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TABLE OF CONTENTS

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 About the Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . 9 DAY ONE: “SPEAKING TO THE INTERFACE” Overview of Access to Care Issues . . . . . . . . . . . . . . . . 11 Research Perspectives on Access to Healthcare for Ethnic Minority Seniors: A Canadian Snapshot Sharon Koehn, Centre for Healthy Aging at Providence . . . . . . . . . . 12 Access to Health Care for Ethnic Minority Seniors Betty Ann Busse, Fraser Health Authority . . . . . . . . . . . . . . . 20 The Research-Practice Interface Neena Chappell, University of Victoria

. . . . . . . . . . . . . . . . 23

Panel Sessions Session 1: Culture: Who Cares? . . . . . . . . . . . . . . . . . 26 Consideration of Nursing Home Care Placement for the Elderly in South Asian Families Rashmi Gupta, San Francisco State University . . . . . . . . . . . . . .

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Clinical Cultural Competence: Barriers to Accessing Health Care for Ethnic Minority Seniors Farimah Shakeri, Royal Columbian Hospital . . . . . . . . . . . . . 31 Indo-Canadian Seniors: Culture, Who Cares? Bikkar Singh Lalli, Senior Delegate . . . . . . . . . . . . . . . . . 34

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Speaking to the Interface

Session 2: Knocking on Doors. . . . . . . . . . . . . . . . . . . 37 Navigating Health/Mental Health Care for Ethnic Minority Seniors Rosemary Meier, St Joseph's Health Centre

. . . . . . . . . . . . . 38

Experiences of a Home Care Pharmacist Caring for Ethnic Minority Seniors as They Navigate the Health Care System Carla Ambrosini, Fraser Health Authority . . . . . . . . . . . . . . . 42 Barriers Facing Indo-Canadian Seniors . . . . . . . . . . . . . . . . . . . 46

Mohinder Sidhu, Senior Delegate .

Session 3: When is a Home not a Home? . . . . . . . . . . . 49 Service Utilization: Issues Surrounding Seniors’ Use of Long-Term Care Options Naina Patel, Policy Research Institute on Aging and Ethnicity (PRIAE) . . . . . . .

. . . . . . . . . . . . . . . 50

Service Utilization: Barriers and Solutions Jocelyne Wong, Providence Health Care . . . . . . . . . . . . . . . 54 A Filipina Perspective Pepita Hernandez, Senior Delegate

. . . . . . . . . . . . . . . . . . 57

Building the Interface: Open Discussion . . . . . . . . . . . . 59 Topic 1: Medical Services and Medication . . . . . . . . . . 60 Topic 2: Ethno-Specific Homes . . . . . . . . . . . . . . . . . 63 Topic 3: Cultural Competency . . . . . . . . . . . . . . . . . . 66 Summary of key points and recommendations . . . . . . . . 69

DAY TWO: “PUTTING RESEARCH INTO PRACTICE” Concurrent Workshops . . . . . . . . . . . . . . . . . . . . . . . . . 68 Workshop 1: The Senior in the Family Co-chairs: Karen Kobayashi, Daniel Lai, Sid Chow Tan

. . . . . . . . 69

Workshop 2: Immigrant Status Co-Chairs: Shashi Assanand, Sharon Koehn, Baljit Sethi

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. . . . . . . 73


Workshop 3: Housing Options Co-chairs: Habib Chaudhury, Charan Gill, Saroj Sood

. . . . . . . . 76

Workshop 4: Language and Interpretation Co-chairs: Van Le, Hien Phu Nguyen, Thong Nguyen, Angela Sasso, Noreen Simmons, Jeff Small . . . . . . . . . . . . . . . . . . . . .

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Workshop 5: Complex Care and End-of-Life Issues Jas Cheema, Sue Grant . . . . . . . . . . . . . . . . . . . . . . . . 86

Summing Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 The Interface in a Nutshell: Themes from the Symposium 91 Negotiating the Interface: Concluding Observations . . . . 92 Appendix 1: Conference Agenda . . . . . . . . . . . . . . . . . . . . 102 Appendix 2: References Cited . . . . . . . . . . . . . . . . . . . . . 104 Appendix 3: Speaker Bios . . . . . . . . . . . . . . . . . . . . . . . . 110 Appendix 4a: List of Participants . . . . . . . . . . . . . . . . . . . 120 Appendix 4b: List of Speakers and Workshop Chairs . . . . . . . 124

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REPORT PREPARED BY Sharon Koehn, Louisa Cameron and Susan Kehoe on behalf of the BC Home and Community Care Research Network (HCCRN) and Fraser Health Authority (FHA)

Photo credits: Mr. Hien Phu Nguyen

HCCRN is funded through a Michael Smith Foundation for Health Research Investigative Team Award, which made this symposium possible.

www.msfhr.org

Electronic copies of this document can be obtained from www.hccrn.com or by contacting the BC Home and Community Care Research Network at: 1163-1190 Hornby Street c/o 1081 Burrard Street Vancouver, British Columbia Canada V6Z 1Y6 Telephone: (604) 806-8162 Fax: (604) 806-8173 © HCCRN 2007

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Acknowledgements This symposium would not have been possible without the generous funding and support in kind from our sponsors:

Thanks are extended to our steering committee: Sharon Koehn, Centre for Healthy Aging at Providence (CHAP) Celso Teixera, Health Planning and Systems Development, Fraser Health Authority Neena Chappell, University of Victoria Jean Kozak, BC Home and Community Care Research Network (HCCRN) Charan Gill, Progressive Intercultural Community Services (PICS) Society Jim Sands, Social Planning and Research Council (SPARC), BC The symposium also benefited from the input of the Ethnic Minority Seniors in Care team members (funded by BCNAR) and others who contributed to a brainstorming session to identify the underlying principles and theme of the symposium. Special thanks are due to Louisa Cameron, Susan Kehoe, and Kay Griffiths who pulled out all the stops to make things come together in a very short time. We are especially grateful to all of the presenters and workshop co-chairs who shared their experiences and research findings and whose dedication to this field made the symposium possible. Many thanks as well to several volunteers: Leslie Malloy-Weir for assistance with last-minute organization and evaluation; Barbara Aldaba-Ferguson, Sing Mei Chan, Eunju Hwang, Angela Johnston and Ravin Sandhu for taking notes in the workshop sessions. Finally, thanks to the numerous participants, some of whom traveled considerable distances and all of whom took precious time out of their busy schedules to join us because they care.

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Foreword Canada is experiencing two dramatic changes in its population profile: (a) an increase in the proportion of Canadians 65 years of age and older and (b) a rapid increase in the ethnic diversification of its population of seniors. These trends are particularly significant in British Columbia, where the proportion of ethnic minority seniors is higher than the rest of Canada. Ethnic minority seniors face unique challenges navigating the interface between their communities and the health care system. In acknowledgment of this phenomenon, Fraser Health Authority in collaboration with the BC Home and Community Care Research Network (HCCRN) held a symposium on Access to Health Care for Ethnic Minority Seniors in April 2007. This two-day event brought together a diverse group of stakeholders to share information and identify gaps in our knowledge around this important topic. The stated objectives of the symposium were to: Learn about current research on access to health care for ethnic minority seniors, Explore issues around barriers to access for ethnic minority seniors, and Facilitate knowledge translation and further collaborative research on this topic But in very practical terms, through the attendance of ethnic minority seniors and representatives, researchers, and health service providers, participants acquired a greater common understanding of the potential cultural and linguistic barriers to care, as well as the varying health practices and preferences among different ethnic groups. Consistent with a population health paradigm, the impact of life experiences and circumstances as key determinants of current health status and needs was emphasized. In addition, the exploration of the most appropriate and effective responses to those needs allowed citizens to be heard, and helped to improve the cultural orientation of researchers and providers who were in attendance. While all participants became better informed about the resources that are already in place, there are certainly several major challenges to address. In particular, the serious shortage of culturally oriented service providers

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and the limited resources available for building ethnic community capacity to complement formally available public services require targeted strategies. The symposium served to heighten awareness among citizens, researchers and health authorities across BC in regard to access challenges for ethnic minority seniors and will hopefully lead to the initiation or continuation of effective collaborative strategies aimed at improving the current situation. This publication presents a synopsis of symposium presentations, workshops and discussions. For more information or to obtain a copy of these proceedings and speaker presentations, please visit the HCCRN Website at www.hccrn.com

Celso Teixeira Director, Health Planning and Systems Development Fraser Health Authority

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About the Symposium Speaking to the Interface: A Symposium on Access to Care for Ethnic Minority Seniors was a two-day event held on April 19-20, 2007 at the Sheraton Guildford Hotel in Surrey, British Columbia. We speak about an interface because research on access to health care has shown that ease of access to appropriate and timely health care depends on two things: the experiences that people bring with them and the way in which services are offered. These experiences include the person’s culture, social factors such as age, gender and income level, and the experience of migration, to name a few. Things that affect the delivery of services include health care policies, available resources and the sensitivity of staff to social and cultural differences. In order to capture the perspectives of three key stakeholders involved in that interface, invited speakers and workshop chairs included members from the academic community, health care providers and representatives from the ethnic minority seniors’ community. Because there can be considerable diversity within any given ethnic group, invited academic speakers were individuals who had an indepth knowledge of one or two specific ethnic groups and who understand these variations. These academics represented a variety of disciplines (architecture, anthropology, gerontology, sociology, psychology, social work, medicine, audiology and speech sciences). Health care providers who spoke or co-chaired sessions were also selected from different disciplines: social work, pharmacy, psychiatry, geriatric medicine, speech and language pathology, nursing and administration. Immigrant service providers also co-chaired three of the five workshops. These presenters spoke to the experiences of diverse communities, of which some were members, including Chinese, South Asian, Iranian, Japanese and Caribbean. Senior and family caregiver speakers and workshop co-chairs represented the Punjabi, Chinese, Filipino and Vietnamese communities (see Appendix 4b for a list of contributors). Participants were even more diverse both in their positions (seniors, immigrant service providers, seniors’ advocates, multidisciplinary health care professionals and decision-makers, academics and students) and in their ethnic background (see Appendix 4a for a list of participants).

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While the majority of participants and speakers were from the Lower Mainland of BC, others traveled from Kelowna, Prince George and Vancouver Island in BC, from Regina and Toronto in Canada, and internationally from the USA and the UK. Day One comprised an introductory panel, three topical panels and an open discussion. The interface between individuals and the health system is reflected in the three themes that were used to organize the topical panels. Each was comprised of a senior, a health care provider and an academic, who provided different and equally valid perspectives on similar topics. This strategy was intended to help us identify areas of overlap on which we can build research projects and/or solutions to the identified barriers. The morning of Day Two was dedicated to five concurrent workshops that gave participants the opportunity to delve deeper into topics of interest, to contribute their own experiences in an interactive small group setting and to meet others with similar interests. Representatives from these groups reported back to other participants once everyone had reconvened following a half-hour networking break. Dr. Neena Chappell concluded the morning with a summary of the key themes that emerged from the presentations and workshops. The topics from the workshops were selected according to their predominance in the literature and their alignment with each of the three themes used to organize the topical panels. Workshops 1 and 2 dealt with issues tackled under Culture Who Cares?; Knocking on Doors is represented in Workshop 4; Workshops 3 and 5 speak to the issues that define When is a Home not a Home? Summaries of each of the presentations and workshops are provided in these proceedings. If you would like to read and hear the original PowerPoint presentations, go to www.hccrn.com.

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Access to Health Care for Ethnic Minority Seniors Sharon Koehn provided a brief overview of the Canadian literature on access to health care issues for ethnic minority seniors. The Research-Practice Interface Betty Busse, from Fraser Health, spoke to the Health Authority’s goal of promoting a healthy aging model so as to meet the growing needs of an aging and increasingly immigrant population. Bridging the Research-Practice Gap Neena Chappell set the tone for the day by talking about the ways in which academics and health care personnel can most productively work together.

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Overview of Access to Care Issues

The introductory panel, An Overview of Access to Care Issues, set the stage for the event. Presentations included:


Research Perspectives on Access to Healthcare for Ethnic Minority Seniors: A Canadian Snapshot Sharon Koehn, PhD, Research Associate, Centre for Healthy Aging at Providence Sharon has been conducting research with ethnic minority seniors for the past fifteen years, both as an academic and as a contract researcher for various health authority and government clients. She has recently completed a CHSRF/CIHR postdoctoral fellowship focusing on barriers to access to care for ethnic minority seniors. This work sought to identify both barriers to access and viable solutions within a regional health care context.

Canada is experiencing two dramatic changes in its population: an increase in the number of Canadians 65 years of age and older, and a rapid increase in the ethnic diversity of its senior population. These trends are particularly significant in BC, where the proportion of ethnic minority seniors is higher than the rest of Canada. While some argue that the needs of young immigrants who grow old in Canada will not be as distinct, we must remember that many immigrants will continue to sponsor aging parents and grandparents through the family reunification program. Therefore, the problems of access to health care faced by today’s ethnic minority seniors, who did not grow old in Canada, will not disappear in the future, unless barriers to access are addressed directly through changes to the health care system. Studies have shown that recent immigrants tend to be healthier and use fewer health services than the Canadian-born population. However, over time immigrants’ health status converges with that of the Canadian-born population and may even drop below it (Gagnon, 2002; Gee, Kobayashi and Prus, 2004). This phenomenon is known as the “healthy immigrant effect” and is supported by numerous studies (Beiser, 2005). The health advantage of new immigrants reflects, in part, the criteria for both health and socioeconomic status that they are obliged to meet for entry into Canada. One problem we find with reports like the one cited above on immigrant health is that they tend to lump all immigrants together as if they were one homogeneous group. However, we know that there are many differences among immigrants that have to do with, for example, immigrant class, country of origin, socioeconomic background, the culture from which they came, gender, level of education, and their

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ability to speak French or English, to name a few factors (Gagnon, 2002; Durst, 2005). For instance, refugees, Family Class immigrants, immigrants from Asia, Africa or South America, and older immigrants tend to be less healthy upon arrival in Canada than other immigrants overall (Gee et al., 2004; Newbold, 2005; Statistics Canada, 2005). Recent immigrants aged 65 and older have poorer health than both immigrants who have been in Canada longer and the Canadian-born population (Gee et al., 2004). The health of Family Class immigrants also appears to be lower (on a par with refugees) due to the higher proportion of those aged 65+ among them (Statistics Canada, 2005). These findings suggest that services and programs need to differentiate between immigrants by immigrant status and class, age, country of origin, gender and so forth when determining health care policies. Some studies suggest that recent immigrants tend to underutilize Canadian health care systems. However, the cause for this underutilization is not clear: are new immigrants healthier or do they experience barriers to access for care (DesMeules et al., 2004)? Again, the answer requires a more fine-grained analysis that takes many factors such as gender, country of origin, the services in question into account. Despite the burgeoning population of ethnic minority seniors and their demonstrated need for care, research on this population, particularly around health care access, is sparse (National Advisory Council on Aging [NACA], 2005). This symposium is organized according to the “candidacy for care” model (Dixon-Woods et al., 2006). The idea behind “candidacy” is that you don’t just go to a doctor, tell him or her what’s wrong and receive care. There are many doors between seniors and the care they need, and some can be hard to open. Perhaps because of this, Dixon-Woods et al. (2006) have found that vulnerable people tend to identify candidacy for health care services as a series of crises. Vulnerable groups have low use of preventative services and higher use of accident and emergency facilities. A senior’s own beliefs, as well as those of family members, health care workers and policy-makers all influence whether the senior ultimately receives the care they need. The “candidacy” framework draws our attention to the many ways access to health care may be blocked. It also helps us see where gaps in the research and in services lie, so that we can address them. Some examples of these complex negotiations between stakeholders that we see in the literature are provided below.

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Over the past few decades, there has been a growing realization that the underlying assumptions of Western medicine are not universal (Fabrega, 1991). Most non-Western cultures do not recognize phenomena such as mind and body or nature and culture as distinct, but emphasize instead their interconnections. The prevalence, type of symptoms, course and outcome of illness tend to vary significantly across cultures (Blue and Gaines, 1992; Kirmayer, 1989; Littlewood, 1990; Kleinman, 1987). For example, immigrants may experience high levels of stress due to factors such as poor living conditions, poverty, loss of status, low levels of social support and intergenerational tension. Several studies indicate that the rate of mental health problems, such as depression, is higher than average among new immigrants, particularly women. Depression and other mental health problems are nonetheless under-reported and remain undetected by Western diagnostic techniques (Ananth, 1984; Chen and Kazanjian, 2005; Stephenson, 1991; Krause, Rosser, Khiani and Lotay, 1990; Lai, 2004; Williams, Bhopal and Hunt, 1993; Williams and Senior speaker Mohinder Sidhu Hunt, 1997). Ethnic minority seniors who experience depressive symptoms related to the immigration and settlement experience, and to the experience of racism, identify their mental health issues as “stress” or “spiritual crises” in part because the terms depression and anxiety are relatively non-existent in their home country (Ahmad, Shik, Vanza, Cheung et al., 2004b; Marwaha and Livingston, 2002; Sadavoy, Meier and Ong, 2004). Another problem is that mental illness is highly stigmatized in many cultures, and families can be very slow to seek help outside of a few trusted insiders (Cook, 1990; Furnham and Malik, 1994; Lee, 1986; Marwaha and Livingston, 2002; Sadavoy et al., 2004). The presentation of “mental” illness as “physical” symptoms, known as somatization, provides a passport into the doctor’s office, a means by which the patient is able to protect him- or herself from the perceived shame of mental illness (Ananth, 1984; Williams and Hunt, 1997). This tendency is well known in many Eastern countries such as India and China and among immigrants from those countries (Lee, 1986; Ots, 1990). The symptoms of mental illness can also be expressed quite dif-

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ferently in non-Western cultures and Western health care workers often fail to make accurate diagnoses as a result (Ananth, 1984; Sadavoy et al., 2004). The ideal of filial piety, whereby adult children are obliged to look after their elderly parents until death, may also become a barrier to seeking care (Ahmad, 1996; Cook, 1990; Koehn, 1993). Many ethnic minority seniors were raised in cultures where filial piety is the norm. Several communities maintain, however, that times are changing and seniors cannot always depend on family members to provide sufficient care. This is a source of disappointment and shame for many seniors (Ahmad and Walker, 2000; Koehn, 2006; Sadavoy et al., 2004). Several studies show that structural factors relating to the availability and financial wherewithal of family members to provide assistance, need on the part of the elder, and the patterning of helping behaviour by gender are collectively more important than ethnicity or filial piety (Gupta, 2002; Keefe, 2000; Kobayashi, 2000; Wieland, 1991). More acculturated children are the least likely to provide care for aging parents (Gupta, 2002). However, “ . . . ‘mainstream’ community care organizations are under the impression that, among ethnocultural groups, families look after their own members more than is actually the case. Such misinformation perpetuates the lack of services available to ethnocultural groups” (Canadian Association of Community Care and Canadian Ethnocultural Council, 1998). Families may also resist placement of the senior in a long-term care home because of the guilt or shame that this engenders among family members (Koehn, 2006). Family Class immigrants who are seniors sponsored by adult children or grandchildren, and refugees are especially vulnerable by virtue of their immigrant status. The combination of late-in-life migration to an unfamiliar environment and the reduced entitlements and enforcement of dependency associated with sponsorship typically entail role reversals between the younger and older generations, and hence a dramatic drop in status for the elderly (Koehn, 1993; Sadavoy et al., 2004; McLaren, 2006). Dependent on their children for information, transportation and interpretation at medical appointments, and aware of the busy lives that their children lead, seniors are unwilling to ask them for assistance in seeking medical help unless they feel strongly that the ailment warrants medical attention. As a result, health care providers tend to see them in crisis (Koehn, 2006). The trauma of fleeing from war or famine and arriving in a strange

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country with few resources, as well as the experiences of torture and trauma prior to departure, have a tremendous impact on the family structure of refugees (Amnesty International, 1989-90; Bottinelli et al., 1990; Carlin, 1990; Kolff and Doan, 1985). Oftentimes, the family experiences role reversals on the basis of generation and gender, as well as power shifts in the familial context. Family breakdown and violence, widespread in some refugee populations, is but one part of the spectrum of psycho-social trauma that defines the tragedy of their lives (Farias, 1991). As a result, the elderly in these families may lack the support to adjust successfully to their new environment and to access the care they need. The decision to seek out or accept an offer of care is not always in the senior’s hands. Sometimes the whole family makes the decision; at times, the senior is not even party to the process, depending on cultural mores, the senior’s control over family resources, gender norms, and the senior’s degree of frailty and/or cognitive impairment (Koehn, 1993, 2006; Nandal, Khatri and Kadian, 1987; Punia and Sharma, 1987). For example, Chinese-Canadian seniors questioned about their views on end-of-life care rejected advance planning in favour of a consensual family approach to decision-making (Bowman and Singer, 2001). The Longitudinal Survey of Immigrants to Canada (Statistics Canada, 2005) reports lower levels of service access relative to need for immigrants of East and Southeast Asian origins. The authors suggest that immigrants from countries where religious or traditional healers are customarily consulted for health care may be less likely to seek care from health professionals in Canada. While this is worthy of consideration, research with Chinese and Punjabi seniors in Canada indicates that traditional medicine is used as a complimentary rather than an alternative treatment option (Chappell and Lai, 1998; Foreman et al., 1998; Koehn, 1999; Krause et al., 1990; Sadavoy et al., 2004; Segel et al., 1993; Stephenson, 1991). A combination of cultural differences, lack of experience in this country, language barriers, social networks, and the complexity of health service delivery may limit ethnic minority seniors’ familiarity with available health care services (Koehn, 2006; Sadavoy et al., 2004). Some adult children of seniors don’t know very much about the services themselves. Others chose to keep this information from their parents, particularly when they are required for domestic services and childcare (Koehn, 2006).

