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Cross-cultural Medicine A Decade Later Health Policy and Ethnic Diversity in Older Americans Dissonance or Harmony? LINDA A. WRAY, Los Angeles, California

The rapid growth and diversity of the older population have long-term implications for health care policies in the United States. Current policies designed for a homogeneous population are increasingly obsolete. To ameliorate obstacles that handicap many ethnic minority elders and to provide equal access to adequate and acceptable health care, several factors need to be considered. Enhanced data collection and analytic techniques are needed. The effects of race or ethnicity must be separated from other biologic, environmental, socioeconomic, cultural, and temporal factors on health status and behavior. Health care professionals and organizations serving minority elders must continue to expand their advocacy efforts to articulate the findings and their concerns to policymakers. Policymakers must understand and acknowledge the implications of an increasingly diverse society and determine what will constitute adequate, accessible, and acceptable health care within continuing fiscal constraints. Program planning, implementation, and evaluation methods must be revised to meet future health care needs effectively and efficiently. (Wray LA: Health policy and ethnic diversity in older Americans-Dissonance or harmony? In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:357-361)

[Even] as it may liberate, diversity also complicates. It calls upon society to exhibit a greater sensitivity and responsiveness to the needs of older individuals who vary widely in all [and] fle-xibility on the part of our social dimensions .

.

.

institutions. 1(pt83)

oday's older population is highly heterogeneous, a virtual "symphony of cultural diversity,'tI but the music is not always sweet. Wide differences exist in health status, income levels, education, and living arrangements, all factors that influence quality of life and public policy. The differences are even greater for the rapidly growing populations of ethnic minorities in these older age groups.2 Persons may be recognized as elders at widely divergent ages-as early as 40 for many Southeast Asian and Native American groups, for example. Different cultures mark entrance into older age through social changes such as becom8 __-__-_ _---_

1990

M

2050

60-

a-50K A~~~~~~~~~~

Total

White

African American

Hispanic

Asian or Other

Figure 1.-The projected growth from 1990 to 2050 of persons aged 65 and older is shown by racial or ethnic group (from the US Bureau of the Census).

ing grandparents, retirement, or functional status, rather than chronologic age. In contrast, current health and social policies-and most available research-tend to identify persons chronologically: as younger-old (ages 65 to 74), old (ages 75 to 84), and older-old (age 85 and above). The population aged 65 and older in general, and elderly ethnic minorities in particular, is among the fastest growing groups in the country. In 1990, 10% of all persons aged 65 and older were ethnic minority; by 2025, 15% of the older population is projected to be ethnic minority; and by 2050, 20% will be (Figure 1). Life Expectancy During this century, life expectancy has improved dra-

matically, although unevenly, across minority and majority groups.3 For example, in 1987 life expectancy at birth for all persons was 75 years, ranging from a low of 65 years for African-American men to 79 years for white women. While Asian and Pacific Islanders tend to have life expectancies equivalent to or exceeding whites, the higher numbers obscure considerable intragroup diversity: The life expectancy of Japanese Americans is many years higher than the life expectancy of recent Cambodian refugees, for example. The lower life expectancies for many ethnic minority groups and subgroups stem largely from their disproportionately higher rates of poverty, malnutrition, and poor health care. Although whites are expected to live longer than African Americans at age 65, at around age 75 the reverse appears to be true. A similar pattern exists between whites and Native Americans. Researchers speculate that this "mortality cross-

From the Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southem California, Los Angeles, California. Support for this research was provided by the Geriatric Rehabilitation Policy Alternatives project, conducted by the Rancho Los Amigos Rehabilitation Research and Training Center on Aging and the University of Southern California, and fuinded in part by the National Institute on Disability and Rehabilitation Research of the US Department of Education. Reprint requests to Linda A. Wray, Andrus Gerontology Center, University of Southern California, Los Angeles, CA 90089-0191.

