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Health care equity for ethnic minority older adults

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Recent immigrant older adults and some visible minorities who have aged here—to whom we refer collectively as ethnic or ethnocultural minority older adults (EMOA)—both experience health inequities in Canada. These are primarily related to difficulties with the complex process of accessing suitable services and supports. However, Canadian research on the topic is extremely fragmented and hard to find, and knowledge users charged with designing policy and programs do not have the evidence they need to help them to address access barriers experienced by EMOA. This collection of literature reviews prepared by a team of multidisciplinary academics and multisectoral knowledge users begins the process of consolidating existing evidence. The Candidacy framework for understanding the complex construct of 'access' proved invaluable as a means of exploring the different questions posed by our knowledge user partners. The different dimensions of Candidacy, which take into consideration each of the micro, meso, and macro levels of analysis, unites diverse bodies of literature focusing on community networks, capacity building, community development, health literacy, patient-centred care and communications, cultural competence and responsiveness at the provider and organizational levels, and health care, cultural, housing and immigration policies.
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HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Sharon Koehn & Melissa Badger, Eds.
Gerontology Research Centre,
Simon Fraser University
June 2015
2015
2 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Editors
Sharon Koehn, PhD – Clinical Research Professor, Department of Gerontology, Simon Fraser
University
Melissa Badger, MA (C) – Master’s student, Department of Gerontology, Simon Fraser Univer-
sity
Department of Gerontology & Gerontology Research Centre,
Simon Fraser University - Vancouver
Ste 2800, 515 West Hastings St.,
Vancouver, BC V6B 5K3
Tel +1 778-782-5065
Fax +1 778-782-5066
Acknowledgements
This project was a truly collaborative eort and reects the hard work and willingness to
learn of our graduate students, and the experience of our knowledge user and academic
partners alike. We are grateful to the University of Victoria, Simon Fraser University, the Univer-
sity of Calgary, York University, Ryerson University and Memorial University for their contribu-
tions in kind. Thanks are also due to the BC Ministry of Health, the Public Health Agency of
Canada, Fraser Health, the Canadian Coalition for Seniors’ Mental Health, Family Services
Toronto and the Multicultural Women’s Organization of Newfoundland and Labrador
for providing our knowledge user partners with the time to engage with this project. An
especially big thank you to Geo Gilliard for his time and expertise contributed to the layout
of this book.
Cover Photo
Jon Coupland Photography
Funding
This project was completed with funding from the Canadian Institutes of Health Research
Planning Grants – Priority Announcement: Health Services and Systems for an Aging
Population (201306HLA 309586). Application # 309052; FRN # 132299].
Publication Details
Published by the Gerontology Research Centre, Vancouver, BC, Canada
June 2015
ISBN: 978-0-86491-382-1
Cite whole edited volume as follows:
Koehn, S., & Badger, M. (Eds.). (2015). Health care equity for ethnic minority older adults.
Vancouver, BC: Gerontology Research Centre, Simon Fraser University.
This work will be stored indenitely on Summit, Simon Fraser University’s open access institu-
tional repository, at http://summit.sfu.ca/.
KOEHN & BADGER 2015 | 3
Contents
Acknowledgement of Funding ..................................................................................................... 2
Notes on Terminology ..................................................................................................................... 4
List of Contributors .......................................................................................................................... 5
Chapter One: Partnering to Promote Health Care Equity for Ethnic Minority Older Adults ..... 7
Chapter Two: Optimizing Health Promotion for Ethnocultural Minority Older Adults .............. 14
Chapter Three: Dementia Care Services for Older South Asians ............................................. 23
Chapter Four: Mental Health Treatment Interventions for Ethnic Minority Older Adults: What
has the literature told us? ............................................................................................................. 35
Chapter Five: Intervention Strategies to Address Abuse of Ethnocultural Minority Older Adults
from Dierent Communities ......................................................................................................... 46
Chapter Six: Exploring interventions that enhance the health and healthcare access of ethno-
cultural (racialized) older adults in rural, very small and/or geographically isolated communi-
ties. ................................................................................................................................................. 55
Chapter Seven: Unpacking Access to Health Services and Health Promotion Programs and
Information for Ethnocultural Minority Older Adults ................................................................... 68
Appendix: Team Members and Knowledge User Questions .................................................... 98
4 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Notes on Terminology
Caregiver: This term has been used consistently throughout the book to denote family
members and friends who provide care to older persons on a voluntary basis, usually in their
home. They are most often spouses and adult ospring, although the term can be used to
apply to anyone fullling this role. The term ‘carer’ is more commonly used in the U.K. litera-
ture.
Ethnic or ethnocultural minority older adults (EMOA): This term is applied to both immigrant
older adults and some visible minorities who have aged here. Despite the diversity among
them, they are united in their experience of health inequities in Canada. These are primarily
related to diculties with the complex process of accessing suitable services and supports.
Racialized older adults: This term is sometimes used rather than “visible minority” more
commonly used by the Government of Canada because it acknowledges the problems
arising from discrimination based on essentializing generalisations that reference phenotypic
characteristics rather than an assessment of the whole person.
KOEHN & BADGER 2015 | 5
List of Contributors
Melissa Badger, BSc
MA Candidate, Department of Gerontology, Simon Fraser University
Sean Browning, MA
PhD Student, Department of Sociology, University of Victoria
Neena Chappell, PhD, FRSC
Canada Research Chair in Social Gerontology, Professor of Sociology and Centre on Aging,
University of Victoria
Gabrielle Daoust, MSW
PhD Student, School of Global Studies, University of Sussex
Donelda Eve, BJ
Manager, Health Promotion and Engagement, Population and Public Health,
BC Ministry of Health
Katie Flood, BA Honours Sociology
BA Student, Double Major International Development Studies and Religious Studies, Faculty
of Arts, Memorial University
Kathleen Friesen, RN, BSN, MA
Director of Clinical Programs, Population & Public Health, Fraser Health Authority
Sepali Guruge, RN, PhD
Associate Professor, School of Nursing, Ryerson University
Shamette Hepburn, MSc, MSW, RSW
PhD Student, Ontario Institute for Studies in Education (OISE), University of Toronto
Mushira Khan, BA Sociology, English Literature; MA Sociology
PhD Student, Department of Sociology, University of Victoria
Karen Kobayashi, PhD
Associate Professor, Department of Sociology & Research Aliate, Centre on Aging, University
of Victoria
Sharon Koehn, PhD
Clinical Research Professor, Department of Gerontology, Simon Fraser University & Research
Associate, Providence Health Care
6 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Yamuna Kutty, BSc
Vice President, Multicultural Women’s Organization of Newfoundland and Labrador
(MWONL) and retiree
Daniel W.L. Lai, PhD
Professor, Faculty of Social Work, University of Calgary
Lisa Manuel, PhD
Director, Changing Lives and Family Violence Programs, Family Service Toronto
Atsuko Matsuoka, PhD
Associate Professor, School of Social Work, York University
Delores V. Mullings, PhD
Assistant Professor, School of Social Work, Memorial University
Simone Powell, MSW, MA Public Administration
Acting Manager, Seniors Policy Unit, Public Health Agency of Canada (PHAC)
Bonnie Schroeder, MSW, RSW
Director, Canadian Coalition for Seniors’ Mental Health
Alice Pearl Sedziafa, BScN, MA Gender Studies
PhD Candidate, Department of Community Health Sciences, University of Manitoba
Hongmei Tong, PhD
Eyes High Post-doctoral Scholar, Faculty of Social Work, University of Calgary
KOEHN & BADGER 2015 | 7
Chapter One: Partnering to Promote Health Care Equity for
Ethnic Minority Older Adults
Prepared by: Sharon Koehn, PhD, Melissa Badger, BSc, MA Candidate, Sean Browning, PhD
Student
Supervisor (to S. Browning): Neena Chappell, PhD
Knowledge User: Simone Powell
Introduction
Recent immigrant older adults and some visible minorities who have aged here—to whom
we refer collectively as ethnic or ethnocultural minority older adults (EMOA)—both experi-
ence health inequities in Canada. These are primarily related to diculties with the complex
process of accessing suitable services and supports. However, Canadian research on
the topic is extremely fragmented and hard to nd, and knowledge users charged with
designing policy and programs do not have the evidence they need to help them to address
access barriers experienced by EMOA. This collection of literature reviews prepared by a
team of multidisciplinary academics and multisectoral knowledge users begins the process
of consolidating existing evidence. It serves three purposes: (1) in areas in which the body of
evidence is sucient, it provides guidance to policy makers and frontline providers who seek
to improve access by EMOA to health services and/or health promotion programs and infor-
mation; (2) in domains in which there is a paucity of relevant research, or lack of consensus
within the research record, it identies future directions; and (3) it introduces the reader to
the value of the Candidacy Framework for understanding facilitators and barriers to access,
particularly for underserved populations.
Ethnocultural minority older adults and determinants of
health
In urban metropolises, such as Metropolitan Vancouver, over one half of persons aged 65+
are immigrants and one third are visible minorities.47 Recent immigrant older adults, prima-
rily from Asian countries, are more likely to experience multiple barriers to services and
challenges to mental and physical wellness,17,26,36,50 but many visible minorities who have
aged in Canada are similarly disadvantaged by the eects of lifelong intersections of
economic and social discrimination rooted in racialization.4,15,17,35 The majority of research on
EMOA has been conducted in the United States (U.S.) and its relevance to Canada—where
the immigrant mix and health care context are distinct–is limited.24 Of the 816 sources that
met the eligibility criteria for our scoping review on the health and health care of EMOA,
completed in 2010, more than 70% were published in 192 peer-reviewed journals representing
diverse disciplines and research traditions.24 Hence there is little coordination or recognition
amongst studies. Decision-makers with limited time and resources therefore access only the
most readily available reports.1,13
Especially signicant for EMOA are the compounding eects of social determinants of
health which have a bilateral relationship with health policy, service delivery, and clinical
practice.11,37,43,44,49 Today’s immigrant older adults primarily reside in Canada’s three largest
census metropolitan areas (Toronto, Montreal and Vancouver), arrive from South Asia and
East Asia rather than Western Europe (as did earlier arrivals to Canada), do not know any of
Canada’s ocial languages (69%), remain in the labour force longer than their Canadian
counterparts, and are likely to be married or in a common-law relationship. Compared to
8 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
earlier immigrants, more will have attained a higher education.12,37 Intersections of identity
nonetheless generate considerable diversity among them even within a single ethnocultural
group.24
The healthy immigrant eect has shown that the health of new immigrants is initially better
than their age peers;11 however, disadvantaged groups with low socioeconomic status, high
un- and under-employment, and lack of social support networks, have signicantly lower life
expectancy, poorer health, and higher prevalence of disability than the average Canadian,
with members of immigrant and ethno-racial groups falling disproportionately into these
categories.20,39 Gender dierences have also been identied: the healthy immigrant eect
applies primarily to midlife males, specically those who immigrated less than ten years ago,
whereas women are disadvantaged no matter the time since immigration.22,38,54 The healthy
immigrant eect does not hold true for sponsored (Family Class) older adults or refugees
whose health is poorer than that of their Canadian-born age peers.17 The recent immigrant
status of older adults is positively associated with their level of depression, number of dicul-
ties with instrumental activities of daily living and the type of health insurance they are able
to access.29 However, this last nding and the interaction of immigrant status with race and
ethnicity, are more salient in the U.S. than Canada, pointing to the material and institutional
causes of such disparity.42
Increasingly, research is identifying the complex interactions of socioeconomic status with
other social determinants of health and health care access. For example, among ethnic
and racial minority older adults in the U.S., ‘race’ and ‘ethnicity’ decreased access to care,
and increased less intensive and lower quality care when controlling for socioeconomic
status.19 Engagement in occupations and activities can benet social capital (particularly
as manifested in informal social and attitudinal ties and organizational assets), and both
are positively correlated with health and quality of life or satisfaction among immigrant
older adults.27,48 Social support (which can be conceptualized as a functional dimension of
an individual’s social capital) may buer the negative eects of macro-structural forces to
which older adults are subjected.6
Researchers have identied ‘subjective social status’ as the key means by which educa-
tion and occupational class inuence health in old age.8 Among EMOA, particularly newer
immigrant older adults, subjective social status is undermined by language barriers, trans-
portation diculties, lack of knowledge of local resources, and child-minding responsibili-
ties. These factors are in turn compounded by immigration policies, such as those rendering
older sponsored immigrants dependent on their children for 10-20 years.14 Such policies limit
their access to services,39 and compromise their health and wellbeing.4,19,20,22,27,29,35,42,48,54 These
same factors result in poor access to and utilization of health and social services.3,6,8,9,14,16,21,46
Inappropriate use of emergency services, delayed help-seeking, repetitious but unsatisfac-
tory visits to family doctors and low referral rates attest to their inequitable and ineective
access and represent nancial and health costs to healthcare systems and EMOA respec-
tively.4,15,25,31,32,34,40,55 Women in particular often lack decision-making power in the family and
in relation to their own health7 and are more susceptible to poor mental health46 and various
forms of domestic violence.18,51
The assumption found in policies and among health care practitioners that immigrants take
care of their aging parents is not always viable in the post-migration context,2,23,28,30,33,41,45,52,53
and shifts the onus of responsibility onto the person in need of care and his/her family, which
can render both parties vulnerable to exploitation and abuse.1,15,30 Thus while health care
services are listed by the Public Health Agency of Canada as a social determinant of health,
access to those services is inuenced both by the conguration of the services themselves
as well as other determinants such as social support networks, culture, gender, education
KOEHN & BADGER 2015 | 9
and literacy, socioeconomic status, personal
health practices and coping skills, and
physical location.
Review Methodology
Topics for inclusion in this inquiry were identi-
ed by the knowledge user members of
our six teams (ve dyads and one triad) of
researchers who focus on the health and
healthcare of EMOA and their knowledge
user partners. The latter represent local,
provincial or federal organizations with some
degree of interest in EMOA. Three teams are
located in British Columbia and one team
is located in each of Alberta, Ontario and
Newfoundland. Their interests in EMOA are
broad, encompassing the inuence of deter-
minants of health on health status, health
promotion interventions, strategies to address
abuse, dementia care service improvement,
mental health treatment interventions at the
health care delivery and systems levels, and
provision of services for very small groups
and/or geographically isolated/rural EMOA.
A literature search was undertaken to identify
relevant studies for review according to each
topic of interest. This search was primarily
conducted in a database developed during
a scoping review on the health and health
care access and utilization of ethnocultural
minority older adults.24 Studies included in
the scoping review were peer-reviewed
and published in English from 1980 to 2010.
Search terms pertinent to each research
question are listed in the Appendix. Addition-
ally, the reference lists and citing articles
for the selected publications were inspected for relevance. Post-2010 publications as well
as reports and documents from the grey literature recommended by experts in the eld of
EMOA and health (academics and knowledge users) were also included. Emphasis was
placed on ethnic minority populations in Canada; however examples from the U.K. (which
has a comparable health care system), U.S., Australia, and New Zealand were also selected.
The research assistants hired by each team reviewed between 25 and 53 articles. Findings
from the articles were highlighted relative to the seven dimensions of the Candidacy frame-
work.9 This systematic approach to understanding access enabled research assistants to
consider the knowledge users’ questions in their discussion of the ndings. An exception to
Literature on geographically isolated/rural EMOA and that on intervention strategies for EMOA experiencing abuse from
war-torn countries was relatively sparse. However, tangential literature was examined and examples are included where
possible.
Candidacy Framework
The Candidacy framework for under-
standing access to care speaks to the
patient/client’s dynamic and continually
negotiated sense of legitimacy in using
healthcare,21 which is “subject to multiple
inuences arising both from people and
their social contexts and from macro-level
inuences on allocation of resources and
conguration of services.”9 Establishing
access entails identication of the need for
care, nding your way to it, presenting a
credible claim for care to service providers
who will judge its credibility, and accepting
or rejecting oers made. The ‘openness’
and compatibility of the system and local
operating conditions also play a role. The
seven dimensions of Candidacy shed light
on the roots of inequities in health and
health care, by tying seemingly individual
behaviors in utilization to socially patterned
inuences.”21 Increasingly, it is recognized
as a valuable framework for understanding
the complex process of attaining care by
underserved populations across diverse
health care domains3,16,21,25,40 as well as
public services.32 Here we expand its appli-
cation to include health promotion and
disease and abuse prevention initiatives
that are found outside of the realm of statu-
tory services.
10 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
this was the literature reviewed by Chappell and Powell’s team (Appendix; research assistant,
S. Browning). The broad scope of this question did not lend itself to the same type of consid-
eration in relation to the Candidacy framework. Rather, the ndings have been incorporated
into this introduction.
Topical reports were prepared by research assistants under the supervision of academic
team members. They were then sent to the team’s knowledge user partner for feedback
and modied accordingly. These reports were consolidated into a single document that
informed our discussion at a 1.5 day team meeting (June 2014) in Vancouver, B.C., that
included academics and knowledge users. The meeting was facilitated by Dr. Simon Carroll.
Its outcomes will be reported in a forthcoming publication. We have also translated these
insights into grant applications. The team further agreed that each of the topical reports and
the consolidated document should be openly shared as an e-publication, in order to further
knowledge and promote additional research in this area. We therefore encourage you to
disseminate these ndings widely.
Please cite as:
Koehn, S., Badger, M., Browning, S., Chappell, N., & Powell, S. (2015). Partnering to promote
health care equity for ethnic minority older adults. In S. Koehn, & M. Badger (Eds.),Health
care equity for ethnic minority older adults(pp. 7-13). Vancouver, BC: Gerontology Research
Centre, Simon Fraser University.
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41. Ploeg, J., Lohfeld, L., & Walsh, C.A. (2013). What is “Elder abuse”? Voices from the
margin: The views of underrepresented Canadian older adults. Journal of Elder Abuse
and Neglect, 25(5), 396-424.
42. Prus, S.G., Tfaily, R., & Lin, Z. (2010). Comparing racial and immigrant health status and
health care access in later life in Canada and the United States. Canadian Journal on
Aging, 29(3), 383.
43. Public Health Agency of Canada, Cornwell, L., Hendrickson, T., et al. (2007). Health
status and health needs of older immigrant women: Individual, community, societal
and policy links. [Research report]. Accessed from: http://owhn.on.ca/pdfs/Older%20
Immigrant%20Women’s%20Health%20Report_Final_Final.pdf
44. Raphael, D. (2006). Social determinants of health: Present status, unanswered questions,
and future directions. International Journal of Health Services, 36(4), 651-677.
45. Seabrooke, V., & Milne, A. (2004). Culture and care in dementia. Kent, U.K: Alzheimer’s
and Dementia Support Services.
46. Silveira, E.R., & Ebrahim, S. (1998). Social determinants of psychiatric morbidity and well-
being in immigrant elders and whites in east London. International Journal of Geriatric
Psychiatry, 13(11), 801-812.
47. Statistics Canada. (2006). 2006 census of Canada. Statistics Canada catalogue
no.97-562-XCB2006016.
48. Stav, W.B., Hallenen, T., Lane, J., & Arbesman, M. (2012). Systematic review of occupa-
tional engagement and health outcomes among community-dwelling older adults. The
American Journal of Occupational Therapy, 66(3), 301-310.
49. Stewart, M., Shizha, E., Makwarimba, E., Spitzer, D., Khalema, E.N., & Nsaliwa, C.D. (2011).
Challenges and barriers to services for immigrant seniors in Canada:” You are among
others but you feel alone”. International Journal of Migration, Health and Social Care,
7(1), 16-32.
50. Turcotte, M., & Schellenberg, G. (2007). A portrait of seniors in Canada 2006. .
Catalogue no. 89-519-XIE.
51. Turner, L. (2005). From the local to the global: Bioethics and the concept of culture.
Journal of Medical Philosophy, 30(3), 305-320.
52. Uppal, G., & Bonas, S. (2014). Constructions of dementia in the South Asian community:
A systematic literature review. Mental Health, Religion & Culture, 17(2), 143-160.
53. Victoria Order of Nurses (VON). (2009). Reach up, reach out: Best practices in mental
health promotion for culturally diverse seniors. Accessed from: www.von.ca/en/special_
projects/docs/RR_manual.pdf.
54. Vissandjee, B., Desmeules, M., Cao, Z., Abdool, S., & Kazanjian, A. (2004). Integrating
ethnicity and migration as determinants of Canadian women’s health. BMC Women’s
Health, 4(Suppl 1), S32.
55. Weerasinghe, S., & Numer, M. (2011). A life-course exploration of the social, emotional
and physical health behaviours of widowed South Asian immigrant women in Canada:
Implications for health and social programme planning. International Journal of Migra-
tion, Health and Social Care, 6(4), 42-56.
14 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Chapter Two: Optimizing Health Promotion for Ethnocultural
Minority Older Adults
Prepared by: Mushira Khan, M.A. Candidate
Supervisor: Dr. Karen Kobayashi
Knowledge User: Donelda Eve, B.C. Ministry of Health
Introduction
In 2011, visible minorities constituted 17.7% of the population aged 65 years and older in British
Columbia.31 The largest ethnocultural group was the Chinese (8.1%) followed by South Asians
(5.1%).31 As the proportion of ethnic minority seniors will signicantly increase over the coming
decades, closer attention must be paid to the health needs of this population.
The BC Ministry of Health conceptualizes health promotion as ‘health improvement’ that
is supported by enabling individuals to take control of their own health.32 The Ministry has
developed a number of tools and resources to promote active aging among the older adult
population. These initiatives are largely targeted toward individuals and organizations. For
example, the ‘Healthy Eating for Seniors handbook was created to promote healthy eating
habits and is available in English, French, Chinese and Punjabi. Similarly, the Age-friendly BC
program provides grants and resources for local governments to create age-friendly commu-
nities.
These initiatives, although commendable, must be enhanced in order to fully address the
complexities inherent in the uptake of health promotion interventions by BC’s ethnocul-
tural minority older adults (EMOA). Comprehensive regulatory strategies for behaviour and
lifestyle modication are dicult to implement in ‘less prescriptive’ domains such as healthy
eating because ethnocultural minority groups in Canada are extremely diverse. An added
complexity in the development, dissemination, and uptake of health promotion interventions
is that there is no formal system attached to health promotion in BC. Public education and
social marketing strategies tailored to EMOA are required to promote healthy lifestyles among
BC’s communities.
The health-related needs of EMOA are very diverse. Literature underscores the impact of
multiple axes of inequity related to language, culture, income, gender, social class, place of
birth, and immigrant status.2,17,20,33 While recent immigrants may have better health than the
mainstream population due to a self-selection bias and pre-immigration health screening,6,26
the ‘Healthy Immigrant Eect’ is less apparent among foreign-born individuals who immigrate
in mid-to-later-life.14 Furthermore, EMOA face signicant challenges accessing health care
services and materials.1 7
Research Question
Our knowledge user, Donelda Eve from the BC Ministry of Health, proposed the following
inquiry: What health promotion interventions optimize the uptake of available health promo-
tion materials/services/amenities by EMOA?
KOEHN & BADGER 2015 | 15
Methods
A literature search was undertaken to identify relevant studies for review. The search terms
included: ethnic minority seniors; intervention; health promotion; health promotion strate-
gies; health promotion and ethnicity; chronic disease; and access. A total of 25 articles were
reviewed for this report. The Candidacy lens11 was used to review the literature and ndings
from the articles have been highlighted relative to the seven dimensions of the framework.
