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1
Please cite published version as follows: Koehn, S., Neysmith, S., Kobayashi, K., &
Khamisa, H. (2012, online). Revealing the Shape of Knowledge Using an
Intersectionality Lens: Report on a Scoping Review on the Health and Health Care
Access and Utilization of Ethnocultural Minority Older Adults. Ageing & Society.
Available at http://dx.doi.org/10.1017/S0144686X12000013 [8/14, 2012]
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Revealing the shape of knowledge using an intersectionality lens:
Results of a scoping review on the health and health care of ethnocultural
minority older adults
Submitted December 22
nd
, 2011
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Revealing the shape of knowledge using an intersectionality lens: Results of a scoping review
on the health and health care of ethnocultural minority older adults
Ab
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a
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This paper uses an intersectionality theoretical lens to interrogate selected findings of a scoping
review of published and grey literature on the health and health care access of ethnocultural minority
older adults. Our focus was on Canada and countries with similar immigrant populations and health
care systems. Approximately 3300 source documents were reviewed covering the period 1980-2010:
816 met the eligibility criteria; 183 were Canadian. Summarized findings were presented to groups of
older adults and care providers for critical review and discussion. Here we discuss the extent to which
the literature accounts for the complexity of categories such as culture and ethnicity, recognizes the
compounding effects of multiple intersections of inequity that include social determinants of health as
well as the specificities of immigration, and places the experience of those inequities within the
context of systemic oppression. We found that Canada’s two largest immigrant groups— Chinese and
South Asians—had the highest representation in Canadian literature but, even for these groups, many
topics remain unexplored and the heterogeneity within them is inadequately captured. Some
qualitative literature, particularly in the health promotion and cultural competency domains,
essentializes culture at the expense of other determinants and barriers, whereas the quantitative
literature suffers from oversimplification of variables and their effects often due to the absence of
proportionally representative data that captures the complexity of experience in minority groups.
Key
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: ethnocultural minority older adults; health; health care; scoping review;
intersectionality; immigrant; visible minority; Canada
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Revealing the shape of knowledge using an i
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scoping
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eview on the health and health care of
ethnocultural minority
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In
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Ethnogerontology focuses on the aging experiences of older adults of distinct ethnic and racial
backgrounds in industrialized nations. This field of study is growing, but its literature is widely
distributed across disciplines that use inconsistent terminologies, and some of the more
comprehensive studies are still found in the grey literature. In Canada, there is currently no academic
program or advocacy group that focuses on and has consolidated research on this topic. As a result,
many such studies are hard to find and health care decision-makers seeking guidance with respect to
the health care needs of this population repeatedly resort to a few more readily accessible sources that
are often ill-suited to their knowledge needs. A scoping review of the literature on the health and
health care access of ethnocultural minority older adults aimed to fill this gap. We were especially
interested in visible minorities (i.e., non white and non Aboriginal) to reflect the predominance of
Asian immigrants to Canada since the 1970s (Statistics Canada 2010a, 2010b).
This paper uses an intersectionality theoretical lens to interrogate selected findings of this review in a
manner that respects the ontological and epistemological complexity that our interdisciplinary and
intersectoral team of academics and knowledge users brought to the table. Specifically, we aim to
summarize the state of this literature in Canada, highlighting the forms it takes, what is covered and
what is missing. Based on this case study, we then interrogate the consequences of using ethnicity as
a descriptive/explanatory category by looking more closely at what the literature is saying about
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Canada’s two largest groups of ethnocultural minority older adults: the Chinese and South Asians.
From this examination, we argue that understanding the diverse experiences of ageing both across and
within ethnocultural groups requires complex theoretical and methodological approaches that move
beyond a focus on differences that seem to be associated with ethnicity and/or culture. In parallel with
a growing number of scholars focused on the interrogation of health inequities (e.g., Iyer et al. 2008;
Guruge and Khanlou 2004; Hankivsky 2011), we suggest that although disparities arising from
biological sex differences, gendered experience,
1
ethnicity and class independently affect well-being,
the relationship is a dynamic one; it is how these dimensions intersect and compound that affects the
health and quality of people's lives as individuals and group members as they age.
Ba
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The ageing literature reflects its time and place
In Canada, as in other western societies, age is an axis along which inequities travel. There is a large
and diverse gerontology literature, but it cannot escape the fact that it is rooted in a society that
devalues old age. This inevitably gets reflected in the assumptions and frameworks that permeate this
literature. Gerontology blossomed in the seventies and eighties as the ageing of European and North
American populations, and their implications, became more visible. The substantive content of the
early literature was heavily influenced by a bio-medical orientation and thus was much about the
illness and costs of the ageing body (Estes and Binney 1989; Neysmith 1999). Other foci came
considerably later. Non-medical social, economic and political issues emerged over time (e.g.,
Walker 1981). Gender was part of this expansion, as were intergenerational concerns around social
support and caring (e.g., Ungerson 1987). Gender / class intersections began to emerge as costs were
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documented; statistics showing that women lived longer and thus used more health services were
juxtaposed to data showing that they also did more of the caring labour (e.g., Dressel, Minkler,
andYen 1997).
Theoretical perspectives that incorporate race/ethnicity/culture are not well developed in the ageing
literature even today. The three concepts are often used interchangeably and in different ways that
vary by country and by discipline (Bhopal 2004; Mateos, Singleton, and Longley 2009). At this
moment there appears to be little consensus on how to use the terms even though there seems to be
agreement that when this dimension is factored in, it accounts for health disparities (Ford and Harawa
2010). In this paper, we view race as a social construct. Racialization or “the process through which
groups and their practices are identified by reference to visible physical characteristics” (Johnson et
al. 2004:255), is of interest as a form of oppression experienced by our target population. Ethnicity
and culture are scrutinized in our consideration of intersectional analysis, below.
