{"id":144,"date":"2023-11-15T14:59:23","date_gmt":"2023-11-15T19:59:23","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/intersections\/?post_type=chapter&p=144"},"modified":"2024-09-28T13:48:03","modified_gmt":"2024-09-28T17:48:03","slug":"chapter-14-spatial-and-language-discordance-in-accessing-physicians-among-older-immigrants-in-toronto-canada-identifying-barriers-and-facilitators","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/intersections\/chapter\/chapter-14-spatial-and-language-discordance-in-accessing-physicians-among-older-immigrants-in-toronto-canada-identifying-barriers-and-facilitators\/","title":{"raw":"Chapter 14. Spatial and Language Discordance in Accessing Physicians Among Older Immigrants in Toronto: Identifying Barriers, Facilitators, and Interventions","rendered":"Chapter 14. Spatial and Language Discordance in Accessing Physicians Among Older Immigrants in Toronto: Identifying Barriers, Facilitators, and Interventions"},"content":{"raw":"The Canadian population is aging rapidly, reflecting global trends. Low birth rates, increased life expectancies, and the aging of the baby boom generation have resulted in a shift toward a larger proportion of older adults (Canadian Institute for Health Information, 2011). In 2016 and 2021, about 17 percent and 19 percent of Canada\u2019s total population were classified as older adults (65+ years) (Statistics Canada, 2017a; 2022), and by 2036, this figure is expected to increase to almost 25 percent (Turcotte & Schellenberg, 2007). This demographic transformation will continue to increase demand for existing healthcare services, many of which are unevenly distributed across communities, neighborhoods, and cities.\r\n\r\n \r\n\r\nImmigrants in Canada experience disparities in health and access to primary care compared with their Canadian-born counterparts, and these disparities can be even more pronounced for older immigrants living with chronic conditions (Canadian Institute for Health Information, 2011). Geographical variations in health can be explained by both compositional effects resulting from individual differences and contextual effects related to the differing physical and social attributes of neighborhoods. Recent trends including the suburbanization of older immigrants (Channer, Hartt, & Biglieri, 2020) and the spatial clustering of physicians speaking ethno-specific languages within urban areas have resulted in spatial\u2013language discordance, further challenging older adults with limited mobility, access, and social support. Another issue affecting older immigrants is the influence of interconnected social determinants of health including class, race, and gender (Bryant et al. 2004; Subedi & Rosenberg, 2014). Finally, the health of older immigrants may be affected by length of residency and exposure to the Canadian healthcare system. For example, newly arrived immigrants tend to have better health than non-immigrants, but their health status tends to decline with length of residence (Newbold, 2009; Setia et al. 2011; Subedi & Rosenberg, 2014).\r\n\r\n \r\n\r\nThis chapter presents the results of an ongoing study investigating the barriers and facilitators to accessing primary health care among older immigrants, with the goal of informing policies and improving access through translation services, joint efforts with community agencies, and other community-based practices.\r\n

The Project<\/h3>\r\nThis four-phase project is focused on older immigrants (aged 65+ years) in Canada. Phase 1 involved a scoping review of the relevant literature. For Phase 2, we recruited participants from three stakeholder groups: Arabic- and Hindi-speaking older immigrants, representatives from community organizations, and healthcare practitioners. Phase 3 involved a symposium that took place in June 2019. The project is currently in Phase 4: knowledge synthesis and dissemination.\r\n\r\n \r\n\r\nAll project activities were set within the Toronto Census Metropolitan Area (CMA) in Ontario. According to the most recent census, its total population was 6,202,225 in 2021 (5,862,850 in 2016), including 2,862,850 (2,705,550 in 2016) immigrants (Statistics Canada, 2017b; 2021). Of these immigrants, 460,940 (about 17 percent) are classified as older adults (65+ years) in 2016 (Statistics Canada, 2017b). We focused specifically on Arabic- and Hindi-speaking older immigrants. Canada has a long history of immigration from South Asia, including Hindi speakers, while the Arabic-speaking immigrant population is relatively more recent. About 1.5 and just under 1 percent of the total population of the Toronto CMA lists Arabic and Hindi as their first language, respectively (Statistics Canada, 2016). Both of these groups face settlement challenges and barriers in accessing health care (Gulati et al. 2012; Woodgate et al. 2017). In general, Arabic-speaking older immigrants tend to cluster in the suburb of Mississauga, while Hindi-speaking older immigrants tend to cluster in the suburb of Brampton (see Figure 14.1).\r\n

Figure 14.1. Arabic-speaking and Hindi-speaking populations in Toronto CMA at a census tract level<\/h6>\r\n\"\"\r\n

Phase One: Exploring the Literature<\/h3>\r\nWe conducted a scoping review on access to primary health care among older immigrants in Canada (Wang, Guruge, & Montana, 2019). Specifically, we utilized Arksey and O\u2019Malley\u2019s five-stage framework to examine 31 peer-reviewed articles, focusing on three main areas: access and use of primary care, health promotion and cancer screening, and use of mental health services. The review revealed intersecting factors affecting access to health care, including health literacy, language and cultural barriers, health beliefs, spatial access, and structural barriers.\r\n

Access and Use of Primary Care<\/h4>\r\nFamily physicians are on the front lines, providing primary care for older immigrants who may have various chronic health problems. Our literature review included articles focusing on healthcare access among older immigrants from multiple ethnic and racialized groups including South Asian (Surood & Lai, 2010); Afro-Caribbean, former Yugoslavian, and Spanish (Stewart et al. 2011); and Chinese (Chow, 2012; Lai & Chau, 2007). Healthcare access may be influenced by a lack of culturally appropriate services and health information, personal and traditional beliefs, and spatial factors such as available modes of transportation (Lai & Chappell, 2006; Lai & Surood, 2010; Thomson et al. 2015). One main barrier is the lack of translated health information, especially for older immigrants. In primary care settings with limited language options, older immigrants may use improvised sign language, or have friends or family translate, or utilize paid interpreters (Stewart et al. 2011; Surood & Lai, 2010).\r\n\r\n \r\n\r\nImmigrants are less likely than their Canadian-born counterparts to depend on a family physician. When access to a family physician is limited, older immigrants may seek access to primary care through hospital emergency rooms and walk-in clinics; this appears to be more common among recent immigrants compared to more established immigrants (Tiagi, 2016). One study reported that in Mississauga, older immigrants from China, India, Pakistan, and Romania attributed their reliance on emergency rooms and walk-in clinics to the inability of family physicians to accommodate new patients (Asanin & Wilson, 2008). Another issue is mobility: the unavailability of nearby family physicians is a major barrier to accessing healthcare among older immigrants with limited mobility (Wang et al. 2019). One study also reported that recently arrived older immigrants had lower rates of hospitalization compared with more established immigrants and Canadian-born counterparts (Ng et al. 2014).\r\n

