The Changing Needs of Chinese Seniors in the Greater Toronto Area
A research study commissioned by the Yee Hong Centre for Geriatric Care
in partnership with the University of Toronto Factor-Inwentash Faculty of Social Work
Professor A. Ka Tat Tsang, Principle Investigator
Cindy Choi, Research Coordinator
Kwong Y. Liu, Director of Social Services
Maria Chu, Program Manager
Charles Wong, Program Coordinator
Kwok Keung Fung, Program Coordinator
This research study and report were funded by the Ontario Trillium Foundation.
Published by the Yee Hong Centre for Geriatric Care in June 2013.
Table of Contents
Needs and Chinese Seniors in the GTA
Past Research on the Problem
The Concept of Need
Rationale for Study
- Literature Review
Quality of Life
Demographics and Diversity
Living Arrangements by Gender
Service Models of Care
Balance of Care
Long-Term Care in Ontario
Filial Piety amongst Caregivers
The Role of Gender in Caregiving
Sexuality and Intimacy
Spirituality and Existentialism
Attitudes towards End of Life and Positive Aging
Barriers to Accessing Care
- Research Methods
Sample and Data Collection
Qualitative Data Collection and Analysis
Focus Groups and One-on-One Interviews
Quantitative Data Collection and Analysis
Supplementary Survey Findings
Ethical Considerations and Study Limitations
Potential Benefits to Study Participants
- Study Findings and Recommendations
Common Needs amongst Chinese Seniors
Seeking Help with Mental Health Issues
Spiritual Needs and the Final Stage of Life
Transitions in Life
- Mobility and Language Barriers
- Residential Care
- Aging at Home
Interaction with the Service System
Unique Needs of Middle-Aged Adults
Unique Needs of Caregivers
- Practical and Emotional Needs of Caregivers
- Role of Gender amongst Caregivers
Unique Needs of Mandarin-Speaking Seniors and Middle-Aged Adults
Recommendations for Service Planning and Delivery
Addressing Diversity and Settlement Issues
Recommendations for Addressing Life Transitions
Suggestions for Further Inquiry
Relevance for Other Growing Asian Populations in the GTA
Sexuality and Intimacy
Appendix I: Thematic framework for understanding the quality of life of middle-aged adults and seniors
Appendix II: Personal Interview Guide
Appendix III: Survey
For almost two decades, the Yee Hong Centre for Geriatric Care (Yee Hong) has been serving the communities of the Greater Toronto Area (GTA) with conviction and perseverance. Today, while its four long-term care homes stand proud in the GTA and a comprehensive range of community support services are making impact on the lives of tens of thousands of seniors and their family members, Yee Hong’s unwavering commitment to excellence, quality, and meeting community needs remains the same as our pioneers when they built the first Yee Hong Centre.
“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction, and skillful execution; it represents the wise choice of many alternatives” (William A. Foster). Embracing the Provider of Choice vision, Yee Hong makes no compromise with the quality and relevance of our services to respond to the changing needs of the community, particularly at times of rapidly changing demographics and social structures. To this end, Yee Hong developed a specific strategic direction in our 2010-2015 Strategic Plan to understand the changing needs of Chinese seniors in the GTA.
We are privileged to leverage our partnership with the University of Toronto Factor-Inwentash Faculty of Social Work, under the leadership of Professor Ka Tat Tsang, in conducting the needs study of Chinese seniors. Guided by scientific rigor, the study investigates not only the personal needs of the seniors, but also their interaction with their environment, including family members, service providers, and public policies. The result is a comprehensive depiction of the seniors’ needs not in isolation, but in complex and dynamic interface with their surroundings.
While the study permeates into many aspects of life, one theme has surfaced consistently—“a place like home”. Regardless of whether they live in long-term care homes, on their own, or with families, nothing is more important than “a place like home” for the seniors. The challenge for all service providers and policy makers is how to instigate the sense of homeliness in all aspects of planning and delivery to meet our seniors’ needs. I hope that while providing insights into the changing needs of Chinese seniors, the study will inspire others to pursue further studies to provide needed services to seniors of different communities.
Finally, on behalf of Yee Hong and the seniors we serve, I wish to express our deepest appreciation for the financial support of the Ontario Trillium Foundation to make this study possible. Such financial support serves as a critical catalyst to build and enhance the culture of evidence-informed decision-making in health care policy making, service planning, delivery, and evaluation.
Kaiyan Fu, CEO
Yee Hong Centre for Geriatric Care
This study aims to identify the changing needs of Chinese seniors who live in the Greater Toronto Area (GTA; specifically Toronto, Markham, Richmond Hill, and Mississauga). Using a mixed methods approach, data were collected from 655 seniors and service providers, caregivers, and other informants at the Yee Hong Centre for Geriatric Care. First, our key findings report on the specific needs of these groups in order to achieve “well-being, quality of life, and life satisfaction” (Chappell, 2005, p, 69).
This study documents the common needs amongst Chinese seniors (seeking help with physical care, mental health issues, spiritual needs, and the final stage of life), giving special attention to (1) changes in circumstances such as demographics and social environment, (2) major transitions in life such as immigration, retirement, or onset of chronic conditions, and (3) needs that emerge as a result of the interaction between service users and the service system, as in cases when new service ideas and programs lead to awareness of needs and new demand for services. The findings also cover the special needs of middle-aged adults and caregivers, the role of gender amongst caregivers as well as the unique needs of Mandarin-speaking seniors and middle-aged adults. Sensitive issues such as elder abuse, sexuality, and attitudes towards death and dying have also been explored. Recommendations are provided to inform further service planning and program development.
Changing Needs Emerging from:
- Changing circumstances: Demographics and social environment
- Transitions in life: Immigration, retirement, children leaving home, loss of partner, onset of chronic conditions, etc.
- Interaction with service system: Changes in policy, service philosophy, perspectives, conceptualization, and actual programs
NEEDS AND CHINESE SENIORS IN THE GTA
Seniors in Canada accounted for 14.8% of the national population in 2011. While the Canadian population as a whole increased by 5.9% between 2006 and 2011, the number of seniors aged 65 and over increased by 14.1% (Statistics Canada, 2012e). The aging population in Canada is expected to accelerate in the coming years as the first wave of middle-aged adults or “baby boomers” (born between 1946-1965) reached 65 years of age in 2011 (Statistics Canada, 2012d).
We recognize that “seniors” as a category is arbitrary and socially constructed. It is important to distinguish the terminology between seniors and middle-aged adults, and to recognize that definitions around aging are constantly changing due to culture and social circumstances. For example, the needs study conducted by the Yee Hong Centre for Geriatric Care in partnership with the Faculty of Medicine at the University of Toronto in 1989 defined seniors as individuals aged 60 years and over. In the Budget 2012, the Government of Canada has gradually adjusted the age eligibility for the Old Age Security (OAS) pension and the Guaranteed Income Supplement (GIS) from 65 to 67 years of age. Even if the definition of aging is constantly changing, the fact that Canada’s aging population growth will accelerate in the coming years remains unchanged. Statistics Canada estimated that the number of people aged 65 and over in Canada will reach 10.4 million by 2036. Approximately one in four Canadians is expected to be 65 years or over by 2051 (Statistics Canada, 2013b). According to Statistics Canada, factors that are related to Canada’s aging population growth include low fertility rates, an increase in life expectancy, and the aging of those from the baby-boom generation. This trend in aging is an indicator for an ongoing need for sufficient and appropriate services to help seniors to maintain an adequate standard of life.
The definition of “senior” often implies not only the individual’s physical and mental states and their interaction with the environment, but also their own perceptions around what it means to be part of this age classification. Emergence of needs is often the result of the interaction between the individual and the environment and, to a certain extent, it is a function of what is available. Certain needs are not easily expressed when there is an absence of relevant services. The presenting problem (expressed needs) is often only the starting point in addressing a long list of underlying needs. Service providers who are sensitive and responsive to the needs of clients should remain open to emerging needs and address them as resources allow, but they should also advocate for the implementation of new or increased resources when they see the needs arise.
Being sensitive to the unique needs of seniors by means of combining instrumental care with emotional care can help to provide the highest level of care for seniors. This could include transportation to medical appointments by someone familiar and trusted, which would decrease mobility and physical barriers and could ease stress and anxiety. It could also include a medication reminder phone call delivered in a gentle and caring tone, which would provide seniors with a sense of specialized care and attention with the management of health issues. Furthermore, establishing and nurturing trusting relationships between service providers and clients should be maintained as the hallmark of quality social service. Staff should remain open and sensitive to clients’ changing needs and, similarly, ongoing assessments should ensure that these needs are considered in quality assurance and improvement. Finally, mechanisms for effective communication and knowledge access for both caregivers and seniors should be put into place.
Yee Hong’s recent efforts have helped to develop an empowerment-based model of service delivery providing outreach to middle-aged adults and seniors alike. Thus, it is this very mission that makes Yee Hong a provider of choice amongst Chinese seniors in the GTA.
PAST RESEARCH ON THE PROBLEM
In 1989, the Yee Hong Centre for Geriatric Care (previously called the Chinese Community Nursing Home for Greater Toronto) commissioned a needs study in partnership with the Faculty of Medicine at the University of Toronto. Subsequent to that study, the Yee Hong Centre developed its first culturally and linguistically appropriate nursing home for Chinese seniors with a community centre attached to it. Since then, it has expanded to four long-term care centres offering a wide spectrum of services for seniors with a diverse range of needs in terms of health, abilities, and assistance requirements. The Yee Hong Centre began servicing three areas in the GTA: Scarborough, York Region, and Mississauga. Moreover, these services included outreach support to help prepare younger seniors for healthy aging and to empower family caregivers for senior care at home.
