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PRE-PRODUCTION VERSION – PLEASE CITE AS FOLLOWS: Koehn, S., Jarvis, P.,
Sandhra, S., Bains, S., & Addison, M. (2014). Promoting mental health of immigrant seniors
in community. Ethnicity and Inequalities in Health and Social Care, 7(3), 146-156.
PROMOTING MENTAL HEALTH OF IMMIGRANT SENIORS IN COMMUNITY
Introduction
Evidence has shown that late-in-life immigrants, particularly those from cultural backgrounds
that are incongruent with those found in immigrant receiving communities in North America and
Europe, are susceptible to relocation stress that manifest in higher levels of depressive
symptoms. Yet these same older adults are least likely to seek out mental health services. Our
pilot study used Keleher and Armstrong’s (2005) ‘VicHealth framework’ to explore if and how
community organizations providing services to late-in-life Punjabi immigrants in British
Columbia, Canada, offer services with the potential to promote their mental health or wellbeing.
We also wanted to know how Punjabi seniors themselves perceived available services and if they
supported their mental wellbeing.
Understandings of older immigrant mental health
Increasingly, Canada’s immigrants are arriving from Asian rather than European countries of
origin, and this trend is also seen among those who immigrate later in life (Durst, 2010). In the
2006 census, immigrant seniors comprised almost one third of the Canadian population of
persons aged 65 plus. The majority of immigrant seniors in the province of British Columbia
arrive from China and India (particularly from Punjab). Punjabis are found in especially high
concentrations in the large, medium and small towns of Surrey, Abbotsford and Mission,
respectively (WelcomeBC, 2009a, 2009b, 2010). In 2010, one third of the population of Surrey
and one fifth of the residents of Abbotsford were South Asian and in both communities, Punjabi
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was the most common language spoken at home, other than English (Fraser Health Authority,
2011). Yet relatively little is known about this population in the research literature.
Many immigrant seniors from Asia are at risk for poor health (Newbold and Filice, 2006; Gee
et al., 2004) and the risk of mental illness is higher among those who migrate in later life
(Hansson et al., 2010, Bhattacharya and Shibusawa, 2009). The consequences of migration, such
as the disturbance of family support structures and decline in individual self-worth, can
negatively influence both mental health status and access to mental health services (Sadavoy et
al., 2004, Casado and Leung, 2001; Kang et al., 2013). This is especially true for older adults
whose immigration is sponsored by their adult children, which is true of 80% of persons who
arrive in Canada after the age of sixty (WelcomeBC, 2010). The sponsors of these older Family
Class immigrants are financially responsible for them for ten years post-migration, during which
time they may not be eligible for pensions, social services, extended medical and housing
subsidies, depending on the province in which they live (Koehn et al., 2010). Older Family Class
immigrants struggle with limited knowledge of Canadian society and the local environment, loss
of social connections and role reversals. They often find themselves isolated and dependent on
their adult children for information, translation and transportation, as well as basic needs. These
factors can influence their mental health and access to services (Nguyen, 2012; Koehn and
Kobayashi, 2011; McLaren, 2006).
Mental illness is stigmatized in virtually all populations (Mind and Rethink Mental Illness,
2008), and it is sometimes treated as a religious rather than a health problem (Sadavoy et al,.
2004; Marwaha and Livingston, 2002). Considerable evidence supports the tendency for
immigrant older adults and their family members to hide mental health challenges and avoid
seeking help out of fear of shame or rejection, in order to “save face” and to protect family
honour and reputation (Kovandžić et al., 2011; Magaña and Ghosh, 2014; Tieu and Konnert
2
2014). Beliefs in the adequacy of the care offered, knowledge of services and language capability
also influence care utilization (Koehn, 2009; Wu et al., 2005). Finally we need to consider the
accumulated impact of oppression (e.g. sexism, ageism, racism) and structural barriers on the
determinants of health throughout the lives of immigrant seniors (Mullings, 2006; Brotman,
2003). Mental health promotion efforts aimed at reducing health inequities found among this
population are thus essential.
Well-designed community programs have the potential to address multiple health issues
simultaneously because they are culturally responsive, increase social integration and focus on
addressing inequities and building capacity and health literacy (Lai, 2001; Ahmad et al., 2004,
Victoria Order of Nurses, 2009; Diwan and Jonnalagadda, 2001). Under-resourcing and
marginalization of these community organizations and their staff can nonetheless undermine the
relationship between health care and community partners and result in inappropriate referral
patterns (Bowes and Dar, 2000; Sadavoy et al., 2004).