Each dimension is identied and discussed in greater detail below.
Findings
i) Identication of Candidacy
Dixon-Woods et al. (2006) note that recognition of an individual’s health symptoms as
requiring intervention or attention is crucial to Candidacy. In a U.S. study of health-promoting
measures among 30 older women from three ethnocultural backgrounds, understanding the
older adults’ own perceptions of ‘health’ was an important step toward conducting health
assessments.34 Holistic views of health among South Asian immigrant women, for example,
are related to lower rates of participation in cervical cancer screening, i.e., participation
in screening in the absence of symptoms.15 As the individualism-collectivism framework
indicates, strong kinship and familial ties within visible minority families may result in the
creation of a certain ambiguity of boundaries between one’s own health and the health
of close family members (i.e., spouses, children or parents). In addition, the cultural gender
hierarchy within visible minority families may lead to situations where female members may
ignore or deny their own symptoms.1
The idea of ‘mastery’, or an individual’s belief that his or her choices and actions inuence
outcomes in later life, is an important construct positively related to self-ecacy and self-
evaluation of health.9 For immigrant older adults, achieving mastery is strongly impacted by
their life-course transitions.9 Among South Asian widows in Canada, ambivalence towards
leisure activities was determined by cultural and tradition-driven prescriptions, such as strict
gender-based normative ideals constructed during earlier life stages in their country of
origin.30
Psychosocial factors, such as the stigma attached to cancer as an untreatable disease, are
underscored as barriers to the identication of candidacy among EMOA.8 Indian patients
are likely to deny health problems due to stigma, especially for mental health issues.21 For
sponsored immigrants who co-reside with adult children, the feeling of stigmatization can
be compounded by social isolation and a sense of indebtedness brought about by their
immigrant status.17 EMOA may downplay symptoms in an eort to remain inconspicuous
and avoid troubling their children.18 Acculturative stress, role reversal or loss of role in the
family, and overwhelming nancial, physical and emotional dependence on younger
family members can result in ‘double barreled social debilitation’.4 Feelings of debilitation
negatively impact identication of the need and deservingness for care that necessarily
precedes the individual’s or family’s eorts to establish candidacy.
ii) Navigation
The navigation dimension of Candidacy recognizes that utilization of services requires
considerable eort on the part of individuals.11 Eective uptake of health resources and
16 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
supports requires not only awareness of the services available but also mobilization of
practical resources such as transportation or time o work.11 For example, diculty arranging
transportation to community support centres prevents EMOA from participating in health
promotion programs.7 In a Canadian study, immigrant older adults reported challenges such
as cold weather, transportation issues, and administrative barriers.21 Resource constraints
prevent family members from providing support to older adults with navigation, and not
all older immigrants have children in Canada.18 Correspondingly, the success of an active
living program for South Asian seniors was attributed to oering programs where older adults
naturally gather (such as at parks and temples), providing childcare for grandchildren, and
reducing cultural and language barriers.19
Limited health literacy and poor understanding of chronic disease,24 low levels of linguistic
literacy,13 fear and distrust of bureaucracy,4 as well as misinformation and lack of trust in
formally organized health interventions7 undermine access for EMOA. Poverty, distrust of
formal systems, transportation issues, and language barriers negatively impacted engage-
ment in health promoting behaviours by Chinese American and African American women.34
In addition to poor linguistic prociency and health literacy, limited prior exposure to formal
or institution-based health promotion initiatives is a signicant barrier to system navigation
and service uptake.1 Canadian research reports that expectations held by older women
from China and India regarding health information did not align with the material that was
actually available.1 EMOA may prefer to use alternative sources for health information, such
as practitioners of traditional or complementary medicine.34
iii) The permeability of services
Service permeability describes the ease with which individuals can access health services
and materials.11 More permeable services impose fewer qualications on individuals for
uptake and utilization, such as the mobilization of fewer resources.11 Lack of charter language
skills (English and/or French) and the limited availability of translation services or translated
materials results in low service permeability.18 In a study of immunization rates among Hispanic
older adults, participants were more receptive to health messages from Spanish speaking
promoteras (promoters) than those who spoke only English.22
In considering service permeability, it is important to distinguish between the ‘targeting’
of health promotion interventions and more appropriate ‘tailoring’ of programs to EMOA
groups.1 Health promotion programs that do not align with internalized cultural norms can
deter older women from participating due to life course experiences in their country of origin
such as gender segregation, patriarchal protection, and preparation for marriage and family
life.34 Menu plans with limited options adversely impact participation in nutrition programs for
older adults.7 In parallel, the ability to wear culturally appropriate clothing during community-
based tness classes greatly facilitated participation among Indian and Pakistani women.19
iv) Appearances
The appearances dimension of Candidacy describes how individuals must clearly articulate
the health issue for which help is being sought in order to gain access to health services.11
Underserved populations may be unable to coherently advocate for their health-related
needs.11 It is crucial to note the impact of cultural dierences on patient-practitioner
dynamics which can ultimately aect patient outcomes such as levels of compliance and
adherence.25
Literature emphasizes the key role of language during appearances. EMOA who experience
KOEHN & BADGER 2015 | 17
depressive symptoms may express their mental health issues as ‘stress’ or a ‘spiritual crisis’,
partly because the terms ‘depression’ and ‘anxiety’ are not customary in their country of
origin.17 Linguistically diverse older adults face diculty articulating needs related to falls risk
and prevention,13 and asthma self-management.24 They may also face challenges commu-
nicating through a health information telephone hotline.4 Having a family doctor who speaks
the same language inspires trust and condence in patients during appearances.24 However
nding a family physician, let alone one who shares a cultural background, is a signicant
challenge for older Canadians.3
v) Adjudications
Once a patient has presented their claim for candidacy, health professionals make judgment
calls that facilitate or impede access to health interventions.11 Cultural assumptions made by
practitioners neglect the complexities involved in facilitating access and can reinforce stere-
otypes of EMOA regarding uptake of Western health services.27 In a study of new immigrants,
health professionals incorrectly assumed that older women would be too pre-occupied with
settlement issues to consider exercising.12 Physicians may avoid discussing certain topics, such
as Pap testing, with older immigrant women in order to avoid causing embarrassment.15 A
lack of culturally sensitive policies and limited training for care providers results in misguided
referrals.4 Cultural sensitivity among health professionals is paramount.27
vi) Offers and resistance
Individuals may choose to accept or resist oers made by health professionals for referrals
or treatment options.11 The decision to accept or reject health intervention depends, to a
great extent, on an individual’s belief system.16 Cultural beliefs inuence the ability of patients
to understand and act on the instructions of health practitioners regarding chronic disease
management.25 EMOA may reject formal support in favour of assistance from their extended
family due to cultural and traditional expectations.13 Fatalistic health beliefs based on ideas
that illness is beyond one’s control or that becoming less active is a normal part of aging may
lead to rejection of oers.16 Conversely, EMOA may view declines in health as a warning from
God and modify their lifestyle accordingly.10
Stigma surrounding illness and disease further complicates the conditions surrounding oers
and resistance.5,15 Fear of stigma had a negative impact on acceptance of cervical cancer
screening among immigrant South Asian women.5 Gender norms are also noted, as resist-
ance can result from interactions between opposite-gender patients and physicians.15 Inter-
nalized values of modesty and propriety played a role in the reluctance of older women to
discuss Pap testing with male practitioners15 and to their reluctance to participate in a mixed-
gender tness class, despite acknowledging the benets of exercise.23
Resistance to oers also results from distrust of formal or westernized systems of healthcare
among EMOA.1 As previously noted, older immigrants may be more familiar with, and there-
fore have more faith in, informal sources of health information, such as their network of family
and friends.1 Health messaging through ethno-cultural print and visual media may best facili-
tate acceptance of health promotion strategies.1 Lastly, language barriers can impede the
ability of EMOA to eectively communicate their preferences for intervention and support.13
Physicians may also fail to provide EMOA with adequate written or verbal instructions for
chronic disease self-management, leading to unintentional noncompliance.24
vii) Local operating conditions
The nal dimension of Candidacy considers the impact of local inuences on the production
18 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
of candidacy.11 Neighbourhood contextual eects such as environmental and socioeco-
nomic factors are partly responsible for regional health disparities.29 Local conditions can also
inuence physical activity levels and healthy eating. For example, although traditional diets
of Indian immigrant families in Newfoundland aligned closely with recommendations from
Canada’s Food Guide to Healthy Eating, the relative non-availability of reasonably priced
ethnic foods in local markets contributed to poor nutritional practices.2 8
The BC government has taken some steps towards acknowledging the complexities inherent
in targeting health promotion interventions for EMOA. The recently published ‘Healthy
Eating for Seniors Handbook is an educational resource that assists older adults in making
informed dietary choices. This guide has been culturally adapted and translated into Punjabi
and Chinese. However, in light of the increasing heterogeneity of EMOA in Canada, such
resources must be adapted for additional groups in order to maximize uptake. Another
health promotion initiative is the Intercultural Online Health Network (iCON), which aims to
optimize knowledge exchange across BC’s ethnocultural communities. Finally, PlanH is a
partnership program between BC Healthy Communities and BC Healthy Families that may
facilitate the development of specic health promotion grants for EMOA.
Discussion
This literature review indicates several overlapping issues that impact the uptake of health
promotion interventions among EMOA. These are discussed in more detail below, followed by
recommendations for knowledge users to consider in optimizing the uptake of health promo-
tion materials, services and amenities by ethnic minority seniors.
Language
English language prociency is a salient issue aecting the uptake of health promotion
materials. Limited ability in mainstream languages was seen to play a role in all aspects of
Candidacy in considering access to health promotion intervention. In particular, permeability
of health promotion resources is restricted by a lack of adequate translation services and
limited availability of materials (such as pamphlets and brochures) in minority languages.
Language factors also impact the ability of EMOA to advocate for themselves during
appearances and successful knowledge exchange during adjudications and oers for
support.
Mobility
While transportation is a barrier to access for all older adults, the impact of reduced mobility
may be more pronounced for EMOA and aect attendance rates at health promotion
settings. Those who immigrated later in life may be dependent on adult children for naviga-
tion or have fragmented kin networks and thus limited familial support. Low levels of knowl-
edge about using public transportation and cold Canadian weather also restrict mobility.
The lack of autonomy that results can aect the ability of EMOA to eectively self-advocate.
Gender
Traditional gender norms have a great impact on access to health promotion services by
EMOA. Older women may be used to relying on men due to patriarchal cultural practices,
resulting in low levels of autonomy and self-ecacy. Norms surrounding modesty can impede
eective communication and trust-building with male health professionals and also preclude
participation in exercise and tness programs when there is a lack of same-gender instruc-
KOEHN & BADGER 2015 | 19
tors, gender-segregated classes, or limited options to wear traditional clothing.
Immigration
Immigration is a signicant life course transition for EMOA. New immigrants face diculties
accessing health promotion information due to a lack of knowledge about formal support
and/or a history of reliance on informal means of information gathering in their country of
origin. Immigrant older adults may be resistant towards western medicine and distrust the
Canadian health system and formal health settings.
Culture
Culture is an overarching factor that can both facilitate and impede access to health promo-
tion resources. Cultural beliefs, such as a fatalistic view of health and illness, may prevent
identication of the need or deservingness for health promotion. Paradoxically, a spiritually-
based recognition of illness as a ‘warning sign’ can motivate acceptance of health interven-
tion. Health promotion programs that do not align with the cultural norms of EMOA are much
less likely to be accepted. Feelings of cultural disconnectedness can aect the ability of EMOA
to establish rapport with health care professionals or discern the relevance of health promotion
materials to their lifestyle.
Recommendations
1.
Health education and interventions should foster self-ecacy and autonomy so that EMOA
feel empowered to advocate for their health needs. Similarly, health promotion settings must
support a sense of agency among EMOA.
2.
Health promotion tools and resources must be culturally relevant and use simple and straight-
forward language that is familiar to EMOA. With regard to health and tness programs,
culturally congruent activities such as Yoga, Tai-chi and Bollywood-style aerobics may prove
popular, particularly among women. Activities must not only attend to language but also
cultural conventions that impact EMOA’s continued participation.
3.
In order to facilitate participation in health promotion activities and programs such as tness
classes, the Ministry of Health may partner with community organizations to arrange trans-
portation and childcare services as well as provide familiar settings for activities.
4.
In order to eectively reach target groups, media outlets such as ethnocultural newspapers,
radio and television channels (such as Sher-e-Punjab Radio, Fairchild Radio Vancouver,
ATN, Alpha Punjabi, BTV, and TalentVision) may be used. Health campaigns should promote
health literacy, healthy eating, and preventive screening for chronic disease.
5.
Collaborative engagement between older adults, family members, community partners,
religious and spiritual leaders and health care providers is crucial to building trust among
EMOA of health promotion resources. Outreach workers and community volunteers inspire
trust, particularly among EMOA who are socially isolated. Partnership initiatives should facili-
tate knowledge exchange in the production, marketing, and delivery of health promotion
tools and interventions.
6.
Within the context of economic constraints (i.e., limited government funding and budget
cuts), existing grants and programs need longer term funding and should include criteria
such as community outreach and partnerships between health agencies (such as local
governments, health authorities, and community agencies). The Ministry of Health must
work collaboratively with not-for-prot and community organizations in order to adapt and
distribute resources to EMOA.
7.
In order to design and implement cost eective health promotion strategies, policymakers must
be cognizant of the unique health needs, beliefs and preferences of EMOA. To this end, it is
critical to develop eective needs-assessment strategies, such as community surveys. There
is also a need for evaluation studies that track the ecacy of health promotion initiatives.
20 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Conclusion
The health promoting behaviours of EMOA are inuenced by multi-level and intersecting
factors. The ndings from this review clearly indicate that in order to eectively engage
EMOA, health promotion must address diverse factors such as linguistic ability, transportation
and mobility, cultural competency, immigrant status, and life course events and transitions.
Health promotion is best conceptualized as part of a continuum of comprehensive care,
involving not only the provision of health promotion services and programs but also the facili-
tation of access to these resources.
Recommendations from this review highlight the need for collaborative engagement with
stakeholders (including family, peers, community partners and health practitioners) and
the development of concise, culturally appropriate health promotion tools tailored to the
complex needs of EMOA. Health communication and promotion must be fashioned as a
collaborative, two-way dialogue model with a focus on information exchange as opposed
to information transfer.1 In order for such a model to gain currency in British Columbia, the
government must address salient issues surrounding cultural competency training – what it
looks like and who it serves – across all health care contexts including health promotion.
Please cite as:
Khan, M., Kobayashi, K., & Eve, D. (2015). Optimizing health promotion for ethnocultural
minority older adults. In S. Koehn, & M. Badger (Eds.),Health care equity for ethnic minority
older adults(pp. 14-22). Vancouver, BC: Gerontology Research Centre, Simon Fraser Univer-
sity.
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Research, 63(2), 72-79.
29. Wang, L., & Hu, W. (2013). Immigrant health, place eect and regional disparities in
Canada. Social Science and Medicine, 98, 8-17.
30. Weerasinghe, S., & Numer, M. (2011). A life-course exploration of the social, emotional
and physical health behaviours of widowed south asian immigrant women in canada:
Implications for health and social programme planning. International Journal of Migra-
tion, Health and Social Care, 6(4), 42-56.
31. Wister, A.V., Sixsmith, A., Adams, R.G., & Kadowaki, L. (2014). Fact Book on Aging in British
Columbia, 6th edition. Vancouver: Simon Fraser University Gerontology Research Centre.
32. World Health Organization (2014). Health Promotion. Retrieved on March 22, 2014 from
http://www.who.int/topics/health_promotion/en/
33. Zanchetta, M.S., & Poureslami, I.M., (2006). Health literacy within the reality of
immigrants’ culture and language. Canadian Journal of Public Health, 97, S26-30.
34. Zhan, L., Cloutterbuck, J., Keshian, J., & Lombardi, L. (1998). Promoting health: Perspec-
tives from ethnic elderly women. Journal of Community Health Nursing, 15(1), 31-44.
KOEHN & BADGER 2015 | 23
Chapter Three: Dementia Care Services for Older South
Asians
Prepared by: Melissa Badger, BSc, MA Candidate
Supervisor: Dr. Sharon Koehn
Knowledge User: Kathleen Friesen, Director of Clinical Programs, Population & Public Health,
Fraser Health Authority
Introduction
The Fraser Health Authority is one of British Columbia’s six publicly funded health care regions.
Its jurisdiction includes a number of communities in the Fraser Valley from Burnaby and Delta
in the west to Chilliwack, Agassiz and Hope in the east. This area is seeing rapid population
aging; Fraser Health (FH) is home to 40% more seniors than the province’s next two largest
health authorities.7 In addition, an increasing number of immigrant seniors are settling in
the FH region. In 2012, 60% of the immigrant seniors arriving in British Columbia settled in the
area.7 In particular, the Fraser Health Authority has the province’s largest South Asian commu-
nity.8 South Asians represented almost half of the region’s population growth between 2001
and 2011, and comprise 15% of the current population.8
The unique circumstances of South Asian seniors have important implications for the delivery
of health services in this region. Of special concern is the provision of dementia care services,
where an improved understanding of the experiences of older immigrants and their families
has been underscored in order to inform best practice.1 Where older adults may often have
complex health needs, immigrant seniors in particular may face a ‘quadruple jeopardy’ of
dementia, age, ethnic minority status, and low socio-economic status.3 It is crucial to under-
stand these factors and how they aect access to dementia care in order for the health
authority to plan and deliver eective services, curb health costs, and best serve British
Columbians residing in this area.
South Asians immigrate to Canada from many countries, predominantly India, Pakistan, Sri
Lanka, Bangladesh, East Africa, and Fiji.9 Among them are represented diverse languages,
religions and ethnocultural backgrounds. As Illife and Manthorpe (2004) emphasize, “cultural
dierences and shared understandings of meaning undoubtedly matter in the ways in which
dementia care is organized and experienced, but a focus on ethnicity alone may promote
misunderstanding and potentially stands in the way of tailored, wrap-around services for
diverse individuals” (p.290). Rather, it is more useful to consider factors such as immigration,
language, health beliefs, and socioeconomic status.10 This report will provide an overview of
these factors and how they inuence the experience of dementia among older South Asians
and their families, with the ultimate aim of promoting equity of access to dementia care.
Research Question
Our knowledge user Kathleen Friesen, director of Population Health at the Fraser Health
Authority, proposed the following inquiry: How can the health authority improve dementia
care services for minority older adults, particularly South Asians?
24 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Methods
A literature search was undertaken to identify relevant studies for review. This search was
primarily conducted in a database developed during a scoping review on the health
and health care access and utilization of ethnocultural minority older adults (EMOA).15 The
search terms used included: ethnic minority seniors, dementia, South Asian, and patient
centred care. The studies selected were peer-reviewed and published in English from 1980
onwards. Additionally, the reference lists and citing articles for the selected publications were
inspected for further studies. Reports and documents from the grey literature recommended
by experts (academics and knowledge user) were also included. Emphasis was placed on
older South Asians in Canada, however examples from the U.K. (which has a comparable
health care system) and other ethnic-minority populations were also selected. Twenty-seven
articles were reviewed for this report,11 of which include a focus on South Asian populations.
The Candidacy lens was used to review the literature, whereby ndings from the articles have
been highlighted relative to the seven dimensions of the framework.
Findings
i) Identication of Candidacy
The rst dimension of Candidacy, identication, describes how symptoms are recognized
as requiring and deserving of medical attention.6 Ethnic minorities may be disadvantaged
by alternative understandings of health and illness, where individuals may not only fail to
identify themselves as potential service users but alternative understandings of dementia are
often not incorporated into existing service models.19 Professional and lay understandings of
dementia are inuenced by the knowledge, beliefs and attitudes of both individuals and
groups, and are thus culturally determined.1 Within the South Asian community, discourses
of collectivism and divinity are common and may not align with Western representations of
health and illness.1 South Asian caregivers have expressed traditional religious and spiritual
beliefs about the cause and nature of dementia.18 Dementia was seen as a mental illness
impacting the entire family, and its symptoms were attributed to ‘spirit possession’ and ‘the
evil eye’.18
Participants were commonly described as having little to no previous knowledge of or
experience with dementia.3,17,21,33 There is no set terminology for dementia within South Asian
languages.29 South Asians may not be familiar with the words ‘dementia’ or ‘Alzheimer’s
disease’, despite having varying levels of impaired memory themselves.17 Normalization of
dementia symptoms is underscored as a barrier to early diagnosis.4 Older South Asians have
attributed symptoms of dementia to “somebody getting old and funny” (p.392),3 a “natural
process of decay” (p.202),31 and also as a result of social isolation and poor physical health.32
Although symptom normalization may in part be due to socioeconomic status and educa-
tion level,1 similar processes were found among Chinese-Canadian caregivers and people
with dementia, across diverse educational and professional backgrounds.14 Symptoms of
dementia may also be misidentied as “absent-mindedness”,32 misattributed to pre-existing
personality traits including anger and depression,20 as well as physical illness (e.g. diabetes,
heart disease) and life transitions, such as retirement.22
While family members may also misidentify dementia symptoms for normal aging, people
close to the person with dementia generally play a key role in symptom recognition. Cues
include repeated questioning, problems with driving, diculties managing nances, general
forgetfulness, and changes to personality and usual behaviour.14 Members of both the
immediate and extended family may recommend help seeking, especially upon noting
safety risks to the person with dementia,20 and when family life is disrupted by dementia
KOEHN & BADGER 2015 | 25
symptoms.3 In one example, a family’s lifestyle was radically altered when it was felt they
could no longer pray at home because an older family member with dementia had incon-
tinence. In their view, the entire home was rendered ‘dirty’.3 This case was compounded by
the fact that the family wanted to avoid the temple in order to conceal the symptoms of
the person with dementia from the rest of the community. Literature describes the negative
perceptions and stigma attached to mental illness.1,3,4,16,24 For families, concealing dementia
from the rest of the community may be a coping mechanism to preserve family dignity and
avoid problems during arranged marriages for example.3,18 One study found that a common
belief among people of Punjabi Indian origins is that dementia symptoms are caused by a
lack of care by either one’s self or family.16 Memory impairment may also be viewed by some
men as a threat to their position in the community.17
Similarly, symptoms may be hidden from one’s family for fear of the negative conse-
quences.33 Immigrant South Asian older adults do not always share health problems with
family members; in many instances familial responsibility may take precedence over help
seeking, which is delayed until the family encourages the older adult to see a health care
provider.9 Caregivers may also delay identication in order to avoid causing anguish or
betraying the person with dementia.22 Dementia is thus viewed as a personal or family
matter, rather than an issue requiring medical attention.22 However, when help is not sought,
identication may still take place within health settings during treatment for other medical
conditions,3,14,20,22 or in response to a tipping point such as bereavement,4 leading to referrals
to memory specialists.