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358 35IELHPLC

over effect" reflects a selective survival in which the least robust persons in minority groups die at earlier ages and relatively hardy ones survive to older ages.4 In contrast, a mortality crossover does not appear to occur between Hispanics and white non-Hispanics. Data show that cardiovascular diseases contribute significantly to the mortality crossover phenomenon.5 Higher hypertension rates may explain the higher mortality from heart disease among middleaged African Americans and Native Americans compared with whites.4 The data are inconsistent, however, in explaining the apparent Hispanic advantage.6 A 1991 study found socioeconomic status, as measured by education and net worth, to be a notable factor in health status differences between African Americans and whites older than 55.7 When these differences were absent, African Americans and whites appear to have similar levels ofhealth. Even after controlling for socioeconomic status, however, African Americans tend to rate their health status as lower than whites. They reported more visits to physicians but fewer hospital stays. Mutchler and Burr concluded that socioeconomic status is related to health care use through access-that is, in financial capacity and private health insurance coverage. Whether improvements in the overall economic status of younger and older African Americans will erase health status differences or alter the mortality crossover effect is a speculative but plausible hypothesis.4'7 If correct, the decline since 1965 of the proportion of nonwhites living below poverty8 may signal an increase in the proportion of middle-aged African Americans surviving to older ages.9

Mortality Age-adjusted mortality by cause indicates that African Americans are more likely than whites to die of heart diseases, malignant neoplasms, diabetes mellitus, accidents, and homicides.4'0'11 In contrast, Hispanics living in the Southwestern United States have lower age-adjusted mortality from heart disease and malignant neoplasms than do white non-Hispanics. When compared with both African Americans and non-Hispanic whites, however, Hispanics and Native Americans have higher mortality rates from diabetes and infectious and parasitic diseases. Hispanics, African Americans, and Native Americans are also disproportionately more likely than whites to die of hypertension. 1 High rates of obesity and diabetes mellitus are characteristic of economically disadvantaged populations. Obesity is a powerful risk factor for diabetes among older African Americans and Hispanics4'6 and may also be related to hypertension in older African Americans.12 Diabetes and hypertension are two of the leading causes of death among African-American, Hispanic, and Native-American elders. Hispanics are generally more obese and less physically active than white non-Hispanics, are less likely to participate in lifestyles that promote cardiovascular health, and are two to five times more likely to have diabetes than the general US population. 11.1315 Obesity alone does not explain the higher rates of diabetes among older Mexican Americans, however, suggesting that other factors, such as genetic predisposition, may be at work. 3 Given that the same underlying disease process may trigger obesity, diabetes, and hypertension,16 figuring out the biologic, socioeconomic, and life-style factors may help to predict, prevent, or postpone complications and develop appropriate interventions.6

NDEHI

Morbidity Current research consistently finds socioeconomic status-as measured by income, education, or both-to be negatively correlated with levels of chronic disabilities due to disease or accidents. Given their generally lower socioeconomic status, it is no surprise that ethnic minorities have a higher prevalence of chronic disabling conditions than do elderly whites.2'17 18 For example, Hispanics and African Americans aged 65 to 74 are likely to have a greater number of functional disabilities, as measured by restricted activity and bed-disability days, than are whites of the same ages. In addition, the chronic conditions are appearing at younger ages for nonwhites than they are for whites.18 Injuries are a major cause of mortality, morbidity, and work loss, affecting early retirement decisions, postretirement income, and active (or disability-free) life expectancies. Further research on the epidemiology of injury and disability will help to separate the direct from the indirect effects of race or minority status-workplace opportunities such as health insurance and sick leave, for example-on injury, disability, and retirement decisions.19

Health Behavior Many health problems can be either averted or modified through targeted medical, rehabilitative, or life-style interventions. A variety of factors such as cultural beliefs, social supports, or socioeconomic status may influence the use and effectiveness of such interventions, however. For example, ethnic elders may have beliefs that influence patient compliance. 20.21 A Chinese patient with symptomatic hypocalcemia may refuse to take calcium and other dairy supplements. The patient's refusal may stem from an aversion to milk-and a high rate of lactose intolerance among Asians-but a physician whose expectations derive from Western models may see the patient as noncompliant.22 In addition, social supports may promote positive health behaviors, 93-25 such as diet changes, prevention and detection screening, thus reducing the risk of certain debilitating conditions. 2628 A recent study

examined diet, smoking, and prevention behavior among African Americans and white non-Hispanics and found that race generally did not directly predict prevention behavior. Education was found to be a significant predictor, however.29 Follow-up longitudinal studies may discern whether targeted educational interventions reduce behavioral, and in turn mortality, differences between African Americans and whites. Similarly, analyzing racial differences in smoking behavior may account for the influence of culture and other factors, in turn fostering more effective interventions.30

