Chapter 4. Health Statuses of and Health Determinants among Older Immigrant Women in Canada: A Scoping Review

Background

Aging and migration are two factors that continue to significantly shape population trends worldwide (United Nations, 2022). The number of individuals aged 65 years and older is growing more rapidly in comparison to those in younger age groups, and the global percentage of those aged 65 years and above is projected to rise from 10 percent in 2022 to 16 percent in 2050 (United Nations, 2022). This trend is the result of various factors including diminished fertility rates, advanced medical care, and socioeconomic development, all of which have helped lower levels of mortality and morbidity (Cheng et al., 2020; United Nations, 2019).

The global population of older women exceeds that of older men (Davidson et al., 2011; United Nations, 2019). According to the United Nations (2019), women outlive men by 4.8 years, and in 2022, women accounted for 55.7 percent of people aged 65 or older worldwide (United Nations, 2022). This phenomenon is known as the “feminization” of aging (Sousa et al. 2018). Previous research has demonstrated that older men and women experience different health statuses. Evidence suggests that because women generally live longer, they are at an increased risk of experiencing age-related disability and functional limitations (Crimmins et al. 2019; Rapp et al., 2022; Scommegna, 2019). Women are also more likely than men to survive the death of their spouse and live alone (Carr & Bodnar-Deren, 2009). This can increase social isolation, which can have detrimental effects on their health and wellbeing (Zheng & Yan, 2024). Women also tend to have more obligations related to family caregiving and domestic chores, which can limit their time to engage in health promoting activities and seek care in a timely manner, ultimately affecting their long-term health.

Alongside the above-noted age-related demographic changes, the number of immigrants aged 65 years of age and older has continued to increase in the major immigrant receiving countries (Krzyż & Lin, 2024). In Canada, immigrants constitute about 30 percent of Canada’s population aged 65 years and older (Statistics Canada, 2022). Factors such as language barriers, cultural differences, geographical location, and socioeconomic status impede their access to healthcare services, and place them at an elevated risk for compromised health. Older immigrant women and older immigrant men may have different settlement experiences and challenges. This chapter reports on findings from a scoping review we conducted to comprehensively map and examine research that has analyzed the health of older immigrant women in Canada.

Our review was guided by the following research question: What can be known from the existing literature about the health of older immigrant women in Canada?

Method

We used the JBI method that is outlined in the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA) checklist (Peters et al., 2015).

Eligibility Criteria

Articles were included if they: 1) were peer-reviewed; 2) reported results of primary research; 3) were published in English or French; and 4) examined the health of older immigrant women in Canada.

The United Nations (2019) defines an “older adult” as someone aged 60 or 65 years and older. However, in many low-income countries with relatively shorter life expectancies, this definition may be expanded to include individuals aged 55 and older (Spencer & Gutman, 2008). Because many older immigrants to Canada arrive from low- and middle-income countries, we adopted the definition of older adults as individuals aged 55 or older. We also included studies that did not focus primarily on older women as long as a) their sample mean or median age range was 55 years or older, b) at least half of the participants were women, and c) separate results were available for older women. We defined “immigrants” as individuals who were born outside Canada (to non-Canadian parents) and permanently relocated to Canada. If a study included both immigrant and Canadian-born older adults, we included it only if at least half of the study sample was born outside Canada and separate results were available for this group.

Information Sources and Search

We searched four electronic databases: CINAHL, PsychINFO, Embase, and Medline. A subject librarian was consulted to ensure our search strategy was comprehensive in identifying relevant literature, and to develop a list of the most applicable search terms and strategies.

Separate searches were conducted for the four databases with the last search conducted in May 2024. The search in CINAHL used Medical Subject Headings (MeSH) terms: “old age” OR “senior” OR “elder” OR “older” AND “immigrant” OR “refugee” AND “health” AND “Canada,” following which the keywords and search strategies were tailored to each remaining database source. Boolean operands OR/AND were incorporated throughout the search terms. To produce a comprehensive map of the existing literature on this topic, no time limitations were included. Although the term “health” was deemed an important keyword by the subject librarian and the research team to guide the search and answer the research question, it limited the results. Therefore, we also screened the literature identified by each search without using the term health to ensure that we included all available studies that evaluated the health or determinants of health among older immigrant women in Canada.

The reference lists of all included articles located through the electronic database searches were also reviewed. All additional articles that were identified through reference list searching were entered into the screening process beginning with Stage 1 screening (see below). A saturation point was reached where no new literature was being identified.

