Community healthcare system and its practice for Indigenous elders in Taiwan
Hui-Chuan Chiu
A , Chun-Yen Kuo B Chin-ying Lai A *
A
B
Abstract
In 2017, Taiwan launched a dedicated long-term care plan for Indigenous peoples, enhancing tribal cultural health stations. By 2018, the Indigenous Council introduced a cultural safety mentoring program for caregivers, aiming to improve their cultural sensitivity in providing elder care. This article reviews practical experiences documented in the Indigenous culture care curriculum, examining examples of culturally sensitive care and proposing an elder care model suitable for Indigenous communities based on the findings. The development of social safety policies for Indigenous peoples underscores the critical role of cultural health stations in their welfare. Insights from these stations highlight their adaptation to meet local elders’ needs while respecting diverse tribal cultures. Challenges include aligning with policies, training caregivers effectively and ensuring operational efficiency. Addressing these issues requires stable caregiver salaries, proficiency in ethnic languages, and training programs to enhance professionalism and preserve elders’ traditional knowledge. Integrating this wisdom into future policies, along with collaboration with cultural experts, will build a robust foundation for future generations.
Keywords: community healthcare, culture care, Indigenous health services, long-term care, primary health care, suburban health services.
Introduction
Taiwan’s 16 recognised Indigenous ethnic groups, characterised by distinct languages, cultures, and traditions shaped by migration and colonisation, face significant challenges due to globalisation and urbanisation. The migration of younger generations to urban areas for education and employment has disrupted traditional practices, leaving elders as key custodians of cultural identity. Cultural health stations (CHSs) have emerged as critical centres in supporting Indigenous elders, integrating health care with efforts to preserve traditional knowledge. Building on the critical role of CHSs in supporting Indigenous elders, the systematic promotion of primary health care for Indigenous peoples in Taiwan began with the Council of Indigenous Peoples’ ‘Implementation Plan for Promoting Day Care Centres for the Elderly in Indigenous Tribes’ in 2006. This initiative used community resources to create centres offering preventive and continuous care services to Indigenous elders. Initially addressing geographical challenges, limited welfare delivery, deficient medical facilities and nursing shortages, the plan evolved to train local tribespeople in elder care. Today, these stations offer diverse and culturally specific care options for elders.
Since 2017, Long-term Care Plan 2.0 (Executive Yuan 2022), supported by the long-term care fund, has included a dedicated chapter for Indigenous peoples. This initiative integrates primary prevention with comprehensive disability care, establishing multi-level service systems, such as economic security, health care, home care and tribal care. Over the past 18 years, CHSs, originally established as day care centres for Indigenous elders and renamed in 2016, have significantly improved elder health and fostered tribal development. Operating on the principle of adapting to local contexts and ‘tribes caring for their own’, CHSs provide continuous, accessible and culturally sensitive care for Indigenous elders, which is crucial to implement Indigenous social welfare policies. The health stations enhance elder care, promote cultural inheritance and develop culturally sensitive care professionals, demonstrating the importance of collaboration for effective resource allocation.
Since 2020, with the support from the Council of Indigenous Peoples (CIP), CHSs have developed tailored care models and introduced Cultural Safety Mentors to train caregivers in cultural competence. This article assesses these measures, focusing on the role of CHSs in advancing social welfare policies for Indigenous peoples. It reviews information from 27 stations practicing cultural care, and focuses on culturally sensitive services aligned with tribal cultures and addressing practical challenges. Furthermore, it also suggests policy adjustments to better support the work of the CHSs.
Background
Cultural care and cultural safety have emerged as crucial concepts in contemporary Indigenous healthcare programs. Leininger (2002) introduced the ‘culture care’ concept in transcultural nursing, emphasising cross-cultural competencies. This theory highlights understanding cultural similarities and differences, respecting diverse values and beliefs, and delivering care tailored to cultural needs during disability, illness or death. Leininger’s approach focuses on providing culturally sensitive services by aligning care with recipients’ cultural contexts, ensuring they feel physiologically, socially and emotionally secure.
Ramsden (2002) argues that ‘cultural safety’ allows Indigenous peoples to define their own cultural safety as they shift from passive study subjects to active participants. Heckenberg (2020) applies this in Australia, emphasising the complexity of developing a cultural safety model. Caregivers evolve from cultural awareness to sensitivity and finally to competence, effectively interacting with diverse backgrounds and building trust. In Taiwan, CHS caregivers often reconnect with their tribes and build trust through linguistic and cultural engagement (Chang and Teng 2019; Chiu et al. 2022).
