Health and predictors of health among older Chinese-Canadians in British Columbia

The recently released 2001 Census data on the ethnic background of Canadians indicate that Chinese-Canadians are the largest visible minority group in this country with a total population of more than 1 million.[1] In British Columbia, 43.7% of visible minorities reported an ethnic origin of Chinese. In the Greater Vancouver region, the percentage was even higher at 47.2%.

These figures suggest that health practitioners are serving more Chinese-Canadians and need to pay additional attention to the health status of this large ethnic community. Despite the size of the Chinese-Canadian population, limited health research has been done on this ethnic group, particularly the older adults. A search of the journal databases including MEDLINE, PsycINFO, CINAHL, and AARP Ageline revealed only 16 citations on older Chinese-Canadians. Among the studies cited, many used a small, nonrandom, and localized sample, resulting in findings with reduced generalization power.[2-6] This lack of empirical findings has resulted in a major knowledge gap and the prevailing myth that everyone from an ethnic group is the same. Such a myth perpetuates the belief that a one-size-fits-all approach to health care can be applied, and leads to substandard treatment of some patients or service users. By studying the health status of older Chinese-Canadians, health professionals can better understand and better serve this growing subpopulation. This is particularly important given that many older Chinese-Canadians being treated in a Western health care context maintain traditional Chinese values, health beliefs, and health practices that may influence health outcomes.

Objective

In a multicultural society, building a healthy aging community requires giving adequate consideration to the cultural uniqueness and characteristics of older adults from diverse backgrounds. In an attempt to help health professionals better understand the needs, issues, and challenges facing the older members of the largest visible minority group in BC, this study examined the health status and determinants of health of older Chinese-Canadians in Vancouver and Victoria—cities that accounted for 96.8% of the Chinese-Canadians in British Columbia in 2001[1] and that have the longest history of residency of Chinese-Canadians.

Method

The population health approach proposed by Health Canada[7] has identified 12 determinants of health: income and social status, social support networks, education, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture.

Previous research studies on health predictors have also demonstrated the impact of various sociodemographic variables on health status of older adults. Being a female,[8] having a lower level of education,[9] living alone,[10] having a lower income,[11] and having a lower level of social support[12] are examples of factors that often lead to a poorer health status among older adults. Culture is also an important factor that interacts with these sociodemographic variables in explaining health outcomes. The “Mandala of Health,”[13] a theoretical framework for understanding the relationship between culture and health, views human ecology as a constant interaction between culture and health. Variations in the biological, spiritual, and psychological experiences of individuals are due to the interplay of culture, community, and family. Since these experiences are interdependent and interrelated, individuals’ perspectives and beliefs related to illness, physical health, and mental health are often shaped by their community and cultural context.[13]

The data for this paper were collected as part of a national multisite study on the health and well-being of the older Chinese in Canada,[14] which examined the relationship between culture and health among older Chinese-Canadians in Victoria, Vancouver, Calgary, Edmonton, Winnipeg, Toronto, and Montreal. The study surveyed a random sample of 2272 older Chinese-Canadians aged between 55 and 101 years.

Chinese surnames in local telephone directories of the seven cities were used to form the sampling frame. Though not without problems, using surnames as the identification keys for locating Chinese and other Asian participants has been well researched.[15-20] Based upon the size of the Chinese-Canadian population and the estimated proportion of population aged 55 years and older in each location, a sample of telephone numbers listed under Chinese surnames was randomly selected from this sampling frame. Trained telephone screeners then identified eligible participants who were ethnic Chinese aged 55 years or older. Eligible participants were asked to take part in a face-to-face interview. Only one eligible participant was randomly selected from each household. The interviews were conducted using an orally administered questionnaire, in either English or a Chinese dialect spoken by the participant. Interviews were done between summer 2001 and spring 2002. As a result, 2272 participants aged 55 years and older were successfully interviewed, representing a response rate of 77%. For the purposes of this article, only data collected from 765 Victoria and Vancouver respondents were included in the analysis.

The questionnaire

A wide range of questions in the questionnaire asked about sociodemographic status, physical and mental health status, preferences regarding health-related caring arrangements, use of health services and related community support services, barriers to service use, health maintenance methods and practices, cultural values, health beliefs, ethnic identity, and life satisfaction.