Health Promotion and Cancer Screening<\/h4>\r\nOlder immigrants who receive preventative care services, such as cancer screening and general health promotion strategies, generally obtain them from family physicians. Major barriers to accessing preventative care services include differences in culture and language, unavailability of local practitioners, and challenges related to mobility and access to transportation (Gesink et al. 2014; Koehn, Habib, & Bukhari, 2016; Todd, Harvey, & Hoffman-Goetz, 2011; Todd & Hoffman-Goetz, 2011). Some studies have explored breast and cervical cancer screening among immigrants in various regions of Canada, and have found that older immigrants seeking these services face challenges related to unmet language and cultural needs, inadequate education about screening practices and methods, and inability to access a family physician (Ahmad & Stewart, 2004; Vahabi, 2011).\r\n\r\n \r\n\r\nBreast cancer screening rates among Arab, Chinese, South Asian, and Vietnamese immigrants are also affected by the preference for, and availability of, female physicians (Crawford et al. 2015). Asian immigrant women also appear to use mammogram services less, partly due to their lack of ability to speak English or French in a primary care setting (Sun et al. 2010). Rates for cervical cancer screening methods such as Pap tests are lower among immigrant women than their Canadian-born counterparts, but rates tend to increase with length of residency (McDonald & Kennedy, 2007). Ontario-based research has revealed that cervical cancer screening rates are lower among older women who are recent immigrants, racialized, and\/or living in low-income neighbourhoods (Amankwah, Ngwakongnwi, & Quan, 2009; Lofters et al. 2010).\r\n

Use of Mental Health Services<\/h4>\r\nRelatively few studies have focused on access to mental health services among older immigrants. The limited research evidence suggests that older immigrants generally underutilize mental health services (Kirmayer et al. 2007; Thomson et al. 2015) but rates may vary based on length of residency, as well as ethnic and racialized background. For example, rates of access to mental health services were lower among recent immigrants compared to established immigrants and Canadian-born community members, and rates were lowest among immigrants from Asia and the Pacific (Durbin et al. 2015).\r\n\r\n \r\n\r\nOne study conducted in Toronto, revealed that older Chinese and Tamil adults are limited by a general lack of mental health workers providing services to specific language groups, discrepancies in knowledge of mental illnesses, and cultural stigma that encourages a private approach to mental health problems (Sadavoy, Meier, & Ong, 2004). Another study involving South Asian immigrants also reported that access may be affected by traditional beliefs and attitudes about mental health and illness (Lai & Surood, 2013). A study conducted in Calgary revealed that only 11.4 percent of older Chinese adults could correctly identify depression, compared with 74 percent of the general population (Tieu, Konnert, & Wang, 2010). Interventions to improve access rates should involve culturally relevant health promotion efforts to reach specific immigrant groups.\r\n

Phase Two: Stakeholder and Community Voices<\/h3>\r\nThe second phase of this project involved three stakeholder groups to explore how these they felt about primary care and access to services. We interviewed and surveyed Arabic-speaking and Hindi-speaking older immigrants (in their preferred language). We also interviewed and surveyed representatives from community organizations, as well as healthcare practitioners serving these language groups. Research approval was granted by the Research Ethics Board at Toronto Metropolitan University. We recruited the older immigrant stakeholders through community outreach, using flyers and other media posted in community hubs. Representatives from community organizations were recruited through contacts with our existing community partners; we also asked these community organizations to share information about the project with their older immigrant clients. We recruited healthcare practitioners through word-of-mouth, as we have worked with them in the past on other projects.\r\n\r\n \r\n\r\nData were cleaned and organized, and then analyzed using descriptive analysis for survey data and thematic analysis for interviews (Braun & Clarke, 2006, 2014; Schreier, 2012). As discussed in the following sections, four key themes emerged related to access to primary care by older immigrants: systemic gaps in levels of care; gaps in communication and education; service access gaps and privatization; and mental health gaps, stigma, and fear.\r\n

\u00a0Systemic Gaps in Levels of Care<\/h4>\r\n
\r\n

By the time they get to see a specialist, their health is deteriorated more.<\/p>\r\n

What if they do not even survive until then?<\/p>\r\n

\u2014 Older immigrant<\/p>\r\n<\/blockquote>\r\n \r\n\r\nSeveral systemic gaps were identified by Arabic-speaking older immigrants; these were echoed by representatives from community organizations as well as healthcare practitioners. Older immigrants noted that they generally accessed family physicians as their primary point of care, and most were satisfied with the services they received from these practitioners. However, they considered the long wait times, language barriers, and costs associated with seeing a specialist to be prohibitive, noting that specialists were often unable to accommodate their health needs (e.g., monitoring illness progression, and extended care), and that seeing a specialist involved communication challenges and financial stresses. Healthcare practitioners also identified the need for consistent care, and follow-up when referring patients to other avenues of health care, including specialists.\r\n\r\n \r\n\r\nHindi-speaking community members also reported many of the same problems when navigating the healthcare system beyond their usual family physicians. They referred specifically to the problem of long wait times for specialist care when a health problem was serious and required urgent care. This situation was exacerbated by the inability of most specialists and emergency care providers to speak Hindi. The healthcare practitioners serving these older immigrants noted that they do have some employees who speak the necessary languages, but that trained translators and certified translation services are desperately needed.\r\n

Gaps in Communication and Education<\/h4>\r\n
\r\n

Sometimes the doctor doesn\u2019t have time to listen to the patients.\r\n\u2014 Older immigrant<\/p>\r\n<\/blockquote>\r\n \r\n\r\nBoth Arabic-speaking and Hindi-speaking older immigrants identified communication and education-related gaps. Representatives from community organizations reported that they often assist with translation, transportation, and the completion of medical forms. Despite this, older immigrants commented on issues including a lack of ongoing communication between patients and physicians, lack of information about the Canadian healthcare system\u2019s structure for recent immigrants, and the need for older immigrants\u2019 voices to be genuinely heard when addressing their health issues.\r\n\r\n \r\n\r\nThe language barriers between older immigrants and certain healthcare providers (specialists, emergency attendants, and others apart from family physicians) increase the risk for misdiagnoses. Representatives from community organizations interacting with Arabic-speaking older immigrants also stressed the need for access to spaces of safe communication (e.g., religious spaces such as mosques or other community settings); they also reported that follow-up from doctors helps make older immigrants feel valued.\r\n\r\n \r\n\r\nRepresentatives from organizations working with Hindi-speaking older immigrants noted that patients tend to be embarrassed by their inability to communicate effectively in English. Many older immigrants rely on their children and other caregivers to take them to appointments and relay medical information, and the representatives associated this reliance with frequent misunderstandings of diagnoses, especially related to technical medical terminology. Healthcare practitioners stressed that peer support is important: some noted that Arabic-speaking older immigrants had difficulty with follow-up appointments and taking medication regularly; others noted that Hindi-speaking older immigrants required more community-based education and outreach.\r\n

