Caregiving for older adult immigrants in the U.S.

Transcript

• 00:05Hello and thank you for joining me for
• 00:08today's presentation on caregiving for older
• 00:10adult immigrants in the United States.
• 00:12My name is T and I am a third year PhD
• 00:15student at the Yale School of Public Health.
• 00:18And for today's presentation,
• 00:20I will briefly go over characteristics
• 00:22and demographics of older adult
• 00:25immigrants in the United States.
• 00:27And then I'll talk about some of
• 00:29the barriers and facilitators to
• 00:31well-being among this population
• 00:32as well as their caregivers.
• 00:35And I'll end with some
• 00:37caregiving considerations,
• 00:38as well as other considerations and
• 00:40recommendations for working with
• 00:42older adult immigrant populations
• 00:44and their caregivers.
• 00:48Approximately 89,000 older adults
• 00:50ages 65 and older immigrate to the US
• 00:54every year from the year 2000 to 2019.
• 00:57In 2019, about 6% of immigrants
• 01:00were ages 65 and older,
• 01:03compared to only 2% in the year 2000.
• 01:07And currently, there are about
• 01:097.5 million older adults from
• 01:11immigrant populations who are
• 01:13residing in the United States.
• 01:17The majority of immigrants to the
• 01:19US come from Mexico, China, India,
• 01:22the Philippines, and El Salvador.
• 01:25In 2019, about 30,000 refugees
• 01:27were resettled in the US,
• 01:30with the largest origin countries being
• 01:32the Democratic Republic of the Congo,
• 01:34Burma, Myanmar, Ukraine, and Eritrea.
• 01:38Oftentimes, the terms immigrant,
• 01:41migrant, refugee,
• 01:42or asylum seeker may be used interchangeably.
• 01:46However, a migrant is someone who can
• 01:48return to their home country if they wish,
• 01:51whereas refugees and asylum seekers
• 01:53have been forced to leave their home
• 01:56country and cannot return for safety
• 01:58reasons such as if they are fleeing war,
• 02:01violence, or persecution.
• 02:05Nearly half of the immigrant
• 02:07population reside in just three states,
• 02:09which are California, Texas, and Florida.
• 02:13Other major cities with large immigrant
• 02:16populations include New York, Chicago,
• 02:18Seattle, WA, DC, and Atlanta.
• 02:23There are several factors that
• 02:25impact well-being among older
• 02:26adult immigrant populations.
• 02:28The 1st is economic strain,
• 02:30so 16% of older adult immigrants
• 02:32live below the poverty line and
• 02:3540% are from low income families,
• 02:36while many older adult immigrants
• 02:38reside with a family member
• 02:40when they come to the US.
• 02:42Migrating at a later age means that
• 02:44there are less opportunities for
• 02:46building up economic resources such
• 02:48as a savings or a retirement fund.
• 02:52Second, language barriers stemming
• 02:55from limited English proficiency
• 02:57has been associated with
• 02:59decreased healthcare service use,
• 03:01lower quality of care,
• 03:03and increased social isolation
• 03:05among Latin X Chinese, Korean,
• 03:07Filipino, and other older
• 03:09adult immigrant populations.
• 03:14Mental health is also another important
• 03:16consideration in the research literature.
• 03:19The healthy immigrant effects suggest that
• 03:21immigrants generally have better physical
• 03:23health than their US born counterparts,
• 03:26potentially due to immigration selection,
• 03:28such that mainly healthy people tend
• 03:31to make the immigration journey,
• 03:33and this has mostly been studied among
• 03:35immigrants from South America and
• 03:37Asia and among younger populations.
• 03:39So there is less evidence for this
• 03:41effect among older adult populations,
• 03:44perhaps due to different
• 03:46motivating factors for migration.
• 03:49So while healthy younger adults
• 03:51migrate mainly for job opportunities,
• 03:54older adults migrate to reunite
• 03:55with their loved ones who have
• 03:58settled in the United States.
• 03:59However, in terms of mental health,
• 04:01there is strong evidence that foreign
• 04:04born older adults have worse mental
• 04:06health than their US born counterparts.