The VicHealth Framework for the Promotion of Mental Health and Wellbeing
In order to start the conversation among service providers and immigrant seniors about the
features of community programs that promote their mental health, we turned to the ‘VicHealth
framework’ (Keleher and Armstrong, 2005). This evidence-based framework acknowledges the
powerful influence of social and economic determinants on mental health and clusters those
deemed most critical into three domains:
(1) social inclusion (SI): social and community connections, stable and supportive
environments, a variety of social and physical activities, access to networks and
supportive relationships, and a valued social position;
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(2) freedom from violence and discrimination (FVD): valuing diversity, physical security,
opportunities for self-determination and control of one’s life; and
(3) access to economic resources and participation (ARP): access to work and
meaningful engagement, access to education, access to adequate housing, and access to
money.
These categories were used to inform our research, but we remained open to the possibility
that they may not be transferable across populations and that they may not be exhaustive.
Methods
To address our objectives, our multidisciplinary research team first identified community service
agencies serving older Punjabi immigrants in Surrey, Abbotsford and Mission. A total of 28
service providers (frontline workers and program coordinators) attended two parallel forums held
in Abbotsford [1] and Surrey in Spring 2011, with 14 participants in each location. Represented
were most of the major immigrant senior serving agencies in the three communities, such as
grassroots advocates (e.g. promoting the rights of women or people with disabilities), the non-
profit multicultural and settlement sector, and municipal, provincial and federal programs
(targeting seniors, people impacted by substance abuse, etc.). Expanding on the results of a
survey completed by service provider registrants, two randomly assigned groups of seven service
providers at each of the forums discussed in greater depth what services they offer, how these
promote the mental health of their senior Punjabi clients, and the successes and challenges they
encounter.
In addition, a total of 24 Punjabi older women and 22 Punjabi older men attended separate
focus groups in Punjabi, one for men and another for women at each forum. They discussed the
influence of the VicHealth determinants on their mental health or ‘wellness’ [2]. Seniors (65+),
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mostly Family Class immigrants sponsored by their children, were recruited by our local
Punjabi-speaking forum organizers from gurdwaras (Sikh temples), through advertisements in a
local free Punjabi-language newspaper, staff at local immigrant serving community agencies,
and by word of mouth.
Semi-structured focus groups were selected as the primary tool for data collection because
they are ‘inexpensive, data rich, flexible, stimulating to the respondents, recall aiding, and
cumulative and elaborative, over and above individual responses’ (Fontana and Frey, 1994).
Focus groups took ninety minutes and were recorded by multiple note-takers. Group facilitators
then summarized key themes that arose in their group. After lunch, all groups reconvened and
facilitators presented their findings and hosted lively discussions in both Punjabi and English
with all forum participants. This step affirmed the trustworthiness and reliability of the
facilitators’ interpretations.
Ethics approval was obtained from the University of the Fraser Valley. Consent forms were
available in Punjabi and English, and forum organizers explained the consent process verbally in
Punjabi to all potential senior participants prior to the forums so as to overcome literacy
challenges.
Data analysis and limitations
Transcribed notes and posters developed to summarize the discussions were imported into the
data management program, Atlas.ti 5.2®. Common themes were ultimately derived by
clustering similar inductive and deductive (VicHealth Framework) codes (Huberman and Miles,
1994). Notes and summaries from both forums were reviewed to ensure that the main themes
reflected the discussion and to identify differences between groups and sites. Given the small
size of our sample and diversity across intersecting determinants of health, our findings must be
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understood as specific to older sponsored Punjabi immigrants living in a North American
context. However, our analysis reinforces the trustworthiness and credibility of the VicHealth
Framework, the useful application of which can be generalized to services provided to diverse
older immigrant populations internationally.
Results
To begin focus group discussions with the service providers, we presented each forum group
with their tabulated survey responses, which indicated which determinants they had mentioned
most frequently and prioritized most highly. The top ten most frequently cited activities across
all respondents were divided evenly between the three mental health determinants, with one
sitting outside of this scheme:
SI - increasing people’s access to community resources (17), community involvement
(14), social inclusion (11);
FVD - self-determination and control of one’s life (12), valuing diversity (10), violence
prevention and awareness (10);
ARP - increasing people’s access to economic resources (e.g. government pensions) (10),
increasing people’s access to education (e.g. English classes) and professional
development (10), increasing people’s access to health services (10);
Other - promoting wellness (physical, emotional, psychological or spiritual) (12).