Hispanic disadvantage for health risks prompted a 1990 study of one potential factor in that disadvantage: preventive health service underuse among Mexican-American, CubanAmerican, and Puerto Rican adults. Researchers tested whether acculturation (spoken and written language, ethnic identification) and access to care (health insurance coverage, having a routine place for care, type of facility used, having a regular provider, travel time) influenced the use of such preventive care as physical, dental, and eye checkups, Papanicolaou smears, and breast examinations.27 Results indicated that access to care, particularly having a routine place for care and health insurance, was significantly associated with

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recent screening behavior. For example, Mexican Americans were found to be less likely to have health insurance and to use preventive services recently than were the other groups. Because language but not ethnic identification also predicted use, researchers interpreted language as an "indicator of functional integration" and thus an additional access rather than acculturation factor." Because access is a central health care delivery issue, a 1991 survey explored whether the often-used global measure of regular source of ambulatory care is a useful predictor of access. The data indicated that uninsured persons, those in excellent or good health, Hispanics, and African Americans were less likely to have a regular source of care, but the reasons for that likelihood varied across groups. For example, in general, low-income persons, regardless of race or ethnicity, were more likely to lack a regular source of care for financial reasons, and rural persons were more likely than nonrural persons to lack a local resource for care.3

Health Policy and Ethnic Diversity In recent years we have seen increasing life expectancy and population diversity, generally improved health for the average older person (with wide differences across population subgroups), national and international economic downturns, spiraling health care costs, and changing ideas on what it means to be "older." Health policy debates in the 1980s centered on cost containment, shifting responsibility for health care from the public back to private and individual sectors, and reassessing the need for and structure of myriad

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remain disproportionately among the poor (Figure 2) and chronically ill, policy changes, such as increased Medicare deductibles and cost sharing, have raised the "cost" of publicly funded health care to those most in need. Privately funded health care is often out of financial reach.33 For example, although 83% of Hispanics had Medicare coverage in 1988 compared with 96% of all elders, only 21% purchased supplemental Medigap insurance compared with two thirds of all elders.34 In addition, the work experiences of minorities characterized by less education, fewer occupational opportuTABLE 1.-Health Indicators for Hispanics, African Americans, and Whites Aged 65 and Older: National Health Interview Survey, 1978-1980* Race or

Physican

Ethni Origin Vsits, No. All races............ 6.4 Whitet ............. 6.3 5.7 Male ............ Female .......... 6.6 African Americant 6.7 6.3 Male ........... Female ........... 7.0 All Hispanic ......... 8.2 Mexican American 9.1 Male ........... 9.8 Female .. 8.5 6.6 Puerto Rican ........ Cuban ............. 10.8 6.2 Other Hispanic ....... ....

...

Services Used Per Year Dental Activity Limit Visit Hospital Rate, days Rate, No. Rate, days

18.3

34.4

45.3 44.3

17.3

17.5

57.2

18.5

23.3

52.4

10.5 20.3 20.8

19.3 27.9 34.7

52.6 42.1 44.4

'From Trevino and Moss,2 tNon-Hispanic. tBased on a small sample. cn c

30

E

TABLE 2.-Ethnic Populations in US Nursing Homes, by Age, 1980J

°S 20

Below Povery

Below 125% Poverty

Figure 2.-The percentage of persons aged 65 and older living below the poverty line in 1990 is shown by sex, racial or ethnic group, and those living alone (from the US Bureau of the Census).

age-based health and social programs created since 1930. Whereas efficiency and costs remain priorities in the 1990s, consumers, health care professionals, and policymakers are increasingly emphasizing quality-of-care issues, including concerns about access for all. For example, although need is the primary predictor of health services use for older persons, it is a more important predictor for minority than nonminority elders, suggesting an inherent inequality in the existing health care delivery system.32 Redressing the inequalities requires increasing both accessibility and acceptability of health care. Health Care Access Available data suggest that ethnic minority elders continue to be particularly disadvantaged relative to their white counterparts on measures of socioeconomic and health status and to have a greater per-capita need for health care services, despite often lower rates of use (Tables 1 and 2). While the cause is not clear, to the extent that ethnic minority elders

