Considerations for older immigrants

Background

Ontario is a multicultural province with diverse health, policy, funding and service delivery needs. In 2016, immigrants represented 29.1% of Ontario’s population, the highest share the province has seen in almost a century^{footnote 1[1]}. The majority of immigrants to Ontario in the last three decades are non-European, with 43.7% coming from China or South Asia.^{footnote 2[2]}

A growing body of evidence suggests that ethno-racial and cultural differences need to be accounted for with regards to how older immigrants (i.e. people who immigrated to Canada as older adults [65+]), access and utilize health and community care and in turn, how this may affect health status. Factors such as low fluency in the official languages, low income, and living alone can be associated with health vulnerability^{footnote 3[3]}. Other issues may include a lack of cultural sensitivity by healthcare workers and different conceptualizations and understandings of illness.^{footnote 4[4]footnote 5[5]}

With this increasing diversity in the province, these population trends and issues contribute to a heightened awareness about the needs of the older immigrant populations in planning Ontario’s communities. To begin to address this, the Ontario Age-Friendly Communities Outreach Program conducted a comprehensive narrative literature review, and a multi-phase consultation process to better understand the factors that may impact older immigrants in Ontario, and the unique ways in which communities are engaging and supporting this population.

Factors that impact Older immigrants in Ontario

Based on the literature review and consultation process, the following factors were identified as having an important impact on older immigrant’s well-being within their community: language and transportation barriers; acculturation, changing family support structure, and social isolation; mental health; the issue of mistrust; celebrating cultural diversity; religious affiliations; and civic engagement.

Language and transportation barriers

Language proficiency is a major determinant of health among older immigrants as it relates to every aspect of daily living including reading the newspaper, participating in recreational activities, accessing the healthcare system,^{footnote 3[3]footnote 10[10]} and grocery shopping. Language barriers can also make it difficult for older immigrants to clearly articulate their symptoms, ask medical questions, and follow proper medication and treatment regimens.^{footnote 4[4]footnote 6[6]footnote 11[11]} This can impede older immigrants from seeking out adequate medical care.

Language barriers can also lead older immigrants to be reluctant to navigate the public transportation system or ask for directions.^{footnote 5[5]footnote 6[6]footnote 8[8]footnote 10[10]}The compounding effect of language and transportation barriers can restrict older immigrants’ independence, making them more hesitant to venture out on their own or participate in social activities.^{footnote 3[3]footnote 10[10]footnote 11[11]footnote 14[14]}

Acculturation, changing family support structure, and social isolation

Transitioning to a new country with different lifestyles, norms, and values makes the aging process particularly challenging and more stressful for older immigrants. The differences in values and beliefs around social networks, religious practices, and health and illness can contribute to social isolation.^{footnote 3[3]footnote 7[7]}-^{footnote 10[10]footnote 11[11]}-^{footnote 14[14]} Social isolation can also occur in the immediate home environment as younger generations adapt to Western values of individualism and independence that may not be shared by older members of the family.^{footnote 3[3]footnote 8[8]}-^{footnote 9[9]footnote 12[12]}

Mental health

The combination of these cultural, linguistic and transportation barriers along with the stresses of aging and migration may affect the mental well- being of older immigrants.^{footnote 5[5]} In many cultures, mental illness is heavily stigmatized.^{footnote 8[8]footnote 14[14]} This cultural stigma towards mental illness leads to a lack of understanding of issues faced by older immigrants, delayed access to appropriate supports or healthcare, and creates a vicious cycle of impaired mental well-being, often only addressed as a crisis.

This can lead to older immigrants not only hiding mental health concerns from their children, but also avoiding seeking help due to fear and shame.

