Lessons on social and health disparities from older lesbians with alcoholism and the role of interventions to promote culturally competent services

ABSTRACT

Older adults who are lesbian, gay, bisexual, or transgender (LGBT) face greater health risks and possibly more costly care because of their reluctance to seek out health and long-term care services because of limited cultural sensitivity of service providers. This is particularly evident in older lesbians who face substantial risk of health problems associated with alcoholism and are less likely to be open with health care providers because of stigma combined with feelings of alienation, stress, and depression. An estimated 4.4 million older adults are predicted to have problems with alcohol by 2020, and the rates of alcohol-related hospitalizations are similar to those for heart attacks, creating exorbitant medical costs. More culturally competent health and long-term care may reduce health care costs by effectively addressing the dynamics of alcoholism, aging, and lesbian culture. Training initiatives such as those developed by the National Resource Center on LGBT Aging have begun to address the need of a more culturally competent aging services network. This article provides exemplars from empirical data on older lesbians with alcoholism to highlight some of the health, economic, and social disparities experienced in the aging LGBT community. Current interventions in the form of cultural competence training for service providers are presented as a potential step toward addressing health disparities among LGBT older adults.     

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.     

Client Satisfaction with Live-In and Live-Out Home Care Workers in Israel

Abstract

In an era of globalization where the migration of long-term care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons.

This study examines differences in home care satisfaction between disabled older persons in Israel with “live-in” home care workers and those with “live-out” workers, and explores some differences in socio-demographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva.

Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

Experience,Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans’ experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.     

Lift Every Voice: Voices of African-American Lesbian Elders

Old lesbians of African descent have experienced racism, heterosexism, homophobia, and ageism. This article explores the topics of aging, ageism, heterosexism, and minority stress among older African-American lesbians. The narratives and subsequent analysis offer significant contributions to the dialogue regarding Black aging lesbians in the aging and lesbian, gay, bisexual, and transgender (LGBT) communities generally and in the African-American and African-American lesbian communities specifically.     

Experiences of Informal Caregivers of Older Adults Transitioned From Nursing Homes to the Community Through the Money Follows the Person Demonstration

This study examined experiences of 156 informal caregivers of older adults who transitioned to the community through the Connecticut Money Follows the Person (MFP) Rebalancing Demonstration after prolonged nursing home stays. Caregiver burden, positive aspects of caregiving, depressive symptoms, anxiety, and comparative subjective stress were examined in relation to caregiver demographics and care receiver characteristics with a cross-sectional survey. Caregivers reported low burden, depressive symptoms, and anxiety, and fairly high levels of positive aspects of caregiving and satisfaction with community services. Most caregivers were less stressed compared to the time the care recipient was in, or before they entered, a nursing home. Live-in caregivers experienced more positive aspects of caregiving, but adult children reported higher burden than other caregivers. Unmet service needs also increased caregiver burden. Programs like MFP are a viable option with broadly positive outcomes from a caregiver’s perspective. Enthusiasm for increasing access to community care is growing for older adults who otherwise would reside in nursing homes for extended periods. Identifying unmet service needs and needs for targeted functional support could further enhance caregiver experiences and contribute to the successful transition of older adults to the community.     

Adult Day Centers and Mental Health Care

ABSTRACT

This research focused on the mental health issues at adult day centers and used a cluster analysis to profile older persons who received these services. The sample included 280 participants who attended adult day care. The data were collected from intake files using a biopsychosocial framework to guide the selection of variables from January 1, 1999 to December 31, 2000. A cluster analysis revealed two distinct profiles of participants. The first profile was characterized by women, who were single, African-American, had low incomes, relied more on public funding, and had no psychiatric diagnoses. The second profile was differentiated with more men, who were married, relied more on private funding, and had higher incomes and psychiatric diagnoses. Participants clustered in the second profile, including those diagnosed with psychiatric disorders, disenrolled at a faster rate than those in the first profile, including older adults without psychiatric disorders. Both profiles were similar in age, education, caregiving, religious affiliation, household size, and service intensity. They also resembled each other with respect to functional limitations, nutrition risk, and prior nursing home placement. Slight differences were found in frequency of previous hospitalizations and years of education. Recommendations for strengthening the mental health training of social workers employed at adult day centers were made.     

