Immigrant and Refugee Elders
Immigrant and Refugee Elders
Abstract and Keywords
This chapter discusses social work practice with immigrant and refugee elders. The elderly immigrant population in the United States is becoming increasingly diverse based on racial and ethnic background, reasons for immigration, age at time of immigration, length of residence in the United States, and English proficiency. The well-being and process of adjustment of immigrant elders is affected by their immigration histories, cultural norms and values, and socioeconomic backgrounds. The chapter discusses the role of family and caregiving with immigrant elders, emphasizing both the importance of traditional family values and the impact on family issues of living in a different culture. It also considers mental health issues and psychological distress, service utilization and barriers to service use, and implications for social work practice with immigrant and refugee elders. It emphasizes the need for social workers to be culturally competent and to recognize both intragroup and intergroup differences within this population.
Immigration History and Patterns
As a nation of immigrants, the United States has admitted more than 68 million immigrants, including refugees and asylum seekers, between 1820 and 2002 (U.S. Department of Homeland Security, 2003). Whereas immigrants in the late 19th century and early 20th century were mostly from European countries, the past five decades have seen rising numbers of immigrants from the Americas and Asia (U.S. Department of Homeland Security, 2003). Beginning with the Displaced Persons Act of 1948, more than 600,000 people came from Eastern Europe and what were then “Iron Curtain” countries, and the Immigration and Naturalization Act of 1965 opened the door to several million Asians. Following the fall of South Vietnam in 1975, more than 1.1 million Vietnamese, Hmong, Laotians, and Cambodians came to the United States as refugees between 1975 and 2002 (Niedzwiecki & Duong, 2004).
Of 9.1 million new immigrants from more than 200 countries between 1991 and 2000, almost one half (49%) were from the Americas, 31% from Asia, 15% from Europe, and 4% from Africa. The percentage of older adults age 65 years or older fell from 5.6% of all immigrants in the 1980s to 3.2% in the 1990s (U.S. Census Bureau, 2001). In 2002, however, 7.6% were 60 years or older, and 14.4% were 50 years or older. The vast majority of the 60 and older age group arrived in the United States under the category of “immediate relatives of U.S. citizens.” Over 60% of immigrants live in six states: California, New York, Florida, Texas, New Jersey, and Illinois. In 2000, the median length of residence in the United States was 14.4 years.
The continued increase in the immigrant population, which has grown at a rate faster than that of the U.S. population, especially during the 1990s, has led to an increase in the proportion of the foreign born, from 6.2% (14.1 million) in 1980 to 10.4% (29 million) of the U.S. population in 2000 (U.S. Census Bureau, 2001). In 2000, Mexico, as the country of origin, accounted for over one fourth (7.8 million) of all foreign born in 2000, followed by China (1.4 million), the Philippines (1.2 million), India (1 million), Cuba (1 million), Vietnam (0.9 million), El Salvador (0.8 million), Korea (0.7 million), the Dominican Republic (0.7 million), Canada (0.7 million), and Germany (0.7 million). These numbers represent underestimates to the extent that foreign-born or illegal immigrants did not participate in the census.
(p.206) Growing Diversity and Its Implications
The continued influx of older adult immigrants and refugees from more than 200 countries, together with the aging younger immigrants of past decades, has meant that the elderly immigrant and refugee population in the United States has become increasingly diverse. This diversity includes not only racial and ethnic background but also reasons for immigration (e.g., family reunification, economic opportunities, fleeing from war, fear of persecution, or political turmoil in the country of origin), age at the time of immigration, length of residence in the United States, and English proficiency. Besides historical and demographic diversity, one finds expanding diversity in cultural norms and values governing the family, its role as caregiver for the elderly, living arrangements, family relations, interpersonal behavior, health beliefs, the role of religion and spirituality, and attitudes toward health and social services.
The immigration history, cultural norms and values, and socioeconomic background of immigrants have significant effects on their well-being and on the process of adjustment in the new environment. These factors may vary not only among immigrant elderly groups from different regions or countries but also within the same ethnic group. For example, ethnic Chinese elders from the People’s Republic of China, Hong Kong, Singapore, and Taiwan may have different values and ideologies, different educational and economic backgrounds, different levels of acculturation and English proficiency, and different service needs. Muslim war refugee elders who recently came from Kosovo and Bosnia may experience different levels and types of war-related trauma than Afghan elders who came in the 1970s, when they were in their 40s, fleeing the war with Russia. On the other hand, the importance of religious and spiritual coping and healing may be similar among predominantly Christian Korean, Buddhist Cambodian and Laotian, and Muslim Indonesian immigrant elderly people.
