Chapter 13. Awareness of Formal Social Supports Among Older Immigrants in Mid-Sized Urban Communities: The Case of Waterloo, Ontario

The proportion of older adults (aged 65 and over) in Canada is currently about 18 percent (Statistics Canada, 2020). Estimates suggest that by 2030, nearly one in four Canadians – 23 percent – will be 65 years or older (Employment and Social Development Canada, 2014). Canada is somewhat unique in that a substantial proportion of its older adults have a migration background. These older immigrants face general challenges associated with aging and also contend with heightened risks such as income insecurity, discrimination, and difficulties in accessing and utilizing necessary services later in life. Previous research has revealed that older immigrants – particularly new immigrants and refugees – are especially vulnerable to social isolation, which in turn increases their risk of experiencing poorer health outcomes and a lower quality of life (Employment and Social Development Canada, 2018, 3). ^[1]

In response to these challenges, the “Aging Well” project was conducted to clarify the social needs, networks, and support of older immigrants in Ontario and to determine how best to foster their capacity, resilience, and independence. This large-scale research initiative was funded by the Social Sciences and Humanities Council of Canada (Guruge et al. 2019). The project drew from an intersectionality perspective and an ecological model, and employed a collaborative, community-based, mixed-methods approach. Surveys, focus groups, and interviews were conducted across four cities in Ontario: Toronto, Ottawa, Waterloo, and London. Participants included service providers, community leaders, older immigrant adults, and their families. The research team focused specifically on Arabic, Mandarin, and Spanish-speaking communities.

This chapter explores a subset of the data gathered for the Aging Well study, specifically data collected in the Region of Waterloo. Located about 100 kilometres west of Toronto, the region encompasses the cities of Cambridge, Kitchener, and Waterloo. As of 2019, its population was estimated at 617,870 (Population, Region of Waterloo, n.d). This growing, mid-sized region is home to two large universities and a still relatively important manufacturing sector. As of 2016, 22.6 percent of its residents were immigrants – the third-highest proportion of immigrants in Canada outside of the Greater Toronto Area (Region of Waterloo, 2019, 5). The Waterloo component of the Aging Well study involved eight focus group sessions with a total of 65 older Spanish-speaking and Mandarin-speaking older adults who are 60 years of age or older and had lived in the Waterloo region for 20 years or less. The participants were also asked to fill out a questionnaire about social support. All focus groups were conducted in the first languages of the participants. Additionally, eleven family members and seven community leaders were either interviewed individually or participated in dedicated focus groups.

The following discussion explores these primary data with a specific focus on service awareness, which we define as the knowledge that older immigrants have about the formal supports to include healthcare, legal, educational, social, and settlement services that are available in their community. To assess service awareness, we conducted a thematic analysis. We read through the focus group transcripts, identified emerging themes, and analyzed them within the larger context of the municipality (e.g., community composition and structure, available services). This approach helped reveal how familiar the study participants were with the available formal supports, what information they had about these programs and services, how they had learned about them, and how both services and communication about services might be improved. Our discussion and analysis drew from the social determinants of health approach and from Cantor’s theory of “social care” (1989).

Ensuring access to services is vital for fostering social embeddedness among older immigrants in Canadian cities and can also mitigate the often overlooked but serious and growing epidemic of social isolation. That said, older immigrants can only benefit from available formal services if they are aware of their existence. In this chapter, we aimed to amplify the voices of older immigrants in order to convey their perspectives on service awareness. Our focus did not center on the viewpoints of service providers, or community leaders, nor on their efforts to raise service awareness. Instead, we concentrated on capturing the perspectives of older adults themselves. Our hope was that this discussion would reveal valuable insights, identify place-specific gaps and vulnerabilities, and potentially help stakeholders in Waterloo and beyond optimize the provision of formal supports in their municipalities.

Research on Service Awareness

Several factors affect the reach and effectiveness of formal supports for older immigrants. First, services and programs must be available, which itself requires the recognition of specific needs and a community commitment to meet them. Service availability is also dependent on the characteristics of each individual city/municipality, particularly funding. In Ontario, funding cuts over the past decade have reduced both the quality and the availability of services for immigrants at large (Guruge et al. 2019, 2). Effective coordination between agencies, service providers, and other stakeholders is another factor. Xie and colleagues (2020) noted that ensuring the inclusion of vulnerable populations may not always require new interventions but rather coordinated implementation.