• 04:09For example,
• 04:09one study by Troy ET al.
• 04:11From 2016 where they examined
• 04:14Medical Expenditure Panel Survey
• 04:16data for over 29,000 older adults.
• 04:19They found that immigrants who had been
• 04:22living in the US for less than 15 years
• 04:24reported greater depressive symptoms
• 04:26and higher psychological distress
• 04:28compared to those who had been living
• 04:31in the US for more than 15 years,
• 04:33as well as to those who were born in the US.
• 04:37Additionally,
• 04:37older adult immigrants who are refugees
• 04:40or asylum seekers have been forcibly
• 04:42displaced from their home countries
• 04:44and may have experienced prolonged war,
• 04:47sexual and physical violence
• 04:48and political conflicts.
• 04:50Pre migration.
• 04:51These traumatic experiences can contribute
• 04:53to post traumatic stress disorders,
• 04:56depression,
• 04:57anxiety and other forms of
• 04:59psychological distress that can
• 05:00continue even after settlement.
• 05:07As for interpersonal factors,
• 05:10social isolation,
• 05:11broken social networks,
• 05:12and loss of a partner or spouse
• 05:15are all aspects to consider.
• 05:17Social isolation and loneliness
• 05:19are concerns for all older adults,
• 05:21but in particular for older adult
• 05:24immigrants who are essentially
• 05:26starting over in terms of forming
• 05:28social networks and social ties
• 05:30outside of their immediate family
• 05:32when they resettle in the US.
• 05:36As mentioned previously,
• 05:37a lot of older adult immigrants live
• 05:40with their children or another family
• 05:42member when they settle in the US,
• 05:44so in some instances,
• 05:46new family routines,
• 05:47lifestyles,
• 05:47and intergenerational relationships
• 05:49may have to be established.
• 05:55Language barriers, cultural differences,
• 05:57and discrimination may make it more
• 06:00difficult for older adult immigrants to
• 06:03establish social ties both within and
• 06:05outside their immediate family structure.
• 06:08Additionally, barriers
• 06:09in the built environment,
• 06:10such as accessibility, availability,
• 06:13and affordability of public transportation
• 06:16networks may influence opportunities for
• 06:19social engagement at the structural level.
• 06:22Discrimination based on race, ethnicity,
• 06:24national origin and our immigration
• 06:26status may prevent older adult
• 06:28immigrants from seeking health services,
• 06:30social opportunities and
• 06:33employment opportunities.
• 06:35And lastly, lack of citizenship and
• 06:37temporary status can impact what
• 06:39health services are available and
• 06:41affordable for older adult immigrants.
• 06:44So briefly, U.S.
• 06:45citizens are eligible for Medicare
• 06:47benefits without any work credits or
• 06:49length of residency requirements.
• 06:51But non-us citizens,
• 06:52such as lawfully permanent residents and
• 06:55those with Temporary Protected Status
• 06:57are eligible for Medicare benefits
• 06:59either with a sufficient work history,
• 07:02which is equal to about 10 years
• 07:04of full time work or five years of
• 07:07continuous residence in the US And
• 07:09individuals who are undocumented are
• 07:12not eligible for Medicare benefits
• 07:14under any circumstances.
• 07:16These determinations are made on
• 07:18a case by case basis,
• 07:19so enrolling in Medicare programs
• 07:21may be a challenging and confusing
• 07:24process for older adult immigrants
• 07:26and their caregivers.
• 07:27Additionally,
• 07:28anti immigrant rhetoric over
• 07:29the past few years,
• 07:31for example through policies that cut back
• 07:34on humanitarian programs for refugees,
• 07:36have made it more difficult and
• 07:38dangerous for individuals to
• 07:40seek employment or move through
• 07:42the legal immigration process.
• 07:43So there are approximately 1.3
• 07:45million older adults ages 55 and older
• 07:48who are undocumented in the US and
• 07:51these individuals are excluded from
• 07:53Medicare and Social Security benefits,
• 07:56despite being taxpayers and older.