The survey responses indicate that service providers offering community programs believe that
the programs they offer address all three of the determinants of mental health identified in the
VicHealth Framework. Focus groups revealed that while the participants were not familiar with
this model, all three groups of determinants resonated with them as important. Several explained
how they had consciously factored each of the three dimensions into the design of their
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programs. For example, a seniors group ostensibly designed to teach English to older immigrants
increases their ARP, notably education. The program also promotes SI, by bringing people
together in the group and providing them with language skills that can aid their participation in
the broader community. The facilitators also recognize the importance of ‘self-determination and
control of one’s life,’ an element of FVD: understanding the social constraints to which many
older Punjabi women have been subject throughout their lives, they taught the women how to
take the bus to a nearby shopping centre and encouraged them to order their own ice cream cone
using their newfound English language skills. Most had never selected their own flavour before,
leaving the choice up to their family members. This exercise has made these women less
dependent on their families for transportation to the program and other destinations, and has
further bolstered their confidence in their own judgement, which in turn reduces their
dependency and isolation.
Family
Shaped by migration and sponsorship status, family dynamics influence all three determinants of
mental health and can promote or diminish immigrant seniors’ mental wellbeing. Given the separate
treatment of SI, we focus here on the family’s relationship to ARP and FVD.
Access to economic resources and participation (ARP)
Punjabi seniors depended on their families for support in numerous aspects of their lives and
settlement experience. This was especially pronounced in the Abbotsford group, where the
majority of the participants were more recently-arrived immigrants compared to the Surrey
participants, who had lived in Canada longer and worked since immigrating. More recent arrivals
were still within the ten year period of dependency [3] on their sponsors and were more likely to
be living with adult children. Seniors relied on their adult children for access to resources and
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information such as housing, financial support and banking, transportation to medical
appointments and community programs. Family members were consulted when making personal
decisions. Seniors expected their families to provide guidance and assist them in adapting to the
new environment after immigration, such as learning basic skills (banking, etc.) and navigating
the healthcare, legal and other systems. But not all families have or make the time to address
their needs: “Children need to guide their parents after they immigrate here, about resources, but
they are busy with their lives so there is no guidance” (SM-S[4]). Services provided by
community agencies aim to bridge these gaps in support and understanding both for seniors and
their family members. For example, service providers noted that mental health issues were not
recognized by family members and without guidance, the older adult could be left without
adequate assistance:
Families are in denial or ignore dementia. Families need to be educated. There is a lot of
stigma, guilt and shame around mental health in the community. For example –
grandmother staying at home, waiting for family to come and spending lots of time
sleeping. This is not recognized as depression (SP2-S).
These findings are consistent with the international literature on stigma, noted above, and also
reflects lack of access to health information.
Freedom from violence and discrimination (FVD)
Maintaining control over one’s life (a dimension of FVD) is usually compromised for older
immigrants, particularly those who are sponsored by their adult offspring. Both female and male
seniors reported that their roles within the family were now reversed with their sponsors, who
had taken over as household heads:
We have lost our respect after moving here. … In India we were the owners and had
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power to say something but here everything is owned by the children so we feel dejected
about it. We have to ask everything before making any decision (SM-A).
No longer responsible for household finances or major decisions, many seniors said they lacked
control over their lives. For men, these familial role reversals were often exacerbated by a sense
of shame associated with a sharp drop in social status in the broader community following the
move to Canada. The ‘self-determination and control’ of the lives of many sponsored older
women is especially compromised. Obliged to provide care for grandchildren, these women are
unable to join peer groups and health promotion programs unless they provide child care
facilities.
The lack of understanding between generations was a great concern for the seniors in our focus
groups who reported that many older immigrant Punjabis feel disrespected, lonely and isolated at
times. Service providers said that tension in families can result in elder abuse and violence. Such
negative behaviours are ignored or accepted in the interests of ‘saving face’ and protecting the
‘honour’ of the family.
Service providers emphasized the need to include family members in programs and services for
seniors or vice versa. Some of the programs available for seniors recognized this need by
offering to include other family members in client intake sessions. Child-minding services for
program participants enabled grandmothers to participate in activities that would have otherwise
been inaccessible to them. Service providers recognized issues around lack of understanding
between generations once the grandchildren are a little older: “We need to talk to younger
generations because they are the ones who will create change. Get them to understand what they
[the grandparents] are going through” (SP2-S). The senior participants also wanted programs that
‘strengthen family relationships’ (SW-S). Some related how their grandchildren who had been
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separated from their grandparents until recently have not witnessed first-hand how families need
to care for their elders with affection and respect.