ii) Navigation
After a person’s need and deservingness for health care have been identied, individuals
and their families must locate relevant health services. Dixon-Woods et al. (2006) describe
navigation in reference to one’s awareness of the services available and mobilization of the
practical resources required to access them. South Asian caregivers have compared this
process to “a battle in which they were constantly ghting to receive information, advice
and practical assistance” (p.57).21
Parallel to the process of identication, common barriers to navigation include knowledge-
related factors, such as beliefs about the cause and purpose of a dementia diagnosis;
societal factors, including stigma and cultural expectations; as well as factors related to
health-care, such as resistance to approaching health practitioners and structural service
barriers.22 Punjabi immigrants in the U.K. expressed the belief that “there was nothing that
could be done” and thus there was little point in seeking help from professionals.16 They also
referred to the eect of stigma where “people would gossip about you if something went
wrong” (p.609).16
In addition to a lack of knowledge about health services, families may encounter challenges
in negotiating formal support due to language and communication diculties.11 This may
be true even for immigrants who have been living in Canada for an extended period of
time. For example, despite having lived in Vancouver for three years, a female caregiver
experienced signicant isolation as she spent the majority of her time at home caring for her
child and aging mother.14 Thus the contribution of immigrant status and a heavy caregiving
burden can isolate people who will thus have little awareness of available services or how to
nd information about accessing them.14
Support from family is crucial during navigation, as persons with dementia may not seek
health services on their own.20 Caregivers may lter services to those they deem will be
accepted by their family member with dementia.5 Adult children may be a particularly
important resource in providing information and assistance that facilitates access to the
western health care system, and to emotional and instrumental supports.9 For example,
older women often depend on family members for transportation since they do not drive,
cannot aord a taxi, and avoid public transit due to their lack of English language skills.9
26 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
On the other hand, instances of delayed navigation due to family support have been
noted. Out of respect for family and community hierarchies, family members may choose
to discuss dementia related issues amongst themselves or with a religious leader before
mobilizing support from health care providers.22 In other cases, obtaining any informal
support at all may be dicult, especially among recent immigrants whose social networks
are fragmented.11
Community organizations, such as the Alzheimer’s Society, play a signicant role in
supporting navigation.4,14 Community outreach has been emphasized as a strategy to estab-
lish links with ethnocultural populations, such as organizing ‘roadshows’ at community centres
and religious establishments.21 Bicultural workers are instrumental in using cultural knowledge
to help families navigate mainstream services and in acting as a liaison between clients and
health providers.2 Bicultural workers may also facilitate condentiality, where family members
may make contact “on a friend’s behalf” without having to admit to having a problem of
their own.2
Multipurpose leaets outlining symptoms and the help available that use neutral terms,
such as ‘memory problems’ rather than ‘dementia’ and ‘looking after’ instead of being
a ‘caregiver’ are recommended as eective strategies for service promotion and health
messaging.21 Information provision via DVD and video may be especially critical for individ-
uals who are not literate in either English or their mother tongue.21 Radio broadcasting,
websites, and telephone help lines may be best to connect with people in their own homes.29
In addition to delivery, content, and audience, the source of health messaging must be
considered. Since the government may be perceived with mistrust, information provision may
have more impact if delivered by an independent source.24 Recent research suggests that
awareness campaigns may be useful to reduce stigma, but more evidence is required to
determine their eect on actual help-seeking behaviour.24
iii) The permeability of services
Service permeability describes how accessible services are based on the qualications one
needs in order to use them.6 Factors that commonly aect service permeability include the
location of clinics, hours and language of operation, required levels of health literacy, and
funding models that limit the time health practitioners have per patient.12
Literature suggests that there is a paucity of desirable resources and services for older South
Asians with dementia and their families. Families emphasized the need for tangible support
in dementia care, with one caregiver stating, “We don’t need advice anymore, we need
somebody to come and help us. We need somebody to come and give us respite. We need
money. We need funding. We don’t need talks” (p.390).3 Study participants have expressed
the desire for improved services in the post-diagnostic period including access to community
care, respite, as well as social and psychological support.4 High service demand and ine-
cient referral processes also decrease service permeability.3 As one participant explained,
“It took us a long time to get the help we needed… All they kept telling you is that there isn’t
enough money or the waiting lists are too long” (p.10).29
The organization of health services is also salient. Partnerships between mainstream services
and those oered by the community sector can have a signicant eect on service permea-
bility.3 Divergent views surrounding who should deliver what kinds of services as well as poorly
integrated care may signicantly minimize service access.3 Stereotypes held by organizations
and practitioners regarding the care preferences and family supports of older immigrants
with dementia can also deter service use.19
In order to maximize service permeability, exibility is paramount: services must accommo-
date both people with dementia and their families, and oer multifaceted support such as
regular phone calls and home visits.2 As with navigation, outreach programs are essential to
connect services and service users.2 Moreover, bicultural workers with training in dementia
care, who are procient in community languages, have an understanding of cultural norms,
KOEHN & BADGER 2015 | 27
and are knowledgeable about the healthcare system as well as principles of health equity
and access may be indispensable.2 It is crucial for communities to be oered support
services that are led by sta and volunteers who speak community languages, held at
convenient locations and times, and consider practicalities such as transportation, caregiver
involvement, and childcare arrangements.21,29
iv) Appearances and Adjudications
The appearances dimension of Candidacy describes the presentation of a patient at a
health service to articulate their health issue and make a credible claim for care.6 This dimen-
sion relates specically to the interaction between a client and health professional, and may
be inuenced by the client’s language skills, cognitive functioning, socioeconomic status,
gender, and age for example. The second element in describing this interaction is captured
by the adjudications dimension of Candidacy. After a client presents their need for health
care, practitioners must make judgment calls based on their own knowledge and biases.6
Appearances and Adjudications are presented here together as these dimensions often take
place concurrently when accessing dementia care.
For persons with dementia and their families, appearances commonly begin with the primary
care provider (i.e., family physician) as the rst point of contact.4,14,20,22 Family doctors were
the initial contact in the pathway to diagnosis among 70% of a Chinese-Canadian sample.14
From here, a referral to a memory specialist (e.g., geriatrician, psychiatrist, neurologist) is
likely to be made in order to obtain a diagnosis.14,20,22 However, in a study of South Asians
in Toronto, the time between symptom recognition and consultation with a primary care
provider varied from one to four years.20 If a primary care provider misses dementia symptoms
then it may take a crisis event for the older adult to receive proper diagnosis and care.22
Delays in receiving a diagnosis have also been underscored in the World Alzheimer Report,27
which reports a waiting period between 3 and 6 years for individuals to receive a dementia
diagnosis.
Further delays in obtaining help may be caused by a lack of faith in health professionals,
which can deter persons from making any appearances at all.22 The importance of a sympa-
thetic and supportive primary care provider must be emphasized.22 Older immigrants and
their caregivers may be disinclined to use services if they feel health practitioners lack the
competency required to address their language and cultural background.21 This aspect
speaks to the degree of ethno-cultural alignment between service users and providers. For
example, language barriers were eliminated by a high degree of ethno-linguistic alignment
between a Chinese-Canadian sample of persons with dementia and their family doctors.14
Nevertheless, a practitioner may speak the same language as their client yet do so in a
manner which is overly professional or does not reect the client’s dialect, particularly
when working with older adults.2 Cultural conventions, such as how to address someone,
and non-verbal communication including eye contact and gestures, are also important
in order to build trust with clients.21 Once trust has been established between a client and
health professional, families may ask for advice more readily, conde fears, and recommend
services to friends.2,16 Researchers have elaborated on this point by stating that in working
with older immigrants, ethno-cultural alignment goes beyond addressing language barriers.10
There is a need to overcome age dierences and limits in vocabulary (especially when
discussing Western notions of mental health), address varying levels of comfort with medical
environments and testing, and accommodate family members.30 Researchers have argued
that dementia care services must respect “the diversity and complexity within the life stories
of persons with dementia” (p.5).21 Among older immigrants, important facets of one’s life
history to consider include country of origin, age at immigration, migration route and reasons
for migrating.10
Past negative experiences can also aect appearances: the literature has described a
general wariness among ethnic minority populations toward health services due to past
28 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
experiences of racism, discrimination, and dismissive behaviour by practitioners.23 Individuals
with memory impairment have described memory clinics as ‘shocking’ and ‘frightening’
places.4 In one study, appearances by South Asian participants were hindered by the senti-
ment that practitioners were not willing to help, were dismissive of symptoms, and even
attributed complaints to old age.16 These issues may speak to power dynamics, where
gender-based power imbalances between clients and health professionals can silence an
older adult’s concerns.14 Caregivers have reported feeling that they were not being listened
to, which ultimately led to signicant delays in their diagnostic pathway.22
Appearances of older immigrants at health services are commonly supported by family
members. Daughters in particular play a key role in communicating with physicians,
providing translation, and explaining treatments to their parents.9 While older people may
have condence in their family to represent them during appearances, adult children may
have competing family and work commitments preventing them from assisting the older
adult.9 Using a family member for interpretation, especially a younger person, can lead to
inaccuracies, embarrassment, and miscommunication.10 While the presence of a family inter-
preter may be comforting for the person with dementia, policy requirements may demand
an independent interpretation service in order to avoid biases and miscommunication.28 Use
of family for interpretation is counter indicated in situations when the dependency borne of
sponsorship status may render some older immigrants susceptible to abuse and neglect from
family.13 It is recommended that interpretation services be responsive to the cultural dynamics
of the person with dementia and their families, especially in terms of ethno-cultural align-
ment.28
Adjudications in dementia care are complicated by a lack of culturally sensitive assessment
tools for screening and diagnosis.1 Not only must diagnostic tools show adequate validity
after being translated into South Asian languages, but also cultural specicity.3 Cultural biases
in instruments may skew estimates of dementia severity as instruments are often developed
using samples from the general population.21 A timely and accurate diagnosis of dementia is
critical as it enables access to dementia-specic services, such as particular treatment plans
according to dementia type, home care and respite, and also facilitates future planning with
regard to care preferences and representation agreements for example.21
The literature described several instances wherein primary care providers missed dementia
diagnoses.4,14,20 This may speak not only to diagnostic diculties but also to the limited aware-
ness among health professionals of both the disease and treatment options.3 In one study,
60% of the sample reported delays in diagnosis because the primary care provider dismissed
caregivers’ reports of dementia symptoms.14 There were also instances when physicians
decided not to assess memory since they deemed drug therapy too costly.14 Technology
innovations such as decision support software for primary care physicians may improve the
diagnosis of dementia in health settings.22
Poor medical communication is also responsible for creating confusion between dementia
and other conditions.3 This may be especially salient when practitioners fail to communicate
with and provide support for caregivers.14 Communication diculties with an older adult
with dementia, regardless of ethnic background, may be exacerbated by the nature of the
disease.10 As persons with dementia may not be able to remember details from consulta-
tions, excluding caregivers from client-practitioner interactions can cause delays in obtaining
dementia care.22 Physicians may also delay access to care due to concerns with breaching
condentiality, when they withhold information about the person with dementia from their
family caregiver.4 Service providers who are preoccupied by cultural dierences may have
reduced condence in properly responding to patients from ethnic minorities.3 There is a
clear need for dementia-specic training that focuses beyond culture to the provision of
individually responsive care.3
KOEHN & BADGER 2015 | 29
v) Offers and resistance
Dixon-Woods et al. (2006) describe the oers and resistance dimension of Candidacy as
acceptance and resistance among patients to the oers made by health professionals for
referrals, medication, and additional health support. Readiness to accept a diagnosis of
dementia varies, where both caregivers and people with dementia may aim to “preserve
identity and autonomy in the face of increasing symptoms” (p.7).4 Such resistance may be
less a form of denial than a strategy for self-maintenance.4 Dementia diagnoses are more
likely to be accepted when families have previous experience, either personally or profes-
sionally, with the disease.4 When families lack knowledge about dementia, they may feel
hopeless about options for care beyond family support.3 Recent work suggests that South
Asians are less likely to know about the available treatment options for dementia, although
be more likely to believe dementia is curable versus Caucasians.32 Hope can thus inuence
acceptance of treatment, however attitudes toward medication may become negative as
one’s sense of hope diminishes over time.4 Availability of nancial resources may also impact
decisions about accepting or resisting oers.2
A signicant portion of the literature focuses on the preference for ethnic minorities to ‘care
for their own’ due to cultural norms and religious obligations surrounding lial responsi-
bility.1,17,18,23 Families may be resistant to accept outside help due to the concept of belonging
to a family clan, or ‘biraderi’.28 Oers from services and agencies may be rejected since
acceptance could imply that families need supplemental support and are incapable
of fullling their duty to care.28 Caregivers are reported to believe that acceptance of
mainstream support would lead to placement in long term care, and cause shame to the
family who were perceived as abandoning their relative.18 Services must take into account
the perspectives of the client’s family in order for support to be accepted, and the fact that
service use may be intermittent since acceptance can uctuate over time as health care
providers build trust.2
Not surprisingly, research underscores home care as the preferred service by South Asians.3,16
Remaining in the family home may be imperative both emotionally and practically for older
South Asians with dementia.17 However, there may also be reluctance to allow strangers,
even if they are health providers, into one’s home.3 The literature generally emphasizes strong
resistance among South Asians to accepting residential care,17 which has been deemed
“ideologically unacceptable and culturally inappropriate” (p.390).3 It is dicult for families
to choose and accept long-term care when no suitable options exist.25 There is thus a great
need for caregiver respite, with day care (versus home-based respite or short-stays in care
homes) likely to be the most acceptable option.21
Acceptance and resistance of oers may be impacted by the quality and quantity of
informal support among dierent types of South Asian households.11 Gender norms can
play a role11 where husbands, fathers, and grandfathers may be primary decision makers in
families, and have the ultimate say regarding accepting or resisting medical treatments.9,28
Where men may play a role in decision making and compensatory support, women are
likely to provide more ‘hands-on’ care. For caregivers and care-receivers with traditional
values, the issue of cross-gender caring, especially from persons outside the family, may be
unacceptable.11
While some literature has indicated that older South Asians may be cared for by their family
to a more advanced stage of dementia as compared to the general population, researchers
caution that this may not always be the case.3 It cannot be assumed that all South Asians
have supportive extended families,11 as acculturation may potentially inuence intergenera-
tional attitudes regarding support exchanges and normative expectations to provide care
for an older family member.10 Support from family may also be compromised by immigration
laws, fragmented family networks, the growing preference for nuclear households, nan-
cial pressures, and the changing social practices of marriage, divorce, and women in the
30 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
workforce.11,13,21 The factors inuencing this dimension of Candidacy are dynamic, both within
the South Asian population and over time.
vi) Local operating conditions
The nal dimension of Candidacy, local operating conditions, pertains to local and specic
factors that aect interactions between clients and health professionals, such as the avail-
ability and suitability of resources and services.6 Within the Fraser Health Authority, local
operations for older adults include the Home is Best strategy based on in-home and commu-
nity care.7 For South Asians with dementia and their families, the majority of direct care
services are provided through primary care providers and referrals to specialized clinics
including a chronic disease clinic, specialized geriatric clinics, as well as a new Canadian
clinic. The health authority also supports the South Asian Health Institute (SAHI), which plays
an advocacy role for the South Asian community and individuals managing chronic condi-
tions, and associated South Asian Health Centre, which provides diabetic care among other
services.8
Researchers emphasize a clear need for further service development in dementia care.26
Concerns about service sustainability when funding is short-term have been voiced.21 It takes
time to build trust and establish relationships within local communities, and the deliverables
required by funders may not be possible within the short period for which funding is provided.
Needs-led service development, whereby communities are consulted in order to address
the specic circumstances of the local population, is essential.19 This is an area where more
research is required, especially for systematic evidence and evaluations of eective solutions
and approaches to service design and delivery.19
Discussion and Recommendations
The experience of dementia among older South Asians and their families is a multifaceted
and variable phenomenon with extensive implications for promoting equity in access to
dementia care. Based on this review of the literature, a number of considerations may be
outlined for the health authority in order to improve dementia care services for South Asians
in the Fraser Health region. These are presented according to actions that may be targeted
to specic groups, as follows.
Clients and families
A lack of awareness and understanding of dementia as a medical condition and associated
stigma are signicant barriers to identication of the need and deservingness for care. Older
adults and their families require appropriate information about the cause and symptoms of
dementia, the assessment process, and options for treatment and referrals. It is imperative to
reach out to family members of older immigrants, who often play a large role in most dimen-
sions of Candidacy such as identication and providing support (e.g. with interpretation,
information-seeking, transportation) during navigation and appearances. Information and
decision-making assistance is also needed to help clients understand oers of assistance so
as to increase their utilization. Actions should also target caregivers of persons with dementia,
who may not identify their need or deservingness for self-care or respite. In order for formal
services to be accepted, dementia care must not only provide exible and appropriate
options for individuals, but clients and their families must also understand how these services
compliment (rather than displace) family support. However, it cannot be assumed that all
older adults have access to a supportive family network. Clients who lack informal support
require dierent types of material and assistance in order to facilitate access to dementia
care services.
KOEHN & BADGER 2015 | 31
Communities
Community health education and outreach is crucial to reduce stigma surrounding mental
illness and accepting help, to improve knowledge and understanding of dementia, and to
promote awareness of available services and supports. Health campaigns tailored to specic
communities that use innovative forms of media and provide signposts for services are impor-
tant to this end. Furthermore, partnerships with community organizations and local leaders
are critical to build trust of health services among communities.
Health service providers and family physicians
Family plays a very signicant role in accessing dementia care for older South Asians. Health
service providers must understand that dementia may be seen as a ‘family issue’ and
consider the needs of the family accordingly. Further, health professionals should consider
nuances surrounding gender roles, intergenerational tensions, and issues related to sponsor-
ship that can aect the types of support an older adult may or may not receive from family.
It is important for health service providers and family physicians to be aware of the prefer-
ence for family care yet avoid assumptions regarding the nature and extent of family involve-
ment.
In order to improve ethno-cultural alignment between health service providers and clients,
education and training for health professionals is crucial. Professionals should understand how
dementia might be conceptualized by clients in light of cultural understandings of mental
illness, which could aect how older adults present symptoms and adapt to their experience
of dementia. Ultimately, it is important for health providers to focus beyond cultural dier-
ences to promote individualized dementia care.
Family physicians are often the gatekeepers to dementia care. Training for family physicians
regarding symptoms, diagnosis, and options for treatment and referral is thus imperative. In
addition, training should highlight best practice for medical communication, use of appro-
priate terminology, and call attention to the potential for power dynamics to inuence inter-
actions with clients and their families. This may also be applicable to acute care workers who
attend to older immigrants in crisis or for another health issue. Health providers should have
up-to-date knowledge regarding options for post-diagnostic support including respite, home
services, social and psychological support, as well as programs oered by local community
centres and organizations.
Health service providers and family physicians must aim to build rapport and trust with
clients in working with older immigrants and their families. The importance for sympathetic
health workers and supportive non-threatening environments are key. Bicultural and linking
workers as well as case management may be essential to establish trust over time with clients
and families, and further maximize ethno-cultural alignment. This aspect is also important
when considering interpretation services, where older immigrants should have access to an
independent yet trusted and reliable interpreter.
Health care organizations
Health care organizations may benet from an expanded view of health in order to reach a
wider array of potential service users. This may be done by incorporating community beliefs
and alternative representations of health and illness within existing service directives. Shifting
toward a more holistic view of health and dementia would also benet service promotion
and outreach programs, where health messaging should be tailored to communities in order
to motivate help-seeking and facilitate navigation. To this end, it would be benecial for
health organizations to engage in inter-organization cooperation and agency partnerships.
To maximize ethno-cultural alignment between services and clients, organizations must
provide access to bicultural workers and create comfortable health settings for their clinics
and programs. Training materials for professionals should be developed to promote best
32 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
practice for personalized dementia care in supporting clients from diverse backgrounds.
Ultimately, health providers should be empowered to develop their own strategies for working
with older South Asians.
The importance of exibility in services must be emphasized. The location and environment
of health services should be welcoming, central, and familiar to service users, including
adequate hours and language of operation. Services and programs should take into
account logistical factors that may hinder navigation and appearances for some older
adults and their families, such as work, child-care, and transportation arrangements. In
certain cases, home visits and assessments may be preferable. Health care organizations
should consult with local communities to engage in needs-led service development and
create programs that reect the diverse individuals they aim to serve. In a continuous process
of service development and renement, research should be conducted in order to evaluate
the implementation and reach of existing services and programs.
Policymakers
In the current context of population aging and the growing prevalence of cognitive impair-
ment, an increased societal awareness of dementia is warranted. Policy surrounding an
information and communication strategy to increase awareness of dementia among
communities, health professionals, and decision makers is needed. Policy regarding service
development should call for multifaceted supports including home care, caregiver respite,
daycare, innovative housing models, and appropriate options for long-term care. There is
also a need for further research and technology development (e.g., creating valid and
reliable diagnostic tools and decision support software for health professionals).
In addition, funding models must be revised in order to reduce waiting times and facilitate
the long-term sustainability of services. For example, the patient-practitioner communication
dynamic discussed under ‘appearances and adjudications’ would benet from increased
time per patient with primary care providers, and services oered by the community sector
would be strengthened by funding schemes that allow for a longer period of development
and operation. Greater nancial support for individuals to reduce the cost of medications
and out of pocket expenses is also required.
Conclusion
The experience of dementia among South Asian seniors and their families has important
implications for the delivery of health services in the Fraser Health Authority and beyond.
Through the lens of Candidacy, this review has shed light on the multilevel and intersecting
factors aecting access to dementia care. Findings from this review indicate the importance
of an inter-sectorial approach involving multiple stakeholders in order to address equity in
access. Clients and families require information and exible supports and communities would
benet from tailored health campaigns to increase awareness and knowledge of dementia.
Health service providers must be given opportunities for sensitivity training and healthcare
organizations should engage in inter-agency partnerships and consult local communities to
promote both community capacity and trust of formal health services. Finally, policymakers
should call for multifaceted supports and revised funding and time models to promote equity
in access to dementia care services.
Please cite as:
Badger, M., Koehn, S., & Friesen, K. (2015). Dementia care services for older South Asians. In
S. Koehn, & M. Badger (Eds.), Health care equity for ethnic minority older adults (pp. 23-34).
Vancouver, BC: Gerontology Research Centre, Simon Fraser University.
KOEHN & BADGER 2015 | 33
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29. Seabrooke, V., & Milne, A. (2004). Culture and care in dementia: a study of the Asian
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and attitudes in the diagnosis and management of dementia. Age Ageing, 33(5):461-
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4676.2013.816941.
KOEHN & BADGER 2015 | 35
Chapter Four: Mental Health Treatment Interventions for
Ethnic Minority Older Adults: What has the literature told
us?
Prepared by: Gabrielle Daoust, PhD Student & Hongmei Tong, PhD
Supervisor: Daniel W.L. Lai, PhD
Knowledge User: Bonnie Schroeder, Director of the Canadian Coalition for Seniors’ Mental
Health
Introduction
Despite the unprecedented increase in the population of ethnic minority older adults (EMOA)
in Canada and well recognized mental health problems they may face, gaps remain in
EMOA’s access and use of mental health services. Health providers’ require an improved
understanding of the dynamics of their mental health practice and culturally competent
mental health care. The complex and interconnected factors shaping mental health experi-
ences and interventions require examination, as well as an improved understanding of
aspects of current mental health treatment interventions (particularly those at the levels of
health care system and delivery) that work well for EMOA in Canada.
This literature review explores these inuences and promising approaches to mental health
interventions for EMOA. Findings are discussed in terms of implications for mental health
services for EMOA, with the aim of informing sensitive, appropriate, and eective mental
health practice.
