Health Status and Social Determinants of Health of Immigrant Seniors In Canada

1. Health Status and Social Determinants of Health of Immigrant Seniors In Canada Presented by Daniel Lai, PhD, RSW Professor & Associate Dean (Research & Partnerships) Faculty of Social Work, University of Calgary

2. Introduction • Statistics of immigrants 18.4% born outside of Canada (Ethnic Diversity Survey (EDS), Statistics Canada, 2003) • Aging immigrant population 65 -74: 29.8% immigrants; 10.3% visible minorities 74 and older: 29.8% immigrants; 7.5% visible minorities • Gaps of research on aging immigrant population subgroup The research community and the policy sector have indicated a growth in interest to examine issues related to the health of culturally diverse immigrant seniors and older adults. However, empirical research findings on this aging population subgroup are limited.

3. Research Questions • 1) How are immigrant seniors defined, and what are unique distinctions amongst this population? • 2) How does immigrant seniors’ health status compared to Canadian seniors? • 3) Are there chronic diseases/conditions more prevalent among immigrant seniors?

4. Research Questions • 4) What are the community and individual level determinants that influence the health status of immigrant seniors in Canada the most? Are these determinants the same ones that affect non-immigrant seniors in Canada the most? Are there specific protective factors associated with these groups? • 5) How are immigrant seniors dealing with health care, and other health or social services that they might need? What are the demographic, economic, social and health implications of aging immigrants in Canada? What are the main policy implications and recommendations?

5. Definitions • Foreign-born It is defined in the 2006 Census as persons who are, or who have been, landed immigrants in Canada. • Different ethnic origins Ethnic origin refers to the ethnic or cultural origin of a person’s ancestors, which should not be confused with citizenship or nationality (Statistics Canada, 2006). • Age criteria In some studies, seniors 65 years and older were included (Boyd, 1991; Chappell, 2003; Gee, 1999; Moore & Rosenberg, 2001). In some other studies, people who were 55 years and older were included (Chappell, 2005; Kaida, Moyser & Park, 2009; Lai, 2009; Lai & Surood, 2009; Streiner, Cairney & Veldhuizen, 2006).

6. Demographic and Social Profileof immigrant seniors • 2001 census data In 2001, about 29% of seniors between the age of 65 and 74 and 28% of those between the age of 75 and 84 were immigrants. • Distinctions • The immigrant population is older than the non-immigrant population • Fewer women than men among the immigrant seniors • Residence More of the immigrant seniors than Canadian-born seniors reside in large urban areas

7. Demographic and Social Profileof immigrant seniors • Ethnicity Recent immigrant seniors are more likely to be visible minorities. • Religion Recent immigrant seniors and long-term immigrant seniors are more likely (63% and 58%) to report religion as “very important” than Canadian-born seniors (55%). • Social characteristics Recent immigrant seniors are more likely to be in low income than long-term immigrant seniors.

8. Demographic and Social Profileof immigrant seniors • Educational attainment Immigrant seniors are less likely (22%) to have a post-secondary credential when compared with the Canadian-born seniors (24%). • Living arrangements Recent immigrant seniors are much less likely to live alone than long-term immigrants and Canadian-born immigrants. • Social networks and support Recent immigrant seniors are more likely (65%) to receive care exclusively from informal sources such as family or spouse, than Canadian-born and long-term immigrant seniors (44%).

9. Health Status of Immigrant Seniors • Two perspectives co-exist • Immigrants seniors, probably due to various forms of adjustment challenges and socio-cultural barriers, tend to be less healthy when compared with Canadian-born seniors (Lai, 2004c). • “Healthy immigrant effects,” -- recent immigrant seniors are usually healthier than Canadian-born seniors as well as the immigrant seniors that have been settled in Canada for longer (Gee, Kobayashi, & Prus, 2004).

10. General Health Status • General physical health • In the 2003 Canadian Community Health Survey, 28% of recent immigrant seniors rated their health as either excellent or very good, compared to 38% of Canadian-born seniors and 36% of long-term immigrant seniors. • Recent immigrant seniors who were 65 years and older reported having poorer overall health when compared to Canadian-born persons of the same age range (Gee, Kobayashi and Prus, 2004). • According to the data from 2,272 randomly selected older Chinese in seven Canadian cities (Lai, Tsang, Chappell, Lai, & Chau, 2003), the older Chinese reported a higher prevalence of some health conditions than those in the general population within the same age range.

