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Age and Ethnicity

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Abstract

Understanding the diverse experiences of aging both across and within Canada’s numerous ethnocultural groups thus requires complex theoretical and methodological approaches that move beyond a focus on ethnicity and age to explore the effects of other interlocking markers of social inequality in studying the lives of older adults. We suggest that it is time for a more decisive shift toward an intersectionality approach in ethnogerontology. To illustrate the value of this approach, we will limit our discussion to the context of health status and access to health care. For while many people lead healthy, productive lives as they age, older adults in general average more than two times the number of physician contacts per year than do persons under the age of 65 (Kelchner, 2002) and this ratio doubles again amongst the old-old, aged 85+ (Nie, Wang, Tracy, Moineddin, & Upshur, 2008). ... The need for an intersectional approach to research was thus clearly established over twenty years ago, yet few researchers in this area applied it in their work. With the growth of more critical perspectives over the past decade or so, research on aging and ethnicity has started to recognize the diversity both across and within groups, and to address the complex interplay among statuses in ethnic older adult populations (e.g., Calasanti & Slevin, 2001; Dossa, 1999; Estes, Mahakian, & Weitz, 2001; Gee, 1999; Kobayashi, 2000; Koehn, 2009). The remainder of this chapter will first describe intersectional approaches to research, and then furnish examples that illustrate the use of this approach in the analysis of our own work in the domain of health and aging among EMOA. These in turn explicate how social inequities are generated through discrimination at multiple levels.
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Book title: Age discrimination and Diversity
Sub-title: Multiple discrimination from an age perspective
Editor: Professor Malcolm Sargeant, Middlesex University, London, UK
Delivery date: October 1 2010
Working Title for Chapter: Age and Ethnicity
I. Introduction
Compared to many countries in Europe, Canada is a relatively ‘young’ nation, but its
demographic profile is undergoing dramatic changes. Older adults are the most rapidly
expanding population in Canada, expected to grow from 13.7% today to almost 24% by the year
2031 (BC Ministry of Health Services, 2004). Equally striking is the increase of ethnocultural
minority older adults (EMOA), who now comprise more than 25% of this age cohort (Statistics
Canada, 2006a). Diversification is especially apparent in Canada’s three major immigrant-
receiving metropolitan areas: Vancouver, Toronto and Montreal.
Somewhat belatedly, Canadian researchers, funding agencies and publishers are
beginning to pay more attention to this diverse sub-population. Here we consider literature on
both new immigrants and longer-term Canadians who, by virtue of their visible characteristics,
may continue to experience discrimination. We recognize, nonetheless, that there are marked
differences among them and that some EMOA are clearly more “at risk” than others, with many
such differences shaped by socially defined characteristics such as gender, race, class, sexuality,
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immigration status, and so on (Iyer, Sen, & Östlin, 2008). Indeed, oppressions experienced
throughout the life course influence a person’s social capital
1
which may be further diminished
in the face of role reversal and loss of status, as well as discrimination experienced post-
migration (Guruge, Kanthasamy, & Santos, 2008; Koehn, 2009; Koehn, Spencer, & Hwang,
forthcoming; Sadavoy, Meier, & Ong, 2004). Ultimately, then, “statuses and their intersection
influence a person’s life chances, in terms of education, labour force participation, living
arrangements, health status, and ultimately, the quality of life in old age” (L. McDonald, 2008, p.
139).
But these relationships are not well understood. A scoping review team (Kozak, Koehn,
& Khamisa, 2010), of which this chapter’s authors are members, recently found that the
literature on the health and health care access of EMOA was distributed across a broad span of
diverse disciplines as reflected by the publication of 791 eligible articles across 192 journals. The
two journals publishing the most articles (25 and 17) represented the distinct disciplines of
social work and geriatric medicine; the dialectally opposed paradigmatic stances found in these
two journals is characteristic of this field, which is rife with contradictory evidence.
Understanding the diverse experiences of aging both across and within Canada’s
numerous ethnocultural groups thus requires complex theoretical and methodological
approaches that move beyond a focus on ethnicity and age to explore the effects of other
interlocking markers of social inequality in studying the lives of older adults. We suggest that it is
time for a more decisive shift toward an intersectionality approach in ethnogerontology. To
1
Here defined, per Bourdieu, as the economic, social and symbolic power held by individuals and
reproduced by institutions and practices (Siisiainen, 2003).
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illustrate the value of this approach, we will limit our discussion to the context of health status
and access to health care. For while many people lead healthy, productive lives as they age,
older adults in general average more than two times the number of physician contacts per year
than do persons under the age of 65 (Kelchner, 2002) and this ratio doubles again amongst the
old-old, aged 85+ (Nie, Wang, Tracy, Moineddin, & Upshur, 2008).
II. Gerontological theories of difference
In the early years, efforts to construct theoretical models in the sociological and
anthropological literature on aging and culture or ethnicity was limited to an examination of
conventional concepts such as disengagement (Vatuk, 1980), activity (Palmore & Maeda, 1985),
modernization (Cowgill & Holmes, 1972), and assimilation (Osako, 1979). Overly simplistic and
generalized to diverse populations of older adults, such theories did not stand up to the
evidence and have been routinely critiqued (Driedger & Chappell, 1987; Gelfand, 2003).
