ICARE Forum: Knowledge. Power. Access - Summary Report

Abstract

Purpose of the Forum:
The ICARE forum Knowledge. Power. Access. was held on June 25, 2009 from 10:00 a.m. to 4:00 p.m. at
Langara College in Vancouver, British Columbia.
The forum provided an opportunity for the ICARE team to introduce and communicate our purpose to a
diverse group of stakeholders from the multicultural settlement, community, health service provider and
academic sectors. Participants worked collectively to develop research questions in each of the three
prioritized theme areas:
1. Immigrant Women‐Centred Chronic Disease Care Model.
2. Older Visible Minority Immigrant Grandmothers as Caregivers.
3. Community Resources for Older Immigrant Women’s Mental Health.
THE STATED FORUM OBJECTIVES WERE:
- To clarify how gender, age and immigration can interact to create barriers to health care
access for older visible minority immigrant women.
- To identify and develop research questions in each of the three prioritized topic areas.
- To collectively identify and prioritize next steps for action.
- To create opportunities for participants to stay involved with the project.
Overview of Forum Structure:
An introductory panel provided the context for the forum. Two older women from the South Asian and
Chinese communities presented personal and peer‐based perspectives on health and health care access
issues for older visible minority immigrant women.
In the latter part of the morning participants were led through an interactive exercise to explore how
constructions of gender, age, immigration and visible minority status may interact to influence individual
health care experiences.
For the remainder of the day, three concurrent roundtables explored each of the three prioritized theme
areas. Roundtables began with panel discussions led by members of the ICARE team. Throughout the day
facilitators for each group led participants through a series of exercises intended to articulate research
priorities and begin to develop research questions.

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TableofContents
TableofFigures ............................................................................................................................................................... 3
Acknowledgements ........................................................................................................................................................ 5
Background......................................................................................................................................................................... 7
AbouttheImmigrantOlderWomen–CareAccessibilityResearchEmpowerment(ICARE)team.... 7
Whylookatoldervisibleminorityimmigrantwomen’shealth?.................................................................................7
ResearchFocus...................................................................................................................................................................................7
Context...................................................................................................................................................................................................7
TheICAREForum:Knowledge.Power.Access...................................................................................................... 9
PurposeoftheForum......................................................................................................................................................................9
OverviewofForumStructure......................................................................................................................................................9
Participants.......................................................................................................................................................................................10
LayingtheFoundation................................................................................................................................................. 11
IntersectionalityFramework.................................................................................................................................................... 11
ImmigrationinRelationtoWomen’sHealthandHealthCareAccess .................................................................... 12
ApproachtoStudyingHealthCareAccess .......................................................................................................................... 12
PersonalandPeer‐BasedPerspectivesofImmigrantWomen’sHealth&HealthCareAccess....................13
ConcurrentRoundtables ............................................................................................................................................15
ImmigrantWomenCentredChronicDiseaseCareModel..............................................................................15
RoundtableParticipants.............................................................................................................................................................. 15
ProblemswiththeConventionalChronicDiseaseSelf‐Management(CDSM)Model ...................................... 15
ChronicDiseaseRiskFactorsforOlderVisibleMinorityImmigrantWomen ..................................................... 16
HealthPromotingPracticesbeingusedbyOlderVisibleMinorityImmigrantWomen.................................. 17
TowardsanImmigrantWomen‐CentredChronicDiseaseCareModel..................................................................18
DevelopingaResearchFramework ....................................................................................................................................... 19
OlderVisibleMinorityImmigrantGrandmothersasCaregivers ................................................................. 20
RoundtableParticipants.............................................................................................................................................................. 20
IssuesaffectingOlderVisibleMinorityImmigrantGrandmothersasCaregivers ............................................. 21
SupportingGrandmothersasCaregivers:WhatModelsareWorking?.................................................................. 24

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DevelopingaResearchFramework ....................................................................................................................................... 24
CommunityResourcesforOlderImmigrantWomen’sMentalHealth....................................................... 27
RoundtableParticipants.............................................................................................................................................................. 27
RiskFactorsforPoorMentalHealth......................................................................................................................................27
BarrierstoMentalHealthServices......................................................................................................................................... 28
SupportingPositiveMentalHealth:WhatModelsareWorkingintheCommunity? ....................................... 29
Ideas:What’sneeded?.................................................................................................................................................................. 30
DevelopingaResearchFramework ....................................................................................................................................... 30
NextSteps......................................................................................................................................................................... 32
ReferencesCited............................................................................................................................................................33
Appendices ......................................................................................................................................................................37
AppendixA:AFrameworkforWomen‐CentredHealth ............................................................................................... 37
AppendixB:ForumProgram .................................................................................................................................................... 38
AppendixC:PresenterBiographies ....................................................................................................................................... 40
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TableofFigures
Figure1:TotalICAREForumParticipants...............................................................................................................................10
Figure2:ICARETeamComposition............................................................................................................................................ 10
Figure3:ImmigrantWomen‐CentredChronicDiseaseCareModelRoundtableParticipants.........................15
Figure4:OlderVisibleMinorityImmigrantGrandmothersasCaregiversRoundtableParticipants ............ 20
Figure5:CommunityResourcesforOlderImmigrantWomen’sMentalHealthRoundtableParticipants.27
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REPORTPREPAREDBY
MelanieSpence,SharonKoehnandKarenKobayashi
onbehalfoftheImmigrantOlderWomen–CareAccessibilityResearchEmpowerment(ICARE)team.
September23,2009

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Acknowledgements
TheICAREteamisfundedbyaTeamInfrastructureGrant(2009‐2010)fromtheWomen’sHealth
ResearchInstitute.TheICAREforumKnowledge.Power.Access.wasmadepossiblebytheadditional
fundingand/orsupportin‐kindreceivedfromtheBCHomeandCommunityResearchNetwork,the
Women’sHealthResearchNetwork,theBCNetworkofAgingResearchandLangaraCollege:
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ManythanksarealsoextendedtotheICAREteam:
PrincipalInvestigators:
 KarenM.Kobayashi,PhD,DepartmentofSociology/CentreonAging,UniversityofVictoria
 SharonKoehn,PhD,CentreforHealthyAgingatProvidence(CHAP)/UniversityofBritish
Columbia
ResearchAssistant:
 MelanieSpence,Hon.BA,CentreforHealthyAgingatProvidence(CHAP)
ICARETeamMembers:
 RevaNAdler,MD,MPH,FRCPC,VancouverCoastalHealthAuthority/UniversityofBritish
Columbia
 SatwinderBains,MEd,PhD(C),UniversityoftheFraserValley
 JoanBottorff,PhD,RN,FCAHS,UniversityofBritishColumbiaOkanagan
 DaljitGill‐Badesha,MA,DIVERSEcity
 SukhdevGrewalRN,MSN,LangaraCollege
 LokayataKular,DIVERSEcity
 JanetKushner‐Kow,B.Sc.,MD,MEd,FRCPC,ProvidenceHealthCare,VancouverCoastalHealth
Authority,UniversityofBritishColumbia
 EricLau,S.U.C.C.E.S.S.
 NoreenSimmons,PhD,SLP,BCFamilyHearingResourcesSociety
 SaleemSpindari,BA,MOSAIC

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SpecialthanksareduetoICAREteampartnersAndreaCosentino(BCNetworkforAgingResearch
(BCNAR)),AmyJohal(BCNAR),andColleenReid(Women’sHealthResearchNetwork(WHRN))fortheir
keendirectionandassistanceinplanningtheforum.WearegratefultoElanaBrief(WHRN),Karen
Kobayashi,andColleenReidfortheirskilledfacilitationoftheroundtablediscussions,andfurthermore
toElanaandColleenformoderatingtheforum.ThankyoutoMohinderSidhuandMaggieIpforsharing
theirexperiencesandknowledgeofhealthcareaccessissuesforoldervisibleminorityimmigrant
women.Manythanksaswelltotheroundtablepanelistswhosetthegroundworkfortheday’s
discussions.Thanksareduetoourvolunteernotetakers:BaljitDhaliwal,GloriaMui,andHarshada
Pradhan.Finally,thankstoyou,ourparticipants,foryourdedication,passionandcommitmentto
improvingthehealthofoldervisibleminorityimmigrantwomeninBritishColumbia.