The country
of
immigration is more important than that of e
m
i
grat
i
on
A nation's immigration and refugee regulations shape the world of those seeking permanent status
there. These forces change over time (usually reflecting policy priorities of receiver countries) and
thus cohorts of immigrants differ. For example, in Canada, changing labour force priorities underpin
a point system that determines who is accepted, and who is not (e.g., Sharma 2006). Established
communities and service availability affect where newcomers settle. Large urban centres have first-,
second- and third (plus)-generation families who have been there for varying lengths of time. For
instance, in Toronto, Canada’s largest city, nearly one half of the population in 2006 reported
belonging to a visible minority group. Of these, 12 per cent were South Asian, 11.4 per cent were
Chinese, 8.4 per cent were Black, 4.1 per cent were Filipino, and 2.6 per cent were Latin American.
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One half of all immigrants to that city had lived in Canada for less than 15 years. By 2031 visible
minorities will make up a projected 63 per cent of the city’s population (City of Toronto 2010;
Statistics Canada 2010b).
With the exception of Aboriginal peoples,
2
who are legally defined otherwise, Canada can be defined
as a land of immigrants, and in1971 adopted an official policy of multiculturalism. The focus of
Canadian history and its policy on cultural plurality is distinct from and often compared favourably to
that of the US, where the ‘melting pot’ philosophy that privileges acculturation prevails.
Multiculturalism is not without its critics, however, and some (e.g., Kirmayer and Minas 2000; Henry
and Tator 2006) charge that the failure of the Canadian policy to address racism at the institutional
level impedes access to health and social care for visible minority groups. For example, Brotman
(2000) interrogated the notion of ‘access’ in the context of a publicly funded organization providing
elder care services in Ontario, Canada. She found a considerable disjuncture between older women's
expressed desires regarding access and the way access to services is operationalized in agencies
providing services for older people. She argues that multicultural programs and policies have placed
undue emphasis on the individualized attainment of cultural competency and language skills, but
have not addressed the “institutional structures and power relations marked by racism” that
undermine these efforts and marginalize the women in her sample (Brotman 2003: 209).
In sum, all of these concepts and their debates formed a backdrop to our undertaking a scoping review
of what we finally termed ethnocultural minority older adults. As the findings illustrate, research was
limited to a select number of the many groups that now make up nearly one half of the population in
the country's major metropolitan areas. It also revealed that the literature remains heavily
unidimensional when the focus is on the health needs and service access of this burgeoning sub-
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population of Canada’s older adults, although some authors introduced complexity through a
sensitivity to gender.
Methodology
Data collection: a scoping review of the literature
The Canadian Institutes of Health Research, Canada’s major health research funding agency, defines
scoping reviews as “. . . exploratory projects that systematically map the literature available on a
topic, identifying key concepts, theories, sources of evidence and gaps in the research” (Grimshaw,
2010). Arksey and O’Malley (2005) suggest that scoping reviews that aim to identify gaps in the
literature and publish on those findings can be viewed as a method in their own right rather than a
preliminary step in an ongoing process aimed at producing a systematic review. The intention of our
scoping exercise was to generate a topography of the literature and research on health and healthcare
for ethnocultural minority older adults that would invite critical reflection and thereby inform future
research directions. Arksey and O’Malley’s (2005) five-stage framework provided a useful template.
Their approach entails identifying the research question; identifying relevant studies; study selection;
charting the data; and collating, summarizing and reporting the results. We also conducted a
“consultation exercise” that they recommended as an additional parallel element to inform and verify
our findings.
Based on our familiarity with this field of literature, we knew that we would have to cast our net wide
in order to capture the diverse contributions to this field, and to reflect our interests in the intersecting
influences of social determinants on both health and access to services for this population. In brief,
our five-part research question sought to understand the population health patterns, health risks and
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associated health outcomes, unmet health needs, utilization of health care services, and engagement in
health promotion and disease prevention activities specific to older visible ethnocultural minorities,
i.e., those most likely to be subjected to the ‘processes of differentiation’ or ‘othering’ (racialization,
gendering, sexualization, ethnicization etc.) that our intersectionality framework seeks to interrogate
(Johnson et al. 2004; Dhamoon and Hankivsky 2011). To this end, we also identified the need to
explore within each of these questions: (i) the influence of beliefs, attitudes and values with respect to
‘normal’ aging, health, food, exercise, disease, family relations and social networks, help-seeking, etc.
held by the target population; (ii) how their experience and status as immigrants (trauma, role
changes, legal entitlements, discrimination, etc.) influence this; (iii) the effect of health status on
utilization; and (iv) how each factor is influenced by social determinants (gender, socioeconomic
status [SES], country of origin, location of residence in Canada, etc.). The research questions thus
ensured that health was broadly defined in our study.
The identification and selection of relevant studies was an iterative process that entailed considerable
cross-checking of abstracts between our Research Assistant (RA) and two or more team members.
Using abstracts as the unit of analysis for this study is consistent with scoping review methodology
(Arksey and O’Malley 2005) and necessary in light of the considerable breadth of the search. While
we recognize that this limits what can be confidently inferred about the content of these articles, our
multi-sectoral team agreed that abstracts were an important unit of analysis to consider because their
content often determines whether the reader goes on to retrieve the full article. Decision-makers with
limited time and money access only those reports that are obviously relevant to their needs (Black and
Weiler 2008), hence abstracts are pivotal to effective knowledge translation and research uptake. This
said, full articles were accessed where no abstract existed, and team members often referred to the full
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article in order to ascertain the eligibility of a study.