The issue of mistrust

Older immigrants can be distrustful and skeptical of many services offered to promote their health and wellbeing, resulting in lower healthcare service utilization.^{footnote 10[10]footnote 12[12]} Certain cultural norms and traditions emphasize the central role of family networks for caretaking, so seeking external sources for healthcare can create a sense of shame.^{footnote 10[10]footnote 12[12]} Many community initiatives lack sufficient cultural competence, making it harder for older immigrants to receive adequate services for healthy aging.^{footnote 10[10]}

Celebrating cultural diversity

Opportunities to celebrate cultural norms and traditions have been widely appreciated by older immigrants and help them feel welcomed, valued, and accepted in their host country. Engaging in culturally meaningful activities is an effective way to cultivate intercultural contact, as it provides older immigrants with a safe environment to share their culture with people of other ethnic backgrounds.^{footnote 8[8]}

Religious affiliations

Places of worship and spiritual places of congregation are central sources of support, not just for fulfilling spiritual, religious, and social needs,^{footnote 3[3]footnote 5[5]footnote 6[6]footnote 8[8]footnote 9[9]footnote 12[12]footnote 13[13]} but also for providing a sense of community and belonging by offering a safe and comfortable environment.^{footnote 3[3]footnote 6[6]footnote 8[8]} Religious and spiritual places of worship also offer older immigrants ways to become involved, to gain a sense of purpose and to feel included and valued through official positions including deacons and committee chairs.^{footnote 8[8]footnote 9[9]footnote 12[12]footnote 13[13]} A place of worship helps with acculturation by providing resources such as business advice, financial advice, and political and legal services regarding citizenship and life in Canada.^{footnote 8[8]}

Civic engagement

Many older immigrants express a strong desire to contribute to the community through participation in civic activities like volunteering, applying their skills and experiences towards community projects, and engaging in political processes through voting and advocacy. The ability to actively influence and contribute to their communities re-instills a sense of worth and belonging.^{footnote 9[9]} One of the biggest facilitators of positive mental health and wellbeing is the ability to contribute one’s skills and influence in the community.^{footnote 8[8]}

Engaging older immigrants in AFC planning and implementation

Given these factors, the following framework and checklist linked to the stages of the AFC Planning Cycle is offered to provide guidance for meaningfully engaging older immigrants and planning initiatives that will best meet the needs of this population.

When embarking on AFC development, visit the Statistics Canada demographic profile for your community to understand the specific ethno-cultural composition of your area.

COVID-19 advisory:

In-person activity may not be appropriate in your community while COVID-19 remains active in Ontario. All planning, implementation and evaluation activities and actions must follow local public health advice to prevent and stop the spread of COVID-19.

Read the Remote Events Planning Resource for information and tips on hosting safe and accessible virtual meetings.

Define local principles and conduct needs assessment

Conduct background research and environmental scan

It is important to realize that within any given ethnic group, there is considerable cultural, geographic, linguistic and religious heterogeneity. For example, although immigrants who originate from India and Pakistan are grouped under the “South Asian” ethnicity profile, their cultural customs, religious beliefs and norms may vary significantly. Therefore, it is important to recognize these ethnic and cultural differences when defining a group in order to effectively conduct background research, tailor engagement processes, resources and services to each group.^{footnote 3[3]footnote 4[4]}

Integrate Community-Based Participatory Research (CBPR) principles

Community-based participatory research (CBPR) has been identified as an effective approach for conducting culturally sensitive research among minority populations.^{footnote 5[5]footnote 7[7]footnote 11[11]} CBPR has multi-directional benefits as it allows for the exploration of cultural values, practices, and beliefs specific to each community and may be effective for simultaneously building trust and rapport among participants. It is also in line with the values of many older immigrants who aspire to actively participate in community initiatives and not just be treated as research subjects.^{footnote 7[7]} Involve older immigrants in the research and planning process to demonstrate to them that the service providers sincerely care about their concerns and are not just there to meet personal agendas. This will give older immigrants a sense of control in their lives and helps restore the loss of social status experienced by many.^{footnote 11[11]}

Engage cultural community leaders and champions

Engaging cultural leaders and champions helps to bridge the gap between service providers and older immigrants. The position of cultural leader or champion can be volunteer or paid, and these individuals can be recruited from leaders of faith communities, educators, clan leaders, or healthcare providers, and should be respected members in their cultural communities.^{footnote 4[4]} Engage these cultural community leaders as they have thorough knowledge of the older immigrants’ cultural beliefs and values and can become a resource to facilitate communication and assist with cultural dilemmas and misunderstandings.^{footnote 4[4]footnote 10[10]}

Ensure representative stakeholder engagement

Successful outreach and service delivery to older immigrants requires the cooperation of a wide range of sectors including educational institutions, governments, religious institutions, healthcare facilities, and private businesses. Partner with organizations at various levels of the planning and implementation process to build organizational capacity by maximizing resources and facilitating the sharing of information and ideas.^{footnote 10[10]}