By the late 1970s, however, new theories—such as the concepts of double and multiple
jeopardy—recognized the negative impact that certain statuses, namely age and visible minority
status
2
and later class and gender, conferred on individuals (Dowd & Bengtson, 1978; Markides,
1983). The concept of ‘triple jeopardy’ specifically identified the additive effect of age, sex, and
ethnicity as placing very old immigrant women at a relative disadvantage to other Canadians in
terms of their mental functioning (Havens & Chappell, 1983). This theory continues to be used
2
Statistics Canada (2006b) defines visible minorities as “persons, other than Aboriginal peoples,
who are non-Caucasian in race or non-white in colour.” More importantly, they are people subjected to
racialization, or “the process through which groups and their practices are identified by reference to
visible physical characteristics, thus grounding group distinctions in biology” (Johnson et al., 2004).
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as a framework for understanding the health status of older immigrant women (Public Health
Agency of Canada et al., 2007). Other studies on mental health have nonetheless recognized
that concepts such as ethnicity and SES are multidimensional, as reflected in their findings that
factors such as living arrangements (e.g., co-residence with children), health status, experience
of stressful life events, social connectedness etc. (Kim, 2007; Lai, 2000; Mui, 1998, 2002; Wykle
& Musil, 1993) increase the probability of depression amongst EMOA. Yet others have explored
the influence of social determinants of health
3
independently of gender and found similarly high
rates of depression,(Stokes, Thompson, Murphy, & Gallagher-Thompson, 2001) or have found
that, while there are differences by gender, these are not statistically significant (Wu, Tran, &
Amjad, 2004).
Cool’s (1981) age-leveling hypothesis ran counter to multiple jeopardy theories by
suggesting that age itself leveled out racial and ethnic inequalities experienced by older adults
earlier in the life course. Theoretical developments like age stratification (A. Foner & Kertzer,
1978; A. Foner, 1979; N. Foner, 1984; Riley, 1971) and political economy (Estes, 1979; Walker,
1981), on the other hand, were grounded in the understanding that issues of structural
inequality were central to understanding the experiences of EMOA. Age stratification theorists
focused their discussion on inequities in access to various types of resources that were
contingent on age. Feeling that age stratification theory failed to take into account the dynamics
of inequality and power relationships, however, Marxist and neo-Marxist critics developed the
political economy of aging perspective to address this shortcoming.
3
The social determinants of health are the circumstances in which people are born, grow up,
live, work and age, and the systems put in place to deal with illness. These circumstances are in turn
shaped by a wider set of forces: economics, social policies, and politics (Public Health Agency of Canada,
2003).
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Meanwhile, anthropologists were exploring, through ethnographic studies, the
biological, psychological, social and cultural dimensions of age in order to comprehend its
relationship to health (Fry, 1981a). The discipline’s “concern for dimensions and complex
interactions” sought to enrich gerontology “both through comparative and holistic research”
(Fry, 1981b , p. 2). While these studies provided valuable insights into the operation of various
dimensions of difference, they nonetheless tended to be atheoretical and uncritical in their
analysis, paying no heed to the manner in which power imbalances and discrimination shape the
experience of age or its intersecting categories. Exploration of a variety of experiences of aging
nonetheless began to cast doubts on the validity and explanatory value of socially constructed
categories such as ethnicity and the recognition of the importance of questioning such
categories relative to social policy. Sokolovsky (1990a; 1985) has argued, for example, that an
“overemphasis on ethnicity as a resource has been overly optimistic, especially in the area of
informal social supports and networks of exchange” (1990a, p.203). While differences in
networks between ethnic groups are evident in many studies, the nature of such support and
their differential effect by gender, for example, is rarely interrogated. To illustrate, he cites
Cohler’s (1982) research demonstrating the benefit of ethnic embeddedness on adjustment to
old age for Italian-American men, but the opposite for women. While the incipient
deconstruction of categories and recognition of dynamic intersections between them was
apparent here, it would take another 20 years for the notion of intersectionality to take hold in
gerontology.
Other important contributions to the multidisciplinary hodgepodge of gerontological
theory came from social work. The sub-discipline of ethnogerontology arose out of a concern
with addressing the needs of a burgeoning heterogeneous aging population (Crewe, 2005).
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Jackson’s (1967) early work with African-American older adults led her to define
ethnogerontology as “the study of the causes, processes, and consequences of race, national
origin, and culture on individual and population aging in the three broad areas of biological,
psychological, and social aging” (Jackson, 1985, p. 266). Concerned initially with the confluence
of old age and race (or rather its social construction), ethnogerontology brings a more critical
gaze to the examination of age and ethnicity to which the lens of oppression is applied. Focused
primarily on the “inadequacies of access and availability of services and resources” (Crewe,
2005, p. 50) to EMOA, ethnogerontological social workers advocate for cultural competence as a
solution. Theoretical perspectives adopted by this group share a concern with access to
resources. The “multiple hierarchy stratification” theory draws on both the double jeopardy
hypothesis and life-course perspectives located at opposite ends of a continuum and “focuses
on the importance of the effects of history, social structure, and individual meaning to the aging
process” (Hooyman & Kiyak, 1996, as cited in Crewe 2005, p. 52).