Different perspectives on the relevance of the articles were introduced and debated by members of
our interdisciplinary and intersectoral team, which included academics from the disciplines of
anthropology, sociology, social work and health services research, as well as knowledge users from
provincial and municipal governments (health, seniors services and social planning), the multicultural
settlement sector, ethnospecific long-term and community care, and psychiatry. This process also
clarified the scope and definition of our search terms.
3
Our search strategy reflected the three dimensions of our field of interest: Ethnicity, Health, and
Chronological Age. We were specifically interested in visible ethnocultural minority groups that had
settled in Canada and countries similar in their composition of immigrants and health care delivery
systems, particularly the United Kingdom (UK), Australia, and New Zealand, and to a lesser extent,
the United States (US). We limited our search to post-1980 published and grey research literature
written in either English or French, but most were in English (see Figure 1).
FIGURE 1 GOES HERE
Our inclusion/exclusion criteria were initially applied to the lead author’s personal database of 634
references on ethnocultural minority older adults, which helped us to identify the most salient
keywords to use for the external search. This included an Ebsco combined search of multiple
databases (Ageline, CINAHL, Medline, Pubmed),
4
the New York Library of Medicine – Grey
Literature Report, SIGLE, UMI Dissertation services, and hand searching references and key
journals. Given our focus on Canada, we employed additional strategies such as focused searches of
grey literature (e.g., Amicus Collections Canada
5
for Canadian theses, and publications from the
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Canadian Ethnocultural Council, Metropolis
6
and other agency websites) that were not employed
with the other countries. The Canadian data is therefore relatively more complete.
It was necessary to simultaneously expand some criteria while imposing constraints on others to
ensure that we captured relevant articles while remaining within the limitations imposed by the
resources and time available for the project. For example, relatively few articles focused on
individuals 65 or older exclusively. In the discussion of these preliminary results, we agreed that
conventional demarcations of “old age” (i.e. the chronological marker of 65) may not be sacrosanct as
a determinant of health status or health care utilization or access, relative to multiple intersecting
determinants for this population. Ultimately, we agreed to include articles falling into one of three
categories with respect to age: (1) the study population was aged 65 and older exclusively (13.1%);
(2) the study population was ‘mixed’, i.e., it included a range of ‘older adults’ other than those aged
over 65 (e.g. 55+) or a sub-group of older adults was clearly identified as part of a larger sample
(36.3%); (3) the age of the population was not specified, but the group being referred to was an older
adult group (e.g. using terms such as 'senior', 'older adult', 'frail elderly' etc) (50.5%). Had we not
made this decision to liberalize the inclusion criteria for age, the majority of relevant articles would
have been excluded from our scope.
We intended to use and derive the meaning of ‘ethnocultural’ (and its components, ‘ethnicity’ and
‘culture’) as presented within the literature because as Bhopal (2004: 445) and our own search
experiences have shown, “ethnicity is replacing the scientifically limited and somewhat discredited
term race in the scientific literature.” The exception is the US literature on the impact of race on
African Americans and Latinos (Kirmayer and Minas 2000). These groups differ from African
Canadians and Latin Americans who arrived in Canada for very different historical reasons (e.g.,
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Attewell et al. 2010; Durand and Massey 2010). For this reason, and because of the overwhelming
volume of such references, we also decided to filter out studies that referred exclusively to African
American and Hispanic populations in the US. Our sample nonetheless contains 120 studies that refer
to these populations because they appear alongside the groups of interest to our review, e.g., Asian
Americans. Similarly, a large number of US articles focusing on barriers to health care access
resulting from a lack of universal health insurance in that country were also excluded.
7
Despite this,
the majority of articles retrieved for the review were from the US (see Figure 2). This is consistent
with its large population base which, at over 313 million, is more than five times that of the UK
and nine times that of Canada (Central Intelligence Agency 2011).
FIGURE 2 GOES HERE
Overall, 3,300 abstracts were reviewed, of which 816 met our eligibility criteria. While more than
70% of the references were articles in peer-reviewed journals, we also included books and book
chapters, theses and dissertations, and unpublished research reports, but not opinion pieces. Articles
were located in a total of 192 journals; however 56% of those articles were published in journals that
appeared only once on our list. The Journal of Cross Cultural Gerontology alone had published more
than 20 articles that met our criteria, and only six more, spanning diverse disciplines, had published
more than ten articles on the topic.
8
In order to accurately chart and summarize the data, we made use of Atlas.ti 5.2.0, commonly used to
code and organize qualitative data into inductive categories. The titles and abstracts of eligible
articles were imported and each was coded along multiple dimensions so as to capture who and what
was studied, where and in what journals. The coding structure was initiated by the RA, but was shaped
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to a great degree by team members who engaged in several in-depth discussions and provided ongoing
feedback as to the relevance and composition of the various dimensions. Ultimately, each source
document was coded along each of the following dimensions: research (sub)question; immigration
(immigrant category and length of time in the country); gender; ethnicity; faith; country of study; health
condition/situation; intervention/service; and other social determinants of health. We have used these
categories and their co-occurrences to explore the data set in numerous ways, and considerable potential
remains to explore it further.
In addition to a detailed report submitted to the funder on the methodology and findings of the review
(Kozak, Koehn and Khamisa 2011), we have also generated annotated, indexed bibliographies on the
Canadian sources, as well as one each on South Asian and Chinese older immigrants internationally.
Within the Canadian subset, we identified groups of abstracts relating to topical areas that matched
the foci or expertise of our team members. Each member was asked to review their group of abstracts
and report on the key messages that they communicated. This exercise provided some insight into
how well the current literature meets the knowledge needs of diverse knowledge users, including
policy makers and/or how clearly key messages from this literature were communicated through the
abstracts.