The study in 1989, entitled “Health Care Needs of the Chinese Elderly Population: A Needs Assessment”, collected data through archives and background research, personal interviews conducted with non-institutionalized seniors, and questionnaires completed by seniors and their family members (The Health Care Research Unit, 1989). We can see that some seniors’ needs have remained unchanged, such as their need for dealing with mental health concerns (e.g. loneliness, isolation, and depression) and needs for home care and transportation services. However, it is clear that there have also been significant changes. In 1989, the majority of participants expressed their need and desire to use senior centres. However, participants in this 2012 study articulated a strong need for more varied services and activities. Another example of changing needs reflects more recent immigration trends as the Mandarin-speaking Chinese seniors in this study expressed their needs for services that have specific regional cultural sensitivity (e.g. the culture of Mandarin-speakers from Northern China). This was not an issue raised in the previous study. Furthermore, seniors’ day care was not recognized as a significant need in the 1989 study but it is now widely regarded as a helpful resource for supporting seniors aging at home.
There were also linguistic changes since the previous study was conducted. In 1981, 60,275 of those living the city of Toronto selected Chinese as their mother tongue compared to 420,000 in 2006. The number of Mandarin-speakers in the city of Toronto in 2011 had the fastest growth rate of 32% out of all ethnic language groups. Varying levels of education and competency in the English language are factors that can help explain this significant increase.
THE CONCEPT OF NEED
This study recognizes that human beings experience complex needs and that needs are knowable (Maslow, 1943). First, the meeting of different needs is interrelated because meeting one set of needs may leave a person open to experience another set of more complex needs, as psychologist Abraham Maslow’s (1954) Hierarchy of Human Needs suggests.
Second, when human beings experience needs that are not met, they will be motivated to do something to address those needs. This motivation is understood as drives (Argyle, 1967). The ability to effectively meet those needs is related to a sense of well-being.
Third, individuals’ needs are closely related to the values one has, ideas about what is good, right, and desirable, one’s personal background, and social location (McKillip, 1987).
Fourth, needs are not always simply what one feels (felt needs) or what one says one needs (expressed needs); the construction of needs can emerge when compared to others who do not share those same needs (comparative needs) or it can be the result of a dynamic interaction between personal perspectives and social norms (normative needs) (Bradshaw, 1972).
Fifth, not every need is equally accepted by society. For instance, seniors’ needs for food and shelters are rarely questioned but their need for privacy in nursing homes can be controversial because balancing respect for privacy and safety could be challenging in some cases. Powerful social forces can shape our understanding of different needs and the pursuit of satisfaction of needs can be seen as a larger “social problem” or “political process” (York, 1982).
Finally, our study recognizes that people can experience similar needs but that each individual’s needs are personalized and contingent upon his/her unique circumstances.
RATIONALE FOR STUDY
As part of the Yee Hong Centre’s strategic planning and in collaboration with the Factor-Inwentash Faculty of Social Work at the University of Toronto, a grant application to the Ontario Trillium Foundation was approved to conduct a study on the changing needs of Chinese seniors in the GTA. The study attempts to explore the changing demographics of Chinese seniors in the GTA and their health and social needs. It also attempts to provide knowledge to bridge the gaps in existing gerontological literature amongst this population. Its aim is to provide an account on the changing needs of Chinese seniors in the GTA to assist the Yee Hong Centre in facilitating service planning. Other service providers may also benefit from the findings in this report.
In Ontario, Chinese, not otherwise specified (N.O.S.), (1.6%) and Cantonese (1.5%) were the second and third most common mother tongues respectively in 2011. Of those who spoke Chinese regularly at home, 37% spoke Cantonese while 28% spoke Mandarin. In Toronto, Mandarin as a language spoken at home increased by 32% between 2006 and 2011 (the fastest growth rate amongst the top 15 non-English languages spoken at home in Toronto); Cantonese, on the other hand, decreased by 11% (City of Toronto, 2012a).
Chinese as an ethnic group are very diverse. Mandarin-speaking Chinese from the People’s Republic of China (PRC) are a rapidly growing population in Canada. This study found that Mandarin-speaking Chinese seniors are in need of services, programs, and activities that are culturally appropriate for them. Many Mandarin-speaking seniors did not find services and programs previously designed for Cantonese-speaking seniors relevant to their needs and preferences. Needs include dealing with frustrations due to family tension, managing disappointment with the change of social status during immigration (many expressed their need for social recognition), and facing discrimination in Canada or from the Cantonese-speaking community.
Findings from a needs assessment of Mandarin-speaking newcomers conducted by George, Tsang, Man, & Da (2000) are consistent with the findings of this study that include, for example, settlement challenges including linguistic and communication barriers (especially with health care providers), family conflicts, psychological adjustment problems, and isolation (especially for senior men). Recommendations also include increasing services and community programs for Mandarin-speaking seniors, which would provide more opportunities for interactions with friends and day-time activities to alleviate isolation (George, Tsang, Man, & Da, 2000).
The study aims to explore and better understand the changing needs of Chinese seniors and middle-aged adults in the GTA. In the study, focus groups and one-on-one interviews are used to explore the relationship between Chinese seniors and their caregivers while acknowledging intersecting groups within this population (e.g. gender, Mandarin-and Cantonese-speaking, age) and their social and physical environments as well as the needs (physical, psychosocial, and existential/spiritual) of this group. Supplementary survey data are used to support these findings. The reason for combining both qualitative and quantitative data is to better understand this research problem by synthesizing both qualitative and quantitative data and to advocate for change for this population.
While some needs remain unchanged after almost 25 years, due to changes in demographics, immigration, and general shifts in social environment and culture, it is necessary to take another look at the needs of Chinese seniors in the GTA for the effective planning and refinement of services offered by the Yee Hong Centre.
This study consists of focus groups, one-on-one semi-structured interviews, and supplementary survey data. Topics that were explored include general opinions of needs and expectations of those needs, health, housing, home care, economic status, social aspects of life, service interaction, transitional planning (e.g. retirement), and personal life. Additionally, the needs of Mandarin-speaking seniors, caregivers, and middle-aged adults were explored (see Appendix I).
- LITERATURE REVIEW
QUALITY OF LIFE
Multiple factors influence the health and wellness of seniors in Canada. Canada’s newcomers, including seniors, are subject to health disparities and inequities in health care (Beiser & Stewart, 2005; Villeneuve, 2002). A national study has shown that older Chinese Canadians reported better physical health than older adults overall but that women were less healthy than men (Khamisa & Koehn, 2010). Lai, Tsang, Chappell, Lai, and Chau (2007) found that having a stronger level of identification with traditional Chinese health beliefs is significant in predicting physical health, number of illnesses, and limitations on instrumental activities of daily living. Other cultural variables include religion, country of origin, and length of residence in Canada. Such results call for health interventions that enhance the cultural compatibility between Chinese seniors, health, and social services delivery systems. Lai (2005b) found that the prevalence of depressive symptoms in older Taiwanese immigrants in Canada, for example, was higher than that reported by older adults in the general Canadian population.
Culture influences ideas around health and illness, symptoms of distress, and help-seeking behaviour (Ivanov & Buck 2002; Kirmayer & Looper, 2006). Higher levels of Chinese ethnic identity are a significant predictor of seeking long-term care (LTC; Lai, 2004). Additionally, older Chinese Canadians who had stronger ethnic attachment had a poorer assessment of their lives, their social supports, and their health than their counterparts who identified less as Chinese, and this is more so for women (Gee, 1999; Min, 2002).
DEMOGRAPHICS AND DIVERSITY
Toronto is the most diverse city in Canada with the highest proportion of visible minorities (63%) as opposed to Vancouver (59%) and Montreal (31%) (Statistics Canada, 2011a). Chinese made up the second largest visible minority group in Canada after South Asians (Statistics Canada, 2011b). The 2006 Census reported 3,398,725 foreign-born individuals in Ontario1, which counted for 28.3% of the total population. A significant proportion (77.1%) of recent immigrants who arrived in Ontario chose to settle in Toronto, which made up 8.8% of Toronto’s total population in 2006. One-third of these newcomers were from India (77,800 Indian immigrants or 17.4% of all Toronto’s newcomers) and China (67,000 Chinese immigrants or 15% of the total).
The City of Toronto has the largest number of foreign-born people amongst all municipalities in Ontario and 56.5% of Markham residents were foreign-born. This proportion was the highest in Ontario and the second highest in Canada. The highest proportion (57.4%) of foreign-born people over Canadian-born in Canada was found in Richmond, BC. Mississauga (51.6%), Richmond Hill (51.5%), Toronto (50%), and Brampton (47.8%) were other municipalities with high proportions of foreign-born people (Ontario Ministry of Finance, 2013). The growth rate of Ontario’s foreign-born individuals was 12.2%, nearly three times faster than the growth of Ontario’s Canadian-born population (4.3%).
Despite the fact that Ontario received approximately 96,000 fewer immigrants than that of the 2001 to 2006 period, the province continued to attract 52.3% of all newcomers (total number of newcomers was 1.1 million). In that time frame, 580,740 immigrants came to Ontario and counted for 17.1% of the foreign-born population (4.8% of the total population). Amongst this group of newcomers, the largest proportion (64.6%) of immigrants were born in Asia, an increase of 61% between 1996 and 2001).
1 2011 Census data about foreign-born population and immigrants had not been released at the time when this report was written.