Service Access Gaps<\/h4>\r\n
\r\n

Eye treatments are too expensive, and dentists are too expensive as well.<\/p>\r\n

\u2014 Older immigrant<\/p>\r\n

<\/p>\r\n<\/blockquote>\r\nArabic-speaking older immigrants commented on the long distances between their homes and doctors, although most also said that they would undertake the journey to see doctors who speak their language. Strikingly, one community member lives in Burlington but sees a family doctor in Mississauga: this is a significant distance for an older immigrant facing additional structural and institutional challenges.\r\n\r\n \r\n\r\nHindi-speaking older immigrants commented that physiotherapy services are often difficult to access and pay for. Similarly, the high costs of dental and eye care were cited as major issues for both language groups struggling with financial hardships. Representatives from community organizations explained that transportation systems (Toronto Transit Commission, MiWay transit system in Mississauga, and Brampton Transit) are complicated for older immigrants in both language groups, especially when they must travel long distances. Healthcare practitioners confirmed these transportation difficulties for their Arabic-speaking and Hindi-speaking older immigrant patients and also emphasized the importance of prevention for health issues that would require privatized care services.\r\n

Mental Health Gaps and Stigma<\/h4>\r\n
\r\n

I just want to say that we do not know how much longer we are going to live in this world. God knows what other problems await us.<\/p>\r\n

\u2014 Older immigrant<\/p>\r\n<\/blockquote>\r\n \r\n\r\nOlder immigrant participants from both language groups commented on long wait times for access to mental health professionals. Hindi-speaking older immigrants cited fears of deteriorated mental health while waiting to see a specialist. Representatives from community organizations were quick to note that many Arabic-speaking older adults had recently immigrated from conflict zones and may therefore have serious mental health challenges requiring care from mental health specialists.\r\n\r\n \r\n\r\nRepresentatives from organizations working with Hindi-speaking older immigrants commented that recent immigrant older adults suffer culture shock and anxiety, while long-term older immigrants may experience family-related stresses that can lead to depression and isolation. Service provider participants also noted that there is stigma surrounding mental illness in the South Asian community, as in many others, and that many individuals who need mental health services are told that their issues are \u201call in their heads.\u201d Healthcare practitioners working with Arabic-speaking patients also commented that social workers should be more involved in care. One practitioner working with Hindi-speaking older immigrants noted that the families of older immigrants, and even other healthcare providers, tend to use that \u201creality\u201d against them to exert control over their lives.\r\n

Phase Three: A Collective Exchange of Ideas<\/h3>\r\nThe third phase of this project involved planning and hosting a symposium to facilitate communal knowledge sharing. This symposium was held at Toronto Metropolitan University and brought together a range of stakeholders including students, faculty members, health, social and settlement service providers, and representatives from analytics firms.\r\n\r\n \r\n\r\nThe event included a number of key presentations and provided opportunities to collaborate. Dr. Lu Wang (the first author of this chapter) delivered a keynote presentation outlining the project background, objectives, and methodology. While this project focused specifically on Arabic-speaking and Hindi-speaking older immigrants, Dr. Wang also spoke about Mandarin-speaking and Cantonese-speaking older immigrants \u2013 both large immigrant communities within the Greater Toronto Area \u2013 commenting that older immigrants are not well-represented among secondary data sets such as the Canadian Community Health Survey based data.\r\n\r\n \r\n\r\nIn the discussion that followed Dr. Wang\u2019s presentation, guests noted that those who know how best to navigate the healthcare system benefit the most. They also commented that immigrants require more support in terms of health advocacy, and that community health centres enable better syntheses of services: they may send a patient to a specialist immediately, while going to a private or family practice may create additional barriers. Points of privilege emerged as a central theme: some older immigrants do not have the means to pay for privatized health services or insurance, and services covered by the Ontario Health Insurance Plan may be too far away to access.\r\n\r\n \r\n\r\nGelsomina Montana was a co-author of the scoping review conducted for the first phase of this project (Wang, Guruge, & Montana, 2019), and spoke about the key themes of access and use of primary care, health promotion and cancer screening, and use of mental health services. Guests attending this session discussed screening patterns among immigrants and identified differences based on Ontario Health Insurance Plan coverage, misinformation among older immigrants, and general lack of awareness of the services. Some participants commented that patients felt uncomfortable in waiting rooms and with doctors who did not speak their languages. Community health centres were identified as sources of culturally sensitive service provision, although these also involve difficulties. For example, social workers might ask patients to travel significant distances to reach appropriate services and\/or treatment, which is problematic if the patient lacks access to transportation. This discussion period revealed that older immigrants require holistic approaches to health access: approaches that frame access as multifaceted and \u201cwhole.\u201d\r\n\r\n \r\n\r\nSelasi Dorkenoo presented a paper based on a mixed-methods study she had conducted as part of her Master\u2019s thesis on access to language-specific services for Arabic-, Mandarin-, and Spanish-speaking communities in Toronto (Dorkenoo, 2019). Guests commented on the importance of alternative methods of transportation and services that could be improved to address systemic access gaps (e.g., WheelTrans and 55+ Rideshare in Toronto). They also referred to the need for more awareness about these issues.\r\n\r\n \r\n\r\nSamya Hasan the Executive Director of the Council of Agencies Serving South Asians, a social justice umbrella agency promoting research advocacy and attempting to influence policy for South Asian populations in Canada) outlined the demographics and factors affecting the health and wellbeing of older South Asian adults. In the discussion that followed, guests commented on the intergenerational divide in mental health understanding and care for South Asian immigrants, and the need for narrative-based intervention based on life experience. Guests also identified the general need for culturally based healthcare practices that integrate community and family support, rather than \u201csimply prescribing medication and using a medical lens that tends to exclude other supports and intervention.\u201d Some guests commented on the importance of addressing domestic violence within the community, along with mental health supports to improve self-empowerment of victims and complement existing interventions such as law enforcement.\r\n\r\n \r\n\r\nDr. Peizhong P. Wang from Memorial University presented his unpublished research on healthcare access among recent older adult Chinese immigrants. About 50 percent of his study participants were able to walk to their doctors, and most were in Markham and Richmond Hill, Ontario. The subsequent discussion began with a conversation about transnational medicine. Guests noted that discrimination and other systemic barriers lead to trust issues with healthcare providers in Canada, especially among older immigrants who are often dismissed, minimized, and told that health issues are simply \u201ca part of being old.\u201d Guests also noted that immigrant women are more at risk of medical misconduct as a result of ingrained racist, patriarchal, and colonial practices. One commented that \u201cthe general public needs to help educate doctors on how to practise\u201d when the health outcomes of immigrant women are involved.\r\n