The need for an intersectional approach to research was thus clearly established over
twenty years ago, yet few researchers in this area applied it in their work. With the growth of
more critical perspectives over the past decade or so, research on aging and ethnicity has
started to recognize the diversity both across and within groups, and to address the complex
interplay among statuses in ethnic older adult populations (e.g., Calasanti & Slevin, 2001; Dossa,
1999; Estes, Mahakian, & Weitz, 2001; Gee, 1999; Kobayashi, 2000; Koehn, 2009). The
remainder of this chapter will first describe intersectional approaches to research, and then
furnish examples that illustrate the use of this approach in the analysis of our own work in the
domain of health and aging among EMOA. These in turn explicate how social inequities are
generated through discrimination at multiple levels.
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III. Adopting an Intersectional Approach
Intersectionality considers the simultaneous interactions between multiple dimensions
of social identity (for example, sex, gender, age, visible minority and immigration status) that are
contextualized within broader systems of power, domination and oppression (such as sexism,
ageism and racism) (Hankivsky, Cormier, DeMerich, & Chou, 2009). Intersectionality differs from
predecessors like multiple/triple jeopardy in that it is not an “additive linear model”: “In the
language of statistics, the analysis of intersectionality 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, p. 1787-88). From
this perspective, power imbalances and discrimination, as well as positive health care
experiences, are thus understood as unique to each individual’s constellation of intersecting
identities, social roles and the broader social and political context in which they exist (Hankivsky
et al., 2009). These intersections are at play at each of the micro, meso, and macro levels—that
is relative to our identities, to our interactions with others in different sociocultural contexts,
and at the broader societal level wherein values are entrenched as policies (Colleen Reid, in
Spence, Koehn, & Kobayashi, 2009).
For visible minority older adults, the process of racialization greatly impacts health and
quality of life. The social category of race and the corresponding social production of racial
identities interact with other fundamental determinants of health such as ethnicity, age, gender,
and immigrant status to impact an individual’s ability to access the key social resources
necessary for health promotion and maintenance (Benoit & Shumka, 2009). In practical terms,
racism affects health through systemic and individual-level occurrences of discrimination,
marginalization, and susceptibility to poverty, to name a few.
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Intersectionality is essentially a theoretical and methodological counterbalance to the
tendency for much research to reproduce the essentializing and ‘othering’ that occurs in society.
‘Othering’ practices, typically invisible to those who perpetrate them, take the form of
ahistorical and abstracted over-generalisations that are applied to specific individuals to explain
their behaviour (Johnson et al., 2004). Typically, these explanations invoke the socially
constructed notions of ‘race’, culture or even gender as a means of creating distinctions
between ‘us’ and ‘them’. Othering thus fails to recognize the complex interactions between
different ‘categories’ or sources of social inequity and how the construction of those categories
is based on the experiences and hence the biases of the speaker. This form of inadvertent
discrimination often originates or is supported by policies and institutional structures intended
to be equitable but designed in accordance with anglocentric, middle-class values (Brotman,
2003).
An intersectional approach thus behooves us to ask how age, ethnicity, gender, visible
minority and immigration status interact to create barriers to health and social care access for
EMOA. The processes of discrimination are apparent in such an approach.
Methodological approaches to intersectionality
While much has been written about the theoretical premises of intersectionality, what is
less clear is how one goes about doing it. McCall (2005) suggests that there are three stages or
levels at which intersectionality is practiced. The first of these—anticategorical complexity
finds its origins in anthropology which has long since been successful in deconstructing
categories that rarely hold water cross-culturally. In their critiques of modern Western
philosophy, history, and language, poststructuralists (Lechte, 1994) in particular have been
especially active in questioning the ‘givenness’ of categories of difference such as ‘race’ and
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even ‘gender’. The importance of understanding such categories as complex social constructions
within which specific manifestations may be infinite or at least range along broad continua
entails a shift away from Cartesian dualisms or dichotomies such as male/female, black/white,
or ethnic/non-ethnic that underlie othering.
This leads us then to question the very premises upon which our enquiry is based. For
example, ethnicity can be defined as “a group’s shared cultural heritage based on common
ancestry, language, music, food and religion” (Hankivsky et al., 2009).
Like ‘race,’ it is often
treated as a determinant of health. According to Illife and Manthorpe (2004, p. 283), however,
“[e]mpirical research on dementia and ethnicity reveals that intra-ethnic group variation is
greater than interethnic group variation; supporting the view that ethnicity as a category [when
defined as particular shared cultural characteristics] may not have great explanatory power and
may foster a category fallacy.” They add that a lack of clarity about the more salient
determinants of health that are subsumed under the concept of ethnicity, such as migration,
education, health beliefs and socio-economic status (SES), relegate broader health care access
issues to an ethnic minority agenda.