For many immigrant elders who escaped from persecution and poverty in their homeland, the United States is the land of relief and improved economic opportunities. For many of those who immigrated to join children who had already been living in the United States, arrival in America brings tremendous happiness. Some elders, however, may conclude that the losses involved in immigration to the United States outweigh perceived advantages of the move to the new country (Gelfand, 2003). Indeed, it is difficult to generalize the life experiences and issues of increasingly heterogeneous immigrant and refugee elderly populations, not only because they all have different backgrounds, but also because their experiences and expectations change in the process of adjustment and settlement in the United States.
Although immigration may have a varied impact on individuals, most elderly immigrants and refugees, especially during the early period of adjustment to their new environment, experience stresses associated with migratory grief, attachment to their home country, language, social isolation, unfamiliarity with health and social services, limited social support and mobility, increased dependency on children and their families, lowered status within the family and the society, and barriers to participating in mainstream social and political activities (Casado & Leung, 2001; Gelfand, 2003; Moon, Lubben, & Villa, 1998; Strumpf, Glicksman, Goldberg-Glen, Fox, & Logue, 2001; Wong, 2001). For example, a study of caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugee elders in Philadelphia (Strumpf et al., 2001) found that, with few exceptions, the major impact of immigration on refugee elders was loneliness and isolation. As a result of increased vulnerability and lowered status in the family, some immigrant and refugee elders have become subject to various types of mistreatment by family members (Moon, 2000; Tatara, 1999).
Family and Caregiving
From a general perspective, the family, in all cultures, is the main source of support, and many of the issues and challenges faced by the elderly and their families may be more similar than different among different cultures and ethnic groups. However, the specific problems and needs of older people, and the perceptions of issues and approaches to problem solving, can vary substantially depending on the cultural norms, available economic and social resources, and special circumstances in which the family and the elderly person are situated.
Immigrant/refugee families from developing countries have often been characterized by a strong family tradition of parental authority, rigid sex roles and male dominance, mutual support, strong parent-child bond, and filial piety. For example, a study of caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugees in Philadelphia found that in Asian populations, family harmony, (p.207) negation of personal needs, and self-control were emphasized. For Cambodian caregivers, the “rightness” of parental care was understood as proper repayment of debts owed to elders and a way to show gratitude. Obligation, love, and respect were common themes as well among the Soviet Jewish and Ukrainian care-givers; and for the Ukrainian cohort, commitment to the Baptist faith was highly emphasized, and the focus on spiritual life appeared to mute the losses associated with relocation (Strumpf et al., 2001). In some cultures, an elderly woman who lives with her child’s family, cares for her grandchildren, and helps with house chores typifies happy aging, as opposed to elder exploitation; whereas placing an elderly parent in an institutional facility, such as a nursing home, is considered an abandonment of filial responsibility.
Families have played a critical role in caring for and assisting with daily needs of their elderly members in most immigrant/refugee populations. As reflected in familismo, which can be defined as a “strong feeling of reciprocity and solidarity among family members,” immigrant Latino families mobilize a large network of relatives and friends in order to provide needed care and support for their elderly relatives (Gelfand, 2003). Family is an even more important source of care for the elderly in rural areas, where supportive services in general and culturally and linguistically tailored services in particular may be less available than in urban areas. In a study of Vietnamese immigrant elders in Texas, the family was almost the exclusive source of help with language issues, loneliness, and internal family problems (Die & Seelbach, 1988). A study of South Asian caregivers composed of Hindus, Muslims, Sikhs, and Christians concluded that belief in filial piety norms among care-givers plays a significant role in lowering perceived levels of caregiver burden (Gupta & Pillai, 2002).
In examining living arrangement patterns, Wilmoth, DeJong, and Himes (1997) found that even after controlling for the differences in demographic characteristics, economic resources, functional limitations, and acculturation, elderly immigrants were significantly more likely to live in a household with extended family and nonfamily than were nonimmigrants. Another study further demonstrated that elderly immigrants from developing countries, as compared with those from developed countries, were significantly more likely to live with their children and/or others (Kritz, Gurak, & Chen, 2000). This study also indicated that reduced socioeconomic resources, lack of integration (measured by English-language skills), shorter durations of U.S. residence, noncitizenship status, and demand for the elderly relative’s assistance with domestic work significantly influenced the likelihood of immigrant elders’ living with children and/or others. Thus practitioners must not automatically regard a multigenerational living arrangement as a sign of a strong family ties or practice of filial responsibility for care of the elderly client.
