Disparity of health continues to be a national concern. According to the Federal Interagency Forum on Aging Related Statistics (2003), one of every five Americans will be older than 65 by 2030. The Forum's Web site shows that ethnic minority older adults report poorer health than nonHispanic Whites, with the percentage of ethnic minority older adults expected to double by 2050. An estimated 16% of older adults were ethnic minorities in 2000 compared to a project one third (36%) of older adults in 2050 (Federal Interagency Forum on Aging Related Statistics, 2003).
Program planning must be tailored to more effectively meet the needs of older ethnic minorities. However, program planners currently have limited resources for designing ethnically appropriate health care programs. In addition, program planners have minimal academic preparation in cultural competency, inadequate information about ethnic minority groups, and few working models.
For this project, completed as part of a doctoral course on multicultural women's health, the author:
* Investigated factors contributing to the disparity of health in ethnic women as indicated in the literature.
* Interviewed women in three ethnic groups about their self-definitions of health and related behaviors.
* Explored factors contributing to successful or unsuccessful health programming in three multicultural congregational health teams.
Based on the findings from this exploration, possible interventions in areas of practice, education, and research are suggested.
Little is known about health promotion beliefs and behaviors of community-dwelling elderly adults. However, one qualitative study describes some important patterns. Frenn (1998) found recurrent themes for "going about health" to be
* Keeping active.
* Attending to health behaviors.
* Maintaining relationships.
The "maintaining relationships" theme is consistent with the centrality of family in Asian, Hispanic, and African American cultures. It is also consistent with the women's role in these cultures as primary caregivers in their families. In a similar study, Frye (1995) identified three recurrent themes in interviews and the literature related to health promotion in adults of southeast Asian descent: kinship, solidarity, and the search for equilibrium.
Family centrality increases when individuals are dependent on Englishspeaking family members. Lack of fluency in English contributes to the health disparity of ethnic individuals. Poor English skills were consistently correlated with fewer Healthy People 2000 target behaviors in various ethnic groups (O'Malley et al., 1999), as well as with less knowledge of risk factors and screening recommendations (Markides & Black, 1996). Health risk assessment education has proven an essential component of health promotion with ethnic elderly adults (Uriri & Winger, 1996).
Health Promotion in Older Ethnic Croups
Physical activity and nutrition are 2 of the 28 focus areas identified in Healthy People 2010. A few studies of ethnic groups have found that exercise and diet programs successfully lowered blood pressure, reduced obesity, controlled blood sugar, and reduced cardiac risk (Quatromoni et al., 1994).
More than half of all breast cancer deaths occur among women 65 and older (Parker et al., 1998), with highest mortality among minority women. Rimer's (1994) analytic literature review of this disparity concludes that interventions must be ethnicallysensitive as well as age-specific. Cultural factors affect compliance with screening recommendations, such as Vietnamese women's embarrassment of disrobing. Studies indicate very low breast cancer knowledge levels among elderly individuals (Kantor & Houldin, 1999).
Differences of health concepts in diverse cultures also have implications for health programming. For example, stress is not a concept in the Vietnamese and some other Asian cultures. However, many studies have identified stress as a major health problem in these groups, with depression and post-traumatic stress disorder especially prevalent among older women (Buchwald et al., 1993; Chung & Kagawa-Singer, 1993). However, psychological problems are not as acceptable in these ethnic populations and do not reduce societal demands as effectively as chronic health problems. Therefore, psychological distress becomes somatized rather than verbalized.
Programs specific to certain ethnic populations require access to groups of ethnic elderly adults. Community senior centers and faith-based congregations have been recommended for health programs with ethnic elderly adults. Social acceptance, accessibility, safety, language compatibility, and the absence of socioeconomic disparity at these sites reduces some of the usual barriers for these elderly adults.
Faith Communities and Health
Church attendance is associated with positive health behaviors (e.g., mammography screening) even in the absence of special health programs (Fox, Pitkine, Paul, Carson, & Duan, 1998). After an extensive review, Matthew et al. (1998) concluded that religious commitment was positively associated with illness prevention, positive coping, and recovery from illness. Koenig, McCullough, & Larson (2001) critically reviewed more than 2,500 studies about religion and health from the past century in their groundbreaking book. They suggested possible theoretical models for understanding the mechanisms by which religion may influence health, and described the potential effect on health care costs and use.
