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October 19, 2011
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INFORMATION BRIEFING DOCUMENT
TITLE: “Just scratching the surface”: Mental health promotion for Punjabi seniors (Forums)
PREPARED FOR: The Punjabi Seniors Wellness Coalition (PSWC)
PURPOSE: The ICARE (Immigrant Older Adults—Care Accessibility Research Empowerment) team
was founded in 2009 with an infrastructure team grant from the Women’s Health Research Institute of
BC by co-PIs Dr. Sharon Koehn (Centre for Healthy Aging at Providence Health Care) and Dr. Karen
Kobayashi (University of Victoria). The ICARE mental health team, led by Sharon Koehn (Providence
Health Care) and Satwinder Bains (University of the Fraser Valley), partnered with representatives
from the Canadian Mental Health Association – South Fraser Region, B.C. Healthy Communities and
Fraser Health Authority to form the “Punjabi Seniors Wellness Coalition.”
In 2010, this group secured Community Action Initiative funding to explore the extent to which
community services targeted at Punjabi seniors in Abbotsford and Surrey, British Columbia, address
the social determinants of mental health, as identified by Keleher and Armstrong
1
:
• social inclusion
• freedom from violence and discrimination
• and access to economic resources support
This document summarizes findings from the two forums (held in April and May, 2011) that aimed to
address this goal. Forum participants were Punjabi older adults and service provider representatives
identified as addressing at least one of the social determinants of mental health for Punjabi older adults
and their families in each of the two identified communities.
CURRENT STATUS: The proportion of seniors in Canada is growing and predictions indicate that
the percentage of seniors will reach almost 24% by the year 2031.
2
In 2006, visible minority populations
in Surrey and Abbotsford were 52.1% and 26.2%, respectively.
3, 4
In 2010, approximately one third of
the population of Surrey and one fifth of the population of Abbotsford were South Asian. Punjabi was
the most common language spoken at home, after English, in both communities.
3, 4
There is mounting evidence that the growing cost to society of mental illness is not sustainable. Canada
spent an estimated $14.3 billion in public expenditures for mental health services and supports in
2007-08, but a recent report warns that this is not enough: “By 2030, mental health issues will be the
leading cause of disability in Canada, but Canada appears to be a low spender on mental health.”
5
One
solution lies in mental health promotion. For seniors, the promotion and maintenance of mental health
contributes positively to their quality of life, physical health and effective utilization of health care
services.
6
The PSWC consultation process revealed that many Punjabi seniors are unaware of most services and
struggle to understand the systems and resources available in their communities. Transportation is a
barrier to participation; and families do not always offer help. Many, especially women, struggle with
low literacy in their own language.
7
Multicultural settlement agencies who provide services to Punjabi
seniors in the region also report that they do not have the capacity—either in terms of resources or
knowledge—to provide or maintain all of the necessary supports.
8
Finally, there is no evidence to
illustrate which types of community supports most effectively promote mental health and well-being for
Punjabi seniors.
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DISCUSSION:
Three main themes emerged during the forums:
Social inclusion is an important determinant of mental health and wellness in this population, in
terms of the need to feel respected and valued, to have supportive relationships, to participate in the
community and to have access to basic human entitlements. The social aspect of programs and services
offered was important both from the older adults’ and service providers’ perspectives. Social outings,
social time, social meals and celebrations, cultural exchange and integration programs, groups for
mothers and grandmothers as well as leadership or educational classes are examples of programs
offered to foster social inclusion. However, while the Punjabi seniors embraced the idea of facilitated
integration with ‘mainstream’ seniors, service providers told us that their efforts were often met with
discrimination. The Punjabi seniors had not been made to feel welcome in seniors’ facilities and existing
services do not offer culturally appropriate programming (e.g. Punjabi seniors do not play bingo!)
Family plays an essential role in Punjabi older adults’ mental health and wellbeing, both positively in
terms of providing support and sense of belonging, and negatively in terms of the stress that
dependency on other family members engenders. Also problematic are the seniors’ unmet expectations,
tension between generations and lack of knowledge and awareness within families to assist elders with
their mental health needs. Even within the home, language barriers and different lifestyles and cultural
values cause tension and intergenerational conflict which in turn can result in elder abuse and violence,
substance abuse and/or depression. As in many cultures, such negative behaviours are ignored or
accepted in the interests of ‘saving face’ and protecting the ‘honour’ of the family; the incidence of abuse
is therefore thought to be grossly under-reported. For older women, in particular, taking care of
grandchildren provided an important role in their families. However, childcare responsibilities can also
have a negative impact on their wellbeing. For example, this responsibility was noted frequently as an
obstacle to attending community programs. Mental health promotion and intervention programs
targeted at Punjabi older adults need to find meaningful ways of involving families and younger
generations. However seniors also need access to transportation and interpretation services
independently of their family members.