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Language and interpretation issues are also common barriers to access to health care. Understanding the dominant language is often key to getting health care information (Bowen, 2001). More than half of all immigrants and the majority of ethnic minority seniors, particularly Family Class immigrants who have more physical problems and less English language ability, prefer to consult with a service provider who can speak their native language (BC Statistics, 2006; Koehn, 2006; Statistics Canada, 2005). Health care providers often have limited understanding of the cultural context of the emotional distress of their ethnic minority senior clients (Sadavoy et al., 2004). As a result, seniors in different studies have commented on the need for interpreters. Often, they are forced to rely on family members, which raises numerous ethical and practical concerns (Koehn, 2006; Sadavoy et al., 2004). While there is a need for the translation of more health information into different languages, the low levels of literacy of many ethnic minority seniors (especially women, for whom education levels are typically lower) must be taken into account (Koehn, 2006; Martyn, 1991; Ahmad and Walker, 2000). Language barriers also affect access to information about services that fall under the broader category of social determiDr. Doug Durst greets senior Van Le nants of health such as grants for housing costs and pensions (Ahmad and Walker, 2000). “Immigrant seniors, especially women, face higher rates of poverty than seniors born in Canada” (Boyd, 1989; National Advisory Council on Aging [NACA], 2005; Sadavoy et al., 2004). This is due to a combination of factors, and is especially true of sponsored and refugee seniors (Ahmad et al., 2004a; Koehn, 1993, 2006; NACA, 2005; Sadavoy et al., 2004; Statistics Canada, 2005). Even when language barriers are not present, racism on the part of health care providers toward black ethnic minority seniors can limit access (Ahmad and Walker, 2000; Ahmad et al., 2002; Brotman, 2003). Ethnic minority seniors in majority extended care homes experience three main difficulties: the loss of culture, family and community (MacLean and Bonar, 1983). Each of these losses contributes to the senior’s feelings of isolation and may well accelerate his or her mental

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and/or physical decline. Embedded in all three of these is language, which is an aspect culture (Saldov, 1992). Conversely, when they are able to speak with peers and health care providers in their own language and eat familiar food, residents are happier, able to provide mutual support and tend to eat better (Chaudhury, Mahmood, Kobayashi and Valente, 2005; Koehn, 2006). Unless their families are able to provide meals, however, they rarely get the food they need in facilities. Many seniors prefer to go without and hence compromise their health (Aziz and Campbell-Taylor, 1999). Ethnic minority seniors in care also require some means of satisfying their spiritual needs. Often, people stay connected with their faith by listening to religious programs on the radio or television, or reading their holy books. Typically, however, facilities do not provide radios that tune in to these programs (Koehn, 2006). When these facilities are not available and extended care homes are not prepared to be flexible in order to accommodate these requirements, ethnic minority seniors become more isolated and depressed and their health declines (Koehn, 2006; MacLean and Bonar, 1983). The residential care access policy1 is an example of a provincial policy that has a harmful effect on ethnic minority seniors and their families. While the intention of the policy is to provide care first to those with the greatest need, the “first available bed” clause has resulted in the placement of ethnic minority seniors in extended care homes where they are located far away from staff, residents and family members who might provide some degree of familiarity, speak to them in their own language or provide them with familiar foods (Koehn, 2006). While some of the barriers identified in this review are common to ethno-cultural minorities of all ages, many are specific to the seniors among them. These include lower rates of English/French acquisition and reversion to the mother tongue with age; intergenerational tension, dependency and isolation; vulnerability related to immigration status (especially among sponsored seniors); less familiarity than younger generations with technology (e.g. the Internet) and complex institutions and, hence, greater difficulty in accessing information; and higher levels of adherence to cultural and spiritual practices (e.g. dietary and religious practices not supported in residential care facilities). These factors are further complicated by higher rates of physical and mental illness. References cited are available in Appendix 2. This presentation was 1. Government of BC (2002) Available at: http://www.hlth.gov.bc.ca/hcc/pdf/residentialpolicy.pdf

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based on a literature review jointly prepared by Sharon Koehn and Andrea Gregg. A more comprehensive review on this topic is currently being prepared for submission to a refereed journal. Please do not cite this paper without permission from the authors.

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Access to Health Care for Ethnic Minority Seniors Betty Ann Busse, BSC, MSC, Executive Vice President, Health Promotion and Community Programs, Fraser Health Authority Betty Ann’s professional experience spans more than 30 years in the health care field in the areas of direct patient care, clinical education and a variety of administrative roles across Canada, including CEO of two hospitals. In the spring of 2002 she received the RNABC award for excellence in nursing.

The Fraser Health Authority’s goal is to create new kinds of services to meet the needs of an aging and increasingly immigrant population. In BC, the population is expected to grow by 25% by 2020. When we look at the 65 and over age group, that percentage jumps to an astonishing 74% increase in that same period. Of the 25% anticipated growth in the population as a whole, 61% fis expected to result from international immigration. Even though most of these immigrants will not be seniors, they will become the seniors of the future. Of First, we can’t think of course we shouldn’t forget that future seniors as one homogeimmigrants to Canada will include seniors who immigrate along with their neous group. We need to adult children.

look at them as different

Such large increases among the elderly groups, where culture is will put new pressures on our health care system. Betty Ann shared her hope one aspect of difference. that healthy aging will be moved to the forefront of the social policy agenda. Her sense of urgency is underscored by the findings of a recent paper entitled Healthy Aging: A New Vision: “If left unaddressed the aging of the population will have a far-reaching impact that will far outweigh the cost of investing in healthy aging now.” In the past, providing health care was about making sure people had access to hospitals, doctors and other kinds of health care professionals and services once they became ill. Betty Ann urged us to start to view health care in a new way using the population health approach. From this perspective, providing health care is more holistic, less treatment-centred and more about “upstream” interventions and education aimed at helping people live healthier lives from an early age.

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What do we mean by living a healthier life? We know from research that healthy lifestyle choices include being physically, mentally and socially active, eating healthy foods, not smoking and limiting alcohol. For seniors it also includes fall and injury prevention. One way the Fraser Health Authority can foster healthy living and aging is by creating relationships with community and other kinds of organizations that offer people recreational facilities, social networks and chances to learn more about maintaining a healthy lifestyle. Betty Ann explained that the population health approach is all about individuals and, consequently, The challenges to optimizing populations taking responsibility for being and staying as healthy as they can, the response to this group given their circumstances. A more innowithin our population are vative and holistic health care system is created when hospitals, government not insignificant, but they organizations, community organizations and other stakeholders work together to are also not insurmountable promote health, not just treat illness.

with solid information and

We have the vision to broaden our understanding of health care, but there are serious obstacles to getting the word out about healthy lifestyle choices and making sure everyone – including the most vulnerable members of our society – has access to health care. Those obstacles relate to inequities resulting from gender, culture, ability, income, geography, ageism and living situation. The Healthy Aging: A New Vision report challenges us to remove these barriers by doing the following:

collaborative action.

valuing and supporting the contributions of old people celebrating diversity refuting ageism reducing inequities providing age-friendly environments helping Canadians make healthy choices that will enhance their independence and quality of life What needs to be done to achieve this vision? First, we can’t think of seniors as one homogeneous group. We need to look at them as differ-

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ent groups, where culture is one aspect of difference. This then leads us back to the question of access. We must ask ourselves, Access to what, when and how much? What should be guaranteed under the Canadian Health Act and what should be the responsibility of the individual? And how can we protect the needs of the most vulnerable? Answering these questions while at the same time matching resources to need is not going to be an easy task. Another difficulty is the lack of data upon which to base our policy decisions. Betty Ann elaborated, “The generally available data on the needs of the immigrant population is neither timely nor sufficiently comprehensive to inform program design at a regional level or a community level. And so we generally have to count on community level processes and adaptations to identify and address those needs. No doubt that process can be improved as can the generation and analysis of data.” We do know that ethnic minority seniors face the following barriers: language lack of access to information health care providers’ lack of cultural competence insufficient resources to address poverty, isolation and chronic diseases

Betty Ann concluded her talk with an impassioned call for all of us to learn more about the needs of ethnic minority seniors and the barriers they face: With immigration contributing the biggest component to the population growth across Canada in the foreseeable future, health agencies like health authorities have both a practical and ethical obligation to better understand the dynamics that contribute to their current and future health status, as well as the barriers they might face in accessing services. The challenges to optimizing the response to this group within our population are not insignificant, but they are also not insurmountable with solid information and collaborative action.

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The Research-Practice Interface Neena Chappell, PhD, FRSC, Canada Research Chair in Social Gerontology,University of Victoria Neena has been a leader in gerontological research for over twenty-five years. Her research has focused on three areas: quality of life for seniors, care giving, and the health care system and related policy. Within each of her areas of research, Neena has examined issues pertinent to Chinese seniors, both in Canada and China/Hong Kong. She is currently involved with the HCCRN as an advisory committee member, and holds the Canada Research Chair in Social Gerontology in the Centre on Aging at the University of Victoria, where she is also a professor in the Department of Sociology.

Policy decisions are supposed to be evidence-informed (based on research data). Therefore, there is a natural relationship between ethnic minority seniors, health care providers, researchers and policymakers, all of whom need to work together to provide ethnic minority seniors with the kind of care they want and need. Yet researchers and policy-makers may have different goals and expectations. Policy-makers may expect researchers to provide solutions to problems quickly. Researchers may be interested in things that other stakeholders (policy-makers, seniors, health care providers) do not view as important. Nor are all individuals within each stakeholder category the same. We can and must overcome these difficulties and work together to produce the best possible results. Neena concluded her talk with the following words of inspiration and advice: “I think the problem is not going to be coming up with research questions – areas in which we want new knowledge – the difficulty is going to be narrowing it down and saying, ‘Where are we going to start?’” Observations and Recommendations

Policy-makers, seniors and health care professionals don’t need to come up with research questions and a research design before approaching researchers to collaborate. Identify what you want to know or need to know, that’s enough. Researchers can work together with you to come up with specific research questions and strategies that are of interest to both sides. Health care workers and administrators can allow researchers access to their facilities.

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There are different types of research: quantitative (large and small scale), qualitative, and a lot of diversity within these types. We need all of these approaches in our work, because each brings a different kind of knowledge. Qualitative research is especially important when talking about ethnic minority seniors’ access to health care, because many do not access health care programs. Therefore, there won’t be large numbers for large quantitative studies. The following two examples from qualitative studies show that we have to be careful to understand and respect the values of minority ethnic groups. Westerners tend to value individualism and independence more than Chinese, who tend to value collectivism, centred on the family. If we understand this difference, we can understand Chinese seniors’ desire to “I think the problem is not allocate decision-making about their care to their adult children. They often believe going to be coming up with their children will make the best decisions for the family as a whole. Therefore, trying research questions—areas to make a Chinese senior feel more independent and autonomous could be devastatin which we want new ing to the senior.

knowledge—the difficulty is

going to be narrowing it down and saying, ‘Where are we going to start?’”

Inuit have no word for care giving. This doesn’t mean they don’t give care, just that it is not acknowledged in the language in the same way as in English. Therefore, you have to start from that understanding to explore ways to talk about care giving that makes sense to them within the context of their culture.

Health care providers and policy-makers who are interested in hiring a researcher should go to their local university; they can also form advisory committees with university-based researchers as members to help guide their project. Universities are supposed to do research and also service as part of their job description. Health care providers and others who are looking for a researcher can also go to their local university and talk to faculty members. They might be able to recommend a graduate stu-

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dent to conduct a research project. Again, this service could be free of charge. Researchers should add to existing databases. Data on ethnicity is politically sensitive and therefore often not collected. Stakeholders should insist that it be included. For instance, if someone is conducting research on drugs used in dementia treatment, ask that data be collected on drug tolerance among different ethnic groups. We often hear that Asians tolerate these drugs less well than Caucasians, but we don’t have any research data to confirm these anecdotes nor, if true, to develop drug guidelines. Add a local, in-depth study to a larger study that is being conducted. There’s a lot known in a lot of areas. Syntheses or integrated literature reviews are research. Health care workers, administrators and policy-makers should think about what it is they need to know to serve ethnic minority seniors better, and let researchers know about the kind of work that would make a difference. Seniors should continue to tell researchers, policy-makers, administrators and health care workers about the difficulties they have accessing the health care system, and suggest ways to make access easier.

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Presentations: Consideration of Nursing Home Care Placement for the Elderly in South Asian Families, Rashmi Gupta, PhD, LMSW; San Francisco State University, San Francisco, CA (academic speaker) Clinical Cultural Competence: Barriers to Accessing Health Care for Ethnic Minority Seniors, Farimah Shakheri, MSW, RSW; Royal Columbian Hospital, BC (health care provider speaker)

Session 1: Culture: Who Cares?

The first topical session, Culture: Who Cares?, looks at the ethno-cultural and migration context where seniors and their families decide if the senior needs care and whether or not they will accept care when it is offered. Rashmi Gupta began the session with a discussion of her research with South Asians living in the United States. She looked at the family’s decision to place a senior family member in longterm care relative to the care giving burden and their degree of acculturation. Farimah Shakeri, a professional practice chief of social work within Fraser Health, focused on Iranian women’s experiences of growing old and accessing the care they need in Canada. Finally, Dr. Bikkar Singh Lalli, speaking as a senior, shared his personal experiences with the health care system, as well as his observations and the findings of a study on wellbeing that was conducted with Punjabi seniors at an ethno-specific seniors’ centre.

Indo-Canadian Seniors: Culture, Who Cares?, Bikkar Singh Lalli, PhD; BC Coalition to Eliminate Abuse of Seniors, Vancouver, BC (senior speaker)

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Consideration of Nursing Home Care Placement for the Elderly in South Asian Families Rashmi Gupta, PhD, LMSW; Assistant Professor, San Francisco State University, San Francisco, CA Rashmi is the author of several articles on barriers to health care access for the Chinese and South Asian populations in the United States and India. In her 2002 article, “Consideration of nursing home care placement for the elderly in South Asian families,” published in the Journal of Immigrant Health, she examines characteristics of the care giving family that predict the likelihood of nursing home placement of South Asian seniors. Rashmi is an assistant professor in the School of Social Work at San Francisco State University.

As a social worker in a nursing home with large numbers of South Asian seniors, Rashmi became very involved in the South Asian community, including the problem families have deciding how to best care for seniors. For cultural reasons most South Asian Indians don’t want to put the senior in their family in a nursing home. They would rather care for them at home as long as there are support services available to help them. However, especially in the US, support services are limited and access to services can be especially difficult for ethnic minorities. Because Rashmi was already a part of the South Asian community due to her work and her own ethnic background, she decided to conduct a more extensive study of who provides care for seniors and what factors push families toward placing seniors in nursing homes. Rashmi felt her insider status on two counts would enhance her ability to conduct research on this topic. Rashmi also explained why her study is important. South Asian Indians are the fourth largest Asian minority group in the US and comprise 13% of the Asian population with numbers over two million. Yet there is an astonishing lack of research on the needs of this group of seniors and their families. How can health care workers and administrators provide ethnically sensitive services and support to this community if they have no understanding of the community’s needs? Her research goal, then, was to begin to identify what some of those needs are in terms of services that could help families continue to care for seniors at home – where most families prefer them to be. Rashmi conducted her study of South Asian Indian seniors in the Dallas-

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Fort Worth, Texas area of the United States. Data for this study was drawn from questionnaires completed during telephone interviews with 118 family member caregivers, who were recruited through several religious and nonprofit organizations in the Dallas-Fort Worth area. A caregiver was defined as someone who is at least twenty-five years old and providing substantial care to a senior for at least four hours a week. Each caregiver in the study considered himself or herself, or was considered by other family members, to be the primary caregiver looking after his or her own parent or parent-in-law. All caregivers were first-generation Indian/Pakistani immigrants. The seniors being cared for were at least sixty years old and had lived in a multigenerational Indian/Pakistani household for at ... the most significant facleast one year.

tors in the decision to place a

Who were these caregivers and how does gender come into play? Of the 118 caregivers, about 60% were women and 40% were the level of burden on were men. Nearly 90% of caregivers the caregiver from multiple were married and their average age was just short of 42 years old. Just over 20% roles and responsibilities, of the caregivers were daughters, nearly 34% were sons, 38.1% were daughters-inalong with the level of the law, 3.4% were sons-in-law, and 4.2% caregiver's acceptance of were “others.” It is not surprising that most caregivers were women (nearly Western values. 60%). While it was rare for sons-in-law to provide care to their wife’s elderly parent, sons were considered the primary caregiver in over a third of the cases. This may not be too surprising when we consider the traditional arrangement of an elderly parent living with a son over a daughter. For seniors, 52% were female and 48% male. Interestingly, sons and daughters appeared to be gender blind in terms of the gender of the parent they cared for. For in-laws, however, daughters-in-laws more often took care of their husband’s mother (26 cases) than their husband’s father (19 cases), while sons-in-laws only took care of their wife’s father (4 cases).

senior in nursing home care

Rashmi found that the most significant factors in the decision to place a senior in nursing home care were the level of burden on the caregiver from multiple roles and responsibilities, along with the level of the caregiver’s acceptance of Western values. Other determinants were found as well: the health of the caregiver and the health of the senior,

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which would determine the amount and type of care the senior needed. Where health was poorer and care higher, the burden increased. The level of burden placed on caregivers was found to relate primarily to the so-called “sandwich generation phenomenon,” in which adult children find themselves heavily burdened with the care of their own young children at the same time in their lives that their parents need more care from them. With the necessity for both husband and wife to continue working in many households, the role conflict and care burden can be quite high. How does a typically female caregiver in her thirties or forties juggle the demands of raising children, caring for a senior at home, and working outside the home, all at the same time? An adherence to traditional values of self-sacrifice and caring for all members of the family may ease the perception of burden, but these kinds of non-traditional pressures, brought on by immigration and changes in the economy, may also force families to abandon the ideal of caring for a senior at home. One solution, then, is nursing home placement, but this can be expensive in the US and difficult because of the lack of culturally sensitive care available. Another solution may make all the difference for families faced with this kind of pressure. Increasing the availability and accessibility of home care services that could help ease the burden placed on caregivers in South Asian families would likely result in more seniors being cared for at home by family members. As mentioned above, home is where most seniors and their families want seniors to be. In addition, more home care services that ethnic minority families and seniors could access easily would also result in lower care costs, because nursing home placement is much more expensive.

Recommendations When health care providers and social workers assess South Asian caregivers, they should focus on their level of role overload and burden. Based on their assessment, South Asian caregivers should receive support services to help them care for the senior in their family at home. This would lower the likelihood of nursing home care placement of South Asian seniors. Long-term care facilities should be better designed for minority

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populations. For instance, different types of ethnic food options, ethnic activities and celebrations would make living in long-term care a more positive, familiar experience for people from a wider range of ethnic backgrounds (ie not just for those from European and/or Christian backgrounds). Social workers should be educated about the long term care of minority populations. Staff at nursing home facilities needs to be more culturally aware and sensitive to the needs of ethnic minorities.

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Clinical Cultural Competence: Barriers to Accessing Health Care for Ethnic Minority Seniors Farimah Shakheri, MSW, RSW; Professional Practice Chief, Royal Columbian Hospital, BC Farimah is a professional practice chief of social work at Royal Columbian Hospital. Farimah has been working in the health care system for over eight years in the field of geriatrics as a social worker. She has done extensive work in the areas of cultural competency and anti-racist interdisciplinary practice. Her MSW research entitled, “Aging in a Foreign Country: Voices of Iranian Women Aging in Canada,” was published in the Journal of Women and Aging in September 2006.

Farimah came to Canada from Iran twenty-two years ago as a refugee due to Iran’s war with Iraq. She shared some of her struggle with the audience: “For the first time in my life, I experienced the meaning of ‘otherness,’ of being different. But as a young person, I was twentyfour years old, I was able to gain that identity back.” When Farimah arrived in Canada she found, as many immigrants do, that her education and credentials from her home country were not accepted here. Therefore, part of her struggle involved going back to university and starting from scratch to acquire new credentials. She added that she was very fortunate to be able to do this because of her young age and financial resources. Others who immigrate here may not be so privileged. Another issue that arose after her immigration was Farimah’s view of the way seniors are treated in Canadian society: “The first culture shock I had here was how people were disrespectful toward the elderly. In my culture, we value our elders and we see them as people who have words of wisdom for us, as people we can rely on, learn from and have respect for.” Farimah related another early experience that occurred on her first job in Canada, which was in a care facility for seniors. In the facility there was one Chinese woman who began screaming every afternoon. When Farimah asked the nurses why she was doing this, she was told not to worry about it. Farimah found someone to interpret the woman’s words for her: “Nobody knows me here. Nobody cares for me. They don’t know what I want. They don’t speak my language. They wake me up in the morning and comb my hair and put a bow in it. This is not what I want.” All of these experiences influenced Farimah to enter the field of geriatric social work with a focus on ethnic minority seniors.

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In addition to her social work practice, Farimah conducted research in the form of in-depth interviews on the experiences of five Iranian women who immigrated to Canada. She chose this topic for two reasons. First because she wanted to study the experiences of women, who came from backgrounds similar to her own. Second because women were the first group targeted for repression during the revolution in Iran. Don't think about what is They were forced to cover their heads, they were forced out of programs of appropriate for you, but study like law and engineering, and rather what is appropriate finally they were forced out of their country. In this study Farimah explored for the person you serve the women’s experiences of growing old in Canada and identified some of the key based on their cultural problems they face: social isolation, language problems, a loss of identity, probbackground as well as their lems with the cultural sensitivity of othindividual circumstances and ers, and the difficulty of using Iranian credentials to work in Canada, somebeliefs. times because they don’t speak English well enough to pass professional certification exams. The women’s backgrounds were very diverse in terms of level of education, access to financial resources and their views of the place of women in society. As a result, their experiences and difficulties were also quite varied. Overall, women with a higher level of education, greater financial resources and a more feminist perspective had an easier time adjusting to life in Canada. Women who were more conservative in their views, for instance, who saw women solely as the providers of care to others, felt a greater loss of identity after their immigration. How has this research as well as her own personal and professional experiences informed Farimah’s practice as a social worker specializing in ethnic minority seniors? The most common problems ethnic minority seniors encounter relate to: Language and communication problems Immigrant status. If they are sponsored, their access to services is more limited.

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Their specific immigration experience. If they did not immigrate by choice they may feel less entitled to services and have more adjustment problems. Feelings of isolation. Insensitive attitudes of health care service providers can discourage access to services. Limited organizational and community capacity to serve ethnic minority seniors. Farimah focused on clinical cultural competence or the ability of health care providers, including social workers, to provide care in a culturally sensitive way. She stressed that it is very important for social workers to collect a detailed history of their clients’ situation: Did they immigrate here by choice or was their immigration involuntary? What is their situation at home? Can they ask family members for help to get to doctors’ appointments? What is their level of language competency? Would this client be best served working with someone who speaks their native language? What is their background in terms of education, financial resources, etc.? Without fully understanding these aspects of each client’s history, it is difficult to help them in a culturally competent way. Finally, Farimah cautioned social workers to try to see the world from their client’s perspective and exercise “cultural intelligence.” By this she means: Don’t think about what is appropriate for you, but rather what is appropriate for the person you serve based on their cultural background as well as their individual circumstances and beliefs.