Finally, we conducted a consultation exercise, taking our summaries of key messages emerging from
the Canadian literature to groups of ethno-cultural minority older adults and those who work closely
with them or advocate for their needs in multicultural settlement and social service agencies in
Toronto and Vancouver. These groups were asked to provide feedback on: (a) if and how the
literature reflected their lived experiences or contradicted them; and (b) topics they viewed as
important that were missing in the literature. Each of these strategies informed our impression of the
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shape and content of the literature on the health and health care access of ethno-cultural minority
older adults in Canada relative to multiple dimensions of difference. Many of the 183 Canadian
sources were already familiar to this article’s authors, and others were reviewed in preparation for
writing this manuscript.
Analysing the literature: seeing older adults through an intersectionality lens
Our analysis of the sources identified by our scoping review is informed by an intersectionality
approach which argues that people experience the effects of a country’s social inequities as
simultaneous interactions between multiple dimensions of social identity (for example, gender, age,
sexual orientation, visible minority and immigration status) that are contextualized within broader
systems of power, domination and oppression (Hankivsky 2011; Schulz and Mullings 2006:308).
Responding to ‘how inequities are experienced’ by individuals and communities in different social
locations characterizes the history of intersectionality theory development (Denis 2008), but age is
rarely included in such analyses (Hulko 2011). Unlike multiple/triple jeopardy, intersectionality is
not an “additive linear model.” Rather, its analysis “usually requires the use of ‘interaction
effects’—or ‘multilevel,’ ‘hierarchical,’ ‘ecological,’ or ‘contextual’ modeling—all of which
introduce more complexity in estimation and interpretation” (McCall, 2005: 1787-88; Winker and
Degele 2011). From this perspective, power imbalances and discrimination, as well as positive
health care experiences, are understood as unique to each individual’s constellation of intersecting
identities, social roles and the broader social and political contexts in which they exist (Guruge and
Khanlou 2004; Dhamoon and Hankivsky 2011). These intersections are at play at each of the micro,
meso, and macro level; that is, relative to our identities, to our interactions with others in different
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socio-cultural contexts, and at the broader societal level wherein norms and values are entrenched as
policies and laws.
Models of intersectionality are diverse and often case-specific. The more general metaphor of a
matrix captures “the idea that systems of domination are mutually dependent but analytically distinct”
and facilitates the necessary examination of the interactions of categories of difference as well as the
interlocking and mutually constructed systems of domination that constitute the broader context
within which they must be considered (Dhamoon and Hankivsky 2011:28). Intersectionality is
nonetheless practiced in at least three ways, according to McCall (2005). The first of these—
anticategorical complexity—questions the ‘givenness’ of categories of difference such as race and
gender, or health related conditions such as “addict” or “homeless person” (e.g., Browne et al. 2011).
Such categories should be understood as complex social constructions within which specific
manifestations may be infinite or at least range along broad continua. Importantly, it entails a shift
away from reducing people to single static identities rooted in Cartesian dualisms or dichotomies such
as male/female, black/white, or ethnic/non-ethnic that underlie ‘othering.’
Thus we must begin by interrogating the categories central to our search. Illife and Manthorpe (2004),
suggest that ethnicity—when defined as particular shared cultural characteristics—may not have great
explanatory power as an analytical category or determinant of health, and may represent a category
fallacy. They suggest instead that immigration, charter language ability, health beliefs and SES are
more salient determinants of health, but tend to be subsumed under the concept of ethnicity.
Similarly, the notion of culture is often viewed uncritically, particularly in the health services
literature on ethnocultural minorities. Differences in health outcomes between ethnic groups often
seem to be attributed to cultural differences (e.g., Jones, Chow, and Gatz 2006). While this is
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probably not the authors’ intention, it speaks to a common trend critiqued by Kleinman and Benson
(2006) of simplistically equating culture with ethnicity, nationality, and language and treating it as
static and homogeneous. While the definition of culture is hotly debated, we agree with these authors
and Wedeen (2002) that it does not refer to essential identifiers of a group; rather, it is a process of
meaning-construction wherein people’s practices—which are embedded in political, economic and
social realities—operate in a dialectical relationship with systems of signification. Culture is defined
in reference to these practices and vice versa. This view of culture is consistent with the underlying
premise of intersectionality that our realities are both constructed yet constrained by broader systems
of oppression. These examples demonstrate that no category can be reduced to a single axis of
difference.
A second type of intersectional analysis—intracategorical complexity (McCall 2005)—zeroes in on a
social location at the intersection of single dimensions of multiple categories. This typically entails
analysis of a single social group at a neglected point of intersection of multiple master categories or a
particular social setting or ideological construction, or both, and is characteristic of much
ethnographic work on ageing (e.g., Sokolovsky 2009). Thus while these studies question “the
homogenizing generalizations that go with the territory of classification and categorization,” they do
not reject them altogether; most important is the “process by which [categories] are produced,
experienced, reproduced, and resisted in everyday life” (McCall 2005: 1783). For example, Hulko’s
(2011) study of experiences of dementia found that the label of dementia was resisted in different
ways relative to social location. More privileged participants were more likely to view dementia
negatively whereas those who were more socially marginalized tended to dismiss its significance.
The third type of intersectional enquiry that McCall describes speaks to efforts to employ this
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approach in quantitative studies. Intercategorical complexity is thus concerned with “the complexity
of relationships among multiple social groups within and across analytical categories” (McCall 2005:
1786). Enquiries of this nature begin with the supposition that relationships of inequality exist
between groups. Social determinants of health, such as age and ethnicity, are viewed as anchors in
understanding inequities, but they are not fixed in their relationship to outcomes because they interact
with other determinants as well as biological factors in different contexts (McCall 2005; Kobayashi
and Prus 2011). Categories are understood to be imperfect and ever-changing, but the necessity of
adopting them provisionally is accepted in order to proceed with cross-sectional analyses that seek to
explicate the relationships among them. Here, relationships of inequality are the focus of rather than
the background to the analysis. Analyses of this nature were not identified in our review but new
contributions are beginning to be published, and will be discussed below.
