seriously ill or dying?
Determine if the client or family has positive or negative
attitudes about particular aspects of care being addressed, such
as advance directives :
 Are there certain terms that are to be used to describe illness
or terms that are considered taboo?
What traditional explanations may be used to explain a terminal
illness in the family:
 Spiritual or religious strength sustains many people in times
of distress. What is important for me to know about your
faith or spiritual needs?
 How can we support your needs and practices?
 Where do you find the strength to make sense of what is
happening to you?


Determine the context of the client’s 
and family’s lives, including: place of 
birth; refugee or migrant experience/
status; income level; language
spoken; involvement with
cultural/religious community; level of
acculturation.
Context:

Decision-making style:


What is the client and family’s
decision-making style?
Is the emphasis on an individual
decision-making process or a familydecision making process?
Expression of pain






Where were you born and raised?
How long have you lived in NZ?
How has your life changed since coming to NZ?
What language are you most comfortable using when
talking about your health care?
How are decisions about the health care of family members
made in your family?
Who is the decision maker (if any) in the family regarding
the care of the client?
Who is the head of the family?
Is there anyone else I should talk to in your family about your
condition?
Are pain symptoms expressed freely or only if asked?
Is pain considered a suffering to be tolerated?
83
Managing communication about serious illness and bad news
Here are some suggested approaches for managing communication about serious illness and
bad news:

Ask clients (who are competent to make decisions) whether they wish to be directly
informed about their diagnosis and treatment on their own, or informed together with
family member/s, or otherwise. If a client decides that they do not wish to receive their
diagnosis, and their preference is that a delegated family member/s receive the
diagnosis, find out which family member/s should be informed.
NB. Clinicians must let clients know that they are obligated to inform/discuss the client's
condition with the client directly, unless the client insists that they prefer otherwise.

Ask clients (who are competent to make decisions) how they wish treatment decisions
to be made. At this point, the clinician should determine the extent to which
clients/family members wish to be involved in treatment decisions. It is important to
when breaking the news to the family member(s), to inform them that in New Zealand it
is legally not acceptable if the client is competent to make decisions, that a family
member or family spokesperson makes treatment decisions or signs the informed
consent for treatment on the client’s behalf. Therefore it is necessary to ensure the
family member(s) break the news to the client before treatment decisions are discussed
or before the consent form is presented to the client.

Ideally, the client’s preferences about communication should be asked before and not
after the client is sent for medical investigations.

The outcome of discussion with clients should be clearly noted in the clients’ medical
records and should also be communicated verbally to subsequent care providers at
‘hand overs’.
How to manage when family and medical views conflict
In some cases, family members views are in conflict with medical views regarding what
constitutes the optimum qualify of life and end-of-life treatment or care. The following
approach is suggested for negotiating with the family members:

Listen and hear the values and views of family members respectfully.

Explain the medical view as to why stopping treatment or life support is in the best
interests of the client and explain what quality of life means (some CALD cultures value
length of life more than quality of life).

Demonstrate awareness and understanding of their need to do their very best for their
loved one and negotiate and balance the medical, legal and cultural views to help family
members accept medical advice. It is important to offer advice with empathy and
compassion, and to help reduce the family’s feelings of anguish about potentially not
fulfilling their obligation to do the best for the client from their perspective. If needed,
84
seek support from a cultural support service and the medical-legal advisor in the
organisation.
Case studies
Case Study 1: Cultural relevance in end-of-life care
(Adapted from Coolen, 2012)
Mr Wu is a 70-year-old Chinese man who lives with his wife of 40 years. Mr Wu was
diagnosed with lung cancer two years ago, but is now failing rapidly. He is very weak. He
can no longer eat due to increased difficulty swallowing and breathing. He does not
complain of pain, but his wife says that his back hurts. His two sons live nearby. His daughter
moved in recently to help her mother care for him.
Mr Wu’s GP wants to make a referral to hospice services. Mr Wu says the doctor must talk
with his sons first. In a telephone conversation with the sons, the sons agree to hospice
services. However, the older son does not want his father to know he is dying and does not
want the word “death” to be used when talking with his father. The son tells the doctor,
“We do not tell our father that he is dying. Telling him is harmful, causing undue emotional
burden for him. We are responsible for protecting him from harm”. Mr Wu does not take
part in the conversation nor does he make his wishes known. Mr Wu does not have an
advance directive.
A week later, Mr Wu is admitted to the hospital with aspiration pneumonia. He is barely
conscious, febrile, and his breathing is slow and irregular. The family continues to encourage
Mr Wu to eat. The older son is considering requesting treatment and the use of a feeding
tube and antibiotics. The wife and older son refuse to discuss or participate in the
conversation regarding end-of-life care with the nurse or physician.
However, the younger son acknowledges that his father is dying. After much discussion and
tension within the family, the family agrees to allow Mr Wu to die peacefully with comfort
measures only. Mr Wu dies within 24 hours of admission.
Question:
For this case, describe ways in which the issues of self-determination and informed
consent can be approached with the family respecting their cultural values/wishes.
Discussion:


When discussing medical issues with the family, it is important to confirm their
understanding of the situation. Ask the family to explain what they understand about
Mr Wu’s condition and treatment.
While Mr Wu is fully aware and is able to participate in a discussion, the health provider
should assess Mr Wu’s preference for wanting to know everything about his medical
condition or whether he prefers that discussion occurs with the family and in his
85
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presence. It is also very important to ask Mr Wu if he prefers to make his own decisions
about his medical treatment or if he would prefer that someone else (who specifically?)
makes those decisions for him. Whatever decision Mr Wu makes, it is essential to
confirm his decisions or wishes at that time, and also to let him know that he can change
his wishes at a later stage, if he changes his mind.
It is good to ask the family if there are preferred terms to use when talking about
terminal cancer, whether in front of Mr Wu or the family.
It is appropriate to ask the family if Mr Wu has any religious or spiritual beliefs that he
might rely on to help him deal with his illness. Let the family know that assistance can be
provided in meeting his religious or spiritual needs, such as arranging a visit by a
religious leader (i.e., monk, minister, priest).
If the client does not have an AD the health provider should have an initial discussion
with the family about life-sustaining treatment, such as cardiopulmonary resuscitation
(CPR) or artificially administered nutrition and allow the family time to discuss these
issues amongst themselves. If the client does have an AD, the health provider should
support the client’s wishes and discuss these with the family.
Note: A client or family cannot demand in advance any medical treatment that would not
ordinarily be offered. This needs to be explained in a culturally sensitive manner. Each
clinician makes a decision regarding the type of treatment which is likely to be beneficial to a
patient. If a treatment is not medically indicated it should not be offered. This position is
supported by the New Zealand Medical Council.
Additional tips for interdisciplinary teams to improve end-of-life care for Mr Wu and his
family:
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Ask the family what they would like to see happen to make Mr Wu more comfortable,
such as helping to ease his breathing or ease his pain.
Offer ways the family can participate in his care to make him more comfortable.
Minimise the use of medical jargon to explain what is happening with Mr Wu’s
condition. For example, although they would like to see him eat, ask them what their
greatest concern is if Mr Wu does not eat. Assure the family that not eating is a natural
process, as Mr Wu no longer needs food for energy as his body slows down.
If the family insists on the need to feed the patient with fluids or antibiotics, it is best to
help the family understand that as the body begins to shut down, it is difficult for the
body to absorb and use antibiotics or the extra fluids. Explain that extra fluids may in
fact accumulate in the body making Mr Wu more uncomfortable.
For WDHB staff there is an information sheet on the intranet in the quality documentation
section about “What to expect when someone is dying” which provides a culturally
appropriate explanation about this type of situation. Other DHB staff may have access to
similar types of documents.
86
Case Study 2: Mr Singh
(Adapted from Hasan & Periyakoil, 2010, p.18)
Mr Singh, a 76-year-old Punjabi male, is brought to an outpatient clinic for an evaluation of
gait unsteadiness. He has been diagnosed with renal cancer with metastases to the lungs.
His wife died five years ago and he then moved to New Zealand as all his children are settled
here. Mr Singh is a farmer from Punjab. He does not speak English.
A left hemiparesis is found during the examination and the doctor wants to get a head CT to
rule out brain metastases. His eldest son, who is the interpreter, accompanies Mr Singh and
says that he is the primary decision maker for his father who confirms this statement.
The son takes the doctor aside and requests that she should not tell the client about
suspicions of brain metastases. He agrees with getting the head CT and obtaining a radiation
oncology and oncology consult, but requests that all these doctors not mention the word
“cancer in the brain”. They can discuss treatment without mentioning the word “cancer”. He
thinks that if his father knows about the cancer in the brain, he will lose the will to live.
The son still believes that his father will be cured of cancer. In addition to the medical
treatment he is receiving, the family are also consulting with a spiritual healer who has
assured them that the cancer will be cured in six months.
The CT scan of the head shows a large brain mass on the right side causing cerebral oedema
and midline shift. The client is started on oral corticosteroids and radiation therapy. The
spiritual healer has given Mr Singh and his son butter that is blessed with holy words, and
they apply it to his head, lungs and abdomen. Mr Singh develops dermatitis on the scalp,
and is told by the radiation oncologist not to use this “hair oil”. The client stops eating and
drinking and becomes very weak and is admitted to hospital.
Multiple attempts to address treatment options with the son have been unsuccessful. The
son wishes his father to be coded for resuscitation. He believes that his father will be cured
and that it is in God’s hands. He gets angry with the doctors and thinks that they just want to
get rid of his father because they want to save money.
The palliative care team in the hospital is consulted and they use an interpreter not related
to the client. The interview is conducted at a time when family are not present. During the
interview, Mr Singh starts to cry, and says multiple times that he wishes he were dead. He
says he is so ashamed of the fact that he can’t walk and that his daughter-in-law has to help
him get in and out of bed. He is even more ashamed about the faecal and urinary
incontinence and that his daughter-in-law has to see him naked and clean him. He says
nothing can be worse than this.
He does not want to go to the spiritual healer but he knows that his son still thinks that he
can be cured and wants to go on. He does not want to share his thoughts with his family, as
he does not want them to think of him as a weak person. He still defers all decisions
regarding his health care to his oldest son, but wishes that the son would give up and face
the reality that he is dying and let him die in peace.
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Question 1:
How could the doctor and the palliative care team improve their communication with the
family and the client about the diagnosis?
Discussion:
It is not appropriate for the son to interpret for the patient because the son may not convey
the information provided by the doctor or palliative care team. If the son wishes to withhold
information he believes is not appropriate for his father, he may omit, summarise or add
information or interpret inaccurately.
Additionally, it is important for health practitioners to know that using interpreters has its
own challenges. Often, families tell the interpreter not to interpret what the doctor has said,
especially about the diagnosis or bad news. Interpreters are caught in between the family
being upset with them (the interpreters) and the need to be professional, that is, to
interpret everything said by the doctor and the client/family. Hence, it is very important that
interpreters are briefed about such conversations prior to the session.
It is also highly essential to meet with the family prior to discussion with the patient. In this
meeting the practitioner should discuss with the family: what will be discussed with the
patient; the need to use an independent interpreter as part of the NZ Health and Disability
Codes of Rights; and the role of the interpreter as a conduit to interpret everything said in
the conversation. The meeting will provide the family with an opportunity to express their
views or objections, and for the doctor to explain the patients’ rights to information in New
Zealand; the need to provide choices to patients if they are competent and capable to make
decisions; and the need to ask patients directly for their choice around disclosure.
When communicating with the family: demonstrate an understanding of their need to do
their very best for their loved one; help family members accept the medical advice offered
with empathy and compassion; and help them reduce their anguish about potentially not
fulfilling their obligations to do the best for their loved one from their perspective.
If the family wishes to be there, when the doctor discusses with the patient who to inform in
the case of a serious diagnosis, this should be accommodated.
The following is an example of how to confirm the patient’s stance: “Mr Singh, I now have
your diagnosis, would you like to be informed directly about this on your own, or together
with your family, or otherwise”.
In the above case it is not clear whether the radiotherapy was started with or without the
patient’s consent. In New Zealand it is not legally acceptable to provide radiotherapy
without the patient’s consent.
88
Question 2:
How do you address the son’s concern that not everything is being done for Mr Singh?
Discussion:
In New Zealand, the family cannot demand a treatment option /resuscitation to be provided
if it is not medically indicated. This needs to be explained and the clinician needs to help Mr
Singh’s son and family understand that “doing everything” may also bring about additional
pain and suffering. It is good to explore with the son what it means to him to have
“everything possible done” for his father so that you may have a better understanding of
what’s behind the son’s request. It may be that underlying the son’s insistence on active
treatment there may be a denial of the illness or the progression of the illness, false hope, or
a sense of familial duty.
A religious leader may be of assistance in mediating between the family and the clinical
team.
89
Key considerations
Key considerations: End-of-life care
End-of-life care in general
A provider needs to consider the client and family’s perspective on:
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Chinese communities
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Korean communities
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South Asian communities