Recommendations

We need more caregivers who know about other cultures or are at least sensitive to immigrants’ issues and experiences. Social workers must begin with an understanding of the specific situation of their client as well as a clear understanding that their own perspective is not necessarily the same as their client’s. Ultimately, they must provide care that puts their client’s worldview and needs first.

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Indo-Canadian Seniors: Culture, Who Cares? Bikkar Singh Lalli, PhD; BC Coalition to Eliminate Abuse of Seniors, Vancouver, BC Dr. Lalli is a retired professor and former chair of the Department of Mathematics and Statistics at the University of Saskatchewan. For the last eight years he has served as a member of the senate of the University of British Columbia. As a volunteer with BC CEAS (the BC Coalition to Eliminate Abuse of Seniors) and the BC Security Commission, Dr. Lalli is making seniors tough targets for con artists. In addition, he runs a computer lab for seniors under Industry Canada’s CAP Program. There is a healthy competition between Dr. Lalli and his wife, Surjit, when it comes to carrying out community work aimed at improving the lives of seniors. Dr. Lalli spoke at the symposium as an ethnic minority senior.

Dr. Lalli began his talk by sharing what it was like for him to come to Canada from a village in India many years ago. Like most of the IndoCanadian seniors living in Surrey and Vancouver, he too left behind his language, his food, his neighbours and everything that was familiar to him. Dr. Lalli was an educated man when he left India by choice to further his education, yet he still found coming to Canada difficult. He then asked us to imagine how much more difficult it is for the majority of seniors who come here, also from villages, who are illiterate and may find themselves isolated at home when they get here. When Dr. Lalli retired and moved to Vancouver from Saskatchewan, he visited a senior’s centre and was shocked to see over two hundred Indo-Canadian seniors sitting outside playing cards. In response, he wrote a letter to Allan Rock, the Canadian Minister of Health, asking for help. Dr. Lalli’s goal was the creation of recreational facilities and programs that could offer these seniors more stimulating activities. The Minister of Health wrote back and asked for data to demonstrate a need for new facilities and programs for Indo-Canadian seniors. Unfortunately, there was none. As a result, with the help of academic researchers, the Surrey/Delta Indo-Canadian Seniors’ Society and funding from Health Canada, a report was produced in 2000: “A Wellness Model for Indo-Canadian Seniors.” The material presented in Dr. Lalli’s talk is drawn from both this study and his personal experience as a member of the Indo-Canadian community in Surrey. A number of problems face Indo-Canadian seniors, beginning with the sense of social marginalization many feel because their adult children

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are often too busy with work and childcare to spend time with them. The fact that their grandchildren may not be able to speak their language isolates them further. As we have heard from many speakers, Dr. Lalli identified the language barrier as a major problem when dealing with health care workers as well, reinforcing social isolation and barriers to care. Lack of access to transportation and the Internet, as well as sponsored seniors’ financial dependence on family members are other causes of marginalization. In his study, Dr. Lalli found a number of health problems to be common. Diabetes occurs three times more often among Indo-Canadian seniors than in the general population. Arthritis is widespread and mental health problems, like depression, also occur. Unfortunately, for cultural reasons Indo-Canadian families may try to hide these problems rather than seek outside help. Another obstacle is the tendency of doctors to prescribe medications that may not be necessary. Dr. Lalli suggested that in many cases, what seniors may really need is someone to talk to about their problems. The problems of seniors may also be linked to the problems of younger Indo-Canadians living in Canada. For example, senior and wife abuse, both mental and physical, can arise when young men experience job discrimination and a high level of frustration when forced to do work that denies them dignity and any hope for career advancement. Drawing on his own experience Dr. Lalli spoke of the problems and abuse Indo-Canadian seniors may face when they enter the hospital or an extended care facility: “I have personally experienced a difficulty in one hospital. A male nurse actually yelled at me. I asked a question, ‘If I delayed the medication while I was sleeping by two hours, will it make any difference?’ (I got an infection in the hospital.) He [the nurse] actually yelled at me. After thinking for twenty minutes or so I went to the desk, asked his name and wrote down his number. He said, ‘Why don’t you go back to your room, you are bothering us.’ I said, ‘I want to report this to the management.’ Then after hour or so he came back and he was apologizing. I said, ‘If you can yell at a person like me, who is educated, then what is the situation when an illiterate person comes to the hospital? How do you treat them?’

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Recommendations

Create recreational facilities for ethnic minority seniors to keep them mentally and physically active. (Dr. Lalli runs a computer lab for seniors and holds computer workshops and workshops on other topics, such as how not to become a victim of fraud.) Health care providers who are culturally sensitive and aware and understand the barriers to care that ethnic minority seniors face. Facilities with ethnically appropriate language, food and cultural activities. PICS is an example for Indo-Canadian seniors. Seminars on health and other topics in places where seniors gather. Information about health care and services for seniors in their language. Access to ethnic radio and TV. Changes to curricula at professional colleges to promote multiethnic and multicultural awareness. Encourage youth who speak seniors’ languages to volunteer for activities with seniors. Interpreters should be readily available at health service outlets.

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Presentations: Navigating Health/Mental Health Care for Ethnic Minority Seniors, Rosemary Meier, MB, ChB, MSc, FRCPsych, FRCPC; director of Psychogeriatric Services, Mental Health and Addiction Program, St. Joseph’s Health Centre, Toronto, ON (academic speaker)

Session 2: Knocking on Doors

Session two, Knocking on Doors, looks at how seniors find the information they need to get to services, how they present themselves or make themselves understood once there and how the attitudes of service providers affect that care. The first presenter was psychiatrist, Rosemary Meier (University of Toronto and St. Joseph’s Health Centre), who reported on the findings of her study with Joel Sadavoy on the Ethnoracial Seniors Project in Toronto. This project looked at barriers to access to mental health services for Tamil and Chinese seniors. Carla Ambrosini is a pharmacist working with the Medication Management Program of the Fraser Health Authority. Carla spoke to both the challenges of ensuring that ethnic minority seniors in the community are taking all and only the medications that they need and ways of overcoming perceived barriers. Finally, Mohinder Sidhu, who is active in several Punjabi seniors’ organizations, drew our attention to difficulties that Punjabi seniors experience in their efforts to access services such as home care.

Experiences of a Home Care Pharmacist Caring for Ethnic Minority Seniors as They Navigate the Health Care System, Carla Ambrosini, BSc; Medication Management Program, Fraser Health Authority, Vancouver, BC (health care provider speaker) Barriers Facing Indo-Canadian Seniors, Mohinder Sidhu, MA; Vancouver, BC (senior speaker)

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Navigating Health/Mental Health Care for Ethnic Minority Seniors Rosemary Meier, MB, ChB, MSc, FRCPsych, FRCPC; Director of Psychogeriatric Services, Mental Health and Addiction Program, St. Joseph’s Health Centre, Toronto, ON Rosemary is the director of Psychogeriatric Services for the Mental Health and Addiction Program at St. Joseph’s Health Centre in Toronto and a psychiatric consultant with the Geriatric Mental Health Outreach Team of the Ontario Ministry of Health and Long-Term Care (MOHLTC) and other organizations in Ontario. In addition, she is an assistant professor of psychiatry and public health sciences in the Faculty of Medicine and chair of the advisory committee of the Institute of Life Course and Aging, both at the University of Toronto. Together with Dr. Joel Sadavoy Rosemary was a principal investigator for the Ethnoracial Seniors Project in Toronto.

Rosemary presented the findings of the Ethnoracial Seniors Project she conducted in Toronto from 1992 to 2002 with Joel Sadavoy and Amoy Yuk Mui Ong. The purpose of the study was to identify barriers to mental health services for ethnic minority seniors. Two ethnic communities were the focus: Chinese, including Mandarin and Cantonese speakers, and Tamils from Sri Lanka. The study made use of qualitative research in the form of seventeen focus groups that met for between two and four hours each to discuss issues related to caring for seniors with mental health problems. Ten of the groups were in the Chinese community and seven in the Tamil. The groups varied in size from ten to eighteen people with the exception of the doctors’ focus groups, which had between two and eight. In addition to focus groups for doctors who had significant dealings with one of the communities, the other groups contained seniors only, family members of seniors only, a mix of family members and seniors, and service providers including community service workers and health care providers. Discussion in the focus groups was guided by a researcher and followed a structured format. A preliminary pilot study indicated that vignettes of cases of mental illness were necessary to focus discussion on more severe types of psychiatric illnesses, so vignettes were presented in each group. The vignettes were checked for clinical accuracy by experienced geriatric psychiatrists, who were blind to the study. It was also hoped that using clinically accurate and realistic vignettes would tell the researchers whether the Chinese and Tamil participants recognize

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the same mental illnesses that the Canadian medical system recognizes. Some of the focus groups met once, but some met as many as five times. All the discussions were taped recorded, transcribed and then analyzed by a number of researchers. In addition, the researchers tried to identify their own biases in relation to their analyses of the tapes and their transcriptions. Overall, the researchers involved the two communities in the project by forming relationships with key community members and then branching out, snowball style, to recruit more participants. The focus group discussions were conducted in the language that was most appropriate for the majority of focus group members, whether Mandarin, Cantonese, Tamil or English. A simultaneous interpreter was used if one was needed. Finally, seniors were defined as being aged 65 and older in the Chinese community and aged 55 and older for the Tamil community, because Filial piety was sometimes in Sri Lanka the pensionable age is 55.

put forth as an ideal, but was

The results of the study revealed a lack of information about and understanding of mental disorders. The reasons for this might be cultural, but it is also due to the fact that seniors rely on community organizations they trust for care. These organizations, however, are not designed or funded to provide mental health services. So what we see is a lack of services that combine aging, ethnic knowledge and knowledge about mental health disorders, which is a problem. Of course there are services in the mainstream that are designed to help seniors with mental illness, but limited language interpretation services effectively deny ethnic minority seniors access to these services.

not always practiced.

Methods used successfully to educate seniors about the myths of mental illness were skits and small discussion groups. The skits were part of community conferences that were held as a follow-up to this study. The actors were several generations of local community members whose scripts were vetted to make sure they presented information from the study accurately. Another problem found within the health care system had to do with follow-up care. Although there are more and more opportunities for assessments in terms of mental health problems, there is also a need for continued care and follow-up after the assessments take place. Community service workers can and often do help fill in the gap, but they are not kept informed of seniors’ medical situations by doctors.

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This occurs because doctors are unfamiliar with community organizations. Also, Ontario privacy laws prevent the sharing of patients’ medical information. The issue of inappropriate referrals also emerged from the study. Family doctors have a tendency to refer seniors to other doctors they know, rather than to the most appropriate doctor for treatment. A number of social stressors were identified for the seniors in both communities. Many seniors experienced problems within their families that related to their dependence on family members and in some cases to their status as sponsored (Family Class) immigrants. Filial piety was sometimes put forth as an ideal, but was not always practiced. Seniors’ dependence on their children and the involuntary nature of their immigration were found to lead to low self-esteem and a sense of demoralization for both groups.

Recommendations

Family doctors should form stronger ties to the ethnic communities they serve and increase their knowledge of the community resources that seniors use. Health care services must be made available at times when working family members can take seniors to access them, such as in the evenings and on weekends. More interpretation services are needed so that seniors are able to speak to health care workers without family members present. It is important for seniors to be able to speak to service providers without a family member present because there may be situations of abuse or violence. Education is needed to improve literacy, health literacy and health status. Focus groups and community-based skits were found to be effective. Seniors need to feel connected to support groups; they need a sense of participation and belonging. The importance of friendship was a theme that emerged.

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Recommendations cont.

Outreach and counseling programs should be established for seniors. Two resulted from this study to serve these two communities: the Chinese Seniors Health Centre and Vasantham (Tamil Seniors Wellness Centre). These focused on home visits for assessment, counseling and education with isolated seniors. Follow-up evaluations are needed to make sure that research findings are used to make changes that improve the lives of ethnic minority seniors.

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Experiences of a Home Care Pharmacist Caring for Ethnic Minority Seniors as They Navigate the Health Care System Carla Ambrosini, BSc; Clinical Pharmacist, Medication Management Program, Fraser Health Authority, Vancouver, BC Carla worked as a clinical pharmacist at Surrey Memorial Hospital for 14 years before joining the Medication Management Program at Fraser Health in November of 2005. As a first generation Canadian whose parents were born in Italy, she has first-hand knowledge of the problems immigrants face when they come to Canada and do not speak the language or understand the culture.

The Medication Management Program helps seniors to continue to live in their own homes. As Carla explained, “We hope to keep people living in their communities, because what I’ve found is that’s where they want to be—they want to be at home. They don’t want to be in the hospital.” "We hope to keep people livTo achieve this, the program tries to reduce drug-related problems for seniors ing in their communities, living at home after their release from the hospital. because what I've found is

that's where they want to be

Health care providers contact seniors by telephone soon after they return home —they want to be at home. from the hospital to schedule a home visit, but there can be problems. First, They don't want to be in the there is the problem of language. If hospital." Carla phones a senior, but cannot talk to anyone in English, the follow-up ends right there. There are also time pressures. Carla recognizes that there is only one of her and, as a result, she is not always able to call everyone who has just been released from the hospital. Another common problem is a lack of communication between health care workers, seniors and the family members who take care of them. For example, communication problems mean that seniors and their families may not understand how to take the medication a doctor has prescribed. Seniors and their families may not know who to call for help. In some cases, a senior may not be able to go to a pharmacy to fill a prescription. All of these problems could be avoided if seniors and their families were given more information when they leave the hospital and had someone to go to within their communities for some basic, day-to-day support, especially when they

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are making the transition from the hospital to home. Carla explained, “When patients go home and run into problems, who do they call? How are they going to navigate the system?”

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Case Study 2: This man was 74 years old and Punjabi-speaking. He was being taken care of by his son, who was able to interpret for Carla. This man had a number of conditions he was taking medication for. The lesson we can learn from this case is that not only do we have to think about all the different medicines a senior has been prescribed in this country, but also what they are taking from their home country. As it turns out, this man was taking the same medication from his home country as he was prescribed in Canada.

Case Study 7: In this case, a 76 year old woman who recently immigrated from India was in the hospital. Her blood sugar levels dropped because she wasn’t eating. This was because the food was different. As a result they lowered her blood sugar medication. When she went home and started eating again, her levels shot up. When she went home her blood sugar shot up. Her family was concerned, but no information or dietary recommendations were provided. Carla received help and provided some information in Punjabi.

Case Study 3: This 73 year old, Punjabi-speaking woman came into the hospital with what looked like an allergic reaction to some of her medications. She had with her a piece of paper that had written on it, “Avoid NSAIDS and ACE inhibitors.” How many people know what that is? Sure enough, some of the medications she was taking contained these (Fosinopril and Voltaren). These are also found in Advil, which can be bought over the counter. This woman’s medication was changed and she was given some easy-to-understand information on what she should avoid. The lesson here is: “Use simple language that anybody can understand, but particularly people where English is not their first language.”

Case Study 6: This 77 year-old, Punjabi-speaking woman was living alone in a basement suite in the house of a family from the same culture. Because of this, it was assumed she had lots of family around, but these people were not her family. She was labeled as noncompliant in taking her medication on Pharmanet, but this wasn’t really the case. Her son lived far away and wasn’t able to help her on a regular basis and she was unable to get to the pharmacy by herself. She was also unaware that there is home lab monitoring. Carla and other health care providers contacted the pharmacy to arrange for delivery of medication, and also arranged for her to get the home lab monitoring service. This woman was helped by people who were not able to speak her language. Carla added, “I think we just need to get over language and use whatever tools we can to help our seniors.”


Carla spoke about building those all-important relationships between people — between seniors, nurses, doctors, home visiting health care professionals, and others who work with and know seniors in their own communities. A simple but extremely important idea is building linkages with local, community pharmacists: “There’s a big community system that I am learning to appreciate. One area is the community pharmacies themselves. I like to try to build linkages, especially within ethnic minority communities. If their community pharmacist can speak the language, that’s great! All I have to do is provide information and use them for follow up. They know the families. Sometimes the community pharmacist won’t know what happened to the patient in the hospital, so I try to build linkages. . . . I try to use the people who know the culture and who speak the language to provide that day-today support.” Carla also gives information to doctors about the patients she visits at home. Seniors often do not have a primary care physician or they may use a walk-in clinic after their treatment in the hospital. By the end of the day, the senior may have seen three or four different doctors, who not only do not speak their language, but also have no idea what happened to them in the hospital. How then is the senior’s primary care doctor going to be able to explain medications and treatments to the senior if they have no idea what happened to them? Carla again tries to bridge the communication gap by letting doctors know what happened in the hospital and what the senior’s situation is at home. This might include, for example, information about the level of stress and burden for the senior’s family member caregiver. Another example of important information that can be given to a doctor after Carla visits a senior in their home is whether the senior is actually taking the medication the doctor thinks they are. Carla usually communicates all of this by fax, but sometimes she visits a doctor in their office to provide information about a patient. Examples of the case studies from Carla’s talk appear above. For a summary of all the case studies Carla’s power point presentation can be viewed at www.hccrn.com.

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Recommendations

Information should be communicated in a way that is easy to understand, both verbally and in written form, so that family members and seniors can understand how to take medications and what their side effects might be. This information should be provided in an appropriate language for the senior. Multilingual staff should be increased in Surrey/North Delta. All seniors should be given a phone number they can call or have someone call for them if they have questions or need help. This phone number should be given at the time of their release from the hospital. All seniors should be given a follow-up phone call within 48 hours of their hospital release to see if they have questions or need help. Health care workers should increase their familiarity with the culture(s) of their patients to help them provide better care, even by non-verbal means, if they cannot speak the language of the patient. Health care workers should increase their understanding of the problems their patients face. Health care providers should communicate more with each other about a patient’s care and status. Health care providers should build linkages with care providers and facilitators in the seniors’ communities, for example with local pharmacists, who may know the seniors and speak their language. Although providing information in an appropriate language is important, we should also remember that we can help seniors even when we can’t speak their language.

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Barriers Facing Indo-Canadian Seniors Mohinder Sidhu, MA; Vancouver, BC Mohinder came to Vancouver from India in 1970 after receiving an MA degree in Punjabi Language and Literature. In Vancouver, she taught Punjabi to children at the Khalsa Diwan Society for twenty years, including twelve years as director of the program. She continues to serve the Indo-Canadian community through her work with seniors’ organizations and advocacy programs. As part of this work, Mohinder was trained as a workshop leader and has conducted advocacy workshops in Punjabi for other seniors.

Speaking as a senior, Mohinder identified some of the biggest problems ethnic minority seniors face in accessing health care. The main barrier to accessing health care is language. This is especially true for the seniors who are sponsored when they are already elderly. Most find "When a doctor explains it difficult to learn English if they do not speak prior to immigration. Very few things to a senior, the senior seniors have the opportunity to take ESL classes, and sometimes the ability to says ‘yes,’ but really the senspeak a second language can be lost ior doesn't understand. The with age. Seniors in hospitals and in doctors’ offices cannot express how they senior says ‘yes’ because feel or describe their symptoms, whereas those in long-term care can become they are tired of saying they very isolated and depressed.

do not understand."

The problem of not being able to communicate with health care workers is made worse by the fact that doctors are largely unaware of the barriers to access that seniors face. Mohinder provided an example: “When a doctor explains things to a senior, the senior says “yes,” but really the senior doesn’t understand. The senior says “yes” because they are tired of saying they do not understand.” Without English there are other barriers as well, for instance, access to public transportation. Without being able to use buses and the Skytrain by themselves, seniors become totally dependent on friends and family members. Seniors don’t like to ask family members to drive them because they are often too busy. A senior’s own grandchildren

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may not speak their language or there may be no one in the family who speaks English well enough to help the senior access services. As a result, seniors may become housebound and unable to participate in social and other kinds of activities. In addition, seniors with a number of health risks can have difficulty using medications, or they may take a number of prescriptions at the same time. Who can they ask for help? These difficulties are worsened by their lack of English. In addition to language problems, Mohinder highlighted the fact that many seniors simply do not know what they are entitled to in Canada. This relates both to language and the problem government agencies and other organizations have getting information to those who need it. For example, seniors may not know where to buy low-cost bus passes or how to apply for home support services, if they even know these services exist. Hearing impairment may also be a problem if a senior has to access information or a service by phone. In terms of housing options, seniors are often unaware of the types of housing and services that exist such as assisted living, rental assistance and long-term care. There are other types of services seniors may be entitled to, but again Mohinder explained some of the difficulties involved: “Not many seniors can go to fill out forms and applications and do everything on their own, because they do not know where to go and where to get those forms.” One solution she gave is to hold more government and community sponsored workshops in the seniors’ own language, where seniors gather, such as temples and community centres. Mohinder has been a senior advocacy workshop leader, providing information about where to get forms for government services and how to fill them out. Then there is the issue of sponsorship, which can make seniors very dependent on their families. Often the senior is brought to Canada to do childcare, cook and clean. This can become abusive for the senior if they are not permitted free time. The dependency itself can make abuse possible. Families can become angry when the senior is no longer able to do domestic work. This dependency is also financial. When a senior is sponsored by a family member, the law that denies a senior access to money from the government for ten years after their arrival can be very difficult for seniors. Their situation in their home country would be very different. They would have their own home, land, a pension, status, and they would speak the language fluently. Another health-related problem seniors face is difficulty getting exercise. One reason is the lack of recreational facilities for seniors;

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another is seniors’ fear of going outside: “They are scared. Recently in Bear Creek Park, two East Indian seniors were beaten to death, so people don’t like to walk too far from their houses.” If we want to view health care access in broad terms that include disease prevention, access to a safe place to walk and get exercise is an access issue too.

Recommendations Seniors need more funding and more services, especially access to translation and interpretation services. Seniors need more educational outreach programs in their own languages where they gather, for example, in temples and community centres. Workshops can educate seniors about what services are available for them and how to get them, including how to fill out forms. Seniors need advocacy programs to teach them to speak up for themselves and know their rights. Ethnic-focused housing facilities, such as those run by PICS, are a great option for meeting seniors’ care needs.

Health care professionals, including doctors, need to be more aware of the barriers to health care access seniors face, including language.

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Presentations: Service Utilization: Issues Surrounding Seniors’ Use of Long-Term care Options, Naina Patel, PhD, OBE; University of Central Lancashire and director, Policy Research Institute on Ageing and Ethnicity (PRIAE), Leeds, England (academic speaker) Service Utilitzation: Barriers and Solutions, Jocelyne Wong, BScN, MN, MHA; operations leader, Mount Saint Joseph Residence and the Geriatric Psychiatry Unit, Mount Saint Joseph Hospital, Vancouver, BC (health care provider speaker)

Session 3: When is a Home not a Home?