Selection of Sources of Evidence

We used a reference management software (Rayyan) to organize the articles from the four electronic database searches and to manage the review process. A two-stage screening process was conducted to select the sources of evidence. First, the titles and abstracts were read to remove any studies that were clearly irrelevant. If the study appeared to meet the eligibility criteria, or if it was not clear whether the article was relevant, it was advanced to the second stage screening, which involved assessing the full text of the article. The screening process was conducted by two of the co-authors independently of each other. Discrepancies on article inclusion or exclusion were resolved through research team discussions. The PRISMA flowchart shown in Figure 1 presents the numbers of articles excluded at each level, along with the reasons for exclusion.

Data Items and Charting Process

The data charting process was also performed by two co-authors. Key information was extracted from all eligible articles and inputted into a data extraction tool. The information collected included author(s), year, title, journal, purpose, design, date, location or context, target population/sample, procedures/measures, relevant findings/themes/concepts, limitations, and implications. Table 4.1 presents the extracted data.

Synthesis of Results

Following the data charting process, we conducted a narrative synthesis, which was informed by the approach outlined by Popay and colleagues (2006) consisting of four elements: (1) selecting a theoretical framework; (2) developing a preliminary synthesis of the findings; (3) exploring relationships within and between all included studies; and (4) assessing the robustness of the synthesis. As this scoping review was exploratory, with the goal of mapping the existing literature on this topic, we did not utilize a particular theory, and instead we prioritized the identification of key concepts, themes, and factors that emerged across the literature. The preliminary synthesis consisted of extracting key details from all included articles that were relevant to the scoping review question. A tabulation tool was used to organize the data visually into labelled columns in tables. This helped us identify patterns and compare and contrast the results between included articles. We then used a modified thematic analysis to identify concepts, patterns, and themes across the included studies.

We did not engage in critical appraisal of the included literature because our objective was to map the existing evidence on the topic under investigation. However, to ensure the robustness of the data synthesis process, we adhered to the PRISMA-ScR guidelines, and provided a clear audit trail that is illustrated in the PRISMA flow chart (Figure 4.1).

Figure 4.1 PRISMA Flow Chart

Results

Characteristics of Articles

We identified 47 relevant cross-sectional studies. Ten studies used a quantitative design, 20 used a qualitative design, and 17 used a mixed-method design. The characteristics of each article can be reviewed in Table 4.1.

Summary of the Studies

We organized the 47 articles into six focus areas: physical health (n=1), mental health (n=13), abuse (n=3), health beliefs (n=14), health behaviours and practices (n=8), and barriers to healthcare access and utilization (n=22). It is important to note that the focus areas presented in this scoping review identify recurring patterns, themes, or findings and therefore, some articles focused on more than one theme.

Physical Health

Only one study reported on physical health, and it focused on the influence of workplace environment on the physical health of older immigrant women (Choi et al., 2014a). Choi and colleagues (2014a) conducted a qualitative cross-sectional study involving 15 Korean women to explore their experiences of health after retirement. Their participants described experiencing various physiological symptoms while being employed, such as weight loss, loss of appetite, and headaches, which they attributed to their everyday working environment. A significant number of the participants worked as labourers, cooks, and housekeepers, which exposed them to demanding working conditions. The authors concluded that labouring in such demanding working conditions contributed to a range of health ailments, ultimately predisposing these women to the development of acute or chronic diseases (Choi et al., 2014a).

Mental Health

Thirteen studies reported on the mental health of older immigrant women (Acharya & Northcott, 2007; Ahmad et al., 2021; Alvi & Zaidi, 2017; Lai, 2010; Jo et al., 2018;  Lai, 2004a; Lai, 2004b; Lai et al., 2020; Mackinnon et al., 1996; Madhavi et al., 2014, Salma & Salami, 2020; Su et al., 2022; Wu & Hart, 2002). Eight reported on the experiences of social isolation and loneliness among older immigrant women (Ahmad et al., 2021; Alvi & Zaidi, 2017; Jo et al., 2018; Lai et al., 2020; Mackinnon et al., 1996; Madhavi et al., 2014, Salma & Salami, 2020; Su et al., 2022). For example, participants in Mackinnon and colleagues’ (1996) qualitative cross-sectional study described feelings of loneliness and emotional isolation caused by factors including language barriers and limited access to transportation. Jo and colleagues (2018) conducted a cross-sectional mixed-methods study to explore how a cultural community program affected overall wellbeing among 79 older Korean immigrants, which included 61 older women (77 % of the sample). They found that all participants experienced a sense of belonging when they could communicate and maintain connections with other older Korean immigrants.