11. General Health Status • General mental health • Older Chinese in Canada reported the worst mental health, when compared with the mental health of other older Chinese in Mainland China, Hong Kong, and Taiwan (Lai, 2009). • In one study examining the challenges that elderly women from India encounter, the participants reported experiencing isolation, loneliness, family conflict, economic dependence, a loss of control with settling in, a struggle to cope, and struggling for a sense of interdependence (Choudhry, 2001).

12. General Health Status • Life satisfaction & quality of life • Ujimoto (1987) indicated that aging Japanese Canadians who stressed discipline, perseverance, and self-reliance were satisfied or very satisfied with respect to their financial situation, family relations and health. However, less satisfaction in health was reported. • Women reported significantly lower levels of satisfaction than men. Those who were younger (under 65 years old) and those who lived alone also reported a lower level of life satisfaction than those who were older and lived with others (Lai, Tsang, Chappell, Lai, & Chau, 2003).

13. General Health Status • General oral health • A major study on the oral health of ethno-cultural minority seniors was conducted by Swoboda, Kiyak, Persson, Yamaguchi, MacEntee, and Wyatt (2006). The findings suggested that functional dentition and cavities influence older adults’ oral health-related quality of life, but that ethnicity and immigrant status play a larger role.

14. Health Conditions or Diseases • Depression • Depression is prevalent among older immigrants (Kuo, Chong & Joseph, 2008). • Lai (2000a, 2000b, 2000c; 2004a): Prevalence rates of 20.9% to 24.2% percent were reported for Chinese immigrant seniors, using a 15-item Chinese version of the Geriatric Depression Scale. • 21.4% of 220 randomly selected older South Asian immigrants of 55 years and over reported being mildly depressive (Lai & Surood, 2008b).

15. Health Conditions or Diseases • Elder abuse and neglect • Walsh and her colleagues (2007) explored the experiences of marginalized elders and found that victims of elder abuse often suffered in silence, and cultural factors, ageism and gender were ubiquitous to elder abuse. • Tam and Neysmith (2006) examined the relationship between cultural factors and elder abuse in Chinese communities and pointed out that disrespect was the key form of elder abuse in the Chinese community, and social exclusion and marginalization put a Chinese immigrant senior in vulnerable conditions of abuse.

16. Health Conditions or Diseases • Alzheimer’s Disease • Seniors speaking two or more languages may delay the onset or diagnosis of Alzheimer’s disease by almost 5 years (Chertkow, Whitehead, Phillips, Wolfson, Atherton and Bergman, 2010) . • There was a lack of knowledge about Alzheimer’s Disease among a sample of 125 Spanish-speaking adults 55 and older in the Greater Toronto Area (Fornazzari, Fischer, Hansen and Ringer, 2009) .

17. Health Conditions or Diseases • Diabetes • Health conditions such as high blood pressure, stomach problems, and eye problems were reported as having a higher prevalence among older Chinese than did in the general population within the same age range (Lai, Tsang, Chappell, Lai & Chau, 2003).

18. Health Conditions or Diseases • Substance use • Alcohol drinking Recent immigrants are less likely to be heavy drinkers than non-immigrants (Pérez, 2002). • Smoking Recent immigrant seniors are less likely to be daily smokers than non-immigrants. In 2003, the proportion of recent immigrant seniors who had never smoked in their life was twice that of the Canadian-born (63% versus 31%) (Turcotte & Schellenberg, 2007). • Gambling Lai (2006a) pointed out that being male, having lived in Canada for longer, having a higher level of social support, having more service barriers, and having a stronger level of Chinese ethnic identity would increase the probability for an older Chinese person to participate in gambling.

19. Health Conditions or Diseases • Diet and nutrition • Immigrants were more likely to meet the Canadian recommendations for carbohydrates and fat intake and less likely to have adequate intakes of protein, iron, and calcium, compared to non-immigrants (Pomerleau et al., 1998a; Pomerleau et al., 1998b). • Johnson and Garcia (2003) examined diet and physical activity among 54 older immigrants from Cambodian, Latin-American, Vietnamese and Polish. And found that 72.5% of them were at moderate to high risk of poor nutrition.

20. Social Determinants of Healthin General Canadian Seniors • 1) income and social status • 2) social support networks • 3) education and literacy • 4) employment/working conditions • 5) social environments • 6) physical environments • 7) personal health practices and coping skills • 8) healthy child development • 9) biology and genetic endowment • 10) health services • 11) gender • 12) culture

21. Social Determinants of Culturally Diverse immigrant Seniors • Age • Immigrant seniors who are older in age tend to be less healthy or more likely to be affected by a specific disease or chronic condition. Age has been identified as an important predictor of self-assessed health (Pennings, 1983).