Research Question
Bonnie Schroeder, Director of the Canadian Coalition for Seniors’ Mental Health, posed the
following question: Which mental health treatment interventions (particularly those at health
care delivery and system levels) work well for EMOA in Canada?
Methods
A literature search was undertaken to identify relevant studies for review. This search was
primarily conducted in a database developed during a scoping review on the health and
health care access and utilization of EMOA.14 The search terms used included ethnic minority
seniors; depression; access to services; ethnopsychiatry, and immigrant health. The studies
selected were peer-reviewed and published in English from 1980 onwards. Additional refer-
ences were identied from the bibliographies of selected publications and articles that cited
them. Recommended reports and documents from the grey literature were also included.
Emphasis was placed on mental health of EMOA in Canada, however examples from the
United Kingdom (which has a comparable health care system) were also selected. Thirty-two
articles were reviewed for this report, 11 of which include a focus on mental health of EMOA
in Canada. The Candidacy lens10 was used to review the literature, whereby ndings from
the articles have been highlighted relative to the seven dimensions of the framework. Each
dimension is explained below.
36 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Findings
i) Identication of Candidacy
Identication of one’s candidacy for health care involves EMOA’s recognition of their
symptoms as requiring attention or intervention.10 Older adults and their family members
may have limited awareness of mental health conditions and/or illness symptoms,18,19,22,28
particularly with respect to common disorders in older adults such as depression, anxiety and
cognitive impairment.23 Family caregivers may be lacking an understanding or awareness
due to inadequate information or limited access to appropriate care providers8,13 or denial.13
(Although someone may be knowledgeable about mental health, perceptions of one’s own
mental wellbeing could be inaccurate.15 Mental health symptoms may be viewed as “being
tired,” “thinking too much,” or “negative thinking,” rather than as manifestations of depres-
sion or anxiety.1,15
Understandings of mental distress and illness are shaped by cultural and religious values and
beliefs.12,17,26,27 EMOA may attribute the causes of mental illness to negative character, person-
ality, behavior, spiritual or emotional imbalance, or lack of personal control.17,18,27 Literature
also cites lack of religion, possession by evil spirits, punishment for sins, and symptoms being
seen as a divine test or plan.18 Cultural norms regarding family also play a role. Symptoms
are understood as results of interpersonal stress, family members’ failure to fulll lial duties,
and lack of family support.17,18,27 Mental health challenges have been framed in terms of
immigrants’ settlement and adjustment to a new cultural context as well as loss and power-
lessness.2,17,19 Symptom normalization and misattribution to ‘normal aging’ is also common.8,17
Although mental health symptoms may be identied, the health issue itself may not be
deemed as important.5 Older adults and family members may believe that there must be a
physical or somatic problem in order to legitimize a physician visit.1, 23 Concerns over employ-
ment and nances can cause EMOA to put health concerns “on hold”.2 EMOA may view
mental health challenges as a personal failure or as an expression of weakness, and may
fear of becoming a burden to their families.15 Chinese older adults are more likely to take care
of mental health problems themselves than attain support from mental health services.26
In parallel, EMOA may prefer to “wait and see” rather than seeking immediate support,5,28
which can result in help-seeking only when problems become severe.7,18
The social or cultural stigma associated with mental health and service use has far-reaching
implications for identication of illnesses and help-seeking.7 Expression of mental health
challenges and help-seeking may be avoided due to shame, fear of rejection, or wanting to
“save face” and protect family honour and reputation.8,12,13,15,17,18,23,26,27,28 Family and household
roles, such as childcare responsibilities and the fulllment of gender roles (e.g., completion
of expected daily activities) may prevent EMOA from disclosing mental health challenges to
their family members.2,23 Older Indian immigrants reported “staying busy” in household and
community duties as a means to control one’s ‘inner self’, which was perceived as a form of
moral medicine.1
ii) Navigation
Navigation involves awareness of relevant health services and mobilization of the resources
required to use these supports.10 EMOA and their family members often have limited knowl-
edge of available services and treatments for mental health. This includes poor under-
standing of how to access or obtain services (e.g. how to schedule an appointment) and
how to navigate in the service system.2,5,11,13,15,18,19,22,23,24,27,28 Recent immigrants and immigrant
KOEHN & BADGER 2015 | 37
women who remain at home are particularly vulnerable in terms of having little knowledge
of services and access barriers.13 A compounding factor is the lack of timely, eective, and
culturally sensitive information regarding available and acceptable mental health supports.27
Literature underscores the need for tailored outreach programs that provide health informa-
tion and promote service access among diverse groups.27
EMOA may turn to informal sources (e.g. friends, family members, clergy or church communi-
ties, indigenous healers) for support during navigation.9,15,18,19,21 Literature suggests that greater
perceived social support from family and friends is associated with positive help-seeking
attitudes among older Chinese immigrants requiring mental health support.26 Recent and
sponsored immigrants may be particularly dependent on family members for transportation
to medical appointments and community services, nancial support, addressing language
barriers5,13,27 and assisting with physical challenges.8 Correspondingly, a lack of close social
ties can limit service navigation. EMOA who experience kinship loss due to immigration
face signicant challenges.5,19,24,27 Even when family networks exist, limited time, energy and
nances impede the ability of family members to support or care for older adults.13,23 EMOA
may worry about overburdening family members, and their household or childcare respon-
sibilities limit their ability to seek help.1,13,23 Logistical challenges, such as lack of computer
access, also impede navigation.20
Attitudes towards mental health services and beliefs about mental health treatment as an
eective strategy impact navigation.7,26 Negative past experiences with formal services (e.g.,
painful procedures/treatments and perceptions and experiences of discrimination by health
providers) contribute to distrust of health systems by EMOA.5,18 However, previous interac-
tions with mental health professionals (for example, during a relative’s illness) may be associ-
ated with a better understanding of mental health and need for intervention.18 Support from
trusted ethno-specic agencies is often key during navigation.23 Peer support is also impor-
tant in terms of encouraging help-seeking and health screening, as older adults may be
more likely to listen to other older adults.27
iii) The permeability of services
Service permeability describes how easily people can access services depending on the
qualications needed to use services as well as the mobilization of necessary resources.10
Challenges associated with language signicantly aect the permeability of mental health
services for EMOA. Interpretation services are often unavailable, inadequate or unreliable,
forcing older adults to rely on practitioners with limited language skills or to bring their own
interpreter, such as a family member, to meetings or appointments.5,11,23 Unavailability of
service documentation (including forms, pamphlets, and handouts) in dierent languages
is also a barrier.27 So too is the lack of health information in an accessible format for EMOA
with literacy challenges.21 Discrimination (e.g., ethnocentrism, ageism and sexism) at the
institutional or structural level of mental health care further restricts service permeability for
EMOA.5,8,13,18,19,24,27
EMOA report that the quality of mental health care services that they have received is
poor.19 This might be attributed to dissatisfaction with long waiting periods, perceived lack
of control in referral processes, perceived cultural or religious inappropriateness of services
and supports (such as language and food options), and failure of services to accommodate
family involvement.2,5,11,18
Logistical factors related to accessibility and transportation also inuence service permea-
bility.11,13,1 5 Challenges include large geographic distances from home, lack of available trans-
portation options, and the physical design and accessibility of facilities.1,15,27,28 Researchers
38 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
note that culturally specic services, the preferred option by EMOA, are often located in busy
downtown centres.23 Service permeability is especially low for people living in rural commu-
nities, with limited services and practitioners.27 In addition, available services may not be
physically accessible for the mobility impaired. Mental illness can be associated with poor
physical health and related limitations in functional capacity and mobility.8,16,17,24,25,26 Service
accessibility must therefore simultaneously consider EMOAs’ physical mobility in their design
and layout.8,24 Service timing and scheduling issues can also impact permeability. Service
times may not align with EMOA’s availability due to time-specic obligations such as prayer
time or the provision of after-school childcare.27
iv) Appearances
The appearances dimension of Candidacy describes EMOA’s presentation, formulation,
and articulation of the mental health issue(s) for which support is being sought.10 EMOA are
less likely to use specialist mental health services in favour of primary care physicians. The
stigma attached to consulting with primary care physicians is typically less and they are more
likely to be trusted, thus aording a safer environment in which EMOA can discuss sensitive
personal issues.6,8,18,21,26 Similarly, EMOA are more likely to use mental health supports that are
integrated into primary care services (e.g. brief psychotherapy) rather than services oered
as specialized mental health care.3,4
Cultural factors impact the articulation and presentation of mental health issues. EMOA may
not articulate their health concern in a way that is recognizable as a “legitimate” mental
health problem according to clinical criteria or the English language.15, 27 Articulation can
be complicated by cultural expressions of symptoms, such as the presentation of mental
distress as physical or somatic problems.17,19 EMOA may present mental distress in terms of
headaches, back or joint pain, and/or fatigue.2,15,17,18,19 In some cases, cultural or religious
practices can be mistaken for depression, such as limited communication and social isolation
in preparation for spiritual rituals or during periods of grieving.17,27 In addition, the functional
impairment associated with some mental illnesses, such as limitations in sight, hearing, or
cognition, can impact appearances. 8
Appearances by EMOA can be aected by their perceived sense of inferiority in the formal
health setting.15 The communication dynamics between older clients and health profes-
sionals are inuenced by generational dierences in speech patterns, negative attitudes to
those in authority, limitations in literacy19 and cultural norms regarding interactions between
men and women.27 EMOA may feel ashamed to disclose certain personal health issues5
due to the importance of being respected and honoured by their family and community.1
The service environment or program location can also inuence appearances based on
factors such as privacy and comfort, quiet and calm, and lack of distractions.27 EMOA may
feel overwhelmed by the service system and may not understand what is expected of them
during their appearances before health care providers.11
Language dierences between patients and service providers can present signicant
challenges. A client’s inability to describe or explain their concerns and treatment needs
impedes access to mental health treatment and support.11,18,27 The presence of an experi-
enced native-speaking practitioner contributes to higher rates of service uptake.28 However,
native language health professionals and interpreters are often unavailable and EMOA have
to rely on family to provide translation.5 The presence of an interpreter, particularly a family
member, can interfere with disclosure of concerns and treatment needs due to feelings
of embarrassment, judgment, and lack of impartiality.11,13,23 In these cases, EMOA may be
reticent to discuss stigmatized issues such as elder mistreatment, neglect and substance
abuse.13 Family interpreters may withhold information from either the health professional or
KOEHN & BADGER 2015 | 39
older client in order to control the interaction and protect the patient and/or family.11,13,21 They
may also lack understanding of mental health issues, impacting the accuracy of interpreta-
tion.23
v) Adjudications
The adjudications dimension refers to judgments and decisions made by mental health
professionals, which inuence continued access to services and interventions received by
EMOA.10 Cultural dierences, psychosomatic expression of illness, language and communi-
cation barriers between clients and clinicians signicantly aect adjudications.17,18,19,27 These
challenges complicate diagnostic processes such as in establishing patient history and
using mental health screening tools based on language recognition and ability.19 Literature
emphasizes the importance of cultural and linguistic adapted screening, assessment, and
diagnostic tools (e.g. for depression, cognitive impairment, physical health, social support,
life satisfaction, quality of life) in order to ensure that the meaning and content of diagnostic
procedures correspond with the clients’ needs.16,17,22,28 Treatment uptake by EMOA is more
likely when culturally sensitive psychiatric evaluations are used.28
Adjudications are negatively aected when service providers are lacking cultural compe-
tency,18 reecting an inadequate specialized training regarding best practice with EMOA.21
Low levels of cultural understanding among health providers are associated with a lack
of condence, trust, and compliance among EMOA.17 Practitioners may be perceived as
not listening15 and EMOA may believe that the practitioner is unable to meet their needs.21
Indeed, language barriers become a more signicant issue without an understanding of
culture.27 Literature emphasizes the importance of focusing on EMOA’s personal and familial
cultural history (including immigration status, social support and levels of acculturation) when
considering mental health supports for EMOA.19
Mental health practitioners vary in their level of training, skill, and condence in terms of
identifying mental health issues among EMOA populations.8,20,21,27 Practitioners may view
indicators of depression, anxiety, and cognitive impairment as normal symptoms of aging.8
Value-based decision-making can impede adjudications.15 This includes biases or prejudice
in terms of cultural stereotyping, over-generalizations, or “statistical discrimination” (making
decisions based on knowledge of probability of groups having certain conditions).18,19 Ageist
attitudes can also lead to inaccurate or insucient treatment for older adults with mental
illness.8 In addition, structural level factors inuence adjudications. Immediate pressures on
time available for consultation and treatment, stang shortages, lack of resources, paper-
work, workplace culture (e.g., interest or support from management), competing clinical
priorities, and capacity to integrate dierent aspects of care all impede the ability of mental
health providers to establish a trusting relationship with EMOA.13,15,27
vi) Offers and resistance
This dimension describes resistance and acceptance by EMOA to service referrals and/
or oers of treatment and medication made by professionals.10 Literature emphasizes the
importance of a practitioners’ language when making oers for mental health treatment or
support.20 Alarming, stigmatizing, or discouraging terminology and tone can cause resistance
among EMOA.20 A lack of trust, either in the treatment (e.g. medication) or in the prescribing
mental health professional,5,7 poor understanding of a service’s purpose, as well as feelings
of embarrassment or shame to receive support5 commonly result in resistance. The stigma
associated with mental health service use is a very salient barrier to accepting oers.8,12,13,15,17,
18,23,26,27,28 Beliefs and values about self-control and “self help” may also play a role.1,5,9,15,26 Fear
that use of services will result in loss of independence highlights the importance of freedom
40 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
and autonomy with respect to mental health.1, 5,11,15
Services on oer may be perceived as inappropriate for cultural or religious reasons.5,18
EMOA may prefer homeopathic, alternative, or traditional treatments and remedies.2,5,16,18,25
Religious or spiritual healing practices (e.g. meditation, prayer, fasting, rituals) are also
important for some EMOA in coping with mental health challenges and mental distress1,9,11,18
and often inuence health perceptions and decisions.11,17 Western medicine may only be
accepted if the problem does not eventually resolve.18 EMOA’s beliefs can inuence the
eectiveness of medical interventions and treatment compliance and therefore must
be incorporated into treatment and care plans.11 Diculties arise when practitioners view
mainstream care as superior to traditional healing practices.11 This can result in cultural
tensions between professional views concerning the patient’s ‘best interests’ versus EMOA’s
preferences for care.21
Cultural norms related to expectations of, and reliance upon, family care and support
impact acceptance and resistance.11,18,19,21,27 EMOA may feel that health concerns are best
addressed within the family context and thus involve family members in personal decision-
making.11,13 Values based on lial piety and kinship care, support, and reciprocity will deter-
mine what care is needed and acceptable by EMOA.18 Home support may be resisted out
of concern for respect and the belief that care should be provided by family or community
rather than by “outsiders”.21,27 Support from trusted ethno-specic community agencies18,23
as well as through social groups and day centres5,27 may be better accepted by EMOA over
formal services focused on mental health (e.g. day hospitals, community nurses). Commu-
nity based mental health support may be especially crucial for EMOA who lack family and
peer support. Ethno-specic mental health workers are perceived as the most acceptable
support by EMOA who appreciate receiving treatment from someone of the same ethnic
background.18,23
EMOA with mental illness are at particular risk of non-adherence to prescribed treatment.18
Mental health challenges can be associated with functional impairment and cognitive
decits, which impact understanding of treatment oers and instructions for medication.8
Language and literacy barriers also impede understanding of health materials.19 EMOA may
feel overwhelmed by formal services, treatment procedures, and expectations, resulting in
noncompliance and poor outcomes.11,19 Clients may pretend to understand or agree with
practitioners in an attempt to please, appear compliant, or avoid embarrassment,11 even
when they are dissatised with allocated supports.15
Financial challenges also impact compliance. Cost determines which referrals or treatments
EMOA and their families can or cannot accept.2,11,13,27 Ineligibility for insurance benets,
delays in health care cost reimbursements, and lack of pension negatively impact accept-
ance of oers, particularly for older immigrants.13,27 In addition, EMOA face signicant
economic challenges related to employment including non-recognition of education and
work experience as well as ageism.13,16,27 These prejudices are compounded for persons with
mental health challenges.8 Finally, transportation needs and physical accessibility inuence
EMOA’s ability to comply with service and treatment oers.11,13,15,27,28
vii) Local operating conditions
This dimension describes locally specic inuences on Candidacy that impact interac-
tions between EMOA and practitioners, including the perceived or actual availability and
suitability of resources.10 Generally, culturally appropriate mainstream services for EMOA are
lacking as are services or resources that combine mental health or psychiatric, geriatric,
and ethno-cultural care.13,17,18,23,27 Bilingual/bicultural health professionals, who can provide
culturally and linguistically competent services, are often unavailable within mainstream
KOEHN & BADGER 2015 | 41
services.5,20,23 In addition, there is a paucity of age-appropriate mental health services and
programs for older adults (e.g. mental health education, clinical or rehabilitative programs)
that address issues such as social isolation and socio-emotional support.8,18,27 Poor coordi-
nation and integration across service delivery networks (e.g., between mental health and
elder abuse services), has been noted.8 Environmental factors, such as neighbourhood and
housing quality, also impact the dimensions of Candidacy. Service access is compromised
when older adults live in deprived or unsafe areas5 or when they experience home insecurity
or poor housing conditions.24
Discussion
This review has uncovered a number of complex and intersecting factors that impact access
to and use of mental health services by EMOA and contribute to our understanding of what
sensitive, appropriate, and eective mental health treatment interventions may look like.
Generally, there is a lack of eective and culturally appropriate mental health intervention
strategies for EMOA in Canada, as well as a lack of research examining best practices for
diverse communities. However, a range of interconnected and overlapping factors inuence
the dimensions of Candidacy and are further discussed below. This is followed by recommen-
dations for knowledge users to consider in the provision of mental health supports for ethnic
minority seniors and their families.
Identication of Candidacy for mental health care is aected by limited knowledge and/
or awareness of mental health conditions. Cultural and religious beliefs also shape EMOA’s
understanding and expression of mental health challenges. Other inuences on identica-
tion include beliefs about self-control, fear of stigma associated with mental illness, negative
perceptions and experiences of mental health care, and family inuences including
cultural norms of family support and household roles. Navigation of mental health services
is negatively impacted by limited knowledge of available services, lack of service options,
language barriers, as well as a reliance on traditional, informal, and non-specialist care.
Family support is key during navigation, where dependence on family ties aects resource
mobilization (i.e. social capital). The availability of interpretation services, physical and
geographic accessibility, and institutional discrimination (including racism, ageism, and
sexism) aect navigation and the permeability of mental health services. Financial diculties,
employment challenges, and limited insurance coverage (particularly for older immigrants)
negatively inuence the resources available to locate services and accept oers for support.
Appearances by EMOA at mental health services are shaped by cultural expressions of illness
symptoms and language barriers. Communication challenges impact diagnostic processes,
practitioners’ understanding of patient concerns, and adjudications and treatment oers.
Other inuences on adjudications include practitioners’ limited understanding of cultural
beliefs and values, discriminatory attitudes or practices, as well as institutional constraints
and pressures. Resistance or acceptance of referral, intervention, or treatment by EMOA may
be based on negative perceptions of practitioners or services, a lack of understanding, and
fear of shame or stigma. Oers for support may be resisted based on perceived cultural or
religious appropriateness as well as preferences for traditional or spiritual treatment, family
and peer supports, and practical concerns related to nances and transportation.
Finally, local conditions impacting access include a general lack of appropriate options for
mental health services, a lack of bicultural/bilingual mental health workers, negative percep-
tions among EMOA of service quality and of service providers (including issues of trust and
condence), as well as structural discrimination in terms of service conguration. Geographic
and neighbourhood contextual factors also play a role, as do immigration and settlement
42 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
processes such as acculturation, available family support, and nancial insecurity.
Recommendations
1. Mental health interventions must respond to the cultural and language needs of EMOA.
Bilingual and bicultural service workers are needed to provide culturally sensitive services.
Service documentation and health information (including forms, pamphlets, handouts)
must be translated into dierent languages, use culturally sensitive content, diverse means
of transmission, and be considerate of the time and place of delivery.
2.
Practitioners must recognize that mental health issues among EMOA may not correspond
with English or clinical denitions. Screening, assessment, and diagnostic tools must be
culturally and linguistically adapted and validated for use with EMOA.
3.
Interventions must accommodate EMOA’s specic and diverse understandings and expres-
sions of mental health, which shape help-seeking behaviours, coping, and ultimately
acceptance of treatment. These include cultural and spiritual beliefs as well as the psycho-
somatic expression of mental distress.
4.
Mental health services must provide a supportive environment in which cultural and
spiritual beliefs and practices can be discussed. Services must be accessible in terms of
location, available transportation options, and physical accessibility. The impact of mental
distress or illness on physical mobility must be considered for service provision. For some
older adults, home-based services may be preferred.
5.
Public and internalized stigma associated with mental health must be addressed through
community education. Social inclusion and activity for all EMOA must be promoted to
minimize the risk for isolation and loneliness, as well as foster self-help and peer helping.
Such initiatives might include voluntary activities and intergenerational programming,
especially for EMOA who lack a supportive family network.20 In parallel, mental health
interventions should support development of mental health knowledge and supports for
family caregivers of EMOA.
6.
Treatment plans must be individualized and tailored to meet the specic needs of the
older client. It is important for mental health professionals to address personal and familial
background, immigration status and acculturation. Oers for support must be appropriate
in terms of cultural and religious beliefs, norms and family involvement. Care plans must
balance traditional and modern medicine in order to enhance eectiveness and compli-
ance. Practitioners also require knowledge and understanding of how to accommodate
family support in care planning and treatment intervention. This includes addressing
potential challenges associated with family involvement such as privacy concerns when
using family interpreters and the inuence of family norms during oers and resistance.
7.
Mental health services should include options for community supports, such as social
groups and day programs provided through ethno-cultural agencies. Since many EMOA
prefer to receive mental health support from their primary care physician, it is important
that formal supports be integrated with primary care services.
8. Service models must be revised to better address the multiple health-related and socio-
economic challenges that impede mental health treatment for EMOA. For example,
immigration and settlement processes linked to levels of acculturation, ethno-cultural
identity, length of residence in Canada, charter language ability, social isolation, sponsor-
ship dynamics and nancial insecurity, impact all dimensions of Candidacy. Ongoing
case management and socio-emotional programs are key to address the broad range
of factors that impact mental wellbeing over time for EMOA.4 Accordingly, longer-term
funding models are required to sustain the provision of continuous mental health supports.13
9.
Mainstream mental health services should work to build connections and partnerships
with trusted ethno-specic community organizations to facilitate service promotion and
engage in a process of needs-based program development in the context of EMOA’s
own community.
KOEHN & BADGER 2015 | 43
Conclusion
A number of crosscutting factors inuence multiple dimensions of Candidacy for EMOA
requiring access to mental health treatment and support. These include cultural and religious
beliefs and values, language and interpretation diculties, the central role of family care and
support, perceived cultural appropriateness of services, reliance on traditional or informal
treatment and care, service accessibility, nancial challenges, and local conditions. The
ndings from this review contribute to our understanding of EMOA’s mental health experi-
ences and provide insight for developing appropriate interventions for this population.