Ramsden (2002) views cultural safety as the pinnacle of cultural competence, contrasting it with Leininger’s cross-cultural nursing, which focuses on non-Indigenous staff understanding Indigenous cultures from a Western perspective. Ramsden emphasises a multicultural approach that embraces diversity, prioritising trust and partnership in care. Cultural safety centres on Indigenous perspectives rather than imposing external views, and it highlights individual differences in care practices.
According to Taiwan’s Indigenous Peoples Health Act legislated in May 2023, cultural safety refers to ‘ensuring that Indigenous peoples receive equitable and appropriate health services within the healthcare sector, with a primary focus on Indigenous knowledge systems, thereby ensuring that their identity and culture are adequately protected’. Culturally safe care ensures that recipients feel secure mentally, socially, emotionally, and physically free from aggression and discrimination; it is shaped by the recipients’ sense of security and respect (Williams 1999). As Ramsden asserts, cultural safety empowers users to determine their own sense of safety.
For Indigenous communities, culture is central to life, and in Taiwan, CHS caregivers often share cultural ties with those they care for, reinforcing trust through shared language and cultural knowledge. However, a gap exists in younger generations’ understanding of Indigenous culture due to colonisation and social development. Although elders maintain traditional customs, young caregivers need time to learn these traditions and languages. Therefore, cultural education for caregivers is crucial for providing culturally safe care. The cultural care offered at the stations, thus, also plays a key role in the cultural revival of many tribes.
Taiwan’s social safety development is integral to its broader social welfare construction. The government’s efforts, in collaboration with private organisations, aim to enhance services amid socioeconomic and environmental changes. Basic Law on Social Welfare amended in May 2023 reinforces multiculturalism and equity, ensuring that all citizens, including Indigenous peoples, remote communities and economically disadvantaged individuals, receive fair and just welfare. Notably, the Indigenous Peoples Health Act (the Act) enacted the same year underscores the government’s commitment to respecting autonomy, and addresses the unique needs of ethnic groups. These legislative advancements were designed to more effectively meet public welfare needs, in alignment with initiatives, such as the ‘Social Safety Development of Indigenous Peoples Plan’.
The Indigenous social safety development plan and cultural health stations
Indigenous ethnic groups in Taiwan, totalling 589,038 registered individuals as of 2023, constitute 2.52% of the national population. They comprise 46.70% flatland Indigenous and 53.30% mountain Indigenous. Women make up 51.77% of the Indigenous population, with a higher life expectancy than men. In 2021, the Indigenous People’s Social Safety Development Plan (the Plan) entered its fourth phase. It prioritises health rights, welfare and medical care to address existing inequalities. Emphasising principles, such as ‘adapting measures to ethnic groups and local conditions’ and ‘localisation’, the policy promotes Indigenous participation in localised health initiatives, such as childcare, long-term care and family support. The CHS Implementation Plan promoted by the CIP had established 503 stations by the end of 2023. These stations are recognised as invaluable centres for elder health, cultural inheritance and community support (Chiu et al. 2022).
Cultural safety mentors training program
The training program launched by the CIP in 2018, trains experienced professionals for long-term service in Indigenous communities. It focuses on cultivating instructors for the ‘Indigenous Cultural Safety Programs’, targeting those in tribal health care and related fields. Eligibility includes qualifications in caregiving, academic expertise, practical experience and teaching in Indigenous courses, with priority given to those with Indigenous identity or language certification.
The Act specifically mandates that public healthcare institutions in Indigenous areas prioritise hiring healthcare personnel who are either of Indigenous descent or proficient in local Indigenous languages and ensure the provision of culturally safe services. To meet this requirement, certified mentors are now involved in training caregivers and social workers in cultural safety within Indigenous elder care. The program includes cultural competency, case analysis and culturally appropriate intervention models, with a strong emphasis on respecting language, beliefs and traditions. The goal is to enhance health outcomes and community well-being through culturally respectful care practices. By the end of 2023, 164 mentors had been certified, playing a key role in guiding caregivers to deliver culturally sensitive care. Their expertise helps caregivers navigate the complex cultural landscapes of Indigenous primary health care.