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BACKGROUND
AbouttheImmigrantOlderWomen–CareAccessibilityResearchEmpowerment
(ICARE)team
Whylookatoldervisibleminorityimmigrantwomen’shealth?
ThenumberofolderimmigrantwomeninBritishColumbiaisgrowing,butresearchisnotkeepingpace.
ThelargestproportionofwomeninthisgroupcomesfromChinaandIndia.Mostaresponsoredbytheir
families,whichrendersthemfinanciallydependentfortenyears.Manyarewidows.Oftentheyprovide
much‐neededchildcareservicesfortheirgrandchildren.Thesefactorsalonecanmakeaccesstohealth
careverychallenging.Suchchallengesneedtobeunderstoodinthecontextoftheconsiderable
discriminationthatmanyofthesewomenhavefacedthroughouttheirlives.Limitedaccesstoeducation,
paidworkopportunities,andfreedomoutsideofthehomehasleftmanywithouttheskillstoovercome
suchbarriers.Furthermore,asoldervisibleminoritiesinanunfamiliarculturalenvironmenttheyare
alsosusceptibletodiscriminationbasedontheirage,genderandskincolour.
ResearchFocus:
ThepurposeoftheICAREteamistodeveloparesearchprogramthatexploresthemyriadwaysinwhich
intersectingoppressions,experiencedbeforeandafterimmigration,influenceaccesstohealthcareby
oldervisibleminorityimmigrantwomen.
Context:
Ethnoculturalminorityolderadultsareneglectedinbothresearchandsocialandhealthpolicybecause
theirnumbersarethoughttobetooinsignificanttoconstitutea‘problem’.Genderedanalysesofthisage
grouparelikewiseextremelyrare.Buthealthinequitiesareoftenexperiencedfarmoredramaticallyand
atgreatcosttoindividuals,familiesandhealthcaresystemsbysuchminorities,indicatingtheneedto
directresearcheffortstoaddressingthosewiththehighestunmetneeds.Moreover,thenumbersareno
longerinsignificant.OlderadultsrepresentthefastestgrowingsegmentoftheCanadianpopulationand
averagemorethantwotimesthenumberofphysiciancontactsperyearthandopersonsundertheageof
65.1Althoughtheagingprocesscanbepositive,italsopresentschallengesrelatedtobothphysicaland
sociallossesoverthelifecourse.Theexperienceofsuchlossesdiffersconsiderablyaccordingtovariables
suchasethnicity,gender,andimmigrationstatus.
IntheGreaterVancouverregionin2006,one‐third(31%)ofthepopulationaged65+werevisible
minorities,80%ofwhomwereChinese(56%)andSouthAsian(24%).2Between2002and2006,65%of
foreign‐bornolderadultsarrivedinB.C.withoutofficiallanguageability.3Refugeesaccountedforonlya
smallproportion(4%)ofimmigrantolderadultsduringthisperiod;themajority(88%)arrivedas
FamilyClassimmigrants;usuallyasparentsandgrandparentssponsoredbychildrenandgrandchildren.
Bothclassesofimmigrantolderadultshavepoorerhealththanlong‐termimmigrantsandtheCanadian‐
bornpopulation.4‐7
InBC,almostone‐thirdofFamilyClassimmigrantsareaged50+and60%arefemale.8Comparedto
immigrantstoCanadaoverall,arrivalsinthisclasshavelowerlevelsofeducationandEnglishlanguage

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ability.IndiahasconsistentlyaccountedforthelargestproportionofFamilyClassimmigrantstoBC(30%
from2000‐04),withChinabeingsecond.Overall,however,theChinesehaveconstitutedthelargest
proportion(28%)ofallimmigrantolderadultstoBCfrom2002‐2006;thosefromIndiawerethesecond
largestgroup(18%).3

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TheICAREForum:Knowledge.Power.Access.
PurposeoftheForum:
TheICAREforumKnowledge.Power.Access.washeldonJune25,2009from10:00a.m.to4:00p.m.at
LangaraCollegeinVancouver,BritishColumbia.
TheforumprovidedanopportunityfortheICAREteamtointroduceandcommunicateourpurposetoa
diversegroupofstakeholdersfromthemulticulturalsettlement,community,healthserviceproviderand
academicsectors.Participantsworkedcollectivelytodevelopresearchquestionsineachofthethree
prioritizedthemeareas:
1. ImmigrantWomen‐CentredChronicDiseaseCareModel.
2. OlderVisibleMinorityImmigrantGrandmothersasCaregivers.
3. CommunityResourcesforOlderImmigrantWomen’sMentalHealth.
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THESTATEDFORUMOBJECTIVESWERE:
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 Toclarifyhowgender,ageandimmigrationcaninteracttocreatebarrierstohealthcare
accessforoldervisibleminorityimmigrantwomen.
 Toidentifyanddevelopresearchquestionsineachofthethreeprioritizedtopicareas.
 Tocollectivelyidentifyandprioritizenextstepsforaction.
 Tocreateopportunitiesforparticipantstostayinvolvedwiththeproject.
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OverviewofForumStructure:
Anintroductorypanelprovidedthecontextfortheforum.TwoolderwomenfromtheSouthAsianand
Chinesecommunitiespresentedpersonalandpeer‐basedperspectivesonhealthandhealthcareaccess
issuesforoldervisibleminorityimmigrantwomen.
Inthelatterpartofthemorningparticipantswereledthroughaninteractiveexercisetoexplorehow
constructionsofgender,age,immigrationandvisibleminoritystatusmayinteracttoinfluenceindividual
healthcareexperiences.
Fortheremainderoftheday,threeconcurrentroundtablesexploredeachofthethreeprioritizedtheme
areas.RoundtablesbeganwithpaneldiscussionsledbymembersoftheICAREteam.Throughouttheday
facilitatorsforeachgroupledparticipantsthroughaseriesofexercisesintendedtoarticulateresearch
prioritiesandbegintodevelopresearchquestions.

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Participants:
Therewere60participantsinattendance.Participantsreflectedadiversityofsectorsandpositions,
includinghealthprofessionals,multiculturalsettlementworkers,olderadults,policymakersand
researchers.MostparticipantscamefromBC’sLowerMainland;howevertherewasalsorepresentation
fromtheFraserValley,theInteriorofBC,andVancouverIsland.
ThefollowingdiagramillustratestheparticipantbreakdownbysectorforthetotalnumberofICARE
forumparticipants.
32%
22%
10%
3%
17%
8%
8% ICARETeam&Partners
Research ers
GovernmentRepresentatives
Front‐lineHealthServiceProviders
MulticulturalSettlement&
CommunityAgencyWorkers
OlderAdults
HealthAdministrators

Figure1:TotalICAREForumParticipants(n=60)
47%
37%
16%
ICARETeamMembers
ICAREPartners
ICAREForumVolunteers

Figure2:ICARETeamComposition(n=19)

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LayingtheFoundation
ThefollowingconceptualframeworksreflecttheICAREteam’sapproachtohealthcareaccessforolder
visibleminorityimmigrantwomen,andserveasatheoreticalgroundingforeachofthethreeroundtable
topics.
IntersectionalityFramework:
Thesociallossesoftenassociatedwithagingaremorefrequentlyandacutelyexperiencedwhenthey
intersectwithgender,visibleminorityandimmigrantstatus.Accesstohealthservices,employment,
childcareandotherkeyresourcesnecessaryforpromotingandsustaininghealtharedeterminedbythe
dynamicintersectionofsociodemographiccategoriessuchasgender,ageandimmigrationstatus.
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(forexample,sexism,ageismandracism).9
FortheICAREteam,anintersectionalapproachbehoovesustoaskhowgender,age,ethnicity,visible
minorityandimmigrationstatusinteracttocreatebarrierstohealthandsocialcareaccessforolder
visibleminorityimmigrantwomen.
Althougholderwomenareunderrepresentedinhealthresearch,10considerableevidenceexiststolink
healthinequitieswiththesocialdeterminantsofhealth,amongwhichgenderandculturalfactorshave
cross‐cuttinginfluences.Biologicaldifferencesintersectwithsocio‐politicalconstructionsofgenderto
producehealthinequitiesthatbecome,forexample,“violenceagainstwomen,lackofaccesstoresources
andopportunities,andlackofdecision‐makingpoweroverone’sownhealth.”11
ForolderChineseandSouthAsianimmigrantwomen,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.10Inpracticalterms,racismaffectshealththroughsystemicandindividual‐level
occurrencesofdiscrimination,marginalization,andsusceptibilitytopoverty,tonameafew.10
EthnicityisdefinedbytheWomen’sHealthResearchNetworkas:“…agroup’ssharedculturalheritage
basedoncommonancestry,language,music,foodandreligion.”10Likerace,ethnicityisafundamental
determinantofhealth.Culturalpracticesontheirowndonotnecessarilydeterminehealth;ratheritis
thetreatmentofcultural/ethnicdifferenceswithin,forexample,ourhealthcaresystemthat
(re)produceshealthinequalitiesforethnoculturalminorities.
ApplyingIntersectionalitytoResearchDesign:
Inpracticalterms,anintersectionalperspectiveinformshowresearchisdesigned,fromthetypesof
questionsweasktoprocessesofknowledgetranslationandexchange.
Whendevelopingaresearchquestion,anintersectionalityframeworkimplicateswhatisoftenreferredto
asa“bottom‐up”orinductiveapproachthatrecognizesandvalidatesanindividual’sknowledgeand
authorityovertheirownuniquesetofexperiences.9Researchquestionsshouldfurthermoreaimtobring
historicallymarginalizedperspectivesandexperiencestotheforefront.9