However, the current literature does not adequately respond to the guiding research
question, namely, which mental health treatment interventions (particularly those at the
levels of health care system and delivery) work well for EMOA in Canada. This reects a signi-
cant need for intervention research in this topic area in order to support the development
and provision of sensitive, appropriate, and eective interventions for increasingly diverse
older adult populations. These interconnected and overlapping factors must be considered
to promote appropriate and eective strategies for mental health treatment interventions for
EMOA.
Please cite as:
Daoust, G., Tong, H., Lai, W.L.D., & Schroeder, B. (2015). Mental Health Treatment Interven-
tions for Ethnic Minority Older Adults: What has the literature told us? In S. Koehn, & M. Badger
(Eds.),Health care equity for ethnic minority older adults(pp. 35-45). Vancouver, BC: Geron-
tology Research Centre, Simon Fraser University.
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44 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
8. Cummings, S. M., & Kropf, N. P. (2011). Aging with a severe mental illness: challenges
and treatments. Journal of Gerontological Social Work, 54(2), 175-188.
9. Diwan, S., Jonnalagadda, S. S., & Balaswamy, S. (2004). Resources predicting positive
and negative aect during the experience of stress: A study of older Asian Indian
immigrants in the United States. The Gerontologist, 44(5), 605-614.
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Katbamna, S., Olsen, R., Smith, L. K., Riley, R., Sutton, A. J. (2006). Conducting a critical
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11. Evans, C. A., & Cunningham, B. A. (1996). Caring for the ethnic elder: even when
language is not a barrier, patients may be reluctant to discuss their beliefs and practices
for fear of criticism or ridicule. Geriatric Nursing, 17(3), 105-110.
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ethnic older people and mental well-being: Possibilities for practice. Working with Older
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406-411.
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& Wilson, N. L. (2007). Healthy IDEAS: A depression intervention delivered by community-
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23. Sadavoy, J., Meier, R., & Ong, A. Y. M. (2004). Barriers to access to mental health services
KOEHN & BADGER 2015 | 45
for ethnic seniors: the Toronto study. Canadian Journal of Psychiatry, 49(3), 192-199.
24. Silveira, E. R., & Ebrahim, S. (1998). Social determinants of psychiatric morbidity and well‐
being in immigrant elders and whites in east London. International Journal of Geriatric
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25. Su, T. P. (2005). Prevalence and correlates of depressive symptoms in older immigrants
(from Taiwan and mainland China) in Canada. Journal of the Chinese Medical Associa-
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26. Tieu, Y., & Konnert, C. A. (2013). Mental health help-seeking attitudes, utilization, and
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27. Victorian Order of Nurses (VON). (2008). Reach up, reach out: Best practices in mental
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28. Yeung, A., Yu, S. C., Fung, F., Vorono, S., & Fava, M. (2006). Recognizing and engaging
depressed Chinese Americans in treatment in a primary care setting. International
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46 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Chapter Five: Intervention Strategies to Address Abuse
of Ethnocultural Minority Older Adults from Different
Communities
Prepared by: Shamette Hepburn, MSc, MSW, RSW, PhD Student
Supervisors: Atsuko Matsuoka, PhD & Sepali Guruge, PhD
Knowledge User: Lisa Manuel, PhD, Director of the Changing Lives and Family Violence
Programs, Family Service Toronto
Introduction
Ethnic minority older adults (EMOA) represent a signicant proportion of older adults (65+) in
Canada: whereas 30% of the older adults were immigrants in 2006, this proportion was nearly
70% in the metropolitan area of Toronto.19 Immigration, settlement and family obligations are
key issues aecting the health and wellbeing of immigrant older adults. In light of particular
concerns surrounding elder abuse and neglect in the post-migration context,15,16 the ability of
EMOA to access support services is paramount.
This report discusses the capacious factors that inuence the experience of elder abuse and
neglect among EMOA and access to support services. We focus on the social, cultural, polit-
ical and economic factors that impact older people, their caregivers, and service providers.
Intervention strategies to address abuse and mistreatment are also discussed.
Research Question
As Director of the Changing Lives and Family Violence Programs at Family Service Toronto,
our knowledge user partner Dr. Lisa Manuel was interested to ascertain: What types of inter-
vention strategies address abuse of ethno-cultural minority older adults as it is dened and
experienced in dierent communities, especially those coming from war-torn countries?
Methods
A literature search was undertaken to identify relevant studies for review. Search terms
included: ethnic minority seniors; abuse and neglect; sponsorship; immigration; access to
services; immigrant health; refugees. Emphasis was placed on older adults from war-torn
counties. Twenty-six articles were reviewed for this report. The majority of studies empha-
sized the experience of Tamil, Punjabi, Chinese, Vietnamese, Japanese and African-Carib-
bean immigrants and refugees. The Candidacy lens4 was used to review the literature. As
highlighted below, each dimension of Candidacy is explored in relation to the unique experi-
ences among visible minority communities living primarily in North America and the United
Kingdom.
KOEHN & BADGER 2015 | 47
Findings
i) Identication of Candidacy
In situations of abuse and neglect, the identication dimension refers to the process in which
EMOA recognize abuse and mistreatment and a need for intervention. A widespread lack
of awareness of elder abuse and mistreatment undermines identication of Candidacy by
EMOA11 and service providers.2 As there is no minimum standard of care for older adults,
health professionals overlook warning signs of abuse, especially in cases of neglect.2,28
EMOA’s conceptualization of abuse may not correspond to mainstream deni-
tions.1,2,5,7,15,16,18,21,22,24,27,28 The term ‘abuse’ can connote extreme violence when translated
into certain languages.7 Chinese older adults, for example, have indicated that they would
be more likely to report elder abuse if the situation constituted a ‘criminal case’.5,28 ‘Senior
abuse’ has been described by Punjabi older adults to include a lack of respect, being forced
to baby-sit, social isolation, and loneliness.18 Receiving the ‘silent treatment’ from children
may also be seen as an abusive behaviour.1 1 It is recommended that term ‘mistreatment’ be
used to better address the spectrum of abuse and neglect experienced by EMOA.1,7
The multidimensional eects of elder abuse and mistreatment are compounded by
emotional distress from adjustment factors, language barriers, and cultural isolation, all of
which interfere with identication of candidacy to services.12,13,21,22,25 Acculturation2,11,12 and
cultural norms of lial piety12 impact perceptions and tolerance levels of abuse and mistreat-
ment. Community expectations and ideals of familism are also underscored. Concerns for
the welfare of children and grandchildren,8,9 fear of shame,1,7,21 and fear of ‘losing face’ in
the community5,12,28 negatively impact identication and help seeking. Factors related to
immigration, such as fear of deportation or loss of sponsorship3,6,7,8,17,18,24,26,27 and pre-migration
experiences of trauma, especially among refugees,8,9,11,12,13,17,29 hinder the ability of EMOA to
recognize abuse and mistreatment and seek help.
ii) Navigation
After identifying their candidacy, EMOA must have knowledge of available support
services and the ability to mobilize practical resources in order to use them.4 Lack of knowl-
edge2,5,8,11,12,21,22,28,29 and low levels of social capital6,7,8,9,18,17,25 negatively impact navigation
by EMOA and their family caregivers. Navigation depends not only on literacy but also
on an understanding of service conguration, which places newcomers at a disadvan-
tage.8,9,12,13,21,22,25 EMOA may view health professionals as primarily concerned with physical
ailments and thus do not consider disclosing experiences of abuse and mistreatment,
especially in cases of emotional or nancial abuse.2,5,13,28
Navigation is constrained by a number of factors aecting EMOA. These include a
lack of time due to paid and/or unpaid work, low income, unfamiliarity with Canadian
living (weather, transportation, language), as well as social and geographic isola-
tion.6,7,8,9,12,1317,18,26,27,29 A lack of community support for new immigrants and refugees can lead
to social isolation.15,16,17 EMOA who have aged in Canada may share similar experiences of
isolation.26 As a service provider describes:
The seniors who are sponsored to come here are relegated to babysitting duties. They are
very isolated, they don’t have money for transportation, they’re not able to link to other
seniors in their community. Sometimes they have been here ten, fteen years but they
haven’t been able to learn the language because they have been isolated and kept in the
48 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
home as babysitters (p.69).26
Limited social support, nancial dependence, and fear of stigma impede navigation among
immigrant women experiencing intimate partner violence.6,8,9,18,27,29 Literature also underscores
fear of deportation, fear of involvement by public authorities, and perceived racism and
discrimination.13 Indeed, citizenship and sense of belonging to the community impact EMOA’s
feelings of entitlement to receive services.6,8,9,13
iii) The permeability of services
This dimension of Candidacy refers to the manner in which services are organized and
made available to service users. Service permeability is restricted by implicit and explicit
gatekeeping such as referrals, multiple appointments, wait-lists, and the requirement for
stable addresses and other qualication criteria.1,3,7,24,27 Researchers report that service
providers may be reluctant to accept new clients with multiple health issues, linguistic
challenges, and complex insurance coverage in the United States.17 EMOA who experi-
ence immigration and settlement issues (such as isolation associated with coming to a new
country, learning new customs and increased dependence on adult children) or do not
qualify for services are forced to endure situations of abuse.2
A lack of cultural alignment between services and clients contributes to low service perme-
ability.1,3,7,11,12,13,17,21,22,24,25,27 Incorporating cultural perspectives within service delivery is critical
to increase permeability for members of immigrant communities.1,7,16,24,27 For service providers
working with EMOA in the UK, an overwhelming response to specialized services precluded
the need for service promotion or advertisement.7
Service permeability is aected by the ageism apparent in the overall lack of services
for older adults.27 EMOA report feeling socially isolated due to the impact of institutional
discrimination as evidenced by inadequate healthcare and social services for immigrant
older adults and their exclusion from government programs.1,11,12,13,17,21,22,25 In this way, formal
institutions reinforce abusive situations rather than create solutions or provide intervention
for EMOA.27 Service providers note funding limitations and other systemic factors such as
inadequate government assistance for seniors, inadequate safe housing and family poverty,
stigmatization that undermine their ability to adequately respond to EMOA.26,27
iv) Appearances
EMOA are required to have a set of competencies in order to assert a convincing claim
regarding their candidacy for support or intervention.14 These competencies include “the
ability to formulate and articulate the issue for which help is being sought, and the ability to
present credibly” (p.13).4 EMOA and their family caregivers are at peril when they are unable
to clearly articulate their experience of abuse. EMOA have reported ambivalence, belittling
or dismissive behaviour by medical professionals.27 The narratives of older adults from disem-
powered, disenfranchised and marginalized groups suggest that interactions with health
professionals are inuenced by power dierentials related to socio-demographic factors.7,8,9,17
Gender, age, race and class mediate the disclosure of abuse and thus access to statutory
support.7,8,9,17 Conversely, successful appearances are more likely to result when EMOA can
access culturally specic services and professionals with whom they can easily relate.1,2, 7,17,18
During appearances at health services, EMOA may report symptoms of insomnia or back
pain rather than disclose abuse or neglect.11 Korean older adults in New Zealand expressed
the eects of abuse in relation to ‘Haw-byung’, an anger syndrome known as “re-illness”.21,22
The eect of stigma also comes into play during appearances. EMOA may be reluctant to
KOEHN & BADGER 2015 | 49
report abuse in order to preserve family harmony and honour28 or to prevent “losing face” in
their community.5
Language and communication issues negatively impact appearances of EMOA at health
services and can extend beyond the initial consultation to subsequent appointments and
follow-up support.17 Service providers are often unable to provide interpretation services due
to restricted budgets and limited resources.1,3,7,8,9,18,24,27 Candidacy for care is clearly compro-
mised when EMOA are unable to successfully present their need for support.
v) Adjudications
Following appearances at health or support services, adjudications or judgments made
by professionals about an EMOA’s claim for candidacy impacts access to intervention and
support services. Inaccurate adjudications inhibit the progression of Candidacy. Racism and
institutional abuse have been cited as causes of unequal access to state-sponsored care
and support.7 Ineective assessment and referral processes are also underscored.1,3,7,24,27 The
failure of service providers to recognize abuse can be construed as complicity in maintaining
abusive situations.1,7
These issues reinforce the notion of Candidacy as a process without a dened timeline.4,14
Based on access inequities across public services, manyolder adults and their caregivers are
often forced to wait for protracted periods of time for services.7 EMOA risk further stigmatiza-
tion when their situation is not accurately adjudicated. This scenario, which may be regarded
as unresolved candidacy, captures the idea that one’s candidacy journey may be incom-
plete. Structural forces resistant to individualized solutions present a signicant barrier to
accessing services,14 even when EMOA may be able to engage with services.
vi) Offers and resistance
Oers for support services can be appropriately or inappropriately recommended by service
providers and either accepted or refused by EMOA. Literature emphasizes the perceived
appropriateness of oers, especially in terms of service language.4,14 EMOA may have to
choose between having their condentiality compromised by the presence of a family or
community member to provide interpretation or else remain on a waiting list for services in
their own language.7,17 Many EMOA are forced to remain in abusive relationships in order to
avoid ostracism by family members, such as adult children, for accepting help.8,9,25 For older
Tamil women, pressures related to lack or loss of nances and fear of living alone played a
signicant role in the decision to leave an abusive situation.8 These factors also contributed to
stress and loss of self-esteem.8
EMOA often refuse oers for litigation or police involvement.2,11,12,13,21,22 EMOA are typically
marginalized and belong to groups that are located outside of mainstream cultures. There-
fore, eective intervention strategies in cases of abuse and neglect may also lie outside of
the mainstream. Restorative justice, for example, recognizes that traditional approaches may
not provide justice for all ethno-cultural minority groups and also takes into account strengths
of EMOA and denitional dierences of abuse and neglect between groups.15 Thus as an
intervention strategy, restorative justice approaches may present an alternative to the tradi-
tional justice system.15
Despite an overall paucity of intervention strategies addressing elder abuse among EMOA,
let alone their evaluation,23 there is evidence that participatory action strategies hold signi-
cant potential. For example, participatory action theatre has been used by a multiservice
organization in Toronto to engage EMOA through short plays and community development
50 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
projects.20 This model can reduce linguistic and literacy barriers and promote opportunities
for collective problem identication and solving. Researchers contend that a cross-sectorial
approach involving policy makers, agency administrators, social and health professionals,
community leaders, researchers, and older adults themselves is vital to elder abuse preven-
tion and intervention.9,10,16,23
vii) Local operating conditions
Overall, the production of candidacy is considered to take place at the local level. Potential
service provider responses (which are often discretionary) are an amalgamation of structural
and localized perceptions, social values, and resources. Given that formal services for EMOA
are funded municipally, provincially and federally and/or provided within a broader systemic
framework of provincial and federal priorities, decisions taken at these levels invariably
aect local operating conditions such as localized priorities and resource distribution. Time
and resource constraints in clinical settings often restrict health professionals from providing
sucient support; for example they rarely have time to have the detailed discussions with
EMOA that are needed to identify experiences of abuse.2,5,11,12,13,21,22,24,25,28 Many families are
bound together by a culture of collectivism, a family centred norm, familism, which raises
the interests of the family above those of the individual. Government policies, funding priori-
ties and societal expectations are often structured around the ideology of familism – the
ideology that families should support and care for their elderly members or that the family
unit is the best and most cost-eective provider of care.8,9,12,16,18,29 This can pose a risk for older
immigrant women for example, as they are often forced to remain in abusive relationships or
face ostracism if they leave.8,9,25 Without question, these policies restrict service conguration
and reinforce dependence of vulnerable EMOA experiencing abusive situations. As McKeary
and Newbold17 assert, “the solution must be addressed at the policy/governmental level by
acknowledging that accepting refugees (and immigrants) must be simultaneously recog-
nized within health care budgets….” (p.530) and budgets for social services as well.
In the local context of Ontario, the provincial Strategy to Combat Elder Abuse exists to
raise public awareness of elder abuse, training front-line service providers and coordi-
nating existing community resources.3 However, there are no specialized services for older
adults in general and for EMOA in particular within the strategy. Government funded local
services such as shelters and transition houses for survivors of family violence accept all ages;
however, underlining assumptions are that they are victims of intimate partner violence (IPV)
and come from a younger population. Most EMOA do not dene abuse and neglect within
the context of IPV and thus may not access related programs.29 Incongruence between such
local contexts and EMOA’s identication limits EMOA’s candidacy to services.
Discussion
The ndings contextualized the ways in which elder abuse and neglect is dened and experi-
enced within EMOA communities and highlights the unique ways in which they move through
the stages of Candidacy. However, in considering our knowledge user’s question, it is clear
that the literature does not adequately address intervention strategies that concern abuse
of ethno-cultural minority older adults as it is dened and experienced in dierent communi-
ties. Furthermore, research has yet to address the additional layer of trauma among certain
groups such as older refugees from war-torn countries. Government policies, the experience
of immigration in late life, and dependence on sponsoring families impact the risk of experi-
encing abuse. Structural factors, barriers to knowledge, and an overall lack of appropriate
services reinforce dependence of EMOA on their families in the post-migration setting.
KOEHN & BADGER 2015 | 51
The denitions and experiences of elder abuse and neglect by EMOA are contextual and
determined by a host of socio-economic and cultural factors. The subjective ways in which
elder abuse and mistreatment has been examined in the literature is useful to inform the
candidacy process in understanding access to support services for EMOA. The marginalized
position of EMOA in relation to mainstream culture permeates their candidacy by impacting
identication of abuse, help-seeking behaviour, availability of appropriate services, and
eventual service uptake or resistance. The unique needs of diverse immigrant and refugee
communities must be recognized in order to develop eective intervention strategies and
ensure equity in access to health and social services. The following recommendations are
important to this end.
Recommendations
1.
Denitions of elder abuse and mistreatment should focus beyond extreme and overt forms
of violence in order to capture the range of situations and inappropriate behaviours that
EMOA experience. Public discourse and service providers must reach consensus regarding
denitions of abuse, mistreatment and neglect as well as minimum expectations of care
for older adults. Since EMOA may not necessarily identify their situation within the context
of intimate partner violence, it is important for services and programs to be based on a
wider framework.
2.
Community education is paramount in the promotion of awareness among EMOA of elder
abuse and mistreatment, their rights, available services and supports, and to reduce stigma
related to help seeking and accepting oers for support. Information provision regarding
how to assert a claim for candidacy should be included in the service delivery mecha-
nism of agencies serving EMOA. Health and social service providers require education
regarding the identication of elder abuse and mistreatment, options for support, as well
as cultural responsiveness and the building of trust and rapport with EMOA.
3. National and provincial policies regarding immigration must be examined and revised in
order to avoid reinforcing the dependence of EMOA in post-migration settings. Policy must
attend to the isolation of EMOA, such as considering aordable transportation options
and income security, in order to facilitate navigation and acceptance of oers. Policy
considerations should include specic programs aimed at immigrant and refugee groups
who face linguistic and/or material challenges.
4.
Ethno-specic community organizations require additional resources to facilitate outreach
and related supports (such as education, counselling, safe havens, case management
etc.) for EMOA experiencing social isolation. Agencies may liaise between EMOA and the
service system and work with community members to provide culturally congruent services.
5.
Funding models and service conguration require continued assessment so that we
can improve service permeability and service response by reducing waiting times and
re-examining and removing stringent qualication criteria.
6.
At the systemic level, policies and programs promoting restorative interventions may be
more benecial to EMOA than mainstream strategies. Alternative approaches such as
restorative justice approaches and participatory action strategies should be considered
and evaluated for their ecacy in addressing abuse and neglect among EMOA.
7.
Increased research attention regarding the experience of abuse and neglect by EMOA in
general and refugees in particular is required. The development and evaluation of inter-
vention strategies is key in order to formulate guidelines for best practice in this complex
domain.
52 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Conclusion
There is a paucity of research on abuse of EMOA from war-torn countries and evaluating
intervention strategies that organizations might use to support EMOA. Our review of current
literature, using the Candidacy model, reveals the ways and processes in which EMOA, their
family caregivers, and service provider organizations understand, dene and address abuse
and mistreatment. The analysis further highlights these processes are invariably linked to
social, cultural, economic and political factors and the interplay of these complex factors
must be considered in order to develop, maximize access to, and administer eective inter-
vention strategies to address abuse and mistreatment of EMOA.
Please cite as:
Hepburn, S., Matsuoka, A., Guruge, S., & Manuel, L. (2015). Intervention strategies to address
abuse of ethnocultural minority older adults from dierent communities. In S. Koehn, & M.
Badger (Eds.),Health care equity for ethnic minority older adults(pp. 46-54). Vancouver, BC:
Gerontology Research Centre, Simon Fraser University.
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older people in black and minority ethnic communities: Some implications for service
provision. Journal Elder Abuse Neglect, 24(3), 251-274.
2. Carerst. (2002). In disguise: Elder abuse and neglect in the Chinese community. City of
Toronto: Breaking the Cycle of Violence Grants Program: Carerst Seniors and Commu-
nity Services Association.
3. Carstairs, S., & Keon, J. (2009). Final report: Canada’s aging population: Seizing the
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Katbamna, S., Olsen, R., Smith, L.K., Riley, R., & Sutton, A.J. (2006). Conducting a critical
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7. Forbat, L. (2004). The care and abuse of minoritized ethnic groups: The role of statutory
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8. Guruge, S., & Kanthasamy, P. (2010). Older women’s perceptions of and responses to
abuse and neglect in the post-migration context. Toronto: Wellesley Institute.
9. Guruge, S., Kanthasamy, P., Jokarasa J,Yi Wai Wan, T., Chinichian, M., Shirpak, K.R.,
Petroiya P., & Sathananthan, S. (2010). Older women speak about abuse & neglect in
the post-migration context. Women’s Health and Urban Life, 9(2), 15-41.
10. Lachs, M.S., & Pillemer, K. (2004). Elder abuse. Lancet, 364(9441), 1263-72.
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KOEHN & BADGER 2015 | 53
Journal of Elder Abuse and Neglect, 9 (2), 51-62.
12. Lee, H.Y., & Lightfoot, E. (2014). The culture-embedded social problem of elder mistreat-
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ment and Trauma, 23(1), 5-19.
13. Lee, Y., Kaplan, C.P., & Perez-Stable, E.J. (2014). Elder mistreatment among Chinese and
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behaviors. Journal of Aggression Maltreatment and Trauma, 23(1), 20-44.
14. Mackenzie, M., Conway, E., Hastings, A., Munro, M., & O’Donnell, C. (2013). Is ‘Candi-
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10.1111/j.1467-9515.2012.00864.x
15. Matsuoka, A., Clarke, A., & Murphy, D. (2010). Restorative justice mediation for elder
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Diversity and aging among immigrant seniors in Canada: Changing faces and greying
temples. Calgary, AB: Detselig Enterprises Ltd.
16. Matsuoka, A., Guruge, S., Koehn, S., Beaulieu, M., & Ploeg, J. (2013). With M. Lithwick, D.
Mullings, K. Roger, C. Spencer, V. Tyyskä, C. Walsh, F. Gomes & S. Brisebois. Prevention of
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seniors aging in Canada? A demographic, socio-economic and health prole. CERIS
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The views of underrepresented Canadian older adults. Journal of Elder Abuse Neglect,
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Caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrai-
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26. Tyyskä, V., Dinshaw, F.M., Redmond, C., & Gomes, F. (2013). Where we have come and
are now trapped”: Views of victims and service providers on abuse of older adults in
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Tamil and Punjabi families. Canadian Ethnic Studies, 44(3), 59-77.
