The Implement of Aging Care Services with Cultural- Based Consideration at Tribal Culture Health Station in Taiwan

Tribal culture health stations are currently important platforms for tribal elderly care services. However, do tribal culture health stations, which are designed based on the characteristics of the Han society, meet the cultural characteristics and service demands of the indigenous elderly? From the perspective of care attendants in tribal culture health stations, this study explored the current operations of tribal culture in tribal culture health stations. In addition to providing general services, tribal culture health stations also make adjustments or provide innovative services according to the living habits of the elderly. The adjustments or innovations are based on knowledge of tribal cultures, in order to introduce the culture and specific lifestyles of tribal elderly in the services of the tribal culture health stations, thus, enhancing the cultural features in the services and simulating realistic indigenous tribal living situations.

Keywords: Tribal Cultural Health Station; Indigenous; Cultural-based aging care

In 1996, the Council of Indigenous Peoples Executive Yuan Organization Bylaws was established in Taiwan to enhance the care provided for indigenous older individuals. In the same year, the Indigenous Council of Executive Yuan was established, whose name was later changed to the Council of Indigenous Peoples in 2014. To formulate adequate social welfare policies, a 6-year care program for indigenous older adults and children was implemented in 1998 to provide care, shelter, and food for older adults living in tribal settings. In the same year, this program was expanded to include social welfare subsidies for indigenous inhabitants and offer sub sidized home and food services for tribal older adults. In 2002, the Provisional Act Governing the Welfare Allowance for Indigenous Elderly was established to provide a living allowance for indigenous individuals aged 55 to 65 years in Taiwan. During the period from 2001 to 2009, phases 1 and 2 of the Four-Year Diversified Welfare Program for Indigenous People were implemented to establish an indigenous tribal service system and provide care services for older individuals. In 2006, a daytime care station was established for older adults residing in tribal settings, serving as the bedrock of local community care for this group. From 2009 to 2016, phases 1 and 2 of the Four-Year Societal Safety Development Program for Indigenous People were implemented. This program gradually enhanced the care services and support systems available for older adults in tribal settings and focused on the development and establishment of additional care stations on an annual basis [1].

One of the key objectives of phase 1 of the Societal Safety Development Program for Indigenous People was to establish a connection with the local organizational resources of indigenous villages by building care stations and offering jobs through the care stations available in these villages. In phase 2 of the program, efforts were made to reinforce the care services and support systems offered for older adults in tribal settings, and these services were subsidized to provide appropriate care for these individuals. During phase 3 of the Societal Safety Development Program for Indigenous People in 2017, the Council of Indigenous Peoples established a platform to determine the health-care needs of older individuals living in tribal settings. A long-term care collaborative platform was also established for indigenous older adults to meet their care needs and protect their care rights. In 2015, after the social welfare policies of indigenous villages were modified, the term “care stations” was changed to “tribal culture health stations” (TCHSs). Despite these changes, these stations served a similar function, and their primary focus remained on tribal care services for older adults.

Traditionally, indigenous peoples accord considerable respect to older adults. These adults are given priority when it comes to the distribution of resources (in particular, games from hunting). For example, in the Paiwan society of nobles, people offer part of their game as taxes to the nobility after a hunt, and the remaining game is distributed first to older adults [2,3] and then to the remaining members of the tribe. In Bunun culture, tribal resources or daily necessities are distributed first to older adults [4].

In Amis society, seniors are also respected, and hierarchy is based on age. Specifically, higher-ranking (i.e., older) members guide lower-ranking (i.e., younger) members [1]. Tao society, by contrast, has no explicit hierarchy, and the head of the tribe is chosen by the oldest member in each family, underscoring the esteemed status of older adults [5]. In Rukai society, older adults assume key positions, and when houses are built, they lead rituals and get to be the first to choose where they wish to put their bed [6].

In Taiwan, indigenous peoples have unique cultures, and these cultures influence their values, lifestyle, and way of thinking [7]. Given that each indigenous group has unique expectations and methods in how they care for older adults in their group, the provision of such care, especially by outsiders, should be adapted to the culture at hand. To achieve this goal, welfare policies should be made with a sensitivity to indigenous cultural welfare [8] to ensure their utility and acceptance.

Since 2017, Taiwan has strived to implement mutual care for indigenous peoples and enhance qualification regulations for the administrative supervisors of TCHSs. To achieve these goals, care attendants and administrative supervisors should be indigenous individuals who act in support of the present system where older adults are served by others in the community. Therefore, the training programs designed for care attendants should foster cultural sensitivity and competency for integration into care services. To ensure that these efforts are effective, several questions must be answered. For example, do the care services provided fit well with the culture of the indigenous people they serve? Thus, this study analyzed the current status of care services provided for older adults in indigenous settings at TCHSs with a view toward their cultural fit.