Congregational or parish nurses, paid and unpaid, frequently coordinate and provide health promotion and health prevention services. Boss (1999) articulated the potential effect of congregational nurses in meeting the needs of underserved and marginalized clients. Two parish nursing research studies documented the progress made toward Healthy People 2000 goals through congregational health activities in rural counties (King, Lakin, & Striepe, 1993) and in other communities (Weis, Matheus, & Schank, 1997).
Congregational health programs have also shown effectiveness in promoting health behaviors in ethnic congregations, such as improved breast cancer screening in older African American women (Earp & Flax, 1999) and improved weight and blood pressures in African American women (Kumanyika & Charleston, 1992). Ransdell (1995) explained why church-based health promotion has been successful, but found few programs addressing the needs of ethnic older women in 29 articles on church health promotion in minority communities.
Many congregations are multicultural or largely composed of a single ethnic group. Because of the need for culturally appropriate program planning, the National Health Ministries Association organized its 1999 annual convention around the theme of cultural diversity. McRae et al. (1998) proposed that the therapeutic support of ethnic churches on health behaviors has foundations in systems and group relations theories. Paniagua (1994) describes church as part of the extended family for African American individuals.
Spirituality, Hearth, and Religion
Perhaps the relationships between healthy behaviors and religion are rooted in beliefs and practices connecting spirituality and health as well as religious practices. Koenig reported that 30 of 44 studies found a lower mortality rate in those who had religious affiliations (1997, p. 78). Dossey (1993, p. 211) summarized findings from 77 of 131 controlled trials of spiritual healing which found spiritual practices significantly associated with health. Matthews et al.'s (1998) systematic review similarly found a positive correlation between spirituality, religiosity, and healing. Stolley and Koenig (1997) explored the central role of religion and spirituality in health among elderly Hispanic adults and elderly African American adults. Paniagua (1994) described several religious healthrelated beliefs of the Hispanic and African American cultures.
Despite the significance of spirituality in health and healing, Schnorr (1999) cites five articles which conclude that many nurses do not address the spiritual dimension in their care. Classic nursing spiritual assessment tools are still the best resources, such as Stoll's (1979) and Radde's (1984a, 1984b) work for clinicians, and Hungelmann et al.'s (1985) research tool on spiritual well being for senior citizens. Spiritual distress is a well-developed and well-accepted spiritual diagnosis.
The significance of spirituality in health has prompted congregational nurses to identify the role function of "interpreter of faith and health" as the central focus of their role (Schnorr, 1999). In one study of 1,800 elderly adults contacted by 40 parish nurses, 34% of the nursing interventions treated spiritual distress (Rydholm, 1997). Congregational health programs are uniquely designed to integrate the faith and health aspects of holistic health because of the faith-based setting and the underlying philosophy.
Women as Family Caregivers and Keepers of Health
Congregational health programs frequently identify the need to support caregivers and homebound adults through home visits and supportive services such as respite care. By 2050, one quarter of Americans older than 65 will be 85 or older (Sultz & Young, 1997, p. 43), and most of these adults will need some home assistance. Twenty percent of individuals caring for their parents are older than 65 (Brogna, 1998). Volunteer congregational care teams address many of these needs. Brown-Hunter and Price's (1998) program successfully provided African American church lay visitors, who were not health professionals, to African American patients with cancer.
Rydholm's (1997) study of parish nurses found a cost savings of approximately $200,000 in 1 year because parish nurses' support for caregivers and frail elderly adults postponed nursing home placement. The caregiving experience is particularly embedded in cultural values, and has great implications for the acceptability of various options for the care of disabled elderly adults. Many studies have examined cultural components of caregiving (Leininger, 1995; Dai & Dimond, 1998; Sterri« & Pokorny, 1998).
In most cultures, women serve as family caregivers and are the "keepers of health" (Maltby, 1998). To plan culturally appropriate health programs, it is necessary to better understand how ethnic women define "healthy." Children learn about health from their mothers, mothers make the decisions about how to treat health problems and when to access the health system, and women usually manage family nutrition. In addition, in certain cultures, family systems tend to be matrifocal such as African American families (Cherry & Giger, 1995).