Their observation also draws our attention to the uncritical treatment of the notion of
culture as a determinant of health. Too often we see evidence of an inherent but unstated
assumption that differences in health outcomes between ethnic groups are de facto attributable
to cultural differences (e.g., Jones, Chow, & Gatz, 2006) This rests on a simplistic equation of
culture with ethnicity, nationality, and language that assumes that culture is static and
homogeneous (Kleinman & Benson, 2006). From a critical anthropological point of view, culture
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—
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operate in a dialectical relationship with systems of signification. Culture is defined in reference
to these practices and vice versa (Wedeen, 2002). Immigrants have thus been found to adapt
cultural practices to their environments. For example, faced with the challenges of dementia
care giving, the adult-child caregivers of Chinese-Canadian persons with dementia have shifted
the meaning of filial piety that would traditionally mandate that they take care of aging parents
in the home, to the responsibility of ensuring that they seek out the most appropriate, high
quality long-term care facilities (Hicks & Lam, 1999; Ho, Friedland, Rappolt, & Noh, 2003). This
ability to renegotiate cultural meanings nonetheless depends on the individual’s position on the
matrix of social determinants, including age. Failure to acknowledge these determinants in
explanations of behaviour that resort to culture are seen by critical theorists as essentializing
and discriminatory—that is, they oversimplify the various influences on the person’s thoughts
and actions, and often do not take into account the conditions that give rise to them. In so
doing, the burden of responsibility is shifted to the individual and their culture and the
underlying conditions are not addressed. For example, people may not adequately access the
services they need due to barriers such as the unsuitability of the service (hours, language, etc.)
or lack of appropriate outreach. Culture should nonetheless be understood as a determinant of
health insofar as:
Some persons or groups may face additional health risks due to a socio-
economic environment, which is largely determined by dominant cultural values
that contribute to the perpetuation of conditions such as marginalization,
stigmatization, loss or devaluation of language and culture and lack of access to
culturally appropriate health care and services (Public Health Agency of Canada,
2003).
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These examples demonstrate that no category can be reduced to a single axis of
difference. Yet the 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 the ethnographic work already described (e.g., Fry,
1981a; Sokolovsky, 1990b). 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, p. 1783).
The third type of intersectional enquiry that McCall describes speaks to efforts to
employ this 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, p. 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). Categories are understood to be imperfect and ever-
changing, but the necessity of adopting them provisionally is accepted in order to proceed with
analyses that explicate the relationships among them. Here, relationships of inequality are the
focus of rather than the background to the analysis. Researchers are now beginning to develop
methodologies that capture the multidimensionality of such categories. For example, Sen, Iyer
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and Mukherjee (2009, p. 401) probe the “relative importance and magnitudes of class and
gender inequities” as they relate to health outcomes.
IV. Health inequities, aging and ethnicity
A popular hypothesis concerning the health status of immigrants that is well-supported
in the Canadian literature is that of the “healthy immigrant effect” (HIE) which posits that recent
immigrants are healthier (and subsequently, that they use the health care system less) than
their Canadian-born counterparts but that, over time, this health status advantage decreases
(Ali, McDermott, & Gravel, 2004; Dunn & Dyck, 2000; Gee, Kobayashi, & Prus, 2004; Newbold,
2005a; Newbold & Danforth, 2003). These studies also find that recent immigrants from Asia
report better health status than those from Europe (Ali et al., 2004; Chen, Wilkins, & Ng, 1996;
Laroche, 2000). This initial advantage is associated with self-selection for the lengthy and
expensive process of migration and the medical screening required of all immigrants (Kennedy,
McDonald, & Biddle, 2006). Health status declines, as indicated by higher morbidity of chronic
disease (Newbold, 2006), or increased body mass index (McDonald & Kennedy, 2005) among
longer-term immigrants, for example, are often associated with changes in behaviour following
migration (Dean & Wilson, 2010; Newbold, 2005b; Perez, 2002).
Beiser (2005) denounces this emphasis on ‘sick’ and ‘healthy’ immigrants as “wrong-
headed” and asks instead what policy makers in Canada are doing to ensure the ongoing health
of its immigrants. Specifically, he argues, we need to adopt a model that examines “salient
resettlement stressors that act alone or interact with predisposition in order to create health
risk, and the personal and social resources that reduce risk and promote well-being” (2005, p.
S30). Support for this argument, which is consistent with an intersectionality approach, is found
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in the literature on older immigrants. For example, recent immigrants aged 65 and older have
poorer health than both immigrants who have been in Canada longer and the Canadian-born
population; this is especially true of Family Class (sponsored) immigrants and refugees (Gee et
al., 2004; Newbold, 2005b; Statistics Canada, 2005). Gee, Kobayashi and Prus (2004) report that
this disadvantage largely disappears when a number of socio-demographic, socio-economic, and
health behaviour factors are controlled. Still salient, however, is the fact that multiple markers
of inequity recognized as social determinants of health—particularly age, SES, type of
immigration, and possibly visible minority status—converge in the older Family Class immigrant
or refugee. Controlling for such factors allows us to say that compared to a group of Canadian-
born older adults who experience the same disadvantages, the immigrants studied are no worse
off; this does not preclude the fact that the disadvantages or their intersecting influences may
be found in higher proportions within a particular ethno-cultural community.