Three studies reported on experiences of mental distress, such as depression among older immigrant women (Acharya & Northcott, 2007; Jo et al., 2018; Lai, 2004b). Acharya and Northcott (2007) conducted a qualitative cross-sectional study to explore the strategies that older immigrant women utilize to cope with mental distress. Their participants emphasized the importance of keeping occupied with personal, familial, and social obligations as a means of preventing mental distress, and also noted that religious rituals during times of stress helped contribute to a stronger sense of control over their internal emotional state. Jo and colleagues (2018) found that maintaining relationships and connections with other older immigrants from similar cultures provided enhanced feelings of emotional support when experiencing depression. Lai (2004b) conducted a quantitative cross-sectional study with 1537 older Chinese immigrants that showed that less financial adequacy, diminished levels of social support, and cultural barriers increased the likelihood of experiencing depressive symptoms.

Experience of abuse

Three studies reported on abuse against older immigrant women (Alvi & Zaidi, 2017; Lai, 2011; Souto et al., 2016). Two studies explored intimate partner violence, experienced by older immigrant women. Souto and colleagues (2016) conducted a qualitative study to explore intimate partner violence among 10 older Portuguese female immigrants in the Greater Toronto Area; Alvi and Zaidi (2017) conducted a qualitative study to explore experiences of abuse among 10 older South Asian immigrant women in Southern Ontario. Both studies reported a range of abusive behaviours towards older immigrant women by their intimate partners, including daily threats, isolation, humiliation, and experiences of financial, verbal, and sexual abuse (Alvi & Zaidi, 2017; Souto et al., 2016). Lai (2011) conducted a cross-sectional study to explore abuse among a random sample of 2272 aging Chinese immigrants in seven Canadian cities and found that the most common forms of abuse included being scolded, yelled at, treated impolitely, and ridiculed.

Women in each study reported various experiences with regard to reporting their experiences of abuse. Souto and colleagues (2016) reported that their participants had experienced supportive and favourable encounters with legal agencies. More specifically, their participants referred to challenges in reporting their experiences of abuse in their home country, Portugal, where reports were often encountered with disbelief or dismissal; in contrast, they noted that in Canada they were able to obtain the social and legal supports they needed to end the ongoing intimate partner violence (Souto et al., 2016). This was in contrast to participants’ experiences in the other two studies. Participants in other studies described unsatisfactory experiences with authorities (Alvi & Zaidi, 2017) or instances where abuse remained undisclosed indefinitely (Alvi & Zaidi, 2017; Lai, 2011). Participants in Alvi and Zaidi’s (2017) study referred to challenges disclosing their experiences of abuse to authorities due to structural discrimination, including a lack of knowledge or understanding of their legal rights as well as language barriers. Some of these participants feared potential repercussions to their families, which stemmed from perceptions of political bias or racism among authorities, as well as stereotyping based on ethnicity, race, and cultural background (Alvi & Zaidi, 2017). With regard to underreporting of abuse, older immigrant women in both studies expressed apprehensions about reporting due to feelings of guilt and loss of respect among other family members (Alvi & Zaidi, 2017; Lai, 2011).

Health Beliefs

Fourteen studies reported on the health beliefs that influenced the utilization of healthcare services among older immigrants (Acharya & Northcott, 2007; Choi et al., 2014b; Fornazzari et al., 2009; Jette & Vertinsky, 2011; Lai, 2004b; Lai & Hui, 2007; Lai & Kalyniak, 2005; Lai et al., 2007; Lai & Surood, 2009; MacEntee et al., 2012; Su et al., 2022; Tieu et al., 2010; Tjam & Hirdes, 2002; Zou, 2019).

Of these, 11 explored how older Chinese immigrants in Canada combine traditional Chinese health practices with Western health practices (Jette & Vertinsky, 2011; Lai & Hui, 2007; Lai & Kalyniak, 2005; Lai, 2004b; Lai et al., 2007; Lai & Surood, 2009; MacEntee et al., 2012; Su et al., 2022; Tieu et al., 2010; Tjam & Hirdes, 2002; Zou, 2019). Participants from across the 11 studies referred to preferring traditional Chinese health approaches over Western approaches. Three studies reported that older immigrants who followed Chinese philosophical and religious values, as opposed to Western religions or no religion at all, identified more with Chinese health beliefs (Lai, 2004b; Lai et al., 2007; Lai & Surood, 2009). Lai and Surood (2009) found that older Chinese immigrants from mainland China reported higher levels of traditional health beliefs and the use of traditional Chinese medicine.