Fi
nd
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Who’s researched and who’s not?
Taken together, the Chinese and South Asian populations—the two largest groups of immigrants to
Canada since 1991 (Statistics Canada 2010a)—account for two-thirds of post-1980 publications.
Research on older adults of Chinese origin accounted for the majority (almost 45%) of the Canadian
studies that we identified, which exceeds their share of the visible minority older adult population (see
Figure 3). This is due, in part, to the productivity of researchers of Chinese Canadian origin interested
in this population. South Asian sources accounted for almost one quarter of the Canadian studies,
which is comparable to their share of the visible minority older adult population. Upon more detailed
examination, however, coverage of these two groups is more partial than these figures imply.
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FIGURE 3 GOES HERE
Figure 3 requires careful interpretation. It can visually suggest a more substantive presence of an
ethnocultural minority group in the literature than in fact exists because any mention of an
ethnocultural group is reflected here, even if their presence in the study is minimal. When we limit
our consideration to abstracts focusing on a single ethnocultural population, wherein there is
ostensibly space to attend to internal heterogeneity and the effects of intersections between multiple
axes of difference, some groups disappear entirely (see Figure 4). Thus we identified no Canadian
articles that focused exclusively on Arab,
Korean or Filipino older adults, despite the fact that
Filipinos are now the fourth most populous immigrant group in Canada after “blacks” in third place
(Statistics Canada 2010a). The paucity of articles referring to “black”
older adults is also notable
both relative to their 2006 share of the older adult population, depicted in Figures 3 and 4, and in
light of their increasing numbers since that time. The relative proportions of articles on Latin
American and Southeast Asian older adults are also considerably smaller in Figure 4 than in Figure 3.
FIGURE 4 GOES HERE
Gaps in the lite
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Our search also examined the focus of the published literature, exploring what areas are represented
in the articles: which were popular and where were the silences? Viewing the abstracts relative to
our coding framework we identified several gaps and opportunities for future research relative to
the disease categories covered in the literature. The disease codes, as with all others, emerged
inductively from the abstracts. Subsequent to coding, however, we decided to compare the extent to
which various disease categories have been researched and reported (number of abstracts) relative to
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the ten categories used in the International Classification of Diseases (ICD) and clustered our codes
accordingly. The ICD-10 is a well-established framework with which to explore health conditions
relevant to older Canadians in the general population vis-à-vis the Canadian literature on
ethnocultural minority older adults. Figure 5 provides a comparative baseline of the leading causes
of death and hospitalization of Canadians aged 65 and above.
FIGURE 5 GOES HERE
By comparison, Figure 6 starkly illustrates the gaps in research on Chinese and South Asian older
adults in Canada. Maintaining the order of the leading causes of death and hospitalization along the
x-axis, we plotted the number of abstracts referring to each disease category for each of the two
ethnocultural groups.
Predispositions to certain diseases exist among particular groups. For example, foreign-born
populations from South Asia experience higher rates of diabetes mellitus and heart disease (Gupta,
Singh, and Verma 2006; Raymond et al. 2009). And these patterns are often gender-specific with
different patterns than those commonly seen in the West—for example, South Asian women are at a
higher risk than men for developing heart disease (Fikree and Pasha 2004)—yet we see very little
research on either Chinese or South Asian older adults that reports on any of the leading causes of
death or hospitalization in the Canadian literature. One apparent exception is the literature on mental
disorders for the Chinese population, particularly that on rates of depression, which were found to be
higher than those for Canadian older adults overall (Lai 2000a, 2000b, 2004a). On closer examination
of the full articles, however, mental disorders were not the main focus of many of these studies, but
were referenced only in general terms. The mental disorders category included inductive codes that
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captured alcohol consumption, dementia, depression, post-traumatic stress disorder and general
mental health. Articles are thus spread thinly across these diverse topics. Having reviewed the
abstracts and some of the articles included in this category, cross-cultural psychiatrist Dr. Soma
Ganesan concluded that there is no clear understanding as to whether cultural factors are mediating or
moderating variables in global mental and physical health. With no clear mechanism identified, it is
difficult to develop or implement policy for culturally responsible mental health care for immigrant
older adults, their families and/or their care providers. Thus, even in an area in which relatively more
research has been done, we do not know enough about the intersections among various axes of
inequality and the ways in which these factors influence the health and health care access of
ethnocultural minority older adults.
FIGURE 6 GOES HERE
Missing: intersectional analyses
of
the lite
r
a
t
u
r
e
In seeking to understand if and how an intersectional analysis was actually present, we reviewed
abstracts and often the full-text articles. We probed, for instance, whether ethnocultural attributes
were used to explain variations in phenomena such as diabetes, or if the disparities experienced by
certain ethno-cultural groups were the starting point, with structural and environmental factors
examined to try and account for differences.
Overall, two dominant patterns emerged along methodological lines. The first was seen in the
quantitative literature in which variables such as gender, socio-economic status and other social
determinants of health are routinely explored. The problem here lay with the integration of the
dimensions of age and/or ethnocultural status in ways that meaningfully contributed to the focus of
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22
our study. For example, considerations of the impact of ethnicity on health care utilization rarely
factored in the differential effects of age; although the sample may have included some older adults,
there was little or no analysis of age-based differences. Similarly, studies focusing on age differences
rarely incorporated the dimension of ethnocultural identity. The possibility of considering the
intersection of these two axes of difference with other social determinants of health is thus limited to a
relatively small number of articles where this overlapping consideration is explicit.