22. Social Determinants of Culturally Diverse immigrant Seniors • Gender • Most of the studies examining determinants of health of immigrant seniors reported gender differences in the health and health behaviors. Women often report a less favorable health and well-being in most of research studies (Penning, 1983). • Women reported to be have poorer physical health, more chronic illnesses, and more limitations in Instrumental Activities of Daily Living than their male counterparts (Lai, Tsang, Chappell, Lai & Chau, 2007) .

23. Social Determinants of Culturally Diverse immigrant Seniors • Marital status • Marital status is identified as a significant factor of psychological well-being of elderly Chinese in Canada (Chow, 2010; Lai, 2005a). • Lai’s (2005a) study on older Taiwanese immigrants also indicated that being single was a predictive factor of someone reporting more depressive symptoms.

24. Social Determinants of Culturally Diverse immigrant Seniors • Education • A higher level of education was significant in predicting better mental health status of aging Chinese in Canada (Lai, Tsang, Chappell, Lai, & Chau, 2007). • Older Chinese who reported a higher level of education reported a lower level of limitation in Instrumental Activities of Daily Living (Chow, 2010).

25. Social Determinants of Culturally Diverse immigrant Seniors • Financial status • Poorer financial status (i.e., lower adequacy of finances, less satisfaction with economic status) was a significant predictor of depression among immigrant older seniors and older adults in Canada (Kuo & Guan, 2006; Lai, 2004a; 2004b; 2005a). • Financial status not only influences the health of immigrant immigrants but also their health behaviors (Oliffe, Grewal, Bottorff, Hislop, Phillips, Dhesi & Kang, 2009).

26. Social Determinants of Culturally Diverse immigrant Seniors • Living arrangement • Living alone was a significant predictor of less favorable mental health among older immigrants. Those who live alone more were more likely to experience social isolation, depression and poorer mental health (Lai, 2007a; 2009).

27. Social Determinants of Culturally Diverse immigrant Seniors • Language • Immigrants who are more proficient in English and more acculturated into the new host culture will suffer less from cultural and other adjustment related stressors, and therefore report lower levels of depression (Lai, 2004a). • The lack of proficiency in English language led to an increasing distance between immigrant seniors and their grandchildren, causing additional strain for the elderly immigrant (Choudhry, 2001).

28. Social Determinants of Culturally Diverse immigrant Seniors • Ethnicity and religion • Maintaining a stronger ethnic identity would result in Chinese immigrant seniors being able to have better access to one’s ethnic networks that could assist them with adjustments and challenges (Gee, 1999). • Religion was a powerful spiritual coping resource for elderly immigrant Indian women (Acharya & Northcott, 2007; Choudhry, 2001).

29. Social Determinants of Culturally Diverse immigrant Seniors • Values and beliefs • Cultural variables were significant in explaining variance in physical health, mental health, number of illnesses, and limitations in Instrumental Activities of Daily Living (Lai, Tsang, Chappell, Lai, & Chau, 2007). • Experience of elder abuse is also affected by cultural values. Walsh and her colleagues (2007) indicated that culture affects how elder abuse is revealed due to the cultural reluctance to openly address the issue.

30. Social Determinants of Culturally Diverse immigrant Seniors • Length of residence • Those who lived in Canada for a longer period of time reported a better psychological well-being (Chow, 2010). • Length of residence affects the use of Western health services. For aging South Asian immigrants, those who had lived in Canada for a longer period of time reported using more Western health services (Surood & Lai, 2010).

31. Social Determinants of Culturally Diverse immigrant Seniors • Social support • Social support was found to be a strong predictor of life satisfaction of Chinese elderly immigrants (Lai & McDonald, 1995; Gee, 2000). • Lower social support increased the risk for depressive symptoms of elderly Chinese (Lai,2004a). • Family conflicts among the elderly immigrants and their younger generation will increase the stress for the seniors. Particularly, conflict with daughter-in-law is the most frequent source of strain and stress for the elderly people (Choudhry, 2001).

32. Social Determinants of Culturally Diverse immigrant Seniors • Life transitions and coping strategies • Kuo and Guan (2006) measured how older Chinese Canadians would cope with a hypothetical scenario of depression. The study found that coping was significantly correlated with lower depression scores.

33. Social Determinants of Culturally Diverse immigrant Seniors • Service barriers • The perception of service barriers to health and social services was a significant predictor of depression in Chinese older adults in Canada (Kuo & Guan, 2006; Lai, 2004b, 2005a). • Older immigrants reporting more service barriers reported less healthy physical and mental health (Lai & Chau, 2007).