Based on his study on the health care utilization patterns of immigrants, Globerman
(1998, p. 31), argues that age trumps immigration status as “the strongest single determinant of
health problems.” Kobayashi, Prus and Lin’s (2008) comparison of self-rated health status and
functional health differences between first-generation immigrant and Canadian-born persons of
the same ethnocultural origin nonetheless establishes that being an immigrant does influence
health status, but not always in the same direction: “first-generation immigrants of Black and
French ethnicity tend to have better health than their [Canadian-born] counterparts, while the
opposite is true for those of South Asian and Chinese origins” (2008, p. 129). Menec’s (2007)
finding that Eastern European older adults in Canada are significantly more likely to rate their
health as poor compared to older British Canadians, even when controlling for SES, language
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spoken and health status, similarly suggests that ethnicity and immigrant status do indeed
matter in self-reported evaluations of health. But why is this so?
Predispositions to certain diseases exist among particular ethnic groups. For example,
foreign-born populations from South Asia experience higher rates of diabetes mellitus and heart
disease (Fikree & Pasha, 2004; Gupta, Singh, & Verma, 2006; Raymond et al., 2009). The
diversity in health status found among older adults is nonetheless better understood as the
outcome of different life trajectories that are influenced only minimally by biology, genetic
endowment or behaviour. Rather, it is sociocultural determinants that produce health inequities
in vulnerable, at-risk populations and account for 75% of the influences on Canadians’ health
(Canada. Standing Senate Committee on Social Affairs, Science and Technology, 2009; Mikkonen
& Raphael, 2010; Public Health Agency of Canada, 2003). The differential impact of interactions
of these factors across groups of older adults depends on their social location in Canadian
society (Neysmith, O'Connell, & Bezanson, 2005).
V. Two examples of intersectional analyses
The following examples of the application of intersectional approaches to data on health
inequities experienced by EMOA illustrate the relationships between markers of difference that
help us to understand how the experience of immigration to Canada as older adults predisposes
them to discrimination that contributes to inequities in health status and health care access.
Kobayashi and Prus take an intercategorical approach to the analysis of quantitative data
whereas Koehn’s qualitative data is better suited to an intracategorical examination.
An intercategorical analysis of the ‘Healthy Immigrant Effect’
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In their examination of the HIE, Kobayashi and Prus (forthcoming) use an
intercategorical approach to answer the questions, “Does gender, age, and ethnicity matter in
assessing the health of immigrants? And, if so, in what ways?” Such an approach is appropriate
in that it recognizes that “pre-existing categories of difference” (Hankivsky et al., 2009, p. 6) can
be useful in exploring within and between-group inequalities in health. Further, by including age
as a salient marker of inequality, the study: (1) adds to an HIE literature that has, to date, been
largely focused on examinations of the influence(s) of the typical research triumvirate of
“ethnicity-class-gender” on immigrant health; and (2) based on its findings, identifies and
proposes policy responses to health inequalities among immigrant populations that can be
translated cross-nationally to countries such as the US, UK and Australia, where similar results
for the HIE have been found (Kennedy et al., 2006).
By using an intercategorical approach to secondary data analysis to answer their
research questions, Kobayashi and Prus acknowledge the potential of this type of analysis to
transform the health and health care experiences of visible minority immigrant men and women
at different stages of the adult life course. Further, it is their intention that findings from their
study can then be explored qualitatively through in-depth interviews, focus groups, and/or
participant observation with mid-life and older visible minority immigrant men and women to
provide insights into the self-reported and functional health statuses of individuals in these
groups. Such a mixed methods approach is a good “fit” with an intersectionality perspective for
studies on immigrant health.
The results of their study are based on data from the public-use microdata file of the
2005 (Cycle 3.1) Canadian Community Health Survey (CCHS). The sample consists of 132,221
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Canadians aged 12 or older living in private occupied dwellings, with an overall response rate of
approximately 85 percent.
One of the key findings from the current study is that the healthy immigrant effect
applies to midlife males. Specifically, recent immigrant men—i.e., those who immigrated less
than 10 years ago—between the ages of 45 and 64 years have better functional and self-rated
health compared to the Canadian-born. And, upon further examination, the results suggest that
there is a convergence in health differences between foreign- and Canadian-born men in
midlife. Interestingly, the health advantage of recent immigrants is especially strong for visible
minorities, suggesting that the observed HIE for middle-aged men is due, in part, to the
exceptionally good health of recent visible minority immigrants. Finally, it should be noted that
this advantage is not accounted for by differences in age, SES, or health behaviors between the
immigrant/visible minority groups, contradicting the argument that a healthier immigrant
population can be attributed to advantages arising from such factors.
For midlife women, the findings are less consistent with the HIE hypothesis, and the
disparities are significantly influenced by visible minority status. Further, the study finds that
unlike midlife men, longer term immigrant women in midlife are actually disadvantaged in
health (on both self-reported measures) compared to the Canadian-born, and that these
differences are similar for visible and non-visible minorities even after controlling for socio-
demographic, socio-economic and lifestyle factors.
A different picture emerges in later life for men, particularly for visible minority men, as
recent immigrants 65 years of age and older are more likely to be disadvantaged vis-à-vis self-
reported health even after controlling for key factors. On the other hand, recent visible minority
immigrant women in the latter stages of the life course fare much better on self-reported health
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measures. This advantage, however, disappears when the data are adjusted for other
differences. The same holds true for longer term visible minority immigrant women who are
similarly disadvantaged when socio-demographic, SES and lifestyle factors are held constant.