Command of English is an important factor for effective access to health care services, especially for newcomers and immigrant seniors (Flores, 2006; Harari & Heisler, 2008; Wayland, 2006). Many older immigrants in Canada are excluded from social security programs as there is a 10-year waiting period for program eligibility, and such income insecurity significantly impacts health (Alternative Planning Group, 2009; McLeod et al., 2003).
Income is a well-established predictor of health (McLeod, John, Lavis, Mustard, & Stoddart, 2003). Many older immigrants in Canada are excluded from social security programs as there is a 10-year waiting period for program eligibility as mentioned above (Alternative Planning Group, 2009). Lai (2005b) found that low income is a predicting factor for depressive symptoms amongst older Taiwanese immigrants in Canada. The probability of using home care services decreases with increased self-rated financial adequacy by Chinese immigrant seniors (Lai, 2004b).
Cultural factors are more important predictors of preferred living arrangements than factors related to health and need amongst Chinese seniors (Khamisa & Koehn, 2010). The national review by Khamisa and Koehn (2010) found that female Chinese seniors who lived alone experienced greater concerns with mental health and other indicators of quality of life compared to their male counterparts. Chinese seniors in Canada who preferred living with children reported a significantly higher level of dependency on others with regard to activities of daily living (Lai, 2005a). Those who did not prefer living with their children were likely to be married, living alone, and born in Canada, and have higher levels of education, lower levels of identification with traditional Chinese values, and a western religion (Lai, 2005a).
A national study of 1,537 Chinese immigrant seniors 65 years and over (with a mean age of 79.4) revealed that only 5.2% used home care services, which was significantly less than other Canadian seniors (Lai, 2004b). However, for those who did use such services, significant predictors include older age, post-secondary education, immigrating from Hong King or Southeast Asia, high attachment to Chinese beliefs around health, social support, physical health, and mental health. Personal support workers (PSWs) and adult day programs are also important sources of support in the community that aid in home care. However, fees incurred through these external services can become financially burdensome for seniors and their families. The probability of using home care services decreases with increased self-rated financial adequacy (Lai, 2004b). With regard to financial status and its relation to well-being, some studies found that there is a positive correlation to health (McLeod, John, Lavis, Mustard, & Stoddart, 2003) and that low income is a predictor of depressive symptoms (Lai, 2004b).
Housing plays an important role for Chinese Canadians in how they interact with the community (Hwang, 2008). A report released by the University of British Columbia in October 2011 claimed that there would be an overwhelming need for providing Chinese-language specific housing support amongst senior immigrants in Vancouver. Somerville, Wazeer, and Wetzel (2011) estimated that there would be up to 3,500 Chinese-speaking seniors requiring some level of assisted living in the Vancouver area in the next 15 years. The demand for additional housing was significant as wait-times at existing senior care homes could be up to five years. In the Peel Region of Ontario, Chinese immigrant seniors still experienced salient housing challenges. Many Chinese immigrants still lived in basement apartments and multi-generational households. The Region also needed to address the lack of affordable housing for newcomers, seniors, and families in crisis (Bau, Ling, So, & Qin, 2008).
Census 2011 counted 4,945,000 seniors 65 years and over in Canada. 92.1% of seniors lived in private households or dwellings (with a partner, alone, or with others) while 7.9% lived in collective dwellings (including health care facilities). Census 2011 data also revealed that (1) living with a partner was the most common living arrangement; (2) a decreasing number of women were living alone; (3) the proportion of seniors living in a single-detached house declined with age; (4) the proportion of seniors living in special care settings increased with age; and (5) living alone was the most common arrangement amongst seniors living in residences (Statistics Canada, 2013a).
Living Arrangements by Gender
Most senior women lived in private households and many lived with a partner. In 2006, 46% of women and 76% of men aged 65 years and over lived with a partner (Statistics Canada, 2013d). The higher life expectancy as well as remarriage and other unions later in life may have contributed to these figures (Milan & Vézina, 2011). Even still, a large proportion also lived alone, especially amongst Canada’s older seniors. 54% of women aged 80 years and over lived alone, compared to only 24% of men in that age group. Living alone during later senior years implies more reliance on formal or informal care, housing, and financial needs (Milan & Vézina, 2011).
Senior immigrants were more likely to live with relatives and this was especially the case for senior women. Close to 13% of senior immigrant women lived with relatives, whereas only 3.4% of senior immigrant men did. Amongst recent immigrant seniors who arrived between 2001 and 2006, 40% of women and 9.5% men lived with relatives (Milan & Vézina, 2011).
Having social support networks in the form of family and friends plays an important role in life satisfaction (Milan & Vézina, 2011). In the study by Milan and Vézina (2011), almost all women (98%) aged 65 years and over reported having at least one family member with whom they felt at ease and from whom they could ask for help.
SERVICE MODELS OF CARE
Various senior service models have emerged to address the physical and psychosocial needs of seniors in Canada, particularly for those who have more pronounced ethno- or culture-specific needs. The role of health care professionals is important in realizing client-centred care for seniors, which would improve the level of care for seniors especially in long-term care settings (Fung, 2006).
Balance of Care
Given many seniors’ preference to age in “place” or in their own communities, the Balance of Care (BoC) model pioneered by Dr. David Challis and colleagues at the University of Manchester has been implemented in multiple Local Health Integration Networks (LHINs) across Ontario (Challis & Hughes, 2002). The BoC model assumes that the need for long-term care placement for seniors is determined by two factors: (1) the type of needs and (2) the availability of community-based health and social care required to meet such needs. By assessing the holistic needs of seniors at the margin of placement into long-term care settings and matching those needs to existing community services, the BoC model aims to identify at-risk seniors who could be safely maintained in the community with better outcomes and also identify priorities for care investment for the future (Challis & Hughes, 2002).
The Virtual Ward model of care, pioneered by Geraint Lewis in the United Kingdom in 2004, aims to reduce hospital re-admission by providing short-term transitional care to high-risk, complex patients in the community who have recently been discharged from the hospitals. An admission criterion was based on the use of a mathematical model that predicts the risk of re-admission. A multidisciplinary team would provide home-based care to patients at their homes (Toronto Central Local Health Integration Network, 2010). Currently, such institutions as St. Michael’s Hospital, Women’s College Hospital, and the Toronto Central Community Care Access Centre are implementing the virtual ward service collaboratively.
In British Columbia, the S.U.C.C.E.S.S. Simon K. Y. Lee Care Home adopted the Eden Alternative (a person-centred approach to long-term care) in the care for ethno-cultural seniors. In a small qualitative study conducted on this model, Fung (2006) found that: (1) the approach is relevant to the Chinese population; (2) the approach requires modifications to take into account Chinese’s more collective sense of personhood; and (3) the Eden Alternative is a process regardless of culture.
The Eden Alternative has 10 core principles (as cited from Eden Alternative, 2009): (1) The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering amongst seniors. (2) An elder-centred community commits to creating a human habitat where life revolves around close and continuing contact with plants, animals, and children. It is these relationships that provide the young and old alike with a pathway to a life worth living. (3) Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship. (4) An elder-centred community creates opportunity to give as well as receive care. (5) An elder-centred community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. (6) Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health. (7) Medical treatment should be the servant of genuine human caring, never its master. (8) An elder-centred community honours its elders by de-emphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the elders or into the hands of those closest to them. (9) Creating an elder-centred community is a never-ending process. Human growth must never be separated from human life. (10) Wise leadership is the lifeblood of any struggle against the three plagues (loneliness, helplessness, and boredom) (Eden Alternative, 2009).
LONG-TERM CARE IN ONTARIO
The overall wait times for long-term care2 (LTC) beds in Ontario have increased dramatically in recent years. Wait times for LTC increased by 129%, with the median wait time increasing from 45 days in 2003 to 103 days in 2009. Mental health issues are prevalent amongst those in long-term care settings in Canada. Recent studies have shown that 80% to 90% of LTC residents suffered from some form of mental disorder. Depression was present in approximately 50% of the residents, while 15% to 25% were severely impacted by major depression (Canadian Coalition for Seniors’ Mental Health, 2006; 2009; Rover et al., 1990; The Standing Senate Committee on Social Affairs, 2006). According to the Ontario Long-Term Care Association (OLTCA), almost a quarter of residents who had depression showed signs of worsening over a three-month period (CMHA, Ontario, n.d.). Some residents did not experience an acute episode but were suffering from some form of chronic mental health issue such as major depression, other mood disorders, and dementia.
2 Long-term care (LTC) homes (such as nursing homes, charitable homes, and municipal homes for the aged) provide care for people who are no longer able to live independently and safely in their own homes and who require 24-hour personal care, support, and/or supervision.
Filial Piety amongst Caregivers
Regarding the use of long-term care services, a national survey of 339 Chinese-Canadian caregivers revealed that filial piety, caregiving responsibilities, individual seniors needing care, and health conditions are the most common motivating factors for home care support and long-term care services (Lai, 2008). Other predictors of long-term care usage by Chinese seniors include higher levels of dependence in instrumental activities of daily living3, living alone, higher levels of social support, and higher levels of ethnic attachment amongst Chinese (Khamisa & Koehn, 2010). Additionally, multiple factors influence the care that Chinese LTC residents receive. Chan and Kayser (2005) found that communication barriers, a dislike of Western food, and differing cultural beliefs and customs from the dominant culture pose further challenges in the care available for this population.