Sexual Harassment of Lesbians in the Workplace

Abstract

This article explores the literature addressing sexual harassment of lesbians and discusses the ways in which one form of prejudice, that against lesbians, contributes to this problem. The first section of the article discusses the lesbian experience of violence, harassment, and discrimination. In exploring the above experiences of lesbians it becomes apparent that lesbians are the victims of a specific form of prejudice–homophobia. Homophobia impacts lesbians in two ways: (1) in the form of negative attitudes and denigrating or destructive acts; and (2) by means of actual discrimination, whether overt or subtle. Unlike sexism and racism, homophobia has had little public discussion, and the article concludes with a discussion of the impact of homophobia on lesbians in the workplace.     

Older Lesbians and Work in the Australian Health and Aged Care Sector

While research has identified challenges lesbians face in the workplace, there is limited understanding of the particular experiences of older lesbians, especially those working in the health and aged care sector. This article draws on the stories of four women who participated in a narrative research project on lesbian and gay people's experiences of health and aged care. It highlights the need for future research to examine the complexity of identity expression and community affiliation, how people negotiate “coming out” in the workplace, the impact of discrimination, and the resources (such as friends) available to lesbians in the workplace.     

Managing Risk in Community Care of Older People: Perspectives from the Frontline

Abstract

Since the mid-1980s, Australian governments have focused on expanding community and home-based services for older people. This has led to increased levels of dependency, vulnerability, and complexity to be managed in the community. Consequently, aged care services have had to develop mechanisms for regulating and managing these increased risks, and risk management has become more central to the practices of professional workers in this field. This paper reports on some findings from a large-scale study that explores the way risk management policies have been translated into practice by community-based services in Victoria, Australia. Drawing on interviews with 18 frontline and management professionals employed in community aged care, we found that these workers were wrestling with a diverse and new range of institutional risks beyond those encountered in the actual delivery of frontline care. We found that these workers experienced “risk” in four different contexts, which often created demands for contradictory or conflicting responses. Here we examine these “contexts of risk practice”: professional workers' relationships with their clients, relationships with other service providers, the unregulated nature of the home as a work environment, and community expectations about the management of risk. Despite tensions that frequently arose, workers expressed strong professional commitments to their clients and were motivated to find positive resolutions amid competing interests. We conclude that tensions experienced by workers were embedded in the structural dimensions of institutional relationships and the systematic absence of shared understandings of “acceptable” risks in the community care of older people, rather than in the failure of professional agency.     

Older Gays and Lesbians

Summary

This article discusses the impact that coming of age in the Pre-Stonewall era has had on older gays and lesbians. Anti-gay hate and violence, within a historical context of homophobia and heterosex-ism, are examined. Risk factors, as well as coping capacities, for older lesbians and gays are explored. Research on the psychological adjustment and well-being of older gays and lesbians is reviewed, and suggestions for intervention with this population are proposed.     

Aging in Place at Home Through Environmental Support of Physical Activity: An Interdisciplinary Conceptual Framework and Analysis

This article presents a conceptual framework to link issues of health, services, physical activity, and environment to help older adults age in place in their own homes, which may reduce the demands on society to provide institutional long-term care. Using environments to promote physical activity has received attention by researchers, but its impact on aging-in-place at home has been largely ignored. This article interprets and synthesizes existing studies on aging-in-place in relation to health and services, contributions of physical activity to health and service accessibility, and environmental support of physical activity. The conceptual framework can serve as the core construct to address gaps in previous research and as a tool to refine practical targets for policies and interventions aimed at promoting healthy aging.     

Client satisfaction with live-in and live-out home care workers in Israel

In an era of globalization where the migration of longterm care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons. This study examines differences in home care satisfaction between disabled older persons in Israel with "live-in" home care workers and those with "live-out" workers, and explores some differences in sociodemographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva. Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

Willingness to Use Formal Long-Term Care Services by Korean Elders and Their Primary Caregivers

This study examined predictors of older adults' and primary caregivers' willingness to use formal long-term care (LTC) services to understand possible use patterns of mandatory public LTC insurance programs in Korea. It focused on views regarding who (adult children or the government) should bear the responsibility for older adults' care. Logistic regression models were estimated using data from 1,168 older Korean adults aged 65 or older and their primary caregivers from a national survey. The results showed that older adults' and their caregivers' views on care responsibility were a dominant predictor of their willingness to use both formal home care services and nursing home care services. Both older adults and their family caregivers' willingness to use LTC services should be considered when predicting demand for LTC services. Efforts should promote the perspective that formal LTC services are an acceptable social norm.     