To ensure that the meanings of the questions were conveyed to the participants in an accurate and culturally appropriate manner, the questions were initially constructed in plain Chinese language, translated into English, and back-translated into Chinese to ensure that both versions were consistent and accurate in meaning. (This process was not needed for the standardized instruments, which came with a Chinese-language version.) Both English and Chinese versions of the questionnaire were used, depending upon the language of the participant. The research protocol received ethics approval from the Conjoint Faculty Research Ethics Board of the University of Calgary. Written or oral consent was obtained from the participants before the interview.

Several self-reported health assessment tools were also used to measure the health status of respondents:

• Number of illnesses was measured by the total number of illnesses or health problems reported by each participant.
• Functioning capacity was measured by each participant’s self-reported level of dependency using a list of basic Activities of Daily Living (ADL) such as bathing, eating/feeding, and toileting, and Instrumental Activities of Daily Living (IADL) such as doing heavy house chores, transportation, and shopping.[21] 
• General physical and mental health were measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) in a Chinese version of the Medical Outcome Study 36-item Short Form (SF-36),[22] a popular and well-established standardized health assessment tool that has been used with a wide range of patients and people from various cultural backgrounds.[23-26] 
• Depression was measured by a revised Chinese version of the 15-item Geriatric Depression Scale (GDS), which was translated, adapted, and validated to better fit the cultural context of the elderly Chinese in North America.[27]

A Composite Health Index was constructed to represent the overall health status of the older Chinese-Canadians in this study. The index was based upon the findings from the six self-reported health measurements: number of illnesses, ADL, IADL, PCS, MCS, and GDS. However, since the scoring method and score range of these health instruments differed, standardized z-scores were used in calculating the Composite Health Index. First, the resulting scores of each of the health measures were transformed into z-scores. Scores that were below the 33.34 percentile of the available score range were assigned a score of 1. Scores that were between the 33.34 and 66.66 percentiles, inclusive, were assigned a score of 2. Finally, those scores above the 66.66 percentile were assigned a score of 3. All assigned scores of all health measures were summed to form the Composite Health Index, with a possible range between 6 and 18, and with a higher score representing better health status. The correlation coefficients between the resulting Composite Health Index and each of the health measures ranged between -.36 and .68, with all the probability levels significant at the .001 level.

Health predicting variables

Many health predictors were considered in the study, including the following personal demographic variables: age, gender, marital status, education level, English competency, living arrangement, religion, income level, self-rated financial adequacy, country of origin, length of residency, social support, number of service barriers, and city of residency.

Living arrangement referred to whether the respondent was living alone or not. Income level referred to the monthly income of the respondent and was grouped as “less than $500,” “$500 to $999,” “$1000 to $1499,” and “$1500 and above.” Self-rated financial adequacy was measured by asking the respondents to indicate how well their income and investments satisfied their financial needs—“very inadequate,” “not very well,” “adequately,” or “very well.”

English competency was assessed using two questions asking the participants whether they were able to understand and speak English “very well,” “a little bit,” or “not at all.” Scores were assigned to the answers and a higher sum represented a higher level of English competency.

Social support was measured by five questions adopted from the Older Americans Resources and Services (OARS) Social Resource Scale.[28] These questions assessed family structure, patterns of friendship and visiting, availability of a confidant, and availability of a helper should the need arise. Scores for all questions were summed to form a Social Support Index ranging from 5 to 15, with a higher score representing a higher level of social support.

Service barriers were measured by asking the participants to indicate the barriers they faced in using health services by selecting items from a list of 22 potential service barriers identified in previous research, as well as through inputs from service providers in the Chinese-Canadian community. The number of barriers reported by the participants could range from 0 to 22.

Three cultural variables were also included in the study as health predictors: Chinese health beliefs, Chinese cultural values, and Chinese ethnic identity. Chinese health beliefs were assessed by a list of statements measuring the respondent’s levels of agreement with health beliefs related to eating, health maintenance, and functions of traditional Chinese medicine. The scores were summed and weighted by the total number of items in the scale, which ranged from 1 to 3, with a higher score indicating a higher level of Chinese health beliefs held by the respondent.