In contrast, Acharya and Northcott (2007) found that the South Asian cohort in their study viewed their cultural beliefs as supplementary to maintaining their health rather than as a substitute for Western medicine. Participants in their multiple case study included 21older South Asian immigrant women who noted that their beliefs – including having faith in God, performing religious rituals, and attending religious institutions – were essential to maintaining health and wellbeing (Acharya & Northcott, 2007). The authors concluded that traditional beliefs related to “dharma” (fulfilling one’s duties to perform well in life) were empowering, and that their participants leveraged these as resources for health promotion and illness prevention. Their participants also referred to using religiously oriented self-talk, such as worship, prayer, and meditation, as an especially important non-clinical resource to avoid mental distress, with some describing it as therapy or medicine (Acharya & Northcott, 2007). Overall, participants felt that their religious rituals and activities were better than medication to treat mental and physical health problems, especially when they did not perceive the health problem as life-threatening.

Health Behaviours and Practices

Eight studies reported on the health behaviours and practices of older immigrants (Choi et al., 2014a; Choudhry et al., 2002; Johnson & Garcia, 2003; Lai & Surood, 2009; Salma et al., 2020; Tong et al., 2019; Tong et al., 2018; Zou, 2019).

Six explored levels of physical activity among older immigrant women (Choi et al., 2014a; Johnson & Garcia, 2003; Lai & Surood, 2009; Salma et al., 2020; Tong, et al., 2019; Tong et al., 2018). Salma and colleagues (2020) conducted a qualitative cross-sectional study involving 58 older immigrants (74% of whom were women) to analyze what barriers may prevent them from engaging in physical activity. Female participants specifically described chronic or intermittent pain during physical exertion that significantly impeded their capacity to engage in physical activities and noted that they were unfamiliar with ways to modify their  activity to accommodate and manage this pain (Salma et al., 2020). Tong and colleagues (2019) explored how gender affects physical activity in a mixed-methods cross-sectional study involving 18 older immigrant women. Their participants referred to the necessity of prioritising household chores, such as cooking and cleaning over exercising within their daily routine (Tong et al., 2019). These authors also reported that engaging in culturally familiar activities appears to be a powerful motivator to engaging in outdoor physical activity; many of their participants noted they enjoyed going outside to shop at culturally familiar stores, such as those in their local Chinatown (Tong et al., 2019).

Three studies reported on nutritional and dietary habits among older immigrants in Canada (Johnson & Garcia, 2003; Lai & Surood, 2009; Zou, 2019). The authors found that women were more likely than men to take a vitamin D supplement due to their belief in its benefits for their own health and wellbeing. Johnson and Garcia (2003) conducted a mixed-methods cross sectional study on the health and dietary profiles of older adult immigrants in Canada, and found that the dietary intake of fibre, vitamin A, calcium, and vitamin D were insufficient. Two studies reported on the barriers that influenced healthy eating behaviours among older immigrant women (Johnson & Garcia, 2003; Zou, 2019). Zou (2019) conducted a qualitative cross-sectional study to explore barriers to healthy eating among 30 older Chinese Canadians. Participants noted that living a busy, fast-paced life hindered their ability to eat healthily and referred to time limitations that prevented them from cooking at home, which affected the quality of the food they consumed. In particular, they referred to frequent meals at restaurants, which made it difficult to manage their salt intake (Zou, 2019). Johnson and Garcia (2003) conducted a mixed-methods cross-sectional study to analyze the dietary profiles of older immigrants and found that financial constraints, transportation, illnesses (e.g., dental conditions), and eating alone on an everyday basis were barriers to healthy eating.

