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Seniors Support Services for South Asian Community (S4AC) project: PROCESS EVALUATION

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Abstract and Figures

The Seniors Support Services for South Asian Community (S4AC) project was developed in response to a problem in the community: although South Asian seniors were especially numerous in the Newton area of Surrey, they were not using recreation and seniors’ facilities in this neighbourhood. Addressing the problem required the collaboration of the Parks, Recreation and Culture Department of the City of Surrey, and DIVERSEcity, a registered non-profit agency offering a wide range of services and programs to immigrant and refugee communities. Through creative outreach, reduction of language and cultural barriers, provision of childcare for grandchildren, and by taking programs to where seniors naturally gather (e.g., parks, temples), the project has succeeded, since 2008, in engaging 100 Punjabi seniors annually in diverse exercise activities, facilitating the development of peer networks and close friendships among participants, and empowering the seniors to utilize existing community resources (pool, seniors centre, etc.), initiate activities on their own and socialize with other communities. The project also offers educational workshops on various topics, including health and self-care, and counseling is provided as needed.
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Seniors Support
Services for South
Asian Community
(S
4
AC) project:
P
ROCESS
E
VALUATION
Sharon Koehn, Sanzida Habib, Syeda Bukhari
June 24, 2013
Research reported herein was generously supported by the
LiVWELL research group and funded through the Community
Trust Endowment fund at Simon Fraser University and the
United Way of the Lower Mainland.
This evaluation brief is a companion document to the full report:
Achieving Self-Management Supports for Immigrant Seniors
team: South Asian Seniors Project.
34
2
Contents
Introduction ..................................................................................................................................... 3
Background and Rationale .............................................................................................................. 3
Spotlight on South Asian Immigrant older Adults ..................................................................... 3
Health promotion and exercise: South Asian older adults .......................................................... 4
Methodology ................................................................................................................................... 5
Interviews ................................................................................................................................ 5
Recruitment ............................................................................................................................. 6
Opportunity mapping exercises .............................................................................................. 6
Data verification...................................................................................................................... 6
Evaluation Brief .............................................................................................................................. 7
The S
4
AC Program: what’s it all about? ..................................................................................... 7
Program characteristics-overview ........................................................................................... 7
Program participant characteristics ......................................................................................... 8
Benefits perceived by staff and senior participants .............................................................. 14
The quality of program components: staff and participant perspectives .................................. 17
Program demand and expansion ........................................................................................... 17
Opportunities for connection ................................................................................................ 18
Facilitating access and retention ........................................................................................... 20
Recommendations ..................................................................................................................... 27
References Cited ........................................................................................................................... 30
3
Introduction
IntroductionIntroduction
Introduction
The Seniors Support Services for South Asian Community (S
4
AC) project was developed in
response to a problem in the community: although South Asian seniors were especially
numerous in the Newton area of Surrey, they were not using recreation and seniors’ facilities in
this neighbourhood. Addressing the problem required the collaboration of the Parks, Recreation
and Culture Department of the City of Surrey, and DIVERSEcity, a registered non-profit agency
offering a wide range of services and programs to immigrant and refugee communities. Through
creative outreach, reduction of language and cultural barriers, provision of childcare for
grandchildren, and by taking programs to where seniors naturally gather (e.g., parks, temples),
the project has succeeded, since 2008, in engaging 100 Punjabi seniors annually in diverse
exercise activities, facilitating the development of peer networks and close friendships among
participants, and empowering the seniors to utilize existing community resources (pool, seniors
centre, etc.), initiate activities on their own and socialize with other communities. The project
also offers educational workshops on various topics, including health and self-care, and
counseling is provided as needed.
This report serves as a process evaluation of the S
4
AC project commissioned by the project’s
funder, the United Way of the Lower Mainland (UWLM). The evaluation study benefits from
data collected for a related study funded by Simon Fraser University aimed at understanding if
and how the project enhanced the capacity of immigrant South Asian senior participants to ‘self-
manage’ their chronic conditions, a full account of which can be found in the companion report,
Achieving Self-Management Supports for Immigrant Seniors team (ASSISt): South Asian Seniors
Project.
34
Background and Rationale
Background and RationaleBackground and Rationale
Background and Rationale
Spotlight on South Asian Immigrant old
Spotlight on South Asian Immigrant oldSpotlight on South Asian Immigrant old
Spotlight on South Asian Immigrant older Adults
er Adultser Adults
er Adults
Older adults are the most rapidly expanding population in Canada, expected to grow from 13.7%
today to almost 24% by the year 2031. Immigrant older adults now comprise almost one third of
this age cohort nationally,
1
but research on immigrant older adults in Canada is still very
fragmented.
2
Research specific to this population on health promotion is especially sparse,
leaving gaps in understanding of their needs. Recourse to the more abundant U.S. literature on
this population
3
is limited by considerable differences in the groups studied and in our health
care systems and insurance coverage.
South Asians are now the most populous minority group in Canada and include the highest
proportion of older adults, most of whom have arrived as Family Class (sponsored)
Seniors Support Services fo
r South Asian Community (S
4
AC)
4
immigrants.
1,4
In British Columbia, high concentrations of South Asians are found in the Lower
Mainland city of Surrey where in 2010, they constituted 32% of the population; 18% identified
Punjabi as the language they most often speak at home.
5
Recent family class immigrant seniors
have poorer overall health compared to their Canadian-born counterparts,
6
and the burden of
chronic illness is especially high among South Asian immigrants.
Research by Koehn
7-11
and others
12,13
with Punjabi-speaking seniors has also documented the
difficulties that late-in-life immigrants experience in accessing information and appropriate
social and medical care. Contributing factors include the intersecting and deleterious effects of
living in isolation due to language issues, transportation difficulties, lack of knowledge of local
resources, and child-minding responsibilities. Oppressions experienced throughout the life
course also influence their social capital which may be further diminished in the face of role
reversal and loss of status, as well as discrimination experienced post-migration.
7,9,14-16
Support
services that promote healthy living are thus badly needed by South Asian immigrant older
adults, as is research to understand their needs and evaluate interventions.
Health promotion and exercise: South Asian older adults
Health promotion and exercise: South Asian older adultsHealth promotion and exercise: South Asian older adults
Health promotion and exercise: South Asian older adults
Immigrant older adults, particularly those designated as “visible minorities,”
1
bear a
disproportionate burden of chronic conditions.
17
Both male and female South Asian immigrants,
such as those who participate in the S
4
AC programs, are especially susceptible to cardiovascular
disease and diabetes and its complications, with the latter often present as a risk factor for the
former.
18-25
The strongest evidence to explain this high morbidity points to the role of extremely
low levels of physical activity amongst South Asian immigrants as a risk factor for these chronic
conditions.
26,27
Levels of physical activity are especially low among women and the elderly.
In some South Asian immigrant populations, low levels of physical activity and other forms of
risk modification can be explained by a combination of comparatively low levels of knowledge
about the chronic conditions and their risk factors, lack of accessible information and advice, and
religious and cultural beliefs about health, illness and aging.
22,28-31
For example, among
immigrants from India, female sex, poor health, low levels of acculturation and less time since
immigration were associated with low levels of physical activity.
31
Additional influences on
South Asian older adults’ participation in exercise and physical activity include
the following:
Communication barriers ~ relying on relatives for translation of information, lack of
understanding;
Relationships ~ social support from family, friends, community;
Beliefs ~ not culturally appropriate to exercise, fatalism; and
1
Visible minorities are defined by Statistics Canada
42
as “
persons who are non-Caucasian in race or non-white in
colour and who do not report being Aboriginal persons who are non-Caucasian in race or non-white in colour and who do
not report being Aboriginal.”
5
Environment ~ lack of accessible recreational areas/facilities.
32
Cultural beliefs that can translate into barriers include perceptions of gender roles and body
image, misconceptions about physical activity, cultural priorities, cultural identity, and
explanatory models of disease – all of which make it difficult for many South Asians to change
behaviors and lifestyles that increase their risk of morbidity and high mortality associated with
cardiovascular disease.
30
Retired and widowed South Asian immigrant mothers living in
Halifax, Canada similarly attested to the powerful role played by gender segregation, patriarchal
protection and early preparation for marriage on their propensity to be physically inactive. In
balance, however, they were found to be more emotionally and socially healthy than their non-
South Asian peers. Importantly, later life events, migration, retirement and widowhood ironically
afforded them the freedom to renegotiate and reconstruct their late-life styles to be more
physically and socially active through ethno-cultural social networks they had built after
migration.
33
The root causes of limited physical activity found among South Asian immigrant
populations, particularly women and the elderly, are thus multiple and complex. Research
nonetheless indicates that health and social policies and programs that address these barriers and
promote social inclusion as well as physical activity can influence activity levels and ultimately
health outcomes.
Methodology
MethodologyMethodology
Methodology
Interviews
InterviewsInterviews
Interviews
The data collected to support this process evaluation focused on the activities, staff and
participants in the S
4
AC programs that are delivered at the Sunrise Pavilion of Bear Creek Park
and the Newton Seniors Centre, both in Surrey-Delta, BC. The evaluation study benefits from
data collected for the SFU-funded ASSISt study aimed at understanding if and how the project
enhanced the capacity of immigrant South Asian senior participants to ‘self-manage’ their
chronic conditions.