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Thequestionofhowknowledgeistranslatedintoactioniscriticalwithinanintersectionalapproachto
research.Intersectionalityencouragestheinvolvementofmultipleanddiversestakeholders;assuch,
plansforknowledgetranslationandexchangeshouldbedevelopedcollaborativelybetweenthese
groups.9
ImmigrationinRelationtoWomen’sHealthandHealthCareAccess:
Theimpactoftheprocessofimmigrationonoldervisibleminoritywomen’shealthisdifficultto
disentanglefromotherfundamentaldeterminantsofhealth.10Itisclear,however,thatoppressions
experiencedearlierinlifebythiscohortofolderimmigrantwomenoftenleavethemwithlowlevelsof
socialcapital(e.g.lackofeducation,experienceoutsideofthedomesticsphere,andilliteracy)12,13thatin
turninteractwithethnicityandotherdeterminantsofhealthtoinfluencetheresettlementexperience.
Theimmigrationexperienceitselfcriticallyinfluenceshealth.The“resettlementstress,newpathogens,
poverty,inter‐racialandinter‐generationalconflictandfamilyseparation”commontotheexperienceof
manyimmigrantscanexertaheavytollonthephysicaland,mostespecially,thementalhealthof
immigrants.14Theintersectionofgenderandtheimmigrationexperiencerenderswomenespecially
vulnerabletopsychologicaldistress.15
Asimmigrants,womenencounternewformsofoppressionbasedontheirimmigrantstatus,racialization
andstatuswithinthefamilywhichcanrenderthemvulnerabletosocialisolationandloneliness,16,17
familyconflict(possiblyevenabuseandneglect),16‐19andeconomicinsecurity.20,21Thesefactorsinturn
havebeenfoundtonegativelyinfluencehealth.22,23
ApproachtoStudyingHealthCareAccess:
Thehealthinequitiesofolderimmigrantwomenhighlighttheneedtobetterunderstandtheirunique
healthcareaccessexperiences.However,theconceptofhealthcareaccessisextremelycomplexandhas
beenfraughtwithinaccurateassumptions.Studieshaveshown,forexample,thatlong‐heldbeliefsby
providersthatcertainvisibleminoritypopulations“takecareoftheirown”,resultinginlowerformal
serviceneeds,isflawed,andthatthisbeliefitselfcaneffectivelylimitaccessbyshiftingtheburdenof
responsibilitytofamilycaregivers.24‐27Likegenderstereotyping,suchracializedandculturalist
explanationsofneedoperateasabarriertohealthcareaccessforoldervisibleminorityimmigrant
women.
TheICAREteamhasadoptedarecently‐developedmodelonaccesstohealthcarebyvulnerable
populationsthatidentifiesmultipleintersectingpointsalongthecontinuumofcareatwhichhealthcare
accessisnegotiatedandcanbecompromised.27‐29Thesevendimensionsofthemodelincludethe
person’sself‐identificationoftheneedforcare,theirabilitytoidentify,locateandgettothecarethey
need,theinteractionsbetweenpatientandproviders,involvingboththepatient’spresentationoftheir
claimforcareandtheprovider’sassessmentofthatclaimthatmayormaynotresultinappropriate
treatmentorfollow‐up,thepatient’sdecisiontoacceptorrejectthetreatmentorreferral,theextentto
whichparticularservicesareaccessiblerelativetotheresources(suchastime,money,andknowledge)
availabletopatients,andspecificlocal(forexample,geographic)andpolicylevelfactorsinfluencingcare
options.Itisourbeliefthatthismodelholdsgreatvalueforfacilitatingacomprehensiveandsystematic
understandingofhealthcareaccessforethnoculturalminorityolderwomen.

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PersonalandPeerBasedPerspectivesofImmigrantWomen’sHealth&HealthCareAccess:
Aspartof“layingthefoundation”fortheICAREforumtwospeakers,MohinderSidhuandMaggieIp,
providedpersonalandpeer‐basedperspectivesonSouthAsianandChineseolderimmigrantwomen’s
healthandhealthcareaccessissues,respectively.Theirpresentationsaresummarizedinthearticle
belowpublishedbytheGeorgiaStraightnewspaperonJuly9th,2009.30

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
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CONCURRENTROUNDTABLES
ImmigrantWomenCentredChronicDiseaseCareModel
RoundtableParticipants:
24%
20%
16%
4%
12%
12%
12%
ICARETeam&Partners
Researchers
GovernmentRepresentatives
Front‐lineHealth Service
Providers
MulticulturalSettlement&
CommunityAgencyWorkers
OlderAdults
HealthAdministrators

Figure3:ImmigrantWomenCentredChronicDiseaseCareModelRoundtableParticipants(n=25)
ProblemswiththeConventionalChronicDiseaseSelfManagement(CDSM)Model:
TheChronicDiseaseSelf‐ManagementPrograminBritishColumbia(CDSMP)teachespatientsthe
practicalskillsneededtocopewithandmanagetheirchronicdiseases.31Coursesareledbytrained“lay
leaders”whomeetwithgroupsof10to12peoplewithchronicconditionsfortwoandahalfhourseach
weekforasix‐weekperiod.31Individualsaregivenlessonsonperformingactivitiesofdailylivingsuchas
healthyeating,exercisingandcommunicationskills.31TheCDSMmodelisintendedtosupporttraditional
patienteducationprovidedbyhealthprofessionalsinprimarycaresettings.
ParticipantsinthisroundtableexpressedconcernthattheconventionalCDSMmodelfailstoconsiderthe
uniqueneedsofethnoculturalminoritywomenwithchronicdiseases,specificallySouthAsianand
Chineseolderwomen.PanelistsJoanBottorffandSukiGrewalpresentedaschematicframeworkfor
discussingthecontextual,interrelateddimensionsofwomen’shealth(seeAppendixA).Inadditiontothe
keydeterminantsofhealthsuchaseducation,incomeandbiology/genetics,awomen‐centredhealth
frameworkincludesconsiderationsofwomen’sinvolvementandparticipationinservicedesignand
delivery,preferencesinobtainingcareandempowerment.32
Theoverarchingquestionsthatemergedfromthisroundtablewere:(1)Istheframeworkforwomen‐
centredhealthtrulypractical?(2)Whatwoulditlookliketoimplementalloftheseoptionsinpractice?

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Whenconsideredinconjunctionwithanintersectionalityapproach,thewomen‐centredhealth
frameworkprovidesastartingpointforguidingpolicymakersastohowthehealthcaresystemmight
bestrespondtotheuniquechronicdiseasemanagementneedsofoldervisibleminorityimmigrant
women.Thefirststepistofindoutwhatthoseneedsare,understandingthattheywillbeshapedbythe
manywaysinwhichculture,ethnicity,age,immigrationstatus,visibleminoritystatus,andgendercan
convergetodetermineanindividualwoman’suniquehealthexperiences.Appropriatehealthsystem
responsestoolderSouthAsianandChinesewomen’schroniccareneedswillinvolve:(1)gender‐
inclusivemethodsofresearch;(2)gender‐inclusivecurriculainmedicalschools;(3)knowledgeofhow
systemicinequalitiesimpactwomen’shealth;and(4)recognitionofservicedeliveryprocessesthat
engageandempowerwomen.32
ChronicDiseaseRiskFactorsforOlderVisibleMinorityImmigrantWomen:
Chronicdiseaseriskfactorsforoldervisibleminoritywomenwerediscussedwithinthecontextofthe
entireimmigrationexperience,frompre‐topost‐immigration.Themajorityofdatabroughtintothe
roundtablediscussionwasfromworkdonebythepanelistswithintheSouthAsiancommunity.Future
workinggroupdiscussionsshouldstrivetoadditionallyincludeinformationfromtheChinese
community.
Pre‐ImmigrationHealthStatus:
Aspreviouslydiscussed,oppressionsexperiencedbyoldervisibleminorityimmigrantwomenpre‐
immigrationoftenleavethemwithlowlevelsofsocialcapitalthatinturninfluencehealthoutcomes
throughtheresettlementexperience.
Immigrantwomenareatgreaterriskthanmenfordevelopingcertainchronicdiseases.Forexample,
SouthAsianwomenareatahigherriskthanmenfordevelopingheartdisease.33,34TheHeartandStroke
Foundationrecognizesthistrendandiscurrentlylookingtocollaborateonresearchtoexaminethis
issue.
InIndia,53%ofdeathsarerelatedtochronicdiseases.35IndiahasthehighestrateofTypeIIDiabetesin
theworld,34anddiabetes‐relatedvisuallossiscommonlyseeninSouthAsianwomen.36
Post‐ImmigrationRiskFactors:
Therearemanybarriersoperatingonindividual,communityandorganizationallevelswithinthepost‐
immigrationcontextthatpredisposeoldervisibleminorityimmigrantwomentodevelopingchronic
diseases,andmoreovercreatedifficultyincontrollingtheprogressionofchronicdiseases.
Languagebarriersoftenpreventolderimmigrantwomenfromunderstandinghowtonavigatethehealth
systemandaccessappropriatehealthservices,suchasmedicalspecialists.Inthedoctor’soffice,language
barriersrequireinterpretation,ataskmostoftenperformedbyfamilymembersalthoughthisisfarfrom
ideal.Thedisclosureofintimatehealthconcernstofamilymembersinthedoctor’sofficeisproblematic
forsomeolderimmigrantwomendependingontheage,genderandnatureoftheirrelationshipwiththe
familymemberwhoisinterpreting.Olderwomenmayalsobedependentonfamilymembersfor
transportationtoandfromthedoctor’soffice.