In this project, the author explored the question of how to offer culturally appropriate health programs in hopes of reducing the disparity of health status in ethnic groups. In this study, older ethnic women were asked to self-define what it means to be "healthy" and then explored factors contributing to effective or ineffective congregational health programs. Senior centers and congregations were chosen as the settings for the informants because these settings offer large gatherings of ethnic elderly adults who can serve as informants as well as benefit from appropriate programs.
Semi-structured interviews were used to explore self-definitions of health and health promotion behaviors of older ethnic women in senior centers of predominantly three different cultural heritages: Hispanic, Indochinese, and African American. Unstructured interviews of congregational health ministry team members were used to examine factors contributing to effective or ineffective congregational health programs in three multicultural congregations.
For the purposes of this study, ethnic minority women were defined as those of Hispanic, Indochinese, or African American heritage living in a neighborhood composed of a majority of that respective heritage. Women representing these three ethnic minority groups agreed to be interviewed: Vietnamese (5), Hispanic (5), and African American (7). These 17 women attended three different senior centers, each situated in an ethnic neighborhood. All three of these centers serve elderly adults in inner-city areas designated as "most economically impoverished" (Planning & Development, 1996).
The predominantly Hispanic center provides case management services, recreational activities, van pick-up, weekly nursing clinic monitoring, and various health promotion classes and activities. This center was created to implement and evaluate a nurse-managed model of health promotion coordinated by case managers. Students from nursing and allied health professions regularly participated in supervised clinicals at this site.
The center predominantly used by Indochinese adults offers daily Mass, a gathering place for seniors, a meal 5 days a week, a Buddhist temple, English as a second language (ESL) and citizenship classes, game tables, and a beauty school upstairs. The largest Asian group involved in this center is Vietnamese.
The last center, attended by mostly African American seniors, serves a meal 5 days a week, offers a walking program and some health classes taught by various health professional students, has several gathering rooms and game tables, and provides van pick-up.
The 17 women who agreed to be interviewed were between 62 and 86 years old. Two women were in their 60s, 13 in their 70s, and 2 in their 80s. Only three of the women lived alone and four lived with their husbands. One lived with a female roommate, and nine with grown children and grandchildren. None of the Vietnamese women lived alone.
All except one woman described themselves as in fairly good health, in spite of chronic conditions such as arthritis, diabetes, high cholesterol, and high blood pressure. Two of the women, ages 73 and 86, had provider services. The oldest interviewee was the most disabled. She was a "healthy" 82-year-old African American woman who could only stand for 5 minutes because of her arthritis. However, she adjusted her activities and self -expectations accordingly. She used the van pick-up service to attend the center 3 days a week and had arrangements to be the first in line for the center's meals to avoid exceeding her standing tolerance.
The researcher used a semi-structured format when interviewing the women. The four main questions asked were:
* What does being healthy mean to you?
* What do you do to stay healthy?
* What has been important to you throughout your life?
* What is your life like now? Additional questions were asked to establish rapport or clarify responses as needed. Interviews lasted from 20 to 55 minutes.
Interviews of the congregational health team members began with an explanation that recommendations for successful health programming for ethnic groups were being gathered and the wisdom of their experience would be shared with others. The interviews were informal and allowed for spontaneous remembering and storytelling. Occasional prompting questions included: "Why do you think that program was or was not successful? Can you tell me more about that?" The interviews were closed with the summary question: "What final word of advice would you like to give to congregations regarding culturally appropriate health ministry programs?"
Permission was obtained from the administrator at each senior citizen center site to ask for female volunteers. The women at each center were approached by the nursing professor or a doctoral nursing student and asked if they would be willing to answer questions about their health.
Some volunteers were interviewed by a pair of nurses, with one or both nurses taking notes. Some women were interviewed by only one nurse, depending on how many women agreed to be interviewed at each center.
Interviewing the older Vietnamese women was difficult because of the language difference. Volunteer interpreters stepped forward to help translate during two of the interviews with Vietnamese women. The validity of the translations could not be determined. As reflected in the literature, few of the Vietnamese women were fluent in English.
In soliciting informants for the congregational health programming part of the project, the investigator described the purpose of the project to the lead contact for each of three health ministry teams, and all three agreed to be interviewed. Interviews with the congregational health team members lasted from 30 to 75 minutes. One interview was conducted with three members of the health team at once, and the others were conducted individually with the congregational health or parish nurse of the team.
Analysis the interviews involved identifying most commonly emerging classes of comments, such as
* Defining self through significant others.