Case study context and methods
This article explores the information documented in the Cultural Curriculum of Cultural Health Stations (the Curriculum), published in 2022 by Aboriginal Educational World and later on widely utilised in Taiwan’s CHSs training program. The Curriculum comprises 28 articles developed collaboratively by 11 scholars, editors and two regional centres overseeing the current 503 CHSs across Taiwan. These contributors draw on their research and fieldwork in various culture and service contexts, providing diverse perspectives on the CHSs’ operations. The Curriculum also includes results of in-depth interviews and analyses conducted by the editorial team, highlighting the cultural care practices and distinctive features of 10 selected CHSs. Showcasing practical experiences from 27 stations nationwide in total, it emphasises how these CHSs adapt to the unique needs of local elders while respecting tribal traditions and promoting culturally sensitive care. Additionally, the regional centres, serving as hubs for the East and West Coasts, identify exemplary practices and assist in presenting them as case studies. Together, these elements provide a comprehensive resource for understanding the integration of cultural care within the CHSs framework.
From 2016 to 2023, supported by funding from the Long-term Care Plan 2.0, the number of CHSs increased from 121 to 503, with 414 in Indigenous areas and 89 in urban areas, marking a fourfold rise in 7 years. This expansion ensures that Indigenous elders in both tribal and urban settings can access culturally sensitive care. The 2023 Annual CHSs Review Report noted that approximately 15,935 Indigenous elders have benefited from these services, and 1272 local Indigenous caregivers have gained employment. CHSs have become crucial for providing continuous, accessible care, enhancing social interaction, as well as offering communal dining, and health promotion for older adults. Despite increased participation and improved quality of life, challenges remain due to rigid review mechanisms and administrative procedures that hinder flexibility (Chang and Teng 2019; Chiu et al. 2024).
To address these issues, it is essential to align activities more closely with the needs and autonomy of Indigenous seniors, and enhance caregivers’ cultural competence and professional skills (Hou 2024). Consequently, the government has been urged to implement a ‘Cultural Safety Mentors’ Training Program’ that would promote culturally appropriate care for Indigenous communities (Huang et al. 2021a). Nevertheless, CHSs continue to play a vital role in providing a safe and culturally enriching environment. Through diverse and accessible activities and courses, CHSs support Indigenous older adults in aging healthily across physical, mental, social and spiritual dimensions.
Establishing a cultural safety model for CHSs involves honouring and empowering traditional cultures, languages and family structures. CHSs, deeply rooted in tribal communities, use local resources to tailor care models to the specific needs of older adults, strengthening social bonds, cultural practices and promoting healthy aging, intergenerational learning, caregiver employment and cultural preservation.
The Curriculum introduces and reviews a total of 27 CHSs, each dedicated to promoting culturally sensitive health care tailored to local tribes, with a strong emphasis on safety and traditional lifestyles, particularly for older Indigenous people. In this article, we synthesised and analysed in-depth discussions and studies from the Curriculum, incorporating research on individual stations conducted by various scholars. We analysed those case studies and assessed the social safety policies in place for Indigenous peoples. Our aims were to discover the key elements of effective and respectful elder care in Indigenous communities, while also assessing the challenges faced by caregivers.
Analysis of cultural safety care of cultural health stations
The analysis of the result in the following sections clearly shows that the CHSs employ a diverse range of cultural care models tailored to the specific needs of local elders across various rural tribal and urban contexts. Many cultural activities are integrated into the overall practices of stations that share similar traditions within the same ethnic groups. Although there is no survey currently assessing the cultural safety of all care services offered at these stations from the elders’ perspectives, it is evident that these services emphasise the strengths of elders and highlight the advantages of Indigenous culture. These care services foster partnerships between caregivers and recipients based on mutual trust and respect, promote mutual aid and empowerment, and create environments conducive to tribal learning – all of which are crucial elements for establishing a culturally safe environment. Furthermore, they integrate community resources to strengthen Indigenous social and cultural identities overall. The description of the results will highlight the various approaches community health services use to promote cultural safety for Indigenous elders, while outlining the challenges caregivers at CHSs face in implementing these programs.
Long-term care for Indigenous peoples in Taiwan necessitates tailored planning due to their unique cultures (Ru and Yu 2019). CHSs are uniquely positioned to address care gaps by prioritising cultural and holistic approaches that resonate with the specific needs and values of Indigenous communities. Unlike traditional care settings, CHSs focus on empowering older adults and fostering robust social engagement, rather than merely providing caregiver-directed assistance. Each station develops tailored care models that reflect local tribal characteristics, adapting programs to align with the cultural and geographical contexts of their communities. Despite these strengths, the effectiveness of CHSs is contingent upon the skills of caregivers and the ability to navigate operational challenges, such as meeting the diverse needs of older individuals in terms of age, health and personal preferences. This underscores the critical importance of a well-trained nursing workforce, and the consistent application of effective policies to ensure the delivery of culturally sensitive and comprehensive care.