Similarly, living alone or with a spouse only may not necessarily mean isolation or a lack of family support. For example, in some locales, the majority of Asian immigrant elderly appear to live alone. This in part reflects suburbanization of younger Asian American families and the desire of the elderly parents to live near the center of their ethnic community, such as Chinatown, Koreatown, Little Saigon, and Little Tokyo (Cheung, 1989; Yoo & Sung, 1997). By living close to the ethnic community, they can socialize with people in their ethnic language and take advantage of various health, social, recreational, and other services offered by ethnic-specific agencies.
Thus the location of the residence, in terms of geographic proximity to their ethnic community, appears to be an important factor in influencing the ability to live independently and the quality of life among immigrant elders, although perceived good relationships and frequent contacts with their children still remain important for their life satisfaction (Moon, 1996). This also suggests that those who live alone in locations where there are few people like themselves or where access to health and social services for the elderly is severely limited due to language and cultural barriers are at higher risk for developing health and psychological problems associated with isolation and loneliness.
Although the centrality of the family and the norm of family care for the elderly prevail in many immigrant families, there has been a gradual shift in values and attitudes regarding traditional family structure, relations, and care arrangements for the elderly. Typically, younger immigrant women tend to experience these changes sooner and faster than their older relatives. This implies that to the extent to which American norms and values differ from those of the country of origin, elderly immigrants may face cultural conflicts and related problems with their children who have been assimilated or acculturated into the American culture.
For example, an elderly immigrant from a culture of extended, hierarchical family structure that emphasizes interdependence and collective well-being of the family may find it difficult to accept or adjust, initially at least, to the American norm of nuclear family (p.208) arrangement and the values of independent living and individualism, as well as the principle of democracy in defining the status and relationships among family members. Tension, conflict, and distress can result from the differences between the elderly immigrant/ refugee and the children in their expectations about where and how they should live, what and how much the children should do for the parents, and what the parents should do for the children in return.
Studies suggest that dissatisfaction and isolation of the elderly in immigrant families stem from the el-derly’s high expectations for family socialization and from constraints on kin interaction, limited mobility, inability to speak English, and heavy domestic responsibilities in their children’s household (Balgopal, 1999; Jones, Zhang, Jaceldo-Siegl, & Meleis, 2002; Treas & Mazumdar, 2002). Overall, fear of dependence on children or others and uncertainty about whether children will care for them as they grow older and whether they would be placed in a nursing home are perhaps the most common concerns across the immigrant elderly population (Balgopal, 1999; Kropf, Nackerud, & Gor-okhovski, 1999). Practitioners, however, must not underestimate the ability of immigrant elders to cope with and adapt to the new environment.
Issues and challenges faced by family caregivers of elderly immigrants may vary depending on the intensity of care needed, available economic and other resources, and quality of the relationship with the elder, as well as culturally expected roles of family care-givers. After moving to the United States, most elders, especially those from non-English-speaking countries, become dependent on their children and grandchildren for help with even the tasks of daily living, such as making doctor’s appointments and going places. After some adjustment period, however, some elders find other sources of help and become independent in performing a variety of tasks.
Although this situation undermines elders’ authority and their traditional status in the family and may cause distress and worry for the elderly, their family caregivers are also challenged to adjust not only their thinking back and forth between the traditional and Western values in the process of caregiving but also their ability to perform caregiver roles, as they have other competing demands for their time and resources (Chenoweth & Burdick, 2001; Jones et al., 2002). Prolonged dependence of the elderly can lead to the caregiver’s feeling of overburden and frustration, causing intergenerational conflicts in families. This is especially true for women in immigrant/refugee families who are already overburdened by dual or triple roles they perform in and outside the family: the traditional role as homemaker and a new role as participant in the labor force.
Performing filial responsibilities is especially challenging to those children who have their own adjustment problems and other family issues, such as unemployment, conflicts with their children, crowded housing, and pressure to succeed in the new homeland. Caring for immigrant/refugee elders may require a greater intensity of care than in the previous homeland, but family caregivers may be less able to provide adequate care due to decreased economic resources, limited knowledge of services, few appropriate coping resources, and little experience in resolving cultural conflicts with their elderly parents (Kropf et al., 1999). Studies have also shown that caregivers’ ambivalence about the use of formal services, misperceptions about the legal and other eligibility requirements of government programs, and strong view of formal services as the last resort, as well as the elder’s belief that children would provide full support and care, present additional barriers to use of social services among some immigrant/refugee elderly and their families (Chicago Department on Aging and Disability, 1988; Chenoweth & Burdick, 2001; Jones et al., 2002; Kropf et al., 1999; Strumpf et al., 2001).