Chinese seniors in Canada tend to live with children even when their partners are still living; their sons or daughters-in-law are those involved in the care. However, the involvement of daughters is greater than the care provided by daughters-in-law (Khamisa & Koehn, 2010). Caregiving becomes particularly important to Chinese seniors’ aging at home. Amongst Chinese providing care for seniors with dementia, feelings of obligation as well as feeling overwhelmed, anxious, and fearful of the future motivated applying to LTC homes for seniors. Interestingly, caregivers viewed this action as part of their filial obligation as well (Khamisa & Koehn, 2010).
3 Instrumental activities of daily living (IADL) refer to a series of life functions necessary for maintaining an individual’s immediate environment. IADL measure an individual’s ability to live independently, including use of the telephone, shopping, food preparation, housekeeping, transportation, medication management, and financial management.
The Role of Gender in Caregiving
Studies have shown that women are more likely to be caregivers than men (Baines, Neysmith, & Evans, 1998). Caregiving by women takes place in both the public and private spheres. They often provide care to spouses, elderly, relatives, and children, but also through low-wage jobs providing care and services to others. They are exposed to inequalities in the labour market, influenced by social welfare policies and demographic trends including the aging population (Baines, et al., 1998).
There are multiple factors influencing the physical well-being of older Chinese in Canada (Khamisa & Koehn, 2010). Some of these include education, place of origin, use of medications, physical mobility, and perceived financial needs. Risk factors contributing to poorer health include being a woman and being socially isolated. Furthermore, Khamisa and Koehn (2010) found that the predictors of life satisfaction for Chinese elders in Vancouver, Hong Kong, and Shanghai include physical and psychological health, social support, economic status, and a sense of personal control. Racial oppression, lack of family support, single marital status, length of residence, and lower education and economic status, along with poor general physical health, contribute to depressive symptoms (Khamisa & Koehn, 2010).
Chinese seniors’ experiences with chronic disease are unique. For example, the Heart and Stroke Foundation of Ontario has identified low awareness of risk factors for heart disease and stroke in the Chinese community (Chow, Chu, Tu, & Moe, 2008; HSFO, 2009). In a national study, Lai (2004a) found that Chinese seniors experienced poorer mental health than Canadian-born seniors. In particular, senior Chinese immigrant women reported poorer mental health than their male counterparts (Lai, 2004a).
Another similar report has indicated that Chinese seniors experienced much higher rates of depressive symptoms than seniors in the general Canadian population. In particular, mild to moderate levels of depressive symptoms were found amongst 21% of older Chinese immigrants. Chinese immigrant seniors with lower income levels are at a higher risk for depression (Lai, 2004b). Interestingly, a lower level of identification with Chinese beliefs around health amongst the Taiwanese population is a predictor of depressive symptoms (Khamisa, & Koehn, 2010).
Access to health care significantly impacts the mental and physical well-being of Chinese seniors. In particular, Khamisa and Koehn (2010) documented the following barriers to accessing mental health services: lack of trained and competent mental health clinicians and services that can provide ethno-cultural, geriatric, and psychiatric care, limited awareness of mental health, language barriers, disturbance of family support structures, decline in individual self-worth, reliance on ethno-specific community agencies that are designed to provide formal mental health care, fear of rejection and stigma amongst seniors and families, and the lack of appropriate professional referral. The lack of familiarity with the Canadian model of primary care often leads to overall dissatisfaction with care (Liu, So, & Quan, 2007; Zhang & Verhoef, 2002). Furthermore, the lack of transportation support contributes to the under-utilization of health services by older Chinese immigrants in Canada (Aroian, Wu, & Tran, 2005).
Abuse and neglect is an area that demonstrates the close relationship between physical and psychosocial well-being of Chinese seniors in Canada. Khamisa and Koehn (2010) noted factors that increase Chinese seniors’ vulnerability to abuse, including social isolation, sponsorship laws that enforce dependency, and lack of knowledge or resources surrounding immigration laws and the Canadian social and health care systems.
Senior women are more likely to be victims of elder abuse than senior men. According to Public Health Agency of Canada (Public Health Agency of Canada, 2012), the rate of violence against older women was 22% higher than the rate of violence against older men. However, this could be influenced by disproportionate reporting by gender. In 2004, the police received 3,370 incidents of elder abuse for those aged 65 years and over, 29% of which were committed by a family member. In 1999, 9% of senior men and 6% of women reported being victims of emotional or financial abuse (related to stealing of household property) by adult offspring. There is not enough information and evidence about the risk factors causing elder abuse being related to ethnicity, race, and culture (Public Health Agency of Canada, 2012).
Chinese seniors would benefit from having their service providers demonstrate cultural sensitivity in their professional practice, particularly around awareness of Chinese cultural constructions of the body, traditional Chinese medicine, and how these intersect with primary care in Canada as part of an overall disease management strategy (Lee, Rodin, Devins, & Weiss, 2001; Liang, Yuan, Mandelblatt, & Pasick, 2004; Liu, So, & Quan, 2007; Zhang & Verhoef, 2002). Other psychosocial factors also influence the health of Chinese seniors.
A network of family and friends can be a source of support and play an important role in seniors’ feelings of satisfaction with life as a whole (Milan & Vézina, 2011). Seeking pleasure activities and leisure is also tied to psychosocial well-being. Yvonne Ng (2011) found that Chinese seniors (from both Mainland China and Hong Kong) valued leisure as an essential component of life and holistic health. The aspects of exploring leisure amongst Chinese seniors include: leisure influenced by the exposure to changing cultures, achieving and maintaining health, experiencing freedom and choice, cultural expression and learning, and feeling a sense of community through leisure activities (Ng, 2011).
SEXUALITY AND INTIMACY
Seniors often maintain sexual interest and activities well into later years in life across the world (Goh, Tain, Tong, Mok, & Ng, 2004; Guan, 2004; Moreira, Glasser, & Gingell, 2005; Nusbaum, Singh, & Pyles, 2004). Currently, there is a lack of research in the area of sexuality in later life (Bauer, McAuliffe, & Nay, 2007; Nicolosi, Glasser, Kim, Marumo, Laumann, & GSSAB Investigators’ Group, 2005). In Canada, Tsang, Fuller-Thomson, and Lai (2012) conducted a unique national survey using a random sample of 2,272 Chinese-Canadian seniors, which investigated the relationship between the socio-demographic and sexuality-related variables along with the respondents’ self-reported health. The study revealed that sexuality does play a role in the health of older Chinese-Canadians. Both sexual activity and subjective levels of satisfaction have a positive relationship with health amongst older men. For older women, only the latter has been shown to be significant to their overall health.
Seniors face multiple barriers in exploring their sexuality across settings. In long-term care facilities, researchers (e.g. Bauer et al., 2007; Edwards, 2003; Hubbard, Tester, & Downs, 2003; Kamel, 2001; Lemieux, Kaiser, Pereira, & Meadows, 2004) have pointed out that residents face multiple barriers in meeting their sexual needs, including the negative attitudes of sexuality in later life by staff and families, the lack of available or willing partners, lack of privacy and physical environment that discourages intimacy and privacy, physical or mental illness, adverse side effects of medications, poor self-image, and physiological challenges with aging.
Systematic barriers surrounding seniors and sex include stereotypes and discrimination in society, which portray older people as asexual, embarrassing or having sexual needs that are not validated, and as having a decline in sexual needs (Bauer et al., 2007; Gott, 2005; Hodson & Skeen, 1994). For example, older adults in rehabilitation and residential care facilities are unable to explore their sexuality because they are often seen as having behavioural problems by staff (Kamel, 2001; McCartney et al., 1987). Since the attitudes and knowledge levels of helping professionals significantly impact seniors’ exploration of sexual needs (e.g. Bouman et al., 2006; Gott & Hinchliff, 2003; McAuliffe et al., 2007), extensive guidelines and ongoing professional activities on the issue of senior sexuality are required.
SPIRITUALITY AND EXISTENTIALISM
In 2002, the Canadian Mental Health Association (CMHA) project, “Seniors’ Mental Health and Home Care”, reported factors influencing positive mental health of older adults in Canada, which include spirituality amongst others such as independence and control over one’s life, a sense of dignity and purpose, physical health, and social interaction (as cited in MacCourt, 2008). Service providers and academics recognize the contribution of faith-based organizations in addressing the mental health needs of seniors in Canada. The CMHA Ontario Forum in 2012 recommended initiating educational and feedback opportunities for non-health, non-social service oriented groups (e.g. interfaith clergy) so that they may gain necessary information and resources to increase informed practice.
Lai (2005) revealed that more Chinese seniors who preferred living apart from their children practiced “western” religions (e.g. Christianity). In a random sample of 1, 537 elderly Chinese immigrants in Canada, Lai (2006) found that 28.8% of the elderly Chinese immigrants reported using a senior centre within the past year. Significant predictors of usage include: religion, living alone, and having stronger ties to one’s ethnicity and social support networks.
Attitudes towards End of Life and Positive Aging
Attitudes towards end of life and palliative care are mixed amongst North American Chinese seniors. Crain (1997) indicated that Chinese American seniors were not more fearful of death than others, and they freely discussed issues concerning death and dying. Many were willing to share personal stories along with strong beliefs and choices regarding end-of-life issues. However, other scholars found that the end-of-life decision-making of healthy older Chinese adults in Toronto is influenced by hope, suffering and burden, the future, emotional harmony, the life cycle, respect for doctors, and the family (Bowman & Singer, 2001). Such attitudes can be attributed to values from Buddhist, Confucian, and Taoist traditions. Bowman and Singer (2001) urged health care workers to achieve quality end-of-life care by addressing cultural differences as they arise, understanding the perspectives of patients and their families, and by continually striving for balance and communication at all stages of the caregiving process. Qiu (2005) found that simply addressing the limited understanding around end-of-life care through the translation of assessment tools, consent forms, and brochures amongst older Chinese adults would be beneficial.