Data collected for the ASSISt project included reviews of public
documentation of the project (advertising, annual reports to the funder), eight hours of
participant observation in the programs offered, and one to one-interviews with staff (n=8; 3 City
of Surrey & 5 DIVERSEcity; 1 male & 7 female) and senior participants (n=15; 14 Bear Creek
& 1 Newton; 2 male & 12 female). Additional funds from the United Way of the Lower
Mainland (UWLM) enabled us to compile a database of the relevant literature and conduct three
focus groups with program participants. Ultimately, we conducted three focus groups that
included a total of 25 participants: one at Bear Creek in Punjabi (all South Asian women; n=7),
one in English with non-South Asian women at Newton (n=7), and a third in Punjabi with South
Asian men and women from the Newton site (n=11).
6
Recruitment
RecruitmentRecruitment
Recruitment
Staff interviewees were from either of the partner organizations (DIVERSEcity and the City of
Surrey), and had been involved in planning and/or delivering the S
4
AC project for at least a year.
Senior participants recruited for individual interviews as part of the ASSISt project had to be of
South Asian descent and have diagnoses of two or more chronic conditions from a list of the
most common chronic conditions experienced by British Columbians.
35
Recruitment criteria for
the focus groups of program participants were broader than that for the individual interviews.
Participants did not need to have any chronic conditions and could include non-South Asians
who have now been encouraged to join the Newton programs. People who previously but no
longer attend either the Bear Creek or the Newton programs were also included so that we could
gain an understanding of the barriers to their participation.
Opportunity mapping exercises
Opportunity mapping exercisesOpportunity mapping exercises
Opportunity mapping exercises
At the conclusion of each of the staff interviews we also asked interviewees to map their
relations to one another and to each of the sites. The mapping exercise identified the different
project sites and technologies (e.g. e-mail) through which staff from the participating
organizations are linked and through which opportunities are created by the project.
36
Mapping
connections between people and sites acknowledges the more dynamic role of the project within
the complex ecological system that comprises the larger geographic community. We also asked
senior participants in the focus groups to produce opportunity maps
36
similar to those completed
by staff that indicated their relationship to each of the sites, City of Surrey or DIVERSEcity staff,
any old friends with whom they originally came to the programs, and new friends that they had
made through programs.
Data verification
Data verificationData verification
Data verification
At the conclusion of our project, we held a member checking event that included interviewees
and other participants in the S
4
AC programs from the different sites at which the program is
delivered (n=42). Feedback from participants in this event serve as a check against our
interpretations of what the senior participants told us in the one-to-one interviews. This step
enhanced the trustworthiness of our interpretations of the data.
7
Evaluation Brief
Evaluation BriefEvaluation Brief
Evaluation Brief
The combined findings of the ASSISt and Evaluation studies are reported at length in the
Achieving Self-Management Supports for Immigrant Seniors team (ASSISt): South Asian Seniors
Project document.
34
This brief aims to summarize the findings most salient to the process
evaluation commissioned by the United Way of the Lower Mainland. Here we seek to answer the
following process evaluation questions, identified as important by Chinman, Imm and
Wandersman.
37
What are the program characteristics?
What are the program participants’ characteristics?
What is the participants’ satisfaction?
What is the staff’s perception of the program?
What were the program components’ levels of quality?
So as to make the best use of the rich qualitative data that we have collected, we will combine
the last three questions under a single heading, The quality of program components: staff and
participant perspectives. This strategy reveals differences in the perceptions of service providers
versus consumers relative to different features and objectives of the programs, and facilitates
identification of strengths and weaknesses.
The perspectives of staff and senior participants in the S
4
AC programs are derived from one-to-
one interviews and focus groups. Pseudonyms have been assigned to all of the individual
interviewees to protect their identity. The South Asian seniors were given Punjabi surnames and
addressed with a title of Mr. or Mrs. according to their gender while staff interviewees were
allocated Anglophone first names. Data collected from focus groups are not attributed to
individuals and are referred to by the site and composition of the group.
The S
The SThe S
The S
4
44
4
AC Program: what’s it
AC Program: what’s it AC Program: what’s it
AC Program: what’s it all about?
all about?all about?
all about?
Program characteristics
Program characteristicsProgram characteristics
Program characteristics-
--
-overview
overviewoverview
overview
The Seniors Support Services for South Asian Community (S
4
AC ) project was developed in
response to a problem in the community: although South Asian seniors were especially
numerous in the Newton area of Surrey, they were not using recreation and seniors’ facilities in
this neighbourhood. Addressing the problem required a collaborative approach achieved through
“A process evaluation assesses what activities were
implemented, the quality of the implementation, and the
strengths and weaknesses of the implementation.”
37, p. 93
8
a unique partnership between the United Way of the Lower Mainland (UWLM), the Parks,
Recreation and Culture Department of the City of Surrey, and DIVERSEcity Community
Resources Society (DCRS)—a registered non-profit agency offering a wide range of services and
programs to immigrant and refugee communities. Together these agencies have funded and
implemented two programs, one at Newton Seniors Center and another at Bear Creek Park
(North Surrey). The UWLM began funding and hence initiated the Newton program in 2008,
then increased its commitment by funding the Bear Creek Park program in 2009. Both programs
have been funded continuously since their inception. As an embedded funder, the UWLM has
maintained an active interest in the development, implementation and evaluation of these
programs throughout their tenure.
The two S
4
AC programs are unique in their successful deployment of outreach strategies that
initially targeted isolated South Asian seniors, with the goal of integrating them into community
facilities for social and recreational activities. Active and creative outreach strategies, in
combination with the reduction of language and cultural barriers, provision of childcare for
grandchildren, and a client-focused approach to the location, timing and content of the programs
have succeeded in engaging predominantly Punjabi seniors in diverse exercise activities. In
addition they facilitate the development of peer networks and close friendships among
participants and empower the seniors to utilize existing community resources (pool, seniors
centre, etc.), initiate activities on their own and socialize with other communities. The project
also offers educational workshops on various topics, including health and self-care, and
counseling is provided as needed.
The Newton Seniors’ Centre and Wave Pool site is distinct in its organization and the
participants it attracts from the Bear Creek Park site. At the Newton Senior’s center, chair
exercises are offered once a week. Membership also includes weekly Aquacize classes at the
adjacent Newton Wave Pool. Seniors from a variety of ethnocultural backgrounds participate in
these classes which are integrated into the Centre’s program and infrastructure. Bear Creek
participants attend chair exercises twice a week and yoga once a week. While non South Asians
are welcome to join these classes, they are primarily composed of Punjabi-speaking participants.
Classes are held in a stand-alone building located in a park.
P
PP
Progra
rograrogra
rogram participant characteristics
m participant characteristicsm participant characteristics
m participant characteristics
Senior participants
Approximately 100 senior participants are currently registered in both programs; most are South
Asians, the original target population, but the program is now open to seniors of diverse
backgrounds. From our observations, the chair exercises at the Newton Seniors’ Centre attracted
an average of 25 participants, of which 6-8 (mostly couples) were South Asian. Most of the
South Asian participants also attended the Aquacize class at Newton Wave Pool. All but two of
9
the approximately 40 regular attendees at the Bear Creek Park site were South Asian. Of these,
only 4-5 were men. The age range of self-identified seniors who participate in the S
4
AC
programs is broad, as reflected in our sample of 15 one-to-one interviewees whose ages ranged
from 53 to 87, with the majority aged between 65 and 74 years.
Although the South Asian participants are predominantly (or even exclusively) Punjabi Sikhs
from India, there are many differences among them. Importantly, the group attending the Newton
site is quite distinct from the majority of participants at the Bear Creek site. For example, Bear
Creek participants, particularly women, were more religiously conservative as evidenced by
religious symbols, such as turbans and kirpans, which were part of their daily attire.
The Bear Creek seniors were typically sponsored by a son who came to Canada before them.
They usually lived with the sponsoring child and their grand-child/ren, and they often had other
children living here. If they were sponsored by a daughter, they more often lived alone or with a
son who may have been sponsored along with them. Some of our one-to-one interviewees had
lived in Canada for less than ten years and were therefore still legally dependent on their children
who had sponsored their immigration; however, the majority had been in Canada for more than
ten years.
Most of the women interviewees who participated in the Bear Creek Park program said they
came from farming families in India in which their responsibility was to do chores inside the
home. Some of the seniors were previously or currently involved in part-time or seasonal
farming work in Canada. Here they typically help their older children with household chores and
most are currently or have previously been engaged in taking care of young children.
Most female interviewees had a little or no formal education, whereas both male interviewees
were well-educated and fluent in English (one at Bear Creek, one at Newton). Overall, most of
the participants had already retired; some, but not all, participants had control of their own
finances. Both male and female participants attending the Newton Center program, most of
whom came with their spouses, were from urban backgrounds. Compared to the Bear Creek
group, they were relatively well-educated, professional and, could speak English well. Both
South Asian men and women in this group had worked and aged in Canada.