Phase Four: Synthesizing and Disseminating Knowledge<\/h3>\r\nThis chapter is a key component of the final phase of our study, because it is helping to disseminate our findings. Together, the four phases of the study are helping to clarify the current state of practice and evidence-based knowledge related to access and use of primary health care among older immigrants, including barriers. The work done has helped reveal similarities among older immigrants from various regions and with differing residential locations, language skills, lengths of residency in Canada, and socioeconomic conditions. In particular, the primary data collected in Phase 2 helped clarify the barriers and facilitators related to delivering culturally appropriate health care to older immigrants. We found that Arabic and Hindi-speaking older immigrants face barriers including communication, lack of paid and trained translation services, long wait times, transportation, mobility issues, high costs related to eye and dental care, and stigma of mental illness. These are consistent with the key findings from the scoping review in Phase 1, and similar issues were discussed by the symposium attendees from community organizations and the health sector. Together, our findings provide evidence-based insights that can inform the development of initiatives and policy interventions. Healthcare delivery to older immigrants can be improved in four key areas: enhancing communication and providing timely and appropriate translation; providing assistance in transportation to access care including preventive care; providing additional coverage and support for eye care, dental care, and mental health care; and education for older immigrants through collaborative efforts among community organizations, community health centres, social workers, and other relevant interest groups.\r\n

Moving Forward<\/h3>\r\nIn our future research, we plan to further explore primary and secondary data, including Census data of different years. We will use a mixed-methods approach to collect additional data from the stakeholders. We also expect to identify supplementary funding opportunities with engaged stakeholders to further explore the barriers and facilitators for older immigrants of different backgrounds in healthcare access to develop interventions and to inform policy.\r\n

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Setia, M. S., Lynch, J., Abrahamowicz, M., Tousignant, P., & Quesnel-Vallee, A. 2011. \u201cSelf-rated Health in Canadian Immigrants: Analysis of the Longitudinal Survey of Immigrants to Canada.\u201d Health & Place 17, no. 2: 658\u201370. doi: j.healthplace.2011.01.006<\/p>\r\n

Statistics Canada. 2016. Census Data at census tract level, Accessed from Chass Data Centre https:\/\/datacentre.chass.utoronto.ca\/<\/p>\r\n

Statistics Canada. 2017a. \u201cCensus Profile, 2016 Census \u2013 Canada (Country) and Canada (Country).\u201d Statistics Canada. Government of Canada. https:\/\/www12.statcan.gc.ca\/census-recensement\/2016\/dp-pd\/prof\/index.cfm?Lang=E<\/p>\r\n

Statistics Canada. 2017b \u201cFocus on Geography Series, 2016 Census \u2013 Toronto (CMA), Ontario.\u201d Statistics Canada. Government of Canada. https:\/\/www12.statcan.gc.ca\/census-recensement\/2016\/as-sa\/fogs-spg\/Facts-cma-eng.cfm?LANG=Eng&GK=CMA&GC=535&TOPIC=7<\/p>\r\n

Statistics Canada. 2021. Census Profile, 2021 Census of Population Profile table. https:\/\/www12.statcan.gc.ca\/census-recensement\/2021\/dp-pd\/prof\/details\/page.cfmLang=E&amp;SearchText=Toronto&amp;DGUIDlist=2021S0503535&amp;GENDERlist=1,2,3&amp;STATISTIClist=1&amp;HEADERlist=0<\/p>\r\n

Statistics Canada. 2022. Demographic estimates by age and sex. https:\/\/www.statcan.gc.ca\/en\/subjects-\r\nstart\/older_adults_and_population_aging<\/p>\r\n

Stewart, M., Shizha, E., Makwarimba, E., Spitzer, D., Khalema, E. N., & Nsaliwa, C. D. 2011. \u201cChallenges and Barriers to Services for Immigrant Seniors in Canada: \u2018You are Among Others but You Feel Alone.\u2019\u201d International Journal of Migration, Health and Social Care 7, no. 1: 16\u201332. doi: 10.1108\/17479891111176278<\/p>\r\n

Subedi, R. P., & Rosenberg, M. W. 2014. \u201cDeterminants of the Variations in Self-Reported Health Status Among Recent and More Established Immigrants in Canada.\u201d Social Science and Medicine 115: 103\u201310. doi: 10.1016\/j.socscimed.2014.06.021<\/p>\r\n

Sun, Z., Xiong, H., Kearney, A., Zhang, J., Liu, W., Huang, G., & Wang, P. P. 2010. \u201cBreast Cancer Screening Among Asian Immigrant Women in Canada.\u201d Cancer Epidemiology 34, no. 1: 73\u201378. doi: 10.1016\/j.canep.2009.12.001<\/p>\r\n

Surood, S., & Lai, D. W. L. 2010. \u201cImpact of Culture on Use of Western Health Services by Older South Asian Canadians.\u201d Canadian Journal of Public Health 101, no. 2: 176\u201380. doi: 10.1007\/BF03404367<\/p>\r\n

Thomson, M. S., Chaze, F., George, U., & Guruge, S. 2015. \u201cImproving Immigrant Populations' Access to Mental Health Services in Canada: A Review of Barriers and Recommendations.\u201d Journal of Immigrant and Minority Health 17, no. 6: 1895\u2013905. doi: 10.1007\/s10903-015-0175-3<\/p>\r\n

Tiagi, R. 2016. \u201cAccess to and Utilization of Health Care Services Among Canada\u2019s Immigrants.\u201d International Journal of Migration, Health and Social Care 12, no. 2: 146\u201356. doi: 10.1108\/IJMHSC-06-2014-0027<\/p>\r\n

Tieu, Y., Konnert, C., & Wang, J. L. 2010. \u201cDepression Literacy Among Older Chinese Immigrants in Canada: A Comparison with a Population-Based Survey.\u201d International Psychogeriatrics 22, no. 8: 1318\u20131326. doi: 10.1017\/S1041610210001511<\/p>\r\n