Session three, When is a Home Not a Home?, focused on the design and delivery of services. These presenters were asked to speak to issues surrounding seniors’ use of long-term care options. Our first speaker in this panel, Naina Patel (University of Central Lancashire), came to us from the United Kingdom where she is the founder and director of PRIAE: Policy Research Institute on Ageing and Ethnicity. Naina’s talk focused on the findings of two studies: the work for the Royal Commission on Long-Term Care for the Elderly in 1998 and PRIAE’s ten-country European study begun in 2001, the Minority Elderly Care Project, which took an indepth look at the experience of aging across twenty-five ethnic groups. Jocelyne Wong is the operations leader for the Mount St. Joseph Residence and the Geriatric Psychiatry Unit at Mount St. Joseph Hospital, Providence Health Care. Jocelyne spoke about Chinese cultural values and how they might affect care in a Western hospital setting. Our last speaker was Pepita Hernandez, president of The Philippine Bagong Pag-asa Society, an organization for Filipino seniors. Speaking as a senior and a retired health care provider, she related the experiences of some Filipino seniors with Canada’s health care system.

A Filipina Perspective, Pepita Hernandez, BA; Surrey, BC (senior speaker)

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Service Utilization: Issues Surrounding Seniors’ Use of LongTerm Care Options Naina Patel, PhD, OBE; University of Central Lancashire and Director, Policy Research Institute on Ageing and Ethnicity (PRIAE), Leeds, England Naina is founder and director of PRIAE, the Policy Research Institute on Ageing and Ethnicity, an independent, non-profit institute working in the UK and across Europe since 1998. Naina designed and led the Minority Elderly Care (MEC) Project at PRIAE under the European funded Fifth Framework Research Programme, a ten-country research project that explored the experiences and needs of 3,277 minority elders (50+ years of age), 901 health care professionals and 312 voluntary organizations. In addition to her work with PRIAE, Naina is Professor of Ageing and Ethnicity at the Centre for Ethnicity and Health at the University of Central Lancashire. She was awarded the Queen’s Honour in 2001 for her work on aging minorities.

Naina’s talk focused on the findings of two studies: the work for the Royal Commission on Long-Term Care for the Elderly in 1998 and PRIAE’s ten-country European study begun in 2001, the Minority Elderly Care Project, which looked at the experience of aging across twentyfive ethnic groups. The MEC study was carried out using face-to-face interviews to complete a structured quantitative questionnaire, which was designed through a pilot study of ethnic minority seniors. Results of this study can be downloaded from PRIAE’s website at www.priae.org. Naina began with the hidden power of language: “You talk about ‘ethnic seniors’ in Canada. Let me say how refreshing it is to come to this event and not hear the word ‘migrant.’ That is a popular term across Europe; people constantly call you a ‘migrant.’ I’ve been in the UK for over thirty-five years and I often ask people, ‘When do I stop being a migrant?’ Forty percent of the minority population in the UK are born there, so clearly it’s an absurd term. Of course migration is the reason we’re here, but to continue to refer to people as ‘migrants’ may well explain why we have such huge problems with integration.” In Europe organizations like PRIAE have promoted the term “minority ethnic elderly,” which is increasingly being used by policy-makers. But of course there are still many problems. As Naina explained, “One minority elder had this to say, ‘Paying taxes, I’m treated as English. Getting services, I’m treated as Asian.’ That’s a very powerful quote for us because it’s

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really talking about the inequity of services.” In the European context there has been very little in the way of research on the ways age and ethnicity or race intersect to address barriers to care. Naina described the area of aging and ethnicity as an issue of “undevelopment in the developed world”: When race is considered, age is blind (left out); when age is considered, race is blind (minorities are left out). This lack of focus on the specific needs and problems of minority elders is what gave rise to PRIAE’s large-scale project, Minority Elderly Care (MEC). However, conducting research is not enough. A consistent message from seniors across the UK is, “We’ve had too much discussion, action is overdue.” PRIAE’s goal is to inform policy decisions to improve the everyday lives of seniors. Turning to the results of the two studies, Naina noted that the health of minority elders is poor compared to non-minority "Atmosphere" or "the soul of seniors. Yet there is a belief that “they [ethnic minorities] look after their own.” a house" goes beyond simply Statistically more minority seniors do supplying material goods and live in extended family households, however, living in an extended family doesservices. If there is no soul, n’t necessarily mean that all their needs are taken care of. Increasingly family there is no home. members are working very long hours and have less time to provide elderly care. Within the context of housing options for seniors, the research has shown that, “One of the things minority ethnic elders say when they have an opportunity to express a viewpoint is that they do like to have different choices.” What should some of those choices look like? Based on the MEC study, what minority elders want most in a care facility is the following: culturally responsive care, staff who know how to work with elders, and “atmosphere.” “Atmosphere” or “the soul of a house” goes beyond simply supplying material goods and services. If there is no soul, there is no home. Minority elders also want to have a say in how the facility they live in is run. For example, visitors shouldn’t be asked to leave at nine in the evening. In ethnic homes in the UK people often visit late at night and this needs to be accommodated. All of these points relate to the idea of quality. Overall, a key finding from the MEC research is the need for an increase in the quality of services provided. As Naina observed, “Until this research was published nobody even thought

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about quality as an important dimension of service for minority ethnic elders.” The largest barrier to access is that information about services is not reaching the minority elderly. There is no doubt that not being able to speak English is a barrier to care. However, getting information to those who need it goes far beyond this problem. Often information is not widely available to the public or it is just too complicated to understand, even by those who may be better educated and/or speak English as their first language. Unfortunately, government agencies often blame seniors themselves for not being able to access information about services. Naina explained, “The research The largest barrier to access tells us consistently that the marketing of services needs to be tailor-made to is that information about these communities.” In other words, services is not reaching the getting information about services to minority elders is the job of the service minority elderly. providers. We know that minority elders want information to make choices. We need to get that information out there. What are some solutions? Naina believes non-governmental, ethnic organizations are a key to providing services of high quality. These ethnic organizations are “critical players” precisely because they already have the trust of ethnic minority elders and are being used by them for service provision. Rather than replacing them, government agencies should help them innovate and grow. As Naina explained, “They are not like your not-for-profit majority organizations. They set themselves up because of the lack of culturally responsive care. Today some of them are vibrant organizations. Over 80% want to expand into housing provision and into much larger daycare service provision, but they have consistently found that they lack resources.” The downside of ethnic organizations is that they can be passive in terms of the kinds of services they offer. Naina used Dr. Lalli’s example of seniors playing cards at one ethnic seniors centre in British Columbia to illustrate her point. This passive, card playing scenario occurs across Europe. As mentioned above, the problem may be that these organizations are unfunded and, therefore, unable to provide more stimulating and productive services. If government agencies increase their funding, foster greater co-operation/exchange and encourage them to innovate, this problem can be solved.

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Recommendations

Information about services needs to be made available to communities in more appropriate and accessible ways. Local, ethnic-focused community organizations need to be financially supported by governments at national and local levels so they can expand their services into areas such as housing and health care. Most would like to expand into these areas, but cannot because they are entirely self-funded or under-funded by the government. We must recognize that these organizations are the ‘primary providers of services’ (i.e. they are ‘substitutes to the mainstream services’ to ethnic elders [Patel 1990]). As such, we must help them innovate and improve. More emphasis must be placed on providing high quality services to seniors, not just on whether a service is provided or not. For example, quality in an ethnic home or care facility includes “atmosphere.” This goes beyond simply supplying goods and services. Housing facilities need to be more participatory in terms of letting the elders who live in them and their families shape their policies and decide how they are run. Minority elders should be given more opportunities to be active participants in deciding upon and shaping services and policies in general.

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Service Utilization: Barriers and Solutions Jocelyne Wong, BScN, MN, MHA; Operations Leader, Mount Saint Joseph Residence and the Geriatric Psychiatry Unit, Mount Saint Joseph Hospital, Vancouver, BC Jocelyne has worked in the health care field for the past fifteen years and is currently an operations leader at Mount St. Joseph’s Hospital, where she oversees a one-hundred-bed longterm care facility and an acute geriatric psychiatry unit. Mount St. Joseph’s (MSJ) is the most interesting place Jocelyne has worked due to the fact that about 96% of the seniors there are ethnically Chinese, which is also her background. As a result Jocelyne has had to make use of her professional training and experience, as well as her personal knowledge of Chinese culture.

Jocelyne spoke about Chinese cultural values and how they might affect care in a Western hospital setting. Chinese parents are thought to have sacrificed their lives for their children. In return, children are expected to do the same for their parents. By definition then the decision to put a parent into long-term care is likely to be seen as a failure on the part of the child. What happens once a Chinese senior is placed in long-term care or admitted to a hospital? Chinese expect that decisions about care will be based on an extended family model. In other words, decision-making is a group process centred on the family. Within the family there is a designated decision-maker, typically the oldest child, son or daughter. Decisions are viewed as affecting all the members of the family as a unit and therefore they must not compromise the family’s “face” or honor within the community. Health care providers should be aware of this so that extended family members can be included in meetings to discuss health care options. Health care providers should also not expect a decision to be made right away if the family’s designated decision-maker is not present. Another aspect of Chinese culture is its emphasis on hierarchy, which leads Chinese to both fear and respect authority figures. In a hospital setting, this means that dissatisfaction with care will not be openly stated because of a fear of retaliation. How then should feedback from patients and their families be elicited? Jocelyne explained that indirect and informal channels of communication work best and provided the following example. A year or so ago, a number of families

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complained to the staff at MSJ about the quality of the hospital’s food. Surveys were carried out and a food committee was set up so that family members could formally voice their complaints. However, in nearly every case the very same people who had criticized the quality of the food had only positive things to say. Jocelyne decided to follow up by speaking informally to the families. Once again, the complaints surfaced and this time they were effectively dealt with. Jocelyne has experienced this on a number of occasions and recommends that dissatisfaction with care be handled informally, rather than through in Chinese culture talking official channels such as surveys and meetings. Although these methods may about death is considered make sense in the context of Western culture, they are unlikely to be effective taboo. with Chinese seniors and their families. Jocelyne made another interesting point about the care concerns of Chinese families. Sometimes a steady stream of concerns from family members is a way for children to show their parents that they still care for them. By voicing their concerns to nursing staff and then coming in and providing the “missing” care themselves, adult children may be saying symbolically to their parents, “I still care for you.” This harks back to the point made above that the decision to place a senior in a facility is likely to be experienced by children as a failure to live up to their obligation to care for their parents at home. In addition, because Chinese are not comfortable talking openly about their feelings, using the pretext of unmet care needs enables family members to show their feelings for one another through their actions rather than words. Health care providers caring for Chinese seniors may have to address end-of-life issues. However, in Chinese culture talking about death is considered taboo. In a hospital context it’s easy to see how this death taboo can prevent people from making end-of-life medical decisions and funeral arrangements in advance. On the other hand, waiting for an emergency is the worst possible time to begin to discuss these issues. Jocelyne explained the strategy used at MSJ for dealing with the death taboo and making end-of-life decisions. A clinical nurse leader holds a family meeting, but doesn’t talk about death directly. The nurse finds out if the decision-maker is present. If not, he or she prepares materials explaining care options, but understands that a decision will not be made at that time. The nurse shows a graph of the patient’s weight to the family indicating a gradual decline and

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explains his or her condition in simple terms. The nurse then explains that eventually the patient will not be able to eat enough to sustain life. At that point the family understands that a decision has to be made about end-of-life treatment and care without ever having spoken about death directly. A final topic raised by Jocelyne is the meaning of quality of life from a Chinese perspective. The idea that a patient might reach a point where their quality of life is so low that life is not worth living is a modern, Western concept that most Chinese have never considered. From a Chinese perspective, life must be extended for as long as possible regardless of “quality.” This view may also lead family members to expect what Western doctors, nurses and hospital administrators would view as ... two very different cultures extreme measures. Jocelyne again presented an example based on her experican create different sets of ence in the field. A Chinese senior whose condition was rapidly deteriorating was expectations and behaviors rushed down for emergency triage on within the health care setting. Jocelyne’s orders. However, the patient died just as she reached the triage nurse. The family was satisfied with the care the senior had received, because from their perspective all attempts to prolong the woman’s life had been made. Jocelyne, however, received an incident report for her behavior, because the hospital administration thought the treatment the woman received had been extreme under the circumstances. Overall, Jocelyne’s experiences highlight how two very different cultures can create different sets of expectations and behaviors within the health care setting. Educating health care providers about these differences should help them provide more effective and appropriate care to seniors and their families.

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A Filipina Perspective Pepita Hernandez, BA; Surrey, BC Pepita earned degrees in accounting and music at universities in Manila, the Philippines, before immigrating to Canada in 1972. Before retiring eight years ago, she was employed at the New Vista Care Home in Burnaby, where she cared for seniors in intermediate and extended care. For the past four years she has served as president of The Philippine Bagong Pag-asa Society (The New Hope Society), an organization for Filipino seniors. Pepita spoke at the symposium as a senior.

Pepita highlighted what she sees as some of the similarities between Filipino seniors and seniors from other ethnic backgrounds in Vancouver. Seniors often find they have little free time because their children "As the case of Filipinos expect them to take care of their grandchildren. Filipino seniors’ families are shows, we cannot all be put often very busy with their own lives and might not have time for the senior. As is into the same box called 'eththe case for other ethnic groups, if a nic minority seniors.' We Filipino senior becomes ill or unable to care for their grandchildren, there can must take into account the be tension within the family because of the increased burden on the adult chilunique culture and history of dren, who now must care for both their each minority group. There is parents and their children. For cultural reasons, Filipinos expect to take care of no one-size-fits-all problem their elderly parents at home.

or solution."

Despite these similarities, in Pepita’s view many Filipino seniors may not find themselves facing the same barriers as other ethnic minorities, especially in relation to language: “Because 80% to 95% of Filipino seniors speak English, language is not a big problem for us. Filipino immigrants here are mostly professionals – including the seniors. In the Philippines all professionals speak English.” Pepita cited another important difference for Filipino seniors who are in long-term care: “In care facilities, many of the caregivers are also Filipinos, so our seniors do not feel culturally isolated. My experience working in a care facility was very positive. The facility was very multicultural – both staff and residents.”

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From Pepita’s perspective, cultural similarities between Canada and the Philippines make the transition to life in Canada easier for Filipino seniors than for other ethnic minorities. In terms of religion most Filipinos are Catholic, as are many European-Canadians. Pepita noted, however, that Filipinos who are Muslim may experience more of a sense of isolation or cultural otherness. She noted that food in care facilities is not a big problem for Filipino seniors either, “Because of our long history of being colonized by Western countries and our location in Asia, our food is very varied.” Pepita concluded: “As the case of Filipinos shows, we cannot all be put into the same box called ‘ethnic minority seniors.’ We must take into account the unique culture and history of each minority group. There is no one-size-fits-all problem or solution.”

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Thus far we have heard from a diverse forum of speakers in the area of ethnic minority seniors’ access to health care. This open discussion gave those in the audience a chance to respond. What further issues need to be raised? What further questions need to be asked as we continue to explore and develop avenues of inquiry into this important topic? The following section presents highlights and comments from the discussion on the three main topics that were raised by participants:

Open Discussion

Facilitator: Akber Mithani, MD, Mount Saint Joseph Hospital, Vancouver, BC

Topic 1: Medical Services and Medication Topic 2: Ethno-Specific Homes Topic 3: Cultural Competency

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Topic 1: Medical Services and Medication Polypharmacy (Multiple Medications) The number of medications a senior is on is not the problem. The issue is whether they are clinically indicated, the impact they are having on the patient, and how we judge their benefits to the patient. When prescribing medication to seniors, use as little medication as you need: “start low, go slow.” Seniors tend to have multiple diseases, so it’s easy to get to eight to ten medications. I don’t find medication is overprescribed. The solution is to go through each medication, make sure each is appropriate, and find out if the senior is having adverse reactions. If so, we need to consider the dosage. I do this using hospital records and by talking to the patients and their families during home visits. The biggest problem I find is that often a medication should be prescribed because of an indicated condition, but it is not. So the problem is the opposite of over-prescribing medication. With medication usage there is sometimes a problem of a snowball effect of over-prescription: Someone has an adverse reaction to a medication and then they are put on another medication to treat the adverse reaction to the first. Another medication is then prescribed to treat the adverse effect of the second, and so on. Medicine Sharing In the South Asian population specifically, I find my elderly patients share their medications with their friends. In Canada you have to pay for everything, but in India advice is free. Indian seniors do share medications. Seniors need more education about why they shouldn’t do this, for example, their medication may be inappropriate for their friend, they could be legally liable for any adverse reactions their friends have.

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We know from research that Caucasian seniors also share their medication. We should compare data to see if this is more frequent among ethnic minority seniors. Patient Education Even educated, English-speaking family members have difficulty understanding how and when medications prescribed to seniors should be taken. The solution is for family members to talk to the nurse who has been looking after the senior in the hospital and ask questions about the medication before the patient is discharged. Also, arrange to talk to the doctor, in person if possible, by telephone if it is not. All seniors need to have an up-to-date medication list of what they should be taking at home. When they leave the hospital all seniors should be given the phone number of someone they can call with questions or to discuss problems. Medication usage should start while the senior is still in the hospital so that the hospital staff can see if the medication

Bikkar Singh Lalli contributing to the open discussion Building the Interface.

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is working and if there are side effects or dosage issues. People are being discharged from the hospital too early. Seniors sometimes use medication that is out-of-date. People need to be educated not to do this. They need to know that medications get too old to be effective. Doctors should explain a medication’s side effects when they prescribe it. Typically the patient learns about the side effects when they go to the pharmacy to fill the prescription. They become frightened and decide not to take the medication. The key to all of this is how we educate patients and their families. Language Patients and their families must receive information about medication in the language that is appropriate for them. They need this information when they are in the hospital. All seniors should be called in their own language right after they leave the hospital. Invariably, they do have questions and they also need to clarify what happened to them in the hospital. Interpreters are sometimes used when a senior is admitted to the hospital, but they are not used during the hospital stay, at the time of discharge or afterwards. Interpreters should be used at each stage to explain things. When I read information about medication, I don’t understand it. It doesn’t seem like translation into other languages is the only issue. We need to have information that is written and/or verbally explained in a way that is easy to understand. People need to receive information they can understand, and this is not only an issue of translating information into foreign languages. The BC Health Guide is now in Punjabi and Chinese. Medication-specific information depends on the pharmacy. Many ethnic minority seniors can’t find doctors who speak

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their language for a number of reasons. For Hispanics there are not many Spanish-speaking doctors in the Greater Vancouver area. Also many women want to go to a woman doctor, but there may not be a woman doctor who speaks their language. Another issue is that seniors don’t always want their children to interpret for them at the doctor’s office, and their children are not always available to take them. All of these situations point to a need for more accessible interpretation services for doctor’s appointments. Anyone can receive interpretation services about medication and medical issues over the phone in the form of a conference call in 130 languages including dialects. This service can be accessed twenty-four hours a day by calling (toll free): 1-866-215-4700. In Greater Vancouver: 604-2154700. Deaf/hearing impaired (toll free): 1-866-889-4700. On the Internet go to: www.bchealthguide.org. Configuration of Services/Fee Structure Seniors need more time for a doctor’s appointment, but Medical Services only pays a physician for a fifteen-minute visit. The configuration of service and payment is inappropriate for seniors.

Topic 2: Ethno-Specific Homes Segregation/Integration Ethno-specific homes exist in the United Kingdom and people like them. Yet each home contains a broad range of people speaking different languages and from different religious faiths, even though they share some ethnic identity such as being Afro-Caribbean or Asian. Health care providers manage to cater to that. Rather than being an example of isolation and segregation, we tell policy-makers that this is a great model for coming together. I certainly promote ethno-specific homes, but how do we promote integration and tolerance? There have been studies that looked at condos where mostly seniors live and concluded that they are like walled cities. This kind of isolation causes intolerance on both sides.

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Maybe multi-generational-based housing is better: all generations living and working together and learning from each other. This could be a city planning initiative. Segregation can promote ghettoization, but integration can mask the different needs of ethnic communities. What are we asking for, segregation or integration? We need to serve all groups. I am more and more concerned about issues of multiculturalism and interculturalism. The latter is what we are really looking for in Canada. In the United States the government is not interested in ethno-specific homes. What we have done is integrated ethnic minority seniors into mainstream homes in a way that recognizes their distinctive needs. For example, we have social workers bring in ethnic food and provide cultural activities, including ethnic festival celebrations. Integration and tolerance should not be an issue. Planners and policy makers, however, do need to think about these issues. We should focus on providing housing and other things for minority elders. In the UK, 40% of minority elders are in ethnically mixed marriages. Their ideal model is multiethnic care where groups live together and are catered to in different ways. That is already happening. So the issue of integration and tolerance is not very helpful, because minority elders are already integrated in different ways. For example, my dad was given the Indian menu in hospital. He asked for the regular English menu; he wanted custard. He has lived in the UK for thirty years. I think the issue is choice. We need a range of options for individuals. We don’t want to force people into ethnic homes if they don’t want to be there, any more than we want to force them into a non-ethnic home if they want to be in an ethnic environment. I want to comment on ethno-specific homes for Chinese. I have found that the Chinese are more active and much happier in them. One senior didn’t interact in a mainstream home and was diagnosed with dementia. After he transferred to our ethno-specific home, he became very active and talkative. He doesn’t have dementia. So we can under-

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stand the need for ethno-specific homes. When the Ministry of Housing puts out a call for a new housing project, I’ve heard the result is different cultural groups competing for the same resources. Cost/Savings The biggest problem is ethno-specific homes cost more, because you need a more specialized staff. It costs more to set up ethno-specific homes, but we also have to think of the savings. If seniors are happy, they are less likely to fall ill. We have to think long term. Descriptive In Vancouver we have ethno-specific homes. Mount St. Joseph’s is mostly Chinese. At Mount St. Joseph’s the building is very old and, therefore, looks like an institution. We are trying to come up with ways to make it look more like a Chinese home. PICS is an ethno-specific home for Indo-Canadian seniors, who are extremely happy there. They get the food they have eaten all their lives. Every week we ask them what they want. They can call where they live their ‘own home’ for the first time. Research/Informing Policy It’s good to have individual case discussions like this, but until we look at this in an evidence-based way, there won’t be a lot of change in policy. The only way we’ll be able to advocate for ethno-specific homes is if there are studies that show a need for them. At PRIAE we use a community engagement model. We use policy etiquette to help minority elders become more competent at engaging policy-makers. What minority elders haven’t had is a channel and structure to get their ideas across.