BARRIERS TO ACCESSING CARE
Lack of appropriate information and access barriers can negatively impact seniors’ concepts around positive aging. Some of these include the lack of familiarity with the Canadian model of primary care, lack of awareness of existing services, potential overload of information especially for newcomers, inaccessibility of service outreach activities, and communication barriers (Liu, So, & Quan, 2007; TPH & Access Alliance, 2011; Zhang & Verhoef, 2002). Based on case studies of Chinese and South Asian seniors, Koehn, Spencer, and Hwang (2010) found that Canadian laws and policies have an important effect on intergenerational tension, senior status, social isolation as well as the risk of abuse and neglect or domestic and workplace exploitation. These factors can influence access to essential services such as housing and health care services.
- RESEARCH METHODS
This mixed methods study aims at identifying the changing needs of Chinese seniors in the GTA. Qualitative data were collected through focus groups and semi-structured one-on-one interviews with Chinese seniors, middle-aged adults, and caregiver participants as well as key informant consultations with Yee Hong Centre staff. Supplementary quantitative data were collected through surveys that were administered amongst service users at the Yee Hong Centre. Research literature and archived data were also used to identify areas of major needs during the preliminary stage of planning.
Qualitative methods have been used in a range of social science disciplines and applied fields extending to needs assessments (Miles & Huberman, 1994; Reichardt & Rallis, 1994). They offer the opportunity to investigate an issue or question in depth, and to explore respondents’ views and perspectives based on their own terms and frameworks of understanding. As a result, it provides a greater open space to learn about and explore individual lives, stories, behaviours, organizational functioning, social movements, or interactional relationships (Strauss & Corbin, 1990). Individuals’ needs are related to particular life experiences. This method of research allows researchers to engage in an exploratory process that can provide narrative spaces for participants’ own ideas to emerge, meanwhile allowing them to also participate in the construction of meaning.
SAMPLE AND DATA COLLECTION
Due to limited financial resources, a non-probabilistic convenient sample was used instead of randomized household sampling. Therefore, the results of this study do not allow us to make statistical inferences about the Chinese population as a whole in the GTA. All participants were affiliated with Yee Hong services in some capacity. However, the data do provide us with a valuable preliminary overview of the types of needs and the scope of needs amongst Chinese seniors. This study recruited research participants aged 65 years and over (seniors) and caregivers over the age of 18 years.
QUALITATIVE DATA COLLECTION AND ANALYSISTable: Percentage of Study Participants by Age
Focus Groups and One-on-One interviews
Theoretical sampling was used during qualitative data collection in the form of semi-structured focus groups. 23 focus groups were conducted with 264 Chinese Canadian seniors, their family members, and caregivers. Participants were loosely grouped by similar experiences, characteristics and/or background, and so on (e.g. Mandarin-, Cantonese-, or English-speaking seniors and middle-aged adults, gender, recently retired, Canadian work experience, seniors waiting for senior housing, religion, mental health, ability, living situation, economic status, Community and Social Services (CSS) clients, seniors who are living in the community and waiting for LTC and their caregivers, seniors in adult day programs, caregiver support groups, PSWs, and one group of non-Yee Hong service users). 25 individuals were selected for in-depth, one-on-one interviews that elaborated on living arrangements, health issues and life before and after, and immigration and settlement experiences.
QUANTITATIVE DATA COLLECTION AND ANALYSIS
Supplementary Survey Findings
Qualitative data collection was supplemented by a survey in which 347 Yee Hong service users participated. 20% were middle-aged adults under the age of 64 years. 71% were seniors aged 65 years and over (see table on page 51). More women (63%) than men (36%) participated in the study. The majority of participants spoke Cantonese (74%); some spoke both Cantonese and Mandarin (13%), and some only Mandarin (10%). There were a few participants who neither spoke Cantonese nor Mandarin (3%). The proportion of Cantonese speakers in the study may reflect the current reality of users at the Yee Hong Centre but it could also mean that more Cantonese-speaking users were more inclined to participate in the study for reasons unknown.
The quantitative data support qualitative findings as they both revealed the need for maintaining better family relations, mental health, and an overall sense of well-being (especially in relation to social interaction and recognition). Although Mandarin-speaking respondents varied slightly in their needs from Cantonese-speaking respondents, this may be due to the disproportionate representation in the sample.
Data from our survey show that seniors aged 65 years or over included needs that were health related (19%) or overall well-being related (17%), needs related to other services (e.g. PSWs) and supports for aging at home (17%), needs related to mental health and daily living (14 %), and financial needs (14%). The top 5 needs prioritized by most seniors were: (1) the need for more physical activities, (2) feeling a sense of self-acceptance and efficacy, (3) feeling a sense of belonging in society, (4) feeling a strong sense of self-esteem, and (5) participating in social networks and making friends. These quantitative findings somewhat support our qualitative findings that what seniors need most during their journey of aging is to deal effectively with their physical and mental health in addition to overcoming barriers in everyday lives.
Cantonese-speaking middle-aged adults provided a unique look at the influential factors on their quality of life. Increased physical activity was highlighted as a priority need. Other equally important needs involved satisfying sexual and intimacy needs, overcoming mobility barriers, affiliation with the community and society at large, and getting along with family members. Other needs revealed by the survey results include: overall sense of well-being (19%), daily living needs (18%), health (17%), financial (15%), other service needs (12%), mental health (11%), and support for aging at home (8%). There is a great amount of congruence between the quantitative and qualitative data regarding these needs.
The survey data revealed that 20% of Mandarin-speaking seniors’ needs were health-related; 16% were related to an overall sense of well-being; 14% were related to mental health and day-to-day needs; and 12% were related to finances, aging at home, and other services such as having the need for PSWs.
ETHICAL CONSIDERATIONS AND STUDY LIMITATIONS
Each study has its own ethical considerations and limitations. There are several factors to consider in this study as influencing the research findings: researcher and respondent bias, stigma around taboo subjects, and limitations in existing gerontological literature pertaining to this population. It should also be noted that this is a report requested by the Yee Hong Centre and thus, it focuses largely on informing practices from an agency perspective and may be biased towards service-related issues. The literature review is also guided by such a pragmatic purpose.
The expression of needs in research is another important process. People do not just answer straightforward questions about their needs. While some needs are more socially accepted and therefore easier to express, other needs are negatively valued or even stigmatized, making it difficult for the individual to admit and communicate them. For example, the needs for protection against abuse, sexual gratification, intimacy, or treatment for mental health conditions are not readily expressed by research participants. As a result, it is vital to create an atmosphere of trust and acceptance in order to give voice to these concerns. Even then, there is always a possibility of under-reporting of these issues.
Potential Benefits to Study Participants
Needs are subjective and often, they can emerge through the interaction between the individual and the service provider. The availability of culturally appropriate senior care services such as those available through the Yee Hong Centre has led to a better understanding of the needs of Chinese seniors and it has also facilitated the expression of needs. During the data collection process, researchers explored the changing needs of seniors and, more specifically, those during life transitions. This subsequently encouraged respondents to review their lives. They were able to identify their own needs due to the interaction and involvement with this study, which we anticipate can be empowering. We found that seniors welcomed and enjoyed the opportunity to share their life stories whether they were of joy or hardship, and these stories were embedded with important values that made up each of their individual identities.
- STUDY FINDINGS AND RECOMMENDATIONS
Our findings show that strategies for effective health management are required along with support around day-to-day responsibilities such as cooking and household duties. Seniors additionally need support around dealing with fear, frustration, and social isolation, complicated feelings towards family and friends, and their own changes in health. This study has identified that many seniors need assistance in maintaining their mental well-being, mostly to overcome loneliness, depression, and anxiety. Some Chinese seniors expressed a desire to live happier lives independent of their children. Interestingly, they viewed this as a Canadian way of life rather than a traditional Chinese way of life. The pursuit of better quality of life is related to positive attitudes towards aging.
It should be noted that the majority of respondents were Cantonese-speaking and female. However, there were unique themes and characteristics that emerged unique to the Mandarin-speaking participants and middle-aged caregivers, which will be further discussed in the upcoming sections.
COMMON NEEDS AMONGST CHINESE SENIORS
Our study revealed common needs shared amongst Chinese seniors who participated in this study. These include such topics as seeking help around mental health issues, spirituality, end of life, and sexuality and intimacy.
Seeking Help with Mental Health Issues
Barriers Chinese seniors are facing when they access mental health services include: lack of adequately trained mental health clinicians and services that provide ethnoculturally-specific care, language and information barriers, decline in individual self-worth, reliance on ethno-specific community agencies that are designed to provide formal mental health care, and fear of rejection and stigma (Khamisa & Koehn, 2010).
Some Chinese seniors are hesitant to seek professional help because they feel shame around mental health issues and diagnoses. Due to the stigmatization of mental health issues, increased culturally and language-specific psychoeducation, programs, and support would be beneficial for this community. Other seniors who are suffering from stressors of everyday life such as dealing with anxiety, fear, and loneliness are also in need of support. Appropriate supports and services can better be developed and planned if one is able to communicate one’s needs in a non-judgmental and safe environment.