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OlderSouthAsianandChineseimmigrantwomenmayfurthermorebeunawareofexistinghealth
services.Forexample,manyofthesewomenarenotawareoftheavailabilityofcancerscreeningtests.
Additionalbarriersmaypresentevenwhenthereisanawarenessoftheseservices;forexample,the
genderofthecareprovidermaybesignificantforsomewomenwhoareuncomfortablespeakingabout
theirhealthconcernstoamalephysician,particularlyayoungerone.37
Manyolderimmigrantwomenmaynothavethetimeorresourcestoseekoutthehealthservicesthey
need,particularlyiftheyaresponsoredbytheirfamiliestolookaftergrandchildrenandperform
householdchores.Theseresponsibilitiesoftenmakeitdifficultforolderwomentofindthetimetoaccess
notonlyhealthservices,butbroadersocialsupportservicessuchascommunitygroupsthatsupportthe
developmentofgoodhealth.
FortheSouthAsiancommunityinBC,changingfood/nutritionhabitscanleavewomenatriskfor
developingdiabetes,heartdiseaseandotherchronicdiseases.Richfoodsareeasilyavailableand
affordableinCanada,incontrasttothesimplerfoodsthatmainlycomprisepeople’sdietsinIndia.In
Canadarichfoodsbecomeassociatedwithstatus,andpeople’sintakeofthesefoodsincreases.
Theself‐caremodelpresentsmanyassumptionsaboutanindividual’sabilitytonavigatethehealth
systemthatmaynotbetrueformanyoldervisibleminorityimmigrantwomen.Forthosewhohave
limitedmeansoftransportation,moneyandEnglishlanguageskills,systemicbarrierstohealthcare
accessexist.Traditionalhealthcaremodelsareliteracy‐centred,andthereisalackofresourcesfor
womentoknowwheretogoforhealthpromotionanddiseasemanagement.Questionsastowhoto
contactfordiseasemanagementandwhatservicesareavailableareprevalent.Difficultiesnavigatingand
accessinghealthservicesmeansthatforsomewomenchronicdiseasemaygoundiagnosedand/or
unmanaged.
HealthPromotingPracticesbeingusedbyOlderVisibleMinorityImmigrantWomen:
Religiouscentresprovideanimportantspaceforhealthpromotionamongolderimmigrantwomen.For
SouthAsianwomen,weeklyvisitstothetempleprovideanopportunitytosocializewithpeerswhilealso
addressingspiritualhealthneeds,combatingthesocialisolationexperiencedbymanyasaresultoftheir
householdandfamilyresponsibilities.
Someolderimmigrantwomenalsochoosetopracticetraditionalformsofhealthmaintenance.38Taichiis
oneexampleofatraditionalformofexercisethatagrowingnumberofolderChinesewomenpractice.
Communitycentresandneighbourhoodhousesareotherplaceswhereolderwomenmaysocializeand
findsupportamongpeers.Variouswomen’sgroupshelpaddresswomen’sphysical,socialand
psychologicalhealthneeds.Forexample,women’s‘walkinggroups’helpthemtogetoutofthehouseand
exercisewhilesocializingatthesametime.Manywomenareaccessinghealthservicesthroughsuch
‘informal’meansbyapproachingfamilyandfriendstogettheappropriateinformation.19
Forallofthesehealthpromotingpracticesundertakenbyolderimmigrantwomentherearealsobarriers
–manyofthemstructural.Forexample,whilecommunitycentresmayoffersupportgroups,older
womenareoftenunabletofindthetime,transportationandmoneyneededtoparticipateincommunity
programming.

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TowardsanImmigrantWomenCentredChronicDiseaseCareModel:
Throughoutthecourseofthedaythegroupbegantodiscussthenecessaryelementsofachronicdisease
caremodeltailoredtosuittheneedsofolderChineseandSouthAsianimmigrantwomen.
WhatModelsareWorking?
DiseasemanagementclinicsarepopularwithSouthAsianandChinesecommunitiesbutfundingis
limited.Paptest/breastexamclinicsinitiatedintheSouthAsiancommunitywereverysuccessful:
womentendedtobringupmanyotherhealthproblemswhenbeingexaminedbyfemalephysicianswho
spoketheirlanguage.Thebiggestdrawbackoftheseclinicswasthattherewasnocapacityormandate
forhealthproviderstodealwithwomen’sbroaderhealthconcerns.39
Fundedservicesandprogramsthatareofferedthroughtrustedcommunityorganizationshavebeen
successfulinrecruitingolderimmigrantwomen.Forexample,apilotscreeningprograminCalgarytested
forcardiovasculardiseaseamongSouthAsianindividualsinfourdifferentlanguages.40Theindividuals
performingthescreeningtestswerespecifically‐trainedlayvolunteersfromtheIndo‐Canadian
community.40,41Ofthosescreened,81%ofhighriskwomenand82%ofhighriskmenfollowedupwith
theirfamilyphysicianswithinayear;however,only45.5%ofhighriskwomenand30%ofhighriskmen
wereactuallyreferredtoaspecialist.41Ofthosereferred,87%ofwomenand100%ofmenattendedthe
appointment.41Testswereofferedatthetempleduringevenings;interestinglysimilartestsofferedat
communitycentreswerenotaseffectiveinrecruitingpeopletotheprogram.
Self‐careoptionssuchasyogacanworkifprovidedinanenvironmentfamiliartowomen(suchasthe
temple).
RequirementsforanImmigrantWomen‐CentredChronicDiseaseCareModel:
Thegroupdevelopedasetofquestionstoassesstheappropriatenessofanypotentialchronicdisease
managementprogramforoldervisibleminorityimmigrantwomen.

ISTHEMODEL…
Women‐centred?
Ethnoculturally‐centred?
Family‐focused?
Life‐course‐focused?
Locatedwithinthecommunity?
Reciprocity‐based?


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1919
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
DevelopingaResearchFramework:
Thegroupaimedtoproduceaseriesofinitialresearchquestionsandaccompanyingresearchstrategies
todevelopanimmigrantwomen‐centredmodelofchronicdiseasemanagement.Thesequestionswill
serveasthestartingpointforamorein‐depthdiscussionleadingtothedevelopmentofaresearch
proposal(s)inthisarea.
ResearchObjectives:
 Tocreateservicesandprovideimprovedaccesstowantedservices(promotion,preventionand
treatment)thatwillhelptoimprovethehealthandwell‐beingofolderSouthAsianandChinese
immigrantwomeninBritishColumbia.
 Todeterminewhatservicesareneeded,howtocreateandsustainaccesstotheseservices,and
howtoachieveandevaluatesuccessful(desired)outcomes.
RESEARCHQUESTIONS:
1. Whatarethehealthcareneedsofolderimmigrantwomenlivingwith
chronicdiseaseandhowmighttheybeaddressed?
2. Whatisthemostappropriatemodeltoincreaseaccesstochronic
diseasemanagementhealthservicesforoldervisibleminority
immigrantwomen?
3. Whatkindofcommunity‐based/community‐ownedserviceswouldbe
mosteffectiveinimprovingaccesstochronicdiseasemanagement
servicesforoldervisibleminorityimmigrantwomen?

PreliminaryDiscussionofResearchMethods:
Preferredresearchmethodscitedbythegroupincludedvariouscollaborativeresearchstrategies,suchas
ParticipatoryActionResearch(PAR).Modelsofserviceprovisionmustbeevaluatedand/ordevelopedin
partnershipwithimmigrantwomen,theirfamiliesandcommunitiesinordertoensuretheirrelevancy.
Processesofknowledgetranslationandexchangearelikewiseenhancedthroughacollaborative
approachtoresearch.
Acomparativestudytomeasuretheeffectivenessofexistingprogramsholdspotentialforthistopic.For
example,theCDSMPhaslaunchedpeertrainingsessionsformembersofthePunjabicommunityin
Vancouver.TheseindividualswillfacilitateworkshopsspecificallydesignedforthePunjabicommunity.
Thismodelcouldbecomparedwith,forexample,acommunityprograminRichmondwherepatients
diagnosedwithchronicdiseasesareimmediatelyconnectedtocommunitynetworks(forexample
volunteersandspecialists)forassistanceinmanagingtheirchronicdisease(s).