Barriers to Healthcare Access and Utilization

Twenty-two studies examined the barriers older immigrants face when attempting to access or utilize health care (Ahmad et al., 2011; Alvi & Zaidi, 2017; Ballantyne et al., 2011; Brotman, 2003; Brual et al., 2023; Charpentier & Quéniart, 2016; Chau & Lai, 2010; Donnelly, 2006; Lai, 2004b; Lai & Chau, 2007; Lai & Hui, 2007; Lai & Kalyniak, 2005; Lofters et al., 2010; McWhirter et al., 2011; Salma et al., 2020; Salma & Salami, 2019; Salma & Salami, 2020; Su et al., 2022; Sun et al., 2010; Todd et al., 2010; Todd & Hoffman-Goetz, 2010a; Todd & Hoffman-Goetz, 2010b). Of these, eight identified language barriers as a challenge for older immigrant women attempting to access healthcare services in Canada (Ahmad et al., 2011; Ballantyne et al., 2011; Brual et al., 2023; Chau & Lai, 2010; Lai & Chau, 2007; Lai & Kalyniak, 2005; Salma & Salami, 2020; Todd & Hoffman-Goetz, 2010b).

Ballantyne and colleagues (2011) conducted a qualitative study on the use of medications among older immigrants and found that participants had difficulty communicating with Western doctors due to limited English language proficiency. This was noted specifically when attempting to understand the health information or treatment recommendations provided by doctors and reading the English-language instructions on prescriptions (Ballantyne et al., 2011). Todd and Hoffman-Goetz (2010b) found that while some of the older Chinese immigrant women in their study spoke fluent English as a second language, most indicated that speaking in Chinese is more comfortable. Some even reportedly preferred obtaining health information directly from mainland China, rather than translating between English and Chinese. Participants noted that translating medical terminology is particularly challenging because there is not always a Chinese equivalent for the English terms, or the terms are not commonly used in their immigrant community (Todd & Hoffman-Goetz, 2010b). Lai and Chau (2007) also reported that older Chinese immigrants experienced challenges when attempting to access healthcare services due to communication barriers such as limited English proficiency and service providers lacking cultural competence; these factors may result in negative perceptions of service providers and the healthcare system in Canada (Lai & Chau, 2007).

Three studies reported on cultural barriers faced by older immigrant women when attempting to access the Canadian healthcare system (Lai, 2004b; Lai & Chau, 2007; Salma & Salami, 2020). Salma and Salami (2020) conducted a qualitative cross-sectional study to explore social isolation and loneliness among Muslim older immigrants; they observed a lack of cultural and religious sensitivity as participants attempted to access continuing care facilities, as evidenced by the lack of provision of ethnic foods, designated prayer spaces, cultural activities, and privacy measures (Salma & Salami, 2020). Lai and Chau’s (2007) survey on the effects of service barriers on the health of older Chinese immigrants found a lack of culturally sensitive services, as well as interaction styles between service providers and users that are culturally dissimilar. Lai (2004b) conducted a qualitative study analyzing the effects of culture on depressive symptoms among older Chinese immigrants, and also reported cultural barriers to accessing healthcare services in Canada, specifically a lack of understanding of Chinese culture among healthcare professionals and health services that are not tailored to meet the needs of Chinese clients.

Two studies reported on the challenges faced by older immigrants when attempting to access virtual healthcare services including the fact that some older immigrants lack access to technological devices (Brual et al., 2023; Su et al., 2022). Brual and colleagues (2023) conducted a repeated cross-sectional analysis on the use of virtual care among older immigrant adults in Ontario during the COVID-19 pandemic. They found that older immigrants not only lacked access to technological devices, but also reported challenges in acquiring and utilizing digital skills. The authors concluded that many of the communication difficulties experienced by patients who are unable to speak the dominant language during in-person encounters are likely exacerbated during virtual care (Brual et al., 2023).

Two studies reported that older immigrants’ access to healthcare services can be hindered by financial barriers (Charpentier & Quéniart, 2016; Salma & Salami, 2020). Salma and Salami (2020) found that older immigrants desired more financial support, including for medication costs. These authors reported that women who stayed home to act as caregivers and did not participate in the workforce were under significant financial strain during older age. Another issue is that Canadian immigration policies mandate that immigrant families financially support sponsored parents and grandparents for 20 years from the arrival date to Canada; one of their participants referred to finding it difficult to ask their children for constant assistance. The authors concluded that being financially dependent on younger family members, who had their own families to care for, took away the dignity of older immigrants (Salma & Salami, 2020).