Spiritual Needs and the Final Stage of Life
Values, spirituality, and beliefs contribute to positive attitudes around the final stage of life. Many respondents in this study expressed the need to leave this world with dignity. Contrary to traditional Chinese practice, seniors were willing to discuss their own fears of death openly. When the opportunity to review information and arrangements regarding end of life arose, some seniors found themselves beginning to think, understand, and eventually accept the reality of death in accordance with their own life values.
Human needs emerge within specific environmental and social contexts. Macro level factors such as government policies and collective lifestyle changes can influence demographics, social environment, and cultural conventions. The seniors and middle-aged adults who participated in our study found themselves in an ever-changing social context in which they had to learn how to adapt and navigate. For instance, immigration patterns and housing market forces have worked together to produce a growing number of seniors living in suburban neighbourhoods around Toronto that are not served by public transportation provided by the Toronto Transit Commission (TTC). The more costly and less convenient service can have significant impact on the lives of the seniors in terms of increased isolation and helplessness, and therefore contribute to more unmet needs (for independent living, socializing, activity, and so on).
TRANSITIONS IN LIFE
“When I first arrived, I tried to make friends, mostly immigrants. We were helping each other, spending time together. The environment here was new to all of us. So we learnt new things together, like taking English lessons. Gaining more friendship, exchanging more information, and staying connected with society, I found my knowledge in many respects gradually expanded.”
In this section, we will discuss the individual and transitional needs expressed by the participants in this study. These may include needs during transitional stages in life (e.g. housing and living arrangements, relocation, settlement, etc.), personal experiences with elder abuse, and sexuality and intimacy.
Positive factors that contribute to overall life satisfaction for seniors include exploring sources of support, e.g. family, friends, and community, positive attitudes towards life and spirituality, providing recommendations to health care and social service practitioners, improving attitudes and knowledge around sexual and intimacy needs, exploring different service models, positive impacts of cultural identity, and the use of senior centres and nursing homes.
Current studies on the well-being of seniors focus on problem causes or categorical contributing factors, and researchers often overlook that aging itself is a transitional process. The satisfaction of individual seniors’ lives is always contingent upon multiple and changing factors including the changing social circumstances (e.g. long settlement processes), life stages (e.g. children leaving home, downsizing from a house to an apartment, loss of spouse, divorce, and remarriage), and their interaction with existing social forces, perspectives, and service options (e.g. openness in talking about taboo subjects). Not all changing needs will be discussed in this report but factors voiced by the participants of this study will be highlighted.
Mobility and Language Barriers
For those who have immigrated to the GTA, mobility and language barriers can be a daily concern that can cause stress and anxiety amongst other challenges. Many Chinese immigrant seniors shared stories about their past struggles, joys, and successes in adjusting to their new lives in Canada. Many respondents expressed feelings of loss and regret after immigration due to different barriers they encountered in Canadian society. These barriers hinder seniors from performing everyday tasks such as running errands and navigating their social environment. For example, transportation service and interpreters are required when seniors make doctor visits.
Other studies support our findings regarding the lack of transportation support as a contributing factor to the under-utilization of health services by older Chinese immigrants in Canada (Aroian, Wu, & Tran, 2005). Additionally, the ability to speak English is an important factor for effective access to health care services, especially for newcomers and immigrant seniors (Flores, 2006; Harari, Davis, & Heisler, 2008; Wayland, 2006). Lack of communication skills in English (e.g. with the police, medical professionals, etc.) further increases the chance of experiencing mental distress and feelings of isolation, loneliness, anxiety, and insecurity, thus compromising their overall life satisfaction.
“When you enter the room, you smell the rice cooking. It is such a comforting feeling. It makes me feel like home.”
Seniors require a living environment that is safe and favourable to their physical well-being and mental health, and more importantly, a residence that feels like home and allows certain degree of autonomy. Our findings show that cultural factors are better predictors of preferred living arrangements than health-and need-related factors (Khamisa & Koehn, 2010). Many seniors prefer Yee Hong residential care mainly because of their need for a culturally familiar living environment. Such an environment includes Chinese food, familiar faces, local dialects, similar shared experiences from their home country, and more. Higher attachment to one’s Chinese ethnic identity is also a significant predictor in applying to a long-term care home (Lai, 2004).
This study found that the deliberation process between seniors and their caregivers is a long one that includes contemplating adjustment and potential struggles around various living arrangements when considering residential care. During the transition to senior care homes, seniors anticipate many challenges and difficulties. For example, seniors who have just moved into assisted living residences often need to adjust to their smaller living spaces and may experience anxiety about relationships with neighbours. Soon after arriving, one may feel a sense of loss including loss of ownership of residence, separation from partner and familiar faces, loss of privacy, lack of choice, and loss of some degree of autonomy.
Meanwhile, caregivers are also required to deal with the separation and change in addition to a mixture of emotions during this transition. Although they recognize that their aging parents may have increased attentive care in their new homes, they may feel guilty about their inability to provide them with the care to age at home. Therefore, a longer period of psychological preparation and emotional support for both seniors and their caregivers is necessary. However, there were individuals who did perceive this transition in a positive way (e.g. safer environment, less social isolation). Lastly, participants expressed their frustration with long waiting periods for nursing homes, which is not surprising as demands for LTC beds in Ontario have increased dramatically in recent years.
Aging at Home
Seniors require a certain level of comfort while adjusting to new environments because they may be required to change homes temporarily or permanently and have interfaced with different levels of support. These are often based on health conditions and available family support. This study found that family members provide significant help and care for seniors aging at home.
Chinese seniors in Canada tend to live with children even when their partners are still living; their sons or daughters-in-law are often involved in caregiving. However, the involvement of daughters is greater than the care provided by daughters-in-law (Khamisa & Koehn, 2010). In 2008, 98% of women aged 65 years and over reported having at least one family member with whom they felt at ease and from whom they could ask for help (Milan & Vézina, 2011). Another study conducted in 2007 also found that nearly 70% of care was provided by close family members. However, not only close family members provide care. Almost one-third of all caregivers were friends (14%), extended family (11%), and neighbours (5%) (Milan & Vézina, 2011). This is consistent with our observations that caregiving is best provided by those whom the seniors trust and are comfortable with.
INTERACTION WITH THE SERVICE SYSTEM
The expression of needs is often affected by whether the needs would be recognized or accepted by the service system. Certain needs, such as sex and protection from abuse, are not easy to talk about. Public education information (e.g. on elder abuse) can promote awareness while available service programs (e.g. those addressing sexuality or mental health issues) help to legitimize such needs, thus facilitating their articulation and expression.
Needs often emerge with new or improved service programs. Service providers who interact with clients on a daily basis are in a privileged position to observe such needs. A sound service system is one that can take full advantage of such information. As a matter of fact, consultation with staff and service providers in the current study has enriched our understanding of the needs of seniors, middle-age adults, caregivers, and families. Beyond medical and physical care, more services are needed for supporting seniors in meeting a spectrum of psychosocial needs, including their needs related to spirituality, dignity (freedom from abuse and maltreatment), sexuality, intimacy, emotional and mental health, social participation, and so on. More programs that offer opportunities to strengthen positive attitudes towards aging and death, build self-confidence, and define individual lives and their meanings will set this process on a positive track.
Unique Needs of Middle-Aged Adults
“You would be surprised that many of us [middle-aged adults] have so many professional skills and talents. We are looking for changes when we can contribute, and we can be valuable resources for serving seniors.”
The changing needs of seniors are often related to transitions during major life stages. Our findings show that the current group of middle-aged adults (those under the age of 65 years in 2012) generally have a greater capacity for self-fulfillment, higher levels of education, and higher expectations for the quality of care provided by social services. They also strive for more independence and prefer having more choices with regard to the services they use, and are generally more assertive about their needs. They expressed a need for building relationships with family, friends, and other social networks as well as being active participants in different interest groups, social circles, and religious organizations. Studies have found that social support networks in the form of family and friends can be a source of support and play an important role in satisfaction with life as a whole (Milan & Vézina, 2011). Middle-aged adults appeared to use their own capacity for satisfying deeper needs, building identity, and gaining self-fulfillment and satisfaction in their lives. Some of these include acknowledging the need to feel pleasure, taking leadership roles, learning new things, volunteering, and so on.
Middle-aged adults voiced concerns over the need to deal with employment-related stress and pressures of unemployment, financial support, and the need for additional support from PSWs and adult day programs when providing care for seniors at home. Additionally, they voiced a need for management strategies when dealing with chronic health issues. Furthermore, the results of this study show that the majority of middle-aged adult respondents anticipated changes when transitioning to becoming seniors themselves. Many believed it would be a time to plan for the future, thus requiring information about senior welfare and senior housing applications. Middle-aged adults also generally have higher levels of education and service expectations than older people, revealing their capacity and self-efficacy to seek strategies to manage their health to achieve healthier lives later on. Therefore, they may benefit from increased opportunities to use these strengths when offering support to seniors.
The husband said, “Those PSWs have long become my emotional support. When they came over, they talked to me and comforted my wife. They try to help me occasionally.”
Unique Needs of Caregivers
Practical and Emotional Needs of Caregivers
“I told myself: I cannot collapse; even if I don’t take care of myself, I need to take care of my aging parents and my family.”
This study found that self-care is important to the caregiver’s own physical and emotional well-being. Often, a senior can become a caregiver of another senior who has greater needs. Those senior caregivers often feel stressed and worried about their own physical condition, which may affect their capacity for caring for another senior. Caregivers can benefit from receiving emotional support through the care of social workers, other support staff, and social support networks. Other studies confirm our findings about caregivers’ needs for more emotional support. For example, caregivers felt providing care was obligatory. However, they still felt overwhelmed, anxious, and fearful of the future and thus had begun applying for long-term care homes to look after this responsibility (Khamisa & Koehn, 2010).