Increased burden on family caregivers and limited coping resources, combined with lower social pressure to practice filial piety and declining status of the elderly, could result in neglect and abuse of elders in immigrant/refugee families. In fact, there is a growing concern that elder abuse and neglect in immigrant/refugee populations may be equal to or even more serious than in U.S.-born populations and that incidents in immigrant/refugee populations may be more likely to be kept hidden or secret within the family (Tatara, 1999). In two similar studies, 34% of Korean and 33% of Mexican immigrant elders reported awareness of at least one incident of elder abuse in their respective community (Chang & Moon, 1997; Sanchez, 1999).
Mental Health Problems and Psychological Distress
Stressful life events have a significant impact on physical morbidity and mental health problems, and depression, both major and minor, has been reported to be the most prevalent affective disorder found in the elderly population in the United States (Blazer & Koening, 1996; Hendrie et al., 1995). Given the inherently (p.209) stressful nature of the immigration experience and the concomitant stressors associated with living as an immigrant/refugee, these problems have been more pronounced in elderly immigrant/refugee populations (Black, Markides, & Miller, 1998; Brener, 1991; Casado & Leung, 2001; Ghaffarian, 1998; Min, Moon, & Lubben, 2005; Mui, 1996, 2001; Ngo, Tran, Gibbons, & Oliver, 2001). For example, one study found a high prevalence of depression among elderly Chinese immigrants and identified migratory grief as the most significant contributing factor (Casado & Leung, 2001). A similar significant relationship between psychological distress and migratory grief was found among Mexican, Haitian, and Hispanic immigrants (Brener, 1991; Prudent, 1988; Lakatos, 1992).
In another study (Black et al., 1998), 26% of the immigrant Mexican elderly showed high levels of depression. As found in other ethnic minority groups, gender (female), lack of health coverage, financial difficulty, and presence of chronic health conditions and disabilities were major predictors of depressive symptoms. Brener (1991) found low acculturation levels associated with high depression and high perceived losses among most of the Mexican immigrants. In a study of Iranian immigrants, a significant relationship was found between age and acculturation: The older Iranians had lower levels of cultural shift and cultural incorporation and higher levels of cultural resistance than the younger Iranians (Ghaffarian, 1998). These findings suggest that older immigrants may experience more difficulties in learning and adjusting to the new environment than younger immigrants, as reflected in low acculturation levels, thereby experiencing more mental and psychological difficulties than younger immigrants. Among older Soviet immigrants, unsatisfactory living arrangements, such as the stress of multiple generational households, could lead to the feeling of depression (Kropf et al., 1999), whereas lack of contact with children was a significant factor contributing to low morale and high depression among older Korean immigrants living alone or with spouse only (Lee, Crittenden, & Yu, 1996; Moon, 1996).
Depression is also one of the most significant risk factors associated with suicide in late life (Carney, Rich, Burke, & Fowler, 1994; U.S. Surgeon General, 1999). In addition, immigration, particularly during old age, and being female seem to be associated with high risk of suicide (Barron, 2000; Yu, 1986). For example, Yu (1986) found that the suicide rate for elderly Chinese immigrants was almost three times higher than the rate for U.S.-born Chinese elderly in 1980. The high prevalence of depression and suicide among elderly Asian immigrant women may be attributed to a variety of adjustment difficulties and stressful life events, poverty, and low socioeconomic status (Bagley, 1993; Gelfand & Yee, 1991).
Refugees from war-torn countries are a high-risk population for mental health problems because of their extensive exposure to numerous premigration traumatic events and stressors, such as torture, extensive detention, starvation, battlefield experiences, massacre, separation and loss of significant others, and hardships during the flight and/or in the refugee camps (Abueg & Chun, 1996; Morioka-Douglas, Sacks, & Yeo, 2004; Ngo et al., 2001; Olness, 1998). The effect of traumatic life experiences among refugees is often a lifelong process that is likely to continue from the country of origin to the country of exile (Olness, 1998).