Nine studies reported on accessing healthcare services, including preventive care and screening among older immigrants in Canada (Ahmad et al., 2011; Donnelly, 2006; Lai & Hui, 2007; Lai & Kalyniak, 2005; Lofters et al., 2010; Sun et al., 2010; Todd & Hoffman-Goetz, 2010a; Todd & Hoffman-Goetz, 2010b; Todd et al., 2010). Lofters and colleagues (2010) conducted a quantitative cross-sectional study to explore cervical cancer screening among older urban immigrant and Canadian-born women. They found that screening rates were notably lower among South Asian older women compared to Canadian-born women: only 21.9 percent of older South Asian women who lived in the lowest-income neighbourhoods had been appropriately screened. Similarly, Donnelly (2006) found that lower income and socioeconomic status made it difficult for older Vietnamese immigrant women to access breast and cervical cancer screenings. Ahmed and colleagues (2011) conducted a cross-sectional mixed-methods study exploring mammography access among South Asian immigrant women aged 50 years and older and found that 85 percent of their participants had never had a screening mammogram due to barriers related to language, transportation, and lack of health knowledge. Lastly, Todd and Hoffman-Goetz (2010b) conducted a qualitative cross-sectional study and found that older Chinese immigrants obtained cancer-screening information from physicians, community centres, family and friends, and written pamphlets or books, but reported difficulties understanding cancer information and complex medical terminology due to language barriers.

Discussion

We assessed the available literature exploring the health status and determinants of health for older immigrant women in Canada. One study reported physical inactivity to be attributed to chronic or intermittent pain during physical exertion (Salma et al., 2020). Physical inactivity among older adults in general is known to be associated with poor health and wellbeing; for example, sedentary behaviour has been found to increase the risk of early mortality, and is correlated with common chronic diseases such as type two diabetes, obesity, and mental health disorders (Le Roux et al., 2021). One possible explanation reported in other research for the low levels of physical activity reported in the studies included is a fear of movement can decrease levels of physical activity among older adults, and that women are more likely than men to experience fear of movement and subsequent declines in physical activity (Atıcı et al., 2022).

Three studies focused on factors that hindered older immigrant women from having an adequate dietary intake (Johnson & Garcia, 2003; Lai & Surood, 2009; Zou, 2019). These studies make an explicit link to the report by Statistics Canada (2015) that found that women are more likely to be at nutritional risk than men. More specifically, women are more likely than men to be on medication, which can affect their appetite or the absorption and metabolism of food; women are also more likely to experience pain and depression, which is associated with a decline in appetite and eating (Statistics Canada, 2015).

Two studies reported that environmental factors can negatively affect the health of older immigrant women (Choi et al., 2014a; Tong et al., 2019). Other studies have reported that immigrants are more likely to engage in more physically demanding employment and to have poor working environmental conditions, putting them at increased risk for occupational injuries (Drydakis, 2021). In particular, Choi et al. (2014) reported older immigrant women who labour in demanding working conditions to report experiencing a range of health ailments. This aligns with previous research which has also found immigrant women tend to report higher rates of workplace absences due to illness and often retire earlier than their counterparts (Akhavan, 2007).

Social isolation and loneliness among older immigrant women and its effect on their mental wellbeing was a common theme in the studies we reviewed. Other research has shown that the degree to which an older adult experiences social isolation, and its effects on their psychological wellbeing, are dependent on their personality, social network, and ability to cope (Akhavan, 2007). Older immigrants are particularly vulnerable to social isolation for many reasons including language barriers and lack of knowledge regarding available services (Drydakis, 2021). Similar to the studies we reviewed here, Perkins and colleagues (2016) reported that being widowed is also associated with worse health outcomes such as psychological distress and reduced cognitive ability, especially among women.

This scoping review also found older immigrant women reported experiences of mental distress, such as depression, which was attributed to factors such as lower levels of social support. Religious rituals were a coping mechanism among older immigrant women in many of the studies we reviewed. Mental distress and depressive symptoms among older immigrant women in Canada are a significant issue. In a literature review that analyzed gender differences and depression among the general older adult population, Girgus and colleagues (2017) found a lack of social support is known to be related to depression, and women are at increased risk for depression because they are more likely than men to feel they have less social support. Previous literature has also found that religious beliefs and practices to help individuals cope with stressful situations and contribute to a sound mental health (Chireshe, 2024). More specifically, among women, engaging in religious prayers and a sense of closeness to God has been reported to provide them with a sense of hope (Chireshe, 2024).