• 07:59Adult immigrants in these situations do
• 08:01not have access to affordable medical
• 08:03care outside of nonprofit community
• 08:06health centers and public clinics
• 08:08that offer free or sliding scale
• 08:10services to those without insurance.
• 08:12And these places are often working
• 08:14with limited resources.
• 08:16So older adult immigrants who are
• 08:18undocumented may have to continue
• 08:20working minimum or below minimum
• 08:23wage jobs even in their seventies,
• 08:2580s,
• 08:26and 90s to support themselves and
• 08:28their families.
• 08:33Stress from the acculturation
• 08:34process may also play a role in the
• 08:37well-being of older adult immigrants.
• 08:39Acculturation refers to the process
• 08:42by which individuals adopt the,
• 08:45adopt and adopt to the values,
• 08:47beliefs, customs and practices of the
• 08:50new country in which they reside.
• 08:53So the factors that I've discussed
• 08:54in the previous two slides can
• 08:56contribute to a culture of stress.
• 08:58For example, social isolation due to
• 09:00language barriers and the process of
• 09:03learning a new language later in life
• 09:05can contribute to psychological and
• 09:07social stress as well as feelings
• 09:09of disempowerment and exclusion.
• 09:12In the research literature,
• 09:14acculturate of stress has been
• 09:15linked to loneliness, depression,
• 09:17anxiety and grief among older
• 09:20adult immigrants.
• 09:21So the two example quotes I have
• 09:23here are from a study by Sarah
• 09:26FICA and Reyes where they conducted
• 09:28interviews with Filipino American
• 09:30grandparents who had been living in
• 09:32the US for less than 10 years and who
• 09:34are currently Co residing with their
• 09:36adult children and grandchildren.
• 09:37And these quotes by the participants
• 09:40highlight the nuanced experiences of a
• 09:43culture of stress that can occur in everyday,
• 09:46seemingly mundane situations.
• 09:48SO1 participant highlighted
• 09:49cultural differences stating it's
• 09:52hard to keep up here in America.
• 09:54Everyone is rushing to get somewhere.
• 09:56My family during weekdays is like a madhouse.
• 09:59Everyone is rushing to get out the door.
• 10:01It worries me just to see them like that
• 10:03and I'm playing catch up most of the time,
• 10:06but I'm slow now and sometimes my mind is
• 10:08so much faster than what my body is doing.
• 10:11Another participant noted language
• 10:12barrier saying someone needs to
• 10:14be with me all the time.
• 10:16I understand English very well,
• 10:18but I don't have that confidence
• 10:19when I go outside or go to the doctor
• 10:22because my family are afraid and
• 10:24I'm worried that I would not do a
• 10:25good job communicating in English.
• 10:27I've only been here three years.
• 10:29I hope that this will get better.
• 10:31I'm stressed about it
• 10:36because so many older adult
• 10:37immigrants live with their relatives.
• 10:39It's important to understand how
• 10:41health services can better meet
• 10:43the needs of their caregivers.
• 10:451 Nationally representative phone
• 10:47survey carried out in 2006 found
• 10:50that one in five informal caregivers
• 10:53to an elderly parent were either
• 10:56first generation Americans,
• 10:58meaning they had at least one parent
• 11:00who was born outside of the US,
• 11:02or they themselves were born outside
• 11:03of the US and then immigrated.
• 11:09Racial and ethnic differences among
• 11:11immigrant populations should also
• 11:13be considered so 17% of caregivers
• 11:17in the US identify as Hispanic,
• 11:2013% as Black or African American,
• 11:22and 6% as Asian.
• 11:24These numbers don't exclusively
• 11:26represent immigrant populations,
• 11:28but it provides a general idea
• 11:30of who caregivers are in the US
• 11:33Minority caregivers are less likely
• 11:35to use formal support services,
• 11:37such as paid care by a
• 11:40professional institution,
• 11:42compared to non Hispanic whites.
• 11:45Cultural norms, values,
• 11:46and role expectations have been noted
• 11:48as motivating factors for greater
• 11:51use of informal support networks.