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Studies tend to focus on specific homes and are not comparative. The question of comparing ethnic homes would be an excellent basis for a study. The issue is making care personal. We should think about making long-term care better for all seniors, not just ethnic minorities.

Topic 3: Cultural Competency There is a staff problem at Mount St. Joseph’s. The staff, which is 90% Filipino, has very little knowledge about the population they serve, which is mostly Chinese. There is a need for culturally sensitive care as opposed to making sure that a caregiver is from the same ethnic background as the senior. There are a lot of cultural competency and anti-racism programs in the UK, especially in the field of social work. However, in relation to care for minority elders, cultural competency programs are in their infancy. In regard to encouraging integration and raising tolerance, I

hesitate to use the word ‘tolerance,’ because I feel it has a negative connotation. I say, ‘raising acceptance.’ Doing this takes the whole community, the whole organization at all levels to make changes. Overall, it’s an ongoing process. Where I work we have workshops on cultural sensitivity. Afterward people say, “We’re done, we’re sensitive now.” No, it’s not done. Organizations have to keep training people. Changes need to take place at the micro- and macrolevels and they need to be ongoing.

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Summary of Key Points and Recommendations The key issue regarding medication is that seniors should be provided with easy-to-understand information at the time of their release from hospital. This information should be in an appropriate language and should include a phone number the senior or a family member can call to discuss questions or problems. The following numbers can be called to receive interpretation services about medication and medical issues in the form of a conference call in 130 languages including dialects. This service can be accessed twenty-four hours a day by calling (toll free): 1-866-215-4700. In Greater Vancouver: 604-215-4700. Deaf/hearing impaired (toll free): 1-866-889-4700. On the Internet go to: www.bchealthguide.org. Clear, simply information in an appropriate language should be given to seniors to prevent them from sharing medications with their friends or using old medications. Seniors should have a choice of quality care housing that includes ethno-specific homes, ethnically integrated homes with special services for ethnic minorities, intergenerational homes as well as other options. Organizations should help ethnic minority seniors become more competent at engaging policy-makers. Research data from systematic studies are needed to advocate for policy changes to better the lives of ethnic minority seniors. Cultural competency training for the people who work with and care for ethnic minority seniors is important and is an on-going process.

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Workshop 2, Immigrant Status, focused on the effects of immigration status (especially sponsorship) on the experiences of immigrant seniors and their efforts to access appropriate health care. Their potentially higher susceptibility to neglect and abuse was also explored. Workshop 3, Housing Options, raised key issues surrounding the range of housing available for ethnic minority seniors from community housing to care facilities. Participants explored what has worked well, what has been less successful, and what could be done in the future to enhance the lives of ethnic minority seniors in this area.

Concurrent Workshops

Workshop 1, The Senior in the Family, aimed to enhance participants’ understandings of the ethno-cultural characteristics of older adults in Canada and explored barriers to service access within the context of intergenerational relationships and the family.

Workshop 4, Language and Interpretation, explored issues related to language and interpretation as barriers to ethnic minority seniors’ access to health care and other services. Cultural and historical influences on communication skills and styles were also discussed. Workshop 5, Complex Care and End-of-Life, drew on the co-chairs’ experiences as health care providers who have worked with ethnic minority clients in both palliative care and hospice settings. Topics of discussion included culturally informed beliefs that can surface when a family member is terminally ill, some of which are not supported by institutional policies and health care practices in Canada.

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Workshop 1: The Senior in the Family Co-chairs: Karen Kobayashi, Daniel Lai, Sid Chow Tan Karen Kobayashi, PhD, is an assistant professor in the Department of Sociology and a research affiliate at the Centre on Aging at the University of Victoria, British Columbia. She presented findings from her research with ethnocultural minority older adults from the Japanese, Chinese and South Asian Canadian communities at this workshop. Daniel Lai, PhD, is a professor and Alberta Heritage Health Scholar in the Faculty of Social Work at the University of Calgary. Daniel is involved in numerous research projects on the health of Chinese seniors across Canada. His 2003 project, Caregiving in the Chinese Community, was the focus of his workshop presentation. Sid Chow Tan, BA, was born in China and has lived in Vancouver for the past thirty-five years. A media producer and activist in the Chinese-Canadian community, he is also employed as a seniors organizer with the Downtown Eastside Residents Association. Sid spoke at the workshop as a family member caregiver based on his experience caring for his Chinese grandparents.

Daniel Lai began by presenting his research findings on the health of Chinese older adults (55+) living in seven Canadian cities compared to the health of older adults in the general population. There were a total of 2,270 Chinese older adults in the study. These seniors were recruited for the study by initially cold-calling households with Chinese surnames that were listed in the local telephone directory of each city involved. If there was a senior in the household who fit the research criteria, he or she was invited to take place in a face-to-face interview conducted in either English or an appropriate Chinese dialect. Interviews took place in 2001 and 2002 using a structured questionnaire. Based on self-reporting, the Chinese seniors in the study had consistently lower levels of health than seniors in the general population in terms of a number of illnesses: high blood pressure, stomach problems, eye problems, and diabetes. In fact, the Chinese seniors reported having an average of 3.3 illnesses each, while those in the general population reported 2.2. Within the context of this higher rate of illness, how do families provide care for their aging Chinese parents?

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According to another study by Daniel on Chinese family caregivers (n=339) in Calgary, the findings show that the adult children of Chinese seniors are strongly motivated to provide care for their parents at home, based on the Chinese cultural value of filial piety. Filial piety refers to a Confucian belief that children are obligated to take care of their parents as well as worship the family’s ancestors after they die. In this way, younger generations ensure the continuity of the family and serve those who have gone before them. Individuals are embedded within the family and are expected to put their duties to the family first, above their personal wishes. Chinese-Canadians are more likely to care for their parents at home if they accept the idea of filial piety. They are also more likely to view the care they give in positive terms and as less of a burden if they accept and identify with the values of filial piety. Of course this doesn’t mean these caregivers never experience a sense of burden. The study found caregivers are more likely to feel burdened if they themselves have health problems or if the senior they are caring for has complex care needs. There are other reasons Chinese families might avoid putting the senior in the family in long-term care or using other types of health care services: a long waiting list, language problems, not knowing that services exist, the expense, the facility or services are not provided in a culturally sensitive way, office hours are inconvenient, the procedures for using the services are too complicated, no transportation to access services. Karen Kobayashi has done research with ethnocultural minority older adults in British Columbia – i.e., from the Japanese, Chinese, and South Asian Canadian communities. She spoke about the difficulty of gaining access to individuals within these communities to conduct research. Being a community insider can be helpful, but it can come with other problems such as an awareness of factions within the community and a vulnerability to them. Another issue is that an outsider may be allowed access that an insider would not. In Karen’s case, older second generation Japanese Canadian males were reluctant to provide her with information (their income and work history) primarily because they felt uncomfortable with her insider status as a younger, third generation female (she is Japanese-Canadian). Other obstacles that relate to doing research in ethnocultural minority communities include advisory committee scrutiny (Karen’s work involved traveling throughout BC to a number of residential locations where Japanese Canadians live). The types of questions the researcher

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wishes to ask must be approved in advance and some may not be deemed culturally or generationally sensitive. For example, Karen found that questions related to sexual health were taboo in her project. Research in general tends to try to pigeonhole people, including the researcher. Yet the reality is that there is diversity and variation within all communities. Also, general values and beliefs are not necessarily the same or consistent with actual behavior. Even eliciting answers to questions can be difficult. People may answer “yes” when they think that is what the researcher wants to hear. A key solution to this is to base research on a relationship of trust, which only develops over a long period of time. Research often is designed to present one aspect of a group or community, which can be misleading or at the very least not paint a complete picture. Finally, findings are often interpreted by researchers who have their own biases. There is no “cure” for this dilemma that has come to be known as “the postmodern condition,” but that does not mean we should stop doing research. It does mean we have to ensure that what we use to inform policy is credible. How do we achieve this? We use a peerreview process in order to have our work published. We constantly reevaluate whether we can rely on a study to inform policy. And we try to have multiple studies that inform one another to enrich our understanding of findings. Just as research is multilayered, so is filial piety. The seniors in the communities Karen studied had a diverse understanding of filial piety in terms of the expectations for care they would receive from their children. Yet Karen emphasized that we should be aware of the complexity and context of their expectations. For example, there may be different understandings across generations with the result that seniors’ expectations for care may not be the same as the level of care children are willing or able to provide. Sid Chow Tan told his family’s story beginning with his grandfather’s emigration to Canada from China in 1918 after paying the $500 head tax. When the Chinese Exclusion Act was lifted in 1947, his grandfather “created” paperwork to enable his wife and “family” to enter Canada in 1950, after a quarter century of separation. While his wife was a legal immigrant, the two “paper son” boys (a nephew and a grandson) were illegal until a government general amnesty in 1964. This meant there was always the worry that the authorities would come after the family. Sid focused on his grandparents’ relationship with one another and on his relationship with each of them, including

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how he cared for them in their old age. Sid’s story put a face to the workshop’s focus on family history and the nature of intergenerational relationships. As Karen explained, “We can only truly begin to understand care giving and the negotiation of social support in families if we have insights into how and why relationships have evolved over time. Sid’s life story provided a wonderful example of how historical, social and cultural needs shape family relationships over the lifecourse.” It also reminds us that each senior a researcher, health care provider or policy-maker encounters has a long history full of stories, including those that are difficult to tell.

Recommendations It takes a long time to build up relationships and trust to do meaningful research. Researchers need to take that time and be patient. The personal background and context of the people researchers study must be included for research to be meaningful. These may be missed if we rely only on large surveys or if we do not take the time to get at the stories people might be willing to tell. Ethnocultural minority older adults are often excited to be asked for their opinions in their own language by people who really want to listen to them. Researchers should make use of their willingness to cooperate by speaking to them in their own language and taking the time to listen. We need to build strong connections between researchers, policy-makers and practitioners or frontline workers.

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Workshop 2: Immigrant Status Co-Chairs: Shashi Assanand, Sharon Koehn, Baljit Sethi Shashi Assanand is a registered social worker, who has worked with the immigrant community for the past thirty years. Shashi is the founder and executive director of the Vancouver and Lower Mainland Multicultural Family Support Services Society, an organization funded to help immigrant and visible minority women and their families cope with domestic violence. Sharon Koehn, PhD, has been conducting research with ethnic minority seniors for the past fifteen years. Her master’s research focused on sponsored Punjabi senior women. She has recently completed a CHSRF/CIHR postdoctoral fellowship focusing on barriers to access to care for ethnic minority seniors. She is currently working with the Home and Community Care Research Network and with support from the BC Network for Aging Research to develop initiatives focusing on health care access and utilization of ethnic minority seniors in British Columbia. Baljit Sethi is the executive director and founder of the Immigrant and Multicultural Services Society of Prince George, BC. Baljit, who immigrated to Canada in 1972 from India, currently works with the Committee on Seniors in Prince George and the Prince George Council on Seniors. In 2006 she was honored as the Prince George Citizen of the Year and received the BC Community Achievement Award in April 2007.

This workshop discussed issues that ethnic minority seniors face when they are sponsored by their children or grandchildren as Family Class immigrants to Canada. Many problems arise because of the structure of sponsorship itself, which denies seniors’ access to many BC and Canadian government services for the first ten years of their residence. This means that for their first ten years in Canada, sponsored seniors are not eligible for senior discount bus passes, funding for medication and specialized medical services, housing assistance or pensions. Sponsorship can make seniors completely dependent on their sponsors, who are often their own adult children. For example, seniors may depend on family members for transportation, including trips to the doctor, translation and interpretation, information about services and activities, spending money and housing. Specific examples of hardship that may arise from this dependency include isolation from other sen-

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iors, having to wait three months before being eligible for health care, not being able to afford treatment for chronic illnesses, and not having knowledge about services here in Canada. Sponsored family members are also vulnerable to abuse because of their lack of knowledge of available services and basic rights, language barriers, and social isolation. A short film (in Chinese) made by the Vancouver and Lower Mainland Multicultural Family Support Services Society showed how relations between sponsors and elderly parents can go sour and how this can lead to different types of abuse. If the sponsorship relationship breaks down, the family faces shame in the eyes of the community, the sponsors must repay the government for any assistance provided to the elderly parents, and will often lose the right to sponsor any additional relatives. The seniors in turn have a very difficult road ahead finding their way through the system and securing adequate housing and food on a very low income. A less common but equally vulnerable type of sponsored senior is the person who is sponsored in later life as a spouse and then abandoned. A participant shared her personal testimony of how she was left with few rights or resources when her husband left her for another woman while she was still legally sponsored. In some cases, seniors work as casual labourers on farms because they are expected to contribute to the household income and seek some level of independence from their sponsors. Asking for spending money, or even receiving it from children when freely offered is hard on the self-esteem of the seniors. Yet working conditions are often harsh and may be dangerous. Where this type of work is not available, as in

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northern communities like Prince George, seniors migrate seasonally to the Lower Mainland. Once here, they are away from family members and may find themselves in crude living conditions without access to health care. The Punjabi seniors who participated in Sharon’s research often reported problems of isolation. Women in particular say that they are kept at home to provide childcare and housekeeping services for their adult children. With limited access to transportation and minimal English language skills, they are often totally dependent on family members. Baljit spoke about sponsorship issues that are specific to ethnic minority seniors living in rural, Northern BC. In addition to the usual problems of language, isolation and not knowing about services, seniors in places like Prince George must endure more extreme weather conditions that they may be unfamiliar with, transportation problems in a rural environment and other abuses around finances. For example, in some cases a senior’s adult son or daughter records some of their earnings on the senior’s tax returns to reduce their own taxes. This then reduces the senior’s pension, increasing their financial dependency.

Recommended Research Topics Dementia and sponsored seniors Quality of life comparisons between sponsored seniors and ethnic minority seniors who have grown old in Canada, and/or with sponsored seniors living in Northern BC communities, where access to services is different. The relationships between sponsorship and the abuse of seniors. The processes that result in social isolation and loneliness among sponsored seniors and their consequences for health care access.

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Workshop 3: Housing Options Co-chairs: Habib Chaudhury, Charan Gill, Saroj Sood Habib Chaudhury, PhD, is an assistant professor in the Department of Gerontology at Simon Fraser University in Vancouver. Habib and his colleagues have recently completed a study on the housing needs of immigrant seniors in the South Asian community in British Columbia. Charan Gill, MA, MSW, OBC, is the executive director of PICS (Progressive Intercultural Community Services Society), which has recently opened a federally, provincially and community funded assisted living residence in Surrey, BC. The $13.4 million, 72-unit assisted living development project is the first of its kind in BC and was designed specifically for South Asian seniors. Saroj Sood is originally from India and spoke as a senior in the workshop. In February of 2007, Saroj moved into the IndoCanadian assisted living facility created by the Progressive Intercultural Community Services Society (PICS).

Housing options were defined broadly to include community housing across generations, assisted living for seniors and extended care facilities. The goal of the workshop was to talk about how to make more housing options available to ethnic minority seniors. The issue of ethnic housing as a kind of segregation was raised, but all agreed that what housing is really about is providing choices. No one wants to force a senior into ethnic housing if they do want to go. The point is to make more choices available to seniors based on what the seniors themselves want. Charan Gill spoke about the planning process behind the creation of the PICS assisted living project, which took many years to complete. This process began in 1985, when a group of volunteers formed PICS to meet the needs of the growing South Asian community in Surrey-Delta. One million dollars were raised, which was roughly 10% of the capital investment needed to purchase the $11 million 54 unit building that was transformed into the Multicultural Seniors Housing Complex, opened in 2002. The complex is a 72 unit assisted living facility designed for Indo-Canadian seniors. The money for the project was raised from donations by many organizations and government agencies

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including the BC Gaming Branch, the Canadian Cancer Society, Human Resources and Development Canada, the Ministry of Health, the Provincial Ministry of Community Services and the Provincial Ministry of Human Resources, to name only a few. Overall, the PICS assisted living project provides a good example of the length of time and the amount of fundraising it takes to create ethnic senior housing that is worthwhile. We need to carry out more research to convince funders and policymakers that more projects of this kind are necessary. Charan noted that often new organizations created to help immigrant communities increase housing options don’t know where to begin. The answer, he suggested, is for them to partner with more established organizations to move forward. Habib Chaudhury highlighted the growing need for ethno-specific housing in the Lower Mainland of different types: independent housing, assisted living, and care facilities. The success of PICS’ independent and assisted living and SUCCESS’ care facilities have provided positive role models. The need for culturally responsive housing options is clear in several ethnic communities. Both Habib and Charan stressed the need for community-based organizations to learn from each another the strategies and techniques to advocate, plan and fundraise in their respective communities. Habib also stressed that if we want to expand housing options in a meaningful way, we should conduct formal evaluations of the existing ethno-specific facilities, for example, in terms of their physical activity programs, nutrition and health advising, so we can identify what is working well and what is not. We must then consider other types of services that could be developed to increase quality of life for residents and their families. Habib raised two final points. First, ethno-specific housing has to be planned and developed as part of the larger community so that services, goods and activities are within walking distance from where seniors live. As part of this, city or community governments should consider providing incentives to ethno-specific service providers and businesses. Second, we have to find ways to give seniors and their families a stronger voice in planning and development of housing options. We must study how ethnic, community-based organizations are currently impacting on policies at the provincial and regional levels. Once we understand this process better, we can learn more effective ways to

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participate in the decision-making process in an ongoing way. Saroj Sood spoke as a senior who is currently living in PICS’ senior assisted living home in Surrey. She explained that she had been living with her eldest son and his family, helping to care for her grandchildren. She decided, however, that at her stage in life (she was 75), she wanted to have more free time and privacy to pursue the things that were most important to her. Saroj added, “I wanted to be away from my family and be with God.” Moving into Indo-Canadian assisted living seemed like the perfect way for Saroj to gain a sense of independence, while at the same time receiving the care she needs, as well as the companionship of other seniors. Today she likes to spend her time reading and meditating. She also hopes to create a small garden. Saroj stressed that she enjoys each day in her new home. At the PICS’ senior assisted living home all meals are Indian and are prepared for residents, freeing them from the difficulties of having to shop and cook. The kitchen boasts a tandoori oven and the entertainment room has satellite channels from the Indian subcontinent. Communication with staff is not a problem either, as the staff speaks all major South Asian languages. Beyond these basics, the PICS home is within walking distance from amenities and services. There is also a van service that takes residents where they need to go. Group outings for fun are planned by residents and administrators. The facility itself has a feeling of warmth and community. In addition, extended family members live close by to residents. Recreational activities and workshops on various topics of interest to residents are also part of the lifestyle at PICS. Beyond the specific example of the PICS project, workshop participants identified what they believe create a successful assisted living facility: Good staff – multilingual and multicultural Housing should be in residents’ own community near amenities, for example, near the community’s business district. The housing should be near shopping, services and places of religious worship. Transportation from the housing to shopping, services and place of religious worship should be available for those who cannot walk (e.g. vans, shuttle buses).

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The ambiance should be warm and welcoming with a sense of community. Outings and activities should be offered, including educational workshops. In some cases, extended family could live together. Ethnic specific amenities, such as language, food, celebrations, and music should be available. Seniors and families should have a say in how the facility is run. While recognizing the need for action, the group also identified the need for more research to inform policy and advocate for new projects. “Action research” and “community capacity building” were viewed as important concepts. In other words, research should be used to establish a need for housing options and identify what communities, including seniors, want in terms of options. Research is the way that funders and policy-makers can be pushed to make options a reality. It is also a way to give seniors and other community members an active voice in identifying suitable options.

Recommendations Researchers should begin by learning about issues in the community. One way is to help organize forums with service providers, older adults and families to identify and prioritize issues. Forums can be composed of a network of existing community organizations and individuals. New research questions and directions will emerge from the forums. Research could involve evaluations of existing projects that could serve as models or generate ideas, such as PICS and SUCCESS facilities. Create a network of existing community organizations and individuals to advocate specifically on housing options of ethnic older adults based on research outcomes.

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Identify two to three issues to focus on. This helps organizations stay on track toward their goals. Approach multiple ministries and associations for funding and seek city/municipal involvement. Organize awareness and fundraising events and follow-up with relevant individuals and organizations.

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Workshop 4: Language and Interpretation Co-chairs: Van Le, Hien Phu Nguyen, Thong Nguyen, Angela Sasso, Noreen Simmons, Jeff Small Van Le immigrated to Canada from Vietnam in 1975. After being employed for fifteen years as an engineer at the University of British Columbia, Van went to work for Statistics Canada. In 2002 he founded his own company, which develops software for language translation. Van is also an active member of the Vietnamese Canadian Seniors Society. Hien Phu Nguyen is active in numerous seniors’ organizations including the Vietnamese Canadian Seniors Society, the Vancouver Cross-Cultural Seniors’ Network, the Delta-Mekong Fellowship Association and the BC Coalition to Eliminate Abuse of Seniors. Before immigrating to Canada, Hien Phu worked as a health care technician and later served as a provincial chief of public health in South Vietnam. Mr. Thong Nguyen was a high-ranking official of the Vietnamese government before immigrating to Winnipeg in 1982. After arriving in Canada he became a French immersion high school teacher and also served as president of the Vietnamese Seniors Association of Manitoba. After he retired, Thong moved to Vancouver, where he is now a member of the Vietnamese Canadian Seniors Society. Angela Sasso has been developing training programs in the areas of health care access and cultural competency for over fifteen years. She works closely with major hospitals in BC’s Lower Mainland and is currently a manager in Communication and Consulting Services at the Provincial Language Service. Noreen Simmons is a doctoral candidate in the Faculty of Audiology and Speech Sciences at the University of British Columbia. Her dissertation research focuses on linguistic and cultural factors that affect language therapy services for IndoCanadian clients. Noreen is also a speech-language pathologist, who works part-time at the BC Family Hearing Resource Centre. Jeff Small, PhD, is an associate professor in the School of Audiology and Speech Sciences at the University of British Columbia. He conducts research on cultural and linguistic issues

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related to health care services for ethnic minority seniors.