The three studies we reviewed focusing on abuse against older immigrant women primarily discussed victimization by intimate partners (Alvi & Zaidi, 2017; Lai, 2011; Souto et al., 2016). However, previous research focusing specifically on elder abuse has revealed that older immigrant women may experience abuse in relationships with children, grandchildren, sons-in-law, and daughters-in-law (Mehdi et al., 2022). Guruge and colleagues (2021) conducted a quantitative cross-sectional study of elder abuse risk factors among older immigrants in Toronto, and found living together in a multi-generational household to be a risk factor to abuse. Cultural obligations like filial piety can make older adults dependent on family members such as their children for advice and support, due to social, financial, language, and transportation barriers; ultimately, this dependence may make them more vulnerable to abuse (Guruge et al., 2021). Moreover, older immigrant women who were raised in households with strong patriarchal values may be more likely to remain in abusive relationships to continue providing care to their aging spouse (Roger et al., 2014).

Studies we reviewed showed that health beliefs tied to culture and religion affected the utilization of healthcare services among older immigrants in Canada (Lai, 2004b; Lai & Chau, 2007; Salma & Salami, 2020). A review of the literature by Iwamasa and Hilliard (1999) that examined depression and anxiety among older Asian American adults reported that views about traditional Chinese medicine along with cultural beliefs about psychology and physiology may influence how older Asian immigrants experience depression; they may not express emotions readily and internalize their feelings, in comparison to younger Asians who are more likely to follow Western health beliefs (Iwamasa & Hilliard, 1999). Lai and colleagues (2007) theorized about how each culture has a health care system, arguing that the symbolic meanings, values, and behavioural norms associated with different illnesses are culturally unique; they also found that those suffering from a serious illness tend to prefer treatments that are rooted in familiar cultural beliefs and ideas (Lai et al., 2007). Ultimately, it is imperative to adjust the Canadian healthcare system to provide tailored care that can meet the unique needs of immigrants and refugees (Lane and Vatanparast, 2022).

According to the studies we reviewed, barriers faced by older immigrant women when trying to access and utilize healthcare services include: language barriers (Ahmad et al., 2011; Ballantyne et al., 2011; Brual et al., 2023; Chau & Lai, 2010; Lai & Chau, 2007; Lai & Kalyniak, 2005; Salma & Salami, 2020; Todd & Hoffman-Goetz, 2010b), cultural barriers (Lai & Chau, 2007; Lai, 2004b; Salma & Salami, 2020), technological barriers (Brual et al., 2023; Su et al., 2022), financial barriers (Charpentier & Quéniart, 2016; Salma & Salami, 2020), and preventative care and screening barriers (Ahmad et al., 2011; Donnelly, 2006; Lai & Hui, 2007; Lai & Kalyniak, 2005; Lofters et al., 2010; Sun et al., 2010; Todd & Hoffman-Goetz, 2010a; Todd & Hoffman-Goetz, 2010b; Todd et al., 2010). Among immigrants in general, language is considered a key barrier to the uptake of health promotion practices (Kobayashi & Khan, 2021). For example, few translator services are available in Canada, resulting in poor-quality interactions between patients and doctors. Another problem is the limited availability of health promotion pamphlets printed in other languages, which may prevent the uptake of health promotion practices (Kobayashi & Khan, 2021). Coombs and colleagues (2022) examined 12 healthcare providers from diverse training backgrounds to explore barriers to healthcare access in the patient populations they care for; their participants emphasized the need for cultural humility in care to enhance their access to healthcare services. Technological barriers can include limited technical skills, difficulties with a specific device, software updates, complex platforms, digital literacy, and concerns about privacy and security (Lin et al., 2023; Pang et al., 2022). Older immigrants who lack digital literacy are at a particularly significant disadvantage, as they may struggle to perform essential tasks such as online health management and social interaction with their support networks. Being unable to access important information and services that are primarily provided online may increase their feelings of social exclusion and disconnectedness from society (Lin et al., 2023).

Determinants of Health not Addressed in the Literature

Several determinants of health were not sufficiently addressed in the literature we reviewed including education, genetic predispositions, and early childhood development. Only two studies (Charpentier & Quéniart, 2016; Tong et al., 2018) reported on education as a determinant of older immigrant women’s health. Education is known to be an important determinant of longevity because it affects various factors including employment opportunities, income level, and access to information, which in turn influence the adoption of healthier lifestyle decisions (Aris et al., 2024). None of the studies we reviewed addressed genetic predispositions among older immigrant women in Canada, even though genetic factors can lead to an inherited predisposition to a wide range of health-related issues (Public Health Agency of Canada, 2011). Finally, none of the studies included in this scoping review reported on early childhood development. A child’s development and environment are extremely important: experiences in the first six years can become physiologically imprinted and affect outcomes throughout life, both positively and negatively (Likhar et al., 2022). Likhar and colleagues (2022) found that disruptions during the early years can have a major influence on behaviour and adult health consequences, and also that a healthy diet and being vaccinated can have long-term benefits including on physical, social, and emotional development.