• 11:53For example,
• 11:54norms around filial piety in East
• 11:57Asian cultures emphasize respect and
• 11:59care for one's parents and elders.
• 12:02However,
• 12:02less use of formal services could
• 12:05also indicate that caregivers
• 12:07may face additional barriers
• 12:09to accessing these services,
• 12:11such as cost, language barriers,
• 12:13negative prior experiences
• 12:15with the healthcare system,
• 12:17and lack of culturally
• 12:19competent healthcare services.
• 12:21Caregivers themselves may also be
• 12:22the ones experiencing a culture of
• 12:25stress if they have recently gone
• 12:26through the migration process.
• 12:33Beyond the influence of socio
• 12:35economic factors, cultural values,
• 12:37beliefs and practices,
• 12:38can it all impact caregivers,
• 12:41coping styles, social support, resources,
• 12:44who provides care in the family,
• 12:45and how care is provided in the family?
• 12:48For example, one study based in
• 12:50Israel compared immigrant versus
• 12:52non immigrant spousal and adult
• 12:53child caregivers to an older adult,
• 12:56and they found that immigrant
• 12:58caregivers has significantly
• 12:59lower levels of social support,
• 13:01higher levels of role overload,
• 13:03economic difficulties,
• 13:05and psychological distress.
• 13:07Another study with Vietnamese American
• 13:09spousal and adult child caregivers
• 13:12of a family member with dementia
• 13:14found that acculturation differences
• 13:16impacted how different family members
• 13:18responded to caregiving stress.
• 13:20One participant, for example,
• 13:22stated, quote for my sister,
• 13:25she came from Vietnam later than me,
• 13:27so she's still very Vietnamese.
• 13:29She doesn't know how to cope
• 13:30with all of the stress,
• 13:32She was just upset all the time.
• 13:34Participants in this study also
• 13:36expressed that placing an elderly
• 13:38parent in a nursing home was a quote,
• 13:40UN quote American thing to do because
• 13:42it contradicted the Vietnamese
• 13:44culture's emphasis on filial obligation
• 13:46and honoring older adult relatives.
• 13:53There are a few key considerations,
• 13:55recommendations, and takeaways that I
• 13:57would like to highlight for working with
• 13:59older adults and their caregivers who
• 14:01are coming from immigrant backgrounds.
• 14:04The first is that we need to recognize that
• 14:06culture is an asset by affirming the values,
• 14:09beliefs, and practices of family
• 14:12caregivers and adult immigrants.
• 14:14This could look like, for example,
• 14:15finding ways to form sustainable
• 14:18partnerships with community agencies
• 14:20and nonprofits serving refugee and
• 14:22immigrant populations in your local area.
• 14:25I'm highlighting highlighting a few
• 14:27different organizations that serve the
• 14:29greater New Haven and Connecticut area.
• 14:31So Haven Leaf, for example,
• 14:34provides job training,
• 14:36education, work experience,
• 14:38and Wellness events for refugee women.
• 14:42IRIS provides housing assistance,
• 14:44legal assistance, career counseling,
• 14:46case management,
• 14:47and help with navigating the
• 14:49healthcare system for refugees.
• 14:53And Sanctuary Kitchen provides
• 14:55job training and employment for
• 14:58immigrant and refugee communities.
• 15:01These are just some examples.
• 15:02So depending on the population and
• 15:04needs within your own community,
• 15:06it's important to be aware of the
• 15:08available resources outside of the
• 15:10healthcare setting that you can
• 15:11recommend to patients or clients.
• 15:16Second, it is fundamental to
• 15:17examine your own cultural biases
• 15:19and practice self-awareness.
• 15:21So how do your own cultural values,
• 15:23beliefs, and practices influence
• 15:25interactions with family caregivers and
• 15:27older adult from immigrant backgrounds?
• 15:32Along with this, it's also important to
• 15:35examine the systemic and institutional
• 15:37factors that contribute to health.
• 15:39Inequity, ageism, xenophobia,
• 15:41and racism can all impact how older
• 15:45adult immigrants and their caregivers may
• 15:47seek and use different health services.