Todd, L., Harvey, E., & Hoffman-Goetz, L. 2011. \u201cPredicting Breast and Colon Cancer Screening Among English-as-a-Second-Language Older Chinese Immigrant Women to Canada.\u201d Journal of Cancer Education 26, no. 1: 161\u201369. doi: 10.1007\/s13187-010-0141-7<\/p>\r\n

Todd, L., & Hoffman-Goetz, L. 2011. \u201cA Qualitative Study of Cancer Information Seeking Among English-as-a-Second-Language Older Chinese Immigrant Women to Canada: Sources, Barriers, and Strategies.\u201d Journal of Cancer Education 26, no. 2: 333\u201340. doi: 10.1007\/s13187-010-0174-y<\/p>\r\n

Turcotte, M., & Schellenberg, G. 2007. A Portrait of Seniors in Canada. Ottawa: Statistics Canada. https:\/\/www150.statcan.gc.ca\/n1\/pub\/89-519-x\/89-519-x2006001-eng.pdf<\/p>\r\n

Vahabi, M. 2011. \u201cKnowledge of Breast Cancer and Screening Practices Among Iranian Immigrant Women in Toronto.\u201d Journal of Community Health 36, no. 2: 265\u2013273. doi: 10.1007\/s10900-010-9307-9<\/p>\r\n

Wang, L., Guruge, S., & Montana, G. 2019. \u201cOlder Immigrants' Access to Primary Health Care in Canada: A Scoping Review.\u201d Canadian Journal on Aging 38, no. 2: 193\u2013209. doi: 10.1017\/S0714980818000648<\/p>\r\n

Woodgate, R. L., Busolo, D. S., Crockett, M., Dean, R. A., Amaladas, M. R., & Plourde, P. J.\r\n2017. A qualitative study on African immigrant and refugee families\u2019 experiences of accessing primary health care services in Manitoba, Canada: it\u2019s not easy!. International journal for equity in health, 16, 1-13.<\/p>","rendered":"

The Canadian population is aging rapidly, reflecting global trends. Low birth rates, increased life expectancies, and the aging of the baby boom generation have resulted in a shift toward a larger proportion of older adults (Canadian Institute for Health Information, 2011). In 2016 and 2021, about 17 percent and 19 percent of Canada\u2019s total population were classified as older adults (65+ years) (Statistics Canada, 2017a; 2022), and by 2036, this figure is expected to increase to almost 25 percent (Turcotte & Schellenberg, 2007). This demographic transformation will continue to increase demand for existing healthcare services, many of which are unevenly distributed across communities, neighborhoods, and cities.<\/p>\n

 <\/p>\n

Immigrants in Canada experience disparities in health and access to primary care compared with their Canadian-born counterparts, and these disparities can be even more pronounced for older immigrants living with chronic conditions (Canadian Institute for Health Information, 2011). Geographical variations in health can be explained by both compositional effects resulting from individual differences and contextual effects related to the differing physical and social attributes of neighborhoods. Recent trends including the suburbanization of older immigrants (Channer, Hartt, & Biglieri, 2020) and the spatial clustering of physicians speaking ethno-specific languages within urban areas have resulted in spatial\u2013language discordance, further challenging older adults with limited mobility, access, and social support. Another issue affecting older immigrants is the influence of interconnected social determinants of health including class, race, and gender (Bryant et al. 2004; Subedi & Rosenberg, 2014). Finally, the health of older immigrants may be affected by length of residency and exposure to the Canadian healthcare system. For example, newly arrived immigrants tend to have better health than non-immigrants, but their health status tends to decline with length of residence (Newbold, 2009; Setia et al. 2011; Subedi & Rosenberg, 2014).<\/p>\n

 <\/p>\n

This chapter presents the results of an ongoing study investigating the barriers and facilitators to accessing primary health care among older immigrants, with the goal of informing policies and improving access through translation services, joint efforts with community agencies, and other community-based practices.<\/p>\n

The Project<\/h3>\n

This four-phase project is focused on older immigrants (aged 65+ years) in Canada. Phase 1 involved a scoping review of the relevant literature. For Phase 2, we recruited participants from three stakeholder groups: Arabic- and Hindi-speaking older immigrants, representatives from community organizations, and healthcare practitioners. Phase 3 involved a symposium that took place in June 2019. The project is currently in Phase 4: knowledge synthesis and dissemination.<\/p>\n

 <\/p>\n

All project activities were set within the Toronto Census Metropolitan Area (CMA) in Ontario. According to the most recent census, its total population was 6,202,225 in 2021 (5,862,850 in 2016), including 2,862,850 (2,705,550 in 2016) immigrants (Statistics Canada, 2017b; 2021). Of these immigrants, 460,940 (about 17 percent) are classified as older adults (65+ years) in 2016 (Statistics Canada, 2017b). We focused specifically on Arabic- and Hindi-speaking older immigrants. Canada has a long history of immigration from South Asia, including Hindi speakers, while the Arabic-speaking immigrant population is relatively more recent. About 1.5 and just under 1 percent of the total population of the Toronto CMA lists Arabic and Hindi as their first language, respectively (Statistics Canada, 2016). Both of these groups face settlement challenges and barriers in accessing health care (Gulati et al. 2012; Woodgate et al. 2017). In general, Arabic-speaking older immigrants tend to cluster in the suburb of Mississauga, while Hindi-speaking older immigrants tend to cluster in the suburb of Brampton (see Figure 14.1).<\/p>\n

Figure 14.1. Arabic-speaking and Hindi-speaking populations in Toronto CMA at a census tract level<\/h6>\n

\"\"<\/p>\n

Phase One: Exploring the Literature<\/h3>\n

We conducted a scoping review on access to primary health care among older immigrants in Canada (Wang, Guruge, & Montana, 2019). Specifically, we utilized Arksey and O\u2019Malley\u2019s five-stage framework to examine 31 peer-reviewed articles, focusing on three main areas: access and use of primary care, health promotion and cancer screening, and use of mental health services. The review revealed intersecting factors affecting access to health care, including health literacy, language and cultural barriers, health beliefs, spatial access, and structural barriers.<\/p>\n

Access and Use of Primary Care<\/h4>\n

Family physicians are on the front lines, providing primary care for older immigrants who may have various chronic health problems. Our literature review included articles focusing on healthcare access among older immigrants from multiple ethnic and racialized groups including South Asian (Surood & Lai, 2010); Afro-Caribbean, former Yugoslavian, and Spanish (Stewart et al. 2011); and Chinese (Chow, 2012; Lai & Chau, 2007). Healthcare access may be influenced by a lack of culturally appropriate services and health information, personal and traditional beliefs, and spatial factors such as available modes of transportation (Lai & Chappell, 2006; Lai & Surood, 2010; Thomson et al. 2015). One main barrier is the lack of translated health information, especially for older immigrants. In primary care settings with limited language options, older immigrants may use improvised sign language, or have friends or family translate, or utilize paid interpreters (Stewart et al. 2011; Surood & Lai, 2010).<\/p>\n