27. Walsh, C., Olson, J.L., Ploeg. J., Lohfeld, L. & MacMillan, H.L., (2011). Elder abuse and
oppression: Voices of marginalized elders. Journal of Elder Abuse & Neglect, (23)1, 17-42.
28. Yan, E., So-Kum Tang, C., & Yeung, D. (2002). No Safe Haven: A Review on elder abuse in
Chinese families. Trauma Violence and Abuse, 3(3), 167-180.
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abuse in mid- and old age. Journal of Elder Abuse & Neglect, 26, 80-105.
KOEHN & BADGER 2015 | 55
Chapter Six: Exploring interventions that enhance the
health and healthcare access of ethnocultural (racialized)
older adults in rural, very small and/or geographically
isolated communities.
Prepared by: Alice Pearl Sedziafa, BSc, MA & Katie Flood, BA
Supervisor: Delores V. Mullings, PhD
Knowledge User: Mrs. Yamuna Kutty, Vice President, Multicultural Women’s Organization of
Newfoundland and Labrador
Introduction
Health has been conceptualized as not only the absence of disease or inrmity but also as
a state of complete social, physical, and mental well-being72 which is embedded in cultural
expectations and meanings.60 A lack of access to equitable healthcare services contrib-
utes to health disparities particularly given the unique barriers that some groups experi-
ence.8 Although access to healthcare embodies the social value of equity in Canada,3,41 an
emerging body of literature indicates that ethnic minority older adults (EMOA) face signi-
cant challenges in accessing healthcare. The term EMOA is used to denote newcomers to
the province as well as racialized older adults who have aged in place. The challenges
they face result from intersecting disadvantages along multiple axes of inequity including
sociocultural characteristics, income, gender,37 immigration status,24 place of residence10 and
language.54,73
Residing in rural or remote and geographically isolated areas also compounds access
barriers for EMOA.43 According to Statistics Canada,62 a rural area consists of fewer than
10,000 people and is located outside of large urban centres. Researchers conceptualize rural
communities as geographically isolated areas and/or under-populated with inadequate
infrastructural development.19 Isolation and loneliness are major concerns among older
cohorts in remote and rural Atlantic Canada due to small populations, non-existent commu-
nity programs, limited facilities, high travel costs and severe weather conditions.35
In Newfoundland and Labrador (NL), a high percentage of the population is ageing: 16% of
the population in 2011 was aged 65 and older (the national average was 14.8%); this popula-
tion is projected to double to 36% by 2031.65 Moreover, nearly half of the total population of
NL resides in an isolated area.65 Improving health services for older adults in the province is a
priority for the government; considerations for racialized older adults must be included in that
agenda.
Recent immigration strategies aimed at recruiting and retaining newcomers to the province
are expected to help support labour market needs and replenish a declining population
due to rapid out-migration and the ageing population.26 The majority of new immigrants
arrive from China, but they also come from East and South Asia, Africa, the Middle East
and the Caribbean.16 In 2006, the NL racialized population was approximately 5,720 and
included South Asians (1,590), Chinese (1,325), Blacks (905) and Koreans (60).64 Consistent
We use the term “racialized” rather than “visible minority” more commonly used by the Government of Canada63 because
it acknowledges the problems arising from discrimination based on essentializing generalisations that reference phenotypic
characteristics rather than an assessment of the whole person.
56 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
with the healthy immigrant eect, the health status of recent immigrants may be adequate
in comparison to Canadian-born individuals, but many experience signicant health deterio-
ration during their rst ten years in Canada.14,22 Compared to the general population, EMOA
and recent immigrants experience slower rates of recovery after hospitalization;55 and report
lower satisfaction in accessing the Canadian healthcare system.39 Equitable access to
healthcare is therefore a concern for both newcomers and racialized older adults who have
aged in place in NL.
Research Question
Although literature addressing healthcare access among EMOA in rural and remote areas
is limited and fragmented, the trends discussed are useful to frame this report’s research
question: What types of interventions enhance the health and healthcare access of very
small and/or geographically isolated, rural EMOA, who may lack larger community networks
and the institutional completeness to ensure that they can access health and social service
providers who speak their language?
Methods
A literature review was conducted to identify relevant studies on health and healthcare
access among racialized older adults and rural populations. This search was primarily
conducted in a database developed during a scoping review on the health and health
care access and utilization of EMOA.38 The Google Scholar database was also used to
search for articles published between 1970 and 2014. Two searches were conducted: 1) a
primary search was done using the following keywords: ethnic minority older adults, health-
care access, rural, and language barrier(s) and 2) a secondary search which included the
following terms: ethnic minority AND healthcare access, health services utilization AND rural
residence, ethnic minority AND rural residence. Academic peer-reviewed studies, published
in English were selected in addition to documents from the grey literature (e.g., institutional
and government reports or projects) were also included. The reference lists and citing articles
for the selected publications were inspected for further studies. Fifty-three articles were
reviewed, sixteen of which included a focus on ethnic minority populations. Emphasis here is
placed on EMOA in Canada and specically in NL; however, examples from the U.K. (which
has a comparable health care system) and U.S.A are also included. The Candidacy lens
was used to review the literature and ndings from the publications have been highlighted
relative to the seven dimensions of the framework.
Findings
i) Identication of Candidacy
The rst dimension of Candidacy involves recognizing one’s need and deservingness for
healthcare.17 Geographically isolated and marginalised groups often manage their health
in response to crisis events and may not seek help related to disease prevention.40 Older
adults who live in rural areas, have fewer visits to general practitioners, specialists, and
dentists compared to their urban dwelling counterparts.2,45 They are also more likely to use
emergency rooms.32 A lack of healthcare services coupled with EMOA’s reluctance to use
available services creates dependency on familial relationships. Mair and Thivierge-Rikard42
support this idea by suggesting that family relationships are particularly intense among
traditionally marginalized and isolated communities. As such, EMOA residing in rural areas
KOEHN & BADGER 2015 | 57
are likely to turn to familial and community-based supports over formal assistance when they
experience poor health.10 In many cases, EMOA’s perception of their health or illness contrib-
utes to how they access healthcare.
Constructions of health and illness by EMOA can inuence their perceptions of whether or
not consultation with a health professional is warranted or deserved. Rural culture, commu-
nity context, and spirituality may all contribute to such constructions.25 Carlton-Lenay10
found that older Black farm women chose to ignore signs of illness in their eorts to avoid
the stigmatization that goes with being ‘weak’ and unable to complete expected work
duties. Illness thus challenged both their identities as independent, as well as their economic
security. Land ownership among older women in rural areas is linked to increased wealth
and power and seen as a form of old age security.36 There is often a lack of understanding of
work in relation to health and illness within the mainstream healthcare system.10 Perceptions
of formal healthcare access cannot be separated or isolated from the lived experiences of
racialized individuals.
ii) Navigation
Navigation requires an awareness of healthcare services that are oered and the ability to
access them. There are few healthcare facilities available in rural areas and those that exist
are widely dispersed.46 Members of rural communities must travel long distances to access
healthcare, often to urban centres, and transportation options are infrequent and expen-
sive.35 Poverty among older adults in Canada is well documented (particularly among those
living in small urban centres, isolated or rural areas50 and this has a negative impact on their
health.59 Rural EMOA are disadvantaged by low socioeconomic status and inadequate
community infrastructure.68,71 A lack of viable transportation options signicantly restricts and
minimizes individuals’ visits to healthcare facilities for regular health check-ups and consulta-
tions with specialists.9,67
Access to public transportation can have an important eect on how older adults interact
with formal healthcare systems. For example, an intervention to address public transporta-
tion barriers increased mammogram participation rates among older racialized women.56
In NL, transportation costs to attend medical appointments are subsidized by the provincial
government;11,33 however, individuals may face personal costs related to loss of income from
missed work and living expenses while away from home. Decreased personal mobility due
to age-related frailty can also hinder EMOA’s ability to travel long distances.23 Given these
concerns, rural cohorts are more likely to rely on communications technology such as the
Internet to obtain health information.69 However, services such as the Internet and telephone
are sometimes minimal or compromised, especially during inclement weather.11,33
iii) The permeability of services
This dimension of Candidacy describes the ease with which EMOA can access services.17
Service access in isolated areas is a standard challenge. Restricted availability of healthcare
resources is a common institutional barrier in geographically isolated settings.29,31 Rural regions
do not have the institutional completeness and resources required to support the needs of
racialized individuals.47 Limited access to family physicians and culturally sensitive practi-
tioners is a signicant barrier for rural and geographically isolated EMOA.59 Of the estimated
15% of Newfoundlanders and Labradorians who do not have regular family doctors, most
(75%) reside in rural areas.4 4 Access to physicians is thus a concern for a large percentage of
the rural NL population and these issues are compounded for many racialized older adults.8
Individuals want to be cared for by healthcare practitioners who are knowledgeable about
58 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
their cultural norms and values.17 While it may be benecial to have care providers from
within one’s culture, it is not always possible outside of the family setting, especially for EMOA
living in rural and isolated communities.28 Browne8 notes that culturally inappropriate modes
of healthcare delivery hinder service permeability for EMOA. Practitioners in health and
long-term care services in small urban centers of NL are often culturally uninformed about
best practice for maintaining health among racialized older adults.47 Service permeability is
reduced when linguistically appropriate information about health services is unavailable.28 In
addition, after being discharged from care facilities, EMOA report feeling ill-equipped to take
care of their health at home.28 Limited options for receiving health information further hinder
service permeability. For example, Gray and colleagues29 conducted a study of Canadian
women residing in rural areas who were living with breast cancer. The study revealed that
patients were concerned about having to rely on physicians as their only source of health
information. Permeability is compromised when services are lacking and EMOA are forced to
rely on a single information source, often in a language in which they are not uent.
iv) Appearances
This dimension describes appearances of EMOA at healthcare services and how well they
are able to articulate their candidacy for medical attention.17 In the Canadian context,
EMOA are expected to present medical problems prociently and coherently in English or
French and/or display symptoms that align with mainstream understandings of health and
illness. Not surprisingly, EMOA are often aware that their racialization complicates the ways
in which they engage with healthcare professionals.6 EMOA may thus avoid making appear-
ances due to the shame of their perceived linguistic illiteracy.15 Appearances in rural areas
are greatly hindered by a lack of culturally appropriate services, linguistically congruent
professionals, and interpretation services.61 In some cases, linguistic barriers may contribute
to EMOA being stereotyped as passive and distant while receiving medical care.58 However,
the steady rotation of healthcare and social service personnel in rural areas also impacts
appearances for EMOA, who nd it dicult to establish a trusting relationship with each new
professional.24
Health care providers in most rural and remote regions of NL do not typically share the
religious and cultural values of racialized individuals. Such dierences can result in discrimi-
nation against EMOA patients by healthcare providers.52 Religious and cultural proscriptions
among some racialized people further preclude women from seeing male health profes-
sionals.1,18,20 EMOA have thus reported feelings of discomfort when interacting with practi-
tioners in the formal healthcare system.52 Factors related to immigration also thwart appear-
ances by EMOA. New immigrants may believe that contact with healthcare providers will
jeopardize their immigration status and avoid health services accordingly.49
v) Adjudications
The adjudications dimension describes professional perceptions of a patient’s claim for
Candidacy, such as perceiving the patient as either deserving or undeserving of health-
care.17 Institutionalized healthcare is often designed in accordance with Eurocentric
mainstream values and norms, which can initiate and perpetuate discrimination against
racialized people51 and hence limit EMOA’s eligibility for healthcare. The biomedical or
allopathic model of health, which underpins the Canadian healthcare system, separates
the functioning of an individual’s physical body from the mind. This model is at odds with
the holistic notions of healthcare held by some groups of racialized people.7 A holistic
model of care proposes that the mind, body and spirit are linked to one’s social environ-
ment, emotions, and health status; professionals in the mainstream system may undermine
EMOA who express holistic health views and therefore impede their access to healthcare.13
KOEHN & BADGER 2015 | 59
As noted in the previous section, healthcare providers’ assumptions about EMOA may also
be informed by cultural and religious stereotypes.52 Weerasinghe and Mitchell70 found that
racialized older women with professional qualications were concerned about being treated
as uneducated and ignorant about their personal and family health issues by healthcare
professionals. Doubt cast over the EMOA patients’ rights to access healthcare services by
discriminatory or uninformed professionals deters them from seeking and accepting the
healthcare services they need.
vi) Offers and resistance
This dimension describes the active participation of EMOA in accepting or rejecting services
oered by health professionals.17 Research suggests that EMOA may resist practitioners’
oers of medication and health referrals17 and a number of factors underpin their decisions.
Stephenson’s study66 with Vietnamese residents in a midsize city in British Columbia highlights
several important factors that facilitate understanding of racialized people’s reluctance to
accept formal healthcare directives: 1) EMOA may be motivated by cultural understandings
of health that dier from biomedical notions, coupled with a mistrust of Western medicine;
2) EMOA may have a preference for traditional herbal remedies instead of allopathic
medicine; and 3) EMOA (particularly men) may visit doctors rarely and seek attention only
during emergency situations. Research has also found that immigrants may prefer spiritual
or religious types of health treatment since certain types of health concerns and related
symptoms can be associated with evil spirits.21 Spiritual and religious prescriptions, such
as prayers, are believed to help cure curses that are placed on individuals and/or their
families.21 Treatment oers, particularly for mental health concerns, may also be rejected
based on a fear of community stigmatization34 and conicting perspectives between the
patient and other family members of their ecacy relative to that of spiritual solutions.21
For some EMOA residing in rural areas, assistance from their families and immediate commu-
nities is preferred over options for formal support. Racialized persons report satisfaction with
services provided through community groups that oer language and culturally specic
services, such as settlement service organizations, local health centers, and faith-based
organizations.28 Among racialized communities in NL, family members are often responsible
for older relatives’ care.24 Adult children may work together as a caregiving unit in order to
support the health needs of an older relative.24 However, familial support for older adults
residing in rural areas is signicantly compromised by the outmigration of young people to
urban centers in search of employment12 and the historically small number of racialized
people in these locations.24
vii) Local operating conditions
This dimension describes multiple inuences on Candidacy at a macro level, such as polit-
ical, economic, and environmental factors.17 Structural barriers, such as lack of infrastruc-
ture to provide culturally sensitive services, compromise access. Low rates of service utiliza-
tion in rural settings are attributed to underdeveloped infrastructure and minimal success
in recruiting and retaining health professionals.8,32 Importantly, economic restructuring has
resulted in the reduction and elimination of hospital services including access to family physi-
cians, specialists, and pharmacists.31,53 Restructuring has also downloaded state responsibili-
ties to families and has created an over-dependency on informal supports from community
groups, family members, and volunteers.57 The province of NL does oer transportation and
accommodation subsidies for residents who must travel in order to access specialized health-
care (e.g. cancer treatment).27 Newfoundland and Labrador’s Centre for Health Informa-
tion has also developed a Telehealth Program that uses videoconferencing technology to
connect clients to health care providers located in another community. An evaluation of
60 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
the program reports that Telehealth was associated with high levels of satisfaction among
patients and providers and also improved access to patient information, continuity among
providers, and frequency of patient-follow-ups.11 However, the applicability of the program to
the health and access needs of EMOA was not examined.
Research suggests that most Canadian provinces, including NL, oer culturally responsive
strategies and incentives for training, recruiting and retaining healthcare professionals.30
However, current strategies are insucient.47 In an attempt to provide voluntary culturally
sensitive support to patients, nurses in NL unwittingly broke condentiality by contacting
community leaders to alert them of EMOA who were admitted to hospitals.47 In many cases,
patients were reluctant to share personal matters with members of their community and felt
betrayed by the nurses’ actions.47
The immigration process is a signicant barrier to EMOA’s eligibility for healthcare services.
Individuals born outside of Canada spend considerable time visiting government oces and
agencies in order to seek clarication and obtain approval for their citizenship entitlement
before becoming eligible for healthcare services.5 These costly and exhausting bureaucratic
procedures are systemic barriers that are challenging for recent immigrants to understand
and navigate.61 In addition, EMOA with limited public and/or private pension benets or
personal assets are likely to live in poverty.10 Lack of nancial resources therefore undermines
EMOA’s ability to access and accept oers for healthcare that are not state funded.
Discussion
This report highlights a number of issues that must be attended to when developing interven-
tions to enhance the health and healthcare access of geographically isolated and rural
EMOA, such as those residing in the province of NL. Access to healthcare in rural and isolated
settings is greatly complicated by geographic location. Rural communities face challenges
related to limited economic and employment opportunities, lack of service infrastructure,
underdeveloped transportation services, limited availability of healthcare professionals, and
out-migration of younger community members. In addition, the healthcare system is poorly
structured to accommodate racialized people’s needs due to a lack of culturally congruent
services and the persistency of institutional discrimination. These factors often lead EMOA to
rely on informal sources for healthcare support.
Families, friends and neighbours commonly provide informal support for EMOA residing in
rural or geographically isolated communities. Older adults seek support from family members
and cultural groups when they are unable to self-manage their care. However, access to
family members and cultural communities may be very limited due to the small numbers
of racialized people who reside in rural and geographically isolated regions. To compound
the situation, discrimination based on multiple and intersecting social identities such as
class, language, religion, gender, culture, sexual orientation, age, health status and race
signicantly impact EMOA’s access to healthcare services. The literature fails to account for
EMOA’s intersecting realities, instead discussing EMOA mostly in a two-dimensional manner
wherein age is viewed as the independent variable relative to which all other variables such
as gender roles, health status, language, culture, or religion are dependent. In addition,
there are serious gaps in the literature relative to explicit discussions of racism, sexual orienta-
tion and gender identities. Future work must consider these intersecting identities in order to
fully address the experience of EMOA in accessing health and social services in rural and
geographically isolated communities.
KOEHN & BADGER 2015 | 61
Recommendations
Interventions to enhance the health and healthcare access of geographically isolated, rural
EMOA are important, especially given that they may lack larger cultural community networks
and experience institutional discrimination. The individual, community and institutional
health system factors impacting Candidacy must be addressed to ensure that EMOA have
equitable access to culturally relevant healthcare services and culturally sensitive service
providers. In particular, strategies that lie outside the formal healthcare system are necessary
to address the healthcare service needs of rural EMOA. The following recommendations are
oered:
Accept alternative interpretations of health and healthcare
EMOA’s interpretations of health and healthcare may dier from the mainstream biomedical
model to which healthcare practitioners in NL subscribe. Therefore, healthcare strategies
and interventions must integrate EMOA’s understandings of health, diagnosis and treatment
modalities in order to facilitate identication of the need for candidacy, appearances and
adjudications at health services, and acceptance of oers for treatment.
Initiate and strengthen community partnerships and networks
The strengths of rural and marginalized communities are grounded in the premise of commu-
nity solidarity and close-knit relationships.36,48 Policy makers and practitioners must therefore
acknowledge and partner with community stakeholders and family networks to design eec-
tive healthcare interventions and services. Collaboration with community-based networks is
essential to delivering equitable, accessible, and culturally appropriate healthcare services
for EMOA in rural regions.
Schedule ongoing and integrated professional training
Cultural sensitivity training promotes respect of ethnocultural customs and traditions.70
Providing culturally sensitivity services is key to ensuring patient satisfaction with the health-
care system.5 Medical training must integrate complimentary and/or alternative educa-
tion within the biomedical model to promote a better understanding of holistic healthcare.
Ongoing training and development for healthcare professionals must include collaboration
between community members, healthcare providers and EMOA themselves in a process of
continual recruitment and training.47
Address transportation challenges
Interventions to improve access to appropriate healthcare services in rural settings must
consider challenges related to transportation. Mobility limitations can impede EMOA’s ability
to travel long distances to and from health facilities and may be compounded by limited
nances. Options for subsidized transportation services as well as in-home and/or mobile
health support are necessary. Nurse practitioners and social workers may play a key role
in the provision of services in rural communities by travelling to clients to deliver healthcare
services in their homes or communities.4
Revise discriminatory and inexible policies
Limited nancial means translates into limited access to healthcare, since many of the costs
associated with access are collateral to the cost of the care itself. Policy makers must be
62 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
attentive to nancial challenges concerning under-employment, stringent and discrimina-
tory eligibility criteria, and personal expenses that place nancial pressure on EMOA, many of
whom are economically disadvantaged. In this regard, eligibility criteria and income testing
policies need revision in order to accommodate the nancial needs of EMOA.
Develop and promote telemedicine
The development of healthcare service infrastructure is a necessary long-term solution to
address healthcare disparities in Atlantic Canada. Telemedicine is a viable option with the
potential to confer immediate gains in the delivery of healthcare services in remote and rural
areas. Telemedicine services may be used to link individuals located in isolated settings to
larger health centres that are better equipped, for example, in terms of bilingual/bicultural
sta and related health resources. Telemedicine can also oer options for health information,
screening, and management that can be tailored to the unique needs and circumstances
of EMOA. NL’s Telehealth program, which focuses on chronic disease management, must
be expanded to meet the growing needs of EMOA who are unable to access healthcare
services by more traditional means.
Conclusion
Access barriers to health care are compounded for EMOA who reside in rural or remote and
geographically isolated areas, such as NL. This report has highlighted a number of multilevel
and intersecting issues that must be attended to in order to address the health needs of
isolated and rural EMOA. In eorts to improve the infrastructure and delivery of health care
services for older adults in NL, the government must make considerations to ensure that rural
EMOA have equitable access to culturally relevant healthcare services. It is crucial for health-
care organizations to recognize alternative interpretations of health, maintain community
partnerships, and provide integrated cultural sensitivity training for health professionals. Trans-
portation challenges must also be addressed, as well as discriminatory and inexible policies
that disadvantage EMOA in multiple and intersecting ways. Finally, telemedicine must
continue to be pursued as a long-term solution to promote health equity in Atlantic Canada.
Please cite as:
Sedziafa, A.P., Flood, K., Mullings, D.V., & Kutty, Y. (2015). Exploring interventions that enhance
the health and healthcare access of ethnocultural (racialized) older adults in rural, very small
and/or geographically isolated communities. In S. Koehn, & M. Badger (Eds.),Health care
equity for ethnic minority older adults(pp. 55-67). Vancouver, BC: Gerontology Research
Centre, Simon Fraser University.
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68 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Chapter Seven: Unpacking Access to Health Services
and Health Promotion Programs and Information for
Ethnocultural Minority Older Adults
Prepared by: Melissa Badger, BSc, MA Candidate & Sharon Koehn, PhD
Introduction
In chapter one, we outlined the process of producing ve topical reports in preparation for
our Planning Meeting in June, 2014. All topical reports were submitted to the project coordi-
nator (M. Badger) who imported them into NVivo 10 (2012) to allow for consistent coding.
Text segments from each report were coded deductively relative to the seven dimensions
of Candidacy. Inductive codes were also assigned to illustrate the types of negotiations for
care dened by each dimension, as well as any outliers not accommodated by the frame-
work. Comparisons were made across the ve topics to extract patterns related to cross-
cutting and topic-specic themes. In this way we identied all instances of each of the seven
dimensions of Candidacy (access) across the dierent topics. Our cross-cutting analysis is
presented in this nal chapter.