Studies also show that immigrants and refugees are more susceptible to a broad range of symptoms associated with culture-bound folk illnesses (Molina, Zambrana, & Aguirre-Molina, 1994; Pang, 1990). For example, Hwa-Byung (HB), literally anger syndrome, is a widely perceived folk illness among elderly immigrant Korean women who endured feelings of victimization within their oppressive patriarchal family structure and experienced suppressed anger for an extensive period of time in life. Many of those experiencing HB report a variety of somatic, as well as psychological, symptoms, such as headache, sensations of heat, oppressed sensations in the chest, presence of epigastric mass, diminished concentration, and anxiety (Lin et al., 1992; Park, Kim, Schwartz-Barcott, & Kim, 2002).
In fact, physical complaints or somatizations of psychological or emotional problems are relatively common among many immigrant and refugee elderly groups. According to Hong, Lee, and Lorenzo (1995), typical somatic symptoms commonly reported by immigrant Chinese clients, especially elderly Chinese, include difficulty falling asleep, loss of appetite, headaches, feeling weak, shortness of breath, and pain all over their bodies. Pang (2000) also found a significant relationship between somatization and symptom expression among elderly Korean immigrants: Those who met the criteria for depression on the Brief Symptom Inventory (BSI) had the highest mean score on the BSI somatization dimension.
As a result of their tendency to experience the body and mind as a unitary system and to communicate psychosocial distress arising from old age, immigration, cultural adjustment difficulties, and other stressful life events through somatic symptoms and complaints, these elderly are more likely to seek medical (p.210) care for physical symptomatology than to seek mental health services (Brodsky, 1988; Trevino & Rendon, 1994). Among the Afghan immigrant elders, for example, the most frequently reported “health” complaint was mental health problems, particularly depression and physical symptoms related to stress from refugee trauma and loss, occupational and economic problems, cultural conflict, and social isolation (Lip-son, Omidian, & Paul, 1995; Morioka-Douglas et al., 2004). Similarly, in the Russian culture, mental health and psychosocial problems are defined in somatic terms (Kropf et al., 1999), and it is a cultural norm among elderly immigrants from the former Soviet Union to use medical rather than psychiatric or social services for loneliness and depression (Aroian, Khatutsky, Tran, & Balsam, 2001).
In many of the cultures from which immigrant and refugee elders come, mental illness is a stigmatized condition, and cultural explanations of mental health problems often do not coincide with Western interpretations (Die & Seelbach, 1988; Gelfand, 2003). The non-Western traditional causes of mental or even physical illness may be strongly rooted in traditional spiritual and religious beliefs, such as punishment for sins committed in one’s previous life among some Buddhist elders from Asian countries or failure to adhere to the principles of Islam and the will of God and possession by evil spirits among Muslim elders. Many elders from Asian cultures tend to view mental health problems as one’s emotional weakness and failure to control one’s own emotions and thereby internalize the problems.
It is generally found that acculturation—often measured by the length of residency in the United States and ability to speak English—economic well-being, and social support can reduce the negative impact of premigration traumatic experiences and postmigration adjustment difficulties on the psychological well-being among immigrant and refugee elders. For example, in a recent study of 261 adult Vietnamese Americans, premigration traumatic experiences had a stronger effect on depression among those with lower levels of acculturation than among those who were highly acculturated (Ngo et al., 2001). Research generally shows that family and social support or coping resources as potential mediators for stressful life events can help prevent the development of psychological pathologies, such as depression, anxiety, and posttraumatic stress disorder (PTSD), not only among the U.S.-born elderly population but also among the immigrant and refugee elderly (Husaini et al., 1990; Mui, 1996, 2001; Ngo et al., 2001).
Health and Social Service Utilization
Research shows that immigrant and refugee elders, especially among those recently arrived from non-English-speaking and less developed countries, tend to underutilize community-based health and social services, whereas a higher proportion of them receive government income support and have access to health care services through Medicare and/or Medic-aid. For example, a study of foreign-born Hispanic elderly (707 Cubans, 369 Mexicans, and 295 Hispanics from other countries) found that Hispanic immigrants had a generally low use of both community-based health and social services (Tran, Dhooper, & McInnis-Dittrich, 1997). Age, activity of daily living (ADL) limitations, and living alone were common factors associated with use of health services in these groups, whereas living alone and being in poverty were common factors for social service use. The study also revealed that psychological factor variables had no significant relationship with the utilization of either health or social services among these Hispanic immigrant groups.