• 15:51And lastly, the immigrant population
• 15:52in the US is not homogeneous.
• 15:55What works for one group may
• 15:59not work for another.
• 16:01So it's really important to do some
• 16:03ground work and understand where
• 16:04your patients are coming from,
• 16:06not just in terms of the geographic location,
• 16:08but also the historical,
• 16:10cultural and social contexts of their
• 16:12lived experiences and backgrounds.
• 16:18I also want to highlight a few
• 16:20resources that may be of interest to
• 16:23healthcare providers, researchers,
• 16:24or community advocates who want to learn
• 16:26more about how to improve clinical
• 16:29and psychosocial health for older
• 16:30adult immigrants and their caregivers.
• 16:32So the first resource is the Services to
• 16:36Older Refugees Program Fund offered by
• 16:38the US Office of Refugee Resettlement.
• 16:42This Fund provides agency funding to
• 16:44establish and expand relationships
• 16:46with state and local agencies to
• 16:48ensure that older refugees have
• 16:50access to aging services and provide
• 16:52them with appropriate services not
• 16:55currently available in the community.
• 16:57These services may include access
• 16:59to senior community centers,
• 17:01supportive services and
• 17:03intergenerational activities,
• 17:05nutrition services and meals delivered
• 17:07to delivered to homebound clients,
• 17:10transportation,
• 17:10interpretation and translation,
• 17:12help with the citizenship
• 17:15and naturalization process,
• 17:17home care, adult day care,
• 17:19and respite care,
• 17:20as well as elder abuse prevention,
• 17:22education and awareness.
• 17:27As a part of this program,
• 17:28each state has a state refugee
• 17:30coordinator whom you can contact
• 17:32For more information about local
• 17:33resources and how to apply to
• 17:36receive this federal funding.
• 17:42One example of a program that has
• 17:44used this funding is the Older
• 17:46Adult Refugees and Friends program
• 17:47by the Denver Regional Council of
• 17:50Governments Area Agency on Aging.
• 17:52So this program was a partnership
• 17:55between several community organizations,
• 17:57and these organizations provided
• 17:59health literacy, English,
• 18:01nutrition, and citizenship classes,
• 18:04as well as social events,
• 18:06interpretation services,
• 18:08transportation assistance,
• 18:10and a physical space for older adults
• 18:13to go to for social engagements
• 18:15and group fitness classes.
• 18:17They also employed community navigators
• 18:19who were from the home countries
• 18:21of the older adults and spoke their
• 18:23language to connect the older adult
• 18:26refugees to mainstream services,
• 18:27build trust and serve as cultural
• 18:30and linguistic interpreters.
• 18:31So if you go to the link provided on
• 18:33the slide or just Google the program,
• 18:35the organizers have put together a
• 18:37document that highlights lessons
• 18:39learned and best practices of this
• 18:41program that they wanted to share
• 18:43with other agencies working with
• 18:44older adult from refugee communities.
• 18:46So if you are interested in
• 18:48doing something similar,
• 18:49this document might be a good
• 18:51resource and a good starting point.
• 18:56On the legal side,
• 18:58the National Center on Law and Elder
• 19:00Rights sometimes has webinars,
• 19:01trainings, and fact sheets to help
• 19:04providers and advocates better
• 19:06understand eligibility issues,
• 19:08available services,
• 19:09and asserting language access rights,
• 19:12such as this fact sheet that they put
• 19:14together advocating for older adults
• 19:17with limited English proficiency.
• 19:20They also offer free case
• 19:23consultations to legal and aging
• 19:26network professionals on a range of
• 19:28legal issues impacting older adults.
• 19:33Justice and Aging also
• 19:35offers similar resources.
• 19:36So for example, they put together
• 19:38this really easy to understand brief
• 19:41on Medicare access for older adult
• 19:43Immigrants which provides a quick but
• 19:46informative overview of this topic.
• 19:48And that is all I have.
• 19:50I hope that you were able to
• 19:51take something you learn from
• 19:53this presentation into your work
• 19:55or into your future practice,
• 19:57and thank you for your time.