Building Strength Through Challenging Homophobia: Liberation Workshops with Younger and Midlife Irish Lesbians

Drawing on the theoretical framework of liberation psychology, this article details workshops on liberation psychology conducted in Ireland with lesbian and transgendered persons aged from early 20's to late 50's. Both younger and older lesbians in the workshops benefited from the opportunity to focus on oppression and to explore options for transformation. The workshops illustrated many of the strengths and vulnerabilities associated with living with homophobia and demonstrated the value of action and engagement. Midlife lesbians were more aware of the systemic nature of homophobia and of the negative emotions related to that. They saw many of these as understandable and even necessary reactions to oppression rather than as negative patterns. These older lesbians tended to be more accepting of the course their lives had taken and of the ways in which choices had been influenced by homophobia and heterosexism. They tended to be more relativistic in their views on coming out, viewing coming out as a decision for each context rather than an overall principle. They valued the importance of community and of activism, and though they were aware of some of the challenges, they also had more positive experiences in this area. These strengths can facilitate managing both homophobia and aging more effectively.     

Housing for Older People in Iceland: Apartments and Nursing Homes

The first residential and nursing homes in Iceland were built in the early 1920s, and the first apartments for older people in the early 1970s. Most of the existing housing for older persons was built in the last 30 years. Legislative provisions on housing and particularly on assisted living have not changed significantly since laws relating to the affairs of the elderly were first passed in 1983. While approximately 90% of older people in Iceland own their own home and the primary stated goal of the government is to support independent living, official policy relies on placement in nursing homes. Services and care at home, provided by social and home healthcare services, has not been developed to the same extent as in the other Nordic countries. Clearer guidelines on integrated service housing are needed to reach the government's primary stated goal. Placing more emphasis on delivering services, care, and rehabilitation to people living in the community could shorten individuals’ length of stay in hospitals, delay admission to nursing homes, and better meet the expectations of older people for independent living.     

Health and Well-Being for Late Middle-Aged and Old Lesbians in a Rural Area

Abstract

Previous research on lesbian health care has drawn primarily from samples of young lesbians living in metropolitan areas. Through face-to-face interviews with twenty-one lesbians aged 54 or older and living in rural communities, this exploratory, naturalistic inquiry begins to fill a gap in the literature by examining the health care experiences of older, rural lesbians. Five themes emerged from the narrative data: issues of access; good health/good care; open to her own diversity; family and community; and visions-ideals and fears. We present these themes through informant quotes and discuss implications for policy and practice.     

Social Work Practice with Older Soviet Immigrants

ABSTRACT

With the recent sociopolitical changes in the Former Soviet Union, significant numbers of older Soviets have arrived in the U.S. with their families. Soviet immigrants who enter the U.S. are no longer automatically considered political refugees, which has limited their entitlement to services. Recent changes in public welfare and immigration policy place the responsibility for care of elderly members solely on the family. While caring for older adults is stressful for any family, new immigrants may be especially burdened since they have limited knowledge of services, few coping resources to provide adequate care, and little experience resolving cultural conflicts with their older parent. By using a practice model designed to evaluate late-life caregiving situations, two case scenarios are presented to examine practice and service delivery issues of older Soviet immigrants and their families.     

Exploring Attitudes Toward Older Workers Among Australian Employers

Abstract

Research suggests that negative stereotyping is at the heart of age discrimination in not hiring older workers. As the aging of the population creates pressures to maintain older adults in the work force, it is important to gain knowledge of such stereotyping. A random sample of 128 hiring decision-makers across Australian industries responded to a questionnaire that was specifically developed to assess attitudes toward older workers. Results showed systematic negative stereotyping: Respondents indicated that they were unlikely to hire older workers. The likelihood of hiring significantly correlated with employers' attitudes. Specific attributes for which older workers were seen as inferior compared to younger workers included trainability, adaptability, creativity, and interest in new technology. The findings could inform policymakers and be utilized to develop interventions aimed to reduce hiring discrimination.     

Caregiving and Care Receiving Among Older Lesbian,Gay, and Bisexual Adults

Abstract

A survey research design was used to examine caregiving, care receiving, and the willingness to provide caregiving among lesbian, gay, and bisexual (LGB) older adults recruited from community groups. More than one-third reported receiving care from people other than healthcare providers in the last five years; more than two thirds provided care to other LGB adults. Those who had given care were more likely than non-caregivers to give care in the future. The gender and sexual orientation of recipients of future help affected participants' willingness to provide care, as did their education level and style of coping. Participants willing to provide care to older LGB adults perceived such experiences to be less burdensome and more personally rewarding than those who were un-willing to provide care.