Reaching out to Punjabi seniors by service providers and community groups is required in order to
address the seniors’ mental health needs. Seniors and their family members need to know about the
programs and services available to them. They also need reliable information about mental health
issues. Multiple strategies are needed to accomplish these goals. Workshop participants recommended
disseminating information through temples, multicultural media (especially Punjabi radio and
television programs), newsletters and notices in appropriate languages at diverse locations (including
approaching potential clients in parks or private homes). Successful outreach also entails the
acknowledgment and alleviation of barriers that prevent access and meaningful participation. Offering
programs at convenient locations and times (such as evening hours and weekends) and providing
transportation, child-minding and free of charge services and programs are examples of promising and
more inclusive practices.
Next Steps:
Access to mental health supports by this population can be improved by offering supportive and
inclusive services that address the discrimination Punjabi seniors sometimes face in ‘mixed company’,
reflect language and health literacy barriers, provide transportation and child-minding for
grandparents with childcare responsibilities, and employ culturally-sensitive approaches to raising
awareness of programs and mental health issues.
Service providers need additional supports in terms of training and resources (such as long term
funding to promote continuity of mental health supports). This team will further explore the
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sustainability and capacity-building potential of promising practices and the development of mental
health promotion competencies amongst community service providers.
Given the needs and complexities identified during the forum the team has identified the following
steps to support mental health promotion in Punjabi older adults. These steps will move us closer to
mental health promotion.
• Build the capacity of the community and service providers to provide more effective reaching
out in a culturally sensitive manner.
It is apparent from the discussions that service providers in this sector would greatly benefit from
additional supports in order to fully promote mental health and wellness to their older Punjabi clients.
The necessary supports include training, for example on family violence, elder abuse and neglect issues
relevant to this community, as well as culturally responsive approaches to mental health promotion in
diverse populations (e.g. learning more about the culture and history of the community, building closer
ties to community leaders, etc.). Additional resources are required in terms of longer-term sustainable
funding that would allow for continuous mental health supports.
• Focus on making mental health promotion more culturally sensitive and accessible to the needs
of diverse newcomer communities (including family members)
Findings from our consultations also lead to areas for future research. For example, many South Asians
do not separate mind and body or the self and family/community to the extent that we do in the West.
Therefore, there is a cultural mismatch when services for mental and physical health are distinct and
health promotion efforts are focused on changing individual behaviours.
• Address and enhance resilience factors influencing the social determinants of mental health
At a broad level, mental health promotion addresses the social determinants of health through
approaches that strengthen resilience, promote stronger and healthier communities, and address the
structural determinants of health, including some factors we described above (however more could be
done to address how we can support capacity building to be healthy). More research is needed to
determine how Punjabi seniors, families and service providers can more effectively address resiliency to
proactively influence the social determinants of mental health.
• Explore the differences in the way services are approached by seniors and provided by service
providers.
What are the pros and cons of providing services that promote the mental health of Punjabi older adults
through inclusive “mainstream” services (as in Abbotsford) versus services offered from within the
settlement sector and hence situated within the broader needs of new Punjabi immigrants (as in
Surrey)? An evaluation of ‘promising practices’ for mental health promotion is required that takes into
the account the determinants of mental health per the VicHealth Framework
1
and the four quadrants of
the Integral Framework.
9
• Support capacity building and healthy public policy development in mental health promotion to
sustain effective action that addresses the upstream determinants of mental health
This includes an exploration of:
How we can we work collaboratively across different levels and sectors and segments of
society to promote mental health and prevent mental illness;
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How we can collectively support the development and implementation of Mental Health
Promotion policies and plans; and
How we can combine our current efforts to promote mental health across our silos of
practice.
These facilitated collaborations could explore development of place-based strategic approaches that
have the potential to connect the currently diverse and disconnected efforts underway within
communities and across jurisdictions. These collaborations would help us invest in targeted mental
health promotion and prevention strategies and would help define an upstream and united approach at
the community, provincial and national levels. This planning would also serve to identify strategies that
would be helpful to inform policy and practice guidelines. A broader more holistic view implies that
there is no whole health promotion without considering mental health promotion.
Appendix A: Qualitative Analysis - Thematic Definitions and Frequencies
All notes from both sessions were transcribed, as were the posters developed to summarize the
discussions. These notes were imported into the data management program, Atlas.ti 5.2.0 ®. Both
inductive and deductive coding strategies were employed simultaneously. Of the three broad domains
identified as determinants of mental health by the ‘VicHealth Framework’
1
—i.e. social inclusion;
freedom from discrimination and violence; and access to economic resources—social inclusion emerged
as the most prevalent deductive theme. Two inductive themes—family and reaching out—were most
prevalent in the data.