While the majority of participants at the Bear Creek site reported that they had two or more
chronic conditions, this was not true of the South Asians attending the Newton programs. Only
one male South Asian senior and none of the women at the Newton site met the inclusion criteria
of having two or more chronic conditions to participate in the ASSISt study. Overall this group
was younger and fitter. The physical and mental chronic health conditions reported by the senior
participants included diabetes, hypertension, high cholesterol, arthritis, “heart conditions”,
asthma, thyroid problems, anxiety and depression.
S
eniors participating in the focus groups
sites and the people they met there (staff and othe
they went to the program in the first place.
themselves (a male or female sign in the centre of the page)
friends with whom they came
to the S
a green dot and friends they had met through their involvement with the program with a purple
dot. DIVERSEcity
staff with whom they were connected through the S
Table 1
summarizes the average number of connections with sites, staff and friends for each of
the three focus groups.
Newton
Non South Asian
Sites
DIVERSEcity staff
City of Surrey staff
Friends - prior
Friends - new
5.7* (4.5)
Table 1: Connections (
) with sites, staff and friends by focus group
* This average is skewed by o
ne individual who reported 13 new friends; she was clearly the exception to the norm
which is reflected by the figure in parentheses (i.e. the average of all responses except for this individual)
Bear
Creek
/
Figure 5: sample diagram mapping seniors relationships to sites, staff and friends
Figure 1: Sample diagram mapping senior’s relationships to sites, staff and friends
10
eniors participating in the focus groups
were asked
to map their relationships with the S
sites and the people they met there (staff and othe
r participants) as well as others with whom
they went to the program in the first place.
P
articipants were asked to draw lines
themselves (a male or female sign in the centre of the page)
to the sites they used and indicate
to the S
4
AC program (i.e. people they knew prior to joining) with
a green dot and friends they had met through their involvement with the program with a purple
staff with whom they were connected through the S
4
AC program were
indicated wi
th stars and City of Surrey
staff with squares
(Figure 1)
summarizes the average number of connections with sites, staff and friends for each of
Newton
Non South Asian
(n=7)
Newton
South Asian
(n=11)
Sout
1.3 2
0.7 1.1
1.9 0.9
0.7 8.6
5.7* (4.5)
6.5
) with sites, staff and friends by focus group
ne individual who reported 13 new friends; she was clearly the exception to the norm
which is reflected by the figure in parentheses (i.e. the average of all responses except for this individual)
Newton
Seniors
Centre
Newton
Wave
Pool
Figure 5: sample diagram mapping seniors relationships to sites, staff and friends
Figure 1: Sample diagram mapping senior’s relationships to sites, staff and friends
to map their relationships with the S
4
AC
r participants) as well as others with whom
articipants were asked to draw lines
from
to the sites they used and indicate
AC program (i.e. people they knew prior to joining) with
a green dot and friends they had met through their involvement with the program with a purple
AC program were
th stars and City of Surrey
(Figure 1)
.
summarizes the average number of connections with sites, staff and friends for each of
Bear Creek
Sout
h Asian
(n=7)
1
1.3
2
4.7
5.1
ne individual who reported 13 new friends; she was clearly the exception to the norm
which is reflected by the figure in parentheses (i.e. the average of all responses except for this individual)
.
11
While all of the South Asian participants at the Newton site availed themselves of both the chair
exercises and the Aquacize classes (and hence report connections with two sites apiece),
participation in Aquacize is considerably lower among the non South Asian group at Newton. On
average, this group was older and reported more chronic conditions and mobility impairment
than the South Asians attending the Newton sites. Bear Creek participants only attended one site,
but the higher level of connection with City of Surrey staff that they report reflects their
participation in both the chair exercise and yoga classes offered there, each taught by a different
instructor. More non South Asian seniors than South Asians reported that they had a meaningful
relationship with the City of Surrey staff in administrative positions at Newton Seniors Centre, to
which they felt the greatest connection. South Asian seniors did not express the same level of
connection with the Centre overall; rather their attachment was to the classes offered by the
S
4
AC program.
Not surprisingly, the non South Asian seniors connected the least with the DIVERSEcity staff
whose main role is to facilitate participation for South Asian seniors. South Asian seniors at Bear
Creek report more connections with DIVERSEcity staff than do those at Newton. In part this
may be because they are more dependent on the coordinator’s interpretation and referral
services; it may also reflect their use of childcare and or counselling services provided by
DIVERSEcity.
Seniors in both South Asian groups came into the program with considerably more friends than
the non South Asian seniors who were primarily lonely widows seeking social engagement
through Newton Seniors’ Centre. South Asian seniors attending the Newton sites primarily came
as couples and knew other couples who were attending the S
4
AC program. They have friendly
but not close relations with other non South Asian participants. Like our interviewees from Bear
Creek, the focus group participants at this site typically came to the program with friends and/or
extended relatives and have expanded their social networks considerably through participation in
the group.
Staff interviewees
Eight staff from the two partner organizations (five from DIVERSEcity, and three from the City
of Surrey) were also interviewed. The staff sample included administrators (n = 3) and frontline
workers (n = 5) from both organizations. All but one of the staff interviewees were female. We
included two staff who had previously worked with the S
4
AC program at DIVERSEcity because
they had been central to the program’s development. Another interviewee left the organization
while the research was underway. An outstanding challenge to the continuity of the project
vision and the energy invested in the S
4
AC programs has been staff turnover and changes due to
maternity leave at the management level of both organizational partners. Moreover, in the past
year, both of the initial frontline DIVERSEcity staff responsible for recruitment of participants
12
into the program have moved on to other positions. The role of manager of the DIVERSEcity
coordinator has also been vacated twice in less than a year.
Frontline workers employed by the City of Surrey were physical instructors, while those from
DIVERSEcity provided language assistance and other supports (including psychological
counseling) for the immigrant South Asian seniors in a culturally appropriate manner. They were
also responsible for outreach work and recruitment of South Asian senior participants in the
program. Two of the frontline workers from both organizations also assumed some
administrative or management responsibilities, such as coordination. All but two staff had some
post-secondary education ranging from diplomas to graduate level degrees.
All of the DIVERSEcity staff involved in the program had originally migrated from Punjab,
India, and could speak Punjabi. They also had previous experience of working with ethnocultural
minorities in Canada, including South Asian immigrants. Most did not share the lived experience
of growing up in rural Punjab with the majority of the South Asian seniors registered in the
S
4
AC programs, although one of the frontline workers had past experiences of working with
seniors in the field of adult literacy in rural Punjab. Overall, however, the Punjabi-speaking
DIVERSEcity staff understood the needs and sociocultural realities of seniors migrating to
Canada from rural Punjab. None of the City of Surrey staff could speak Punjabi but they had
previous work experience and/or training that equipped them to work with seniors in Canada.
The personnel involved with the programs and their connections to one another and the two sites
is represented in Figure 2 by a composite of the ‘opportunity maps’ that we asked all of the staff
interviewees to render at the conclusion of their interviews. Blue lines represent connections to a
particular site, whereas red lines indicate connections between people. Several of the staff
indicated relationships with certain people and/or sites that were less well-established with dotted
lines.
Figure 2: 9 DIVERSEcity
staff (blue circles) and 9 City of Surrey staff
squares) at Newton (A) and Bear Creek
(B)
Ultimately, we see a core group of staff that comprises
diagram. The square is nonetheless somewhat deceptive for while the coordinator of the program
assumed some managerial responsibility over the staff member assigned to Bear Creek, in
reality, she did not usuall
y attend the Bear Creek site and did not have to be present in the same
intense way at the Newton site, where the seniors spoke more English, were more acculturated
and hence less dependent on her than those at Bear Creek. Similarly, her former manager who
one of the other blue dots in the square, was considerably more involved with the sites and
different personnel within DIVERSEcity and the City of Surrey than are either of her subsequent
successors. This is due in large part to the role she played in
two
corners of the square are the childcare worker (who does not appear to be working at the
Newton site any more) and the counselor who attends both sites for an hour a week.
The original DIVERSEcity
staff member assig
outreach responsible for recruitment of a large number of seniors, particularly women, into the
program. Although she was no longer working at the site, many of the senior participants
referred to her often and
with affection, hence we decided to interview her as well. She added to
her diagram an additional DIVERSE
This woman provided a program based on English language acquisition at the same site in Bear
C
reek Park to an overlapping group of seniors on the days that the S
13
staff (blue circles) and 9 City of Surrey staff
(green circles) connected to two S4AC sites
(B)
– composite of all 8 staff diagrams.
Ultimately, we see a core group of staff that comprises
the square of blue dots in the centre of the
diagram. The square is nonetheless somewhat deceptive for while the coordinator of the program
assumed some managerial responsibility over the staff member assigned to Bear Creek, in
y attend the Bear Creek site and did not have to be present in the same
intense way at the Newton site, where the seniors spoke more English, were more acculturated
and hence less dependent on her than those at Bear Creek. Similarly, her former manager who
one of the other blue dots in the square, was considerably more involved with the sites and
different personnel within DIVERSEcity and the City of Surrey than are either of her subsequent
successors. This is due in large part to the role she played in
the de
sign of the program. The other
corners of the square are the childcare worker (who does not appear to be working at the
Newton site any more) and the counselor who attends both sites for an hour a week.
staff member assig
ned to Bear Creek played a large role in the
outreach responsible for recruitment of a large number of seniors, particularly women, into the
program. Although she was no longer working at the site, many of the senior participants
with affection, hence we decided to interview her as well. She added to
her diagram an additional DIVERSE
city
staff member from the Settlement Services division.