Reaching out to facilitate ARP
In order to promote participation of isolated seniors and facilitate their access to resources,
community service providers must be able to reach seniors with the greatest need. Asked to
estimate their service coverage to Punjabi seniors that could benefit from them, service providers
at the Abbotsford consultation believed this figure was as low as 5%; Surrey service providers
guessed that they reach between 15% and 25% of potential clients. Service providers emphasized
that the isolation of many women and stigmatized issues such as substance abuse, violence and
elder abuse can precipitate mental health decline and are especially hard to address.
Punjabi seniors and service providers alike affirmed that the seniors were very interested in using
services offered to them in their area, but often they were not aware of available programs.
Seniors repeatedly expressed their interest in programs and services by saying, ‘[We attend]
where invited – we always go when we come to know’ (SF-A); ‘[We] would attend if there was
more information provided’ (SM-A). Understanding how to reach them is key:
When we had our wellness forum for seniors, we had Punjabi-speaking health
professionals as speakers, but we didn’t have many coming to the first one, even though
we advertised everywhere. So for the second one, we went out to so many places where
the seniors were and we phoned them up to encourage them to come. In the end, we had
so many we had to turn many people away due to fire regulations (SP1-S).
Multiple strategies are needed to reach out to Punjabi seniors and their families. Workshop
participants recommended disseminating information through gurdwaras, multicultural media
(especially Punjabi radio and television programs), newsletters and notices in appropriate
10
languages at diverse locations (including approaching potential clients in parks or private
homes). Successful programs meet seniors on their own turf and their own terms:
The systems here are very different and it is not easy to translate to them how they all
work and how they can use them. Working out of the gurdwara connects me with a large
number of clients – it’s a great bridge because it is a place they always go to, so we go to
them making it easier for them to access us and the link to community services we
provide. We make the connection easier to build. Making appointments doesn’t sit well
with them—they see it as, ‘I am here and I need help, why can’t I be helped now?’ (SP1-
S).
Collectively, our participants told us that recruitment and retention of Punjabi seniors into
programs entailed the creation of a supportive environment, where program participants are able
to access culturally sensitive information in their own language, feel respected and understood,
and where they have opportunities to gradually build trusting relationships.
At the systems level, however, service providers struggle to offer meaningful continuing
support due to funding constraints. In both groups, several service providers offering innovative
programs were concerned that their funding would be curtailed within the next few months, and
the programs, although well attended and showing positive results would be discontinued. Not
only are the programs reaching a very small proportion of those in need, lack of long-term
funding may result in the loss of clients currently being supported:
It takes a long time to develop trust with clients and they attach to you as an individual
… they feel that very personal attachment, so they expect you to know and they rely on
you and you alone. But here I am—I don’t know if I still have my job in June, because
the funding for the program is never long-term . . . And if there is no funding for a while,
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then you get the program going again later, maybe some of them will come back, but
often many of your clients have lost the only connection to services they had and you
won’t get them back again—they’re lost to you (SP1-S).
Building trust is essential in addressing the needs of Punjabi seniors, and this takes considerable
time. This is especially true for mental health issues that tend to go unrecognized and are more
often stigmatized.
Social Inclusion
In a socially inclusive community or society, individuals are integrated into the community
feeling valued, living with dignity with their basic needs met and their differences respected.
Punjabi seniors repeatedly expressed their need to integrate and to be valued and respected.
Older women spoke of their low self-esteem, the need to be recognized and to celebrate their
achievements. This need seemed to be even more pronounced for men, who also emphasised
their desire for cross-cultural social interaction. Yet programs aimed at facilitating integration of
Punjabi with other seniors have been hampered by discrimination and racism in the broader
community. A service provider in Surrey who tried to introduce a group of Punjabi older adults
to a ‘mainstream’ seniors centre found that ‘[t]hey weren’t welcome; there wasn’t even a
willingness to provide a corner for them to sit in. Also, the programs weren’t appropriate—they
just played bingo and not one of our seniors knew how’ (SP2-S). Similarly, in Abbotsford,
service providers felt that more inclusive community services need to be created to combat
discrimination.