Furthermore, the availability and delivery of quality information are crucial. Older immigrants need to be aware of the available community supports to be able to access them. Several Canadian studies have explored this and other related topics in detail, including the quality of information about formal services available across different communities, awareness levels among older adults, and communication strategies employed by service providers. However, there remains a gap in research specifically focusing on older immigrant adults themselves. Some Canadian studies have aimed to understand how service providers across various sectors can increase their visibility in local communities and be more effective in terms of their communication, information dissemination, and outreach methods. For example, Deville-Stoetzel and colleagues (2021) recommended using a series of strategies to increase attendance at cardiovascular health awareness program meetings by older adults living  in subsidized housing in Quebec. Their suggestions included improving confidentiality, relying on community peer networks to enhance recruitment, engaging opinion leaders and other types of “bridging” individuals, and pairing attendees to increase the likelihood of participation. MacLeod and colleagues (2016) found that innovative programs, such as the one they helped design in Ontario with the help of volunteers interested in the expressive arts, can help reach isolated older adults living in rural areas. Additionally, numerous service providers, umbrella organizations, and different levels of government have compiled lists of “best practices” to optimize outreach strategies (see Edmonton Seniors Coordinating Council, 2010; Ontario Age-Friendly Communities, 2021; Public Health Agency of Canada, 2010).

Other studies have focused on the perspectives of older adults themselves more specifically and the degree to which they are informed about the available supports in their communities. Tindale and colleagues (2011), for instance, studied the social determinants that influence awareness of community support services among older adults in Hamilton, Ontario. Denton and colleagues (2008) reported high levels of perceived need but low levels of awareness of available support. Employment and Social Development Canada (2018) also identified lack of awareness of community programs as a significant risk factor for the increasing numbers of new immigrants and refugee older adults who are at risk of social isolation.

Diversity of Perspectives

As we began to analyze our dataset, we noticed a clear diversity of perspectives among older immigrants within the Spanish and Mandarin-speaking communities in the Region of Waterloo in terms of their awareness of the available services and their related concerns. Significant differences were also evident among individuals from the same community. Factors including gender, educational level, socioeconomic status, and residency status all clearly influenced the information older immigrants had about available social support services in the Region of Waterloo. Our findings also revealed that additional variables such as personality and extraversion, energy levels, degree of connectedness, interests, and hobbies – which tend to be overlooked in academic analyses – also played significant roles in this respect.

These findings highlighted the importance of nuanced analysis. While broad concepts and terms such as “Spanish-speaking older immigrants” are valuable in some contexts, it is important to acknowledge that older immigrants are a heterogeneous group with significant differences among individuals. They all have diverse life courses, personal circumstances, and varying experiences of aging, all of which influence their independence, capacities, resilience, and long-term care needs.

As noted, we identified varying levels of familiarity with the available social supports in Waterloo. Some respondents were very well connected and embedded in the social matrix of the community. Typically, they were younger, and many were women. They tended to participate actively in social programs and activities in the Region of Waterloo, whether as clients or volunteers. Their engagement had a positive cascading effect: these residents were quite knowledgeable about the available formal supports in their community, which, in turn, made them more resourceful and socially connected. Other respondents were moderately aware and felt that there was a general lack of awareness among their community members. One participant said, “There is a lack of awareness … Not everybody knows about the available programs and services.” This sentiment was echoed by other respondents who made comments such as, “Yes. Definitely. There is that lack of information … it seems that most of us don’t know these kinds of supports.” Some, who were relatively dependent on their children, mentioned “we are not sure of what is out there – what is available and not. Everything is done by others, not us.” Even the least connected and least active respondents had some degree of awareness of the supports available in the community. However, some focus group participants indicated that this was the first they had heard about many of the available supports. Our research also revealed that some older immigrants were not connected at all and that they remained difficult to reach. Previous studies have reported the problem of underutilization of services among older immigrants^[2], with lack of awareness being a significant contributing factor.