This woman provided a program based on English language acquisition at the same site in Bear
reek Park to an overlapping group of seniors on the days that the S
4
AC program was not
(green circles) connected to two S4AC sites
(yellow
the square of blue dots in the centre of the
diagram. The square is nonetheless somewhat deceptive for while the coordinator of the program
assumed some managerial responsibility over the staff member assigned to Bear Creek, in
y attend the Bear Creek site and did not have to be present in the same
intense way at the Newton site, where the seniors spoke more English, were more acculturated
and hence less dependent on her than those at Bear Creek. Similarly, her former manager who
is
one of the other blue dots in the square, was considerably more involved with the sites and
different personnel within DIVERSEcity and the City of Surrey than are either of her subsequent
sign of the program. The other
corners of the square are the childcare worker (who does not appear to be working at the
Newton site any more) and the counselor who attends both sites for an hour a week.
ned to Bear Creek played a large role in the
outreach responsible for recruitment of a large number of seniors, particularly women, into the
program. Although she was no longer working at the site, many of the senior participants
with affection, hence we decided to interview her as well. She added to
staff member from the Settlement Services division.
This woman provided a program based on English language acquisition at the same site in Bear
AC program was not
14
offered. Both the Bear Creek S
4
AC program worker and the senior interviewees referred to the
complementarity of the two programs (although most seniors were not aware that they were
separate): “We also did some common workshops during my last days with this program; we
shared our clients for both programs. She arranged kitchen workshops and I would send my
clients to her. She worked honestly, she also did trips, local trips, but she did some” (Selena).
Selena’s replacement was a young Canada-born Punjabi woman who was not as well-received
by the Bear Creek participants. Her eagerness to leave immediately after the exercise classes and
her manner of speaking to the senior women, which they viewed as disrespectful, was both
witnessed in our participant observations and commented on by the women in the one-to-one
interviews. A subsequent replacement appears to communicate in a much more respectful and
friendly manner, and is on good terms with the aforementioned settlement services worker.
City of Surrey staff at the Bear Creek site included the chair exercise and yoga instructors or
“facilitators” and the seniors coordinator for Bear Creek Park. At the Newton Seniors Centre site,
one chair exercise facilitator, a program coordinator and a seniors coordinator were identified.
The Aquacize facilitator was not included in the diagram by any of the staff, but the program
coordinator at Newton Seniors’ Centre indicated in her interview that she used to teach these
classes.
In the top level of the diagram, the largest blue circle in the centre of a cluster of three is
DIVERSEcity’s Family Services Director who is ultimately responsible for the S
4
AC program
within the agency. He is connected to some degree with most of the DIVERSEcity and City of
Surrey staff in the diagram, with the exception of the exercise facilitators. Adjacent to him in the
diagram is a Family Services manager who reports to him and served as an ‘arms-length’ agency
liaison to our research team, and the Executive Director of DIVERSEcity to whom the director
reports. The triangular cluster of green circles at this level represents the City of Surrey manager
responsible for seniors and this program as well as another manager and coordinator with whom
he confers on matters to do with the program.
Benefits perceived by staff and senior
Benefits perceived by staff and senior Benefits perceived by staff and senior
Benefits perceived by staff and senior participants
participantsparticipants
participants
Exercise skills and fitness:
Exercise skills and fitness:Exercise skills and fitness:
Exercise skills and fitness:
The main skills that participants gained from the current program are the exercise moves taught
in the chair exercise and yoga classes at Bear Creek, or chair exercises and Aquacize at Newton.
In addition to attending the classes between one to three times a week, some of the participants
stated that they also practiced some of the exercises at home.
Overall, the participants expressed satisfaction with the quality of the program and especially
with the instructors. The skill and understanding of the instructors was especially important to
15
women venturing into the pool for Aquacize classes, often for the first time. All of the
interviewees reported that as a result of regularly attending the exercise program both their
physical and mental health conditions generally improved. Coming to an organized group
encouraged participants to do the exercise regularly and also gave them the opportunity to meet
with their friends and neighbours, which benefitted their mental health. Participants remarked on
how they now they typically ‘feel happy’ or ‘feel good’ and ‘relaxed.’ Physical benefits included
reduced hypertension and the medications needed to control it, improved digestion, flexibility
and strength, weight control, and balance.
To accommodate the different levels of fitness and readiness to try new things within the group,
Ashley, one of the instructors explained that she has tried from the inception of the project to
adapt the exercises to the comfort level and health conditions of the South Asian seniors. Focus
group participants confirmed that the instructors adapted the lessons to their individual needs.
The staff also commented on their observations and feedback from participants with respect to
their satisfaction and the physical and mental health gains they had reaped from exercising
regularly.
Enhancing
Enhancing Enhancing
Enhancing social network
social networksocial network
social networks:
s:s:
s:
Participation in a group exercise program also broke the isolation experienced by many
immigrant South Asian seniors and provided a supportive environment where they were not only
able to exercise, but also shared their experiences of and approaches to self-care with one
another. All of the interviewees said that they had a ‘good time’ coming to the program because
they met with their old friends and family members, and also made new friends. On the one
hand, the existing social networks of the participants were used by the service providers to reach
out to isolated immigrant seniors and to recruit new participants in the program. Some of the
interviewees, as well as all of the women interviewed in the Bear Creek focus group, said they
brought somebody along, or were brought to the program by a friend or family member. On the
other hand, the program helped seniors to expand as well as improve the quality of their social
networks through building new social skills and a sense of connectedness.
Providing health
Providing health Providing health
Providing health information
informationinformation
information:
::
:
In addition to teaching exercise skills the program has also attempted to provide health-related
and other information to the participants. Nancy explained that staff recognized that many of the
participants in the exercise program were interested in learning about health issues such as
diabetes management and healthy eating and arranged workshops on such topics. Efforts were
made to invite a Punjabi-speaking expert on the topic but if that was not possible, DIVERSEcity
staff provided interpretation into Punjabi. The mental health counselor assigned to the program
also organized a workshop on depression. DIVERSEcity staff additionally provided oral and
written information in Punjabi on topics such as falls prevention and nutrition.
16
Most senior interviewees, however, said that they did not recall receiving much health
information. For instance, Mrs. Badyal said that the program staff mainly gave them “exercise
related scheduling information” and that “they don’t tell us much [information] because they are
also in a hurry and we also want to go home quickly after the exercise.” Some participants
recalled participating in some information sessions with invited speakers provided by
DIVERSEcity’s settlement services program. This program is offered at the Bear Creek location
on alternate days to the exercise program and many participants did not realize they were
separate. A few participants also said that they received written information such as fliers in
Punjabi that their family members would read to them (notably many of the women are not
literate, even in Punjabi). More participants related how they had received health information,
e.g., on the importance of breast cancer screening, from fellow female participants in the
program.
Participants in the Newton focus groups said that they received information regularly after the
exercise classes when the program first started up. A South Asian man said, “These programs are
organized by City of Surrey for fire safety, fraud, abuse but it was from City” (Newton focus
group – South Asian). Subsequently, they did not recall receiving any further information form
the S
4
AC program. A South Asian woman in the same focus group told us, “We go for exercise,
one hour and we come back, no information, no talking, nothing. Yah, have coffee or tea and go
home.”
Most participants expressed a strong desire to receive such information, but indicated that the
most suitable means of doing so would be through more informal and relational processes with
their fellow participants, such as field trips and tours to different places. Selena explained that
the staff had arranged a couple of field trips to the gurdwara (Sikh temple) and a South Asian
grocery store that brought the seniors at both program sites together. Many of them told us that
they were very keen to “go out to see the world,” as Mrs Badyal put it. Their own families are
too busy to take care of their social needs. These trips also provided opportunities to increase the
health and self-care awareness among the seniors. As Mrs. Paliwal suggested, “You get some
information and knowledge when they take you out, so they should.” The seniors’ thirst for more
hands-on information also reflects their aspirations to expand their horizons and to become more
efficient in navigating the systems and environments around them and to enjoy their lives with
their families and friends. The informational objectives of the program thus clearly need to be re-
visited and enhanced.
Enhancing self
Enhancing selfEnhancing self
Enhancing self-
--
-care:
care:care:
care:
Nancy told us that one of the main goals of the S
4
AC program was to teach the senior
participants the importance of self-care, a concept often ignored among South Asian elderly
women who usually put the care of their family members ahead of their own needs. Ashley, an
17
S
4
AC exercise instructor, similarly commented that she had emphasized the importance of self-
care in her classes. She felt she had achieved some degree of success and had noticed that the
seniors had further generalized these lessons from exercise to other self-care domains such as
washing hands after the exercise and before eating snacks. Other program staff sought to
empower the seniors by increasing their confidence and independence. One strategy was to make
them aware of “their rights, access to services, [making them] familiar with the services and
teaching them how to use bus service” (George). Self-care of mental health and emotional well-
being was also promoted by Karen, the mental health counsellor from DIVERSEcity, who
attended each site for one hour a week. When Karen conducted a mental health screening of
program participants, she diagnosed four women as highly depressed and referred them to their
family physician. Laurel also noted that having some chronic conditions may hinder the active
engagement of seniors with their community and even with health promotion activities. This
disengagement has further negative implications for their mental wellbeing. She felt that the
improved ability of senior participants to engage in and recognize the importance of self-care,
based on their participation in the S
4
AC program, has helped them to engage more actively and
meaningfully with their family and community. For example, although most senior participants
at the Bear Creek Park site said that they have never taken an Aquacize class, many of them are
now keen to go and try it, and suggested that S
4
AC program staff should arrange to take them to
the pool.