Based on these findings, a key implication for health care policy and program planning
for immigrant men and women in mid- to late adulthood—individuals that make up over one-
half of the foreign-born adult population in Canada and increasingly larger proportions of the
populations in the US, UK and Australia—is noteworthy here. In particular, the findings
underscore the necessity for policymakers in these countries to address the differential health
care needs of immigrant adults by gender and age group. Recent immigrant visible minority men
in midlife and, to a lesser extent, their later-life female counterparts may have fewer needs for
services and programs in the early years of their residency, while certain new immigrant sub-
groups, namely older men and midlife women of color, may actually have increased needs for
services due to poor health status. This higher need is likely to persist for these women as they
age.
In response to this reality, it is important that policies and programs be developed at
both the national and provincial/state levels—particularly in urban centers in which the majority
of immigrants choose to reside—that: (a) target midlife immigrant and certain sub-groups of
older immigrant women as they age over time; and (b) respond to the needs of an older
immigrant male population from the outset. The fact that “evidence of strong positive selection
effects for immigrants from all regions of origin in terms of education” (Kennedy et al., 2006, p.
i) was found across all four countries in a study seeking to explain the HIE—despite differences
in demographic composition and policy frameworks in the immigration and health care
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domains—provides some evidence to support the cross-national application of these findings
and their policy implications.
An intracategorical analysis of sponsorship status, age and gender
A qualitative enquiry into the experiences of older Punjabi women in the Canadian
province of British Columbia (B.C.) who were sponsored by their adult children (Koehn, 1993)
brought to light the importance of the type of immigration as a marker of difference that
receives very little attention in the literature. Cultural values exert a powerful influence over
family dynamics, gender roles, the construction of identity, and beliefs around health and
illness, as detailed in previous work (Koehn, 1999; 1993). We also know that the immigration
experience itself is a strong determinant of health: “resettlement stress, new pathogens,
poverty, inter-racial and inter-generational conflict and family separation” that is common to
many immigrants can exert a heavy toll on the physical and, most especially, the mental health
of older immigrants (Centre for Addiction and Mental Health (CAMH), 2009; Health Canada &
Kinnon, 1999). Also salient, however, are the effects of discrimination and othering on the
health of these sponsored older adults (Johnson et al., 2004; Koehn, 2009).
In B.C., almost one-third of sponsored or Family Class immigrants are aged 50+ and 60%
are female (BC Stats, 2006). Compared to immigrants overall, arrivals in this class have lower
levels of education and English language ability. India has consistently accounted for the largest
proportion of B.C.’s Family Class immigrants (30% from 2000-04). Unlike sponsored spouses,
these older Family Class immigrants are dependent on their sponsors who must support them
financially for a period of ten years, a significantly longer period than for any other Family Class
group. During the initial dependency period, seniors may not be eligible for public pensions such
as the Allowance, Old Age Security or the Guaranteed Income Supplement, social services,
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subsidized housing or housing subsidies or other local benefits such as reduced fare bus passes
(Koehn et al., forthcoming).
Family Class immigrants account for almost 80% of elders who arrive in Canada after the
age of sixty. Of these late-in-life immigrants, 25 – 40% report no source of income (Dempsey &
Citizenship and Immigration Canada, 2004). Approximately 60% of the income reported by this
group is earned through participation in the labour market. Ageism and racialization combine to
limit job opportunities for these older immigrants, as do limited English skills. These inequities
are perpetuated by the government’s provision of targeted funding to the settlement sector
that prioritizes return-to-work initiatives. English as a Second Language classes for seniors are
thus extremely limited (Friesen & Hyndman, 2004; Koehn, 2009).
At least 50% of all elderly Punjabi Sikh women in Koehn’s (1993) study participated in
farm labour during the summer months. This can be extremely arduous work, typified by long
hours, low wages, and poor working conditions (Assanand, Koehn, & Sethi, 2007; Special Senate
Committee on Aging, 2009). They are nonetheless motivated to offset their sense of
indebtedness to their sponsors and boost their self-esteem (Koehn, 1993). Health hazards
associated with farm work include dermatitis and respiratory problems associated with
exposure to pesticides, and chronic musculoskeletal problems, heat stress and traumatic injury
associated with stoop work over many hours under all weather conditions (Hansen & Donohoe,
2004; Koehn, 1993).
In addition many older immigrants remain economically disadvantaged even after the
ten year period ends, because of the way the residency criterion for Old Age Security is
calculated (Koehn et al., forthcoming). Reciprocal agreements on social security that Canada has
with countries such as Australia, New Zealand, and the United Kingdom translate into more
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residency credits which determine the eventual amount of Old Age Security the person will
receive. Historical inequities in wealth between these Western superpowers and former
colonies such as India, unable to offer reciprocal arrangements of this nature, are perpetuated
by such policies, which are to the detriment of immigrants from these countries (Government of
Canada, 2006). Gender norms that prevented women from participating full-time in the
workforce also contribute to economic disadvantage among older women (Grewal, Nazroo,
Bajekal, Blane, & Lewis, 2004). This is especially true of the immigrants in this group who are
among the poorest in Canada and other immigrant receiving countries (Ahmad & Walker, 1997;
Boyd, 1989; Centre for Addiction and Mental Health (CAMH), 2009; Choi, 2002; Joyce, 2007;
Koehn et al., forthcoming; National Advisory Council on Aging (Canada), 2005; Ordonez, 2006;
Zahno & Rhule, 2008).