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Death and dying.
Health and suffering.
Hospice and palliative care services.
The acceptance of Western health care practices and their use of
alternative traditional practices.
The role of spiritual and religious beliefs and practice.
The role of the family, including who is considered part of the family.
How the client and family communicate (such as the need for
interpreter services or that only certain words are acceptable when
discussing illness and dying).
The client’s own role in problem solving and in the process of decision
making.
Many Chinese clients may be reluctant to discuss end-of-life issues due
to the belief that if you talk about something bad, it could occur.
Families make every attempt to prevent someone from dying. Longevity
is more important than the quality of life. For Chinese people an
advance directive is uncommon.
Illness is considered a family event, rather than an individual occurrence
with decision makers traditionally the leader of the family.
There may be a conflict between the quality of life of the dying person
and the filial piety of the children who are expected to do their best for
their loved one who is dying.
Beliefs about life after death differ according to a person’s age, religion,
education and life experiences.
It is very important for family members to be at the bedside of the
terminally-ill client praying and chanting hymns.
Sikhism and Hinduism share a culture and world view that affects endof-life decisions and care in a number of ways:
 There is a perception that talking about death may make it
occur and therefore the family are often reluctant to let their
loved one know about a terminal illness.
 There is a preference to die at home or in a hospital but not in
a palliative care unit as the latter are seen as a place for dying
people and may be seen as tainted.
 Withdrawal of food and water at the end-of-life is not likely to
occur because it is believed that both are needed for a good
death.
 There may be a reluctance to use pain killers as pain must be
90
Key considerations: End-of-life care

Muslim communities

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Managing communication
about serious illness and bad
news

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How to manage when family
and medical views conflict