 <\/p>\n

Immigrants are less likely than their Canadian-born counterparts to depend on a family physician. When access to a family physician is limited, older immigrants may seek access to primary care through hospital emergency rooms and walk-in clinics; this appears to be more common among recent immigrants compared to more established immigrants (Tiagi, 2016). One study reported that in Mississauga, older immigrants from China, India, Pakistan, and Romania attributed their reliance on emergency rooms and walk-in clinics to the inability of family physicians to accommodate new patients (Asanin & Wilson, 2008). Another issue is mobility: the unavailability of nearby family physicians is a major barrier to accessing healthcare among older immigrants with limited mobility (Wang et al. 2019). One study also reported that recently arrived older immigrants had lower rates of hospitalization compared with more established immigrants and Canadian-born counterparts (Ng et al. 2014).<\/p>\n

Health Promotion and Cancer Screening<\/h4>\n

Older immigrants who receive preventative care services, such as cancer screening and general health promotion strategies, generally obtain them from family physicians. Major barriers to accessing preventative care services include differences in culture and language, unavailability of local practitioners, and challenges related to mobility and access to transportation (Gesink et al. 2014; Koehn, Habib, & Bukhari, 2016; Todd, Harvey, & Hoffman-Goetz, 2011; Todd & Hoffman-Goetz, 2011). Some studies have explored breast and cervical cancer screening among immigrants in various regions of Canada, and have found that older immigrants seeking these services face challenges related to unmet language and cultural needs, inadequate education about screening practices and methods, and inability to access a family physician (Ahmad & Stewart, 2004; Vahabi, 2011).<\/p>\n

 <\/p>\n

Breast cancer screening rates among Arab, Chinese, South Asian, and Vietnamese immigrants are also affected by the preference for, and availability of, female physicians (Crawford et al. 2015). Asian immigrant women also appear to use mammogram services less, partly due to their lack of ability to speak English or French in a primary care setting (Sun et al. 2010). Rates for cervical cancer screening methods such as Pap tests are lower among immigrant women than their Canadian-born counterparts, but rates tend to increase with length of residency (McDonald & Kennedy, 2007). Ontario-based research has revealed that cervical cancer screening rates are lower among older women who are recent immigrants, racialized, and\/or living in low-income neighbourhoods (Amankwah, Ngwakongnwi, & Quan, 2009; Lofters et al. 2010).<\/p>\n

Use of Mental Health Services<\/h4>\n

Relatively few studies have focused on access to mental health services among older immigrants. The limited research evidence suggests that older immigrants generally underutilize mental health services (Kirmayer et al. 2007; Thomson et al. 2015) but rates may vary based on length of residency, as well as ethnic and racialized background. For example, rates of access to mental health services were lower among recent immigrants compared to established immigrants and Canadian-born community members, and rates were lowest among immigrants from Asia and the Pacific (Durbin et al. 2015).<\/p>\n

 <\/p>\n

One study conducted in Toronto, revealed that older Chinese and Tamil adults are limited by a general lack of mental health workers providing services to specific language groups, discrepancies in knowledge of mental illnesses, and cultural stigma that encourages a private approach to mental health problems (Sadavoy, Meier, & Ong, 2004). Another study involving South Asian immigrants also reported that access may be affected by traditional beliefs and attitudes about mental health and illness (Lai & Surood, 2013). A study conducted in Calgary revealed that only 11.4 percent of older Chinese adults could correctly identify depression, compared with 74 percent of the general population (Tieu, Konnert, & Wang, 2010). Interventions to improve access rates should involve culturally relevant health promotion efforts to reach specific immigrant groups.<\/p>\n

Phase Two: Stakeholder and Community Voices<\/h3>\n

The second phase of this project involved three stakeholder groups to explore how these they felt about primary care and access to services. We interviewed and surveyed Arabic-speaking and Hindi-speaking older immigrants (in their preferred language). We also interviewed and surveyed representatives from community organizations, as well as healthcare practitioners serving these language groups. Research approval was granted by the Research Ethics Board at Toronto Metropolitan University. We recruited the older immigrant stakeholders through community outreach, using flyers and other media posted in community hubs. Representatives from community organizations were recruited through contacts with our existing community partners; we also asked these community organizations to share information about the project with their older immigrant clients. We recruited healthcare practitioners through word-of-mouth, as we have worked with them in the past on other projects.<\/p>\n

 <\/p>\n

Data were cleaned and organized, and then analyzed using descriptive analysis for survey data and thematic analysis for interviews (Braun & Clarke, 2006, 2014; Schreier, 2012). As discussed in the following sections, four key themes emerged related to access to primary care by older immigrants: systemic gaps in levels of care; gaps in communication and education; service access gaps and privatization; and mental health gaps, stigma, and fear.<\/p>\n

\u00a0Systemic Gaps in Levels of Care<\/h4>\n
\n

By the time they get to see a specialist, their health is deteriorated more.<\/p>\n

What if they do not even survive until then?<\/p>\n

\u2014 Older immigrant<\/p>\n<\/blockquote>\n

 <\/p>\n

Several systemic gaps were identified by Arabic-speaking older immigrants; these were echoed by representatives from community organizations as well as healthcare practitioners. Older immigrants noted that they generally accessed family physicians as their primary point of care, and most were satisfied with the services they received from these practitioners. However, they considered the long wait times, language barriers, and costs associated with seeing a specialist to be prohibitive, noting that specialists were often unable to accommodate their health needs (e.g., monitoring illness progression, and extended care), and that seeing a specialist involved communication challenges and financial stresses. Healthcare practitioners also identified the need for consistent care, and follow-up when referring patients to other avenues of health care, including specialists.<\/p>\n

 <\/p>\n

Hindi-speaking community members also reported many of the same problems when navigating the healthcare system beyond their usual family physicians. They referred specifically to the problem of long wait times for specialist care when a health problem was serious and required urgent care. This situation was exacerbated by the inability of most specialists and emergency care providers to speak Hindi. The healthcare practitioners serving these older immigrants noted that they do have some employees who speak the necessary languages, but that trained translators and certified translation services are desperately needed.<\/p>\n

Gaps in Communication and Education<\/h4>\n
\n

Sometimes the doctor doesn\u2019t have time to listen to the patients.
\n\u2014 Older immigrant<\/p>\n<\/blockquote>\n