It is important to note that, in some cases, lack of information is not the main problem; certain services and programs may simply not be available in medium and small cities. Larger cities, such as Toronto, tend to have a higher proportion of foreign-born residents, and immigrant communities in these cities tend to be better organized, have community centres of their own, and more able to offer programs and services targeting older immigrants. Given the relatively short distance between the Region of Waterloo and the Greater Toronto Area, comparisons are inevitable. However, living in larger cities may not always be the best option for older immigrants. For example, larger cities can be less affordable and present challenges related to transportation. Typically, though, they have the capacity to offer more services compared to smaller cities and towns.

Aspirations and Experiences

Members of both communities generally hoped to enter a language-specific long-term-care facility if needed, or at least to have access to services provided in their mother tongue. The Region of Waterloo provided some services in German, but few institutions offered services in Spanish or Mandarin. The Mandarin-speaking community was particularly vocal about the need for ethno-specific care, partly due to language barriers and food preferences. To a lesser degree, Spanish-speaking participants had similar hopes. Several respondents from both communities reported feeling uneasy about care facilities in Canada, citing concerns about affordability and quality. ^[3]

With regard to the provision of health care, the Region of Waterloo had several health professionals who spoke Spanish or Mandarin, but respondents felt there was a need for more. Some mentioned that they rarely visited their doctor for this reason, while others noted they were reluctant to go to hospitals due to potential language barriers with nursing staff^[4], and tried to manage their health problems on their own, (e.g., by self-medicating). The lack of English proficiency posed a significant barrier to their access to healthcare, especially during emergencies.

With regard to social/educational programs, participants commented that some of the activities they wanted (e.g., Zumba) were not offered at local community centres or were offered exclusively in English (e.g., yoga.) Ethno-cultural groups and associations serve as places of care, identity, and connection, playing crucial roles in service provision and fostering awareness about available supports. However, at the time of writing, the Spanish-speaking community in the Region of Waterloo lacked its own cultural centre. ^[5]

We also found that while a relatively large proportion of the older immigrants were aware of available support services, many were unable to access them. One main barrier was transportation, as cultural centres and churches were often far from the homes of some participants. Others could no longer drive or did not have a license. Despite some access to public transit or senior-specific accessible buses, respondents expressed concern about fares. For instance, in many parts of China, older residents do not pay to use local buses. Additionally, issues, such as, inconvenient schedules,routes, commuting time, and hazardous winter conditions hindered access.

Another important issue is lack of adequate English-language skills: Waterloo is becoming more multicultural, but most services continue to be offered predominantly in English. Some respondents also highlighted affordability as a significant barrier, referring not only to the costs of activities and services (e.g., theatre, courses at community centres, dental care), but also the associated costs (e.g., course materials). Many older immigrants in Canada have modest incomes (Kei et al. 2019): one of our respondents stated simply: “it’s the money; it is not enough.” Financial insecurity among older immigrants can have many consequences: from poor nutrition to difficulties finding appropriate housing, to increased risk of social isolation.

Disability and limited mobility were also identified as challenges, and some older immigrants spoke about disappointing experiences with service providers in some settings, which made them reluctant to seek assistance. Participants also had different conceptions of public space. For example, Chinese older adults tended to be relatively physically active and prioritized physical activities such as dancing and tai-chi. However, without a dedicated place of their own, some had received complaints about being “very loud” when using public spaces or even their own residential spaces.

Another issue worth noting is that awareness of a service (e.g., legal assistance) does not always guarantee that individuals will be able to benefit from it. Some participants commented that they did not know how to obtain satisfactory information about certain services. Others noted that some available programs did not consider cultural differences, and that certain topics (e.g., sexuality, mental health) were not handled appropriately. As a result, some programs that focus on older adults become inapplicable or uninteresting to some groups or individuals. In addition, some programs struggled to stay afloat because they were underfunded.

One issue requiring more research is fragmentation, especially the lack of trust within some communities. Financial scams, intracommunity dynamics, and other issues can make older immigrants more guarded and less proactive in reaching out^[6]. Some respondents reported discriminatory incidents and other difficulties preventing them from fully integrating into local culture.