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endured (to help reach a higher state of mind).
Withdrawal of treatment is acceptable if it is futile.
Traditional Muslim patients consider physicians as the authority in
matters relating to medical intervention. They tend to symbolically and
formally introduce the physician into the family and the physician is
expected to direct rather than just facilitate medical management.
During illness, Muslims are expected to seek God's help with patience
and prayer with family and an Imam present.
Following death, allow the family and Imam to follow the Islamic
guidelines for preparing the body for an Islamic funeral.
It is important that funeral and burial arrangements are made in
advance in consultation with the family and according to the wishes of
the dying or deceased client if possible.
Do not insist on autopsy or organ donation unless legally necessary.
Ask clients (who are competent to make decisions) how they wish to be
informed about their diagnosis and treatment information, and about
how treatment decisions are to be made.
It is important to, when breaking the news to the family member(s), to
inform them that in New Zealand it is legally not acceptable if the client
is competent to make decisions, that a family member or family
spokesperson makes treatment decisions or signs the informed consent
for treatment on the client’s behalf. Therefore it is necessary to ensure
the family member(s) break the news to the client before treatment
decisions are discussed or before the consent form is presented to the
client.
The outcome of discussions with clients should be clearly noted in the
client’s medical records and, should also verbally be communicated to
subsequent care providers at ‘hand overs’.
Listen and hear the values and views of family members respectfully.
Explain the medical view and what quality of life means (some CALD
cultures value quantity of longevity more than quality of life).
Demonstrate awareness and understanding of their need to do their
very best for their loved one and negotiate and balance medical, legal
and cultural views to help family members accept medical advice.
If needed, seek support from a cultural support service and the
medical-legal advisor in the organisation.
91
Resources
Below are details of some helpful resources for people 65 years and older:
Day care programmes for CALD groups
Organisation
Chinese Positive Ageing Charitable Trust
Name of service
Chinese Positive Ageing
Description of
service
Suitable for Senior Chinese 65+ years living in Auckland willing to participate
in group activities and able to care for themselves.
Programme
Tai Chi, crafts, health talks, mah jong, outings, Chinese movies, puzzles, chess,
sing-alongs and games
Locations
Pakuranga - 16 Swan Cres, Thursdays
Takapuna - 7 The Strand, Fridays
Grafton - 70 Khyber Pass Rd, Saturdays
Hours: 10am to 3pm
Meals: Morning / afternoon tea, lunch
Transport not available
How to access
Sandy Nip
Phone: (09) 624 1368
Mobile: 021 052 0930
Email: cpa.trust@gmail.com
http://cpacharitabletrust.wordpress.com/contact/
Fees
$5 per session, extra fees may apply
Organisation
Korean Positive Ageing Charitable Trust (KPACT)
Name of service
Korean Positive Ageing Charitable Trust (KPACT)
Description of
service
KPACT makes information available in Korean to allow seniors to access
social services, facilities and events.
As well, KPACT plans to give advice, promote good health and organises
volunteers to keep in contact with seniors.
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Programme
How to access
KPACT has a Silver School at the Highland Park Community House every
Friday from 2pm till 4pm where senior citizens do a variety of activities from
learning English to crafts and exercise.
Ph: 09 2727040
Email : info@koreanpositiveageing.org.nz
Organisation
NZ Fijian Seniors Association Inc.
Name of service
NZ Fijian Seniors Association Inc.
Description of
service
To reduce social isolation; speakers are invited to share information on NZ
systems, social & health wellbeing, friendship and home visits
Programme
Meeting : once a month (Sunday)
Locations
Blockhouse Bay Community Centre
How to access
Contact : Mehar Singh on 8284338
Organisation
Shanti Niwas Charitable Trust
Description of
service
Services provided
Locations
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Culturally appropriate advocacy, counselling, interpreting and help to
access publicly funded services.
Elder Abuse and Neglect Prevention Service.
Cultural, creative, educational, social and physical activities,
entertainment, outings, festival celebrations.
Suitable for older people of Indian and South Asian origin living in the
Auckland region who are socially isolated, lonely and have various agerelated issues.
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Hours: 10.00am to 2.00pm
Meals: Indian vegetarian meal, tea / coffee
Transport is available on request
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Positive Ageing day programmes run four times a week in Onehunga.
Tuesday and Wednesday for seniors living in central Auckland.
Thursday for the Counties-Manukau area.
Friday for central Auckland for people with health difficulties.
1st & 3rd Thursday every month seniors day at Glenfield community
centre, North Shore 10.30 to 12 midday.
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How to access
Shanti Niwas Seniors Centre, 14 Spring St, Onehunga
Phone: 622 1010
Email: shantiniwas@xtra.co.nz
Website: www.shantiniwas.org.nz
Organisation
Refugees as Survivors
Name of service
Afghani Senior Men’s Group
Description of
service
The purpose of the group is to reduce the isolation of older Afghan men and
to improve their health and wellbeing.
Programme
Meeting : weekly Tuesday evenings
Locations
Wesley Community Centre,
740 Sandringham Road,
Mt Roskill
How to access
Contact : Arif Saeid on 2701251 or email Arif@rasnz.co.nz
Fees
No charge
Organisation
Rainbow Club ( for Korean older people)
Name of service
Rainbow Club
Description of
service
Suitable for Korean older people who are socially isolated, lonely and would
like to join the weekly activities that organises fun activities, exercises,
health talks, sing-alongs and games for members.
Programme
Meeting every Wed @ Takapuna Methodist Church.
Locations
Cnr. Lake Rd & Tennyson Ave. Takapuna
How to access
Coordinator: Mr. Shin, Hyun Kook
Mob. 0274715156
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Organisation
Bhartiya Samaj Charitable Trust
Name of service
Bhartiya Samaj Charitable Trust Senior Citizens Wing ,
AASHIRWAD - Culturally Appropriate Rest Home
Description of
service
Senior Citizens Wing
As a regular service, every fortnight there is a community meeting for the
Senior Citizens. Senior Citizen members are transported from their residence to
the venue and back. These meetings are aimed at providing mutual support
and companionship to the community elders.
AASHIRWAD - Culturally Appropriate Rest Home
BUPA has joined hands with Bhartiya Samaj to deliver a culturally appropriate
care for the South Asian Communities within its facility. The Aashirwad wing in
the David Lange Care Home would ensure:
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Caregivers communicate in their language and understand cultural values.
Culturally appropriate care and handling.
Selection of food will be available similar to that relished at home.
Visits to places of worship and cultural events.
Participate in the celebration of popular festivals.
Entertainment via popular Indian TV Channels and Radio Stations.
Day Care for older adults
At the David Lange Care Home, there is a day care service, weekdays, from 8am
– 5pm. It is available to clients who have been assessed by the Needs
Assessment Service Co-ordination Team (NASC) as being eligible for the service
and is funded by the Counties Manukau District Health Board.
Clients are offered a programme of games, entertainment, exercise, outings,
crafts, music, reminiscence, theme days, picnics and barbecues. The
programme is monitored and is overseen by a qualified occupational therapist.
Transportation is available at a small charge.
Locations
Activities Center
13 May Road, Bhartiya Samaj Hall, Mt. Roskill, Auckland
David Lange Care Home,
4 James St, Mangere, Auckland
Phone: 09 443 0579
Email: info@bsct.org.nz
Website: http://www.bsct.org.nz
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Hospices
Organisation
Description of
service
Services Offered
The Amitabha Hospice Service
The hospice is based on and practices Buddhist principles
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Locations
How to access
Free in-home confidential, practical help with normal activities of
everyday life and companionship, Auckland wide.
Specially trained and supervised volunteers offer individuals and
families support and respite on a regular basis as needed.
Multicultural and multilingual staff and volunteers for the most
appropriate assistance.
Liaison and cooperation with members of the medical and nursing
professions and with other involved individuals and support
organisations.
Grief counselling and support including bereavement follow up.
Pastoral care for people of all spiritual beliefs by qualified
practitioners.
Provision of relaxation, meditation, massage, Reiki and advice on
appropriate adjunctive therapies.
Classes on stress management and meditation for carers and clients.
A resource for education on Buddhist philosophy and practices for
death and after death care when requested.
Auckland region
Amitabha Hospice Service
44 Powell Street
Avondale
Auckland, 1026
Phone: 828 3321
For referrals go to:
http://www.amitabhahospice.org/public/contact_forms/referral_form.php
Translated information flyer: A Guide for Carers
Information flyer for A Guide for Carers now available in CALD languages
In recognition of the changing demographic makeup of New Zealand, the Ministry of Social
Development now provides the flyer for A Guide for Carers – He Aratohu mā ngā Kaitiaki in
traditional and simplified Chinese, Korean, Hindi, Farsi and Arabic. The flyer includes
information about how to get a copy of the Guide plus important contact phone numbers
and web site addresses for services and information.
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The guide is of practical help for people caring for family or friends who are older or have ill
health, a disability or a mental health, alcohol or other drug issue. It includes information on
the government-funded services and supports available for carers. To obtain copies of the
translated flyer or for more information about A Guide for Carers go to
http://www.msd.govt.nz/what-we-can-do/community/carers/.
The SuperGold Card
The SuperGold Card is for eligible seniors and veterans and gives access to:
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Discounts and offers from a wide range of businesses.
Government funded free off-peak public transport concessions.
Services and discounts from your local council.
Primary Health Interpreting Service
The Primary Health Interpreting Services is is available free of charge in the Auckland region
to improve access to primary health services for non-English speaking communities. The
following are a range of services for older people which can access free Primary Health
Interpreting Services:
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PHO services (GP, podiatry etc.).
Community based retinal screening.
GP consults in ARC.
Home based support services.
Community laboratory services.
Community radiology services.
Aged Concern (Auckland Region only).
Arthritis NZ (Auckland Region only).
Cancer Society (Auckland Region only).
Hospices.
Life Unlimited Hearing Services.
The Parkinsonism Society of NZ Inc.
Iris.
Vision West.
NZ Hearing Ltd.
Auckland eye (Retinal screening services only (ADHB only).
University of Auckland Optometry Clinic.
University of Auckland Tinnitus Clinics.
Alzheimer’s Auckland Charitable Trust.
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When and how to access Primary Health Interpreting service:
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When to access: when clients are not able to communicate in English or have a
hearing impairment and require an interpreter when making an appointment
with their GP or primary care provider.
Who: only GPs or primary care providers can book interpreters directly (not the
clients).
How: (a) For immediate / same day appointments, face to face and telephone
interpreters can be booked over the phone (b) For advanced appointments, face
to face and telephone interpreters can be booked by fax or via the interpreter
service online booking systems.
For more information about the service criteria and how to register with the provider in
your area contact:
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Waitemata Auckland Translation and Interpreting Services
Call centre: 0800 887 765 Fax: (09) 486 8307 Email:
watis@waitematadhb.govt.nz
Website: http://www.watis.org.nz
Counties Manukau District Health Board Interpreting and Translation Service
Call centre: 0800 744 735 Fax: (09) 276 0198 Email: phip@cmdhb.org.nz
Auckland District Health Board Interpreting Service
Call centre: (09) 630 9943 Fax: (09) 623 4695 Email: phip@adhb.govt.nz
Website: https://interpreters.adhb.govt.nz
Enduring Power of Attorney
To ensure CALD older people’s wishes are followed when they become unable to make
decisions for themselves, it is advisable to appoint someone to act on their behalf by giving
them “enduring power of attorney”.
Age Concern NZ has information and flyers that can be downloaded in English and Simplified
Chinese from
https://www.ageconcern.org.nz/ACNZ_Public/Enduring_Power_of_Attorney.aspx
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Services for CALD older people - elder abuse and neglect
The following services provide support services for elder abuse and neglect for CALD older
people:
Organisation
Contact details
Shakti Asian Women's Support Group
Phone: 09 630 7728 or 0800 742584
New Zealand Federation of Ethnic
Councils
nzfec@xtra.co.nz
RMS Refugee Resettlement Agency
(Refugee and Migrant Service)
ms@actrix.gen.nz
Age Concerns
Local Age Concern, especially in the Auckland area provides
specialist services to older Asian migrants.
See www.ageconcern.org.nz Local Age Concerns page.
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Tools and Guidelines
CALD Older People Assessment Tool
Adapted from Periyakoil, V. J. (2013). Ethnogeriatric Assessment. Stanford School of Medicine.
CALD Older People Assessment Tool
Background
Acculturation