In addition to shedding light on the topic of access to health care services and information
and health promotion programs for ethnocultural minority older adults (EMOA), our analysis
will contribute to an understanding of the relevance of the Candidacy framework to the
dierent health and social care contexts that our knowledge users represent. It will also
contribute to the development of the framework by illustrating the types of negotiations for
care that dene each dimension, as well as any outliers that are not accommodated by the
framework.
Cross-cutting Findings: Dimensions of Candidacy
I) Identication of Candidacy
The rst dimension of Candidacy, identication, describes how symptoms are recognized
as requiring and deserving of medical attention or intervention.34 Here, a desire to protect
individual and cultural identity may play a role in one’s decision to seek health and/or social
services.35 Negotiations during this stage take place mainly with oneself but family members
may also be involved. Delayed identication of candidacy among disadvantaged popula-
tions, including EMOA, is common and can precipitate a crisis event.34,87 Common issues that
emerged across all topical reports to aect identication include:
• Alternative understandings of health and illness;
• Awareness of the health issue;
• The role of stigma;
• Family factors;
• Maintaining agency;
• Immigration factors; and
• Identication in health settings.
KOEHN & BADGER 2015 | 69
Alternative understandings of health and illness
The literature has emphasized that ethnic minority populations are disadvantaged by alter-
native understandings of health and illness: individuals may not identify themselves as poten-
tial service users and such alternative understandings are often not incorporated into existing
service models.85 Cultural norms signicantly inuence the ways in which people understand
their health and thus perceive their candidacy. For example, ambivalent attitudes among
widowed South Asian women toward participation in leisure-time activities are inuenced by
cultural and tradition-based gender norms constructed during early life experiences in their
country of origin.145 Such attitudes thus prevent them from participating in exercise and other
health promotion activities.
There is considerable diversity in the ways in which symptoms are experienced and identi-
ed (or misidentied) by EMOA. The symptoms of dementia and mental illness, as well as
inactivity in later life, are commonly normalized.16,29,56,75,137 Also common is the attribution of
these symptoms to social isolation and poor physical health.139 Although symptom normali-
zation may in part be due to socioeconomic status and education,12 such normalization of
symptoms can be found among EMOA with dementia and their family caregivers across
diverse educational and professional backgrounds and can be related as well to the preser-
vation of identity.69
Within certain ethnic minority communities, discourses of collectivism and divinity are
common and may not align with Western representations of health and illness.12 For example,
family caregivers of South Asians with dementia in the U.K.84 interpreted the disease through
a traditional religious and spiritual lens: it was thought to be a mental illness caused by ‘spirit
possession’ or ‘the evil eye’. In other studies, EMOA have referred to mental health issues as
spiritual weakness, an emotional imbalance or a lack of control,75,86,141 or as punishment for
sins.86 The fatalistic belief that symptoms are beyond individual control may also result in the
acceptance of health problems, precluding identication of the need for care or preventive
measures.56
EMOA who experience depressive symptoms may identify their mental health issue as ‘stress’
or a ‘spiritual crisis’ since terms such as depression and anxiety may not be customary in their
rst language;65 there is no set terminology for dementia within South Asian languages.122
Despite having varying levels of impaired memory, South Asian older adults in a U.K. study
were not familiar with the words ‘dementia’ or ‘Alzheimer’s disease’.79 In parallel, mainstream
denitions of elder abuse have been criticized for focusing on extreme or overt forms of
violence (particularly when translated into some languages). Some abusive behaviours,
such as disrespect and government or systemic abuse, are thus not recognized as such by
immigrant seniors or by social service agencies that aim to protect their wellbeing, until there
is a crisis event.113
Chinese older adults in several studies preferred to “wait and see” rather than seek support
or treatment from mental health services.70,136,147 This can result in help-seeking only when
problems become severe.28,86 Immigrant seniors and their families may believe that medical
attention is not warranted until physical or somatic symptoms present.121 Mental distress in
particular may not be considered harmful until it manifests as a physical pathology or hinders
one’s daily activities.2
Awareness of the health issue
EMOA were commonly described as having low levels of general awareness and knowl-
edge regarding the various health issues under investigation. This was especially pertinent
70 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
in the literature on elder abuse and mistreatment. Poor knowledge of what constitutes an
abusive behaviour and to the sources of help available contribute to the underreporting
of abuse among Asian communities in Western countries.80,146 Similarly, lack of exposure to
dementia and mental illness make it dicult for anyone to connect their own suering to such
conditions. EMOA are less likely to be familiar with such diagnoses due in part to the rise in
incidences of dementia and depression now that people are living longer in combination
with the alternative aetiological attributions of such diseases and their limited communica-
tion to the general public in their countries of origin.16,72 While younger caregivers and other
family members are more likely to be familiar with such diseases, and are often crucial in their
identication, recent immigrants and those with lower socioeconomic status sometimes lack
the knowledge and awareness to recognize their symptoms.59,69
Stigma
Negative perceptions and stigma surrounding health issues, especially concerning mental
illness, also have a profound inuence on the identication of candidacy for health and
social services among EMOA. Numerous studies of EMOA speak to denial of health problems
such as cancer, which is viewed as incurable, due to the stigma associated with them.50,77,98,
The need for help thus goes unrecognized. The expectation within a community that victims
not speak out about the abuse they experience, which is deemed to be shameful to the
entire family can similarly mute cries for assistance.53
Stigmatization may stem from factors such as fear, shame, and social exclusion.15,40 For
example, a reluctance among Asian immigrants to report elder abuse has been attributed
to ‘shame culture, which can also lead older adults to believe that the abuse was deserved
and should remain private.108 EMOA may be more likely to report elder mistreatment if they
believe an abusive situation constitutes a criminal case, however the fear of ‘losing face’ in
the community may prevail.36,146
For families, concealing a mental health issue, such as dementia of an elderly relative, from
the rest of the community may be a coping mechanism to preserve family dignity and avoid
problems during arranged marriages.16,29,84 One example is the common belief found among
people of Punjabi Indian origin that dementia symptoms are caused by a lack of care, either
by one’s self or one’s family.73 Similarly, mental illness or distress has been attributed to inter-
personal stress, failure of family members to fulll lial duties, or a lack of family support.75,86,141
As EMOA internally negotiate their candidacy for care, the extent to which they are
respected by the family and community may impact whether or not mental health issues are
expressed.2 Men in particular may view memory impairment as a threat to their position in the
community.79
Family factors
EMOA often exhibit cultural ideals of familism, whereby “solidarity of the family as a group
supersedes the interests of individual members of the family.”94 In this context, members
of both the immediate and extended family can play a key role in identication of candi-
dacy.69,96 While family members may misidentify symptoms of dementia for normal aging or
as personality traits, they often make important observations regarding changes to person-
ality and usual behaviour, and recommend help-seeking especially upon noting safety risks
to the older adult.69,96 Families may be more likely to facilitate identication when household
life is disrupted by the older adult’s symptoms. For example, the incontinence of an EMOA
with dementia left one family feeing they could no longer pray at home, which they consid-
ered ‘dirty’ as a result.16 This case was compounded by the family’s avoidance of the temple
based on their fear of shame or stigmatization by their community. Such feelings can lead
EMOA to hide symptoms from family members.139
KOEHN & BADGER 2015 | 71
Ideals of familism combine with culturally-informed gendered household roles (e.g. comple-
tion of expected daily tasks), that are reinforced by structural factors such as the high cost
of childcare.3,51,71,121 EMOA, particularly women, are thus encouraged to downplay their
own health needs relative to their familial responsibilities; thus immigrant older women do
not necessarily share their health problems with family.51,86 The sense of indebtedness felt by
sponsored family class immigrants who co-reside with adult children, can also contribute to
this tendency to minimize their apparent need for medical or social supports or access to
health promotion activities.65 The “double barreled social debilitation” (p.1772)10 that arises
from the nancial, physical, and emotional dependence of sponsored immigrant seniors on
family members can have far-reaching implications for identication.
Family dynamics strongly inuence an older adult’s decision to leave or endure an abusive
situation. Among older Tamil women, for example, lack or loss of nances, fear of poverty,
loss of social status in the home and community, and loss of self-esteem may deter identi-
cation of candidacy.52 Ideals of familism may thus perpetuate mistreatment of EMOA.53,82,107
Abuse inicted by family members on older adults is typically under-reported due to their
feelings that reporting the abuse is disloyal, their desire to protect the abusive family member
and the family’s standing in the community, and/or fear of reprisal, abandonment by family,
and institutionalization. For EMOA these feelings are magnied by ideals of familism as well as
their higher propensity to co-reside with adult children and to be nancially dependent upon
them, particularly if they are sponsored immigrants.23,40,71,94,131,143
Maintaining agency
Research has identied ‘mastery’—control over one’s life and the ability to deal with life’s
diculties—as a personal coping resource against sadness, depression and loneliness among
older Asian Indian immigrants.33 Unfortunately, this strong desire among EMOA to address
mental health challenges on their own in order to maintain personal agency38,1,70 can inhibit
help-seeking. This preference may partially result from the fear that service use will lead to a
loss of independence.38 Correspondingly, stoicism and an emphasis on endurance in Asian
families may contribute to misidentication of abusive behaviours and thus the need for care
and deservingness of candidacy.81,82,109
Personal characteristics of hardiness and independence may be valued to the detriment of
identication and help-seeking, especially among EMOA living in rural settings.87 Older rural
women who have achieved some level of security and independence through landowner-
ship , have been found to ignore or self-treat symptoms of illness that threaten their hard-won
identities as self-sucient.22,62 Such perceptions of health have been linked to rural culture,
community context, and spirituality, and in combination reduce the likelihood that rural older
adults will seek professional health care.47 In parallel, older adults in the workforce may put
health issues ‘on hold’ due to concerns about employment and nances.3
Immigration factors
Factors related to immigration and settlement can also profoundly aect identication of
candidacy among EMOA. For example, the ability of Vietnamese, Cambodian and Tamil
older adults to recognize and seek help is strongly inuenced by their pre-migration experi-
ences of trauma, which can be compounded by post migration issues related to economic
security, such as ineligibility for pensions and old age benets in their new country.52,53,80,81,82,97,148
For some immigrant seniors, fear of authorities and of jeopardizing immigration applications
may impede their identication of the need for care.45 Finally, tolerance levels of abuse and
neglect are strongly inuenced by fear of deportation and loss of sponsorship.71,52,82,94
72 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Immigration and settlement can also inuence perception of symptoms. In some cases,
EMOA have interpreted their illness symptoms as resulting from loss and powerlessness or the
suppressed emotions of anger and hopelessness associated with migration,75,88,108,109 Levels
of acculturation have also been shown to inuence EMOA’s identication and perception
of elder mistreatment.21,80,82 Among older Korean immigrants to New Zealand, researchers
suggest that the multidimensional eects of elder abuse are compounded by emotional
distress from adjustment factors, language barriers, and cultural isolation, all of which inter-
fere with the process of identication of the need for care or support.81,82,109,131
Identication in health settings
When help is not sought by EMOA or their family members, identication may still take place
within health care settings or by a health provider. In the case of dementia, this may occur
when the older adult is being treated for other medical conditions,16,69,96,103 or in response to
a tipping point such as bereavement,19 leading to referrals to memory specialists. Service
providers often play a key role in the identication of elder abuse and mistreatment by
noting situations in which seniors’ needs are sustained at minimal or sub-minimal levels.97
While EMOA may be reticent to report abuse or simply not perceive the mistreatment
as such, health care professionals are crucial in noticing physical signs of abuse.21,36,81,146
However, neglect is less readily detected by healthcare workers. Researchers note a lack of
consensus surrounding minimum standards of care for older adults, which can cause possible
warning signs of abuse and neglect to be overlooked.146
II) Navigation
Having established that they need and deserve health or social care and support, EMOA
must locate and make their way to relevant services. These tasks require both awareness
of the services available and mobilization of the necessary practical resources.34 Findings
from the topical reports suggest that the navigation dimension of Candidacy is commonly
aected by the following:
• Attitude and trust;
• Knowledge;
• Language;
• Informal support;
• Stigma;
• Geographical location;
• Service level factors; and
• Intersecting determinants
Attitude and trust
Although older persons may recognize their need for health care or social supports, our
review suggests that EMOA may hold negative or ambivalent attitudes towards care
providers. For instance, caregivers may delay seeking a diagnosis for their family member
once symptoms are recognized in order to avoid causing anguish or ‘betraying’ the person
with dementia.102 Delays may be exacerbated when EMOA have little condence that the
service will provide any relief. For example, Punjabi immigrants in the U.K. have expressed the
belief that “there was nothing that could be done” about their dementia symptoms, and
thus there was little point in seeking help from professionals.73
KOEHN & BADGER 2015 | 73
Similarly, a reluctance to seek assistance from health and social services has been noted
among Korean American immigrants experiencing abuse74 and among EMOA experiencing
mental health symptoms.28,92,136 Certain EMOA may perceive service providers as not su-
ciently knowledgeable or able to understand their problems, too busy, or not wanting to treat
them.11,28,72 Delays in help-seeking are further compounded when EMOA reside in geographi-
cally isolated areas; the perceived limited benet is outweighed by the considerable eort
required to mobilize the necessary resources.20,60
Negative attitudes toward help-seeking by EMOA may result from a lack of trust in formal
systems of health or social services due to historical maltreatment,86,99 perceived racism and
discrimination,40,81 or for personal reasons such as negative experiences during past treat-
ments or hospitalizations.11 Therefore, information provision may better facilitate navigation if
delivered by an independent source.59,104
Lack of knowledge
Parallel to the process of identication, common barriers to navigation among EMOA
include a lack of knowledge of the services available. For specic health conditions such
as dementia, this may include a limited understanding about the cause and benets of
obtaining a diagnosis.104 The mental health literature is replete with examples of the inability
of EMOA to navigate the complex system of services; not knowing which services to access,
how to obtain a referral or schedule an appointment impeded their ability to establish candi-
dacy for care.3,11,33,38,59,72,86,116,121,125,141,147 The same can be said of immigrant older adults experi-
encing elder abuse and neglect.21,36,52, 80,108,146,148
Older adults who immigrate later in life may experience particular diculties navigating
health and social systems due to a history of reliance on informal means of information
gathering in their country of origin;4,149 low social capital can hinder navigation, especially
for new immigrants.69 This in turn can result in low levels of service uptake among EMOA.4
Research suggests that previous interactions with mental health professionals are associated
with a better understanding of health services.86 Family and friends of immigrant seniors may
also lack knowledge of services.69,88 The literature describes family caregivers as being unable
to identify appropriate services for EMOA, in part due to their limited ability to mobilize the
social capital required to successfully seek them out.37,40, 52,53,97,107,131 For example, a female
caregiver who had been living in Vancouver for three years experienced signicant isola-
tion as she spent the majority of her time at home caring for her child and aging mother with
dementia and did not know how to access the services she needed.69
Language
EMOA may also encounter challenges in navigating their way to services due to language
and communication diculties.61 Language and literacy barriers to navigation have been
underscored in the literature on chronic conditions,114 falls risk and prevention,43 and mental
health.3,59,38,88,125,147 A lack of linguistic prociency in Charter languages may also result in social
isolation, cultural alienation, and emotional distress among EMOA.81,82,131
Language barriers may be especially pertinent for ethnic minority women. Gender can
have a far-reaching impact on older immigrant women who are kept in the home (for child-
minding duties, for example) thus precluding any opportunity to learn and practice the
mainstream language.32,75,88,89,138 Older women, such as those from the Punjabi community
living in British Columbia, are often heavily dependent on family members for transporta-
tion to and from health services since they may not drive, be able to aord a taxi, and may
avoid public transit due to a lack of English language skills.51 This combination of language
74 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
and transportation barriers prevented diverse EMOA from participating in a state-sponsored
elderly nutrition program.26
Role of social networks
Support from family and friends, can be crucial for successful navigation.32,69,75,88,96 Adult
children may be an especially important resource for information and assistance in
accessing the western health care system, and for emotional and instrumental support.51,86
This may be especially salient for rural elders due to a lack of service infrastructure in outlying
regions, but family members do not always live nearby.91,130 Recent and sponsored immigrants
may be especially dependent on family and others for transportation, nances, and interpre-
tation.11,71,141 Among older Chinese immigrants, greater perceived social support was associ-
ated with more positive mental health help-seeking attitudes.136 Peer support in particular
may be important to encourage service uptake, as older adults may be more likely to listen
to other older adults with regard to help-seeking.141
On the other hand, instances of delayed navigation due to family support have been
described. Out of respect for family hierarchy, family members may choose to discuss
dementia related issues amongst themselves or with a religious leader before mobilizing
practical support.102 The importance of not assuming that support is always available to
EMOA has nonetheless been underscored by several studies that found that the social
networks of recent immigrants were often fragmented.61,88,141 The absence of an established
supportive community is especially acute for recent refugee arrivals.94,97 Church groups
sometimes ll this void for some older adults in rural communities; however dierences in
religious aliation may cause a reluctance to seek help from such groups among EMOA.124
For older immigrant women experiencing intimate partner violence, limited social support
and nancial dependence on the abuser can greatly impede the navigation stage of
establishing Candidacy.37,52,53,107,141,148
Stigma
As seen with identication, stigma also inuences navigation. EMOA have expressed
concerns that “people would gossip about you if something went wrong.”73 Condentiality
presents a major issue for EMOA experiencing abuse, where factors such as fear, shame,
and social exclusion can inuence their willingness and ability to seek help.15 People needing
mental health services are deterred from seeking care by both “public stigma (negative
attitudes held by the public) and internalized stigma (negative attitudes held by stigma-
tized individuals about themselves),” and the latter mediates the response to the former.28
Bilingual/bicultural workers can be invaluable in helping EMOA and their family members to
move beyond the internalized stigma; the option for those seeking care to enquire as though
“on a friend’s behalf” is an important strategy.14 Such workers must be sensitive to the con-
dentiality of such enquiries. Awareness campaigns can be helpful in reducing public stigma,
but more evidence is needed to ascertain their eect on actual help-seeking behaviour.104
Geographic location
Not surprisingly, factors related to geography challenge navigation. For example, many
EMOA live in suburban areas while culturally sensitive services are located in city centres.121
This issue is arguably most salient in rural communities, where there are not only large
geographic distances between health clinics and clients but also shortages in practitioners
and services.54 A lack of viable transportation options signicantly restricts visits to health
care facilities, such as for regular check-ups and consultations with specialists18,133 and harsh
weather conditions frequently add to transportation diculties.17,77 These dierences can
impede access to service. For example, rural women who must travel between one and
KOEHN & BADGER 2015 | 75
three hours to screening centres are only half as likely to receive a mammogram as their
urban counterparts.56 To oset transportation challenges, rural cohorts are likely to rely on
communications technology such as the Internet to obtain health information.144 However,
both the Internet and telephone are sometimes minimal or compromised, especially during
inclement weather.
Navigation and service access may also be hindered when older adults live in deprived or
unsafe areas,11 or experience home insecurity or poor housing conditions.125 Rural EMOA in
particular are often doubly disadvantaged by their low socioeconomic status and inade-
quate infrastructure development.134
Service level factors
Service organization and publicity play a large role in navigation. To promote navigation
to services and information among EMOA, organizations are advised to produce multipur-
pose leaets outlining symptoms and the help available, as well as using neutral terms (e.g.,
‘memory problems’ in lieu of ‘dementia’; ‘looking after’ instead of being a ‘caregiver’).101
Information provision via video or TV may be especially critical for individuals who are not
literate in either English or their mother tongue.66,91,101 Depending on the group, radio broad-
casting, websites, and telephone help lines may connect most eectively with people in
their own homes.66,117 Many immigrant older adults, particularly women, are more comfort-
able and familiar with sources of health information generated within their own ethnocultural
community.6
Linking agencies, such as the Alzheimer’s Society and ethnocultural or immigrant settlement
organizations, are important to facilitate service awareness and uptake among EMOA.19,69
Community outreach activities such as health information ‘roadshows’ held at commu-
nity centres and religious establishments are key to establishing links with EMOA and their
families.101 Similarly, oering health screenings and cognitive assessments in non-institutional
settings can facilitate dialogue and community engagement in the uptake of health services
and interventions.50,121 In their liaison roles within linking organizations, bilingual/bicultural
workers are instrumental in helping EMOA and their families to navigate mainstream services.
14,59 In geographically isolated areas, the closest proxy for this role is often the nurse practi-
tioner.7
Intersecting determinants
Successful navigation requires the mobilization and coordination of diverse resources
such as income, language, social support, time, and transportation, each of which inu-
ences the other. The availability of these resources depends on the intersection of social
determinants of health which are inuenced in turn by systemic issues such as immigration
policy. For example, many Family Class immigrants are sponsored by their adult children so
that they can assist in the care of their young grandchildren. Often wholly dependent on
their sponsors, many also engage in low-wage labour (e.g. temporary farm work).48,71,107,141
In combination with a lack of income and poor social support, restricted free time can
constrain an older immigrant’s ability to seek help.2,68,82,97,121,139 Assisting an older family
member with navigation can also be a nancial burden for families, as it may mean loss of
wages for missed work.17,59
III) The permeability of services
Service permeability speaks to the accessibility of services relative to the qualications one
needs in order to use them.34 Factors that commonly aect service permeability include
76 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
the location of clinics, hours and language of operation, and funding models that limit the
time health practitioners have per patient.66 Relevant factors that emerged from our topical
reports include:
• Service availability;
• Organization of services; and
• Ethnocultural congruence between clients and services.