These concepts were then broken into subgroups, such as "family," "support," and "spirituality and religiosity" under the category "relationships."
The students listed these categories and then agreed upon rudimentary definitions of each code, and the students coded their own interview notes. New concepts or codes emerged after the group discussed the coding process. These were
* Health status, past and present.
* Family health.
* Worries or fears.
Finally, each code and its subgroups were listed with separate columns for each of the ethnic groups. Each nurse listed quotations or comments that fit under individual codes in each of the ethnic group columns. These tables were printed and examined for themes and patterns. This systematic presentation of coded comments facilitated efficient collating of a large volume of group data.
The transcultural definition of "health" emerging from the data was the theme: "Healthy is being able to do activities which have meaning, and these in turn keep me healthy." Meaningful activities included
* Playing baseball with a grandchild.
* Taking care of oneself.
* "Eating what I like to eat."
* Going to the senior center.
* Volunteering at church.
* Going to the casino.
* "Keeping busy as an aide."
* Visiting individuals who are homebound and cannot go to church.
* Going out to dinner.
* Doing housework for the family.
* Volunteering at the church.
One woman summarized "health" as, "I can go, come, and do as I please." Two of the 17 women interviewees actually defined their health in terms of their family's health rather than their individual health. "Health" to these women meant "my family and my husband to be well."
Staying active was an important theme for these women. Comments included
* "I keep busy, and this keeps me from getting old."
* "I keep doing and not worry too much."
* "Being not healthy means you can't do anything."
* "Good health means I can get around."
* "It means everything to me to be healthy. I can do all the things I like to do. And it means helping others."
* "Healthy means going to school [ESL classes] and able to do anything at home."
* "Healthy is everything is normal - like I can do what I want."
* "I'm busy, on the go all the time."
The most repeated phrases related to health behavior were variations on "staying active." This phrase encompassed a wide range of activities these women found self-fulfilling. Meaningful activities not requiring much physical involvement often included social engagements, such as participating in family reunions. These same activities were mentioned as ways the interviewees stay healthy, such as going to the senior centers, visiting friends, cooking for the family, and counseling over the phone. Exercise and diet were the most frequently mentioned health behaviors among all three groups.
Two women at the center attended by Indochinese older adults asked for health programs at their center during their interviews. One African American woman pulled out a pamphlet she had carried with her for months from the center's class on osteoporosis as she talked about drinking milk as a way of staying healthy.
Many women interviewees identified trust in God and a positive attitude as health behaviors. Some comments were: "I try not to worry - I just put it in the hands of the Lord." "If I don't worry too much...I will be healthy." The oldest woman described her attitude related to health and other challenges in life as: "Meet it, greet it, and defeat it." It is interesting to note that not one of the older women interviewees mentioned the word "stress" or managing stress as a health behavior, although many used terms like "try not to worry" and "stop anxious thoughts" when describing their positive attitudes as health behaviors.
Functional independence was the most frequently mentioned goal of health. According to a 72-year-old with a daily provider visit, being healthy "means everything to me. It allows you to live alone, do things for yourself." Most of the interviewees indicated that health was a very high priority in their lives.
After analyzing the data, the consensus of the interviewers was that the similarities between the three cultures were more striking than the differences. The small sizes of the separate ethnic groups precluded making generalizations, but analyses of their combined comments highlighted some common transcultural themes.
CONGREGATIONAL HEALTH PROGRAM EXPERIENCES
One of the three multicultural congregational ministry teams interviewed during this project chose to begin its congregational health ministry program with home visits. Because of tension between the individuals of the Nigerian and Anglo ethnic groups in this faith community, the initial visits were made in pairs of both an immigrant Nigerian and an Anglo nurse until rapport was established. This was a helpful step toward bridging the cultural gap among the volunteer congregational nurses, as well as between the nurses and the clients. The congregational nurse who organized this initiative emphasized that bridging the cultural gap had to start with greater cultural awareness among the nurses themselves.
One multicultural church offered "Pink Ribbon Sunday" as its first congregational health ministry program. The American Cancer Society designed this breast cancer awareness program specifically for churches and it has been successful. However, in this congregation, responses among the ethnic groups were mixed.