The three seniors set the stage by describing the problems Vietnamese seniors have with language within the health care system. Speaking first, Hien Phu Nguyen stressed that language is the biggest barrier. Without being able to communicate with the larger society, seniors are utterly helpless. The key problems he discussed are familiar ones: an inability to speak to doctors and other health care providers, an inability to get information about what services are available, and being housebound, because English is needed to use public transportation. While family members sometimes help with translation and interpretation, they are often too busy to provide much assistance. Hien Phu explained that funding is an obstacle to providing more information and services in Vietnamese. The fact that the Vietnamese community in Vancouver and other parts of Canada is relatively small and spread out adds to the problem. Thong Nguyen framed the problems that Vietnamese seniors confront in terms of the educational system in Vietnam pre-1945: Ninety percent of the population that was educated in Vietnam before 1945 is illiterate. This problem is the result of the educational system the French imposed on Vietnam when they occupied our country. The school system under French domination was set up in stages and students were forced to take entrance exams to enter each stage. These exams were very difficult. As a result, only five per cent made it to grade six. Very small percentages of people could continue to attend school because of the exams. In my case, I

The Language and Interpretation workshop chairs and participants.

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made it through the system, but I had to spend eight years in elementary school – eight years! This is because I failed the exams a number of times. This system was changed after 1945, but for my generation this is what the system was like and illiteracy is the result. Van Le, the third Vietnamese senior to speak, told us about his work developing language translation software. His message to workshop participants was that the technology to translate into many languages using computer software is available. By making use of committed people and new translation technology, he hopes to improve the lives of ethnic minority seniors. Noreen Simmons discussed her dissertation research, which is being supervised by Jeff Small. Noreen is originally from India and began her career as a speech pathologist in India and the Middle East. Her experience working in foreign countries led her to ask the following questions: What are the linguistic and cultural barriers that hinder speech therapy? What strategies do speech therapists use when they don’t share the language and culture of their client? Because her own background is Indian, she chose to study Indo-Canadians with aphasia (an inability to speak, usually due to stroke) in the health care system in Vancouver. Noreen presented some of her research findings: Often seniors and family members say “yes” to whatever a person in authority (for instance, a doctor or a speech therapist) asks them. This automatic agreement and tendency not to ask questions was done out of deference to the person in authority, not because the client or family member understood what was said. As they explained, “The doctor/clinician knows everything, so why should I say anything. What do I know about it?” A solution is for health care providers to ask directed questions to stimulate interaction: “Do you have a question about X? How about Y?” If the doctor or clinician is more specific, they can start to identify what people don’t understand. When clients are evaluated for services, they receive too much information all at once, much of it given verbally. Even if they are illiterate, seniors say, “Give the information to us written in our own language. Then we can take it with us to the temple and ask someone to explain it. If it is in English, what are we going to do with it?”

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One of the biggest barriers to providing quality speech therapy is time. “Everything is go, go, go. Interpreters are frustrated too. Sometimes they go into a [speech therapy] session not knowing what the clinician wants to achieve. If they are given at least ten minutes before a session to be briefed, it makes a big difference. . .” Overall, clinicians serve their clients better if they have experience with Indo-Canadian clients and, therefore, some level of cultural sensitivity. Angela Sasso spoke about the availability of interpreter services in hospitals and other types of health care facilities. Interpreter services are available in over 100 languages through the Provincial Language Service, which is a program of the Provincial Health Services Authority. Many health care providers are unaware these services exist. In some cases, even when they do know about the services and how to access them, health care providers still appear hesitant to use interpreters. Angela stressed that more information about language services still needs to be disseminated. The issue of confidentiality in relation to interpreter services was raised in the workshop. This can be a serious concern for clients, who may not want to use a professional interpreter because they worry that what they say will be shared with others. Angela explained that clients need to be educated about the job of an interpreter. Interpreters are fully aware that they cannot share information with outsiders. If an interpreter did so, they would place their job in jeopardy and breach their contractual obligations. Clients, and health care professionals, need to know that professional interpreters will respect and protect what they say.

Recommendations Health care related information should be given to clients in written form in their own language Health care workers should be aware that, due to cultural differences around authority and respect, some clients may hesitate to ask questions of them. Health care workers can counter

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this by asking more probing questions, such as, “Do you have a question about X procedure? How about Y part of X procedure?” Because language and culture are interdependent, we need interpreters who are both bilingual and bicultural, although interpreters are specifically language facilitators Health care providers need to be culturally competent to provide care that is responsive to client needs. Health care providers should speak directly to the client, even if they are using an interpreter, Clients need to be able to trust interpreters, but they may not fully understand an interpreter’s role and obligations. The client should be told that nothing the interpreter hears will ever be shared with anyone else. This is taken very seriously by professional interpreters, who may lose their job if they do not protect the privacy of their clients. Interpreters can take an active role in helping doctors and other health care professionals frame questions and relay information in culturally sensitive ways. Interpreters provide better service when they are briefed about a client’s situation or a therapy session (eg a speech therapy session) in advance. An additional ten minutes before an appointment can make a big difference. Interpreter services, including 24 hour on-demand telephone interpreting services, are available through the Provincial Language Service by calling 604-875-3402 or toll-free, provincewide by calling 1-877-BC TALKS (228-2557).

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Workshop 5: Complex Care and End-of-Life Issues Co-chairs: Jas Cheema, Sue Grant Jas Cheema, MA, is the diversity manager for Surrey Health Services. She has volunteered with hospice/palliative care patients for a number of years and has been instrumental in creating awareness in the South Asian community about hospice and advance care planning. She has a regular column, “Across Cultures,” in the Surrey-North Delta Leader newspaper. Sue Grant is the project leader for advance care planning in Fraser Health. A health care professional with backgrounds in both nursing and broadcasting, Sue has over twenty-five years of experience in health care management in a wide range of areas including critical care nursing, palliative care, pediatrics and residential care.

The workshop facilitators began with the observation that often health care providers believe they are providing competent end-of-life care to patients. Patients, however, may not always agree. How can health care staff and patients learn from each other to improve end-of-life care? In the US, focus groups have asked seniors how they view quality of life. Seniors typically respond that they don’t want to be on life support and they don’t want to place a financial burden on their families. Although the health care situation in the US is quite different from here in Canada, it raises the issue of how important it is to ask patients what they view as quality of life and what they want in terms of end-of-life care. The questions we ask should be open ended and we should expect a wide range of views. For instance, some people believe they shouldn’t be taken off life support because of their strong religious beliefs. The facilitators have seen patients who were willing to continue to be on life support, even when it meant selling their house. Another reason patients or family members may want to continue life support is because their religious faith leads them to believe the situation will change and the patient will become well again. We need to be aware of and sensitive to these feelings. Jas and Sue emphasized that whatever a particular patient’s belief, it is crucial in health care to communicate with them to find out the answer to the question, “What is it that gives your life meaning?” We live in a fast-paced society where we tend to take things at face value. When it comes to discussing of end-of-life issues with patients,

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we as health care providers have to slow down and take the time to talk to patients and find out what they really want. Another issue for health care providers is that family members and patients may want different things in terms of care. This can pose an ethical problem. Jas pointed out that when we have Indo-Canadian seniors as patients we need to understand that many of them come from villages where death and illness can be highly stigmatized. Some seniors are hesitant to go for medical tests because they fear the results. Others seek doctors of the same ethnicity because they believe these doctors won’t talk openly about death and illness as Western doctors are trained to do. Communication issues are not limited to the South Asian community. In some cultures, there is often no discussion about death before it is absolutely necessary, which can be very difficult for the patient and their family. Although death can be a taboo subject in many cultures, if we raise awareness about the need to talk about death, we can help people to become more comfortable discussing issues surrounding endof-life cae. Two fruitful ways to encourage dialogue about death and end-of-life care are through religious leaders and the media. People may be more open to discussion and advice if it comes from a religious leader they trust. The mass media may also serve as a useful tool for demonstrating that communication on these subjects is okay. Overall, communication is a complex, ongoing process. A number of potential research questions, the results from which could help health care providers develop care protocols for end-of-life care, were suggested: At what stage of our lives do we want to start talking about death and end-of-life care? To what extent are views about death and dying cultural or personal? How are discussions interpreted? It may be more useful to have one spokesperson speak for the patient once that person becomes incapable of decision-making, rather than having several family members talk to the health care provider.

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What is the best way to educate and dialogue with patients and their families? For example, where and how should death and end-of-life care information be given out or disseminated? Is it useful to have a “rights advisor” or end-of-life consultant in the hospital or institution? Would having such a person increase family satisfaction? Would a “cultural health broker” — someone who could serve as a mediator between families and health care workers in relation to these issues—be a good solution? What is the best way to tell a patient and their family about a diagnosis? How should health care providers talk about the care plan to follow? This is an important issue because the concept of a disease has a large impact on decision-making. For example, for many people, cancer equals death. What type of care is better, hospital or home care? What are the concepts of hospice and quality of life in diverse ethnic communities and how can we help people better understand these concepts? How do ethical values differ across cultures? How can we provide culturally competent end-of-life care? How can we incorporate spirituality and spiritual leaders into the end-of-life care plan? How can we maximize the informal resources we have available such as volunteers? How can we empower seniors to make their own decisions that still reflect the value of the family? These questions also illustrate the contrast between Western values of individualism and the emphasis on collectivism in terms of decisionmaking and the impact of decisions in many non-Western contexts.

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Recommendations Communication and education are important. Ethnic minority communities need to receive information about end-of-life care options and issues so they can prepare and make informed decisions. Advance end-of-life care planning can only occur if there is discussion and an understanding of options. The way information is conveyed is very important, because it will affect how the patient will accept care and the type of care that is provided to them. Information about end-of-life care options and issues can be provided through discussions with health care professionals, spiritual leaders and through the media. Health care workers must become sensitive to cultural differences and perceptions about end-of-life issues and what quality of life means to their patient.

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Neena Chappell summarizes the main themes that she saw emerging from the presentations and workshops. Negotiating the Interface: Concluding Observations

Summing Up

The Interface in a Nutshell: Themes from the Symposium

Sharon Koehn assesses if and how the presentations and workshops spoke to the different ways in which ethnic minority seniors may need to negotiate access to care.

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The Interface in a Nutshell: Themes from the Symposium Neena Chappell observed that several themes emerged over the course of the two days: Multiple oppressions work together to affect people: racism, sexism, classism. There are differences both between and within groups; it is important for us to remember that an individual’s view may not conform to what you know about their culture. We have to be careful to consider both seniors’ needs as individuals and their embeddedness within their families, which also varies within and across cultures. We must be sensitive to the cultural stigmas and taboos related to various topics such as mental illness, abuse, death and addictions. Language is tremendously important, but we have to remember that we can still strive to serve seniors and their families, even when we do not speak the same language. In the words of one of our speakers, “We need to get over language and use whatever tools we can to help our seniors.” In other words, we cannot use language as an excuse not to do our best. The senior is the expert about their life, not any of us. We must advocate for choice and for individualized or personalized care. Health promotion is very important, not just care once someone is sick. A lot of what we shared doesn’t need more research. We have to raise awareness and educate, and we need action. Qualitative research is particularly useful to us, but we also need large-scale, quantitative studies and studies that compare populations. This is because we need to know how much we can generalize results from our smaller-scale studies to larger numbers of people. We need comparisons to know how ethnic minority seniors differ from each other and from the non-ethnic

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minority population. We can’t just say to the policy-makers that we need more appropriate services, including translation and interpretation. We have to do cost-effectiveness research and show how the services we want can be provided in a cost-effective way. Ministries often don’t want to do research on ethnic minorities, but nursing homes and other care facilities are often eager to participate in such studies. We need to make use of their willingness and interest to further our knowledge about better and more appropriate services. We need research on the resilience of ethnic minority seniors. We tend to focus on the problems, but let’s also start asking and learning about the positive side so we don’t always cast ethnic minority seniors as a problem or in a trouble-laden context. We have much to learn from them about how they cope.

Negotiating the Interface: Concluding Observations by Sharon Koehn The voices of the seniors, service providers and academics presented here reflect the positions that they hold relative to the question of access to care for ethnic minority seniors. There is considerable variation among them, depending on their ethnic affiliation, the type of work they do and/or the focus of their studies. That said, some key themes are apparent. To make sense of this, we have used the “candidacy framework” mentioned in the introductory presentation by Koehn. Dixon-Woods and her colleagues2 explain that getting appropriate health care is a process of negotiation between individuals and the health system. Their model identifies seven different aspects of that negotiation process that we have further collapsed into three overarching categories. The first category, Culture: Who Cares?, looks at the ethno-cultural and migration context in which seniors and their families decide if the senior needs care and whether or not they will accept care when it is offered. Knocking on Doors looks at how seniors find the information they need to get to services, how they present themselves or make themselves understood once there and how the attitudes of service providers affect that care. When is a Home Not a Home? cap2 Dixon-Woods, M., Cavers, D., Agarwal, M. S., Annandale, E., Arthur, T., Harvey, J., et

al. (2006). Conducting a critical interpretive synthesis of the literature on access to health care by vulnerable groups. BMC Medical Research Methodology, 6(35). 92


tures the ways that services are configured and looks especially at issues surrounding seniors’ use of long-term care options. Other environmental factors such as policies are also taken into account. Symposium participants will recognize these three areas as the different panels into which presenters were grouped on Day One. In reality, however, many of the presenters, workshop chairs and participants addressed several of these themes. Even so, the framework is useful in that it helps us to identify areas where there is greater understanding, as well as those that have received little attention and perhaps deserve more. Culture: Who Cares? Everyone pointed to many factors, such as cultural beliefs, family dynamics, and the specific experience of each family, that influence how ethnic minority seniors and their caregivers recognize symptoms as needing medical attention and whether or not they follow-up on referrals for more specialized services. Some of these recurring themes are detailed below. The Ideal of Filial Piety The ideal of filial piety—the notion that children should look after their aging parents—was mentioned by several speakers (Gupta, Hernandez, Kobayashi, Lai, Lalli, Meier, Nguyen, Patel, Sidhu, Wong) as a common cultural belief in communities with origins in South Asia, China/Hong Kong/Taiwan, the Philippines, Vietnam, Japan and Latin America. It is true that children are more likely to provide care for aging parents if they subscribe to this ideal, but in reality many things can get in the way of fulfilling parents’ expectations. For various reasons, adult children are often “too busy” to provide the necessary care at home. Also, the perception of what filial piety means can vary between and within generations; it is a multi-layered concept, and the understandings of caregiver and care recipient are not always the same. Finally, we see that the unrealistic desire to live up to the ideal on the part of some caregivers can result in delays in securing appropriate and timely care for the senior. Assessments of the need for home care should therefore take into account the level of the burden on the caregiver.

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Family Class Immigration Seniors whose immigration to Canada is sponsored by their adult children or grandchildren are not eligible for social services for ten years. These seniors can be completely dependent on their sponsors for services such as transportation, including trips to the doctor, translation and interpretation, information about services and activities, spending money and housing. Outside of the workshop dedicated to this topic (Assanand, Koehn, Sethi), several other speakers (Hernandez, Sidhu) and participants raised the issue of the vulnerability of sponsored seniors. This vulnerability plays out in several ways: With limited knowledge of available services and basic rights, language barriers, and social isolation, sponsored seniors are especially vulnerable to abuse If the sponsorship relationship breaks down, the family faces shame in the eyes of the community and seniors have a hard time securing adequate housing and food on a low income Efforts to offset their dependency can affect seniors’ health and access to health care—for example, they may become too busy to go to the doctor: Many work on farms for low pay and under poor working conditions Women are often expected to take care of grandchildren and do the housework Senior speaker Pepita Hernandez and cooking; families can become angry when the senior is no longer able to do domestic work. Whether or not these same vulnerabilities apply to non-sponsored seniors or to those no longer under the sponsorship clause remains unexplored. Stigmatized Conditions Speakers and workshop chairs (Lalli, Meier, Cheema and Grant, Shakheri, Simmons, Wong) spoke about several conditions that are

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stigmatized within certain ethnocultural groups and prevent seniors or their families from taking the necessary steps to access appropriate care. The most commonly discussed example was mental illness. Simmons’ discussion of clients with aphasia (the inability to speak, usually following a stroke) confirms that other illnesses are also stigmatized. In addition, talking about terminal illness and death is avoided in many cultures. Speakers emphasized that for many seniors, migration to Canada is involuntary—refugees and sponsored seniors may have no other options. This can lead to low self-esteem and demoralization, and those who work and volunteer with ethnic seniors believe that many of them are depressed. Yet very few seek care for this condition and other mental illnesses because they are stigmatized and/or not recognized as illnesses within the community. . Similarly, seniors with stigmatized illnesses may be kept away from others to “save face.” Seniors often rely on community organizations they trust for care, but these organizations are not designed or funded to provide mental health services. Family members may not have the time to provide appropriate care, but seniors and families may prefer to keep the senior at home rather than place them in a mainstream facility. An unwillingness to talk about and plan for death and end-of-life care is common in many Asian cultures (e.g. South Asian, Chinese) and has consequences for access: people avoid medical tests because they fear the results and seniors seek out doctors trained in their own country who will not talk about death, but this does not guarantee that they get the best service. Family decision-making Family-based decision-making is the cultural norm in Chinese, Punjabi and many other Asian communities. Wong and Simmons both talked about how decisions are often not made unless the oldest child is present. In addition, decisions are made in a way that ensures the family does not “loose face.” Sometimes collective decision-making can be accommodated, but there are times when it has important consequences for care. For example, the patient may miss out on some aspect of treatment that requires immediate attention if the appropriate person is not present or the family is trying to reach a consensus.

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Environmental factors Living conditions in different areas may vary and limit seniors’access to care in different ways. For example, ethnic minority seniors in Surrey may be afraid to engage in healthy activities such as walking after two elderly Punjabi men were beaten to death in a park (Meier, Sidhu). In Prince George, harsh weather and rural living conditions have the same effect (Sethi). Local conditions that influence access should always be examined in depth. Knocking on Doors So far, we have looked at the sorts of things that get in the way of making the decision to seek out medical care. Here we focus on what happens once the senior or their family members have made the decision to get help. First, they need to be able to identify and get to a suitable health care provider. Once there, they must be able to communicate the health issue clearly so as to get the services they need. Even when they have done so, the health care provider must be willing and able to provide appropriate treatment or refer them for more specialized services. Communication – Language Senior speaker Dr. Bikkar Singh Lalli

Punjabi and Vietnamese seniors and caregivers identified the language barrier as the major problem seniors face in trying to access services (Lalli, Sidhu, Nguyen, Shakeri). This was less true of Filipino seniors who are more likely to speak English (Hernandez). Language barriers prevent the senior from Speaking with health care providers and getting appropriate treatment (e.g. it’s easier to write a prescription than refer people for psychotherapy or other appropriate psychological or emotional supports when language is a barrier) Accessing information about health care and related services such as housing options via written or electronic means Understanding medication information

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Using public transportation As a result, language barriers reinforce social isolation and reduce access to the health care system. The problem is twofold: (1) there are not enough health care providers who speak minority languages or interpreters to meet everyone’s needs; and (2) important information, for example, about medications and other treatments, is not presented in a way that is easy to understand, even by English-speaking clients (see especially Ambrosini, Meier, Sidhu, Simmons). Communication – Interpreters Interpretation services are provided in many hospitals and clinics (e.g. by the Provincial Language Services), but there are many situations for which they are not readily available, sometimes because clinicians do not make use of existing services (Meier, Sasso). Speakers also noted some populations do not trust professional interpreters and need to be educated about professional standards in Canada (Sasso). Interpretation services are not adequate for all types of treatment, for instance, mental health services for the elderly (Meier), but neither are family members. While they are commonly used for interpretation, family members often do not have the necessary language skills to interpret medical information accurately, their presence may prevent the senior from speaking openly and they sometimes withhold information from the senior (Koehn, Meier, Nguyen, Sasso, Sidhu). One reason for withholding information might be to “protect” a senior from a diagnosis. In some cases, such as therapy or rehabilitation, however, use of family interpreters is unavoidable because funding and the dispatch of interpreters makes it difficult to ensure that the same interpreter can assist a client on an ongoing basis (Simmons). Communication – Translated Materials Some resources are available for larger minority language groups. For example, the B.C. Health Guide has been translated into Chinese and Punjabi (participants, Building the Interface), but there are still very few materials translated into the languages of immigrant communities with smaller and more dispersed populations, such as the Vietnamese (H.P. Nguyen). Also important to remember is that many seniors are not literate in their own language (T. Nguyen), so health information materials need to be tailored to each population using the most appro-

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priate media (Patel). Even so, materials in the language of the illiterate senior can be read to them by others in the community who may not be able to read English (Simmons). Cultural Communication Styles In addition to language, there are other kinds of cultural barriers to care when caregivers do not share the ethnic background of their clients (Simmons). Simmons, Wong and Sidhu talked about how, in hierarchical societies, such as the Chinese and Punjabi communities with which they are familiar, people fear and respect doctors. This can be especially true of seniors. As a result, the seniors and/or their families may not openly talk about their dissatisfaction with care, may not ask questions about treatment and often say “yes” as a form of deference, rather than understanding. Health service providers must be aware of this possibility when working with ethnic minority senior clients. Communication Between Service Providers Canada’s health care system is complex, with services and policies influenced by all decisions made at regional, provincial and federal levels. Ensuring “seamless service” or a better flow of communication and referrals is a priority of many regional health authorities. However, others who do not work for the health authority, such as physicians and multicultural service providers, are also critical to care. A lack of communication between these different care providers limits access for ethnic minority seniors. Ambrosini’s position as a pharmacist who links acute and community care is a good example of how important it is to connect different parts of the health care system. Meier gives the example of the potential value of using community service workers who are trusted by ethnic minority seniors for mental health follow-up. Privacy laws and non-existent links between community services and physicians limit this possibility. Patient Education The need for age- and culture-appropriate education targeted at ethnic minority seniors was made by several presenters (Ambrosini, Lalli, Sidhu) and in the open discussion—Building the Interface—facilitated by Akber Mithani. This is especially true in the area of medications.