Role of Gender amongst Caregivers
Our findings show that gender plays a role in the needs of seniors. Contrary to traditional stereotypes, middle-aged male participants in this study were relatively expressive in terms of their personal emotions, relationships, and sexuality and intimacy. Male middle-aged adults who were recently retired found it helpful to express negative emotions with regard to their previous career struggles in Canada. Male caregivers expressed embarrassment around having to touch their mother’s body while bathing or changing their diapers. Some of them expressed the need for female PSWs to take over the more personal caring tasks.
Some female caregivers voiced concerns around the unfair gender division of labour. They were expected to be responsible for providing care to senior family members mainly because they were daughters or sisters.
Unique Needs of Mandarin-Speaking Seniors and Middle-Aged Adults
Mandarin-speaking seniors appeared to have different needs. The most frequently indicated needs voiced by most Mandarin-speaking seniors in this study were the needs to (1) overcome mobility barriers, (2) increase physical activity, (3) increase coping with long-term health issues, (4) adjust to new social environments, and (5) manage and deal effectively with mental health issues. Another important need reported by most Mandarin-speaking middle-aged adults in our study was self-esteem. Other needs include getting along well with family members, feeling a strong sense of self-acceptance and efficacy, and participating in social networks and making friends.
Another area of concern that has not been widely discussed publicly nor documented accurately in existing literature is the subject of elder abuse. Some seniors found it easier to talk about individual experiences when they learned that elder abuse not only includes physical abuse, but also psychological, emotional, verbal, and financial abuse. Although Chinese social norms largely inhibit any experiences of shame to be heard by others, in a relatively safe environment, seniors may be inclined to gradually reveal their experiences in their own indirect, subtle ways.
RECOMMENDATIONS FOR SERVICE PLANNING AND DELIVERY
Findings from this study show that instrumental care and psychosocial care are not separate and independent of one another, but integrated. When seniors are provided with instrumental care such as being driven somewhere by someone they know and trust, it can also be experienced as a form of emotional care and psychosocial support, which may lead them to feel less isolated and helpless.
Addressing Diversity and Settlement Issues
Immigrant seniors would find it beneficial to have effective ways to adapt to their new lives in Canada (e.g. connecting to the community, building social support networks, reconnecting to home cultures, and learning new social and occupational skills). Those who have been successful in settling in their new environments have experienced less stress and shorter adjustment periods. Chinese immigrant seniors need services to help them adjust to living in Canada. The needs for transportation and culturally and linguistically appropriate services have been salient since 1989. Further information about social services and resources to assist in overcoming everyday barriers would be beneficial. Increased programs and services should be reconfigured to factor in diverse aspects of Chinese culture and its community in order to engage with a greater proportion of Mandarin-speaking Chinese seniors due to their growing numbers in the GTA.
Recommendations for Addressing Life Transitions
Middle-aged adults are an age group with great capacity for self-efficacy. More activities that provide them with opportunities to participate and contribute to the community and society as a whole are required. Through this, they can achieve greater self-satisfaction and a stronger sense of identity. Besides the need for more activities, more information and educational opportunities are necessary to assist seniors in life planning. Volunteering can become a viable option that is mutually beneficial to the individual and organizations. Thus, leadership training and volunteer development are required. Promoting a positive aging attitude: “starting a new phase of life” (?????), which is the current position adopted by Yee Hong rather than “the end of life”, would be beneficial. For those middle-aged adults who have stronger consumer awareness and higher service expectations, there should be more choices consistent with Yee Hong’s aspiration to be a “provider of choice”. It also means that the next cohort of seniors will have higher service expectations and demands, and Yee Hong’s service programs will have to be enhanced and improved to meet them.
Effective strategies are required for coping with declines in health and for empowerment with regard to seniors’ own health conditions. Thus, empowerment and capacity building approaches should be considered in program and service design. Yee Hong’s health education programs and Chronic Disease Self-management Program can help meet these needs.
For seniors aging at home, increased practical and emotional support for caregivers, especially senior caregivers, is vital. More caregiver education promoting assertiveness and self-care is needed. Yee Hong’s expanded Caregiver Support Services are anticipated to meet this need.
For older seniors living in assisted care settings, a strategic battery of care and services are required. This includes building a culturally appropriate living environment and transforming the collective residential environment into more home-like environment. For seniors and caregivers who experience a sense of loss during the seniors’ transition to residential care homes, a longer period of psychological preparation before and more support after the transition are necessary for positive adjustment.
SUGGESTIONS FOR FURTHER INQUIRY
Relevance for Other Growing Asian Populations in the GTa
The largest visible minority group in Canada was that of South Asians, representing 25% of the visible minority population in 2006; Chinese were the second largest group. There was a 51% increase of the population who reported speaking Mandarin. However, the second fastest growing language group in Canada was the Philippines-based language Tagalog, which had an increase of 64% (Statistics Canada, 2013c). Due to the changing diversity of the Canadian cultural and social landscapes, the Yee Hong Centre has already moved beyond the Chinese community in service provision plans and this information may be useful in planning future program development and implementation.
Sexuality and Intimacy
Sexuality and intimacy needs of seniors are often regarded as a taboo in Chinese society. However, during the course of this study, it was realized that with open and non-judgmental spaces for dialogue, seniors were willing to indirectly or subtly express their need for physical comfort in efforts to rebuild intimacy in their marriages. In addition to securing a comfortable space with privacy, providing educational opportunities for both staff and community members around this area would help address and respond to concerns around the sexual and intimacy needs of seniors.
Since gender plays a significant role in caregiving responsibilities, the Yee Hong Centre may wish to plan appropriate services for female caregivers and the transition between home and LTC for their aging parents or family members.
This study attempts to highlight the needs of Chinese seniors and middle-aged adults as well as caregivers through narrative exploration and supportive findings in existing gerontological literature and supplementary survey data. Findings confirm the changing, fluid nature of the needs of seniors and middle-aged adults, contingent upon circumstances, transitions to different life stages, and interaction with the service system. They are the subjects of care and their needs are in constant dynamic interaction with current senior care services. It would be a disservice not to incorporate these unique and valuable experiences and interactions to guide the direction of future services. As the Yee Hong Centre for Geriatric Care continues to be a provider of choice and is committed to responding to those needs and aspirations of their service users, engaging with client needs amidst changing social and service landscapes shall remain a salient character.
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APPENDIX I: THEMATIC FRAMEWORK FOR UNDERSTANDING THE QUALITY OF LIFE OF MIDDLE-AGED ADULTS AND SENIORS
APPENDIX II: PERSONAL INTERVIEW GUIDE
Research Project on the Changing Needs of Chinese Seniors in the Greater Toronto Area
Semi-Structured Interview Guide
- Venue: Wherever is convenient for the participant, and allows sufficient privacy.
- Duration: As long as it takes for the participants to complete their stories, although we try not to exceed an hour and a half. If the participant is tired, we let him or her take a break at any time. Use your discretion; if it is better to go back a second time to continue the interview, please do so.
- Purpose and focus of exploration: The purpose of this interview is to assess the needs of Chinese seniors. The three foci of our exploration are: What needs? Whose needs? How can the needs be met? First, our approach is inherently integrative and holistic in embracing the wide range of factors when defining and assessing the needs of seniors in relation to their pursuit of well-being. Second, when identifying who and where the neediest are and what their deficiencies are, we will focus on how individual preferences are inextricably interwoven with learned social behaviours and cultural values. Finally, our study will ask what supportive action is required of the community service providers and what can be done by the people themselves, and so on. We will examine the overlapping needs shared by the vast majority of people; at the same time, our attention will also be paid to the individual differences that vary considerably according to age, sex, activities, geographic environment, personal value, socio-cultural scripts, and situation despite the similarity of needs shared by the vast majority of people.
To better ensure the usefulness of the findings, which will eventually lead to more seniors actually using the appropriate and accessible services that they need, we will gather information on the three types of variables suggested by some behavioural models. (1) Predisposing variables include demographic variables and individual beliefs, which result in a greater propensity to use services. (2) Enabling variables include resources such as income, insurance, transportation, handicap access, and informal support. (3) Need variables that are assessed in the study, which is a more subjective assessment of need. This information will enhance the usefulness of our study on postulating the level of service utilization.
The primary purpose of our study of Chinese seniors’ needs is to identify and describe needs; however, the identification of needs is not our sole purpose. During the interview process, we can also achieve other secondary goals. These include promoting awareness around the needs of the target groups, providing information on service availability to prospective clients, publicizing the agency’s services and activities, and so on. Most importantly, the data acquired from the Chinese seniors’ needs assessment will help organizations in making educated decisions on planning programs and allocating resources.
- Set Up
- Introduce yourself and the purpose of the interview; e.g. “I am a researcher working on a study about “The Changing Needs of Chinese Seniors in the GTA” conducted by Professor Ka Tat Tsang from the University of Toronto. The purpose of our research study is to explore their experiences in pursuing their wide range of needs for an adequate standard and quality of life…”
- Explain the key content in the consent form (e.g. confidentiality and anonymity, the participant’s right to withdraw and to delete data).
iii. Explain the need for audio recording and obtain approval from the participant. [Remember to bring your recorder and to check it for proper functioning, including sufficient battery life and memory space for recording.]
- Obtain written consent. If the participant can’t read or write, seek the participant’s approval to start recording, read out the consent form and provide explanation if necessary, then obtain the participant’s verbal consent; make sure that you record the whole process.