2020
june2009forum
Knowledge.Power.Access.  Page20of41
OlderVisibleMinorityImmigrantGrandmothersasCaregivers
RoundtableParticipants:
31%
11%
5%
0%
31%
11%
11% ICARETeam&Partners
Rese archers
GovernmentRepresentatives
Front‐lineHealthService
Providers
MulticulturalSettlement&
CommunityAgencyWorkers
OlderAdults
HealthAdministrators

Figure4:OlderVisibleMinorityImmigrantGrandmothersasCaregiversRoundtableParticipants(n=19)
ReunitingimmigrantfamiliesisanimportantgoalinCanadianpolicy.42Olderadultscomprisedalmost
one‐halfofallfamilyclassimmigrantstoCanadain2006.43InBC,88%ofolderimmigrantsarrivedunder
theFamilyClasscategorybetween2002and2006.44
WhenanolderrelativeissponsoredundertheFamilyClassimmigrationcategory,thesponsormakesan
unconditionalundertakingoffinancialsupportforaperiodoftenyearstotheMinisterofCitizenshipand
Immigration.ThisisalongerperiodthanforanyotherFamilyClassgroup.
Thefinancialdependencyofolderrelativesontheirfamilysponsorsoftenleavesthemunderagreat
senseofobligation.Sponsoredgrandparents–andinparticulargrandmothers–areoftenexpectedto
provideunpaidchildcareservicesforgrandchildren.Asgrandmothersageandbecomeunabletocook,
cleanandtakecareoftheirgrandchildren,theyareincreasinglyvulnerabletodepression,isolationand
abuse.
TherearenumerousissuestoaddressforolderSouthAsianandChineseimmigrantwomenascaregivers
tograndchildren.Languagebarriersaresignificant,andrequireservicesandresources.Although
servicesareprovidedinmultiplelanguages,transportation,costandotherbarriersstillexistforsome
families.Elderabusehasbeendocumentedinbothcommunities,andrequiresactiontoreducethe
vulnerabilitythatunderpinsabuse.Whengrandmothersneedhelp,whetherforabuseoranykindof
assistance,theyoftendonotknowwheretobegintoask,andwhattypesofservicesareavailable.

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Thereiscurrentlyalackofresearchtounderstandhowcaregivingrolesaffectvisibleminorityimmigrant
grandmother’shealthandqualityoflife.Futureresearchshouldinvestigatehowsocialisolation,financial
barriers,familydynamics,andthesponsorshipsysteminteracttoimpactthehealthofgrandmothersas
caregivers.
IssuesaffectingOlderVisibleMinorityImmigrantGrandmothersasCaregivers:
Thediagrambelowsummarizesthemultipleissuesaffectingthehealthofoldervisibleminority
immigrantgrandmothers.Theseissuesareunderstoodbythegrouptobeintersecting,dynamicandnon‐
hierarchical.
SponsorshipSystem:
Sponsorshippoliciesandpracticescreatedifficultconditionsforfamilies.Olderrelativesarerendered
financiallydependentontheirfamilysponsorsforanobligatoryten‐yearperiod.Duringtheinitial
dependencyperiod,olderadultsmaynotbeeligibleforpublicpensionssuchastheAllowance,OldAge
SecurityortheGuaranteedIncomeSupplement,subsidizedhousingorhousingsubsidies,orotherlocal
benefitssuchasreducedfarebuspasses.
Manyolderimmigrantsremaineconomicallydisadvantagedevenaftersponsorshipendsbecauseofthe
waytheresidencycriterionforOldAgeSecurityiscalculated.ImmigrantsfromSouthAsia,forexample,

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areatagreaterdisadvantagethanimmigrantsfromcountriessuchasAustralia,NewZealandandthe
UnitedKingdomsinceCanadahasreciprocalagreementsonsocialsecuritywiththesecountries.45These
agreementscanhaveabeneficialeffectonresidencycredits,whichdeterminetheeventualamountofOld
AgeSecuritythepersonwillreceive.
Dependentontheirsponsorsineveryrespect,sponsoredolderadultsseldomhaveaccurateinformation
abouttheirrights.Theyareoftenfearfulthattheirsponsorshipcanbewithdrawn,andtheydonotknow
wheretoturnforhelpifproblemsdooccur.13
Accesstohealthcareisalsoaffectedbytheolderadults’extremedependencyontheirsponsorsfor
translationofwritteninformation,andforridesandinterpretingatmedicalappointments.Thepolicy
alsorenderssponsoredolderadultsineligibleformanyservices,suchasrehabilitationandlong‐term
care,duringtheirten‐yeardependencyperiod.27
Abuse:
Olderadultsareatgreatriskofabusebysomeoneknowntothem.46Adultchildrenareresponsiblefor
morethan35%ofabuseperpetratedagainstolderparents.46Therearetwocomponentsofthelegal
obligationtoprovideforallofthesponsoredolderadult’sneedsthatsignificantlyincreasestheir
susceptibilitytoabuseorneglect.16
Thefirstofthesecomponentsisthelengthoftimeofthesponsorshipobligationduringwhichthe
financialstatusofthesponsorandthehealthstatusofeitherthesponsoredolderadultorthesponsor
maydeclinethroughnofaultoftheirown.Theresultmaybeextremefinancialhardshipandsometimes
emotionalorphysicalabuse,orpassiveoractiveneglect.Onceasponsoredgrandmotherqualifiesforher
publicpension,shemayexperienceabuseintheformofpressuretosignoverherpensionchequetoher
family.
Thesecondcomponentofsponsorship‐relatedpoliciesthatmayincreasethepotentialofabuseisthe
intensificationofdependencyandresultantpowerimbalancebetweenfamilymembersthatthepolicies
invoke.Thedependencyofgrandmothersontheirfamilysponsorsleavesthemsusceptibletomany
formsofabuse.Whileabusiveactsareoftenthoughtofasphysical,manygrandmothersmayalsosuffer
specifictypesofpsychological/emotionalabusesuchasbeingleftoutoffamilyfunctions.46,47
Identity:
Theveryrealsituationofdependencyresultsinthelossofstatuswithinthefamilystructureforsome
olderimmigrantwomenwhosefamilialrolebecomesdefinedthroughcaregivingtasks.13Onabroader
socialscalethelossofstatusisalsoexperiencedbyoldervisibleminorityimmigrantwomenthroughthe
combinedeffectsofracism,sexismandageism.
Theidentityofgrandparentsisoftenconstructedthroughtheirroleintheintergenerationaltransmission
ofknowledge,cultureandvalues–aconceptreferredtoas“generativity.”Recentresearchhasproposed
thatthevariouschallenges(forexample,acculturation)thatemergethroughtheprocessofimmigration
mayimpactthisparticularexpressionofgrandparentidentity.48

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Language:
AlackofEnglishskillscreateschallengesforolderimmigrantwomen.Ascaregiverstograndchildren,
immigrantgrandmothersexperienceadditionalpressuretoachievecompetencyinEnglish.Thepressure
tolearnEnglishasoneaspectofacculturationmayproducefeelingsoflossofcultureandits
transmissiontograndchildren.Asameanstoworkthroughthis,theroleandidentityofSouthAsianand
Chinesegrandmothersmaybetoencouragegrandchildrentospeakbothlanguages.
RoleofFamily:
FamilyisaninvaluableresourceforolderimmigrantstoCanada.Beyondlegalobligations,familiesare
abletoprovideaccesstocommunity–bothformallyandinformally–andhelpgrandparentstonavigate
healthandsocialservices.
Unfortunately,familymayalsobeasourceofconflictforgrandparents.Thesponsorshiprelationship
createsdifficulttermsfortherelationshipbetweenolderrelativesandtheirfamilysponsors.The
situationofdependencyforgrandparentscreatespowerdifferentialsthataredifficulttonavigate.
Differentparentingstylesbetweengrandparentsandtheiradultchildrenisasourceoffamilyconflict.
Grandparentshavedifferentideasofhowtoparentandprepareyoungchildrenforschoolbasedontheir
ownexperiencesofchild‐rearingintheircountryoforigin;howeverinanewfamilyandcommunity
contextmanyfeellostandparentsbecomefrustrated.Grandchildrenobservetheconflictingauthority
betweentheirparentsandgrandparentsandreactaccordingly.
Insomecases,thesponsorshiprelationshipbreaksdown.Declarationofsponsorshipbreakdownisan
infractionofthesponsor’slegalundertaking.Unlesssponsoredolderadultshaveincomeorother
relativeswillingtosupportthem,theymustapplyforsocialassistance,aprocessthatvariesconsiderably
acrossCanadaandwhichisbynomeansguaranteed.16
SouthAsianwomenparticipantsnotedina2005studybyGrewaletal.19thattheyexperienced
unexpectedroleschangeswithintheirfamiliespost‐immigration.Forexample,olderwomennotedthat
intheirpost‐immigrationCanadianfamilycontext,theyfeltobligatedtoprovidechildcareandother
householdservices,evenattheexpenseoftheirownhealth.
ShiftingExperiencesasChildrenAge:
Inmuchoftheworkdoneonimmigrantgrandmothersascaregivers,thefocusistypicallyonthe
experiencesofgrandmotherstoyounggrandchildren.Howdocaregivingexperiencesshiftas
grandchildrengrowolder?Intergenerationaltransitionsmayproduceconflict.Arethereanynew
servicesrequiredtoprovidefortheseshiftingneeds?
Isolation:
Manyconditionsofisolationexistforgrandmothersascaregivers.Caregivingresponsibilitiesinpart
determineagrandmother’sabilitytoestablishasocialexistence,whetherthroughthecreationof
informalsupportnetworksorthroughaccessingavailableprogramsandservices.
InlargeurbancentressuchasVancouver,theexistenceof‘ethnicenclaves’meansthatwhentheyare
abletomovearound,olderwomenareoftenrelegatedtooneparticularareaofthecity.Inruralsettings,