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Multicultural service providers working with South Asian and Latin American populations, as well as a physician with South Asian patients said that seniors in these populations commonly share medications. Another problem that Ambrosini spoke about was the use of medications from the home country in addition to medications prescribed in Canada. Patel emphasized that information about services is not reaching the minority elderly. The problem, she said, lies not only with language barriers. Much of this information is not widely available to the public, even if they speak English, or is too complicated to understand. Comparative studies of Anglo-Canadian seniors and different ethnic groups would help us to better understand the scope of the problem and how best to communicate important health information to Canada’s diverse senior population. When is a Home Not a Home? In this section we focus specifically on how services might be organized to increase the ease with which people can use them. As we have already looked at access issues that arise in the primary care setting, our focus here is on long-term care and other housing options in late life. The context of health service provision, such as the availability of resources and policies that are specific to a particular environment are also important. Time Crunch One theme that came up frequently was the lack of time health care providers have to spend with their clients. Health care professionals need to spend larger amounts of time with ethnic minority seniors in order to meet their needs. In some cases, this involves finding out what their experiences have been, what they value, and what they really need (Shakheri, Wong). Interactions between health professionals and other team members, such as interpreters, also benefit greatly when service providers take the time to discuss the needs of their patient and what they hope to achieve in a session in advance (Ambrosini, Simmons). Housing Options Raise the topic of housing for ethnic minority seniors and people immediately start debating the relative merits of housing and care options that are aimed at a specific ethnic group versus integrating

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seniors into existing, mainstream facilities. Discussions on this topic arose in the Housing Options workshop (Chaudhury, Gill, Sood, Gupta), in several presentations, (Hernandez, Lalli, Patel, Sidhu) and in the open discussion on day one. Those who argue against ethno-specific housing say they fear segregation or ghettoization. Gupta told us that in the United States, integration is the main strategy, although efforts are made to recognize the distinct needs of all clients. Those who support ethno-specific housing relate many success stories in which seniors who were previously withdrawn or diagnosed with dementia, for example, did very well (sometimes requiring re-diagnosis) when they were moved into an ethno-specific care environment. Care homes that cater to seniors from a particular area (e.g. South Asia, the Caribbean) can still be multiethnic, catering to many languages and religions (Gill, Patel, SUCCESS staff). In the end, three was a general understanding that the most important thing is to provide choices. Ethno-specific homes should exist for those who need them, but seniors of a particular ethnic group should not be automatically streamed into these facilities (Chappell, Patel and others). Even more important is that the options provided are of good quality, which may require governmental support of community-based organizations eager to provide care but without the necessary resources to do so (Chaudhury, Gill, Sood, Patel). Open discussion moderator Dr. Akber Mithani

Culturally Sensitive Care

A very important feature in any care home where ethnic minority seniors are clients is the delivery of service in a culturally sensitive manner. Staff who are from ethnic minority backgrounds are not necessarily more sensitive to the needs of the residents, although this is often thought to be the case (Wong, audience, Building the Interface). While it is useful to have staff that can speak the same language as the client or patient, their cultural sensitivity is more important (Patel and others). One way to address this is by providing cultural competency training of staff. This training needs to be at all organizational levels and should be offered on an ongoing basis (Shakheri and others). Staff also need to understand the barriers that ethnic minority seniors face in their efforts to access care (Lalli).

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Increased dialogue among researchers, ethnic minority seniors, health care providers, multicultural service providers and other stakeholders is essential if we are to move ahead on issues that require changes in policy and service delivery. For many participants, the opportunity that this symposium provided to do this was unique. Responsibility for creating such opportunities falls with both the health sector and with academics. The benefits will be felt by all.

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Appendix 1: Conference Agenda Thursday, April 19, 2007, Speaking to the Interface 08:00am

Welcome and Registration

08:30am

Overview of Access to Care Issues Access to Health Care for Ethnic Minority Seniors - Sharon Koehn, CHAP The Research- Practice Interface - Betty Ann Busse, Fraser Health Authority Bridging the Research-Practice Gap - Neena Chappell, University of Victoria

09:30am

Session 1: Culture: Who Cares? Consideration of Nursing Home Care Placement for the Elderly in South Asian Families - Rashmi Gupta, San Francisco State University (academic speaker) Clinical Cultural Competence: Barriers to Accessing Health Care for Ethnic Minority Seniors - Farimah Shakheri, Royal Columbian Hospital (health care provider speaker) Indo-Canadian Seniors: Culture, Who Cares? - Bikkar Singh Lalli, BC Coalition to Eliminate Abuse of Seniors (senior speaker)

10:45am

Break

11:00am

Session 2: Knocking on Doors: Accessing Appropriate Services Navigating Health/Mental Health Care for Ethnic Minority Seniors Rosemary Meier, St. Joseph’s Health Centre, Toronto, ON (academic speaker) Experiences of a Home Care Pharmacist Caring for Ethnic Minority Seniors as They Navigate the Health Care System - Carla Ambrosini, Fraser Health Authority (health care provider speaker) Barriers Facing Indo-Canadian Seniors - Mohinder Sidhu, Vancouver, BC (senior speaker)

12:15pm

Luncheon (provided)

13:15pm

Session 3: When is a Home Not a Home? Service Utilization: Issues Surrounding Seniors’ Use of Long-Term care Options, Naina Patel, Policy Research Institute on Ageing and Ethnicity (PRIAE), Leeds, England (academic speaker) Service Utilization: Barriers and Solutions - Jocelyne Wong, Mount Saint Joseph Hospital, Vancouver, BC (health care provider speaker)

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A Filipina Perspective - Pepita Hernandez, Surrey, BC (senior speaker) 14:30pm

Break

14:45pm

Session 4: Building the Interface: Open Discussion Facilitator: Akber Mithani, Providence Health Care; Vancouver, BC

15:45pm16:00pm

Closing Remarks

Friday, April 20, 2007, Translating Research into Practice

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08:30am

Welcome and coffee

09:00am

Five Concurrent Workshops The Senior in the Family Immigrant Status Housing Options Language and Interpretation Complex Care and End-of-Life Issues

11:00am

Break

11:30am12:30pm

Summary of Workshops The Interface in a Nutshell: Themes from the Symposium, Neena Chappell


Appendix 2: References Cited Ahmad, W. I. U., & Walker, R. (2000). Asian older people: Housing, health and access to services. Ageing and Society, 17(2), 141-165. Ahmad, F., Gupta, H., Rawlins, J., & Stewart, D. E. (2002). Preferences for gender of family physician among Canadian European-descent and SouthAsian immigrant women. Family Practice, 19(2), 146-153. Ahmad, F., Shik, A., Vanza, R., Cheung, A., George, U., & Stewart, D. E. (2004a). Popular health promotion strategies among Chinese and East Indian immigrant women. Women and Health, 40(1), 21-40. Ahmad, F., Shik, A., Vanza, R., Cheung, A., George, U., & Stewart, D. E. (2004b). Voices of South Asian women: Immigration and mental health. Women and Health, 40(4), 113-130. Amnesty International. (1989-90). The breaking of minds and bodies: The long journey home. Amnesty International Bulletin, No. 10-13. Ananth, J. (1984). Treatment of immigrant Indian patients. Canadian Journal of Psychiatry, 29(6), 490-493. Aziz, S. J., & Campbell-Taylor, I. (1999). Neglect and abuse associated with undernutrition in long-term care in North America: Causes and solutions. Journal of Elder Abuse and Neglect, 10(1), 91-117. BC Stats. (2006). Special feature: Family immigrants to British Columbia (Immigration Highlights No. 05-4). Victoria, B.C.: Government of British Columbia. Retrieved July 31, 2006 from www.bcstats.gov.bc.ca/pubs/immig/imm054sf.pdf Beiser, M. (2005). The health of immigrants and refugees in Canada. Canadian Journal of Public Health, 96 Suppl 2, S30-44. Blue, A., & Gaines, A. (1992). The ethnopsychiatric repertoire: A review and overview of ethnopsychiatric studies. In A.D. Gaines (Ed.), Ethnopsychiatry: the cultural construction of professional and folk psychiatries (1st ed.). Albany: SUNY Press. Bottinelli, M. C., Maldonado, I., Troya, E., Herrera, P., & Rodriguez, C. (1990). Psychological impact of exile: Salvadoran and Guatemalan families in Mexico. Washington, D.C: Center for Immigration Policy and Refugee Assistance. Bowen, S. (2001). Language barriers in access to health care. Ottawa: Health Canada. Retrieved January 25, 2007 from www.hc-sc.gc.ca/hcssss/pubs/care-soins/2001-lang-acces/index_e.html

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Bowman, K. W., & Singer, P. A. (2001). Chinese seniors’ perspectives on endof-life decisions. Social Science and Medicine, 53(4), 455-464. Boyd, M. (1989). Immigration and income security policies in Canada: Implications for elderly immigrant women. Population Research and Policy Review, 8(1), 5-24. Brotman, S. (2003). The limits of multiculturalism in elder care services. Journal of Aging Studies, 17(2), 209-229. Canadian Association of Community Care and Canadian Ethnocultural Council. (1998). A feasibility study on multicultural community care: Identifying barriers and finding solutions. Canada: Canadian Association of Community Care and Canadian Ethnocultural Council. Carlin, J. E. (1990). Refugee and immigrant populations at special risk: Women, children and the elderly. In Holtzman, W.H. and Bornemann, T.H. (Ed.), Mental health of immigrants and refugees (1st ed., pp. 224-233). Austin, Texas: Hogg Foundation for Mental Health. Chappell, N. L., & Lai, D. (1998). Health care service use by Chinese seniors in British Columbia, Canada. Journal of Cross Cultural Gerontology, 13(1), 21-37. Chaudhury, H., Mahmood A., Kobayashi, K., & Valente, M. (2005). Addressing distinct housing needs: An evaluation of seniors’ housing in the South Asian community. Report submitted to the Canada Mortgage and Housing Corporation, January 2005. Chen, A. W., & Kazanjian, A. (2005). Rate of mental health service utilization by Chinese immigrants in British Columbia. Canadian Journal of Public Health, 96(1), 49-51. Citizenship and Immigration Canada. 2005. Family class immigration. Available online at http://www.cic.gc.ca/english/sponsor/index.html [25/01/07]. Cook, P. (1990). Chronic illness beliefs and health seeking behavior among Chinese immigrants, Indian immigrants, and Anglo-Canadians. In Bleichrodt, N. & Drenth, P. (Eds.), Contemporary issues in cross-cultural psychology (1st ed., pp. 263-274). Amsterdam/Lisse: Swets & Zeitlinger. DesMeules, M., Gold, J., Kazanjian, A., Manuel, D., Payne, J., Vissandee, B., et al. (2004). New approaches to immigrant health assessment. Canadian Journal of Public Health, 95(3), I22-6.

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Dixon-Woods, M., Cavers, D., Agarwal, M. S., Annandale, E., Arthur, T., Harvey, J., et al. (2006). Conducting a critical interpretive synthesis of the literature on access to health care by vulnerable groups. BMC Medical Research Methodology, 6(35). Retrieved July 27, 2006 from http://www.biomedcentral.com/1471-2288/6/35 Durst, D. 2005. Aging amongst immigrants in Canada: Policy and planning implications. Retrieved January 27, 2007 from http://www.ccsd.ca/cswp/2005/durst.pdf Fabrega, H. (1991). Somatization in cultural and historical perspective. In Kirmayer, L.J., & Robbins, J.M. (Eds.), Current concepts of somatization: Research and clinical perspectives (1st ed., pp. 181-199). Washington, DC: American Psychiatric Press. Farias, P. J. (1991). Emotional distress and its socio-political correlates in Salvadoran refugees: Analysis of a clinical sample. Culture, Medicine and Psychiatry, 15(2), 167-192. Foreman, S. E., Yu, L. C., Barley, D., & Chen, L. W. (1998). Use of health services by Chinese elderly in Beijing. Medical Care, 36(8), 1265-1282. Furnham, A., & Malik, R. (1994). Cross-cultural beliefs about “depression”. The International Journal of Social Psychiatry, 40(2), 106-123. Gagnon, A. J. (2002). Responsiveness of the Canadian health care system towards newcomers. Discussion paper 40. Saskatoon: Commission on the Future of Health Care in Canada. Gee, E. M., Kobayashi, K. M., & Prus, S. G. (2004). Examining the healthy immigrant effect in mid- to later life: Findings from the Canadian community health survey. Canadian Journal on Aging Supplement, 23, S61S69. Government of British Columbia. (2002). B.C.’s new residential care access policy. Retrieved May 8, 2007 from http://www.hlth.gov.bc.ca/hcc/pdf/residentialpolicy.pdf Gupta, R. (2002). Consideration of nursing home care placement for the elderly in South Asian families. Journal of Immigrant Health, 4(1), 47-56. Keefe, J. (2000). The impact of ethnicity on helping older relatives: Findings from a sample of employed Canadians. Canadian Journal on Aging, 19(3), 317-342. Kirmayer, L. J. (1989). Cultural variations in the response to psychiatric disorders and emotional distress. Social Science and Medicine, 29(3), 327-339.

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Kleinman, A. (1987). Anthropology and psychiatry: The role of culture in cross-cultural research on illness. The British Journal of Psychiatry: The Journal of Mental Science, 151, 447-454. Kobayashi, K. M. (2000). The nature of support from adult sansei (third generation) children to older nisei (second generation) parents in Japanese Canadian families. Journal of Cross-Cultural Gerontology, 15(3), 185-205. Koehn, S. (2006). Ethnic minority seniors face a double whammy in health care access. GRC News, 25(2), 1-2. Koehn, S. (1993). Negotiating new lives and new lands: Elderly Punjabi women in British Columbia. M.A. Thesis. University of Victoria, Victoria, B.C. Koehn, S. (1999). A fine balance: Family, food, and faith in the health worlds of elderly Punjabi women. Ph.D. Dissertation. University of Victoria, Victoria, B.C. Kolff, C. A., & Doan, R. N. (1985). Victims of torture: Two testimonies. In Stover, E., & Nightingale, E.O. (Eds.), The breaking of bodies and minds (1st ed., pp. 45-57). New York: W.H. Freeman and Co. Krause, I. B., Rosser, R. M., Khiani, M. L., & Lotay, N. S. (1990). Psychiatric morbidity among Punjabi medical patients in England measured by general health questionnaire. Psychological Medicine, 20(3), 711-719. Lai, D. W. (2004). Impact of culture on depressive symptoms of elderly Chinese immigrants. Canadian Journal of Psychiatry, 49(12), 820-827. Lee, R. N. (1986). The Chinese perception of mental illness in the Canadian mosaic. Canada’s Mental Health, 34(4), 2-4. Littlewood, R. (1990). From categories to contexts: A decade of the ‘new cross-cultural psychiatry’. The British Journal of Psychiatry: The Journal of Mental Science, 156, 308-327. MacLean, M. J., & Bonar, R. (1983). Ethnic elderly in a dominant culture long term care facility. Canadian Ethnic Studies, 15(3), 51-59. Martyn, C. (1991). Hidden faces: A survey of suburban immigrant seniors. Burnaby, British Columbia: Burnaby Multicultural Society. Marwaha, S., & Livingston, G. (2002). Stigma, racism or choice? Why do depressed ethnic elders avoid psychiatrists? Journal of Affective Disorders, 72(3), 257-265.

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McLaren, A. T. (2006). Immigration and parental sponsorship in Canada: Implications for elderly women. Canadian Issues, 34. Nandal, D. S., Khatri, R. S., & Kadian, R. S. (1987). Aging problems in the structural context. In Sharma, M., Dak, T. (Ed.), Aging in India (1st ed., pp. 106-116). Delhi: Ajanta Publications. National Advisory Council on Aging (Canada). (2005). Seniors on the margins: Seniors from ethnocultural minorities. Ottawa: Minister of Public Works and Government Services Canada. Newbold, K. B. (2005). Self-rated health within the Canadian immigrant population: Risk and the healthy immigrant effect. Social Science and Medicine (1982), 60(6), 1359-1370. Ots, T. (1990). The angry liver, the anxious heart and the melancholy spleen: The phenomenology of perceptions in Chinese culture. Culture, Medicine and Psychiatry, 14(1), 21-58. Punia, D., & Sharma, M. L. (1987). Family life of rural aged women. In Sharma, M., Dak, T. (Ed.), Aging in India (1st ed., pp. 145-151). Delhi: Ajanta Publications. Sadavoy, J., Meier, R., & Ong, A. Y. (2004). Barriers to access to mental health services for ethnic seniors: The Toronto study. Canadian Journal of Psychiatry, 49(3), 192-199. Saldov, M. (1992). Communication needs of the ethnic elderly in hospitals and nursing homes. Journal of Multicultural Social Work, 2(2), 1-9. Segel, S., Tam, H. C., Yesavage, J., & Yeo, G. (1993). Determining the effectiveness of DSM-III-R criteria for major depression when applied to Chinese elders. Clinical Gerontologist, 13(3), 3-16. Statistics Canada. (2005). Longitudinal survey of immigrants to Canada: A portrait of early settlement experiences, No. 89-614-XIE. Ottawa: Minister of Industry. Stephenson, P. H. (1991). The Victoria multi-cultural health care research project: Final report. Victoria, British Columbia: Secretary of State, Multiculturalism Canada. Wieland, D. (1991). Elder care in North American Isma’ili families: A preliminary inquiry. Journal of Cross Cultural Gerontology, 6(2), 165-171. Williams, R., Bhopal, R., & Hunt, K. (1993). Health of a Punjabi ethnic minority in Glasgow: A comparison with the general population. Journal of Epidemiology and Community Health, 47(2), 96-102.

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Williams, R., & Hunt, K. (1997). Psychological distress among British South Asians: The contribution of stressful situations and subcultural differences in the west of Scotland twenty-07 study. Psychological Medicine, 27(5): 1173-1181.

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Appendix 3: Speaker Bios

Carla Ambrosini Carla Ambrosini, BSc, graduated from the Faculty of Pharmaceutical Sciences at the University of British Columbia in 1987. After a short time working in community pharmacies, Carla was employed at Riverview Psychiatric Hospital in Coquitlam for four years prior to joining Surrey Memorial Hospital in 1991. As a Clinical Pharmacist at Surrey Memorial Hospital for 14 years, she has worked on many wards of the hospital from pediatrics and maternity to extended care. In November 2005, she joined the Medication Management Program of the Fraser Health Authority. This position involves home visits with and supervision of seniors, who have recently been discharged from Surrey Memorial Hospital and are at risk for medication-related adverse events.

Shashi Assanand Shashi Assanand is a registered social worker and has worked with the immigrant community for the past 30 years. She has extensive counselling and advocacy experience in working with immigrant and refugees (families, youth and women), and is a trained and experienced mediator in family and community disputes. Shashi is very actively involved in the areas of multiculturalism and women’s issues locally, provincially and nationally. In addition, She is the founder and Executive Director of the Vancouver and Lower Mainland Multicultural Family Support Services Society, an organization funded to help immigrant, visible minority and refugee women and their families, who face domestic violence. The organization provides services in 24 languages.

Betty Ann Busse Betty Ann Busse, BSc, MSc, is the executive vice president for Health Promotion and Community Programs at the Fraser Health Authority, which includes the following programs: Home Health and End of Life, Mental Health and Addictions, Prevention and Health Promotion, Primary Care and Chronic Disease Management and Geriatric, Residential and Assisted Living. Along with executive leadership for these programs, her responsibilities include contractual relationships

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with residential care providers for over 5,000 beds stretching from Burnaby to Hope, BC. Betty Ann holds a BS degree in Nursing and a Master’s of Science in Health Administration. In the spring of 2002, she received the RNABC Award for Excellence in Nursing. Her professional experience spans more than 30 years in the health care field, including direct patient care, clinical education and a variety of administrative roles across Canada, including CEO of two hospitals.

Neena Chappell Neena Chappell, PhD, FRSC, has been a leader in gerontological research for over 25 years. Her research has focused on three areas: quality of life for seniors, caregiving, and the health care system and related policy. Neena has written over 250 academic articles and reports, two edited books and seven authored books. She has attracted well over $20 million in research funding. Within each of her areas of research, Neena has examined issues pertinent to Chinese seniors, both in Canada and China/Hong Kong. This interest is reflected in publications (e.g., Aging Among the Chinese in Pacific Rim Countries), in funded research projects (e.g., Health and Well-Being of Chinese Seniors in Canada, Social Sciences and Humanities Research Council of Canada, 2000-2002 [$556,000]) and her appointments as Advising Professor at the University of Shanghai, and Distinguished Visiting Scholar at the University of Hong Kong. She is currently involved with the HCCRN as an advisory committee member.

Habib Chaudhury Habib Chaudhury, PhD, is an assistant professor in the in the Department of Gerontology at Simon Fraser University, Vancouver. Habib’s research interests include: aging and the built environment; housing for ethnic seniors; place-therapy for persons with dementia; self, aging and dementia; design for people with dementia; and acute care environments. He and his colleagues have recently completed a study on the housing needs of immigrant seniors in the South Asian community in British Columbia. Habib plans to advance the goals of research and knowledge translation in the area of responsive planning and design of community, housing and long-term care environments for seniors from diverse ethno-cultural groups.

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Jas Cheema Jas Cheema, MA, is a well-respected citizen of the Surrey community who is an active volunteer and philanthropist for a number of organizations. For over a decade she has been instrumental in building bridges and fostering a cross-cultural understanding between the ethnic communities in the Lower Mainland, and recently completed a masters degree in International and Intercultural Communications. Jas is presently the Diversity Manager for Surrey Health Services and a board member of the Surrey Public Library and the Surrey Memorial Hospital Foundation. She has volunteered with hospice/palliative care patients for a number of years and has been instrumental in creating awareness in the South Asian community about hospice and advance care planning. Jas is the recipient of the Queen’s Golden Jubilee Medal, the Surrey Leader of the Year Award and Woman of Distinction for her services to the diverse multicultural community. In addition, she has received the Griffin Award for her contributions to Canadian society through her writing.

Charan Gill Charan Gill, MA, MSW, OBC, is the executive director of PICS (Progressive Intercultural Community Services), a federally, provincially and community funded assisted living project located in Surrey, BC. The $13.4 million, 72-unit assisted living development project is the first of its kind in BC and was designed specifically for South Asian seniors. In addition to his leadership with PICS, Charan is an outspoken advocate for Indo-Canadian farm workers in BC, and is one of four people worldwide who receives a community service award from the Global Organization of People of Indian Origin (GOPIO) for his work in January 2007.

Sue Grant A health care professional with educational preparation in both nursing and broadcasting, Sue Grant is the project leader for Advance Care Planning at the Fraser Health Authority. Her more than 25 years of experience in healthcare management have encompassed a wide range of specialties, including critical care nursing, palliative care, pediatrics and residential care. Sue is a skilled communicator, both in the office and on the podium. Her many roles include those of storyteller, facilitator, keynote speaker and inspirational writer.

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Rashmi Gupta Rashmi Gupta, PhD, LMSW is author of several articles that report on studies examining the cultural dimensions of barriers to access to care for the Chinese and South Asian populations in the United States and India. In her 2002 article, “Consideration of nursing home care placement for the elderly in South Asian families,” published in the Journal of Immigrant Health, she examined characteristics of the care giving family that predicted the likelihood of consideration of nursing home placement of the South Asian elderly. She is currently a professor in the Department of Social Work at San Francisco State University.