34. Social Determinants of Culturally Diverse immigrant Seniors • Physical environments • Age-induced musculoskeletal impairment and cold, wet Canadian climate were the main restrictors of male Punjabi Sikh seniors ’ physical activity (Oliffe, Grewal, Bottorff, Hislop, Phillips, Dhesi & Kang, 2009)

35. Protective Factors and Key Determinants • Innate personally characteristics • Personally acquired characteristics or resources • Circumstantial and structural advantages

36. Protective Factors and Key Determinants • For example: • In the study examining depressive symptoms of Chinese immigrant seniors (Lai, 2004a), financial adequacy remained the strongest predictor for being depressive. • Cultural values also turned out to be the most significant predictor of depression in the study on aging South Asian immigrants (Lai & Surood, 2008b).

37. Policy Implications • Strengthening mental health services • It is important for service providers and practitioners to pay attention not only to the physical health and wellbeing, but also to the mental health and specific psychological needs of immigrant seniors and older adults.

38. Policy Implications • Addressing financial needs • It is important for policy makers to reduce the financial gap between immigrant seniors and Canadian-born seniors.

39. Policy Implications • Living arrangement and independent living • Services such as long term and institutional care must be sensitive to the different attitudes towards the elderly and sense of place that exist among different culturally-defined segments of the elderly (Moore & Rosenberg, 2001).

40. Policy Implications • Housing and caring facilities • Researchers have reported that most immigrant seniors live with their families are satisfied with their existing residences in Canada (Gee, 2000; Mahmood, Chaudhury, Kobayashi & Valente, 2008). • Immigrant seniors living alone have been found to be less physically and mentally healthy (Lai, 2004a, 2007a, 2009, Johnson & Garcia, 2003). • Service providers should be more aware of the ethno-specific needs of immigrant older adults when planning and designing seniors’ housing and facilities (Ng, Northcott, & Laban, 2001).

41. Policy Implications • Service delivery in health settings • In view of the challenges and associated with access barriers to health services by many immigrant seniors who are culturally diverse, there is a need for strengthening support and resources for this population group (Lai & Chau, 2007b). • Service providers have to consider strategies for closing the cultural gaps that exist between immigrant seniors and service providers.

42. Policy Implications • Training of professionals • Training content and teaching materials of professional schools in various disciplines have to be inclusive to ensure that culturally competent and relevant training is delivered to the future professionals who work in the field that is becoming increasingly culturally diverse.

43. Policy Implications • Staff composition and recruitment • Health care and community service organizations in Canada have to consider developing staff recruitment and hiring strategies to reach out to different ethno-cultural and immigrant communities.

44. Policy Implications • Caregiving for immigrant seniors • Caregiving for a senior can be a burden for the family caregiver (Lai, 2007b; Leung & McDonald, 2001), particularly when the care recipients are frail and ill. This indicates the importance of developing and providing culturally appropriate policies and services to support culturally diverse immigrant caregivers (Lai, 2007b).

45. Recommendations • Strengthening mental health services • It is important for the health care system to establish and develop more culturally appropriate mental health services for diverse immigrant seniors .

46. Recommendations • Creating financial security • Considerations should be given at a policy level to address the financial needs of immigrant seniors. • Address policies related to postponed retirement so that employees and employers would be free to work out arrangements on normal, early, and postponed retirement (Grant & Grant, 2002), facilitating immigrant seniors to continue with earning employment while accumulating future retirement benefits. • It is important to consider the eligibility and sufficiency of income maintenance for immigrant seniors.

47. Recommendations • Supporting independent living • Efforts should not be focused only on providing caring facilities or housing options. Array of coordinated services to strengthen social support from within and outside of one’s community, to provide financial assistance, and to assist one to maintain functioning capacity should be developed. Traditional community home support programs and services should be prepared be more culturally sensitive and appropriate.

48. Recommendations • Development of appropriate housing facilities • Easy access to public transportation should be considered in housing development, particularly due to the fact that immigrant seniors are less likely to drive, particularly those who came in recent years. Voices of culturally diverse immigrant seniors should be incorporated into policy making process.

49. Recommendations • Support for immigrant family caregiving • In order to adequately serve immigrant seniors who are in need for more intensive care, the service delivery system has to be sensitive to the fact that it is the family caregivers who have to be supported as well. • Programs and support designed for immigrant family caregivers should take into consideration the fact that many immigrant family caregivers are faced with the double challenge of providing family caregiving and handling daily struggles related to underemployment, financial challenges, and cultural barriers.

50. Recommendations • Development of culturally competent service delivery system • Services should be provided in ways that align with the cultural and linguistic contexts of immigrant seniors. • Community education for immigrant seniors to build culturally competent services. • Strengthen staff capacity to work with culturally diverse immigrant seniors.