Service availability
The paucity of suitable resources and services for EMOA and their families inuences their
permeability, because the demand always outpaces the supply and long waitlists are the
norm.59,72,115,141 In addition to funding shortages, the recruitment and retention of health and
social workers into services targeting older adults presents a signicant challenge, especially
in rural regions.31 Many rural hospitals have reduced or eliminated specic services including
mental health services, palliative care, as well as cancer screening and treatment, thus
limiting the care available to all older adults.119 Moreover, rural regions do not have the institu-
tional completeness and resources required to support the needs of racialized individuals. For
example, health and long-term care services in small urban centers of Newfoundland and
Labrador are culturally uninformed regarding best practice for maintaining health among
racialized older adults.106
For older immigrants with mental health conditions, services that combine mental health,
psychiatric, or geriatric care with ethno-specic social services are needed,59,121,126,141 as are
age-appropriate services and programs for mental health education and rehabilitation.29,86,141
Low service availability leaves many EMOA without adequate care and burdens more
permeable health services such as walk-in clinics, hospital emergency departments, and
community health centres.97 In addition, some health providers may be reluctant to accept
new clients due not only to their complex health needs but to linguistic challenges and
limited insurance coverage.97
Organization of services
Partnerships between mainstream services and those oered by the community sector can
have a signicant and positive impact on service permeability.16,66 However, divergent views
surrounding who should deliver what kinds of services as well as poorly integrated care may
signicantly minimize service access.16 This is evident in descriptions of the lack of coordina-
tion across service delivery networks between mental health and protective (elder abuse)
services.29 High service demand, inecient referral processes, and thus long waiting periods
further decrease service permeability.3,16,117 In some cases, there may be delays surrounding
condentiality when doctors opt to withhold information about older patients from their
caregivers.19 Some caregivers and older immigrants have had to wait decades after asserting
their candidacy before they could access certain services such as seniors housing, statutory
services for elder mistreatment, and specialized health practitioners.15,21,40,97,107,112,141
Candidacy for care for EMOA is complicated by the eligibility criteria required to receive
services. In both the UK and Canada, EMOA have been aware of services but unable to
obtain support for many years due to complex referral and qualication processes.15,23,40,71,78,141
Ineligibility for services or delays have been attributed to immigration status, racialization,
income inequity and other social determinants of health. The constellation of structural
barriers that racialized and immigrant older adults confront are often more important than
the cultural barriers to which reduced access is most often attributed.78
KOEHN & BADGER 2015 | 77
Flexibility is the key to maximizing service permeability. Services must accommodate both
EMOA and their families, and oer multifaceted support such as regular phone calls and
home visits. As with navigation, outreach programs are essential to connect services and
service users.13,115 Research suggests that bicultural workers with medical training, who have
an understanding of cultural norms, are procient in community languages, and are knowl-
edgeable about the healthcare system as well as the principles of health equity and access
are indispensable.13,83,90,135 Alternatively, ‘mainstream’ services might consider partnering with
linking agencies that possess many of the resources they need to increase permeability such
as appropriate language skills and knowledge about the trust of specic groups of EMOA.59,67
Service permeability can also be aected by the physical and social environments in which
services are oered (e.g. the creation of a welcoming atmosphere, the set-up of a clinic, the
location of a program within a facility) as well as the location of a program (e.g. oered in
a familiar community setting versus an institution). Both can aect levels of comfort, a sense
of privacy, and/or the extent to which clients are distracted.19,141 EMOA have also reported
feeling restricted by short appointment times that do not allow for detailed discussions with
health care professionals about their complex conditions, particularly when language is a
barrier.35,65 Social service providers echo this concern with time and resource constraints in
delivering services to EMOA experiencing abuse.21,36,82
Ethnocultural congruence
The degree of ethnocultural congruence between health services and clients and its eect
on service permeability is greatly emphasized in the literature on EMOA. Many health
services are provided in ways that are culturally incongruent and hence unfamiliar to EMOA,
particularly immigrant seniors. Such incongruences are often associated with religious pract
ices.15,41,64,68,76,86,113,141 For example, the availability of appropriate food has been seen to impact
participation in elderly nutrition programs26 as well as the uptake of mental health services11
and long-term care.38,41,66 A low degree of cultural alignment has been associated with a lack
of condence, trust, and compliance among ethnic minority seniors.76 Mainstream services
that overlook the unique needs and past experiences of older immigrants and refugees
experiencing abuse can place them at further risk for institutional abuse.15,40
Based on their research with older immigrant women from China and India, Ahmad et al.3,6
maintain that ‘tailoring’ health promotion interventions according to cultural and religious
preferences should be understood as distinct from merely ‘targeting’ a population for inter-
vention. Tailored services must consider intersections of health, cultural and geographic
needs that can best be met when developed with local communities.119 Pre-migration
life experiences such as gender segregation, patriarchal protection, and preparation for
marriage and family life may prevent older women from participating in health promotion
programs that do not align with internalized traditional and cultural norms.145 For example,
older Punjabi women were encouraged to participate in an exercise program for the rst
time in their lives when they were permitted to wear traditional clothing and instructions were
provided in Punjabi.66 Adapting an exercise program to include culturally congruent activi-
ties such as yoga, tai-chi, and Bollywood-style aerobics were also key to engaging EMOA in a
U.K. health and tness program.95
Service permeability is greatly restricted when there is a lack of translated health material
and related documentation, or limited interpretation services.66,141 Moreover, language
discrepancies between clients and services often persist beyond initial consultations to
impact subsequent appointments and patient adherence.97 Accommodating language
barriers is necessary, but not sucient; an understanding of the EMOA client’s culture and
past life experiences are also necessary to ensure that services are fully accessible.141
78 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
IV & V) Appearances and Adjudications
Although an older adult may gain access to a health professional, there is no guarantee
that they will be able to successfully assert their claim for candidacy. The ‘appearances’
dimension of Candidacy describes the presentation of a patient at a health or social service
to articulate their need and make a credible claim for care.34 This dimension relates speci-
cally to the interaction between a client and health professional, and may be inuenced by
the client’s language skills, cognitive functioning, socioeconomic status, gender, and age
for example. The care provider’s or gatekeeper’s role in this interaction is captured by the
‘adjudications’ dimension of Candidacy. After a client presents their need for care, practi-
tioners must make judgment calls based on their own knowledge and biases.34 We present
these two dimensions together since they most often coincide in practice and in the litera-
ture. Increasingly, we see publications on critical health literacy that addresses both dimen-
sions.25,126 Factors described in the topical reports that commonly aect these dimensions
include:
• Client factors;
• Practitioner factors;
• Communication issues;
• Family support; and
• The diagnostic context.
Client factors
The claim to candidacy is inuenced by the ways in which EMOA present their claim. Cultural
dierences in the expression of mental health symptoms may complicate diagnosis.125 The
somatic presentation of mental health symptoms (such as headaches, back or joint pain,
and fatigue) commonly found among Asian patients can result in their attribution to a
physical cause.5,72,75,86,88 In parallel, Vietnamese elders experiencing elder mistreatment have
presented with insomnia or back pain.80
EMOA with depression or anxiety interpret and hence present their symptoms as ‘being tired’,
‘thinking too much’ or ‘negative thinking.’2,72 EMOA and their families have misidentied the
symptoms of dementia as ‘absent-mindedness,’139 and have attributed them to pre-existing
personality traits (e.g., anger), mental illness (e.g., depression), physical illness (e.g., diabetes,
heart disease), and life transitions (e.g., retirement).69,96,102
A perceived sense of inferiority relative to the more highly educated care provider can
also aect how EMOA articulate their need for treatment.72 More broadly, they can be
overwhelmed by the service system, which can aect their understanding of what is
expected of them during consultations.38 For example, Asian older adults may believe that
health professionals only treat physical illness and thus do not perceive any reason to disclose
their experiences of abuse and neglect.36,81,82,108,131,146 Some EMOA may feel too ashamed of
a stigmatized condition (e.g. abuse, mental illness, cancer) to disclose the problem,11 or they
may be reluctant to present their concerns as deserving of medical attention according
to clinical criteria.72 They may also be wary of statutory services due to past experiences of
racism, discrimination, and dismissive behaviour by practitioners.11,103,125,141
Cultural norms regarding communication are also signicant; EMOA may not be accustomed
to disclosing personal feelings with unfamiliar persons,80 and asking intrusive questions may
be culturally tabooed.105 The inuence of gender can also be seen, wherein interactions
KOEHN & BADGER 2015 | 79
between men and women aect whether and how personal health issues are discussed.141,144
EMOA may feel uncomfortable, though not necessarily unwilling, to see a health professional
of a dierent ethnocultural background or younger age.28 However, once trust has been
established between a client and health professional, EMOA and their families may ask for
advice more readily, conde fears, and recommend services to friends.13
Practitioner factors
Appearances commonly begin with the general practitioner or family physician as the rst
point of contact;19,29,69,91,96,102,114 EMOA are less likely to use specialist health services.8,9,24,86 Thus,
the importance of a sympathetic and supportive general practitioner must be empha-
sized.102 Just as EMOA may have diculty articulating their needs to practitioners with whom
they cannot relate, health practitioners likewise report a lack of experience and condence
in working with persons from diverse ethnic backgrounds.16,91 Importantly, a practitioner’s
values, prejudices, and fears can compromise the support oered to older immigrants.72
These may include cultural assumptions about patient attitudes and behaviours (essential-
izing) as well as ‘statistical discrimination’ whereby decisions are based on the morbidity
of certain conditions among dierent ethnocultural populations.86,88,141 For example, health
practitioners have avoided introducing sensitive issues such as Pap testing to older immigrant
women for fear of embarrassing the patient.5 0 There is a clear need for specialized medical
training that extends beyond culture to the provision of individually responsive care.16,63,91
Among older immigrants, important facets of one’s life history to consider include country of
origin, age at immigration, migration route and reasons for migrating.57
Assumptions and stereotypes about EMOA are found in multiple domains. In the health
promotion eld, for example, health practitioners incorrectly assumed that immigrant women
would be too pre-occupied with settlement issues to consider exercising.42 Research also
points to ageist attitudes among mental health providers; perceptions of older adults as
non-compliant or uninterested in treatment have lead to insucient oers of care.29 Likewise,
delays in receiving a dementia diagnosis have been attributed to practitioner attitudes such
as dismissing the concerns of caregivers and ascribing memory complaints to old age.69,174,102
These issues may speak to gender, age, and status-based power imbalances between
health professionals and EMOA.69 Similarly, intersecting dimensions of social dierence also
mediate access to statutory support and the expression of abuse among marginalized
groups.40,52,53,97
Communication
At the most basic level, appearances of EMOA are constrained when no culturally or linguis-
tically congruent professionals and/or interpretation services are available.127,129 Consistent
service from linguistically and culturally congruent practitioners is especially dicult to estab-
lish in rural areas where the steady rotation of health and social service personnel through
the region is the norm. Perhaps even more important than a shared language per se is the
lost opportunity that inconsistency presents for establishing trust between rural and remote
EMOA patients and health and social service providers.46
Even though a practitioner speaks the same language as his or her client, they may do so
in a manner which is overly professional or does not reect the client’s dialect, particularly
when working with older adults.13 Cultural conventions, such as how to address someone, and
non-verbal communication including eye contact and gestures, are important for building
trust with clients.101 In working with older immigrants, ethnocultural alignment goes beyond
addressing language barriers.122 Eective communication must accommodate family
members and address age dierences, limits in vocabulary (especially when discussing
80 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
Western notions of health), and varying levels of comfort with medical environments and
testing.123 Additionally, it is important to investigate how cultural dierences impact patient-
practitioner dynamics, such as the ways in which these dierences can contribute to misun-
derstandings around chronic disease management and levels of compliance and patient
adherence.123
The type of language and terminology used during consultations is crucial to facilitate
access to appropriate care. Practitioners must be careful to avoid alarming or stigmatizing
terms that may discourage EMOA from using particular services.90 For example, researchers
advocate that health providers reframe dementia as a medical condition rather than a
mental illness with the goal of reducing the stigma associated with it.16 Use of the term ‘elder
mistreatment’ is also recommended in order to move conversations beyond violence toward
a wider spectrum of abuse (interpersonal and institutional), neglect, and disrespect.15,40
Communication diculties with older adults, regardless of ethnic background, are often
exacerbated by the nature of the health issue or disease.57 Certain illnesses may be associ-
ated with functional impairment including limitations in sight, hearing, or speech and thus
compromise one’s ability to eectively self-advocate.29,88 This can complicate diagnostic
processes, such as establishing patient histories and conducting assessments based on
language recognition.88 In the case of dementia, older adults may not be able to remember
details from consultations, thus excluding caregivers from client-practitioner interactions can
cause signicant delays in obtaining dementia care.102 Likewise, communication diculties
may prevent older immigrants from coherently articulating their needs over the telephone.10
In some cases, lack of language comprehension during appearances with care professionals
has resulted in allergic and/or adverse drug reactions.69,135
Family support
Appearances of older immigrants at health services are commonly supported by family
members. In a Punjabi study, daughters played a key role in communicating with physicians,
providing translation, and explaining treatments to their parents.51 While older people may
have condence in their family to represent them during appearances, adult children may
have competing family and work commitments preventing them from assisting the older
adult.51,59,121 Moreover, the presence of a third party during consultations can compromise the
building of trust between a client and health professional,97 and practitioners may lack the
training and experience to support family relationships.91
When adequate interpretation services are unavailable, EMOA often rely on family members
for communication during meetings and appointments.11,38,97,121 While this support may be key
to facilitating access, using a family member for interpretation, especially a younger person,
can compromise condentiality and lead to inaccuracies, embarrassment, and withholding
of information.57,66,121 For instance, older adults may refrain from expressing their views or
discussing certain problems such as addiction issues.59 Use of family for interpretation is also
counter indicated when older immigrants are susceptible to abuse and neglect within the
family due to the dependency that their sponsorship status engenders.71,94
The diagnostic context
Adjudications are frequently complicated by a lack of culturally sensitive assessment tools for
screening and diagnosis.12 For example, cultural biases in instruments can skew estimates of
dementia severity since instruments are typically developed using samples from the general
population.101 Screening and assessment tools must be adapted to ensure that their meaning
and content reects the language and cultural context of the client.16,74,75,116,147 Uptake of
KOEHN & BADGER 2015 | 81
mental health treatment among ethnocultural minority patients has been positively associ-
ated with the use of a culturally sensitive psychiatric evaluation (the Engagement Interview
Protocol [EIP]).147
A timely and accurate diagnosis of dementia is critical as it expedites access to dementia-
specic services, such as particular treatment plans according to dementia type, homecare
and respite, and also facilitates future planning with regard to care preferences and repre-
sentation agreements, for example.101 Missed and delayed diagnoses by primary care practi-
tioners are nonetheless widely reported.19,69,96 Such errors can have far-reaching implications
for EMOA in abusive situations, where the ability of the service provider to recognize candi-
dacy is crucial: many older adults will not volunteer such information.21 If certain signs and
symptoms are missed, then it may take a crisis event before the older adult receives proper
diagnosis and care.102 The World Alzheimer Report162 has described a waiting period between
3 and 6 years for individuals with memory impairment to receive an accurate diagnosis. This
may speak not only to diagnostic diculties but also issues among the professional commu-
nity regarding awareness of the disease and treatment options. Recent research suggests
that technology innovations such as decision support software for primary care physicians
may improve the diagnostic process in health settings.104
VI) Offers and resistance
The oers and resistance dimension of Candidacy refers to the acceptance and resistance
among patients or clients to oers made by health or social service professionals for referrals,
medication, and additional health and social support. Common issues that emerged across
all topical reports within this dimension include:
• Suitability of oers;
• Knowledge and understanding;
• Informal support; and
• Stigma and self-maintenance.
Suitability of offers
Not surprisingly, EMOA resist oers for care that are deemed unsuitable.88 Mental health
services are much more readily accepted by EMOA when they are integrated with primary
care services.8,9 Similarly, mental health supports and health promotion programs that simul-
taneously address the social and emotional needs of the client are more appealing to
EMOA.29,66 Accordingly, older immigrants and their families are often more likely to accept
support oered by ethno-specic agencies over formal services.11 In parallel, eective inter-
ventions for vulnerable populations often lie outside of mainstream services.93 For example,
EMOA are cited as being resistant to police involvement or litigation in addressing situations
of elder mistreatment.21,80,81,82,109 Restorative justice strategies have been proposed as a more
suitable approach, especially for immigrant seniors who are dependent on their abuser
for support.93 Furthermore, lack of suitability has been noted with regard to the province of
Ontario’s Violence Against Women (VAW) framework concerning intimate partner violence.
Many EMOA may not dene abuse and neglect within the context of intimate partner
violence and thus may not perceive the suitability of programs and services oered.37
The acceptance of oers may also be predicated on cultural, spiritual and religious
factors;38,75 for example, EMOA may prefer traditional remedies or spiritual healing practices
to Western medicine, particularly for mental health concerns.3,11,74,86,132 In particular, research
emphasizes strong resistance among South Asians to accepting residential care,79 which
82 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
has been deemed “ideologically unacceptable and culturally inappropriate.” (p.390)16 It is
dicult for families to choose and accept long-term care when no suitable options exist.110
Incorporating patient beliefs into treatment and care plans is one strategy that can promote
acceptance of and adherence to oers.38 Oers of support should also be sensitive to
clients’ personal and familial cultural history, including immigrant status and levels of integra-
tion.88 To this end, EMOA may prefer bilingual/bicultural health workers.86,121
Knowledge and understanding
Culturally informed understandings of health and illness can also impact one’s interpreta-
tion of oers for treatment and referral, as well as the ability to act on a health professional’s
instructions.123 For example, the literature on dementia suggests that diagnoses are more likely
to be accepted when families have previous experience with the disease, either personally
or professionally.19,69 When families lack knowledge, they may feel hopeless about options
for care beyond family support.16 Similarly, negative attitudes toward mental health services
may cause EMOA to believe that medical treatments are not the most eective strategy for
managing symptoms.28,136
Although EMOA may face challenges understanding their diagnosis and options for treat-
ment, they may still pretend to understand practitioners in order to appear compliant or
prevent embarrassment.38 This in turn can lead to intentional or unwilling noncompliance
(e.g. accepting prescriptions but discarding medications) and poor health outcomes.38,72,88
A lack of understanding may also arise due to disease related cognitive decits,29 as well as
literacy and language barriers.88
Norms of lial piety and gender roles
A signicant portion of the literature focuses on the preference for ethnic minorities to ‘care
for their own’ due to cultural norms and religious obligations surrounding lial responsi-
bility.4,12,59,79,84,86,103 Accordingly, EMOA and their families may be resistant to oers from services
and agencies since acceptance could imply that families need supplemental support and
are incapable of fullling their duty to care.84,117 Thus, remaining in the family home may be
viewed as an emotional and practical imperative by EMOA.79 Oers for caregiver respite
such as day care (versus home-based respite or short-stays in care homes) are likely to be
the most acceptable option for EMOA and families who are reluctant to allow strangers,
including health providers, into their home.16,101 Service use can be intermittent since accept-
ance is likely to uctuate over time as health providers build trust with clients and their
families.13
Gender norms can also inuence acceptance and resistance to oers. For example, In South
Asian immigrant households, men play a stronger role in decision-making and compensatory
support, whereas women are more likely to provide more ‘hands-on’ care.61 Thus, husbands,
fathers, and grandfathers will often have the nal say as to whether medical treatments and
participation in health promotion activities are deemed acceptable or not.51,70,117 The ability
of some EMOA to communicate their needs and preferences to care providers, can thus be
compromised.43 This is especially true for older women with language barriers. For older adults
with traditional values, the issue of cross-gender caring, especially from persons outside the
family, may be unacceptable.61
Although family may care for EMOA into late stages of illness and disease, researchers
caution that this may not always be the case.16 It cannot be assumed that all EMOA have
supportive extended families since there a number of factors related to migration and accul-
turation at play.57,61 Support from family may be restricted by immigration laws, fragmented
KOEHN & BADGER 2015 | 83
family networks, the growing preference for nuclear households, nancial pressures, and
the changing social practices of marriage, divorce, and women in the workforce.61,71,101 In
rural areas, familial support for older adults is signicantly compromised by the outmigration
of young people to urban centers in search of employment.27 Consequently, government
policies based on the ideology of familism may actually leave EMOA without adequate
care.53,82,94,107
Stigma and self-maintenance
As seen in the identication and navigation dimensions of Candidacy, acceptance and
resistance of oers can be inuenced by stigma. For example, fear of stigma can dissuade
EMOA from following up on referrals or partaking in health screening.29,44,50,59,75,121,141,147 Feelings
of shame and embarrassment have been noted among older persons receiving mental
health services.11 Fear of stigmatization may be especially salient in small and isolated
communities.58 Treatment may also be resisted due to fear of the medication itself and
potential side eects, or from past negative experiences with health services.28,69
Readiness to accept treatment can vary among EMOA. For example, persons with dementia
may aim to “preserve identity and autonomy in the face of increasing symptoms.”(p.7)19
Thus, resistance to oers may be less a form of denial than a strategy for self-maintenance.19
The desire to maintain freedom and self-control is also evident in accounts of EMOA who
seek to address mental health challenges on their own and hence resist treatment.2,11,33,72
Acceptance of services or treatment is equated with a loss of independence.38,65
VII) Local operating conditions
The nal dimension of Candidacy, local operating conditions, pertains to local and specic
factors that aect interactions between clients and health professionals, such as the availa-
bility and suitability of resources and services.34 Findings from the topical reports suggest that
Candidacy can be aected by local operating conditions including:
• Service factors (such as service availability and organization); and
• Structural factors (such as policies surrounding immigration and health insurance).
Service factors
Local operating conditions are greatly impacted by the services available for EMOA, with
signicant dierences between regions. In rural areas, the regionalization of health services is
a major challenge to the delivery of health care, as there are often long distances between
services and clients due to low user densities.31 In addition to geographical challenges,
researchers have called attention to market forces (e.g., stang shortages, scal constraints),
and programming issues (e.g., low uptake of services, even during advanced stages of
illness) that inuence access in rural and remote regions.17,31,54,55,120,142 This may prevent older
adults with more specialized needs, such as those with Alzheimer’s disease or in need of
palliative care, from being accommodated in or near their home community.3 1,11 9 Economic
restructuring in rural and remote regions of the country have resulted in the reduction and
elimination of hospital services including access to physicians, specialists, and pharma-
cies.54,118,119 Restructuring has also created an over-dependency on informal supports from
community groups, family members, and individual volunteers, all of whom may be in short
supply.128
Local conditions can also inuence physical activity levels and healthy eating. For example,
although traditional diets of Indian immigrant families in Newfoundland aligned closely with
84 | HEALTH CARE EQUITY FOR ETHNIC MINORITY OLDER ADULTS
recommendations from Canada’s Food Guide to Healthy Eating, the relative non-availability
of reasonably priced ethnic foods in local markets was seen to contribute to poor nutritional
practices among them.140
Service success and sustainability is compromised when funding for programs is short-
term59,101; it takes time to build trust and establish relationships with EMOA and local commu-
nities in general, hence the deliverables required by funders may not be possible within the
short period for which funding is provided.59,101 Other immediate pressures aecting service
availability for EMOA include workplace culture (such as support from management),
competing clinical priorities, and the capacity to integrate multiple aspects of care both
within and across organizations.29,59,72,141
There is a clear need for further service development for EMOA and their families. Needs-led
service development, whereby stakeholders are engaged in ongoing dialogue in order to
address the specic circumstances of the local population, is essential.85,106 Education and
training for health service employees regarding culturally appropriate practice, ideally in
the form of province-wide programs with ongoing nancial support, has also been recom-
mended.106 In rural communities, nurses and nurse practitioners7,106 as well as interdisciplinary
‘one-stop’ clinics171 can potentially make a positive impact on the lives of immigrant seniors.
Improved service development is an area where more research is required, especially for
systematic evidence and evaluations of eective solutions and approaches to service design
and delivery.85
Structural level factors
Many EMOA report feeling underserviced due to the impact of institutional discrimination, as
evidenced by their exclusion from specic government programs, inadequate health care
and social services, and lack of recognition in healthcare budgets.10,80,81,82,97,108,109,131 Indeed,
there are cumulative eects of health and material disadvantage resulting from discrimina-
tion at a variety of institutional and organizational levels.100 These include linguistic discrimina-
tion, duration of residence since immigration, formal labour force participation (including
promotion prospects), reduced income in retirement, and living in areas with a high rates of
harassment and crimes based on race and language.100 Institutional barriers to healthcare for
EMOA must be addressed at the policy and governmental level.97 A focus on linguistic and
cultural competence, and careful consideration of what this training may look like and who it
should serve, is needed across all healthcare contexts.4,135
A number of additional government policies impact Candidacy in terms of the contextual
conditions that they generate. For example, failure to recognize the credentials of newly
immigrated health professionals can minimize the opportunities to provide services to EMOA
in their mother tongue.111 As previously discussed, policies concerning sponsorship of Family
Class immigrants79 and regionalization or amalgamation in rural and isolated communi-
ties134 can leave many EMOA without access to adequate care. The cost for medication,
treatment, and service