As Family Class immigrants, older women can be especially vulnerable and dependent
on their family sponsors. Oppressions experienced earlier in life by this cohort of older
immigrant women often leave them with low levels of social capital (i.e., education, literacy,
experience outside of the domestic sphere) (Koehn, 1993; Raskin, Chiang-Piao Chien, & Keh-
Ming Lin, 1992),
that in turn influences determinants of health and their resettlement
experience. Role reversals between younger and older Punjabi women from India often occur
because younger women here typically enjoy more independence outside of the home, have a
better understanding of Canadian society and its institutions, and speak more English then older
women (Koehn, 1993). The knowledge of older women is often deemed irrelevant here and they
typically exert no economic control, resulting in a considerable drop in social status (Koehn,
1993). This in turn can expose them to abuse and neglect (Carefirst Seniors and Community
Services Association, 2002; Choudhry, 2001; S. Grewal, Bottorff, & Hilton, 2005; Guruge et al.,
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2008; Hossem, 2009; Simmons, 2007; Tam & Neysmith, 2006; Vancouver Cross-Cultural Seniors
Network Society, 2010). Elsewhere (Koehn et al., forthcoming) we have argued that this
situation arises in large part due to the conditions of sponsorship itself.
Discrimination is especially apparent in Canada’s immigration policy that determines
that sponsored parents (i.e., older adults deemed to be an economic burden), should be
dependent on their sponsors for ten years rather than the three years applied to sponsored
spouses (Koehn et al., forthcoming). The reduction in the dependency period for spouses rested
on evidence that the policy created power imbalances and dependency, and increased the risk
of abuse or exploitation (Côté, Kérisit, & Côté, 2001). Yet the same concerns exist for older
Family Class immigrants and for their families upon whom the responsibility for providing a
social safety net falls (Koehn, 1993; McLaren, 2006). McLaren argues that this distinction arises
from immigration policy and associated commentary (e.g., Collacott, 2006) that increasingly
focuses on immigrants’ potential economic value as workers, and frames sponsored parents as
an economic deficit and undesirable burdens on society. This position fails to recognize both the
significant social and financial investment already made by working immigrants’ parents in
raising families to adulthood and of their substantial contribution to the running of the
immigrant household, particularly as child care providers.
Among the older Punjabi participants in Koehn’s (1999; 1993) research, the role of child
care provider is primarily assumed by women as per traditional gender roles. This unpaid
position is accepted because it provides a role for sponsored women and offsets their sense of
indebtedness to their sponsors. While it is satisfying for some, it is also tiring and precludes
participation in activities that support mental and physical health such as exercise or social
gatherings with peers, thus contributing to social isolation (Koehn, 1993; Spence et al., 2009;
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Vancouver Cross-Cultural Seniors Network Society, 2010). Frustration with the role can arise
from a communication/culture gap between themselves and their children, grandchildren and
the community at large. They may not share a language in common with older grandchildren,
ideals around appropriate dress and activities often differ and child-rearing practices may be at
odds with both the child’s parents and the health and education systems in Canada. As a result,
they say, the care giving affects their physical and mental health.
While a complete examination of the dynamics of inequitable access to health care
experienced by EMOA in general is not feasible in this chapter (for which, see for example,
Koehn, Cameron, & Kehoe, 2007; Koehn, 2009; PRIAE (Policy Research Institute on Ageing and
Ethnicity), 2003; Public Health Agency of Canada et al., 2007; Sadavoy et al., 2004), some
features of the intersection of sponsorship with age and gender in particular should be noted.
First, older Punjabi grandmothers responsible for care of their grandchildren and suffering from
a loss of self-esteem often subjugate their own need for medical assistance to the needs of their
grandchildren. Without income, English language skills or subsidized bus passes they will also
need to wait for a busy family member to provide transportation to the doctor’s office—they
rarely drive or even ride bicycles, as do some older Punjabi men—and to provide interpretation
since interpreters are rarely available (Koehn, 2009; 1993). As a result, care providers report
that they often see these older sponsored immigrants, particularly women, in a crisis. Moreover,
during their first ten years in Canada, they are not eligible for more than basic health services:
rehabilitative services or long-term care for example, are not publicly available to them. A
decline in health status during this period can thus prove disastrous for family members and
may result in a breakdown of the sponsorship relationship (Koehn et al., forthcoming). These
factors in turn have deleterious consequences for their physical and mental health (Centre for
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Addiction and Mental Health (CAMH), 2009; Public Health Agency of Canada et al., 2007;
Sadavoy et al., 2004; Vancouver Cross-Cultural Seniors Network Society, 2010; Williams & Hunt,
1997).
The above research examples provide two important illustrations of the different
methodological approaches to interrogating intersectionality in ethnicity and aging research. In
particular, they underscore the need to appreciate and understand different epistemological
standpoints in examining the complex nature—both social structural and cultural—of health
inequities in multi-ethnic societies.