 <\/p>\n

Both Arabic-speaking and Hindi-speaking older immigrants identified communication and education-related gaps. Representatives from community organizations reported that they often assist with translation, transportation, and the completion of medical forms. Despite this, older immigrants commented on issues including a lack of ongoing communication between patients and physicians, lack of information about the Canadian healthcare system\u2019s structure for recent immigrants, and the need for older immigrants\u2019 voices to be genuinely heard when addressing their health issues.<\/p>\n

 <\/p>\n

The language barriers between older immigrants and certain healthcare providers (specialists, emergency attendants, and others apart from family physicians) increase the risk for misdiagnoses. Representatives from community organizations interacting with Arabic-speaking older immigrants also stressed the need for access to spaces of safe communication (e.g., religious spaces such as mosques or other community settings); they also reported that follow-up from doctors helps make older immigrants feel valued.<\/p>\n

 <\/p>\n

Representatives from organizations working with Hindi-speaking older immigrants noted that patients tend to be embarrassed by their inability to communicate effectively in English. Many older immigrants rely on their children and other caregivers to take them to appointments and relay medical information, and the representatives associated this reliance with frequent misunderstandings of diagnoses, especially related to technical medical terminology. Healthcare practitioners stressed that peer support is important: some noted that Arabic-speaking older immigrants had difficulty with follow-up appointments and taking medication regularly; others noted that Hindi-speaking older immigrants required more community-based education and outreach.<\/p>\n

Service Access Gaps<\/h4>\n
\n

Eye treatments are too expensive, and dentists are too expensive as well.<\/p>\n

\u2014 Older immigrant<\/p>\n

\n<\/blockquote>\n

Arabic-speaking older immigrants commented on the long distances between their homes and doctors, although most also said that they would undertake the journey to see doctors who speak their language. Strikingly, one community member lives in Burlington but sees a family doctor in Mississauga: this is a significant distance for an older immigrant facing additional structural and institutional challenges.<\/p>\n

 <\/p>\n

Hindi-speaking older immigrants commented that physiotherapy services are often difficult to access and pay for. Similarly, the high costs of dental and eye care were cited as major issues for both language groups struggling with financial hardships. Representatives from community organizations explained that transportation systems (Toronto Transit Commission, MiWay transit system in Mississauga, and Brampton Transit) are complicated for older immigrants in both language groups, especially when they must travel long distances. Healthcare practitioners confirmed these transportation difficulties for their Arabic-speaking and Hindi-speaking older immigrant patients and also emphasized the importance of prevention for health issues that would require privatized care services.<\/p>\n

Mental Health Gaps and Stigma<\/h4>\n
\n

I just want to say that we do not know how much longer we are going to live in this world. God knows what other problems await us.<\/p>\n

\u2014 Older immigrant<\/p>\n<\/blockquote>\n

 <\/p>\n

Older immigrant participants from both language groups commented on long wait times for access to mental health professionals. Hindi-speaking older immigrants cited fears of deteriorated mental health while waiting to see a specialist. Representatives from community organizations were quick to note that many Arabic-speaking older adults had recently immigrated from conflict zones and may therefore have serious mental health challenges requiring care from mental health specialists.<\/p>\n

 <\/p>\n

Representatives from organizations working with Hindi-speaking older immigrants commented that recent immigrant older adults suffer culture shock and anxiety, while long-term older immigrants may experience family-related stresses that can lead to depression and isolation. Service provider participants also noted that there is stigma surrounding mental illness in the South Asian community, as in many others, and that many individuals who need mental health services are told that their issues are \u201call in their heads.\u201d Healthcare practitioners working with Arabic-speaking patients also commented that social workers should be more involved in care. One practitioner working with Hindi-speaking older immigrants noted that the families of older immigrants, and even other healthcare providers, tend to use that \u201creality\u201d against them to exert control over their lives.<\/p>\n

Phase Three: A Collective Exchange of Ideas<\/h3>\n

The third phase of this project involved planning and hosting a symposium to facilitate communal knowledge sharing. This symposium was held at Toronto Metropolitan University and brought together a range of stakeholders including students, faculty members, health, social and settlement service providers, and representatives from analytics firms.<\/p>\n

 <\/p>\n

The event included a number of key presentations and provided opportunities to collaborate. Dr. Lu Wang (the first author of this chapter) delivered a keynote presentation outlining the project background, objectives, and methodology. While this project focused specifically on Arabic-speaking and Hindi-speaking older immigrants, Dr. Wang also spoke about Mandarin-speaking and Cantonese-speaking older immigrants \u2013 both large immigrant communities within the Greater Toronto Area \u2013 commenting that older immigrants are not well-represented among secondary data sets such as the Canadian Community Health Survey based data.<\/p>\n

 <\/p>\n

In the discussion that followed Dr. Wang\u2019s presentation, guests noted that those who know how best to navigate the healthcare system benefit the most. They also commented that immigrants require more support in terms of health advocacy, and that community health centres enable better syntheses of services: they may send a patient to a specialist immediately, while going to a private or family practice may create additional barriers. Points of privilege emerged as a central theme: some older immigrants do not have the means to pay for privatized health services or insurance, and services covered by the Ontario Health Insurance Plan may be too far away to access.<\/p>\n

 <\/p>\n

Gelsomina Montana was a co-author of the scoping review conducted for the first phase of this project (Wang, Guruge, & Montana, 2019), and spoke about the key themes of access and use of primary care, health promotion and cancer screening, and use of mental health services. Guests attending this session discussed screening patterns among immigrants and identified differences based on Ontario Health Insurance Plan coverage, misinformation among older immigrants, and general lack of awareness of the services. Some participants commented that patients felt uncomfortable in waiting rooms and with doctors who did not speak their languages. Community health centres were identified as sources of culturally sensitive service provision, although these also involve difficulties. For example, social workers might ask patients to travel significant distances to reach appropriate services and\/or treatment, which is problematic if the patient lacks access to transportation. This discussion period revealed that older immigrants require holistic approaches to health access: approaches that frame access as multifaceted and \u201cwhole.\u201d<\/p>\n

 <\/p>\n

Selasi Dorkenoo presented a paper based on a mixed-methods study she had conducted as part of her Master\u2019s thesis on access to language-specific services for Arabic-, Mandarin-, and Spanish-speaking communities in Toronto (Dorkenoo, 2019). Guests commented on the importance of alternative methods of transportation and services that could be improved to address systemic access gaps (e.g., WheelTrans and 55+ Rideshare in Toronto). They also referred to the need for more awareness about these issues.<\/p>\n