Religious and spiritual places of worship are often a central source of social support for older immigrants and provide an excellent network of trust. Places of worship such as mosques, temples and churches often have elderly religious leaders who are highly respected in the community.^{footnote 6[6]}

Approaching older immigrants through religious and spiritual places of worship can feel less threatening since these places are well trusted and provide them with refuge from daily struggles and hardships.^{footnote 6[6]footnote 8[8]footnote 9[9]footnote 12[12]footnote 13[13]}

Action plan

The approach to developing an AFC Action Plan is like that described in the Age-Friendly Community Planning Guide for Municipalities and Community Organizations. There is a special need to:

• anticipate and respond to common issues of:
  • language and transportation barriers
  • changing family roles and expectations
  • mistrust and gaps in awareness of programs and services
  • need for cultural tailoring of health promotion strategies and services
• consider the potential for improved accessibility throughout the Action Plan life cycle.

Implementation strategies

Provide cultural sensitivity training

Providing ongoing cultural sensitivity training to all service providers is the cornerstone of any intervention targeted towards diverse racial and ethno-cultural populations. Ongoing cultural sensitivity training is crucial for all service providers to communicate effectively with older immigrants and deliver effective care and services considering the lifestyle, values and belief systems of each distinct cultural group. Provide cultural sensitivity training that goes beyond educating service providers about the cultural characteristics of each culture. It should consist of self-awareness of service providers’ own personal cultural background, attitudes, and beliefs to help surface some of the biases, and cultural stereotypes that could to be projected towards immigrant groups.^{footnote 3[3]footnote 7[7]}

Develop language and transportation skills

Service providers should partner with immigrant organizations and translation agencies to provide effective translation services for each cultural group in the community and translate resources such as print, Internet, audio, and video to language(s) that older immigrants can read and comprehend.^{footnote 6[6]} It is crucial to not only increase effective translation services in the area, but to also effectively guide older immigrants on how to access these translation services.^{footnote 3[3]footnote 7[7]}

Formal travel training workshops have been recommended to help older immigrants understand the public transportation system, use maps and travel to common places in the community such as shopping malls, banks, libraries and hospitals.^{footnote 9[9]}

Culturally-tailor health services and support

To help reduce health disparities among older immigrants, partner with universities and the healthcare sector to provide cultural sensitivity training to healthcare providers, increase translation services and use cultural leaders. These strategies have been shown to be effective in enabling healthcare providers to deliver culturally and linguistically appropriate healthcare services.^{footnote 3[3]footnote 6[6]}

Offer educational workshops

In addition to specific language and transportation initiatives and workshops, further educational workshops, training sessions, and events should be offered to older immigrants to provide them with resources and information to help them settle in their host country. Some examples of workshop topics are: understanding the political and legal system, information on senior benefits, using the library, environmental safety, understanding the banking system and the healthcare system.^{footnote 7[7]}

Celebrate cultural traditions and diversity

Celebrate cultural events and holidays, such as Diwali for Hindu immigrants or the Chinese New Year for Chinese immigrants, as it is significantly appreciated by older immigrants.^{footnote 3[3]footnote 5[5]footnote 7[7]footnote 8[8]}

Create leadership opportunities

Create culturally appropriate volunteer opportunities to help older immigrants replenish the loss of social status and respect that many tend to experience. Integrate opportunities to mentor the younger generation and share experiences with them to help bridge the intercultural and generational gap that often exists between older immigrants and children/youth.^{footnote 13[13]}

Case example: Toronto Kensington-Chinatown Neighbourhood (KCN)

Steps 1 and 2: define local principles and needs assessment

In 2016-2017, the National Initiative for Care of the Elderly received an Age-Friendly Planning Grant from the Ministry for Seniors and Accessibility (formerly the Ontario Seniors Secretariat) to develop an evidence-based action plan for addressing social isolation in older Chinese adults living in the Toronto Kensington-Chinatown Neighborhood (KCN). A series of activities were undertaken to build an evidence-base for the proposed action plan and to foster a strong working relationship with the people living in the KCN, as well as the professionals serving that community.