- Open Exploration
- Start the conversation with a brief prompt; e.g. you may repeat the purpose of the research and invite the participant to share his/her experience freely. The following are some examples of what you may want to say to the participant:
Thank you for taking the time to do this interview with us. The main purpose of this interview is to explore how social service providers can better “meet your needs”. We are most interested in your personal experiences. You can start with whatever you want to talk about first.
- Open-Ended Questions
Only consider using these open-ended questions if the participants insist on asking what they should start with. Once they feel more comfortable to talk, we should not guide the conversation with any specific questions/direction.
- What Needs
We want to hear your experience in pursuing your wide range of needs for a better quality of life.
Have you encountered any situations where reality does not meet your expectation?
Would you consider certain needs as more important to you and some as less important?
- Whose Needs
Why do you have this preference? Would it be related to any personal reasons? (If participants asked for more explicit directions: e.g. age, sex, activities, geographic environment,personal value, religious belief.)
Do you think what you have just mentioned about what you need is somehow affected by the fact that you are a Chinese Canadian living in the GTA?
- How can the Needs be met?
Do you feel certain things should be changed in order for your needs to be better met?
In your experience of using certain services and programs, can you think of anything that should be improved and how?
Do you have any crucial needs that are currently being met by using certain services and programs?
Do you have any needs that could be met by current services and programs, but you are unable or not willing to use them due to some other reasons? (If participants asked for more explicit directions: e.g. expensive fees, insurance issue, transportation problem, and lack of handicap access or other informal support.)
Do you have any needs that cannot be met by any existing services and/or current programs? Can you provide some constructive suggestions for new programs or services that would help to meet these needs?
If these new services and/or new programs are provided to you, do you think you will really be able to use them? Can you think of any possible barriers that may prevent you from using these new services/programs?
Can you think of anything that you can do, or maybe anything that you can change in pursuing the satisfaction of your needs?
- Last Two Questions
We have gained a great deal of useful information and insightful suggestions from you in regard to seniors’ needs today; do you think the satisfaction of these needs could allow you to attain a better quality of life? How would you describe “a better quality of life” for seniors in your own concrete terms?
If we asked you to provide your opinions to the service providers, the community, and the larger society about “how the needs of seniors can be better met”, what would you say to each of them? …What would you say to other seniors?
iii. The main purpose of this part of the interview is to allow the participants to express themselves as freely as possible. This can be achieved by keeping in mind that:
(1) The participant decides what is important to him/her, so let them talk about whatever they want to as much as possible. That means we DO NOT control the agenda rigidly, but try to allow maximum narrative space. You may also want to make sure that you do not interrupt the participant or cut her/him off.
(2) Each individual has his/her own idea of what is relevant to the research question. You should let them talk even though you may find what he/she says is irrelevant, unless the speech is obviously cyclical or incoherent (e.g. when we work with mentally-challenged populations). You may, however, repeat the research question at times to remind the interviewee.
(3) Respect the participant’s language by using their expressions and their phrases as closely as possible. This will avoid unnecessary (mis)interpretation and narrative conditioning on our part.
(4) Try and use more prompts and invitations rather than questions; e.g. invite them to elaborate on or explain something, or provide them with examples for a topic or an experience that they have mentioned. A question-and-answer format tends to put the participant in a passive mode, and severely compromises the opportunity for the participant to volunteer information which is not on your list of questions, therefore defeating the very purpose of ethnographic or discovery-oriented interviewing. If you need to ask questions, ask open-ended and not close-ended questions. Ask specific questions only when you have collected enough information on a topic and need to know the specific details.
(5) By summarizing what the participant has said, you can let him/her know that you’ve been listening, and this helps to build a good rapport. This is also helpful when you want to shift the conversation to another topic—make a summary first, then smoothly transition to the next topic. Try to be brief with summaries, for long summaries might turn people off.
(6) The purpose of this interview is to explore and discover, NOT to solve problems, provide therapy/counseling, or offer help. If you think the participant is not receiving the service he/she needs, you can make necessary referrals after the completion of the interview (it is a good idea to familiarize yourself with counseling services available to the participants in your area).
(7) Pay attention to “free information” (content not required by your question or request, but given to you freely) the participant offers as he/she responds to your prompts and questions. These are often things that the participant wants to talk more about.
- Please try to jot detailed notes during the interview. This will help you keep track of what has been said and to summarize. Please also note down your impressions and the participant’s non-verbal behaviours whenever possible. These notes can be especially valuable in the unlikely event of recording failure.
- When you think the open exploration part has been completed, try to summarize the main points of the conversation and ask the participant if he/she has anything more to add. If not, thank him/her for sharing. Then prepare them for the structured exploration part by saying something like, “In the remaining time, I am going to ask you some further questions.”
- Structured Inquiry
- The purpose of structured inquiry is to focus on specific areas or issues we are interested in, but have not yet been addressed by the participant in the Open Exploration section. These areas may include those that are potentially sensitive or embarrassing for the participant (e.g. elder abuse, sexuality, family conflicts, stigmatized conditions such as disability, cancer, mental illness, etc.). It is hoped that by this time, you would have established a good relationship with the participant and he/she might be more ready to talk about these topics.
- Before we ask the questions, note if any of them have already been answered during the Open Exploration. Ask only those that have not been addressed. Asking the question again can make the participant feel that we have not been paying attention and/or listening carefully.
iii. Topics for exploration:
Needs Related to Health Status
- Heart disease
- Alzheimer’s, Parkinson’s, and other dementia
- Pain management
- Post-stroke recovery
- Other physical conditions
- Elder abuse cases and prevention
- Other mental health conditions
- Medical care experience (e.g. clinic, hospital)
- Healthy eating habit
- Medication compliance
- Post-surgery/incident care
- Housing with support services, e.g. life lease, retirement
- Nursing homes
- On waiting list for nursing homes
Home Care Needs
- At-risk seniors aging at home
- Other service models assisting seniors aging at home
- Service gaps to support seniors in the community
- Needs for caregivers (family/spousal, unpaid care, hired, etc.)
- Practical skills
- Emotional support
- Other support
Needs Related to Economic Status
- On social assistance
- Economically dependent on family members
- Family members’ economic situation
Baby Boomers’ Special Needs
Needs Related to Social Life
- Overcoming different barriers in life
- Language barrier
- Immigration – old/new immigrants
- Immigrants dealing with different problems
- Newcomers blending into Canadian society
- Adjusting to cultural and other differences
- Connection with home countries
- Yee Hong Services
- Meeting service access challenges
Needs Related to Planning
- Retirement planning
- Issues and concerns about retirement
- Other legal arrangements
- Other pre-planning matters
- Activities and hobbies
- Couples’ relationship
- Generation gaps
- Intimacy and sexual needs
- Friends’ support
- End-of-life care of Chinese seniors (attitudes, beliefs, and preferences)
- Spirituality and life values
- Creating narratives of the past
- It is important for you to prepare yourselves for translating the questions into the appropriate languages/dialects.
- You may want to follow up participant’s responses with an invitation to providing additional information and/or comments.
- When you have finished, thank the participant again and prepare him/her for the last part—the Face Sheet information collection.
- Demographic data—filling in the Face Sheet
- The reason for not doing this at the beginning of the interview is that we do not want to set the participant into a passive, question-answer mode of response.
- We do not need to know the name of the participant, so we’ll leave it out to ensure confidentiality. We can invite the participant to create a pseudonym for him/herself, and a second choice in case the first one is already in use by someone else.
iii. Most questions are self-explanatory. For some of the questions, you may already have obtained some of the information during the interview. In that case, summarize the participant’s previous response; then focus on what you still need to find out. For example: “You have shared a lot of valuable experiences on how your professional role as a psychotherapist has impacted your personal life, but I’m also curious about how your personal life is affecting your professional practice as a psychotherapist.”
- We have only drafted these guidelines in English. If you are conducting interviews in other languages/dialects, please prepare yourself for translating the introduction, instructions and questions into the appropriate languages/dialects.
- Please send a copy of the Face Sheet to firstname.lastname@example.org for record and tracking purposes.
Guidelines for transcription
- It is the best if the interviewer can also do the transcription, in the language that the interview was conducted in.
- If you have any problem with transcribing, please email/call us and we’ll seek out an alternative with you.
- Remember to include the code no. and the participant’s chosen pseudonym on the transcription documents.
- Send in the whole package for each interview (including the audio files or tapes, the transcription documents, the Face Sheet, and your written notes) to the research coordinator as soon as possible.
- Please save electronic files in rich text format (.rtf ) and send them to us via email attachment. Do not use headers, footers, or page number on those files. Save files in password protected format; we will give you the password separately.
APPENDIX III: SURVEY
Research Project on the Changing Needs of Chinese Seniors in the Greater Toronto Area
Needs Assessment Survey
I would like to invite you to participate in our research project. Our aim is to examine the changing needs of Chinese seniors in the Greater Toronto Area. The study findings will provide applicable and constructive suggestions to the related social service providers to improve their overall services to better meet these needs. Your participation is completely voluntary. If there are any questions that make you uncomfortable, you have the right to refuse to answer them. To protect your privacy, this is an anonymous survey and you are not required to provide us with any self-identifying information.
We really appreciate your input!
Gender: Male ___ Female ___ Age: ___
Mother tongue: Mandarin ___ Cantonese ___
If applicable: Senior ___ Baby boomer: born between (1946-1964) ___ Caregiver ___
In the following questionnaire, please indicate whether a given situation is or is not a problem for you:
Thank you for sharing your valuable opinions and participating in this survey!