Life Experience of Personal Care Assistants in Anchorage: Cross-Cultural Caring of Older Adults: A Qualitative Phenomenological Study The increase in racial and ethnic diversity in the United States and specifically in Anchorage Alaska and the compelling evidence of ethnic health disparities (Smedley, Stith and Nelson, 2002) makes the incorporation of ethnogeriatric perspective into the practice of geriatric health care of critical importance. Reported are the "federally designated racial and ethnic groups…[of]…"American Indian/Alaska Native, African-American/Black, Asian-American, Native Hawaiian Pacific Islander, Hispanic/Latino-American, and white/Caucasian-American…" (McBride, 2012, p.1) Also reported are "vast differences or heterogeneity…found between and within these categories related to health beliefs and practices, access and utilization of health care, health risks, family dynamics and caregiving, decision making process and priorities, and response to interventions and changes in health care policies." (McBride & Lewis, 2004; McBride, Morioka-Douglas, & Yeo, 1996; McCabe & Cuellar, 1994; Richardson, 1996; Villa, Cuellar, & Yeo, 1993; Yeo, McCabe, Talamantes, Henderson, Scott, & Yee, 1996 in: McBride, 2012, p.1) Additionally reported is that the heterogeneity within each of the categories of ethnic/racial minority older persons such as sociodemographic characteristics, modes of social interaction and communication, health and healing belief systems, learning behaviors, and certain values and traditions…" all of which "contribute degrees of complexity to the delivery of culturally sensitive health care." (Yeo, McCabe, Henderson, Talamantes, Scott & Yee, 1996 in: McBride, 2012, p.1)

Specifically to Alaskan natives stated is that American Indian/Alaska Native (AI/AN) Older persons is the fact that there are "…at least 558 different tribes/nations recognized by the federal government. Recognition is still being sought by 126 tribes/nation. About 106 of 300 Indian languages are still spoken today although the languages of Alaska Natives are usually not part of this count. There are six major groups of Alaska Natives - Yup'ik, Alutiiq, Aleut, Inupiat, Athabascan, and Southeastern (Tlingit, Tsimshian, and Haida). Each group speaks a distinct language and unique history and culture. Contemporary Alaska Native older persons share a common sense of urgency to pass on their culture and tradition to the next generation (Easley, Kauaqlak, & Graves, 2005). Currently, California has the largest number of older AI/AN people. Other states with large number of older Indians are Oklahoma, Arizona, Texas, and New Mexico while Alaska is home to most older Alaska Natives who live in remote, isolated, and most rugged regions of the U.S. In contrast, since the 1990 census, about 62% of people who self-identify as American Indian are living in urban areas and are not served by the Indian Health Service. An urban Indian subculture is evolving into Pan-Indianism in which AIs from different tribes/nations formed to preserve their culture and develop culturally relevant services in the community. The challenge of creating culturally congruent health care programs for older AI/ANs underscores the heterogeneity of this group (Hendrix, 2001)." (McBride, 2012, p.1) In addition, Anchorage, Alaska is characterized by a mixture of various races and ethnicities in the older aged group of individuals.

Key Terms and Definitions

(1) Culture: the way of life of a population, including shared knowledge, beliefs, values, attitudes, rules of behavior, language, skills, and worldview among members of a given society. It shapes human behavior because it is the foundation of conscious and unconscious beliefs about "proper" ways to live. Cultures change constantly. Different members of a society internalize and express different parts of their culture. Subcultures can also reflect differences by geographic region or other subgroups within a larger society (Andrews & Boyle, 1995; Henderson, 1990: Klein, 1995).