In the qualitative literature on barriers to health care access, some studies problematically use culture
as both as an explanation of the issue and as the route for addressing it (Filinson 1992, e.g., Acharya
2004; Masi and Disman 1994). Culture in these studies is often treated as static, failing to account for
the changing dynamics in such populations. This approach is especially apparent in the cultural
competence and health promotion literature that tends to focus on change in the beliefs and
behaviours of individual care providers or care recipients (e.g., Choudhry 1998; Dhaliwal 2002;
Johnson and Garcia 2003). While the development of community capacity that many of these
initiatives seek to engender is important, they do not address the underlying organizational or policy
issues that support the inequities that shape the experiences and capacities of ethno-cultural minority
older adults.
Closer examination of the Canadian abstracts coded as ‘interventions’ provides insights into the
implications of these limitations. This group of codes includes both services as well as preventive or
care approaches (e.g., cultural competency, health promotion) and services offered both formally
(e.g., palliative care, Home Care) and informally (e.g., caregiving by family or friends). The same
five 'intervention' topics emerged as most commonly researched both internationally and in Canada,
although not in the same order (see Table 1). These codes are not mutually exclusive; abstracts were
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23
tagged with multiple codes where appropriate. Here we focus on the Canadian references coded
under any of the following five topics.
TABLE 1 GOES HERE
Five quantitative studies and one qualitative study established that ethnocultural minority older
adults in general or specific groups, e.g., Chinese Canadians, are not adequately represented among
users of services such as long-term care facilities (Wasylenka 2004) or home care (Lai 2004b;
Majumdar, Browne, and Roberts 1995). When variables other than ethnicity were considered as
explanations for this low utilization, they were simply reported as predictors for service use.
Ignoring the underlying power dynamics associated with social determinants of health such as
gender, time since immigration, country of origin or education, and the compounding effects of
these intersections among them, leaves us wondering why and how the variables identified (if any)
influence utilization.
Abstracts included within the top five intervention code groups also attest to the paucity within the
Canadian health care system of linguistically and culturally appropriate services that meet the needs
of an ethnoculturally diverse aging population (e.g., Hossem 2009; Lai and Chau 2007; Mullings
2006). Some research has placed specific emphasis on culturally charged components of the care
experience such as food (Forster- Coull and Koehn 2001) and language and communication styles
(e.g., Saldov and Chow 1994), or explored the cultural appropriateness of models of care (e.g., the
Eden Alternative: Fung 2006). Relatively few researchers (Brotman 2000; Koehn 2009; Mullings
2006) have spoken to the intersecting oppressions experienced by visible minority older adults,
especially women, which influence their admission to and shape their quality of life in long-term
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24
care facilities. Culturally-targeted long- term care facilities are positively evaluated as meeting the
needs of ethnocultural minority older adults (Fung 2006; Kromer 2004; Pereira Lazarowich, and
Wister 1996). This solution nonetheless requires sufficient community capacity, which may not be
available to smaller communities or even sub-populations within communities, as differentiated by
religion, for example (van Dijk 2004). Also noted are the health care system’s (inadequate) efforts
to address through appropriate outreach and health promotion programs a lack of knowledge among
some immigrants and their family caregivers of the availability of relevant services (e.g., Koehn
2009; Sadavoy, Meier and Ong 2004;Sanghera 1991) or of specific illnesses, such as dementia
(Fornazzari, Fischer, Hansen, and Ringer 2009). Thus while multiple variables are often recognized,
they are poorly understood in terms of their contribution to inequities in health or health care access,
are often considered independently of one another rather than interactively, and are rarely situated in
the context of systems characterized by power imbalances and discrimination.
Discussion
Categorical complexity
Categories, although useful and necessary for organizing complex phenomena, hide important
differences even as they highlight others. For instance, the categories used in Figure 3 to classify
ethnocultural minority older adults tend to reflect the immigration histories and policies of the
countries in which people settle. They hide the fact that each group of immigrant older adults, as
defined by Statistics Canada, is extremely heterogeneous. For example, Chinese Canadians hail from
many countries, including China, Hong Kong, Taiwan, or Macau. Others emigrate from Chinese
Diasporas in Malaysia, Vietnam, Singapore, etc. Similarly, South Asians may arrive directly from
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25
India, Pakistan, Bangladesh, or Nepal, while others emigrate from South Asian Diasporas in countries
such as Uganda, Tanzania, Malaysia and the UK. In both cases these immigrants also differ in many
of the determinants of health, such as SES and gender, as well as the length of time they have been in
the country of settlement (some are Canadian-born whereas others have migrated late in life). In
addition, they arrive as different types of immigrants: a relatively small number are refugees, whereas
the majority arrive as economic or family class immigrants. The importance of recognizing this
heterogeneity was underscored when we shared the preliminary results of the scoping study with
community groups. In the ‘Chinese’ community, sessions were held in Cantonese and Mandarin.
Strongly apparent in these discussions were the different ‘cultures’ of both groups and how these
resulted in very different health practices and service use patterns.
Further, similar groups of immigrants are categorized differently in different receiver countries
(Bhopal 2004). Thus, in Canada, we refer to Chinese Canadians and Indo-Canadians; in the US, both
groups fall under the rubric of ‘Asian and Pacific Islanders’. In the UK, they are denoted as ‘Chinese’
and Asian respectively, with the latter term reserved almost exclusively for South Asians.
Recognition of the diversity within these populations, both in terms of religion and country of origin,
is most meticulously and consistently recognized by British researchers. In Australia, Chinese and
South Asians are typically subsumed under the broad umbrella of people of Non-English Speaking
Background (NESB).