Strengths and Limitations

We performed this scoping review to understand the state of knowledge on the health status and health determinants of older immigrant women in Canada. To ensure the rigour of our scoping review (Peters et al., 2015), we utilized the JBI methodology, including the PRISMA-ScR checklist. There are several limitations to our review. We did not search grey literature because it can vary in terms of quality, rigour, and relevance. Since the focus of the scoping review was on health, we did not search social science databases. We excluded literature that was not written in English, studies that did not take place in Canada, and any studies in which fewer than half of participants were older immigrant women. These decisions may have excluded studies with important findings on the health and experiences of older immigrant women. In spite of these limitations, our scoping review identified important findings that have research, practice, and policy implications related to the health of older immigrant women in Canada.

Implications

Implications for Research

The vast majority of studies reviewed were conducted in urban settings such as the Greater Toronto and Metro Vancouver Areas. Further research is needed across various geographical regions in Canada to clarify how the physical environment and specific healthcare settings affect health status and access to services among older immigrant women. Only one study in this scoping review (Lai et al., 2020) included a longitudinal design. More longitudinal studies would help clarify health, social, and economic changes, as well as the aging process over time for older immigrant women and how these affect their health and access to services over time. Future research exploring the health of older immigrant women should also place more emphasis on comparative research, larger sample sizes, and the inclusion of older immigrants from various immigration categories, including refugees and others with precarious status, and family-sponsored immigrants. Finally, more research utilizing an intersectionality approach would help address knowledge gaps by clarifying the interactions between health and immigration, gender, race, and ethnicity, along with other elements of social identity.

Implications for Practice

Overall, our findings suggest that the Canadian healthcare system has been ineffective for older immigrant women. Older immigrant women face unique stressors, including trauma, isolation, and acculturation challenges, and it is imperative to ensure they have access to affordable and comprehensive healthcare in Canada. Holistic programs and services that address older immigrant women’s social determinants of health can help them overcome challenges and adjust to their lives post-migration. Healthcare providers must give attention to health education, that includes information on the significance of physical activity, nutrition, and preventive care, as well as different programs and services they can utilize to improve their overall health and wellbeing. Moreover, healthcare providers must be trained to provide culturally competent care to understand and respect the differences in cultural values, beliefs, and backgrounds among older immigrant women. This includes being cognisant of language barriers and the use of medical jargon, and using translation services whenever necessary.

Implications for Policy

Policy changes are urgently needed to address the various health and social concerns encountered by older immigrant women. For example, it is vital to ensure timely access to and effectiveness of health services for older immigrant women. Policies should be developed based on the awareness that each older immigrant woman is an individual with unique needs, while promoting their access to resources that are culturally safe including language interpretation services, as needed, to overcome such barriers. To address abuse among older immigrant women, it is imperative to look at personal experiences and insights provided by women themselves to better inform service providers and policymakers in designing service aid programs. It is also important to implement policies regarding education for nurses and other healthcare professionals, such as integrating multicultural content into curricula.

Conclusions

This scoping review provided an overview of the health status and determinants of health for older immigrant women in Canada. Studies reported on the influence of the environment on physical health; mental health with respect to social isolation, feelings of loneliness, and depressive symptoms; experiences of abuse; and the influence of cultural and religious beliefs, health behaviours, and health practices on health outcomes. The scoping review highlighted numerous barriers that older immigrant women face when accessing healthcare services in Canada, underlining an urgent need to reformulate healthcare delivery systems to address their needs. Stakeholders can draw from these findings to implement tailored interventions to improve the health and wellbeing of older immigrant women in Canada. For example, the government could adapt current policies to address the unique needs of older immigrant women, such as improving access to adequate language interpretation services, and providing more education to healthcare providers to ensure culturally competent care. More research is needed to analyze social determinants of health that were not addressed in the literature, such as how education, income, genetic predispositions, and early childhood development influence the health of older immigrant women.

References