Introduction to TCHSs

TCHSs are typically designed to provide care services, including physical, psychological, and social care, for older adults living in an indigenous tribe. These stations are required to provide these individuals with services such as telephone assistance, life consultation, transfer of care assistance, food assistance, health promotion programs, exercise programs, cultural and spiritual courses, and home care. They should also conduct surveys on health and cultural care and establish culturally appropriate health-care platforms [9].

Multiple studies have examined the role of culture in tribal care for older adults. For instance, Li [8] explored the rights of cultural welfare in traditional societies and discovered that indigenous peoples often face obstacles while practicing their traditional lifestyle and culture. These findings indicate the importance of implementing social welfare within the framework of traditional culture. An indigenous peoples-based care system is required to ensure that recipients of care feel that their cultural background is respected [1]; such cultural sensitivity has become increasingly emphasized as part of the global shift toward multicultural awareness. Certain questions, however, remain to be answered. One key question is what role does culture play in the provision of services by TCHSs? This study was conducted to answer this question.

Culture and Care Services

Culture influences how care behavior is treated and executed, indicating the importance of cultural care as a concept. Cultural care refers to cultural sensitivity, propriety, and competency in professional health care [10]. Cultural care theories value the relationship between care and culture, meaning that they focus on the provision of care services with cultural sensitivity depending on each individual’s cultural background. According to the literature, the concept of culture depends on the living habits of older adults and is used as an appropriate care service model for these individuals [11,12]. When cultural differences are present, the care services provided for different peoples vary, resulting in diverse cultural care techniques.

Cultural care refers to professional care associated with cultural sensitivity, cultural propriety, and cultural competency [7], aimed at meeting the care needs of individuals, families, communities, and cultures. Given the uniqueness of care behaviors, care behaviors that differ from those of traditional cultures are usually not recognized by society or governmental sectors. According to Ru [12], cultural care refers to care services that respect local cognitive behaviors and material conditions and meet the expectations of individuals. In the 1960s, multiple cultural care theories were proposed, and cultural care was defined as the values, beliefs, and lifestyles that are both subjectively and objectively learned and conveyed. Cultural care helps individuals or groups maintain their health, improve their living conditions, or cope with illnesses, physical problems, and death [13]. Leininger [10] conceptualized three types of guidance for cultural care actions: cultural care preservation and maintenance, cultural care adaptation and coordination, and cultural care adjustment and reconstruction.

Cultural Care in the Context of Indigenous Peoples in Taiwan

According to the Council of Indigenous Peoples (2021b), officially Taiwan has 16 groups of indigenous peoples, each with their unique social and cultural context. This study reviewed previous studies on care provision in indigenous settings published from 1996 to 2018. Most of these studies have not explored the role of culture, and no study has comprehensively examined the role of culture in care provision among indigenous peoples in Taiwan. Given the limitations of data collection, this study explored the cultural characteristics of care toward older adults only in the Bunun, Atayal, Paiwan, and Tao tribes.

Bunun society is patriarchal and based on the extended family. Bunun tribe members value their older adults, who guide younger members on how to live, work, and care for each other [4], and older adults are given priority in the distribution of everyday resources. Atayal society is characterized by a common livelihood, which includes hunting and agriculture; a shared set of taboos; and a culture of sharing [14]. In Atayal tradition, older adults and children are collectively cared for by the tribe, and this care is centered around meeting food needs [2,14].

Paiwan society is hierarchical, with the highest rank being the tribe leader or mamazangiljan. This leader is a respected figure who collects taxes and takes care of the tribe [15]. Members may criticize the leader or even leave if the leader fails to fulfill these responsibilities. Paiwan society’s system of primogeniture (called vusam), which has no regard to gender, shapes their approach to care. Specifically, the older child inherits most of the family’s property but also shoulders the responsibility to care for older relatives and siblings [15]. The older child functions like the mamazangiljan but on a smaller scale. Rukai society is similar to Paiwan society, where tribal nobles are responsible for maintaining order and caring for the vulnerable in their midst, including older adults, widows, children, and individuals living alone [16].

Tao society is such that children leave the nest upon reaching adulthood but shoulder an expectation of filial piety, where they take care of their parents or send them everyday necessities [5]. Tao beliefs hold that illness is caused by spirits called anito. When an older person becomes ill, they typically request to move out of the family home. At this point, they may build a separate dwelling nearby or live alone in a workhouse. If the older individual remains in the family home while ill, they are believed to transfer misfortune to their children. Children who refuse their parents’ requests are deemed unfilial [5].