Prior to participating in the S
4
AC programs, the senior participants ‘self-managed’ their chronic
conditions to some extent by eating healthy foods, taking regular medications and going to see
the doctor when they had any health problems. But after attending the program they said that
they felt more fit, independent and confident that they could take care of themselves.
Significantly, the value of ‘self-care’ and ‘independence’ was re-framed by many of the seniors
as a benefit not only to themselves but to their families. When the seniors were able to do their
own chores at home and to help other family members they felt they became ‘independent’ and
‘self-sufficient.’ In other words, they were less of a burden and more of a help to their family
members when they took the time to exercise (self-care) and become stronger. This newfound
confidence has further enabled some senior participants to overcome the fear of being the targets
of racism or simply of interacting with non-South Asians that formerly inhibited their ability to
move around freely in their communities.
The quality of program components: staff and particip
The quality of program components: staff and participThe quality of program components: staff and particip
The quality of program components: staff and participant perspectives
ant perspectivesant perspectives
ant perspectives
Program demand
Program demandProgram demand
Program demand
and expansion
and expansionand expansion
and expansion
According to Nancy, the biggest problem with the S
4
AC Project is that it is limited to two sites –
Bear Creek and Newton. She maintains that she could easily fill classes in other locations in
Surrey. In our participant feedback session, the strongest message to emerge from the senior
18
participants was that they wanted to see an expansion of the program. They asked for a
continuation of the program throughout the summer break in July and August. They also
underscored their desire, expressed strongly in the interviews, for more field trips and social
gatherings.
South Asian seniors in the Newton focus group felt that the Bear Creek seniors fared a little
better with respect to exercise programming because they had three days on which activities
were scheduled, whereas at Newton there are only two. They would like activities on more days
as well as more activities: “There should be more things other than chair exercise like may be
bowling or something” (Newton focus group – South Asian). They also pointed out that while
they used to have access to the gym when they attended their Aquacize class at Newton Wave
Pool, this privilege has since been withheld from S
4
AC program participants. The men in
particular are keen to have it reinstated.
Opportunities for connection
Opportunities for connectionOpportunities for connection
Opportunities for connection
According to Hawe,
36, p.267
a health promotion intervention such as the S
4
AC Project, can be
viewed “…as a critical event in the history of a system, leading to the evolution of new structures
of interaction and new shared meanings. Interventions impact on person-time-place interaction,
changing relationships, displacing existing activities and redistributing and transforming
resources.” This insight is relevant to this project in two respects: (1) the partnership between
DIVERSEcity and the City of Surrey has the potential to increase the capacity of both
organizations to provide more effective recreational services to underserved ethnocultural
minority older adults; and (2) one of the objectives of the project was to introduce immigrant
seniors to facilities such as the Newton Seniors Centre and Wavepool and other recreation
centres with the goal of integrating them into a range of existing services available to seniors in
the City of Surrey.
Linkages between partner agencies
Linkages between partner agenciesLinkages between partner agencies
Linkages between partner agencies
Some of the staff emphasized the ways in which linkages between the partner agencies involved
with the S
4
AC program increased their potential access to resources and opportunities for
adaptation and growth.
36
For example, Nancy told us that the City has invited support workers
from DIVERSEcity to participate in Open Houses at their facilities and bring seniors along to
‘healthy eating’ and other City-sponsored events. The S
4
AC program has also facilitated regular
interactions between the DIVERSEcity program coordinator and City of Surrey seniors’ program
coordinators and managers. These exchanges lay the groundwork for the development of new
initiatives between the partnering organizations and encourage the involvement of DIVERSEcity
in various projects and events organized by the City. Karen also noted that through Nancy’s and
her manager’s connections with the City, she has come to know about training opportunities, and
has learned more about the programs that they offer. George is equally enthusiastic about the
19
positive potential of DIVERSEcity’s ongoing partnership with the City of Surrey: “[W]e are
working in a partnership and now we are trying to do other projects with them for all
communities. Now whenever I write a proposal, I show them as partners and that’s a huge…and
they are willing to partner too.” George further attested to instances whereby the City had
provided resources, such as cash and space, to support initiatives in which they are jointly
involved, such as the Seniors Planning Table, indicating the extension of the positive influence
of their partnership beyond the two organizations.
There are nonetheless differences in the vision as to how the partner organizations work together
that reveal the limitations of their mutual understanding. Susan explained that while the City
understood that they would have to make adaptations to accommodate ethnocultural minorities,
they ultimately needed “to find out how do we equip people within a community to know that we
are there and to be able to be participating in any program.” From her perspective, the program
was intended to be a bridge to integrate South Asian seniors into existing programs. She
perceives that George, on the other hand, envisioned a much more comprehensive make-over of
the system to make it amenable to South Asians, and other immigrants.
Linking seniors to other programs
Linking seniors to other programsLinking seniors to other programs
Linking seniors to other programs
Nancy told us that one of the major objectives of this program was “not only [to] encourage [the
seniors] to come to these two or three day exercise classes but also to connect them with other
programs at the centers as well, like walking club.” For example, they tried to connect South
Asian participants to other programs at the Newton Seniors Centre by enrolling them as
members. Nancy reported that many of the participants were attending other programs and
events at the Newton center (such as healthy eating/ healthy breakfast program and the computer
club) and that they were “not dependent on [the] support worker anymore” (Nancy). S
4
AC staff
also raised the program participants’ awareness of and encouraged their participation in special
events such as International Women’s Day. To this Selena added, “They started using the
facilities like pool and gym, going to Senior’s Forum, they started going to beach so they
[liked it].”
Yet the seniors themselves tell a different story. Newton focus group participants, both South
Asian and non South Asian, are more educated and independent and hence more aware of and
connected with health promoting activities and community opportunities than those at Bear
Creek. Some of these participants felt that while their health has benefitted from participation in
the S
4
AC program, it has done little to connect them with other programs or expose them to new
activities or settings. However, like the South Asian interviewees and focus group participants at
the Bear Creek site, all of South Asian focus group participants at Newton said that they would
like to have more opportunities to engage in social events, cooking classes, bowling or crafts.
They would also like to be invited to join the programs arranged at Bear Creek, such as yoga.
20
Efforts to introduce the seniors at the Bear Creek site to other resources offered by the City of
Surrey have been limited to date. Referring to the field trip to Chuck Bailey Recreation Centre,
Ashley said, “[We] tried to get them to North Surrey because we just, [my supervisor] and I
talked about it and we tried to do that but, like, 5 or 6 people came - no it didn’t [work]. Because
we were trying to get them to be self-sufficient, be more independent, try to use other facilities.”
The most successful collaboration across different programs that further expanded the
opportunities for the seniors to engage with different settings was that established between
Selena, the DIVERSEcity staff member responsible for the S
4
AC at Bear Creek, and a Settlement
Services worker from DIVERSEcity who provided programs focused on English Language
acquisition and other skills for South Asian seniors at the same site on different days of the
week: “If they would do cultural show like in Fleetwood Seniors centre, they invited us. Then
they arrange some lunch and entertainment program at Sunrise, so they invited us and we
participated in that. Even they charged little money for the lunch but so many people wanted to
go which was unbelievable” (Selena).
Facilitating access and retention
Facilitating access and retentionFacilitating access and retention
Facilitating access and retention
Narrow understandings of ‘access’ have led those offering health promotion interventions to
devise limited solutions to the barriers that marginalized people experience. Acknowledgement
of the role of culture is important, but in the absence of any consideration of broader social
processes and more systemic barriers to access, such assessments can inadvertently shift the onus
of responsibility entirely onto the shoulders of the person in need of support.
38
It is evident from
our findings, our previous stakeholder forum,
39
and the literature that barriers to accessing health
promotion interventions and supports are to be found at each of the micro, meso and macro
levels: individuals, families, health care providers, organizations, and society all play a role. This
finding is captured by the candidacy framework for understanding access to health and social
services for marginalized populations.
7,40,41,41
The complex notion of access can be broken down into seven dimensions (Figure 3): the first six
can be viewed as transition points at which a person’s candidacy for care must be negotiated, and
the seventh captures the broader environmental context relative to which the negotiations take
place. In a nutshell, the dimensions of candidacy capture the negotiations that take place within
oneself, with one’s family and other supports, and with health care providers to access
appropriate health and social services, including—we argue—health promotion interventions and
supports. Individuals and/or members of their support networks must first recognize the need for
care or support, find their way to it, present a credible claim for the care or support needed and
have that claim recognized and affirmed by the person in a position to provide or permit access
to the care or supports needed. The person in need of care/support is then in a position to accept
or refuse the offer. Their decision will be influenced by the confluence of their identity, social
circumstances (akin to the determinants of health) and the suitability of the offer (its proximity,
21
cultural congruence, etc.). Each of the negotiations inherent in these five dimensions are
additionally influenced by organizational structures and policies, and local operating conditions –
both of which are also recognized as dimensions of candidacy.