Cultural transformation at cultural health stations
Our review of CHSs focuses on how cultural care fosters culturally safe environments. Recent advancements include diversifying care models to integrate local cultural elements and address the specific needs of elderly ethnic groups. We find that the cultural care in the stations cited in the Curriculum achieves several positive outcomes: (a) reconnection with tribal roots in urban centres, (b) innovations through corroborative intergenerational engagement and (c) validation of elder’s knowledge within the tribal community. First, in urban centres, CHSs facilitate activities, such as traditional singing, weaving, food preparation and costume-making, to help urban elders reconnect with their ethnic identity. These practices preserve cultural heritage, and bridge the gap between tribal and urban life, restoring pride and continuity of cultural traditions. Second, in tribal areas, activities, such as farming, ceremonies and harvest festivals, become innovative collaborative projects that integrate tribal industries with newly created community events, bridging generational gaps and sustaining cultural traditions. CHS activities, such as joint farming and crop harvesting, preserve cultural heritage and promote self-sufficiency. CHSs utilise tribal markets, botanical gardens and other new settings to involve elders in daily activities, fostering community bonds and cultural cohesion. Third, for elders, especially those impacted by Typhoon Morakot in 2009, traditional practices, such as singing and recording ancient songs for future generations, offer therapeutic benefits and reinforce collective identity and resilience. The elders’ traditional values are validated. Therefore, it is clear that services have expanded beyond traditional offerings, such as meal delivery and home visits, to include tribal language exchanges, agricultural studies, intergenerational learning and genealogy projects. Most importantly, these observations found in the Curriculum adhere to principles of cultural safety.
Three types of cultural safety models found in cultural health stations
In urban centres, reconnecting Indigenous elders with their tribal roots empowers them by preserving cultural heritage and restoring ethnic pride through traditional activities, such as songs, crafts and ethnic dishes. Similarly, CHSs in tribal areas empower elders by providing culturally safe spaces tailored to their needs, where they can engage in activities that support their well-being and preserve their cultural stories. For instance, Sakur Station in Hualian uses tribal markets and botanical gardens to build community, whereas Ta-Kuang in Tainan and Iyo in Yilan offer programs that reconnect elders with their roots, reinforcing their dignity and cultural identity.
Our review of CHSs underscores the importance of collaboration in creating culturally safe environments and enhancing the well-being of elderly ethnic groups. These centres integrate local cultural elements and offer services such as tribal language exchanges and cultural activities, which foster physical health and social engagement. Collaborative practices, such as joint farming, illustrate how elders and younger generations work together to preserve tribal values and share knowledge. At Paridrayan station, the activity of singing ancient songs provides therapeutic benefits and strengthens community bonds. Additionally, some stations, such as Ciyakang and Songpu, involve elders in designing culturally relevant activities, whereas Luhung and Mkzihing use traditional medicinal plants in meal planning. Some stations, such as San-Ying and Kinyawpan, use traditional songs and crafts to connect elders with their heritage, highlighting the power of collaboration in preserving cultural traditions and supporting personal development.
CHSs promote tribal wellness by integrating elders into cultural activities that reinforce community connections and cultural identity through intergenerational engagement. At Alang Snuwing in Nantou, traditional harvest rituals link elders with younger generations, whereas Kaaluan in Taitung utilises community gardening to incorporate elders’ cultivation practices into daily life. Naluwan station in Kaohsiung engages college students in collaborative activities with elders, enhancing cultural exchange and boosting their dignity. These innovations in intergenerational engagement support a comprehensive approach to tribal wellness, emphasising the importance of cultural participation and the strengthening of community bonds.
In summary, these culturally safe practices could potentially help preserve cultural heritage, and bridge the gap between tribal and urban life, and restore pride and continuity of cultural traditions. Elders’ knowledge within the tribal community is validated in the curriculum and fulfils the goal of cultural safety. The multicultural care model implemented by CHSs may effectively support healthy aging and cultural inheritance within Indigenous tribes. Rooted in the Indigenous perspective, this model upholds the right to self-determination, allowing Indigenous peoples to define cultural safety outcomes. By leveraging tribal resources and fostering community engagement, CHSs enhance support networks, inspire cohesion and promote shared learning experiences, benefiting the entire tribal community (Heckenberg 2020). These successful examples notwithstanding also reveal challenges to establishing durable cultural care through Indigenous health stations.