Traditionally, in Tao culture, male older adults are primarily taken care of by their male children or their children’s male spouses and vice versa for female older adults [5]. Tao tradition also proscribes neglect by one’s own children, and the provision of care to an older adult by an outsider to the family signals such neglect. Thus, the Tao tribe differs from the other tribes in that older adult care is not something that is done in common. Older adults with no children may be taken care of by their siblings or an adopted child, who then also become the receiver of any inheritance.

In summary, older adult care in indigenous settings in Taiwan depends on the cultural institutions of the tribe in question. In tribal settings, social structure, and inheritance systems further influence who among the family should care for the older adults among them and how this care should be administered.

For indigenous peoples, tribal medicine, traditional value of soul, and land integrity have positive influence on their health [15]. However, Western medicine (and Western culture more generally) has gradually replaced traditional tribal medicine [17]. This study thus investigated the following question: Has this cultural and medical shift affected the care of older adults, specifically with regard to the operations of TCHCs?

This qualitative study conducted in-depth interviews for 90- 120 minutes with care attendants who were versed in the provision of services to indigenous older adults, doing so to uncover how they interpreted and constructed their reality [18]. Specifically, individuals meeting the following criteria were invited to participate: (1) being employed at a TCHS for more than 6 months, (2) living within a tribe for at least 3 years, and (3) being willing to provide their written informed consent to participate. In 2017, a total of 21 cultural health stations were documented in Hualien County, all of which were coded and randomly selected. Ultimately, 12 participants were selected for this study (Table 1).

Introductory questions and focus questions were asked in the interviews. The introductory questions were on basic demographic characteristics (e.g., “Can you please introduce yourself briefly?”), and the focus questions were on the interviewee’s experience of service provision and their reflections on the role of culture therein (e.g., “Can you please explain how culture plays a role in your provision of service?”).

Thematic analysis, where words are categorized on the basis of their conceptual relevance [19], was then applied to the data. During the initial stages of data analysis, ideas and concepts were separately coded, with similar incidents and reflections grouped together. This study was approved by the China Medical University and Hospital Research Ethics Center (approval no. CRREC-1-5-083). The study protocol adhered to the three ethical principles of respect for people, beneficence, and justice [20].

Table 1: Summary of the study participants.

The themes identified in the interview data were as follows.

Life and care as cultural elements

Older adults in tribal communities often continue to work or cultivate the land as they have always done, working until they can no longer physically do so. For older adults living alone, agriculture is not merely labor but also an essential part of their livelihood and existence.

“If it’s an older farmer like us, unless he can’t move, he just lies there, he won’t move, and he won’t go to the mountains.” (A1)

“I believe it is a way to sustain our lives. If we do it, we have something to eat.” (A2)

Given that many older adults remain engaged in farming, TCHSs must schedule their services around these older adults’ working hours for their services to be accepted.

“Because older people have to go to the mountains to work early in the morning, it’s impossible for you to ask them to come at 8 o’clock. Maybe five or six people will come from 8 to 9 o’clock, but the TCHS services will wait until 9:30.” (A3)

Given that the timing of care services is influenced by the rhythm of agricultural activities, care attendants should be aware of local agricultural practices. Regardless of their capability to perform physical labor, older adults should have the opportunity to engage with their agricultural heritage, whether by assisting in or observing activities such as harvesting and cultivation, depending on how physically able they are.

“We move the classroom to the field from the TCHS. For example, to plant red quinoa, we move to the red quinoa farmland and allow older adults to receive care services while farming.” (A5)

Agricultural work should be distinguished from exercise for older adults to grasp the importance of engaging in proper exercise.

“The prevention and treatment of chronic diseases must be guided by culture for them to cut deep into changes in lifestyle. For example, older individuals go to their fields early in the morning. They believe that their labor counts as exercise. Therefore, we must help them understand what (proper) exercise is.” (A12)

With regard to cultural awareness in their work, one participant emphasized the seamless integration of culture into daily life, stating that “culture is not designed and used with a purpose but is naturally integrated into daily lives through services.”

“Many courses at TCHSs do not have to be tied to cultural festivals because in fact these things should come from accumulation throughout one’s life; we just give room for an alternative presentation.” (A11)

Traditional tribal characteristics in services and inheritance

In addition to general care services, the Council of Indigenous Peoples encourages TCHSs to incorporate elements of indigenous culture into their services and activities. For the participants of this study, the integration of indigenous culture was primarily based on traditional languages.

“Language is very important. Your own language is very important and must be passed on, followed by skills like weaving and cooking.” (A10)

“As with traditional headwear making, our community places great value on the harvest festival. We encourage older adults to engage more formally and personally in crafting these items for major occasions such as family celebrations or the New Year festival.” (A1)

Traditional indigenous food culture is a key component of the services offered by TCHSs. Older adults in tribal communities enjoy traditional foods and often actively request that care attendants prepare these delicacies.