African American, Hispanic, 9b Age, yr 9b 3 65and older 3 85 and older . 12 10

Asian or

Pacific Native Isander, American,

White,

9b

'lb

'l

2 10

4 13

5 23

'Based on US census data on institutionalized populations, American Assoiation of Retired Persons Minority Affairs Initiative, 1987

nities, and higher rates of work disability-often provoke adverse retirement experiences.35 The work histories and citizenship status of ethnic and minority elders may have precluded jobs within the Social Security or Medicarecovered system as well. Thus, older minorities may be less adequately insured in their retirement years than are other elderly, leading some to continue working despite substantial health problems. For many older persons-particularly those older than 85 years, ethnic minorities, and women living alone-out-of-pocket health care expenses are onerous, depleting their meager resources, putting them at risk for poverty, and often forcing the choice of spending down to Medicaid eligibility levels or going without any health care. 36-41

Health Care Acceptability Older ethnic minorities are currently underrepresented in nursing homes (Table 2), tending to rely instead on informal

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support systems for their care. Whether this reliance is due to an extended family orientation or that ethnic minorities "care for one's own,"42 economic constraints, or other reasons is not firmly established. Available research suggests that many ethnic families are limited in their ability to care for their older members to the extent they may desire.43 Most older persons, whether minority or nonminority, prefer home- or community-based long-term care to institutions. The latter dominate current health care policies and programs, however.

Although changes in mortality, fertility, marriage, and divorce levels will increase the probability that in the future older persons may have surviving children or spouses, the mere existence of family members does not guarantee their availability as care givers.44 Thus, given the lack of noninstitutional long-term care benefits, families with limited resources who may want to care for their elderly at home may be particularly burdened economically. Health care data indicate that more rather than fewer older persons are returning home earlier from formal health care settings (although not necessarily healthier) after a major illness, that African Americans and Hispanics tend to underuse preventive services and delay seeking care until advanced stages of their conditions, and that the prevalence of chronic rather than acute conditions is associated with increasing age and socioeconomic as well as minority status. Sociologic data document that minority populations have benefited from increased life expectancy but remain at a disadvantage relative to nonminorities; that expectations regarding aging, health, and appropriate illness behavior vary across the older population; and that ethnic minority elders have historically been cared for in home environments to a greater extent than have nonminority elderly. Health care locus differences have been attributed to informal networks that encourage the use of, or act as substitutes for, formal services,45-48 as well as differential opportunity costs and language barriers.26 27'49 To the extent that equal access to and acceptability of adequate health services for all persons is acknowledged as an important investment in this country's future, a health care system that provides preventive, acute, and chronic care for all throughout life is important. While health care delivery remains two-tiered, however, increased access to and acceptability of health services may be fostered by uncapping the number of Medicare-reimbursed physician visits; reimbursing for preventive health care services, patient and family education, and often-expensive medications; standardizing Medicaid eligibility requirements and increasing minimum services across states; moving away from the traditional institution-based acute care model and toward a flexible, accessible, and acceptable community- or home-based chronic care model50; strengthening community efforts such as counseling, information, and referral to encourage families to use available services and to provide nonfamilial support-respite, adult day care42; designing program criteria and procedures that do not bar participation because of immigration status or language of choice; and using functional rather than chronologic age as a measure for health and social benefit eligibility. In addition, health policies may be revised to increase incentives, through revisions in reimbursement policy or individual tax breaks, to provide culturally and linguistically sensitive outreach, health promotion, prevention, and

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chronic care services targeted to those most in need.51-53 The availability of equitable employment and educational opportunities earlier in life may also increase access to appropriate services and, in turn, may reduce the mortality and morbidity disadvantage of minorities. Finally, research is needed to examine the effects of changes in health or functional status and economic or environmental circumstances on changes in the use and costs of health and social services.54 REFERENCES 1. Bass SA, Kutza EA, Torres-Gil FM (Eds): Diversity in Aging. Glenview, Ill, Scott, Foresman, 1990 2. Trevino FM, Moss AJ: Health indicators for Hispanic, black, and white Americans. Vital Health Stat [10] 1984; (148):1-88 3. Kitigawa E, Hauser P: Differential Mortality in the United States: A Study in Socioeconomic Epidemiology. Cambridge, Mass, Harvard University Press, 1973 4. Markides KS, Mindel CH: Aging and Ethnicity. Newbury Park, Calif, Sage, 1987 5. Nam CB, Weatherby NL, Ockay KA: Causes of death which contribute to the mortality crossover effect. Soc Biol 1978; 25:306-314 6. Markides KS, Coreil J, Rogers LP: Aging and health among Southwestern Hispanics, In Markides KS (Ed): Aging and Health: Perspectives on Gender, Race, Ethnicity, and Class. Newbury Park, Calif, Sage, 1989 7. Mutchler JE, Burr JA: Racial differences in health and health care service utilization in later life: The effect of socioeconomic status. J Health Soc Behav 1991;