The promoter of this pink ribbon program was a Hispanic woman, and Anglo and Hispanic participation was high. However, some Vietnamese women actually held their hands in front of them with a defensive motion to indicate their resistance to participate - a strongly negative response, especially in view of the high cultural value of politeness. African American participation was similarly low.
The low participation was attributed to not engaging Nigerian and Vietnamese leadership in the planning or promotion of the program, and to not conducting activities in the Vietnamese language. The health ministry team learned the significance of ethnic sensitivity in program planning through this event. The nun who provided leadership in this congregational health team emphasized the importance of shared ownership by all cultures in the use of space and worship styles and the essential need to engage ethnic leaders in all steps of the program planning and implementation process.
This same large, multicultural Catholic community had earlier discovered the lines of authority in their Vietnamese subgroup when trying to implement a healing ministry through visiting the sick and administering the healing sacrament of Communion. No Vietnamese individuals made visits after the training because the Vietnamese "head man's" support had not been recruited. This experience emphasized the importance of honoring the chain of authority in close-knit cultural groups, and that learning was applied when conducting a congregation-wide health educational needs survey. Before conducting the congregational survey, the Anglo "head man" (senior pastor) spoke with the Vietnamese "head man" (not the Vietnamese associate pastor) via the interpreter to obtain "permission" and support for the survey. The pastor also presented the idea to the Hispanic leadership group before passing out the survey at all the Masses. The survey was written in Vietnamese, Spanish, and English.
Stress was identified as the top educational need by the Anglos and Hispanics, but stress was near the bottom of the list for Vietnamese. By contrast, the Vietnamese rated very concrete physical health services, vision and dental care, as top priorities. The translation of the word "stress" was problematic on the survey because stress is not a recognized concept in the Vietnamese culture. In discussing the low score for stress programs in the Vietnamese group, the researchers concluded that a more meaningful and a closer translation might be the phrase and the concept of "too many worries" rather than "stress."
The first health program offered to one church in an ecumenical coalition of churches in a Hispanic neighborhood was a nutrition program. This had been requested through a congregational assessment survey in a church composed exclusively of older adults (average age of 70). These elderly adults had identified nutrition and dietary issues as their primary educational need, even writing them in for several other categories.
The nutrition program was presented by a bilingual dietitian who presented in both Spanish and English and incorporated information consistent with beliefs about hot and cold foods in the riispanic culture. This program was well attended and provided a good basis for the ongoing dietary counseling during individual blood pressure monitoring at the weekly meal and bingo days which followed.
The Hispanic congregational health nurse developed a trusting relationship with the congregation's formal and informal ethnic leaders through these initial programs. The formerly "invisible" undocumented Hispanic elderly population became more "visible" as trust was established. Months later, a Women's Health Day drew a large response from the Hispanic and Anglo populations for breast self-examinations and mammograms. The trusting relationship supported the participation of ethnic women in the breast cancer awareness activities. The congregational nurse who organized these activities said the critical factors related to program success were the trust factor and support of the pastor.
DISCUSSION AND IMPLICATIONS FOR GERONTOLOGICAL NURSING
The potential role of faith communities in health promotion needs more attention. Although voluntary agencies like churches provide only a fraction of health services, their congruence with community values of volunteerism and charity, as well as their alliance with their members, position them for effective outreach and advocacy with marginalized minorities.
Trust must be established before offering programs with potential for causing embarrassment or discomfort created by differences in cultural values and practices, such as breast selfexamination and other breast cancer awareness activities.
Nutrition programs addressing foods relevant to all of the participating cultural groups might be an effective place to start, especially when combined with exercise information. These programs must incorporate belief systems such as the balance between hot and cold foods in the Hispanic and Vietnamese cultures. Introducing exercise programs including movements with spiritual meaning, such as Tai Chi, can emphasize the holistic nature of healthy living.
Health programs for ethnic elderly adults should start with information dissemination about risks and screening recommendations. Actual prevention activities, such as breast selfexaminations, should be introduced by individuals of the same ethnic background after being promoted by the pastor and ethnic leaders. When the practices deviate from the usual cultural norms, it is especially essential to educate elderly adults' family members as well.
The value these women place on staying active emphasizes the importance of senior activity centers for such senior cohorts and the potential for senior centers in faith-based communities. It must be remembered that this group of women represents women who choose to attend senior centers - they choose social engagement and activity. Perhaps Lemon, Bengtson, and Peterson's (1972) theory of activity in aging needs to be revisited.