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alackofneighbourscreatessubstantialisolation–bothgeographicandsocial–forolderimmigrant
women.
CaregiversofChildrenwithHealthChallenges:
EmpiricalevidencefromDr.NoreenSimmonsoftheBCFamilyHearingResourceSocietyrevealsthat
grandparentstochildrenwithhearinglossexperiencemultiplecaregivingchallenges.Grandparentshave
difficultylearningsignlanguageinadditiontotryingtolearnEnglishasasecondlanguage.These
challengesareexacerbatedwhengrandchildrendonotspeakorusetheirnativelanguage.Alossof
dexterityandvisioncreatesdifficultiesforgrandparentsattemptingtolearnhowtousesmallauditory
devicesfortheirgrandchildrensuchashearingaidsorcochlearimplants.Grandparentsalsohave
difficultyadjustingwhennewhearingtechnologiesaredeveloped.
Furtherevidencesuggeststhatwhilegrandparentsoftenprovidecareforgrandchildrenduringtheday,
parentsareoftentheonestoaccompanytheirchildrentothehearingclinic,andtheydonotalways
effectivelycommunicatecaregivinginstructionstograndparentcaregivers.Grandparentsalsoreportnot
feelingrespectedbytheirchildrenbecauseofdifferentparentingstyles.
SupportingGrandmothersasCaregivers:WhatModelsareWorking?
TheFirstStepsprojectmanagedbyDIVERSEcityCommunityResourcesSocietyinpartnershipwith
Options:ServicestoCommunitiesSocietyprovidesnewlyarrivedrefugeechildrenunderfiveandtheir
caregiverswitharangeofprogrammingtosupportearlychildhooddevelopment.Theprojectaimsto
equipcaregiverswith,“informationonparentingintheCanadiancontext.”49
ASouthAsianTaskGroupbeganperformingoutreachandawareness‐raisingstrategiesforSouthAsian
parentswithyoungchildrenbutdiscoveredthatgrandparentsareactuallyprovidingmuchofthecarefor
grandchildren.50Atthisrealizationthetaskforceshiftedtheiroutreachstrategiestoincludeliveradio
andtelevisionshowsasameansoftargetinggrandparentcaregivers.50Additionally,withfundingfrom
theUnitedWayoftheLowerMainland,DIVERSEcityproducedacalendarinPunjabiwithcaregivingtips
targetedatgrandparents.
DevelopingaResearchFramework:
ResearchObjectives:
 Todeterminethosefactorsthatsupportthephysical,emotionalandspiritualhealthandwell
beingofSouthAsianandChineseimmigrantgrandmothersascaregivers.
 TofurtherinvestigatehowtheimmigrationprocessandCanadianimmigrationpoliciesaffectthe
healthandsocialstatusofgrandmothersascaregivers.

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
ResearchQuestions:
 Whatinfluencesqualityof
life(positiveandnegative)
forimmigrant
grandmothersas
caregivers?
 Thisquestionencompasses,butisnot
limitedto,thefollowingconsiderations:
 Grandmothersinruralareas;
 Grandmotherstoteenagers;
 Grandmotherstogrownchildren;
 Grandmotherstochildrenwithhealth
issues;
 Thefinancialandsocialdependencyof
immigrantgrandmothers.
• Sub‐questions:
1. Howdodifferentsocialdeterminantsofhealthinfluencequalityoflifefor
immigrantgrandmothersascaregivers?
2. Inwhatwaysdoesimmigrantgrandmothers’financialandemotional
dependencyimpact/influencetheirhealth?
3. Howaretheseimpactssimilarordifferentfordiversegroupsof
grandmothers(agesandstages,location,etc.)?
Whoshouldbeinvolvedinthis
research?
 Immigrantgrandmothercaregiversfrom
ChinaandIndia;
 Settlement/socialserviceagenciesto
grandparentsandchildren;
 Healthagencies;
 Schools;
 Researchers.
Whereshouldthisresearchtake
place?
 RuralandurbanlocationsacrossBC;
 Placesofworship;
 Communitycentres,specificallyolder
adults’programs.

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PreliminaryDiscussionofResearchMethods:
Thegroupdiscusseddifferentpossibleresearchmethodsincludingfocusgroups(ofthreetofourpeople)
andone‐to‐oneinterviewstousewithinaParticipatoryActionResearch(PAR)methodologicalcontext.
Interviewsandfocusgroupsshouldbeconductedinparticipants’firstlanguage/languageofchoiceand
latertranslatedbytheinterviewer/groupfacilitator.Researchquestionsshouldberefinedin
consultationwitholderwomenandserviceproviders.

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CommunityResourcesforOlderImmigrantWomen’sMentalHealth
RoundtableParticipants:
39%
40%
7%
7%
7% 0%0%
ICARETeam&Partners
Research ers
GovernmentRepresentatives
Front‐lineHealthService
Providers
MulticulturalSettlement&
CommunityAgencyWorkers
OlderAdults
HealthAdministrators

Figure5:CommunityResourcesforOlderImmigrantWomen’sMentalHealthRoundtableParticipants
Thementalhealthneedsofoldervisibleminorityimmigrantwomenhavereceivedlittleattentionwithin
healthresearch;however,awealthofempiricalevidencesuggeststhatthisgroupofwomenhave
significantneedsthatarenotbeingmetwithinthehealthcaresystem.Theseneedsaredeterminedby
manyfactorsthatresultfromtheintersectionofgender,age,ethnicity,visibleminoritystatusandthe
immigrationexperience.Inparticular,formanywomen,mentalhealthissuesemergeasaresultofthe
stressesassociatedwiththeimmigrationprocess.
RiskFactorsforPoorMentalHealth:
SocialIsolation/Exclusion
SocialisolationintheCanadiancontexthasemergedasakeyissueaffectingthementalhealthofolder
immigrantwomen.Socialisolationisexacerbatedby:(1)alackofknowledgeofcommunityresources,
and(2)difficultiesaccessingsocialactivitiesoutsidethehomeduetocost,transportation,inclement
weatherandhousehold/childcareresponsibilities.Withouttheestablishmentofnewandenhanced
culturallyappropriateandrelevantsocialnetworksinCanada,isolationanddepressionarelikelyto
continuetooccurforthispopulation.
Theexperienceofethnicandculturaldifferenceforminoritypopulationscreatesstigmawhenthe
differencesareaccentuated;consequently,olderadultsfeelpressuredtosuppresslanguageandother
identifyingaspectsoftheirculturalpractices.Thispracticeofsuppressionleadstounhappiness.In

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contrast,socialsupportwithinculturalgroupspromotesafeelingofcultural/ethnicidentitythat
supportsgoodmentalhealth.46
AnecdotalevidencesuggeststhatforolderSouthAsianwomen,therearenotenoughplacesto,‘sitand
talk’.Inaddition,manywomenliveinthebasementoftheirfamily’shouseandaresometimesexcluded
fromfamilyeventsandexcursions.
LossofSupportNetworks:
Thelossofbroad‐basedfamilyandfriendsupportnetworksintheircountryoforigincontributesto
depressionamongolderimmigrantwomen,especiallywhentheyarelargelyconfinedwithinthehome.46
Manywomenfeelthat,inCanada,they’reexpectedtotakecareofthemselves,eventhoughtheyoftendo
nothavetheresourcestodoso.Thelossof‘informal’sourcesofsocialsupportpost‐immigrationisa
stress‐inducingandisolatingfactorforolderimmigrantwomen.46
Abuse:
Conflictwithinfamiliesiscommon.Olderwomenaresusceptibletomanyformsofviolence,abuseand
neglect.Elderabuseisdefinedas:
…anyintentional,unintentionalornegligentactthatcausesharmorserious
riskofharmtoanolderperson.Abusiveactscanbephysical,sexual,
psychological,emotional,financialorinvolveneglectandabandonment.46
Withinthecontextoffamilysponsorship,abusemaysometimestakethemorenuancedformofsocial
exclusionfromfamilyactivities.Familyshameofthe‘inappropriate’dressoraccentofolderfemale
relativessometimesresultsinexclusionfromsocialgatherings.46Moreover,agapiscreatedifolder
womenbelieve,‘mychildrenwilllookafterme,’butchildrenexpectolderparentstotakecareofnotonly
themselves,buttheirgrandchildrenaswell.
Poverty:
ThecurrentconfigurationofthesponsorshipsystemplacesmanyolderSouthAsianandChinese
immigrantwomeninapositionofpoverty.Alackofeconomicstabilitycausesstress,andleadstomental
healthissuesforthesewomen.Aftertheinitialten‐yearsponsorshipdependencyperiodisover,many
womenexperienceadditionalpressurefromtheirfamiliestosignovertheirpensioncheques,andsome
arecoercedintodoingso.
BarrierstoMentalHealthServices:
Immigrantpopulationsareunderservedbythementalhealthsystem.Thisisprimarilyduetostructural
inequalitieswithinthedeliveryandorganizationofmentalhealthservicesthatlimit,prohibit,omitand
excludecertainpopulationsfromgainingaccess.Thereismoreoverafalseassumptionthatthenature
andtypeofservicesprovidedareaccessibletoall.
Infact,groupparticipantsexpressedthatmanycommunitymentalhealthservicesarenotculturally
appropriate,relevantorsignificantforolderSouthAsianandChineseimmigrantwomen.Forone,
culturalnotionsof‘counseling’and‘depression’arenewtomanyimmigrantpopulations.Insome
instancessharingsuchpersonalinformationwithstrangersisconsideredshamefulandunacceptable.