Choi (2001) also found that far fewer Asian Americans and Hispanics took advantage of elderly nutrition programs, especially home-delivered meal programs, than did African Americans and attributed the lower participation rates to different food habits and preferences, as well as the lack of English-language proficiency among many recent immigrant elders. Lai (2001) reported that although most of the elderly Chinese immigrants visited senior centers, they substantially underutilized support services; predictors of supportive services use were living arrangements (living alone), satisfaction with services, and fewer mental health symptoms. Korean immigrant elderly were found to have very low levels of awareness and utilization of most of the 15 community-based long-term-care health and social services used in the study (Moon et al., 1998). It was evident, however, that they did use the services that were known to them.
Many immigrant and refugee elderly seek both Western medical services and indigenous health care services, predominantly herbal and acupuncture treatment, in their ethnic communities. Chung and Lin (1994), in their study of almost 3,000 Southeast Asian refugee adults (ages 18–68) in California, found that traditional health care methods still continued to be important, whereas all five groups showed a significant increase in the usage of Western medicine after they migrated to the United States: The percentages (p.211) of each group seeking Western medicine in the United States were 88% for Cambodians, 86% for Laotians, 76% for Vietnamese, 69% for Chinese Vietnamese, and 56% for Hmong. The study also reported that younger and more educated respondents and those with a high level of English proficiency were more likely to utilize Western medicine. In fact, studies have generally found that culture and levels of acculturation are related to health and mental health service utilization among immigrants and refugees, specifically suggesting a direct effect of acculturation on increased levels of service utilization (Calderon-Rosado, Morrill, Chang, & Tennstedt, 2002; Chesney, Chavira, Hall, & Gary, 1982).
Many immigrants and refugees, especially those from non-Western and less developed countries, do not seek help for their mental health problems. Recent immigrant Asians and Hispanics, regardless of age differences, are particularly more reluctant to utilize mental health services than Anglo Americans are (Trevino & Rendon, 1994; Wells, Golding, Hough, Burnam, & Karno, 1989). An analysis of national survey data indicates that the proportion of Asian Americans and Pacific Islanders utilizing mental health services at all types of public and private facilities was a third of the proportion for European Americans (Matsuoka, Breaus, & Ryujin, 1997). They may not seek help with mental health problems for several reasons in addition to the barriers to access mentioned earlier. Some of the major reasons include unfamil-iarity with formal mental health services or the concept of professional psychosocial counseling, as these things often did not exist in their home countries; skepticism about the treatability of mental illness; institutional barriers such as lack of understanding regarding the nature of their problems among bio-medically trained psychiatrists or other mental health professionals, especially when the service providers are not from the same culture or class (Trevino & Rendon, 1994); and fear of shame and stigma attached to mental illness.
Furthermore, in many of the cultures from which immigrants and refugee elderly come, religious and spiritual beliefs seem to influence their views of illness, methods of coping, and utilization of formal services (Die & Seelbach, 1988; Gelfand, 2003; Paulino, 1998). Those from Asian cultures prefer not to talk to anyone, including family members, about their emotional or mental health problems. Among them, it is still more common practice to seek advice and help from religious and spiritual leaders for their family problems and emotional support. This situation suggests that effective strategies to increase service use among immigrant and refugee elderly groups whose religion and spirituality have strong influences on them should include working with their religious and spiritual leaders as brokers to link the elderly to potentially beneficial services.
Service utilization among immigrant and refugee elders, regardless of the type of services and agency offering them, requires that services are available, accessible, and acceptable to them (Cox & Ephross, 1998). Although this general principle is also applicable to the U.S.-born elderly population, immigrant and refugee elderly groups face numerous challenges and barriers to service use, including lack of information about available services; language, transportation and financial barriers; negative attitudes toward formal services; culturally and religiously unacceptable perceptions of services; and culture-specific definitions of illness and healing that contrast with Western concepts and biomedical perspectives (Fetzpatrick & Freed, 2000; Marshall, Koenig, Grifhorst, & Ewijk, 1998; Moon et al., 1998; Tsai & Lopez, 1997; Weech-Maldonado et al., 2003).
The most fundamental barrier is the lack of knowledge about available services. Available but unknown services are meaningless and practically nonexistent to the intended population. In this regard, some research findings raise a serious concern. In a study on caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugees, most elders and their caregivers across all groups reported that services for the elderly did not exist or were unknown to them (Strumpf et al., 2001). Across all groups, caregivers identified home health care, transportation, and social opportunities as the most urgent needs for their elders. Tsai and Lopez (1997) found the lack of knowledge of services, English skills, and transportation to be important barriers to Chinese immigrant elders’ utilization of formal services. These and other similar findings on the lack of knowledge and understanding of health and social services reported by other immigrant and refugee groups suggest an urgent need for effective dissemination of information about available services to them (Fetzpatrick & Freed, 2000; Moon et al., 1998; Strumpf et al., 2001).