(2) Cultural Competence in Geriatrics: Ability to give health care in ways that are acceptable and useful to older persons because it is congruent with their cultural background and expectations. At the provider level, it has been described as including the demonstrated integration of: A) Awareness of one's personal biases and their impact on professional behavior;

B) Knowledge of 1) population specific health-related cultural values, beliefs, and behaviors; 2) disease incidence, prevalence or mortality rates; and 3) population-specific treatment outcomes;

C) skills in working with culturally diverse populations. At the institutional level, it can be viewed as those systems of care that acknowledge the importance of culture, assess cross-cultural relations, are alert to cultural differences and their repercussions and adapt services to meet cultural needs. Health care settings may be placed on a continuum of cultural competence that have been described as including stages of: monocultural, nondiscriminatory, and multicultural; or destructiveness, incapacity, blindness, competence, and proficiency (Cross, Bazron, Dennis, & Isaacs, 1989; Foster, Jackson, Cross, Jackson, & Hardiman, 1988; Green & Leigh, 1989; Lavizzo-Mourey & Mackenzie, 1997, Tirado, 1998;...

An ethnic group is a large group in which members self-identify. They internalize and share a heritage of, and commitment to, unique social characteristics, cultural symbols, and behavior patterns that are not fully understood or shared by outsiders. (Barresi & Stull, 1993; Gelfand, 1993; Markides, Liang, & Jackson, 1990; Valle, 1998).
(8) Ethnocentrism: belief or attitude that one's own cultural view is the only correct view.

(9) Ethnogeriatrics: health care for older persons from diverse ethnic populations.

(10) Ethnogerontology: the study of the causes, processes, and consequences of race, national origin, culture, minority group status, and ethnic group status on individual and population aging in the three broad areas of biological, psychological, and social aging (Jackson, 1985).

(11) Immigration: movement of individuals or groups INTO a country or region to settle there.

(12) Minority: subgroup within a population. In social science, it is used to identify a group that suffers subordination and discrimination within a society, usually because of their race, ethnicity or national origin. The term is used by the federal government to describe protected and/or disadvantaged ethnic or racial populations (Hooyman & Kiyak, 1999; Markides, 1993).

(13) Race: socially constructed categories based on parentage and physical appearance. Although the term is now considered by many anthropologists to be obsolete because of difficulty classifying populations with widespread genetic diversity, it continues to be widely used. The term is used in official government documents, such as in the U.S. Census, in which individuals identify their own racial identity. It sometimes serves as a basis for discrimination and demarcation in conflicts over social resources (Fried & Mehrotra, 1998; U.S. Census, 1990).

(14) Spirituality: can be defined as whomever or whatever provides someone a transcendent meaning in life. It may be expressed as a relationship with one's god(s) or the creator, but can also refer to values such as: nature, energy force, belief in the goodness of all, or belief in the importance of family and community. Among some populations, it includes organized religion. It may or may not include belief in, and communication with, forces in the form of spirits (Puchalski, undated).

(15) Transcultural: a term used widely in nursing to apply to people of diverse cultures. Transcultural nursing is sometimes described as a body of humanistic and scientific knowledge with concomitant skills essential to help nurses care for people of diverse cultures (Leininger, 1997).

Research Question

The research questions in this study are those stated as follows:

(1) What are the life experiences of personal health care professionals in caring for older adults in Anchorage, Alaska?

(2) What have these health care professionals learned about culturally sensitive health care provision?

Literature Review

According to McBride (2012)

"Ethnogeriatrics is a developing subspecialty in geriatrics with an emphasis on the intersect of knowledge from the fields of aging, health, and ethnicity (Yeo, 1991).

It is now generally accepted that cultural beliefs and practices influence an individual's health behavior including choices and use of health care services.

Family support and their active participation are significant factors in eldercare that varies across cultures.

For many ethnic older persons, the patient-clinician trust relationship is often influenced by cultural norms. Likewise, the clinical interaction is also impacted by the cultural background of health care providers (Takeshita & Ahmed, 2004).

Over the past 15 years, an explosion of information on older minority health in professional literature and professional meetings has increased the availability of materials to further develop the field. Thus, the depth and reach of ethnogeriatrics will continue to evolve over time.

The work of the National Association of Chronic Disease Directors report on the aging population among American Indian and Alaska Native Elders reports that diabetes and depression are common chronic health problems faced by American Indian elders. Diabetes is reported as "twice as common in American Indian and Alaska Native communities as in the general…