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Thestigmaassociatedwithbeingseenas‘crazy’mayfurthermorepreventolderwomenfromaccessing
theseservices.Althoughtoutedasananswertotheproblemofcross‐culturaldifference,theideaofpeer
counselingisunsafeformanyolderimmigrantwomenbecauseofthefearofaconfidentialitybreach
withinthecommunity.Thesamemightalsoapplyforethnically‐matchedmentalhealthprofessionals.
Inadditiontoconsiderationsofculture,languagebarrierspreventaccesstocommunitymentalhealth
services.ManyolderwomenwithoutEnglishlanguageskillsaredependentonfamilymembersfor
assistancewithserviceaccess,andtheymightnotfeelcomfortableapproachingfamilymemberstohelp
themaccessmentalhealthservices,especiallyiffamilymembersareimplicatedinabuse.Manywomen
arealsoreliantonfamilymembersfortransportationtoandfromcommunitygroupmeetings.Iffamily
membersarebusy,manyolderwomenareunabletogoontheirown.
Furtherempiricalevidencesuggeststhatalackofawarenessofexistingcommunitymentalhealth
servicescontinuestobeacriticalbarriertoserviceaccessforthispopulationofolderwomen.Inpartthis
isduetothelackofsimilarprogramsinwomen’shomecountriesandunfamiliaritywiththeconceptsof
advocacyanddemandforoutreachservices.
SupportingPositiveMentalHealth:WhatModelsareWorkingintheCommunity?
SupportforCommunity‐BasedOutreachServices:
Outreachsupportgroupslocatedinthecommunityhelpkeepwomenconnectedtooneanotherand
preventsocialisolationanddepression.FormanyolderSouthAsianandChineseimmigrantwomen,
communitysupportgroupsmaybetheironlyopportunitytocomeoutofthehouseandsocializewith
peers.Supportgroupsinthecommunityallowolderadultstheopportunitytoopenupaboutfeelingsof
shameandexperiencesofabuseandneglect.Doctorsspecializinginmentalhealthoftenrefer
ethnoculturalminorityolderadultstocommunitygroupsbecauseformalservicesmaynotbeavailable,
relevantorappropriate.
In2008DIVERSEcitystartedaSouthAsianolderadults’outreachsupportgroupinSurreywiththeaimof
raisingawarenessofcommunityresourcesandprovidingmentalhealthinformationwithinthe
community.Theprojectbeganbyreachingouttoimmigrantolderadultsinreligiousgatheringspaces
withtranslatedbrochures,andtalkingtoolderadultsone‐on‐oneinplacessuchasparksandcommunity
centres.Inthisway,thementalhealthneedsofthisparticularpopulationemerged,andwomen’sunique
needsbecameacentralfocus.80%oftheclientsarenowwomen,manyofwhomactivelyseekoutfurther
information,activitiesandresourcestopromotetheirmentalhealthandwellbeing.Thisproject
demonstratesthatlackofinformationandawarenessofavailableservicesaresignificantbarriersand
canbeovercomewiththerightprogrammingandoutreachstrategies.
Settlementagencieslocatedinthecommunityprovideaplacefornewimmigrantstofeelathome.For
example,themulti‐serviceagencyS.U.C.C.E.S.S.helpstosociallyembedolderadultimmigrantswithinthe
greaterVancouverareabyinvolvingtheminprogramdesignandimplementation.Olderadultsin
multiplelocationsmeettogetinvolvedinthecommunity,discusstheirneeds,andplansocialactivities.
Communityempowermentisacentralgoalofgroupsthatareinitiallyrunthroughtheorganizationbut
ideallygrowtobeself‐directed.

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Thesuccessofcommunity‐basedoutreachprogramssuggeststhatwhencommunityorganizationsbegin
toadvocateforolderimmigrantwomen’smentalhealthneeds,womenthemselvesbegintoself‐advocate.
Ideas:What’sneeded?
Thegroupcreatedalistof“needs”forfuturecommunitymentalhealthservicedevelopmentthat
incorporatestheidentifiedneedsofolderSouthAsianandChineseimmigrantwomen.Theyinclude:


 Theneedtogetolderwomentocomeoutoftheircomfortzonesandbecomemore
involvedintheircommunities.
 Theneedtolobbyformoreoutreachresources.
 Theneedforminoritygroupstoself‐advocatefortheircommunitymentalhealthneedsto
governmentandpolicymakers.
 Theneedtooffertransportandonsitedaycareservicesforthosewomenwhohavetotake
careoftheirgrandchildren.
 Theneedforappropriatelong‐termplanning
 Theneedforculturally‐appropriateservices.

DevelopingaResearchFramework:
ResearchObjectives:
 Toconductevaluativeresearchtosupportanddemonstratetheefficacyofexistingcommunity
mental‘wellness’programs.
 Toshowcaseanddemonstratethevalueofsuccessfulcommunity‐basedoutreachservicestokey
decision‐makers.

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
ResearchQuestion: 
 Whatarethepromisingpracticeswithincommunitymentalhealthserviceprovision
thatcouldsupportpositivementalhealthoutcomesforolderSouthAsianand
Chinesewomen?
• Sub‐Questions:
 Whataretheexperiencesofpeoplewhoneedtogethelp?
 Whataretheneedsoftheisolated/hiddenpeople?
 Whatdoessuccesslooklike?
 Howdoweknowthatprogramsareprovidingwhat’sneeded?

PreliminaryDiscussionofResearchMethods:
ParticipatoryActionResearch(PAR)isapreferredmethodologicalframeworkforthisgroup.Ethical
considerationsofinformedconsent,whatmeaningfulparticipationlookslikecross‐culturally,and
avoidingtheuseofacademicjargonthatmightstigmatizeparticipantswerediscussedwithinsucha
framework.

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NextSteps
TheICAREforumwasthefirststeptowardsdevelopingthreeresearchgrantproposalsformajorfunders.
Operationalresearchquestionsdevelopedwithintheroundtablesessionswillbediscussedandfurther
refinedthroughconversationswitholderChineseandSouthAsianimmigrantwomenaswellaswith
thosethatprovideandregulatetheircare.Threeworkinggroupswillmeetregularlybeginningin
October2009toworktowardsthedevelopmentandsubmissionofthreeseparateresearchfunding
proposalsin2010.Westronglybelievethattheinvolvementofpertinentstakeholdersatthisearlystage
ofresearchplanninganddevelopmentwillimproveboththerelevanceoftheresearchandthelikelihood
ofuptakeofrecommendationsintopolicyandpractice.

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46.GurugeS,KanthasamyP,SantosJE.Addressingolderwomen'shealth.In:GurugeS,CollinsE,eds.
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47.SimmonsN.Barriers,bridgesandbeyond:Understandingperspectivesinlinguisticallyandculturally
diverseclinicalinteractions.[Ph.D.Dissertation].Canada:TheUniversityofBritishColumbia(Canada);
2007.
48.MukoyamaKJ,TakahashiM.OlderKoreanimmigrantsandgrand‐generativity.HallymInternational
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49.DIVERSEcityCommunityResourcesSociety.FirstStepsCentre.Availableat:
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50.Gill‐BadeshaD.ICAREforumgrandparentsascaregiversroundtable.2009.

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Appendices
AppendixA:AFrameworkforWomenCentredHealth32


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AppendixB:ForumProgram
Thursday,June25,2009,10:00to16:00
LangaraCollege,Vancouver
ICARE(ImmigrantOlderWomen–CareAccessibilityResearchEmpowerment)forum:Knowledge.
Power.Access.
Welcome:
WearepleasedtowelcomeyoutotheICAREforum:Knowledge.Power.Access.
Webelievethatinordertoproduceresearchthatwillhaveapositiveinfluenceonaccesstohealthcare
byoldervisibleminorityimmigrantwomen,weneedtobuildonthecollectiveknowledgeofadiverse
andcaringgroupofstakeholders.
Webeginwiththerecognitionthatformanyolderimmigrantwomen,gender‐basedexperiencesof
inequitythroughouttheirlivescancombinewiththeirexperiencesasolderimmigrants,creatingbarriers
tocare.Workingwithyou,wehopetoidentifywaysinwhichresearchmayhelptofacilitategreater
powerandequityinhealthcareaccessforthisgrowingsubpopulationofolderadultsinBritish
Columbia.
Thankyouforjoiningusforthefirststageofthisimportantcollaborativejourney.
ForumObjectives:
Toclarifyhowgender,ageandimmigrationcaninteracttocreatebarrierstohealthcareaccessforolder
visibleminorityimmigrantwomen.
Toidentifyanddevelopresearchquestionsineachofthethreeprioritizedtopicareas.
Tocollectivelyidentifyandprioritizenextstepsforaction.
Tocreateopportunitiesforparticipantstostayinvolvedwiththeproject.
Program
09:30 Welcome&Checkin–moderatorfortheday:ColleenReid
10:00  LayingtheFoundation–speakers:KarenKobayashi,MohinderSidhu,MaggieIp
10:45  IntersectionalityExercise
11:15  QuestionPeriod/Transition
11:30  ConcurrentRoundtables|Brainstorming
I:GrandparentsasCaregivers–facilitator:ColleenReid;panelists:DaljitBadesha,Noreen
Simmons,SharonKoehn
II:ImmigrantWomenCentredChronicDiseaseCareModel–facilitator:Karen
Kobayashi;panelists:JoanBottorff,SukiGrewal,