32:342-356 8. Chen YP: Improving the economic security of minority persons as they enter old age, In Minority Elders: Longevity, Economics, and Health. Washington, DC, Gerontological Society of America, 1991, pp 14-23 9. Lieberman LS: Diabetes and hypertension among blacks: A multidimensional perspective, In Jackson JS (Ed): The Black American Elderly: Research on Physical and Psychosocial Health. New York, NY, Springer, 1988 10. Jackson JJ, Perry C: Physical health conditions of middle-aged and aged blacks, In Markides KS (Ed): Aging and Health: Perspectives on Gender, Race, Ethnicity, and Class. Newbury Park, Calif, Sage, 1989 1 1. Health, United States, 1989. Hyattsville, Md, Public Health Service, National Center for Health Statistics, 1990 12. Anderson NB: Aging and hypertension among blacks: A multi-dimensional perspective, In Jackson JS (Ed): The Black American Elderly: Research on Physical and Psychosocial Health. New York, NY, Springer, 1988 13. Stern MP, Gaskill SP, Hazuda HP, Gardner LI, Haffner SM: Does obesity explain excess prevalence of diabetes among Mexican Americans? Results of the San Antonio Heart Survey. Diabetologia 1983; 24:272-277 14. Hazuda HP, Stern MP, Gaskill SP, Haffner SM, Gardner LI: Ethnic differences in health knowledge and behaviors related to the prevention and treatment of coronary heart disease: The San Antonio Heart Study. Am J Epidemiol 1983; 117:717-728 15. Hanis C, Ferrell RE, Schull WJ: Hypertension and sources of blood pressure variability among Mexican Americans in Starr County, Texas. Int J Epidemiol 1985; 14:231-238 16. Donahue RP, Skyler JS, Schneiderman N, Prineas RJ: Hyperinsulinemia and elevated blood pressure: Cause, confounder, or coincidence? Am J Epidemiol 1990; 132:827-836 17. Mehdizadeh S, Taylor S: Comparison of the Extent of Disability Among Older Black and White Population. Poster session presented at the annual meeting of the Gerontological Society of America, Boston, Mass, November 1990 18. Crimmins EM, Saito Y, Ingegneri DG: Changes in life expectancy and disability-free life expectancy in the United States. Population Dev Rev 1987; 15:235267 19. Wagener DK, Winn DW: Injuries in working populations: Black-white differences. Am J Public Health 1991; 81:1408-1414 20. Yeo G: Ethnogeriatric education: Need and content. J Cross-Cult Gerontol 1991; 6:229-241 21. Fineman N: The social construction of noncompliance: Implications for crosscultural geriatric practice. J Cross-Cult Gerontol 1991; 6:219-227 22. Kim SS: Ethnic elders and American health care-A physician's perspective. West J Med 1983; 139:885-891 [81-87] 23. Gibson RC, Jackson JS: The health, physical functioning, and informal supports of the black elderly. Milbank Q 1987; 65(suppl 2):421-454 24. House JS, Landis KR, Umberson D: Social relationships and health. Science 1988; 241:540-545 25. Cohen S: Psychosocial models of the role of social support in the etiology of physical disease. Health Psychol 1988; 7:269-297 26. Kravitz SL, Pelaez MB, Rothman MB: Delivering services to elders: Responsiveness to populations in need, In Bass SA, Kutza EA, Torres-Gil FM (Eds): Diversity in Aging. Glenview, Ill, Scott, Foresman, 1990, pp 47-72 27. Solis JM, Marks G, Garcia M, Shelton D: Acculturation, access to care, and use of preventive services by Hispanics: Findings from HHANES 1982-84. Am J Public Health 1990; 80(suppl): 1 1-19 28. Harlan LC, Bernstein AB, Kessler LG: Cervical cancer screening: Who is not screened and why? Am J Public Health 1991; 81:885-890 29. Jepson C, Kessler LG, Portnoy B, Gibbs T: Black-white differences in cancer prevention knowledge and behavior. Am J Public Health 1991; 81:501-504 30. Kabat GC, Morabia A, Wynder EL: Comparison of smoking habits of blacks and whites in a case-control study. Am J Public Health 1991; 81:1483-1486