“We have a dish similar to our aboriginal meat dumplings…. I asked an older woman in our tribe to be our teacher and teach us how to prepare it…. We must learn how to wash and fry the leaves and how to wrap the meat.” (A5)

Weddings and funerals are key activities within indigenous communities, rooted in the traditional values of shared culture and mutual assistance. During these events, tribal members engage in helping, celebrating, or consoling one another. During such times, TCHSs should adjust their schedules to maintain the connection between older adults, the tribe, and other seniors.

“When someone passes away, we take older adults with us to the funeral. When someone gets married, we also take them to join in the fun…. We all go there together. Our culture is to live together.” (A9)

Communal activities are essential in tribal life. However, TCHSs have standard for the services and usually do not consider indige nous cultures into their services. TCHSs should strive for flexibility and promote the natural integration of local characteristics.

Potential for cultural heritage in TCHSs

Indigenous peoples in Taiwan have long been governed by various authorities, yet a consistent theme has been the gradual decline in indigenous heritage, which is a major concern. Given that TCHSs serve indigenous populations who maintain strong cultural identities, older adults receiving care services can also act as mentors that lead the process of cultural transmission.

“The first part of our culture is language. Older adults are familiar with the Bible, but the Bible has Latin characters. Although our older adults cannot read Latin characters, they can speak it. So, we ask them to speak the Latin version of our language, and we record it to help younger generations learn our mother tongue.” (A7)

“Every day at our station, there are older adults telling stories in their mother tongue, and they are also allowed to present their handicrafts.” (A12)

Finding instructors with appropriate traditional skills and knowledge can be challenging. Hence, older adults tend to engage in TCHS activities through their native language and share their experiences of indigenous culture. As the primary bearers of traditional skills and cultural knowledge, these older adults not only receive services but also provide them, serving as instructors. This dual role allows them to offer insights and receive feedback, thereby increasing their sense of fulfillment and happiness.

According to the study findings, care attendants at TCHSs play a key role in integrating indigenous culture into the services they provide. When these attendants understand the importance of indigenous culture and the expectations of older adults regarding their cultural and living habits, they become more likely to incorporate local culture into their services. Therefore, human elements are crucial for embedding indigenous culture into care services. In addition, care attendants are instrumental in bridging the gap between TCHSs, older adults, and tribes by aligning their services with the actual needs and daily routines of the community.

According to the Council of Indigenous Peoples, being indigenous is a key requirement for care attendants at TCHSs, because this quality increases the depth of the relationships beyond mere service provision. Because some attendants belong to the same tribes as older adults, they share a common cultural background. For these attendants, older adults are not just clients; instead, they are respected seniors in their communities. This shared background fosters a relationship that transcends professionalism and includes affection [21]. Familiarity with older adults, such as understanding their living habits and health status, enables local care attendants to establish more effective service relationships compared with external attendants.

Notably, the Council of Indigenous Peoples expects TCHSs to weave cultural elements into their service design, thereby encouraging care attendants to offer care that also promotes cultural heritage. For instance, in the Paiwan tribes, the culture of mutual assistance and sharing should guide the provision of services, which should not be confined to fixed times or locations as per conventional planning. Instead, services should flexibly accommodate the cultural practices of older adults, such as participating in tribal weddings and funerals or visiting other seniors. By recognizing and respecting the tribal culture and the cultural habits of older adults, care attendants can enhance their culturally sensitive care approaches.

Incorporating common traditional activities into tribal services is essential from a cultural perspective. If these activities reflect the past living habits and values of older adults and offer health-care services that resonate with their lifestyles, these activities will be able to promote physical health, meet the psychological needs of older adults, and minimize cultural conflicts in the provision of care services. Older adults should receive care services that align with their original life values, indicating the importance of care attendants’ knowledge of indigenous culture and life values. According to Teng and Chang [22], health care should be tailored to the actual living contexts of individuals, suggesting that care services must realistically engage with the lives of the recipients to effectively support local older adults throughout their aging process.

During the development of a tribal care service system, a lack of knowledge regarding indigenous culture may impact service delivery. Initially, while planning the tribal care service system, the government was not familiar with indigenous cultures. However, after acquiring the relevant knowledge and integrating these cultures into the system, conflicts were discovered between the service system and tribal cultures. The majority of older adults in these tribes maintain physical labor routines and may be reluctant to use TCHS services if the timing is inconvenient. Government regulations on the number of people to be served have also posed challenges for TCHS workers. With older adults continuing their labor habits, extended service days can interfere with their work time. Many older adults rely on agricultural work not only as a cultural routine but also as a financial necessity. In addition, factors such as the life expectancy of older adults and the demographic size of tribal elders must be considered. Therefore, regulations concerning service quotas are required [23,24].

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