VI. Conclusions
Significant changes in the demographic composition—i.e., the ethnicization and aging—
of the populations in countries like Canada, the US, and the UK have been the impetus for much
of the recent development in theory and research on ethnicity and aging over the past two and
a half decades. Indeed, a large proportion of the research in this area comes from these
increasingly multicultural countries, research that has focused for the most part on outcomes in
the health and social support domains. This chapter has provided an overview of this emergent
and diverse body of literature, and, in the process of reviewing the work, identified several key
issues that warrant further research and/or policy attention.
First, in terms of theoretical directives, the application of an intersectionality
perspective to the study of ethnicity and aging has much promise as it underscores the
importance of understanding the differential impacts that markers of social inequality have on
the social support and health outcomes of ethno-cultural older adults. In order to adequately
address health and social inequities in such populations, a move beyond an analysis of one or
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two possible predictors like ethnicity and age to explore the intersecting influence of several
markers of difference (gender, SES, marital status, geographic place of residence, and sexual
orientation, to name a few), is necessary. An acknowledgement of the complexity inherent in
the production of health and social support in ethnic older adult populations calls for an
understanding of the intersecting relations between these factors.
With regard to physical health status, Canadian research on the “healthy immigrant
effect,” has shown that age does matter in evaluating the health of adult immigrants over time
(Gee et al., 2004). Findings from this area suggest that older immigrants from South Asian or
Asian source countries like India or China may experience changes in health status as lifestyle
behaviours change at an accelerated rate after immigration, and that the rate at which such
behaviours converge to the Canadian norm will, of course, vary according to a number of
different factors related to assimilation and acculturation processes including: age at
immigration; country of birth; level of adherence to traditional (country of birth) value and
belief systems; place of residence (urban versus rural); and degree of institutional completeness
of the immigrant’s ethno-cultural group in the place of residence. And, as Koehn’s work with
South Asian older adults indicates, such processes are inherently marked by experiences of
discrimination at the micro-, meso- and macro-level from pre- to post-immigration.
An examination of the intersections of gender and sponsored immigrant status reveals a
plethora of implications for other determinants of health such as housing environment and SES
as well as access to health care. Women who are sponsored by their adult children to provide
care for grandchildren are economically dependent for ten years and isolated due to a
combination of caregiving responsibilities, lack of English language skills and experience with
Canada or social institutions in general, and no access to subsidized transportation. They are
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unable to access health care without the assistance of busy adult children who must provide
interpretation and transportation and, as a result, they have no means of communicating
familial abuse to the outside world. Researchers thus need to pay more heed to the
multidimensionality of immigrant status so as to acknowledge different types of immigration
and their impact on access to resources, and their implications for social support and health
care. In the end, these and other related factors should be considered in the development of
any comprehensive Canadian health and social care policy and program planning initiatives for
ethnic adults in mid life, given that adults currently in this group represent a rapidly growing age
group in the country, and later life.
Finally, in the policy arena, a number of different recommendations emerge from an
evaluation of the ethnicity and aging research over the past two decades. First, as underscored
earlier, health and social care policymakers in Canada, the US, and the UK must continue to
address key issues related to the growing ethnic diversity in their populations; in particular, the
differential health and social care needs of immigrant adults by gender and age group. For
example, as Kobayashi and Prus (forthcoming) point out, recent immigrant visible minority men
in midlife and, to a lesser extent, their later life female counterparts, may have fewer needs for
services and programs in the early years of their residency in Canada, while certain new
immigrant sub-groups, namely older men and midlife visible minority women, may have
increased needs for services due to poor health status. This increased need is likely to continue
for these women as they age in Canada. In response to this reality, it is important that policies
and programs be developed at both the federal and provincial levels, particularly in Ontario
(Toronto), Quebec (Montreal), and British Columbia (Vancouver), provinces in which the
majority of immigrants choose to reside, that: (a) target midlife immigrant and certain sub-
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groups of older immigrant women as they age over time; and (b) respond to the needs of an
older immigrant male population from the outset.
Immigration and related policies and regulations ranging from pensions to housing
bylaws also require scrutiny with respect to their implications for the health and health care
access of older adults, as detailed in Koehn, Spencer and Hwang (Koehn et al., forthcoming).
Central is the recommendation, now adopted by the Special Senate Committee on Aging (2009),
that the dependency period for sponsored parents be reduced from ten years to three in line
with sponsored spouses. In critiquing the World Health Organization for paying insufficient
attention to the power relations that shape social determinants of health, Navarro (2009, p.
440) states that “It is not inequalities that kill people, . . . it is those who are responsible for these
inequalities that kill people.”
Over the past two decades, research on ethnicity and aging has continued to reflect the
increasing ethnic diversification of the older adult population globally. As social researchers
increasingly facilitate the translation and exchange of this knowledge with various key
stakeholders including policymakers, health care practitioners, front-line workers, family
members, and the older adults themselves are likely to see continued growth and the uptake of
important work in this area. Through the inclusion and exploration of the experiences of a
broader group of older ethnic adults, individuals in their informal and formal support networks,
and those who have the power to empower these individuals through the establishment of
culturally appropriate policies and programs in their home countries, we are setting a strong
foundation for future research on aging populations across the world.
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