Challenges of health care in cultural health stations
Culture care at CHSs differs from general care fields by emphasising empowerment and fostering robust social engagement among older adults, rather than solely providing caregiver-directed assistance. Each station develops diverse care models tailored to local tribal characteristics, prioritising older individuals. This involves customising courses based on ethnic groups and geographical environments. However, varying caregiver skills and station operational challenges, including accommodating diverse needs related to ethnic groups, age, health and individual personalities among older adults, underscore the importance of a well-trained nursing workforce and effective policy adherence.
Challenges in documentation and base standardisation of cultural health stations
CHSs are supported by funding from the CIP, and the operation of the stations is required to meet specific criteria to continue receiving this support. As CHSs embrace their cultural roles, caregivers face increasing burdens from stringent healthcare audits and documentation standards, which detract from caregiving and heighten stress. For instance, Sakur station involves elders in farming, field trips and cultural activities. To preserve the effectiveness of these initiatives, evaluation systems should offer flexibility, minimising rigid documentation and operational constraints. CHSs need to be assessed every 2 years, focusing on older adult participation rates. However, rigid evaluations often overlook cultural safety and traditional practices, as elders involved in farming may not attend daily activities during harvest seasons. Evaluations should be flexible, monitoring elders’ physical and mental well-being without relying solely on rigid indicators that could hinder CHS operations.
Challenges in cultivating local talent
Caregivers play a crucial role in delivering cultural care at CHSs, requiring both cultural sensitivity and professional social work expertise. To meet these needs, caregivers must engage in continuous practical experience and specialised training. Developing effective training programs is essential for equipping caregivers with the cultural knowledge and skills necessary for providing culturally safe elder care.
However, several challenges must be addressed to achieve this goal. First, it is crucial to determine whether caregivers can effectively manage and assimilate the training content. Additionally, the duration and scheduling of cultural courses need to be evaluated to ensure they are suitable for caregivers with varying abilities and backgrounds. The effectiveness of a standardised curriculum in training diverse groups of caregivers remains an open question.
Furthermore, considering the diversified ethnic groups in Taiwan, with 16 officially recognised by the government, balancing the design of training courses with individual care needs presents a significant challenge. Caregivers are expected to be prepared to manage cases involving mild dementia or other additional daily requirements (Yunaw and Besu 2022). Addressing these challenges is vital to ensure that training programs meet the practical demands of caregiving and support the delivery of culturally sensitive care.
The 4-year plan initiated in 2021 aims to support 1500 individuals with disabilities and independent elders through culturally sensitive care. It is vital to assess caregivers’ skills in managing diverse cases, including clerical and information management skills (Huang et al. 2021b). The training program started by the CIP in 2018 had certified 154 mentors by the end of 2023. To meet the diversified ethnic groups, culture care programs and practice models are continuing to be developed. Government agencies, such as the CIP, the Ministry of Health and Welfare, and the Ministry of Education, should actively develop talent in Indigenous cultural safety; it should include offering systematic training courses, subsidising publications on cultural safety, and encouraging research and academic seminars on the topic (Huang et al. 2021b). These measures will help instructors promote the best cultural safety practices in health care.
Conclusion
The description of the integration of Indigenous groups, families and traditional resources at CHSs in the Curriculum effectively showcases elders’ knowledge through practical engagement. By incorporating local cultural elements into their courses and activities, these centres are empowered to highlight the positive traits and relational dynamics of ethnic groups, nurturing cultural competencies and fostering a welcoming environment. CHSs extend services across tribal and urban areas to enhance collective participation, strengthen ethnic identity and promote communal well-being among Indigenous peoples.
CHSs in Taiwan implement a multicultural care model with social safety policies that address service gaps, empower communities, respect cultural values, and improve overall health and well-being. The ‘tribespeople take care of tribespeople’ approach, alongside the training program, creates job opportunities and supports culturally knowledgeable care professionals, helping to prevent economic migration from tribal homes.
Culturally aligned care services are vital for sustaining CHSs. The recent Indigenous Peoples Health Act marks a milestone by enhancing Indigenous participation in healthcare decision-making. However, future policies must address the challenge of allocating long-term care funds effectively to support both mildly disabled elders and those with severe disabilities and dementia, ensuring comprehensive care for Indigenous peoples.
Data availability
The data used to generate the results in this paper are based on the Cultural Curriculum offered by Cultural Health Stations, published in Aboriginal Educational World: Information Journal on Education for Indigenous Peoples, published by Indigenous Peoples’ Council in 2022. The curriculum content is available on the public website, and a hard copy can be accessed through the publication.
Acknowledgements
This article is part of the result of the ‘Knowledge Research and Teaching Activities of Indigenous People among Colleges and Universities’ subsidised by the Council of Indigenous Peoples in Taiwan for the 2024 academic year.
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