Placing older clients on the continuum of
acculturation can help providers avoid mistaken
assumptions about expected differences or
similarities from mainstream elders.
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Record ethnicity, languages spoken and
religion.
Assess level of acculturation.
Assess family patterns of decisionmaking (e.g., individual vs. collective)
and who is the key decision-maker.
Informal indicators of acculturation that can be used
quickly:
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Length of time older clients or their ancestors
have been in New Zealand
Language used at home, fluency in spoken and
written English
Degree of ethnic affiliation, as reflected in
ethnic community participation and use of
ethnic media .
Patterns of decision making
Explore preferred interaction patterns, that is:
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What is the client’s preferred language
Is a direct or indirect form of communication
most appropriate for this client
What is the client’s preferred form of address
(formal or informal)
Are there other considerations in interactions
with the client, such as the gender and status of
the health practitioner.
Health and social history
Elder abuse
Ask about the older person’s migrant or
refugee journey to New Zealand and refer to
these experiences in taking a social history.
Issues of elder abuse may be particularly difficult to
assess in elders from cultural backgrounds in which
there are varying definitions of elder abuse or in
which family image may be more important than
individual health (Tartara, 1999). Particularly
consider when there are:
Ask questions to try and determine if there is
abuse.
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physical signs (bruises, burns, etc.) and/or
behavioral symptoms (e.g. depression).
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CALD Older People Assessment Tool
Physical examination
Physical examinations by someone of the
opposite sex are unacceptable in many
cultures.
Ask if the older person would like other
family members to be present during
physical examination.
Throughout the assessment, inform the
client of procedures and ask for permission
to examine different areas of the body.
The preferred amount and type of information
communicated to the client and their family during
and after the physical exam varies cross-culturally
(Adler, et al, 2004; Adler & Kamel, 2002) (e.g., some
Chinese older people prefer that information be
given to their son or other family member, and that
they be the decision makers about the older
person’s care, especially in relation to serious
illness).
Symptom recognition, meaning, and report are
expressed differently by older people of different
cultures (e.g., “heavy heart" may indicate
depression among Chinese older people).
Cognitive and affective status
Dementia and depression are stigmatised in some
cultures because they are a mental illness. In other
cultures, dementia is seen as a normal part of ageing
and is defined as a minimal problem.
Functional status
Questions can be interpreted or translated, if
needed, and administered orally or in writing if
literacy and reading levels are adequate.
The concepts of Activities of Daily Living
(ADLs) and Instrumental Activities of Daily
Living (ADLs) may be unknown to many older
people from CALD backgrounds. ADLs such
as banking can be difficult to assess where
these skills have not been needed in home
countries.
Drawings, illustrations, and other culturally
appropriate symbols may also be used.
In some cases, the independence of older
people is not a high value, so that
dependency is expected and assumed.
However, it is important to understand the
client’s baseline functioning and previous
occupation/interests/hobbies.
Home assessment