The social aspect of programs and services offered was very 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
12
as well as leadership or educational classes are examples of programs offered to foster social
inclusion. In addition, service providers noted how other group programs, such as exercise
classes, could also foster friendships and combat social isolation. Seniors spoke of their need to
share knowledge and to be mentors and spoke highly of existing mentorship and leadership
programs. In addition to programs offered by multicultural organizations and community
services, gurdwaras play an important, if less formalized, role in providing opportunities for
meaningful social interaction and for building supportive social networks.
Conclusions
In parallel with women’s work as family caregivers (Baines et al., 1992; Schiller, 1993), the
role of immigrant-serving community organizations in providing important health care and
health promotion services, is largely invisible: only one chapter on Canadian immigrant serving
agencies (Creese, 2012) was identified in a systematic scoping review of the international
literature on community organizations in the health sector (Wilson et al., 2012); nor was their
omission identified as a gap.
Despite the critical bridging role they play between new immigrants and statutory services
(Boughtwood et al., 2013), their invisibility in the literature is also reflected in “a trend toward
the homogenization of service provision and the defunding of ethnospecific organizations” in
Canada (Couton 2014). Programs for immigrant seniors are typically short-term and often
restricted to new immigrants (Lim et al., 2005; Victoria Order of Nurses, 2009), thus limiting the
service provider’s ability to engage in extensive outreach and sustain supportive relationships
based on trust with Punjabi seniors. These systemic issues underscore the importance of ‘valuing
diversity’ and access to economic resources (components of FVD and ARP) as important mental
health determinants at the broader policy level.
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Ironically, governments are placing increased emphasis on mental health promotion across the
lifespan in order to optimize return on investment (ROI) (Department of Health, HMG, 2011;
Grimes and Roberts, 2011). ROI studies are nonetheless beleaguered by the difficulty of defining
mental health promotion activities and the fact that investment in one sector (e.g. immigrant
settlement) will be reflected in another (e.g. health care), making cause and effect relationships
difficult to ascertain. Keleher and Armstrong’s (2005) VicHealth Framework is an evidence-
based mental health promotion resource that was developed in response to the need to clarify the
types of activities that contributed to mental health.
Our pilot project explored the viability of applying the framework to the activities conducted
by immigrant-serving community-based organizations. We found that service providers working
in these organizations, particularly those that were targeted at immigrants (versus the broader-
based community services that ‘accommodate’ them) were delivering services that addressed all
three clusters identified in the Framework. Further research is needed to ascertain how well the
components of each cluster are in fact addressed by these programs, but their potential is clearly
illustrated by the examples provided by service providers and the complimentary evidence
furnished by Punjabi seniors.
This preliminary inquiry further reinforces the considerable potential of the Framework as a
means of assessing mental health promotion, and suggests benchmarks to be considered in the
overall design of suites of programs targeted at immigrant older adults by immigrant serving
community-based organizations. Additional research is needed to evaluate ‘promising practices’
for mental health promotion that take into account the determinants of mental health per the
VicHealth Framework. This would provide the evidence needed to inform policy, practice
guidelines, and training efforts specific to mental health promotion for older immigrant
populations.
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Many community service providers are aware of the factors that promote and impede mental
wellness of immigrant Punjabi seniors. 'Promising practices' in combating social isolation
included social outings, time and meals, celebrations, cultural exchange and integration
programs, groups for mothers and grandmothers, leadership and educational classes. However,
our findings point to a need for capacity building in the areas of family violence, elder abuse and
neglect issues. Broad-based community agencies need additional training in 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.). Programs
need to reach out to the community in different languages; funding is therefore needed for
interpretation and translation in different contexts. More frontline Punjabi-speaking staff,
transportation and child-minding are also key to the inclusion of immigrant seniors.
While seniors and service providers alike stress the value of programs that include multiple
family members, care must be taken when including family members in potentially sensitive
discussions with seniors (e.g. around stigmatized topics, such as mental illness and substance
abuse; when they may be victims of abuse or violence within the family, etc.) (Sadavoy et al.,
2004; Guruge et al., 2010).
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Endnotes
[1] Mission is very close to Abbotsford and services are often shared between the two
communities.
[2] The term ‘wellness’ was adopted in place of ‘mental health’ which is typically not
distinguished from mental illness and is often stigmatized (Marwaha and Livingston, 2002).
[3] The period of dependency for older Family Class immigrants has since been raised to twenty
years (Fitzpatrick, 2013).
[4] Participant annotations refer to focus groups: SM = senior male; SF = senior female; SP =
service providers; the A and S following the dash refer to Abbotsford and Surrey, respectively.
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