Such ‘lumping and splitting’ conventions, borne of the socio-political realities of colonization and
migration, complicate systematic literature searches and strongly influence the shape and content of
each nation’s research interests and agendas (Kirmayer and Minas 2000; Bhopal 2006). While the
theoretical and methodological orientations of researchers and the research questions themselves
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26
influence decisions to combine or isolate groups, so too do national differences in the naming and
categorization of one ‘group’ relative to another. The nature of the data collected is also salient here.
Especially influential is Statistics Canada’s tendency to under-sample ethnocultural visible minority
Canadians in national survey research, yielding under-representations of these populations in the large
datasets. As a result, different ethnocultural groups are commonly clustered into generic categories
(e.g., ‘Asians’) to facilitate ‘meaningful’ secondary data analyses.
Methodological conundrums: where’s the data?
The application of an intersectionality perspective in this domain poses a number of significant
challenges for quantitative researchers. The challenge is largely one of operationalization.
Specifically, data extracted from secondary data sources like the Canadian Community Health
Survey or the National Population Health Survey are limited because the variables that these
datasets yield have been constructed from close-ended survey questions asked at one point in time.
The selection and analysis of this data is thus quite narrow and static. For example, questions that
are used regularly as “cultural markers” in ethnicity and health studies in Canada probe place of
birth (an indicator of immigration status), ethnic group belonging (indicator of ethnic identity), and
charter language ability (an indicator of acculturation status) cross-sectionally (Kobayashi, Prus, &
Lin 2008).
Efforts to address the inherent complexity of the inter-relationships between markers of difference
like ethnicity, socio- economic status, gender, and immigration status are therefore limited when
one-dimensional proxies are the only options available. To truly understand the compounding
influence of the intersections of these markers on health and health care access requires the use of
meaningful interaction terms in multiple regression models. Accounts of this approach have only
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27
been published since the completion of our scoping review. For example, Kobayashi and Prus
(2011) examined the healthy immigrant effect using logistic regression to model health for adults
(45+ years) across immigrant/visible minority groups, and Warner and Brown (2011) scrutinized
intersections of race/ethnicity and gender on the age trajectories of disability among older adults.
Until recently, primary data collection has often been the only real option to researchers interested
in applying intersectionality theory to critical examinations of health in vulnerable populations. This
requires considerable input of time and money to ensure the collection of ample and appropriate data
over time. We therefore suggest that an intersectionality approach will often require research that
uses a mix of methodologies and research designs.
Silenced by the research record: invisible immigrants and stories lost
What is missing in the literature is as telling as what is included. For instance, we need to push
obvious interpretations such as the long time presence or relative size of groups when accounting for
their presence or absence in the research literature. Chinese immigrants, whether from the mainland,
territories or Taiwan, have consistently scored high on the Canadian point system in terms of financial
and educational criteria. Thus, the larger community has the security and the capacity to develop
businesses and services to meet the needs of its ageing population. We juxtapose this situation to
those categorized as Black. In this category reside Afro-Canadians who have lived here since the
American Civil War, immigrants from the Caribbean who may have come directly (many women as
domestics) or indirectly through England, and others who are refugees from a number of African
countries. They have little in common, although many live on very low incomes. They also face
individual and institutional discrimination and have few intra-community resources to advocate for
their priorities. One can posit many reasons for the dearth of studies here, but systemic racism needs
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28
to be factored into any explanation (Henry and Tator 2006; Mullings 2006).
Conclusions and
r
eco
mm
e
nd
a
t
io
n
s
In summary, the application of an intersectionality perspective to the study of health among
ethnocultural minority older adults underscores the importance of understanding the multi-
dimensional nature of health inequities in vulnerable populations. This approach compels us to move
beyond an analysis of one or two possible ‘predictors’ to an exploration of the influence of a number
of markers of difference such as age, gender, socio-economic status, ethnicity/race, marital status,
and sexual orientation, to name a few. Ultimately, this is necessary if we are to acknowledge the
complexity inherent in the ‘production’ of health among ethnocultural minority older adults. There
is recognition in the literature of the need to apply an intersectionality lens when examining the
health and health care of immigrant communities. However, this seems to be honoured more in
principle than in how research is undertaken, or at least how the results are written up. One could
interpret this as reflecting a conscious choice made by researchers to emphasize in their work those
dimensions of difference that they deem most critical to understanding the needs of and/or barriers
encountered by various sectors of the population. However, it is equally plausible that the state of the
literature reflects a focus on those problems that press the health care system and institutional
priorities shaped by their own desire to find ways to alleviate some of the pressure. Health care
issues do take different forms in different ‘ethnocultural communities,’ such as the Chinese and
South Asian groups have detailed above, but other social determinants of health such as employment
history, length of time in the country, sponsorship status, income, housing options, etc., many of
which impact on all Canadians, are also relevant and influence the options available to individuals.
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29
To move the debate forward we suggest that it is important to consider the meaning attached to and
the significance of categorizing a group or an individual as belonging to an ethnocultural group.
Immigrants are constantly adapting cultural practices to their environments. For instance, what would
be the effect on research if the concept of ‘hybridity’ were the starting point for understanding the
immigration experience? This concept centres on the process of change, anticipating the creation of
something new or different, and opening up fresh ground for individuals and groups to renegotiate
meaning and representation. Intersectionality is reflected in concepts like 'hybridity' that are dynamic
rather than fixed; where the immigration experience is viewed as a process involving constant
movement between here and there, we and they, self and other, past and present, and homeland and
host land (Bhatia and Ram 2009; Lowe 2003). At the same time the concept encourages analysts to
recognize the fact that such negotiations are linked to processes that are shaped by political,
economic, historical and cultural practices (Bhabha 2004; Lowe 2003). Such a concept prevents the
absorption of all differences into existing categories, including dominant definitions of what
constitutes universal services (Nederveen Pieterse, 2001). Rather than people having one single
identity embedded in ethnicity, which emphasizes separateness, there is “togetherness-in-difference”
(Ang 2003: 141).