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31. Hayward RA, Bernard AM, Freeman HE, Corey CR: Regular source of ambulatory care and access to health services. Am J Public Health 1991; 81:434-438 32. Wolinsky FD, Aguirre BE, Fann LJ, et al: Ethnic differences in the demand for physician and hospital utilization among older adults in major American cities: Conspicuous evidence of considerable inequalities. Milbank Q 1989; 67:412-449 33. Smeeding TM: Nonmoney income and the elderly: The case of the tweeners. J Policy Anal Manage 1986; 5:707-724 34. Poverty and Poor Health Among Elderly Hispanic Americans. Baltimore, Md, Commonwealth Fund Commission, 1989 35. Gibson RC, Burns CJ: The health, labor force, and retirement experiences of aging minorities. Generations 1991; 15:31-35 36. Minkler M, Stone R: The feminization of poverty and older women. Gerontologist 1985; 25:351-357 37. Warlick JL: Why is poverty after 65 a woman's problem? J Gerontol 1985; 40:751-757 38. Burkhauser RV, Duncan GJ: Life events, public policy, and the economic vulnerability of children and the elderly, In Palmer J, Smeeding T, Torrey B (Eds): The Vulnerable. Washington, DC, The Urban Institute Press, 1988 39. Coe RD: A longitudinal examination of poverty in the elderly years. Gerontologist 1988; 28:540-544 40. Dressel PL: Gender, race, and class: Beyond the feminization of poverty in later life. Gerontologist 1988; 28:177-180 41. Holden KC: Poverty and living arrangements among older women: Are changes in economic well-being underestimated? J Gerontol 1988; 53:S22-S27 42. Morrison BJ: Sociocultural dimensions: Nursing homes and the minority aged. J Gerontol Social Work 1983; 5:127-145

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361 43. Sokolovsky J (Ed): The Cultural Context of Aging. New York, NY, Bergin &

Garvey, 1990

44. Hines CL: Future caregivers: Projected family structures of older persons. J Gerontol 1992; 47:S17-S26 45. Mindel CH, Wright R Jr: The use of social services by black and white elderly: The role of social support systems. J Gerontol Social Work 1982; 4:107-120 46. Chapleski EE: Determinants of knowledge of services to the elderly: Are strong ties enabling or inhibiting? Gerontologist 1989; 29:539-545 47. Starrett RA, Decker JT, Aranjo A, Walters G: The Cuban elderly and their service use. J Appl Gerontol 1989; 8:69-85 48. Krause N: Illness behavior in later life, In Binstock RH, George LK (Eds): Handbook of Aging and the Social Sciences. New York, NY, Academic Press, 1990 49. Headen AE: Opportunity Cost of Time and Black/White Differences in Nursing Home Use. Paper presented at the annual meeting of the Gerontological Society of America, Boston, Mass, November 1990 50. Expansion of Community-Based Services to Special Populations. Washington, DC, House of Representatives Committee publication No. 101-725, 1989 51. Lew LS: Elderly Cambodians in Long Beach: Creating cultural access to health care. Cross-Cult Gerontol 1991; 6:199-203 52. Weeks J, CuellarJ: The role of family members in the helping networks of older people. Gerontologist 1981; 21:388-394 53. Lubben JE, Becerra RM: Social support among black, Mexican, and Chinese elderly, In Gelfand DE, Barresi CM (Eds): Ethnic Dimensions of Aging. New York, NY, Springer, 1987, pp 130-144 54. Gilford DM (Ed): The Aging Population in the Twenty-First Century: Statistics for Health Policy. Washington, DC, National Academy Press, 1988