Living patterns: Who lives in the home,
relationship to older person, and length of time
in the home.
Support from those people who live with the
older person.
Safety, comfort, and convenience of the home
to older person’s health status.
101
CALD Older People Assessment Tool

Family assessment






Composition and structure.
Kinship patterns and social support.
Decision-making.
Spokesperson, if any, for the family.
Gender sex-role allocation.
Family connectedness (culture
influences whether the older person and
family are more individualistic or
collectivistic)
Community and neighbourhood Assessment
Kinship patterns and social support: expectations of
and for family members (e.g. for elder care).
Stereotypes that ethnic families "take care of their
own" can be very misleading since some older
people from ethnic backgrounds are not part of
strong family networks and are vulnerable to
loneliness and isolation.
Decision making: In many cultures, there is not the
assumption of client autonomy in decision making
as there is in a western medical ethical paradigm,
and the family is assumed to be the decision maker
about health care.





End-of-Life preferences (when appropriate)



Availability of advance directives and
ACP
Preference for hospital or home end of
life care
Death rituals for care of the body and
mourning behaviour during and after
death
Economic stability and adequacy
Overall features of the community and
neighbourhood: E.g., involvement of CALD older
people in the community and religious
community.
Population characteristics: e.g., ethnic
community, length of time in community,
proportion of older people, children, and adults
in population, intergenerational relations,
status of elders.
Environmental and safety conditions: e.g.,
topography, pavements, road crossings, crime
rate.
Services available and used by older person and
their family: e.g., traditional and alternative
health practitioners, social services, religious
community, shopping (such as food, clothing,
banking), educational, transportation,
recreational and elder services (such as senior
citizens centres; age concern; ethnic older
persons support services).
Support from neighbourhood and community
members.
Since talking about death is considered
inappropriate in some cultures (e.g., Chinese
groups) the issue should be approached carefully
and sensitively, and only in the context of an
established trusting relationship.
A possible introduction after several visits might be,
"In case something happens to you and you are not
able to make decisions about your care, we need to
102
CALD Older People Assessment Tool

Attitudes about organ donation and
autopsy
Problem specific data: Elicit explanatory
models of illness from client and relevant
family members
To elicit the client's explanatory model of
illness, questions such as the following can
be used (Kleinman, Eisenberg, Good, 1978;
Harwood, 1981):








What do you think caused your
problem?
Why do you think it started when it did?
What do you think your sickness does to
your body? How does it work?
How severe is your sickness?
How long do you think it will last?
What are the main problems your
sickness has caused you?
Do you know others who have had this
problem? What did they do to treat it?
Do you think there is any way to prevent
this problem in the future? How?
Intervention-specific data (Tripp-Reimer,
Brink, and Saunders, 1984)






What are you and/or your family doing
for this problem? What kinds of
medicines, home remedies, or other
treatments have you tried for this
sickness? Have they helped?
What type of treatment do you think
you should receive from me?
Is there any other information that
might help us design a treatment plan?
How should family be involved: family
structure, roles, and dynamics, and life
style and living arrangement need to be
identified.
How should family members treat one
who has this condition/problem?
Does anyone else need to be consulted?
know what your preferences are".
The use of explanatory models has been
demonstrated to be effective in improving client provider communication and showing respect for
the client's point of view.
Ultimately, it is argued, its use will increase clients'
trust of providers, appropriate clinical management,
and likelihood of older people’s agreement with and
adherence to provider’s recommendations.
The objective is to elicit the older client's view of
his/her illness experience, its causes, potential
consequences, and possible treatments.
Elicit cultural specific content as needed for specific
interventions. For example, if dietary
recommendations are being made, elicit data about
food preferences and practices; if discharge
planning is needed, elicit information regarding
family care patterns, resources, and residential
preferences.
103
CALD Older People Assessment Tool

Outcomes-specific data: Negotiating
therapeutic outcome criteria with older
adults/Family members



What are individual/family expectations for
quality care?
What are the most important results you hope
to receive from this treatment?
What is the best outcome from
family/individual perspective?
What is the worst outcome from
family/individual perspective?
CALD End-of-Life Care Assessment Tool
CALD End-of-Life Care Assessment Tool
Adapted from cultural relevance in End-of-Life Care (http://ethnomed.org/clinical/end-of-life/cultural relevance-in-end-of-life-care) (Giger et al, 2006; Kagawa-Singer & Blackhall, 2001; Huff &Kline, 2007).
Relevant information
Attitudes of client and family:



What attitudes do this client and
family have about truth telling with
regard to diagnosis and prognosis?
What is their general attitude
towards death and dying?
Do they have positive or negative
attitudes about particular aspects of
care?
Questions and strategies for health provider
Determine the client and family’s perception of an illness:
 What does your illness/sickness mean to you?
 Are there traditional healing or herbal remedies used when
someone is seriously ill or dying?
Determine if the client or family has positive or negative
attitudes about particular aspects of care being addressed, such
as advance directives :
 Are there certain terms that are to be used to describe illness
or terms that are considered taboo?
What traditional explanations may be used to explain a terminal
illness in the family:
What are the client’s and family’s religious  Spiritual or religious strength sustains many people in times
and spiritual beliefs, especially relating to
of distress. What is important for me to know about your
the meaning of death and dying, the
faith or spiritual needs?
afterlife, and miracles?
 How can we support your needs and practices?
 Where do you find the strength to make sense of what is
happening to you?
Beliefs:
Context:
Determine the context of the client’s and
family’s lives, including: place of birth;
refugee or migrant experience/ status;
income level; language spoken;




Where were you born and raised?
How long have you lived in NZ?
How has your life changed since coming to NZ?
What language are you most comfortable using when
talking about your health care?
104
CALD End-of-Life Care Assessment Tool
Adapted from cultural relevance in End-of-Life Care (http://ethnomed.org/clinical/end-of-life/cultural relevance-in-end-of-life-care) (Giger et al, 2006; Kagawa-Singer & Blackhall, 2001; Huff &Kline, 2007).
Relevant information
Questions and strategies for health provider
involvement with cultural/religious
community; level of acculturation.
Decision-making style:


What is the client and family’s
decision-making style?
Is the emphasis on an individual
decision-making process or a familydecision making process?
Expression of pain






How are decisions about the health care of family members
made in your family?
Who is the decision maker (if any) in the family regarding
the care of the client?
Who is the head of the family?
Is there anyone else I should talk to in your family about your
condition?
Are pain symptoms expressed freely or only if asked?
Is pain considered a suffering to be tolerated?
105
Culturally appropriate dementia assessment tools
The following is a list of culturally appropriate dementia tools:

The Rowland Universal Dementia Assessment Scale (RUDAS) is a short cognitive
screening instrument designed to minimise the effects of cultural learning and
language diversity on the assessment of baseline cognitive performance. All
resources associated with this assessment tool are available under Rowland
Universal Dementia Assessment Scale (RUDAS) information page.

The Montreal Cognitive Assessment (MOCA) tool are translated into 36 languages
and dialects (Nasreddine, 2006) The MOCA is used for detection of Mild Cognitive
Impairment in multiple conditions including:
MCI/Alzheimer's disease, Vascular Cognitive Impairment, Parkinson and Frontotemporal dementi. See website for more information at www.mocatest.org.

The Alzheimer's Australia website www.fightdementia.org.au/understandingdementia/culturally-appropriate-dementia-assessment-tools-1.aspx offers a range
of dementia assessment scales and tools which are appropriate for CALD older
people (Basic et al., 2009).

The Alzheimer's Australia (2007) “Screening and Diagnostic Tool Guidelines” for
screening and diagnostic assessment of non-English speaking people with dementia
Includes Guidelines and system recommendations for practitioners, service
managers and policy makers http://www.fightdementia.org.au/understandingdementia/culturally-appropriate-dementia-assessment-tools-1.aspx.
Guidelines for developing trust and rapport
The following are suggested approaches to develop trust and rapport with CALD patients:









Greeting with warm smiles, a slight bow/nod to show respect especially for initial
engagement.
Acknowledge the patient’s status, in particular, for adult or older CALD patients, by
addressing them using a formal title and surname, especially for initial engagement (and
asking if they are happy with being addressed in this way), not assuming.
Showing an interest in the patient’s cultural heritage.
Exploring the patient’s and his/her family’s cultural orientation or level of acculturation.
Assessing English fluency (spoken and written).
Using professional interpreters when required (ensuring a gender-matched interpreter
where appropriate).
Understanding family structure and relationships.
Understanding patient’s attitudes towards sensitive issues (example advance care plan,
advance directive, end-of-life issues, elder abuse, etc.).
Understanding religious and spiritual belief systems.
106





Understanding views on suffering and the afterlife.
Not assuming patient’s understanding of the New Zealand health and legal system and
health professional roles.
Involving families, if they are available.
Exploring the locus of decision making.
Exploring the patient’s understanding of confidentiality.
Guidelines for improving communication
The following are suggested considerations when communicating with CALD patients:







Be aware of differences in communication patterns (formal versus informal; direct
versus indirect; non-verbal and gestures).
Use simple language, speaking clearly and avoiding jargon is important.
Use open ended questions to avoid a “Yes” or a “No” answer when working with CALD
patients is necessary to avoid misunderstanding.
Assess the patient’s ability to comprehend or speak English especially when requiring
consent or decisions to be made. This can be done by:
o Asking open ended questions.
o Asking the patient to repeat a statement in his or her own words.
Access a professionally trained interpreter to assist with communication with limited or
non-English speaking patients, instead of using a family member.
Know how to work with interpreters effectively.
Provide information to non-English speaking patients and their families in their own
language. However, it is important not to assume all CALD patients can read written
information in English or their own language. Assessing literacy is important by asking
and not assuming.
Guidelines for working effectively with interpreters
Before the session: Pre-brief the interpreter:







Introduce yourself and your role.
Explain the purpose and objectives of the session.
Identify a leader for the session if more than one health professional is attending
For face-to-face sessions, arrange an appropriate seating arrangement to facilitate
the communication.
Agree to use consecutive interpreting mode.
Obtain the cultural background from the interpreter if necessary, for example if you
wish to understand cultural issues when disclosing bad news to the client.
If needed ask the interpreter about the cultural context in which the client is being
given information and how best to give the information.
At the start of the session (Briefing): Setting ground rules with the patient and family:
107


Introduce the interpreter and explain your role and the interpreter’s role to the
client (include the fact that everything said in the session will be interpreted, i.e., no
private discussions between parties during the session).
Assure the client that the rule of confidentiality applies to both the practitioner and
the interpreter.
During the session (Communicating):








For face-to-face sessions, maintain eye contact with your client (if appropriate) not
with the interpreter.
Use the first person singular when communicating via the interpreter, e.g., “Mrs
Wong, how do you feel today” and not “Please ask Mrs Wong how does she feel
today”.
Direct the questions/statements to the client or family, and not directly to the
interpreter.
Do not enter into direct conversation with the interpreter.
Do not ask the interpreter for their opinion (except for cultural clarification).
Pause at regular intervals for the interpreter to assimilate and interpret.
Allow enough time for the interpreter to convey information (it may only take three
words to explain but it may take more time for the interpreter to convey the
information in their language).
Use short sentences.
After the session (De-brief): Clinicians can ask for a de-briefing to clarify any cultural issues,
interpretation of words or concepts.
108
Terms Used and Glossary
Summary of terms and definitions used in this resource
Term
Definition
Asian
Asian refers to people originating from Asian countries including countries in
West Asia (Afghanistan and Nepal), South Asia (covering the Indian subcontinent), East Asia (covering China, North and South Korea, Taiwan, Hong
Kong, Japan) and South East Asia (Singapore, Malaysia, the Philippines,
Vietnam, Thailand, Myanmar, Laos and Cambodia). This definition is
commonly used within the health sector and is the basis of the Statistics New
Zealand Asian ethnicity categories.
CALD
CALD refers to culturally and linguistically diverse.
CALD populations
CALD populations in this document refers to culturally and linguistically
diverse populations from Asian, Middle Eastern and African (MEA)
backgrounds.
Carers,
Families,
Family members
These terms refer to the group of people who provide unpaid or paid care for
older people,including care for:

people who are receiving services from the health and disability services
provided by DHB provider services, primary health and NGO sectors;
or

people who are recovering at home after receiving services from health
and disability services.
Consumers,
Service users,
Clients,
Older adults,
Older people,
Residents,
Seniors,
Patients
These terms refer to the group of people who are receiving services from the
health and disability sectors (DHB provider services, primary health services
and non-government organisations).
MEA
MEA in this document refers to Middle Eastern and African groups.
MELAA
MELAA in this document refers to Middle Eastern, Latin American and African
groups.
Migrants
Migrants (also known as immigrants) refers to people who were born
overseas who settle in New Zealand.
Health practitioners,
Clinicians,
Practitioners,
These terms refer to a range of roles in the health and disability services
which provide care for older people.
109
Term
Definition
Health professionals,
Health providers
Refugees
The term ’refugee’ refers to people from a refugee background. Refugees
arrive in New Zealand under one of three categories: Quota refugees,
Refugee Family Sponsored Migrants (family reunification members); and as
Asylum seekers.
Glossary
ACP
Advance Care Planning or Advance Care Plan
AD
Advance Directive
ADHB
Auckland DHB
AT&R
Assessment, Treatment and Rehabilitation
CALD
Culturally and Linguistically Diverse
CMDHB
Counties-Manukau DHB
DHB
District Health Board
EPOA
Enduring Power of Attorney
HPCAA
Health Practitioners Competence Assurance Act
MELAA
Middle Eastern, Latin American, and African
MOH
Ministry of Health
NASC
Needs Assessment Service and Coordination
NDSA
Northern DHB Support Agency
NGO
Non-government organisations
NRA
Northern Regional Alliance Ltd (previously NDSA)
PHO
Primary Health Organisation
RAC
Residential Aged Care
SLT
Speech – language therapist
WDHB
Waitemata DHB
110
Acknowledgements
The resource is funded by the Northern Regional Alliance and produced by Waitemata
District Health Board eCALD® Services.
The Northern Regional Alliance and Waitemata DHB eCALD® Services acknowledge, and
greatly appreciate the contributions and editing advice from the following clinicians,
academics, cultural experts and stakeholders who assisted with the review of the resource
in 2014. Special thanks go to Tanya Bish for reviewing, proofreading, editing and ensuring
that the terms used in the document are accurate.
Name
Section(s) reviewed
Catherine Chiu
Shona Muir
Jane Goodwin
Dr Gary Cheung
Jane Holmes
Cecilia Wing Chun Wong
Chris Frew
Lorellle George
Elle Dagley
Margaret Proposch
Marja Steur
Robyn Buskin
Karyn Murphy
Cathy Taylor
Robyn Gibson
Rik Walstra
Tania Chalton
Victoria Camplin-Welch
Margaret Sullivan
Sue Thomson
Beven Telfer
John Wong
Laura Campbell
Sarah Hood
Advance Care Planning and Advance Directive; End-of-Life Care
Advance Care Planning and Advance Directive
Advance Care Planning and Advance Directive
Dementia, Mental Health, Advance Directive
Dementia
Stroke
Elder Abuse and Neglect
Full document
Full document
Full document
Dementia
Mental Health and Dementia
Mental Health and Dementia
Dementia case study
Stroke – Speech Language Therapy
NASC
End-of-Life Care
Full document
Full document
Dementia
Advance Directive Case Study
Dementia, Mental Health, Daycare programmes
Full document
Full document
The resource was also sent to the Waitemata DHB Specialised Services for Older Adults
(SSOA) Clinical Reference Group and the Specialised Services for Older Adults Steering Group
for their comments and review.
111
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