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III:CommunityResourcesforMentalHealth–facilitator:ElanaBrief;panelists:
SatwinderBains,EricLau,SaleemSpindari,LokayataKular
12:30  Lunch
13:15 ConcurrentRoundtables|Priorities,Purpose,Problem
14:15 Break&Exercise|“TheGrammaroftheResearchQuestion”
14:30  ConcurrentRoundtables|GettingtotheQuestion
15:30  TheGalleryWalk&Wrapup
Acknowledgements
Thisforumwouldnothavebeenpossiblewithoutthegenerousfundingandsupportinkindfromour
sponsors:





ThanksarealsoduetoLasChicasforprovidingadeliciouslunchforourparticipants.
ICARETeam
PrincipalInvestigators:KarenKobayashiPhD|SharonKoehnPhD
ResearchAssistant: MelanieSpenceHon.BA
ICARETeamMembers:RevaAdlerMD,MPH,FRCPC|SatwinderBainsMEd,PhD(C)|JoanBottorff
PhD,RN,FCAHS|DaljitGill‐BadeshaMA|SukhdevGrewalRN,MSN|
LokayataKular|JanetKushner‐KowBSc,MD,MEd,FRCPC|EricLau|
NoreenSimmonsPhD,SLP|SalemSpindariBA
ICARETeamPartners/Forumplanning:
ElanaBriefPhD(WHRN)|AndreaCosentino(BCNAR)|AmyJohal(BCNAR)|Colen
ReidPhD(WHRN)

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AppendixC:PresenterBiographies
SatwinderBains,MEd,PhD(candidate,SimonFraserUniversity)istheDirectoroftheCentreforIndo
CanadianStudiesattheUniversityoftheFraserValley.HerresearchinterestsincludetheIndoCanadian
Diaspora'scultural,socialandhistoricalsettlementandadaptationasitaffectstheirwell‐being.
Satwinderisalsoinvolvedincommunitydevelopmentbybuildingleadershipcapacitywithincultural
minoritycommunities.
JoanBottorff,PhD,RN,FCAHSisaProfessorandDirectoroftheInstituteforHealthyLivingandChronic
DiseasePreventionattheUniversityofBritishColumbiaOkanagan,Kelowna.Herresearchinterests
includehealthpromotionandhealthbehaviourchangewithafocusongenderandcancercontrol.
HerresearchhasincludedstudiesintheSouthAsiancommunityfocusingonwomenandmen’s
health–theseprojectshavebeenconductedincollaborationwithMs.SukiGrewal.
ElanaBrief,PhDisaResearchDirectorfortheWomen'sHealthResearchNetworkwheresheinspiresBC
healthresearcherstoaskhowsexandgendermayinfluencetheconditionstheystudy.SheholdsaPhD
inPhysicsfromtheUniversityofBritishColumbiawhereshedevelopedmethodsforusingMRI(Magnetic
ResonanceImaging)tonon‐invasivelymeasureconcentrationsofchemicalsinthehumanbrain.Elana
currentlyservesasPresidentoftheSocietyforCanadianWomeninScienceandTechnology(SCWIST)to
encourageandpromotewomenandgirlstoengageinscience.
DaljitGillBadesha,MAisCo‐ManageroftheFamilyServicesDepartmentatDIVERSEcity,andoversees
theeducation,preventionandoutreachprogramsofthedepartment.ThroughherroleastheSouth
AsianECDTaskGroupCoordinatorfortheSurrey/WhiteRockareashehasworkedextensivelyinthe
SouthAsiancommunitytoraiseawarenessonparentingintheearlyyears.Shehasworkedinthesocial
servicessectorfor14yearsasafamilysupportworker,educator,counsellor,groupfacilitatorand
manager.
SukhdevGrewal,RN,MSNisanursinginstructorwithLangaraCollege.Shehasextensiveexperience
workingwithmulticulturalpopulationsasacommunityhealthnurse.HerresearchfocusesonSouth
Asianwomen’shealthbeliefsandthefamily’sinfluenceonwomen’sdecisionmakingasitrelatesto
health.
MaggieIpcametoCanadain1966forherpostgraduatestudyattheUniversityofOttawaandreceived
herMEddegreein1967.UpongraduationsheworkedfortheDepartmentofNationalHealthand
WelfareinOttawabeforemovingtoBCin1970withherfamily.SheisthefoundingChairofS.U.C.C.E.S.S.
–anon‐profitorganizationservingnewimmigrantssince1974.MaggiewasaSecondarySchoolteacher
withtheRichmondSchoolBoarduntilherearlyretirementin2003.ShewaselectedtotheVancouver
CityCouncilfrom1993to1996.
KarenM.Kobayashi,PhDisanAssistantProfessorintheDepartmentofSociologyandaResearch
AffiliateattheCentreonAgingattheUniversityofVictoria.Sheisaco‐leaderfortheNationalInitiative
ontheCarefortheElderly’s(NICE)EthnicityandAgingteam.WithfundingfromtheCanadianInstitutes
ofHealthResearch(CIHR)andtheSocialSciencesandHumanitiesResearchCouncil(SSHRC),hercurrent
researchprogramsfocusontherelationshipbetweensocialisolationandhealthcareutilizationamong

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olderadults,thenegotiationofsocialsupportandcareinethno‐culturalminorityandimmigrantfamilies,
andthe“healthyimmigranteffect”inmid‐tolaterlife.
SharonKoehn,PhDisamedicalanthropologistwhohasbeenconductingqualitativeaction‐oriented
researchwithethnoculturalminorityolderadultssince1990.Herresearchhasfocusedonconstructions
ofhealth,illnessandhealthcareprovisionandonorganizationalbarriersandsolutionstohealthcare
access,primarilywithPunjabieldersinBCandIndia.Shehasalsoconductedresearchwitholderadults
fromtheChinese,VietnameseandHispaniccommunitiesinGreaterVancouver.Asaresearchassociate
withtheCentreforHealthyAgingatProvidenceHealthCareshenowleads/participatesinseveral
interdisciplinaryprojectsfocusingondementia,healthandhealthcareaccess,andqualityoflifeof
ethnoculturalminorityolderadults.
LokayataKularwasbornandraisedinIndiaandmovedtoCanadain1998withherfamily.Sheworks
withtheSouthAsiancommunityasaFamilySupportWorkeratDIVERSEcity.HerroleasaMulticultural
OutreachWorkeristoreachouttofamilieswithchildrenfrom0‐6yearsandthe55pluspopulation–
raisingawarenessandconnectingthemwiththeappropriatecommunityresourcesandservices.
Lokayatahas20yearsofexperienceasaneducator,translator/interpreter,administratorandfamily
supportworker.
EricLauwasbornandraisedinHongKongbeforeimmigratingtoVancouverwithhisfamilyin1996.He
iscurrentlytheprogramcoordinatoroftheS.U.C.C.E.S.S.SeniorsQualityofLifeOutreachProject.The
projectoffersdrop‐insocialactivitiesforover200Chinese‐speakingimmigrantseniors,mostlywomen,
attheKillarney,Victoria‐FraserviewandMarpole‐OakridgeneighbourhoodsinVancouver.
ColleenReid,PhDisaResearchDirectorfortheWomen'sHealthResearchNetwork.In2002sheearned
aninterdisciplinaryPhDfromtheUniversityofBritishColumbia(UBC)intheareasofhealthpromotion
research,women'sstudiesandeducation.In2007shecompletedapostdoctoralfellowshipatSimon
FraserUniversity.Colleenhasdevotedherresearchcareertostudyingthesocialdeterminantsof
women'shealth,genderandhealth,andcommunity‐basedresearchmethodologies.
MohinderSidhu,MAcametoVancouverin1970whereshetaughtPunjabitochildrenattheKhalsa
DiwanSocietyfor20years,including12yearsasdirectoroftheprogram.Mohindercontinuestoserve
theIndoCanadiancommunitythroughherworkwithseniors’organizationsandadvocacyprograms.In
2006undertheauspicesofthe411SeniorsCentreSociety,Mohinderconductedaseriesofworkshops
forPunjabi‐speakingseniorsthatfocusedonseniors’rightsandaccesstogovernmentpensionsandother
services.
NoreenSimmons,PhD,SLPworksasaresearcherandSpeech‐LanguagePathologistattheBCFamily
HearingResourceCentre.Herpastandcurrentresearchinvestigatesculturalandlinguisticissuesthat
impactclinicalinteractionsforethnicallydiversefamilies.
SaleemSpindari,BAisthecoordinatoroftheCommunityOutreachProgramatMOSAIC.Hecoordinates
theAfghanWomen’sGroup,KurdishWomen’sGroup,theDropinCentreforTemporaryForeign
Workers,andMultilingolegal.ca.Saleemhaspreviouslyworkedasaninterpreter,settlementcounselor,
communitydevelopmentworkerandalegaladvocate.HeisalsoaboarddirectorwiththeVancouver
Cross‐CulturalSeniorsNetworkSociety.