First, the researchers conducted a scoping review of the literature to synthesize and describe the current state of knowledge on social isolation and loneliness in urban dwelling Chinese older adults living in Western societies.

The second phase was to understand issues of social isolation in older Chinese adults living in the KCN, and to obtain their perspectives on what priorities needed to be addressed to make their community more age-friendly. This included doing a telephone survey with older Chinese adults (N=100) living in the KCN who were asked questions about their physical, mental and social health, which were done in Mandarin or Cantonese. Focus groups with Mandarin (N=19) and Cantonese (N=5) speaking older adults were also conducted to get an in-depth understanding of their experiences of living in the KCN, and what was needed to make them feel more included in their community. An additional focus group was conducted with clinicians and service providers (N=9) from health and social agencies providing support to older Chinese adults living in the KCN.

Finally, a mapping of community resources (e.g., health, social, legal, etc.) was undertaken to provide interested parties with knowledge about what organizations/services are available in the KCN.

Step 3: action plan

Using the information collected from the scoping review, interviews and focus groups, and mapping activity, the researchers in consultation with a set of representative stakeholder groups identified a preliminary list of 25 potential priorities. These items were taken to a consensus meeting of older Chinese residents (N=10), stakeholders (N=3), researchers (N=7) and planners from the municipal and provincial levels of government (N=7). Student research assistants working with the project leads simultaneously translated all meeting materials and discussions in English, Mandarin and Cantonese.

The goal of the one-day consensus meeting was to identify the top five priorities for making the KCN more age-friendly and to develop an initial action plan on strategies to implement them. The first part of the morning session was organized to facilitate knowledge about each other and to provide attendees with an overview of the pre-meeting materials (e.g., scoping review, survey and focus group data) by the project lead. The second part of the morning was focused on the selection of the top five priorities and the afternoon was spent on developing specific strategies and plans for moving the identified priorities forward.

The groups were successful in prioritizing five areas for action, with at least 80% agreement to each. For the development of the action plan, meeting attendees were asked to select a priority of interest and to work in small groups to develop strategies for their implementation. As with the priority selection process, the S.M.A.R.T. approach (Specific, Measurable, Actionable, Realistic, Timely) was highlighted as a potential model to help fill in specifics on the implementation of a specific priority. Following the small group discussions, the neutral facilitator guided a large group report back to maximize the input of the collective expertise of the attendees.

An example of the resulting components of the proposed action plan for one of the dimensions is listed below and the full report that includes activities that span all of the implementation strategies listed above can be found on the Resource Page.

This work aligns with and informs the broader work of the Toronto Seniors Strategy.

Priority #3 (transportation) – identify affordable ways older adults can be more independent in getting around the city.

Problem:

Public transit is too expensive and it is difficult to identify stops on the bus, maps are difficult to read and there is a need for more details on bus schedules. Wheel-Trans clients can only book trips through dispatch in English. As well, drivers and clients do not have direct lines of communication, so changes in pick-up time and location may result in delays.

Action #1:

Need for continued political lobbying to reduce senior fares or create a free transit option for low income seniors. There has been some initial lobbying with other senior groups but further work is needed.

Action #2:

Need to improve processes related to Wheel-Trans use (e.g., providing drivers with client phone numbers to improve coordination), translation support.

Out-of-the box ideas:

Improve social participation in various activities by securing funds at the planning stage to cover transit costs of older adults.

Develop a community shuttle service by engaging school buses that could provide transit between school hours.

Explore how the PRESTO card might be able to serve as a tool for supporting the introduction of special rates for low-income seniors and/or other vulnerable groups.

Meeting the needs of older immigrant populations checklist

Steps 1 and 2: define local principles and needs assessment

• conduct background research and environmental scan
• integrate CBPR principles
• engage cultural community leaders and champions
• ensure representative stakeholder engagement

Step 3: action plan

Respond to issues of:

• language and transportation barriers
• changing family roles and expectations
• mistrust and gaps in awareness of programs and services
• need for cultural tailoring of health promotion and strategies and services
• potential increase need for accessibility as AFC participants continue to age

Step 4: implementation strategies

• provide cultural sensitivity training
• develop language and transportation Skills
• culturally-tailor health services and support
• offer educational workshops
• celebrating cultural traditions and diversity
• leadership opportunities
• providing cultural sensitivity training