Self-/family
identification of
need
Navigation:
identifying services
and getting there
Patient’s
presentation of
their claim for care
Provider’s
assessment of that
claim (referral,
treatment?)
Patient’s
acceptance
/rejection of
treatment offer
Ease of access to
services (flexibiity,
location, time…)
Local conditions
affecting access
(policies,
reputation…)
Figure 3: Seven dimensions of candidacy for access to health and social services
40
Self
SelfSelf
Self-
--
-/family
/family/family
/family-
--
-identification of
identification of identification of
identification of the
the the
the need to
need to need to
need to engage in
engage in engage in
engage in self
selfself
self-
--
-care
carecare
care
The first step in gaining access to health promotion interventions, such as the S
4
AC programs, is
determining that you need to engage in self-care and deserve to be supported in your efforts to do
so. This ability is profoundly influenced by the interdependent nature of the family unit in which
family members prioritize the mutual exchange of support which in turn confers resepct. These
culturally influenced beliefs combine with the increased dependency on family members that the
migration experience and sponsorship regulations engender.
9,12
Women in particular, but
especially those from less educated, more religiously conservative, rural backgrounds, are most
likely to put the needs of the family before their own. Whereas some families will encourage
older parents and grandparents to take advantage of opportunities for self-care, such as that
provided by the S
4
AC program, others will discourage such engagement for fear that it will limit
the senior’s availability to perform household and childcare duties.
8,9
The provision of childcare
is thus essential to ensure the participation of many older South Asian grandparents in the S
4
AC
program. During the temporary withdrawal of this service at the Bear Creek site, our
interviewees told us that many of their friends were now unable to attend, as did those in the
Bear Creek focus group who no longer participated in the program.
22
Many of the senior participants at the Bear Creek site had been brought to the program by other
members of their extended families (e.g. a daughter’s mother-in-law). Contrary to the non South
Asian sample—members of which typically came to the Seniors’ Centre and the S
4
AC program
independently (with an average of 0.7 friends)—both groups of South Asians interviewed in
focus groups said that they came to the program with people who were already part of their
social networks (i.e. an average of 4.6 and 8.7 friends). This brings to light the important
influence of South Asian social networks, particularly their families, on the identification of a
need, and a right, to engage in self-care. George explained that they told the seniors’ adult
children that the program would help their parents “… to be healthy and happy and still look
after their grandchildren and that’s why we are providing child-minding services.”
Navigation
NavigationNavigation
Navigation
Once the decision to seek care is made, people must invest a great deal of effort and resources to
find their way to and through the health and social-care systems. The ability to do so depends, to
a great extent, on their access to informal supports, such as family members who most often
provide transportation, translation and interpretation services. Face-to-face outreach was
especially important to the success of recruitment into the S
4
AC program, particularly for the
Bear Creek participants. While posters in community spaces and newspaper or web-based
advertisements may attract English-speaking immigrant older adults who have worked and aged
in Canada, this form of information dissemination will not reach more barriered older
immigrants such as the female participants at the S
4
AC Bear Creek site.
Limited in their knowledge of even their immediate surroundings, many of these women are not
literate in Punjabi and speak no English. They have no access to information other than that
gained from family members and friends. Nor do they have the confidence to venture out on
their own into unfamiliar territory where they are afraid they may be the targets of racism. South
Asian immigrant seniors, particularly widows, are often isolated because their adult children who
work are usually too busy, and the seniors, especially women, do not have anywhere to go. A
lack of English speaking skills and transportation facilities along with their childcare and
household responsibilities also contribute to their isolation and impede their participation in
health promoting programs.
In recognition of the multiple factors that conspire to make women more susceptible to isolation,
S
4
AC staff Program staff decided to put additional energy into recruiting them into the program.
The DIVERSEcity staff responsible for outreach and recruitment organized “a lot of information
sessions with them through outreach and our [S
4
AC] workers” in order to address “the barrier of
fear and [the fact] that they are not familiar with the resources, with the seniors’ center”
(George). Such outreach work required a Punjabi speaking staff, Selena, to connect and bond in a
culturally appropriate manner with the seniors in the gurdwara and at the school grounds where
23
grandparents drop off their grandchildren. She would register them on the spot and/or offer free
try-out sessions to reduce the risk involved. The program was also promoted on Punjabi radio
talk shows that reach women in their homes. Radio is accessible even for people who are neither
literate nor connected with other organizations where materials are typically circulated.
Now that the programs are established, recruitment occurs more organically at Bear Creek as
participants inform others and the situation of the exercise site in a park frequented by Punjabi
older adults encourages walk-ins. Registration of South Asian seniors at the Newton site, which
is embedded in an existing seniors centre has nonetheless fallen dramatically since the original
recruitment drive. Those who have remained are the longer-term immigrants of urban origins
who speak at least some English. Outreach to others like them who are more likely to feel
confident enough to integrate in this way could use different less intensive strategies that take
advantage of their higher literacy levels.
Most of the women in the Bear Creek group had little or no experience taking the bus, and
certainly would not do so on their own. Offering the program in a location within walking
distance of their homes was extremely important to most. Others commented that they were
reliant on the goodwill of their family members to transport them to the classes, which limits the
frequency with which they can attend. From our participant observations and focus groups we
noted that a very small proportion (1 or 2 out of a class of around 40) arrived in their own cars at
the Bear Creek site. By contrast, all of the South Asian Newton participants drove themselves to
the classes, as did the former participants in this group when they attended our focus group.
Bear Creek participants told us that they could not go to the Newton pool for Aquacize because it
was too far away and they did not have the transportation facilities. We discovered at the
feedback session that Aquacize classes are available to Bear Creek participants at the North
Surrey pool, but the timing overlaps with their chair exercise sessions and the pool is a 20 minute
bus ride from the entrance to Bear Creek Park, making it impossible for them to attend. Notably,
the exercise site is another 650 metre walk inside the park from the bus stop. The seniors were
hopeful that the timing could be changed to permit them to participate in Aquacize classes at
North Surrey without giving up their chair exercise or yoga lessons.
Although participants in our non South Asian seniors’ focus group knew how to take a bus or
drive, they still identified transportation as the biggest barrier to their participation in the S
4
AC
and other programs. Providing seniors with bus tickets will not address the problem for those
challenged by limited mobility, strength, English language skills, or a combination thereof. Many
seniors suggested that arrangements for a bus dedicated to the program would be ideal.
24
Establishing the r
Establishing the rEstablishing the r
Establishing the right to participate in the program
ight to participate in the programight to participate in the program
ight to participate in the program
For both immigrants and older people in general, the process of presenting well in order to
demonstrate the authenticity and legitimacy of a claim to support is complex. Language and
cultural incongruence between the service recipient and provider clearly limits the ability of the
recipient to make a credible claim. Given the efforts made by the S
4
AC staff to ensure that the
program is as accessible as possible, potential participants had to expend minimal effort to secure
a place in the program. DIVERSEcity staff who were fluent in Punjabi helped them to register,
explained what they were doing and how it benefitted them, and worked with the fitness
instructors to ensure that exercises could be tailored to specific participants. Focused on ensuring
equitable access, program ‘gatekeepers’ went out of their way to recruit older women who they
recognized as experiencing the most barriers to access of programs of this nature. The onus of
responsibility for presenting a credible claim for support was thus removed from those least able
to speak for themselves.
Acceptance/rejection of offer of support
Acceptance/rejection of offer of supportAcceptance/rejection of offer of support
Acceptance/rejection of offer of support
Offers of support may be rejected by those in need for many reasons. These include differences
in the perception of the utility of the program between service provider and recipient, cultural
taboos or stigma, the fact that the supports recommended are not feasible, due—for example—to
competing demands on time, such as the need to provide care for a grandchild or spouse, among
others. To address the language and cultural barriers faced by the seniors in accessing programs
and services, the S
4
AC project offered ethno-linguistic congruence of service delivery with the
clientele. This was accomplished by employing Punjabi speaking staff who interpreted what the
fitness instructors were saying and modeled what they were doing. This support proved to be
much more important at Bear Creek than at the Newton sites.
Additional accomodations to create a culturally supportive environment included allowing
women to wear outfits of their choice for exercise and swimming. Most of the women at the Bear
Creek site do in fact wear traditional outfits (shalwar-kamiz) during exercise, and some at the
Newton site have worn either shalwar kamiz, or at least tights and T-shirts when participating in
Aquacize. However, some staff observed that participation in the S
4
AC program, which provided
a comfortable and safe environment, has helped some South Asian participants gradually adapt
and integrate with the mainstream culture in this regard. Some have therefore adapted to wearing
track suits and runners during exercise and a few have even worn swim-suits to the Aquacize
classes.