Finally, engagement with sociocultural programs is influenced by personal preferences. Some older adults were simply not interested in the activities offered or had grown too accustomed to their routines. Overall, there was room for better advertisement strategies, but service providers could do only so much when a segment of the target population is not interested. One excerpt from a conversation illustrates this kind of apathy:

[Person 1] “I have noticed that this information is featured in the bulletins but people…”

[Person 2] “Maybe they don’t read them”

[Person 3] “They don’t read them”

[Person 1] “And they carry them by the hand!”

Overall, many of our respondents perceived the available supports as efficient, fair, fostering equality, and free from corruption. Still, more work is needed to engage with older immigrants and consider their feedback to optimize existing community supports. In spite of the initial recruitment challenges, respondents were grateful for the opportunity to participate in our study and learn more about these topics. They showed eagerness to stay informed and actively contribute to the community. To maintain this momentum and avoid apathy, there is a need for fine-tuning systems. One participant said, “What would be good now is that, since you know about that [service], you [go] tell the secretary here about it so that she can inform us all about these things.”

We observed relatively high levels of political engagement among participants: Many were proactive, informed, and curious about the state of affairs in other cities and countries. For instance, one participant commented, “One more thing that I want to suggest [is] based on what I have learned about the policies practiced in Switzerland.” Others expressed their desire to make meaningful contributions, with statements such as, “even after retiring, we have continued to contribute. In return, we hope that the local government does more practical things for us.” Respondents were eager to engage with other cultures and learn from others, which speaks to their resilience, ability to adapt, and eagerness to contribute and to belong. We also identified differences in terms of willingness to participate more actively in the community and become better informed; these differences were influenced by personal preferences, lifestyle and routines, and narratives of self-reliance.

With regard to optimizing services and facilitating access in the future, we found that most older immigrants relied on word of mouth to obtain information about formal supports. Many reported relying on family, friends, cultural centres, and churches for information. A few said they had seen advertisements in bulletins, magazines, and posters, but questioned their effectiveness (see Choi & Smith, 2014). Others reported accessing information from the internet or messaging apps such as WeChat. Overall, there seemed to be a consensus that better information-dissemination strategies were necessary. During one focus group, the moderator asked “What are we lacking here? What do you miss? What do you think could be improved when talking about institutional services?” Respondents replied with comments including: “communication,” “more [information] about all these services,” and “regarding advertisement, there is not enough diffusion, other than the posters that they hang in the lobbies at these community centres.” Clearly, participants felt that there was room for improvement in the flow of information.

With regard to improving the flow of information, some participants reported that family doctors could play a more active role in facilitating information about support groups or activities such as workshops. Other participants mentioned that social workers or pharmacists could fulfill a similar function. Spanish-speaking participants noted that churches served as crucial nodes in communication networks that effectively disseminate information of interest. To our knowledge, the churches and priests in the Region of Waterloo were informed and active to an extent but they may not have been aware of all available institutional supports. Some participants suggested that a hotline staffed by employees who spoke their native language might be a valuable source of information. Other\s commented on the need for more coordination between local service providers. Overall, improving dissemination strategies will be essential to ensure that available social supports are well known among target populations. Addressing this barrier will be much more effective in the short term than attempts to tackle more complex issues such as income insecurity among older immigrants.

Conclusion

Service awareness is a key factor in the provision of quality care and services for older immigrants. These services can not only help them age well but also benefit broader society by addressing the increasing challenge of social isolation. To optimize existing services, it is essential to listen to older immigrants themselves. Our thematic analysis of the transcripts from a series of focus groups conducted with older immigrants in the Region of Waterloo, show varying levels of familiarity with formal supports among the study participants. Many were aware of the available services in the region. However, a significant proportion did not have access to such information. Moreover, being informed was not sufficient to guarantee access to services. Barriers such as transportation issues, limited English proficiency, and financial constraints hindered access to services for many respondents. The study participants identified a need for ethno-specific long-term care options. We found that many respondents were eager to actively participate in their community and wanted to be better informed about the available supports. Harnessing this enthusiasm will be crucial for future practice and policy efforts. Most participants relied on information from friends, family, cultural centres, and churches, which can be potential avenues for service dissemination. Efforts to enhance service access should prioritize more efficient strategies, recognizing the heterogeneity among older immigrants both across and within communities.

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