Knowledge of a person’s educational level and reading ability is also necessary to determine how to most effectively present information concerning treatment and self-care. Inadequate health literacy is common among elderly patients. Such people often have an array of communication problems that may affect treatment outcome. Cognitive dysfunction may present as a short-term or long-term barrier to optimal communication between the healthcare professional and older person. Bell-McGinty et al. (2002) recommend that relatives should be encouraged to participate in patient interviews or education sessions, with patients’ consent, to ensure that patients have understood essential information. Creative written patient education materials should be used. Cultural differences should also be considered and an effort to understand and adapt to them should be made.

The trends in migration in today’s world make it necessary for healthcare professionals to be aware of each older person’s cultural, ethical and religious backgrounds. In 2010 the estimated number of international migrants was 214 million – 3.1% of the total world population. Approximately 8% of this total is made up of refugees. Former countries of emigration, such as Spain, Italy and Ireland, have become preferred destinations. By 2050 it is projected that 2.4 million individuals will migrate to developed regions annually (United Nations Department of Economic and Social Affairs, 2011). The ramifications of these UN findings are that healthcare professionals will almost certainly treat people from a different cultural background from their own.

A lack of understanding can frustrate both the older adult and the healthcare professional. Both verbal and nonverbal communication can be used to increase understanding. There are differences in both with diverse cultures and an understanding of these can greatly aid communication. Language and respect are closely linked. Several languages include honorifics, and an older person could be insulted quite easily if the wrong word is used. Many cultures have a great respect for older people and the appropriate term should be used.

The definitions of both culture and knowledge do not mention the ability to read or write. One can be rich in both culture and knowledge without the ability to read or write. It has been reported that there are approximately 6909 languages in the world today and very few of these have even been written down (Lewis, 2009). Eleven languages each have over 100 million mother-tongue speakers and these account for approximately 51% percent of the world’s population (Lewis, 2009). The inability to read or write is often based on individual circumstances and has nothing to do with intelligence. Today’s standard of education may not have been available years ago and an older person may not have had the same educational opportunities that are available to today’s youth. Healthcare providers will encounter people who cannot read or write and although this medium of communication is closed this does not mean that the person lacks intelligence. Providers must be aware that low literacy is associated with several adverse health outcomes (Dewalt et al., 2004).

Alternative forms of communication must be explored if a person is illiterate. Take-home instructions, a major part of treatment for medications, exercises or diet, must be provided in an understandable form. If not, adherence will be affected. Logs and diaries of health behavior, if prescribed, must be issued in a format that an illiterate person can complete. The involvement of family members and carers is of vital importance in these situations.

Hamadeh (1987) describes an excellent example of a practitioner of Western medicine who recommended going beyond what some consider to be customary practice in order to understand his patient and the patient’s situation. He used what he described as the Ecological Framework approach to generate hypotheses about the patient’s responses. Hamadeh described several levels of analysis: (i) the individual level, in which psychological problems, stress and depression may all be factors that contribute to a poor response; (ii) the family level, in which the factors affecting the patient’s illness include family myths and beliefs about disease and the family’s experience with the medical profession; and (iii) the cultural level, in which factors affecting illness behavior may be misunderstood by healthcare providers unless they are aware of the larger context of the patient’s background, which includes knowledge of the economic, social and religious factors affecting the patient’s life.

Hamadeh offers a list of pertinent questions to be asked when a healthcare provider is new to a community and wishes to better understand the community and its patients (Hamadeh, 1987):

Is it ethical to keep on insisting on behavioral change when individuals demonstrate that they understand the intentions of the caregiver but they do not wish to change? A patient’s autonomy must be respected and encouraged. Autonomy in relation to healthcare means encouraging individuals to make choices about how to behave, providing them with the information they need to make choices, and respecting the choices they make (Deci & Ryan, 2012). Informed decisions regarding their treatment and their behavior can only be made by the patients. The attitude of the professional can have a great impact on the acceptance of a course of action, depending on whether rigid adherence is required and expected, or whether a course of action toward change is recommended and mutually agreed upon. The attitude of the provider can greatly affect the likelihood that a change in behavior or lifestyle will occur, therefore an autonomy-supportive stance should be taken.

Perceived self-efficacy is defined as people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives (Bandura, 1994). The belief that one can master change in behavior and the belief that one can master an individual task, be it an exercise program or an individual exercise, are equally important examples of self-efficacy. Self-efficacy is modifiable and can influence health status, motivation and adherence across many aspects of health.

To achieve optimal disease management goals, the healthcare professional should facilitate older people enhancing their self-efficacy (Marks et al., 2005). Each individual who presents for treatment brings with them a unique and complex background and it is important to consider that each person also has a unique personality and may respond to treatment situations in a different manner. According to Bandura (1994), there are four main sources of influencing self-efficacy. The first, mastery experience, influences self-efficacy by building on previous success. Health professionals should remind older people of previous success they have had with healthcare behavior. The second, vicarious experience or modeling, influences self-efficacy by seeing people similar to oneself succeed. An example of this is the results from a study published in 2001, a peer-led fall prevention program proved to be more successful than a professionally-led one (Waters et al., 2011). Older people should be used as role-models for older patients. Any handouts or visuals should include pictures of older people completing target behaviors, for example, prescribed exercises. The third, social persuasion, is the easiest and most readily available source of influence for healthcare professionals. Verbally persuading older people that they possess the capabilities to master tasks is likely to mobilize greater effort and increase self-efficacy. The role that physiological factors play is the fourth and final source of influence. Reducing stress reactions and altering negative emotional proclivities and misinterpretations of physical states will influence self-efficacy. How normal emotional and physical responses to stress are interpreted and perceived is an important aspect of increasing self-efficacy. Informing patients about realistic perceptions of normal physiological responses and educating them on their condition and prognosis will also increase their self efficacy.

There are published tools to measure self-efficacy for numerous different conditions; however, health professionals must be aware of methodological limitations of many of these tools (Frei et al., 2009). Bandura believes that general self-efficacy scales are limited, and provides guidance on how best to construct them (Bandura, 1997, 2006).