 <\/p>\n

Samya Hasan the Executive Director of the Council of Agencies Serving South Asians, a social justice umbrella agency promoting research advocacy and attempting to influence policy for South Asian populations in Canada) outlined the demographics and factors affecting the health and wellbeing of older South Asian adults. In the discussion that followed, guests commented on the intergenerational divide in mental health understanding and care for South Asian immigrants, and the need for narrative-based intervention based on life experience. Guests also identified the general need for culturally based healthcare practices that integrate community and family support, rather than \u201csimply prescribing medication and using a medical lens that tends to exclude other supports and intervention.\u201d Some guests commented on the importance of addressing domestic violence within the community, along with mental health supports to improve self-empowerment of victims and complement existing interventions such as law enforcement.<\/p>\n

 <\/p>\n

Dr. Peizhong P. Wang from Memorial University presented his unpublished research on healthcare access among recent older adult Chinese immigrants. About 50 percent of his study participants were able to walk to their doctors, and most were in Markham and Richmond Hill, Ontario. The subsequent discussion began with a conversation about transnational medicine. Guests noted that discrimination and other systemic barriers lead to trust issues with healthcare providers in Canada, especially among older immigrants who are often dismissed, minimized, and told that health issues are simply \u201ca part of being old.\u201d Guests also noted that immigrant women are more at risk of medical misconduct as a result of ingrained racist, patriarchal, and colonial practices. One commented that \u201cthe general public needs to help educate doctors on how to practise\u201d when the health outcomes of immigrant women are involved.<\/p>\n

Phase Four: Synthesizing and Disseminating Knowledge<\/h3>\n

This chapter is a key component of the final phase of our study, because it is helping to disseminate our findings. Together, the four phases of the study are helping to clarify the current state of practice and evidence-based knowledge related to access and use of primary health care among older immigrants, including barriers. The work done has helped reveal similarities among older immigrants from various regions and with differing residential locations, language skills, lengths of residency in Canada, and socioeconomic conditions. In particular, the primary data collected in Phase 2 helped clarify the barriers and facilitators related to delivering culturally appropriate health care to older immigrants. We found that Arabic and Hindi-speaking older immigrants face barriers including communication, lack of paid and trained translation services, long wait times, transportation, mobility issues, high costs related to eye and dental care, and stigma of mental illness. These are consistent with the key findings from the scoping review in Phase 1, and similar issues were discussed by the symposium attendees from community organizations and the health sector. Together, our findings provide evidence-based insights that can inform the development of initiatives and policy interventions. Healthcare delivery to older immigrants can be improved in four key areas: enhancing communication and providing timely and appropriate translation; providing assistance in transportation to access care including preventive care; providing additional coverage and support for eye care, dental care, and mental health care; and education for older immigrants through collaborative efforts among community organizations, community health centres, social workers, and other relevant interest groups.<\/p>\n

Moving Forward<\/h3>\n

In our future research, we plan to further explore primary and secondary data, including Census data of different years. We will use a mixed-methods approach to collect additional data from the stakeholders. We also expect to identify supplementary funding opportunities with engaged stakeholders to further explore the barriers and facilitators for older immigrants of different backgrounds in healthcare access to develop interventions and to inform policy.<\/p>\n

References<\/h3>\n

Ahmad, F., & Stewart, D. E. 2004. \u201cPredictors of Clinical Breast Examination Among South Asian Immigrant Women.\u201d Journal of Immigrant Health 6, no. 3: 119\u201326. doi: 10.1023\/b:joih.0000030227.41379.13<\/p>\n

Amankwah, E., Ngwakongnwi, E., & Quan, H. 2009. \u201cWhy Many Visible Minority Women in Canada Do Not Participate in Cervical Cancer Screening.\u201d Ethnicity & Health 14, no. 4: 337\u201349. doi: 10.1080\/13557850802699122<\/p>\n

Asanin, J., & Wilson, K. 2008. \u201c\u2018I Spent Nine Years Looking for a Doctor\u2019: Exploring Access to Health Care Among Immigrants in Mississauga, Ontario, Canada.\u201d Social Science & Medicine 66, no. 6: 1271\u201383. doi: 10.1016\/j.socscimed.2007.11.043<\/p>\n

Braun, V., & Clarke, V. 2006. \u201cUsing Thematic Analysis in Psychology.\u201d Qualitative Research in Psychology 3, no. 2: 77\u2013101. doi: 10.1191\/1478088706qp063oa<\/p>\n

Braun, V., & Clarke, V. 2014. \u201cWhat Can \u2018Thematic Analysis\u2019 Offer Health and Wellbeing Researchers?\u201d International Journal of Qualitative Studies in Health and Well-being 9: 26152. doi: 10.3402\/qhw.v9.26152<\/p>\n

Bryant, T., Brown, I., Cogan, T., Dallaire, C., Laforest, S., McGowan, P., Raphael, D., Richard, L., Thompson, L., & Young, J. 2004. \u201cWhat Do Canadian Seniors Say Supports Their Quality of Life? Findings from a National Participatory Research Study.\u201d Canadian Journal of Public Health 95, no. 4: 299\u2013303. doi: 10.1007\/BF03405136<\/p>\n

Canadian Institute for Health Information. 2011. Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: Canadian Institute for Health Information. https:\/\/secure.cihi.ca\/free_products\/HCIC_2011_seniors_report_en.pdf<\/p>\n

Channer, N. S., Hartt, M., & Biglieri, S. 2020. \u201cAging-in-Place and the Spatial Distribution of Older Adult Vulnerability in Canada.\u201d Applied Geography 125, no. 1: 102357. doi: 10.1016\/j.apgeog.2020.102357<\/p>\n

Chow, H. P. H. 2012. \u201cHealth Care Service Needs and Correlates of Quality of Life: A Case Study of Elderly Chinese Immigrants in Canada.\u201d Social Indicators Research 106, no. 2: 347\u2013358. doi: 10.1007\/s11205-011-9810-0<\/p>\n

Crawford, J., Frisina, A., Hack, T., & Parascandalo, F. 2015. \u201cA Peer Health Educator Program for Breast Cancer Screening Promotion: Arabic, Chinese, South Asian, and Vietnamese Immigrant Women’s Perspectives.\u201d Nursing Research and Practice 947245. doi: 10.1155\/2015\/947245<\/p>\n

Dorkenoo, S. 2019. \u201cAccessing Informal and Formal Social Supports Among Older Immigrants in Toronto: A Mixed-Methods Approach.\u201d Master\u2019s thesis, Ryerson University. https:\/\/digital.library.ryerson.ca\/islandora\/object\/RULA%3A9446<\/p>\n

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