The S
4
AC program staff also said that they provided chai (South Asian-style tea) and South
Asian snacks after the exercise classes. This was easier to accomplish at the Bear Creek site,
which includes a kitchen, than at the Newton site, where efforts by DIVERSEcity staff to have
Indian food added to the menu of the staffed kitchen were ultimately unsuccessful. During our
25
participant observations, however, snacks at both sites included fresh fruit and granola or fruit
bars, the latter of which the seniors did not approve.
The cost of a program can also result in rejection of an offer by seniors with limited means. To
reduce this likelihood, the S
4
AC partners agreed that the program should be offered at a low cost
in order to encourage the South Asian seniors’ participation. At the Newton site, participants are
required to purchase an annual membership to the Seniors’ Centre costing $21, for which they
are issued a membership card. This provides them with access to the S
4
AC program that includes
chair exercise once a week and Aquacize at the adjacent Wave Pool once a week. The only
additional cost for these classes is 25 cents per visit. At the Bear Creek site, which is not
integrated into an existing facility, participants pay an annual fee of $20.50 and are not required
to pay anything further for the classes.
Program staff have also tried to connect seniors to the City of Surrey’s Leisure Access Program
which offers annual Leisure Access Passes at a subsidized cost of $12.00 for those with low
incomes. The pass provides free access to all of the City of Surrey’s drop-in recreation classes.
However, “what we found out was that our seniors could not access it because their income was
considered a joint family income so we worked with the City to change their system to allow
seniors to come as individuals so that they got access to leisure access program and then they can
access so many services for free all the time” (Laurel). Even so, South Asian Newton focus
group participants reported that they cannot afford the passes because their income is slightly
higher than the maximum allowable to qualify for the Leisure Access Program. The low cost of
the S
4
AC program is thus important in facilitating access to these seniors whose income barely
exceeds the low-income threshold to qualify for the subsidized Leisure Access Pass.
The most dramatic rejection of the services offered can be witnessed at the Newton site. While
the S
4
AC staff were initially successful in attracting large numbers of South Asians to the
programs (around 70, according to Laurel and Nancy), this number has dropped off to 6-8
individuals, 3-4 couples. As discussed in the following section, the integration challenge that the
Newton Seniors Centre represents is not an offer that more barriered South Asian seniors are
willing or able to accept.
Systemic issues
Systemic issuesSystemic issues
Systemic issues
suitable options
suitable optionssuitable options
suitable options
In considering the ways in which organizations impede or facilitate access to care or support,
Dixon-Woods et al.
40
use the metaphor of a membrane – a more porous or permeable membrane
is akin to a more accessible care or support. Services that have low “permeability” (e.g., require
referrals, have limited access hours, have low cultural congruence with users) require the
mobilisation of many resources (such as language skills, transportation, health literacy,
knowledge of the system, time, etc.) of which older immigrants are typically in short supply.
Conversely, those with more resources, such as English language skills, familiarity with
26
Canadian systems, previous interactions with ‘white’ Canadians, transportation of their own, or
the skills to use public transit, and possibly living spouses to accompany them, are able to make
use of services offered in less permeable organizations, such as the Newton Seniors Centre and
Wave Pool. These sites were previously not utilized by South Asians. An important goal of the
initial program was to integrate this population into the existing service structure. The 3-4 South
Asian couples who continue to attend the Newton programs possess sufficient resources to
negotiate the barriers they have encountered. These include an unfamiliarity with exercise (but
most especially swimming), racist attitudes held by some, but certainly not all, members of the
seniors’ centre, and an unwillingness on the part of the board of directors who control the centre
to accommodate a request by some of the South Asian men for space in which to play a card
game that they enjoy.
The stand-alone facility in Bear Creek Park does not require such resources and is therefore
much more permeable for seniors who have less experience with Canadian society and the
English language than the Newton participants. Non South Asians are free to join the group, but
they do so as the minority in relation to the South Asian majority who attend these classes. These
ethnospecific classes also engender more social connections among participants who then share
information, enjoy the time they spend together, and provide mutual support.
Local conditions affecting access
Local conditions affecting accessLocal conditions affecting access
Local conditions affecting access
Local conditions that influence the production of candidacy range from geographic proximity to
services to provincial policies, the effects of which can be profound. Participants in our
stakeholder forum that gave rise to this research project strongly emphasized the importance of
working closely with local and ethnocultural communities (including immigrant societies) and
building community capacity in order to increase community awareness and develop affordable,
effective and sustainable supports.
39
The S
4
AC program, supported financially by the UWLM and logistically through the partnership
between the City of Surrey and DIVERSEcity, is an important means of linking marginalized
South Asian seniors to the City’s services. Our research has clearly shown that linkages of this
nature, which are not currently in place in other municipalities, are essential to promote access to
the most marginalized immigrant seniors not only to exercise but to other components such as
social support and the confidence to engage in self-care. The potential of the S
4
AC program to
link seniors to services and information has not yet been fully realized, in large part because the
program was not designed with this aim in mind. As it matures, the feedback from the seniors
collected for this research project can be fruitfully incorporated into programming so as to
enhance the experiential learning and linkage opportunities that they desire. Health authorities
and others in the public health domain can leverage this eagerness to learn and the access that
such programs provide to hard-to-reach populations to disseminate information about health and
27
wellness. The mode of delivery and content should nonetheless be mindful of the conceptions of
self, multiple barriers to access and the expressed desire for experiential learning conveyed by
our South Asian interviewees.
Recommendations
RecommendationsRecommendations
Recommendations
Our research confirmed that the S
4
AC program has successfully delivered exercise classes and
enhanced the skill set of older adults attending the program. Knowledge and skills that have been
introduced or enhanced include exercise techniques, social participation, an understanding of the
importance of ‘self’ care (that is nonetheless reframed in terms of the interdependent ‘self’
within the family) and information from fellow participants and staff about other programs and
treatments. Participants are primarily Punjabi-speaking older immigrants from India, who should
be viewed as two sub-groups with distinct capacities and needs: (1) people who immigrated
earlier in life and have aged in Canada and/or arrived in Canada with strong English language
skills and urban experience (as typified by the South Asian Newton participants) and (2) late-in-
life immigrants who are typically sponsored by their children, have little or no English language
skills and have spent most of their lives in rural settings. A third group of participants is non
South Asian and most of these attend the Newton Seniors Centre, but not the Wave Pool. The
majority are single (widowed) older women whose participation in the S
4
AC classes is
supplemented by additional activities offered by the Senior’s Centre. The capacities and needs of
each of these three groups are distinct and require separate consideration when planning outreach
and programming.
Evaluation of the S
4
AC program brings to light promising practices that may be transferable to
other programs or populations, as well as areas where there may be room for improvement.
1. Health and social service information: Participants are eager to learn more about
health-related topics that complement the focus of the program on exercise skills.
Translated materials are not always effective because many of the seniors,
particularly women, are not literate in their own language. The seniors emphasize the
value of experiential learning gained from fieldtrips and social events, and are keen to
engage in more such opportunities. These events also increase their opportunities to
learn from one another and benefit their mental health by enhancing their social
connectedness. Written materials are effective for the South Asian and non South
Asian groups who attend the Newton classes.
2. Location of classes. Having classes within walking distance of their homes is
important to reduce the isolation of more barriered seniors who do not drive, speak
little English and rely on family members to overcome these hurdles. Additional
classes in locations that are densely populated with the targeted older immigrants will
maximize their uptake.
3. Transportation. There will always be seniors who do not live within walking
distance of any given site. Even among non South Asian seniors, transportation
28
challenges are the biggest barrier to their participation in such programs if they are
frail or mobility impaired. Lack of English language skills further impedes the
confidence and ability of South Asian seniors to use public transit or alternatives such
as HandyDart. Participants suggest that the program acquire a bus to assist people to
come to the program and for use on field trips.
4. Expanded Offerings. South Asian participants at both sites would like exercise
classes on more days of the week – five if possible. The introduction of additional
activities, such as bowling, into the S
4
AC program would be welcomed, particularly
by South Asian Newton participants. Those attending the Newton site would also like
to be invited to attend yoga classes at Bear Creek. Those at Bear Creek would like to
try Aquacize. Classes at the North Surrey pool would have to be rescheduled in order
for this to be possible; they currently conflict with the existing classes at Bear Creek.
All seniors would like classes to continue over the summer months. Seniors at the
Newton site have also expressed an interest in cooking and craft classes, whereas
some of the Bear Creek participants have attended such classes offered by
DIVERSEcity’s Settlement Services division out of the same location on alternate
days to the S
4
AC classes (which are run out of the Family Services division). More
formalized collaborations between these divisions would encourage optimization of
resources and ensure complementarity rather than competition between them.
5. City of Surrey regulations. South Asian participants at the Newton site would like to
have access to the gym at the Newton Wave Pool reinstated. They have also
complained that reducing the low-income threshold for the subsidized Leisure Access
Pass (LAP) in combination with a slight increase in their pensions has curtailed their
access to recreation centres beyond the S
4
AC program because they cannot afford the
full price. Graduated pricing of LAPs could be a better option.
6. Childcare responsibilities. Although grandparents from all cultures may provide
care for grandchildren to some extent, the majority of South Asian grandparents play
a significant role in the lives of their pre-school and school-aged grandchildren.