Health promotion programs should address kinship solidarity and the centrality of family relationships in older women's lives. Although senior centers offer opportunities for elderly adults to be with one another, the importance of family and intergenerational gatherings and involvement in educational and activity programs must also be addressed in program planning. Many of these seniors engaged in physical activities with their grandchildren, such as playing ball.
Additionally, the concept "worry" and its relationship to older women and to the modern American concept of "stress" must be investigated.
Programs about stress management for Asian adults would need words and presentations which better fit the culture as well as respect the Asian sensitivity related to psychological distress. Older adults from other cultures may need similar modifications.
The centrality of spiritual values in relation to health in these ethnic women supports the proposition that churches can be effective settings for health promotion programs. This emphasis calls for more intentional inclusion of the spiritual dimension in health promotion program planning. Church-based weight control programs, for example, generally integrate biblical or other sacred text teachings as part of their process.
Because many ethnic churches are in economically disadvantaged urban or rural areas and have few health professionals, the lay health promoter model can effectively "multiply the ministers" while also empowering the older adults. Training ethnic lay health promoters and using health professionals of the same ethnicity increases program effectiveness (Bird et al., 1998).
Effective lay health visitor programs serving ethnic minorities need not be limited to churches (Earp Sc Flax, 1999). However, churches can provide a good source of volunteers as well as on-going support for them. Caregiver, respite, and similar programs need to be promoted in churches and in neighborhood centers.
The importance of honoring ethnic lines of authority in planning and providing health programs cannot be overemphasized. Those lines of authority have meaning within the cultural tradition and the relationships with self, family, the church, and society in general. Effective programs require congruence with these unwritten rules and indicate respect for the people and the culture.
Nurses need to educate their health ministry teams about Healthy People 2010 objectives and assist their teams to partner with local community, governmental, and academic institutions to support meeting those objectives (U.S. Department of Health and Human Services, 2000). Health ministry teams must see their efforts as part of an overall effort to iniprove national health.
Nursing Education and Research
Several recommendations for nursing education and research can be inferred from this project. These include:
* Improving cultural competency and contributing to knowledge about ethnic elderly adults.
* Preparing nurses to meet spiritual needs.
* Providing clinical opportunities which facilitate the mutual learning of both clients and nurses related to health promotion and prevention needs in ethnic elderly adults.
Stetler and Dienemann (1997) describe two demonstration projects of academic and health care collaboration in student and staff training in cultural competence. Bailey et al. (1996) describe a student intervention project with ethnic elderly adults. Nursing leaders need to provide better resources on culture and aging issues such as Allender and Rector's (1998) readings and Spector's (1996) book on culture and health.
With 34% of Americans interacting daily with non-English-speaking individuals, nursing students should have familiarity with a second language (Gray, 1999). In addition, educators need to provide bilingual, ethnic nursing students with opportunities to use their language and cultural skills. This will maximize their skills and affirm their ethnic heritages while benefiting society and the profession.
Nursing education must better prepare nurses to meet the spiritual needs of clients. Oldnall (1996) provides beginning guidelines for curriculum development in this area. The Interfaith Health Project has several sample syllabi for nursing courses in spiritual care on its Web site at www.ihpnet.org
A number of suggestions related to program planning emerged from this project. The suggestions follow:
* Settings such as senior centers and faith communities show promise as sites for promoting health in ethnic groups and teaching students about culture and health.
* Culturally appropriate program planning requires enlistment of ethnic leaders and sensitivity to cultural values.
* Student projects could contribute to cultural competency training and the knowledge base about ethnic minority elderly adults.
* Psychological health issues particularly need adapting when addressing ethnic elderly adults.
* The centrality of spirituality in health for ethnic elderly adults challenges nurses to better prepare to provide spiritual care.
* Effective health programming for ethnic women must include family systems considerations.
* Nursing research must incorporate the methods of medical anthropology and other disciplines in developing culturally sensitive assessment and research tools to better understand the needs of ethnic minorities.
* Improving health in ethnic elderly adults requires a multilevel approach in improving health education in minorities, reducing cultural barriers, and providing services based on research-based knowledge about culture and health.
Nurses have an opportunity to implement these and other strategies to reduce the health care gap for ethnic minority elderly adults. The removal of ethnic disparities, a goal of Healthy People 2010, can then be better realized.
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