Deductive Theme Frequency*
Commentary
Social Inclusion
The code “F-Social inclusion” was
applied to all commentaries of
programs fostering supportive
relationships, involvement in
community and group activities and
civic engagement. Needs and
preferences in terms of social supports,
social integration, cultural exchange
and involvement in the community
were included. This code also captured
instances where new skills were learnt,
improving the individual’s
opportunities for integration (language
skills, computer skills, navigating
systems).
63
The following co-occurring codes were
reviewed to further inform “Social
inclusion” as an emerging theme:
Awareness of programs; Barriers;
Building knowledge/awareness;
Childcare responsibilities; Family;
Navigating systems; Needs; Promising
practices; and Willingness to attend.
Inductive Themes
Family
Commentary related to the role of
family in Punjabi seniors’ settlement
experience and mental health was
captured in a number of inductive
codes: Family; Barriers-social
55
Notions of family overlapped with other
major themes, appearing in all of the
following codes: Awareness of programs;
Barriers; Building knowledge/awareness;
Childcare responsibilities; Coping
strategies; Cultural context; F-Access to
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networks; Childcare responsibilities;
and Stressors-family. It became
apparent that “Family” was a major,
reoccurring theme in the discussions.
economic resources; F
-
Freedom from
discrimination and violence; F-Social
inclusion; Lack of control; Navigating
systems; Needs; Programs attended;
Programs offered; Promising practices;
Quadrants interlinked; Reach;
Settlement experiences; Social
isolation/loneliness; Stressors – family;
Stressors – social networks; Stressors –
systemic; and Work obligations.
Reaching Out
Several inductive codes combined to
capture the forum participants’
experiences in accessing services and
managing their mental health needs.
These include the supercode,
BARRIERS, as well as Awareness of
programs, Willingness to attend,
Promising practices, Building rapport,
and Reach. Most of these codes co-
occurred with one another.
131
BARRIERS in mental health promotion
in this population were repeatedly
mentioned in the forum. Subcategories of
this supercode were Barriers –
individual; Barriers – language; Barriers
– social networks; Barriers – systemic;
Barriers – transportation. Together they
comprised 126 quotations
* Frequency refers to the number of quotations or segments of coded text. Care must be taken in interpreting a high number of quotations with
the importance of a theme since multiple short quotations can inflate the count. In light of these limitations, the analyst additionally explored
the code’s co-occurrence with other codes and its appearance in the transcripts of both the seniors and service provider subsets.
References
1. Keleher H, Armstrong R. Evidence-based mental health promotion resource. Melbourne: Report for the Department of
Human Services and VicHealth; 2005. Available at:
http://www.health.vic.gov.au/healthpromotion/downloads/mental_health_resource.pdf. Accessed 3/8/2011.
2. BC Ministry of Health Services. A profile of seniors in british columbia. Victoria, BC: Children’s, Women’s and Seniors'
Health, Population Health and Wellness, Ministry of Health Services; 2004. Available at:
http://www.hls.gov.bc.ca/seniors/profile.htm. Accessed 09/01, 2011.
3. Fraser Health Authority. Population Health Profile 2010: Abbotsford LHA. Available at:
http://www.fraserhealth.ca/media/Abbotsford_LHA_Profile_2010_FINAL2.pdf. Accessed 09/29, 2011.
4. Fraser Health Authority. Population Health Profile 2010: Surrey LHA. Available at:
http://www.fraserhealth.ca/media/Surrey_LHA_Profile_2010_FINAL.pdf. Accessed 09/29, 2011.
5. Grimes K, Roberts G. Return on investment: Mental health promotion and mental illness prevention. Report prepared for
the Canadian Policy Network at the University of Western Ontario. Online: Canadian Institute for Health Information; 2011.
Available at: http://secure.cihi.ca/cihiweb/products/roi_mental_health_report_en.pdf. Accessed 10/04, 2011
6. Parent K, Anderson M, Huestis L. Supporting seniors’ mental health through home care: A policy guide. Ottawa: Canadian
Mental Health Association; 2002. Available at: http://www.cmha.ca/data/1/rec_docs/158_smhhc_polguide.pdf. Accessed
09/27/2010.
7. Koehn S. Negotiating candidacy: Ethnic minority seniors' access to care. Ageing & Society. 2009;29:585-608.
8. Spence M, Koehn S, Kobayashi K. Summary report: Knowledge.power.access forum of the immigrant older women: Care,
accessibility, research, empowerment (iCARE) team, held on June 25, 2009, Vancouver BC. Vancouver, BC: ICARE team;
2009. Available at: http://centreforhealthyaging.ca/documents/iCAREforumreport-FINAL-Sept23-09_000.pdf. Accessed
09/01, 2011.
9. Wilber K. A Theory of Everything. New York: Shambala Publications; 2000.