While that role may be less among grandparents who have lived in Canada for a
longer period of time, this is not necessarily the case. At the Newton site, most
participants were committed to picking their grandchildren up from school which
influenced their ability to socialize after exercise sessions. The timing of classes
targeted at cultural groups in which the grandparenting role is similarly prominent
must take these restrictions into account. The care of pre-school children entails a
much larger investment of grandparents’ time and energy, and it is perhaps this group
that is in greatest need of the self-care opportunity that these exercise programs
represent. Elimination of the child-care component of the Bear Creek classes proved
to be a considerable impediment to participation for many of the registrants, and its
reinstatement was greatly appreciated and well utilized.
7. Outreach. Efforts to recruit “South Asian” participants must take into account the
diversity among them. For the Newton participants, printed materials circulated in
Punjabi newspapers, gurdwaras (temples), or local businesses are probably sufficient.
However, the more isolated and barriered Bear Creek participants required a different
approach that entailed more face-to-face contact with people who could connect to
29
both their language and their cultural background (the two are not always
synonymous, particularly among young adults of Punjabi background who are born
and/or raised in Canada). Women in particular must be sought out in places that they
frequent, such as gurdwaras or schools where they drop off their grandchildren.
Radio talk shows can be used to reach isolated people in their homes. Reaching
people through their social networks is most effective. In particular, recruiters may
need to convince family members of the value of the program for their elders.
Framing the health gains of the senior in terms of their benefits to the family is a
strategy that seniors themselves have used to good effect. Focusing outreach on the
most marginalized populations, such as women, may be necessary in order to help
them surmount the multiple barriers to participation that they experience. Inclusion of
other South Asian groups with significant populations in Surrey (e.g. Pakistani
Muslims) would similarly require targeted outreach by linguistically and culturally
matched staff.
8. Integration. The goal of using the S
4
AC program to introduce participants to services
offered by the City of Surrey has not been entirely successful because it assumes that
unfamiliarity with the services is the only barrier to their utilization. We have seen in
the previous points that this is not the case, and that the ability to negotiate additional
barriers, such as racism encountered in ‘mainstream’ facilities, requires many
resources including confidence. The S
4
AC program at Bear Creek did not have the
same kind of integration agenda as the Newton site. Many of the participants at this
site had never been part of any program nor even dared to walk in the park, despite
having lived in the neighbourhood for more than ten years. What this program has
done is instill in them the confidence and understanding of their need for self-care
that now propels them to ask for more. Programs that ‘meet people where they’re at’
build the foundation out of which more ambitious health promotion initiatives can
grow. For this highly barriered subgroup, particularly the women, having staff
interpret what exercise instructors are saying and modeling what they are doing and
how to dress for exercise is important. It is less so for the South Asian participants at
Newton who, for the most part, are capable of navigating the speed bumps they
encounter. There are nonetheless experiences with which they are less familiar, such
as being in and dressing for a swimming pool, wherein some additional short-term
support is welcome.
In sum, the S
4
AC program offers many physical and mental health-related benefits to South
Asian and other older adults. While exercise is the focus of the program, it provides an
opportunity for older adults to get together and socialize which has a positive impact on their
mental health. Being physically stronger and having the courage to participate in a program that
speaks first to their own needs, while still benefitting the family, has also empowered many of
the participants, particularly the women. Targeted outreach and culturally responsive facilitation
of the program, as well as the dedicated input of the funder (UWLM) and delivery partners
(DIVERSEcity and City of Surrey) underlie the program’s successes to date. Opportunities still
exist, nonetheless, to improve and expand the program, as detailed in the recommendations
30
above. In closing, it is important to point out that there is no one-size-fits-all solution and that
programs must be delivered in consultation with specific target communities in order to best
meet their needs.
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Technical Report
Full-text available
This report is the result of a planning grant exercise which is detailed in the lay summary for the grant that supported it, below: Recent immigrant older adults and some visible minorities who have aged here—together known as ethnic minority older adults (EMOA)—both experience health inequities in Canada. These are primarily related to difficulties with the complex process of accessing suitable care. However, Canadian research on the topic is extremely fragmented and hard to find, and knowledge users (KUs) who design policy and programs do not have the evidence they need to help them to address access barriers experienced by EMOA. Effort is needed to consolidate existing evidence and design research that fills knowledge gaps with respect to access so as to generate a decision-making tool that can guide KUs in their decisions across different health and social care contexts. Our team of 13 multidisciplinary academics and multisectoral KUs is uniquely positioned to meet this challenge. First, however, it is essential that we convene to ensure that we share a common understanding of ‘access’ and the requirements of CIHR’s ‘Partnership for Health System Improvement’ (CIHR) competition that we will target to complete this work. With the proposed planning grant, students hired by each pair of academics and knowledge users in six sites from British Columbia to Newfoundland will review the EMOA literature on topics of interest to the KU on their team. Each will produce topical reports identifying the different dimensions of access that are evident in those studies. These will inform a presentation that the KUs will make about their interests and understanding of access at a 1.5 day face-to-face meeting of team members in Vancouver in June 2014. They will also be consolidated into a single report that will form the basis of discussion at the Vancouver meeting and a peer-reviewed publication. The meeting will provide an opportunity to consolidate our understanding of access and its relationship to our KUs interests and to identify our strategy for applying for funding in Fall 2014.
Technical Report
Full-text available
Older immigrants from South Asia experience higher morbidities of chronic conditions such as cardiovascular disease and diabetes mellitus. They also have lower physical activity rates and higher barriers to accessing knowledge about chronic conditions and the care they need to live well with these conditions. Current models for self-management education and interventions do not take these disadvantages into account. DIVERSEcity Community Services Society and the City of Surrey have collaborated since 2008 to deliver the Seniors Support Services for South Asian Community Project. The project has employed many creative strategies to address barriers to participation in health promoting activities and build community capacity. Our qualitative research study explored if and how the various components of this project have facilitated meaningful linkages between individual, family, community and healthcare systems so as to support the capacity of immigrant South Asian senior participants to live well with their chronic conditions. Findings suggest that the program addresses many of the components deemed central to existing SM interventions. More importantly, however, we identified elements of the program that arguably have a profound influence on the participants’ capacity to live well with chronic conditions that are typically not integral to the most widely promoted SM programs available. Only with the inclusion of these missing elements will SM interventions be accessible and meaningful to barriered populations such as the South Asian older adults in our study.
Article
Full-text available
Objective To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease. Design Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project). Setting International for the review, and England and Wales for the cohort analysis. Patients The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort. Main outcome measures Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort. Results South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation. Conclusions South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention. This is a CALIBER study with ClinicalTrials.gov Identifier: NCT01163513.
Conference Paper
Full-text available
Taking care of chronic disease: realizing approaches for Canada's aging ethnic population was a workshop held in Vancouver, British Columbia, Canada in February 2011. The purpose of this workshop was to begin to address an existing evidence gap on approaches to self management support that meet the needs of immigrant older adults with chronic conditions. This gap was identified by participants in a multi-stakeholder forum and subsequent community consultations with Mandarin- and Punjabi-speaking older adults organized by the Immigrant Older Adults: Care, Accessibility, Research and Empowerment (ICARE) team. In response, we conducted an environmental scan that resulted in an annotated bibliography. From this exercise we concluded that: (1) Literature on self-management supports for ethnocultural minority older adults is sparse and varied; (2) Evaluations of U.K. and Australian programs revealed that they predominately appeal to “white middle-class people with long-term conditions who already viewed themselves as effective self-managers”; (3) Viable alternative models of self-management supports for ethnocultural minority older adults are not reported in the literature; and (4) Individual self-management needs to be situated within a collective understanding of empowerment. Our workshop aimed to facilitate the exchange of ideas between a group of 32 diverse Canadian stakeholders (plus five student volunteers) such as immigrant older adults with chronic conditions and their friends and family members, policy makers, clinicians, multicultural settlement workers, and academics. Ultimately, we seek to develop evidence-based approaches to self-management supports that acknowledge the various challenges faced by this disadvantaged population and build on existing strengths within our communities.
Article
Full-text available
This paper uses an intersectionality theoretical lens to interrogate selected findings of a scoping review of published and grey literature on the health and health care access of ethnocultural minority older adults. Our focus was on Canada and countries with similar immigrant populations and health care systems. Approximately 3300 source documents were reviewed covering the period 1980-2010: 816 met the eligibility criteria; 183 were Canadian. Summarized findings were presented to groups of older adults and care providers for critical review and discussion. Here we discuss the extent to which the literature accounts for the complexity of categories such as culture and ethnicity, recognizes the compounding effects of multiple intersections of inequity that include social determinants of health as well as the specificities of immigration, and places the experience of those inequities within the context of systemic oppression. We found that Canada’s two largest immigrant groups— Chinese and South Asians—had the highest representation in Canadian literature but, even for these groups, many topics remain unexplored and the heterogeneity within them is inadequately captured. Some qualitative literature, particularly in the health promotion and cultural competency domains, essentializes culture at the expense of other determinants and barriers, whereas the quantitative literature suffers from oversimplification of variables and their effects often due to the absence of proportionally representative data that captures the complexity of experience in minority groups.
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