Ongoing research in this area thus requires a conscientious effort by researchers to consider multiple
dimensions of difference and the influence of their intersections for which appropriate raw data are
needed. Regardless of the limitations in the extant literature, we have sufficient evidence to show that
the health care needs of the sizeable ethnocultural minority older adult population in Canada cannot
be met without some assumption of responsibility for the inequities in access to health care
experienced by these older adults. This awareness therefore needs to reach those responsible for the
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30
data collected and the categories conceptualized for large datasets such as the Census of Canada or
the Canadian Community Health Survey, among others. Health and social care organizations as well
as decision makers responsible for immigration, and social and health care policies exert a profound
influence on the capacity of this sub-population of older adults to achieve optimal health, and need to
act accordingly.
Acknowledgements removed for blind copy
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Walker, A. 1981. Towards a political economy of old age. Ageing and Society, 1, 1, 73-94.
Warner, D. F. and Brown, T. H. 2011. Understanding how race/ethnicity and gender define age-
trajectories of disability: An intersectionality approach. Social Science and Medicine, 72, 8, 1236-48.
Wasylenka, K. 2004. Visible Minority Seniors in Long Term Care: Not Many and Frail. Master’s
thesis, University of Regina, Regina, Saskatchewan.
Wedeen, L. 2002. Conceptualizing culture: Possibilities for political science. American Political
Science Review, 96, 04, 713-28.
Winker, G. and Degele, N. 2011. Intersectionality as multi-level analysis: dealing with social
inequality. European Journal of Women's Studies 18, 1, 51-66.
Final before proofs version for self-archiving – please cite published version only
41
Figure 1: Flow chart of exclusion process to identify eligible articles
Final before proofs version for self-archiving – please cite published version only
42
Figure 2: Distribution of articles by country in which research was conducted
Ca na da
25.8%
USA
52 . 8 %
Aus t r al i a
3. 2 %
Ne w Ze al and
0. 6 %
Uni t ed Ki ngdo m
10.5%
Swed e n
0. 1 %
Not Spe ci f i ed
6. 9 %
US A
Ca n a d a
Au st ra l i a
Ne w Z ea la nd
Un it e d K ing do m
S we d e n
No t Sp ec if i ed
Final before proofs version for self-archiving – please cite published version only
43
Figure 3: Percent of abstracts that mention an ethnocultural minority group
9
compared to Canadian
visible minority population aged 65+
Final before proofs version for self-archiving – please cite published version only
44
Figure 4: Percent of abstracts that mention only one ethnocultural minority group compared to
Canadian visible minority population aged 65+
Final before proofs version for self-archiving – please cite published version only
45
Figure 5: Leading causes of death and hospitalization of Canadians 65+
Final before proofs version for self-archiving – please cite published version only
46
Figure 6: Number of Canadian abstracts for Chinese and South Asian older adults classified
according to ICD-10 categories
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47
Intervention topic
All
sources
Cana-
dian
Long-term care (LTC): LTC facilities/nursing homes - types of care
administered/available; transition into LTC.
47 20
Caregivers: Primarily informal caregivers - issues related to care provision
for an older adult, e.g. caregiver burden, filial obligation, etc.
63 19
Cultural Competence: Formalized efforts to provide culturally sensitive
care and their effect on care recipients.
70 14
Promotion: Formal health promotion efforts and behaviours deemed to
promote health.
31 11
Home Care: Medical ‘home care’ services and non-medical home
supports for older adults.
23 7
Table
1: Top five ‘Intervention’ topics in the international and Canadian literature
1
The biological differences associated with sex and the gendered socialization that people experience in
different contexts are highly interactive, but should not be conflated in analysis because the effects on
health and the potential for and types of intervention differ for each (Snow 2008).
2
Aboriginal peoples are outside of the focus of this study because they are not considered ethnocultural
minorities in Canada for historical and political reasons. Aboriginal peoples preceded European contact and
most of the inequities arising across the life cycle are rooted in the racist practices of early European
Final before proofs version for self-archiving – please cite published version only
48
settlement (e.g. placing aboriginal children in residential schools where many were physically and sexually
abused), which continued well into the 20th century. The rights of Aboriginal peoples are also treated
separately in the Constitution (Section 13) (Waldram, Herring, and Young 2006).
3
A full accounting of our methodological processes, including our extensive list of search terms is the
subject of a forthcoming paper.
4
Following links from relevant articles to related articles efficiently expanded our Ebsco search.
5
http://amicus.collectionscanada.gc.ca/thesescanada-bin/Main/BasicSearch?coll=18&l=0&v=1
6
http://canada.metropolis.net/index_e.html
7
After their first three months’ residence in any province, all citizens and landed immigrants in Canada are
eligible for affordable health care coverage (http://www.health.gov.bc.ca/msp/), although not all health
services are covered, notably most regular dental and vision care. This nonetheless compares favourably
with the US where, in 2010, 49.9 million Americans (16.3% of the US population) were without medical
coverage (DeNavas-Walt, Proctor and Smith 2011). A study comparing health care access of immigrants in
Canada (all insured) and insured and uninsured immigrants in the United States found that “health care
insurance is a critical cause of differences between immigrants and non-immigrants in access to primary
care” (Siddiqi, Zuberi and Nguyen 2009: 1452).
8
Journal of the American Geriatrics Society, Journal of Gerontological Social Work, Journal of
Gerontological Nursing, International Journal of Geriatric Psychiatry, Generations, Ageing and Society.
9
Articles may refer to more than one ethnic group. VM n.i.e. is used by Statistics Canada (2006) to denote
“Visible Minorities not included elsewhere.”