Even when immigrant and refugee elders are eligible for health care services through Medicare and/or Medicaid and are provided with access to other services, those with limited English skills still face barriers. Some services may not be culturally responsive or acceptable. For example, some ethnic immigrant elders (p.212) who have strong preferences for their ethnic foods may not use day activity centers and residential facilities that serve typical American-style meals. Although ethnic-specific service facilities may more easily accommodate those who prefer ethnic food, multiethnic agencies or those in areas where ethnic food is not readily available face a challenge.
Similarly, health and social service providers’ lack of knowledge about cultural norms of interpersonal behavior and patterns of relationship formation that are different from the American norms can result in dissatisfaction with the services and consequent un-derutilization of services by the immigrant and refugee elderly (Cox & Ephross, 1988). Cultural differences can create misunderstanding and tension between service providers and their elderly clients. For example, a handshake as a polite greeting gesture may be considered rude by most Asian cultures, especially if the service provider is much younger than the elderly individual and the two are meeting for the first time. Also, it is often a culturally desirable pattern to start a meeting with remarks about topics unrelated to the purpose of the meeting, such as weather, upcoming holidays, and even asking about personal and family well-being rather than “getting down to business” as quickly as possible. The latter can be viewed by some elderly clients as being uncaring and cold, creating a barrier to establishing rapport and trust with the client. In many cultures, respect, authority, and wisdom are closely tied to one’s age: calling an elderly client by his or her first name is disrespectful, and an elder receiving services from a young professional may doubt the professional’s expertise. Elderly men from the Muslim culture are particularly reluctant to be treated by female health and social service providers. Also, asking questions related to sexual behavior is a taboo in most cultures. Therefore, practitioners must be aware and sensitive to potentially different cultural norms and beliefs of their clients, although they must be cautioned not to overgeneralize or stereotype, as clients may be at different levels of acculturation or may be bicultural in both American and their own ethnic culture.
Implications for Social Work Practice
Consideration of the characteristics, major issues, and service needs of immigrant and refugee elders and their families suggests the following social work practice implications within an evidence-based generalist perspective:
1. Understand that there are intergroup and intragroup differences among immigrant and refugee elderly in their religious and spiritual beliefs and practice, in their attitudes toward health and social services, in the appropriateness of involving family caregivers in service planning, in cultural norms for effective interpersonal behavior and relationship formation processes, and in other cultural preferences, such as food and type of program activities, as they influence help-seeking decisions in general and utilization of formal services in particular.
2. Become familiar with and sensitive to the cultural norms of living arrangements and family caregiving practices while acknowledging the potential variability in the actual roles the elderly client's family is willing and able to perform in meeting the needs of the client.
3. Carefully consider whether and how involving family members in discussions regarding service needs and planning would help or hinder service delivery; family endorsement is essential for some elders, yet for others it is inappropriate to involve adult children and caregivers in an open discussion.
4. Become knowledgeable about legal and other eligibility requirements of financial, medical, and other benefit programs that are applicable to different immigrants and refugees. Even when the elderly client and the family seem to be aware of their entitlements, social workers should identify and address their reluctance to use services or their confusion with procedures, which can limit the client's utilization of the supposedly helpful benefits/services.
5. Address the need for concrete services, such as transportation, and for resources for learning English, for performing basic tasks of daily living, and for accessing the community health and social service systems. Provide opportunities for socialization, job skill development, and employment. All of these services and opportunities can contribute to lower dependence on the family and less isolation and loneliness while increasing self-esteem and life satisfaction of the elderly client.
6. Develop intergenerational programs to address cultural conflict between the elderly and their caregivers, to increase mutual understanding across generations, to reduce generation gaps and isolation, and to thereby restore respect and commitment to care for the elderly.
7. Considering the importance of interdependence rather than self-reliance among immediate and extended family members in ethnic minority cultures, mental health service programs targeting the immigrant/refugee elderly should employ treatment strategies designed to facilitate support from family members (Blair, 2000).
8. For optimal treatment effects, identify and respect the indigenous beliefs about the cause and healing practices of physical and mental health problems as an essential part of a holistic treatment plan while addressing the gap between traditional and Western methods of treatment. Mental health practitioners should consider and validate indigenous approaches, including comfort by spiritual leaders and the use of folk medicines, in addition to mainstream treatment methods such as cognitive-behavioral therapy and family intervention.