Pepita Hernandez Pepita Hernandez earned degrees in accounting and music at universities in Manila, The Philippines, before immigrating to Canada in 1972. Before retiring eight years ago, she was employed at the New Vista Care Home in Burnaby, where she cared for seniors in intermediate and extended care. For the past four years Pepita has served as president of The Philippine Bagong Pag-asa Society (The New Hope Society), an organization for Filipino seniors.

Karen Kobayashi Karen Kobayashi, PhD, is an assistant professor in the Department of Sociology and a research affiliate at the Centre on Aging at the University of Victoria, British Columbia, who uses a life course perspective to explore the intersections of structural, cultural, and individual factors affecting health and aging as social processes. Karen believes that in order to develop a better understanding of the nexus between micro- and macro-levels of analysis in sociological theory, a mixed-method approach to research is needed. With funding from the Canadian Institutes of Health Research (2005-2006) and the Social Sciences and Humanities Research Council (2005-2010), her current research program examines the social and economic dimensions of an aging population with particular foci on intergenerational relationships in later life families, visible minority immigrant women’s health, and social isolation among older adults. In her current research, Karen is comparing the health of Chinese and South Asian adults—the fastest growing ethnic groups in the Lower Mainland—with Canadians of British origin. She is examining differences in health status and use of health services among middle age Canadians to determine the factors that may promote or impede healthy aging.

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Sharon Koehn Sharon Koehn, PhD, has been conducting research with ethnic minority seniors for the past 15 years, both as an academic and as a contract researcher for various clients including the former Vancouver/Richmond Health Board, the BC Ministry of Health and the Office of the Attorney General of BC. Sharon has recently completed a CHSRF/CIHR postdoctoral fellowship focusing on barriers to access to care for ethnic minority seniors. This work sought to identify both barriers to access and viable solutions within a regional health care context. Her research interests include health care beliefs, access and utilization, aging of immigrants and ethnic minorities in Canada. Sharon was VP of the Vancouver Cross-Cultural Seniors Network Society for two years (2004-2006), and has served on numerous multicultural health committees and advisory boards. She has worked with a wide array of inter-disciplinary as well as community-based partners and now heads an inter-sectoral team to develop research proposals around the topic of ethnic minority seniors in care funded by the BC Network for Aging Research. Sharon is involved with the HCCRN as a member of the Seniors at Risk working group.

Daniel Lai Daniel Lai, PhD, is a professor and Alberta Heritage Health Scholar in the Faculty of Social Work at the University of Calgary. His research interests include: multicultural/multiracial research, health/mental health, gerontology, social policy and work practice and social work research. Among the many funders of Daniel’s research are the Alberta Heritage Foundation for Medical Research, the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research and the Drummond Foundation. Awards for his work include the Alberta Heritage Health Scholar Award, the Alberta Heritage Foundation for Medical Research, the latter for an ongoing project from July 2003 to June 2008. Daniel participates in numerous professional and community activities, including the Chinese Emotional Health Carnival, which he co-founded and the Calgary Chinese Elderly Citizens Association.

Bikkar Singh Lalli Dr. Bikkar Singh Lalli, PhD, is a retired professor and former Chair of the Department of Mathematics and Statistics at the University of Saskatchewan, Saskatoon. He has published over 150 scholarly articles

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in his field and has been invited to speak throughout the world on his area of expertise. For the last eight years he has served as a member of the senate of the University of British Columbia. As a volunteer with BC CEAS (the BC Coalition to Eliminate Abuse of Seniors) and the BC Security Commission, Dr. Lalli is making seniors tough targets for con artists. In addition, he runs a computer lab for seniors under Industry Canada’s CAP Program. There is a very healthy competition between Dr. Lalli and his wife, Surjit, for carrying out community work.

Van Le Van Le was an engineer in Vietnam before his arrival in Canada in 1975. He was employed as an engineer at the University of British Columbia from 1980 until 1995. Van then worked for Statistics Canada from 1995 until 2002. In 2002 he founded his own company, which develops software for language interpretation. Van’s clients are based in the UK, The US and Canada. He is also an active member of the Vietnamese Canadian Seniors Society.

Rosemary Meier Rosemary Meier, MB, ChB, MSc, FRCPsych, FRCPC, is director of Psychogeriatric Services for the Mental Health and Addiction Progam at St. Joseph’s Health Centre in Toronto, and a psychiatric consultant with the Geriatric Mental Health Outreach Team of the Ontario Ministry of Health and Long-Term Care (MOHLTC) and other organizations in Ontario. In addition, she is an assistant professor of Psychiatry and Public Health Sciences in the Faculty of Medicine and Chair of the Advisory Committee of the Institute of Life Course and Aging, both at the University of Toronto. Rosemary is also a member of the Consent and Capacity Board, the Ontario Guardianship Committee, the Office of Public Trustees, the Ontario Elder Abuse Team, and the Family Service Association, Toronto. She is an honorary board member of COPA (Community Outreach in Addictions) and a former board member and chair of the Health Committee: Canadian Centre for Victims of Torture. Together with Joel Sadavoy, Rosemary was a principal investigator for the Ethnoracial Seniors Project in Toronto, and has held numerous other research positions.

Akber Mithani Akber Mithani, MD, is the past Vice President of Medical Affairs at Providence Health Care. He is a Clinical Associate Professor in the

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Deptartment of Psychiatry and Family Practice (UBC), and has recently returned to practice geriatric psychiatry at Mount St. Joseph’s Hospital in Vancouver. He has an extensive background as a primary care physician, educator, and service planner in care of the elderly. He has served on numerous provincial, national and international initiatives in geriatric care in the community and institution.

Hien Phu Nguyen Hien Phu Nguyen is active in numerous seniors’ organizations, including the Vietnamese Canadian Seniors Society, the Vancouver Cross-Cultural Seniors’ Network, the Delta-Mekong Fellowship Association and the BC Coalition to Eliminate Abuse of Seniors. Before coming to Canada from South Vietnam in 1992, Hien Phu was a healthcare technician and later the Provincial Chief of Public Health for Mytho Province, South Vietnam.

Thong Nguyen Thong Nguyen was a high-ranking official of the Vietnamese government before immigrating to Winnipeg in 1982. After arriving in Canada, he became a French immersion high school teacher and also served as president of the Vietnamese Seniors Association of Manitoba. Thong retired and moved to Vancouver in 2003, where he is now a member of the Vietnamese Canadian Seniors Society and active within the Vietnamese church community.

Naina Patel Naina Patel, PhD, OBE, is founder and director of PRIAE, the Policy Research Institute on Ageing and Ethnicity, an independent, non-profit institute working in the UK and across Europe since 1998. Naina designed and led the Minority Elderly Care (MEC) Project at PRIAE under the European funded Fifth Framework Research Programme, a ten-country research project that explored the experiences and needs of 3,277 minority elders (50+ years of age), 901 healthcare professionals and 312 voluntary organizations. In addition to her work with PRIAE, Naina is Professor of Ageing and Ethnicity at the Centre for Ethnicity and Health at the University of Central Lancashire. She was awarded the Queen’s Honour in 2001 for her work on aging minorities. Among her many publications is a chapter in the Royal Commission on Long-Term Care for the Elderly’s work, With Respect to Age, entitled, “Black and Minority Ethnic Elderly: Perspectives on Long-Term Care.”

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Angela Sasso Angela Sasso has been working in the areas of access and cultural competency for over 15 years. Her expertise in the area of language services is premised on her extensive experience in assisting health care institutions and services in the development and implementation of interpreter services. Angela’s work has included the development and facilitation of training for interpreters, training for health care providers on working effectively with interpreters, and in the broader area of culturally competent care. Angela has worked closely with the major hospitals in BC’s Lower Mainland and is currently a manager in Communication and Consulting Services at the Provincial Language Service.

Baljit Sethi Baljit Sethi, BA, B.Ed, MA, MFA, is the executive director of the Immigrant and Multicultural Services Society of Prince George, BC. She immigrated to Canada in 1972 from the Punjab, India, where she was an instructor and senior tutor counselor at a community college. From 1974 to 1975 Baljit worked for Immigrant Services of BC and in 1976 she joined the Immigrant and Multicultural Services Society of Prince George. Baljit has served on the Advisory Council on Multiculturalism and the premier’s Committee on Working and Living in BC. She is also a pioneer member of Immigrant and Visible Minority Women of BC. Baljit currently works with the Committee on Seniors in Prince George and the Prince George Council on Seniors. In 2006 she was honored as the Prince George Citizen of the Year and received a BC Community Achievement Award in April 2007.

Farimah Shakeri Farimah Shakeri, MSW, RSW, is a Professional Practice Chief of Social Work at Royal Columbian Hospital. Farimah has worked in the health care system for over eight years in the field of geriatrics. She has done extensive work in the areas of cultural competency and anti-racist interdisciplinary practice. Her MSW research article entitled, “Aging in a Foreign Country: Voices of Iranian Women Aging in Canada,” was published in the Journal of Woman and Aging in September 2006. As a member of the Board of Directors of the Affiliation of Multicultural Societies and Service Agencies (AMSSA) and the Multicultural Health Committee, Farimah has been involved in planning and organizing various educational events and activities for people from diverse cultural backgrounds in our community.

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Mohinder Sidhu Mohinder Sidhu, MA, came to Vancouver in 1970 after receiving an MA degree in Punjabi Language and Literature from Punjabi University in Chandigaran City, India. In Vancouver she taught Punjabi to children at the Khalsa Diwan Society for 20 years, including 12 years as director of the program. Mohinder continues to serve the Indo-Canadian community through her work with seniors’ organizations and advocacy programs. In 2006 under the auspices of the 411 Seniors Centre Society, Mohinder conducted a series of workshops for Punjabi-speaking seniors that focused on seniors’ rights and access to government pensions and other services.

Noreen Simmons Noreen Simmons is a doctoral candidate in the Faculty of Audiology and Speech Sciences at the University of British Columbia, where her area of specialization is adult language disorders. Noreen’s doctoral dissertation research focuses on the linguistic and cultural differences that impact service delivery to adult Indo-Canadian clients. Her other research interests include bilingualism/multilingualism, cultural issues and aphasia. Noreen is also a speech-language pathologist and works part-time at the BC Family Hearing Resource Centre, which provides specialized services for children with speech-language problems and hearing loss.

Jeff Small Jeff Small, PhD, is an associate professor in the School of Audiology and Speech Sciences at the University of British Columbia. His research interests lie in the fields of cultural and linguistic issues in seniors’ health care. Jeff’s research goals include identifying communication needs and barriers to successful communication in diverse care settings and, in the long term, developing educational and advocacy materials that target key stakeholders in the provision of care for ethnic minority seniors.

Saroj Sood Saroj Sood worked for eight years in India as a social worker and for another nine years as a District Family Planning Education Officer. Saroj emigrated to Montreal in 1980, where she eventually opened two boutiques. She retired in 1992 and moved to Surrey with her two sons,

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by then grown and married. Saroj quickly became involved with the Indo-Canadian Seniors Centre, where she served for seven years as an assistant secretary, and has been involved in numerous health-related research, advocacy and educational projects. Recently, Saroj participated in the multicultural volunteer project, where she was trained as a peer counselor, providing health education to Punjabi-speaking seniors. She moved to an assisted living facility designed to accommodate Indo-Canadian seniors in February 2007.

Sid Chow Tan Born in China and a 35-year resident of Vancouver, Sid Chow Tan, BA, is a descendant of Gold Mountain adventurers and pioneers. His current community service includes: chairman of the Chinese Canadian National Council, president of ACCESS (the Association of Chinese Canadians for Equality and Solidarity Society), co-chairperson of the Head Tax Families Society of Canada, vice-president of the Firehall Arts Centre and membership and leadership positions in other organizations. A media producer and activist, Sid is also employed as a Seniors Organiser with the Downtown Eastside Residents Association. In addition to his work with seniors, Sid was involvement with his grandparents’ end-of-life care, and spoke at the symposium as a caregiver family member. Sid’s grandmother passed away in his home and his grandfather, because of debilitating strokes, passed away in an extended care facility.

Jocelyne Wong Jocelyne Wong, BScN, MN, MHA, is operations leader for the Mount St. Joseph Residence and the Geriatric Psychiatry Unit at Mount St. Joseph Hospital. Jocelyne has worked as an administrator, clinical leader, clinical instructor, direct care staff member and clinical consultant in a variety of settings, including acute, community and residential care. For the past 15 years, her focus in practice has been on providing service to seniors living in British Columbia’s Lower Mainland. Jocelyne is currently pursuing her certified health executive designation.

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Appendix 4a: List of Participants

Albaba-Ferguson, Barbara Diversity Coordinator, Immigrant and Multicultural Services Society (Prince George) [email protected] Alexander, Mary Lee Policy Advisor, Seniors’ and Women’s Strategic Partnerships and Information Branch, BC Ministry of Community Services [email protected] Alzona, Eleanor Research Coordinator, Centre for Healthy Aging at Providence [email protected] Araki, Yuriko Research Coordinator, BC Alliance on Telehealth Policy and Research, Dept of Kinesiology, SFU [email protected] Bailey, Brenda Regional CNS - Older Adult Health, Fraser Health Authority [email protected] Barroetavena, Maria Physician, Cancer Rehabilitation Network, BC Cancer Agency [email protected] Benoit, Andrea Residential Care, Fraser Health Authority [email protected] Bhaloo, Taj Director, Centre for Healthy Aging at Providence [email protected]

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Blanco, German Multicultural Family Centre REACH Clinic [email protected] Chan, Sing Mei PhD Student, Faculty of Social Work, Centre for Research on Personhood in Dementia, UBC [email protected] Chan, Sherman Director, Settlement Services, MOSAIC [email protected] Cheng, Fred Community Health Nurse, Vancouver Coastal Health [email protected] Chong, Teresa Social Worker, Fraser Health Authority [email protected] Coles, Eileen Manager, Residential Services, Surrey Memorial Hospital [email protected] Conlan, Tracey Delta Mental Health, Geriatric Outreach Team Fraser Health Authority [email protected] Dew, Jacquie Health Care Worker, Langley Mental Health Fraser Health Authority [email protected]


Dhalla, Rishma Occupational Therapist, Senior Falls Prevention Program, Richmond Health Services [email protected] Drummond, Neil DementiaNET, University of Calgary [email protected] Duquette, Adelia Director of Care, Victoria Chinatown Care [email protected] Durst, Doug Faculty of Social Work, University of Regina [email protected] Finlay, Juli DementiaNET, University of Calgary [email protected] Fox, Suzanne Master’s student, UBC [email protected] Friesen , Kathleen Director of Geriatric Services,

Gomez, Clemencia South Granville Seniors Centre [email protected] Gutman, Gloria Director, Dr. Tong Louie Living Laboratory, Gerontology Research Centre, SFU and BCNAR [email protected] Haydamack, Paula Fraser Health Authority [email protected] He, Jie Intern, Innovation in Health Technology, Vancouver Coastal Health [email protected] Hill, Diana Director, Home Support Services, Home Support, Greater Vancouver Community Services Society [email protected]

Fraser Health Authority [email protected]

Ho, Stanly Occupational Therapist, Fraser Health Authority [email protected]

Ganesan, Soma Medical Director, Psychiatry, Vancouver Coastal Health [email protected]

Hollingworth, Jan RN, Geriatric Outreach, Langley Mental Health [email protected]

Geddes, Sandra HCCRN & Fraser Health Authority [email protected]

Hundal, Paul Manager, Community Care Licensing, Health Protection, Fraser Health Authority [email protected]

Ghuman, Karol Nurse Practitioner (Family), Primary Care Clinic - Mental Health, Fraser Health Authority [email protected]

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Gibbons, Valerie Fraser Health Authority [email protected]

Hwang, Eunju Postdoctoral Fellow, Gerontology Research Centre, SFU [email protected]


Johl, Harpal Director of Family Services, DIVERSEcity community resources society [email protected]

Lo, Jenny Manager, Community Services, Assisted Living, Adult Day Care Centre, S.U.C.C.E.S.S. [email protected]

Johnston, Angela M.A. candidate, Dept. Gerontology, SFU [email protected]

Ma, Bernice Support and Education Assistant, Alzheimer Society of BC [email protected]

Kaur, Sinder Manager of Resident Services, Resident Care Department, S.U.C.C.E.S.S. [email protected]

MacCourt, Penny Research Affiliate, Centre on Aging, UVic [email protected]

King, Pat Manager, Residential Services, Trillium Lodge and Westhaven Care Centre Vancouver Island Health Authority [email protected] Ko, Teresa Care Coordinator, Special Care, Resident Care Department, S.U.C.C.E.S.S. [email protected] Ku, Marisa Coordinator, Hospice, S.U.C.C.E.S.S. [email protected] Lalli, Surjit Community volunteer, [email protected] Lerch, Noreen PhD candidate, HSD School of Nursing, University of Victoria [email protected] Leung, Shirley Program Director, Group and Community Services, S.U.C.C.E.S.S. [email protected]

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MacKinnon, Marian Former professor of nursing, UPEI [email protected] Mayeed, Mahiha Researcher/Administrator, Caregivers Association of BC [email protected] McLean, Barbara Case Manager, Residential Care, Fraser Health Authority [email protected] Mihelic, Chrystal Manager, White Rock/South Surrey Mental Health Centre, Fraser Health Authority [email protected] Miles, Rachel Activity and Volunteer Coordinator, Nikkei Home, Seniors Health Care and Housing Authority [email protected] Mithani , Akber Geriatric Physican and HCCRN Advisory Committee co-chair, Providence Health Care [email protected]


Orquiola, Carmencita Seniors Program Coordinator, Multicultural Helping House Society [email protected] Pitman, Beverly Project Coordinator, Research and Consulting, SPARC BC [email protected] Puri, Ajay Research Assistant, Centre for Addiction Research of BC [email protected] Rahim-Jamal, Sherin Project Specialist, Centre for Healthy Aging at Providence [email protected] Rohrer, Irene Manager, Fraser Health Authority [email protected] Rosenau, Brenda Case Manager, Adult/Older Adult, Vancouver Coastal Health [email protected] Rowe, Tim Executive Director, Home and Community Care; Northern Health Corporate Services [email protected] Sandhu, Ravin Student, University College of the Fraser Valley [email protected] Sands, Jim Project Coordinator, SPARC BC [email protected] Sarte, Ann Graduate student, Department of Gerontology, SFU [email protected]

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Singh, Joe [email protected] Sirett, Robena Manager, Older Adult Program, Vancouver Community Mental Health Services VAncouver Coastal Health [email protected] Swamy, Bidar Administrator, PICS Senior Care [email protected] Teixeira, Celso Director - Health Planning and Systems Development, Fraser Health Authority [email protected] Thompson, Jean Community Developer, North Shore Community and Family Health, Vancouver Coastal Health [email protected] Tolson, Margreth Leader, Community Engagement, Vancouver Coastal Health [email protected] Tong, Sharon South Vancouver Neighbourhood House [email protected] Tung, Mabel BC Nurses Union [email protected] Varas, Magaly Coordinator, Spanish Outreach Program, South Granville Seniors Centre [email protected] Wong, Susan Vancouver Cross-Cultural Seniors Network Society [email protected]


Wood, Maureen Executive Director, Home Health and End of Life Care, Fraser Health Authority [email protected] Yarker-Edgar, Kristen Nutritionist, Ministry of Health [email protected]

Yu, Winnie Healthy Aging Manager, Healthy Children, Women and Seniors Branch, Population Health and Wellness Division, Ministry of Health [email protected]

Appendix 4b: List of Speakers and Workshop Chairs

Ambrosini, Carla Pharmacist, Medication Management Program, Fraser Health Authority [email protected]

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Cheema, Jas Diversity Manager, Surrey Health Services, Surrey MemorialHospital, Fraser Health Authority [email protected]

Assanand, Shashi Executive Director, Vancouver and Lower Mainland Multicultural Family Support Services Society [email protected]

Gill, Charan Executive Director, Progressive Intercultural Community Services (PICS) [email protected]

Busse, Betty Ann Executive Vice President, Health Promotion and Community Programs, Fraser Health Authority [email protected]

Grant, Sue Project Leader, Advance Care Planning, Fraser Health Authority [email protected]

Chappell, Neena Canada Research Chair Cahir, Social Gerontology Centre on Aging, UVic [email protected]

Gupta, Rashmi Assistant Professor, School of Social Work, San Francisco State University [email protected]

Chaudhury, Habib Assistant Professor, Department of Gerontology, SFU [email protected]

Hernandez, Pepita President, Philippine Bagong Pag-asa Society of BC [email protected]


Kobayashi, Karen Assistant Professor, Department of Sociology, UVic [email protected] Koehn, Sharon Research Associate, Centre for Healthy Aging at Providence [email protected] Lai, Daniel Professor and Alberta Heritage Health Scholar, Faculty of Social Work, University of Calgary [email protected] Lalli, Bikkar Member of the Senate of UBC [email protected] Le, Van Affiliate, Vietnamese Canadian Seniors Society of Greater Vancouver [email protected] Meier, Rosemary Director of Psychogeriatric Services, Mental Health and Addiction Program, St. Joseph’s Health Centre; U of T [email protected]; [email protected] Nguyen, Hien Affiliate, Vietnamese Canadian Seniors Society of Greater Vancouver [email protected] Nguyen, Thong Affilliate, Vietnamese Canadian Seniors Society of Greater Vancouver [email protected] Patel, Naina Director, PRIAE; Professor, Centre for Ethnicity and Health, U. of Central Lancashire [email protected]

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Sasso, Angela Manager, Communication and Consulting Services, Provincial Language Service [email protected] Sethi, Baljit Executive Director, Immigrant and Multicultural Services Society of Prince George [email protected] Shakeri, Farimah Professional Practice Chief of Social Work, Royal Columbian Hostpital, Fraser Health Authority [email protected] Sidhu, Mohinder Affiliate, South Vancouver Neighbourhood House [email protected] Simmons, Noreen Doctoral candidate, Faculty of Audiology and Speech Sciences, UBC [email protected] Small, Jeff Associate Professor, Faculty of Audiology and Speech Sciences, UBC [email protected] Sood, Saroj Affiliate, Indo-Canadian Seniors Centre Tan, Sid Family caregiver; Seniors Organizer, Downtown Eastside Residents Association [email protected] Wong, Jocelyne Operations Leader, Mount St. Joseph Residence and the Geriatric Unit at Mount St. Joseph Hospital [email protected]


Cameron, Louisa Assistant Coordinator for the Speaking to the Interface symposium, Centre for Healthy Aging at Providence [email protected] Kehoe, Susan Research Project Specialist, Centre for Healthy Aging at Providence [email protected] Kozak, Jean-Francois Director of Research, Centre for Healthy Aging at Providence; UBC [email protected]

126