9. For an effective approach to relationship formation with an elderly client, practitioners must be aware that many immigrant and refugee elders, especially Asians and Latinos, respond better to a congenial, personal manner rather than to an impersonal, businesslike one (Lum, 2000; Molina et al., 1994). Because most immigrant and refugee elders are not familiar or comfortable with the existing service system, it is especially important for the practitioner to show a personal interest and empathy with the client's problems and to be warm, friendly, and reassuring.
10. Practitioners serving relatively recently arrived refugee groups must consider their premigration trauma as the immediate focus of assessment and treatment. The worker should be aware that those refugee clients who experienced the loss of immediate family might have a higher risk for developing both PTSD and major depression than those who were able to live with immediate family in refugee camps.
11. Practitioners must assess whether somatic complaints are indicators of some type of mental health problem or a real physical ailment in order to address the client's problems and service needs accurately and effectively. It is important to consider the cultural perspective that physical complaints, rather than psychological symptom manifestations, are regarded as more acceptable and are given more positive attention. A systematic collaboration among primary care physicians, mental health professionals, culturally accessible indigenous ethnic practitioners, and spiritual/religious organizations can further promote wellness among immigrant/refugee elders.
12. Ensure that services are available, accessible, and acceptable to the intended immigrant and refugee elderly population. Consider three major types of potential barriers to service utilization: (1) institutional or structural barriers, such as unavailability of services, eligibility restrictions related to noncitizen and illegal immigrant status, cost of service, and racism; (2) instrumental or functional barriers, such as the lack of transportation and service information, and (3) cultural and linguistic barriers, such as health beliefs, lack of English skills, and insensitivity to cultural norms of interactive behavior.
13. Actively reach out to the intended ethnic immigrant elderly population and provide information about available services in culturally and linguistically sensitive ways. It is especially important to have outreach workers who speak their language and who are, preferably, from the same ethnic background. Obtain the support and participation of community and religious leaders in the outreach effort. Use ethnic media and organizations, which are often the most effective means of information dissemination in many ethnic communities. Finally, translate the informational materials into the ethnic language and design the materials using a culturally attractive and familiar format.
Social work practice with immigrant/refugee elderly populations requires cultural competence and the ability to understand the target population’s special issues and needs in service delivery, as well as an understanding of their cultural and immigration/refugee background. Special service delivery arrangements to overcome the language and cultural barriers, acknowledgement of the traditional methods of coping and healing, and demonstration of culturally appropriate interpersonal skills, in both verbal communication and behavioral aspects of interaction, can significantly increase effectiveness in meeting the service needs and thereby improving the well-being of the immigrant elderly. For example, the practitioner’s effort to show respect for the client’s culture and special needs, such as expressing an interest in and appreciation of the client’s cultural background during the initial stage of relation formation, and speaking clearly and slowly and sometimes (p.214) times repeatedly, with patience, to clients with limited English can make a difference in gaining the client’s acceptance and trust of the practitioner.
In this regard, although matching a practitioner and an immigrant elderly client by ethnicity often has the advantages of meeting the language need and gaining early acceptance of the client, the practitioner’s ethnicity alone is no guarantee of the desirable cultural competence or responsiveness. Considering the growing heterogeneity not only among different immigrant/ refugee elderly populations but also within the same ethnic group, practitioners must be cautioned against overgeneralizing and stereotyping groups and individuals solely based on their immigrant/refugee and ethnic background. A study of social workers’ interactions with Iu-Mien refugees from Laos found that those who did not exhibit cultural competency made assumptions about the clients with regard to stereotypes, lack of appropriate care for elders, and lack of English-language acquisition (Schuldberg, 2001).
Multiplicity and complexity of ethnicity and culture demand a multidimensional approach to social work practice with the immigrant and refugee populations, whose culture and immigration-related factors are only some of the numerous factors to be considered in practice. Nevertheless, cultural competency enables practitioners to better understand “where the client is” and how best to meet the client’s needs. In this regard, Cox and Ephross (1998) state:
Finally, it is imperative to recognize that all cultural patterns are based on a universal human need: to solve problems of human existence and find meaning in the face of physical, social, and technological ecologies. The framework for social work involvement must respect and legitimize the diverse ways in which ethnicity can influence the efforts to solve these problems. By working through a clear ethnic lens that recognizes the factors that can impede growth and functioning, while also recognizing cultural strengths and preferences, social services can enable ethnic persons and groups to obtain the benefits ascribed to others in society. (p. 118)
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