Chinese cultural values were assessed using a list of 11 statements. These statements reflected beliefs and values with respect to various aspects of Chinese culture, such as language use, gender role, interracial marriage, food and diet, and parent-child relationships. For each statement, the respondents were asked to indicate their levels of agreement using a 5-point scale ranging from “strongly disagree” to “strongly agree.” The answers were coded to form a sum ranging from 1 to 5, with a higher score indicating a stronger belief in Chinese cultural values.

Ethnic identity was measured by 10 questions focused on the respondent’s association with the Chinese community, peers, and cultural activities. The answers were coded to form an Ethnic Identity Index ranging from 10 to 30, with a higher score representing a stronger level of Chinese ethnic identity.

In addition, the respondent’s attitude toward aging was also included as a health predictor. Attitude toward aging was measured using six statements constructed by the research team. These statements focused on values held about being an old person. Respondents were asked to rate their level of agreement to each statement using a 5-point scale ranging from “strongly disagree” to “strongly agree,” with an associated score from 1 to 5 for each answer. The total scores of the six statements were combined, with a higher score indicating a more positive attitude toward aging.

Data analysis

Statistical analysis was performed using the SPSS Version 10.0.5. Descriptive statistics, including frequency distribution and means, were used to examine the demographic variables and other predicting variables. Depending upon the nature of the variables, the chi-square test and t test were used to examine the differences in health status and predicting variables between the older Chinese-Canadian respondents in Victoria and Vancouver. Pearson correlation analysis was performed to examine the relationship between the Composite Health Index and each of the health measures that made up the index.

To examine the predictors of health status, multiple regression (stepwise) analysis was performed, using the Composite Health Index as the dependent variable. Based upon the significant predictors identified from the regression analysis, multivariate analysis of variance was performed using the multivariate General Linear Model to identify the differences between the two cities in the predictors measured by continuous variables. Chi-square tests were performed so that any significant differences between the two cities in the categorical predictors could be detected.

Results

Findings on the demographic background and predicting health variables of older Chinese-Canadians from Vancouver and Victoria are presented in Table 1. In general, these indicate both differences and similarities between the two groups. For example, while there were no age and gender differences between older Chinese-Canadians in Vancouver and Victoria, more of the respondents in Victoria reported being married than those in Vancouver. More of the respondents in Victoria than in Vancouver were born in Canada or migrated from China. On average, the respondents in Victoria reported longer residency in Canada (30.85 years) than those in Vancouver (16.28 years). In terms of financial status, the respondents in Victoria reported a more adequate financial situation and a higher income level than their counterparts in Vancouver. Although the respondents in Vancouver reported a higher level of social support than those in Victoria, they also reported more service barriers, less positive attitude toward aging, lower level of Chinese health beliefs, and higher level of Chinese ethnic identity.

The findings on the health status of respondents presented in Table 2 indicate that Victoria respondents reported better health than their counterparts in Vancouver. Specifically, those living in Victoria reported fewer illnesses, a lower level of dependency as measured by IADL, higher PCS and MCS scores (indicating better physical and mental health), and fewer depressive symptoms. The Composite Health Index also showed a consistent result, with older Chinese-Canadians in Victoria reporting a significantly better health status than those in Vancouver.

Predictors of health

What are the reasons for the differences in the health status between the two cities, particularly when both cities are in the same provincial jurisdiction with the same provincial health care plan? Some answers can be found in a statistical analysis of the predictors of health. Table 3 presents the regression coefficients for each of the significant predictors of the Composite Health Index. City of residency, age, gender, marital status, education, country of origin, self-rated financial adequacy, number of service barriers, attitude toward aging, Chinese cultural values, and Chinese ethnic identity were the significant predictors of health status. All these predictors combined to explain more than one-quarter of the variance of the health index scores. The results indicated that living in Vancouver, being older, being female, being single, not having post-secondary education, being an immigrant from Taiwan, having a lower level of financial adequacy, having more service barriers, having a less positive attitude toward aging, having a higher level of identification with Chinese cultural values, and having a lower level of Chinese ethnic identity were significant predictors of a poorer health status.

Table 4 presents the results of the multivariate analysis of variance of the 11 predictors identified in the regression analysis (Table 3). Multivariately, there were significant differences between the two cities (Hotelling’s Trace = .16; F (6, 758) = 20.32; P< .001), and univariately, city effect was found in four of the six continuous predicting factors, except level of identification with Chinese cultural values and age. Differences between the two cities in attitude toward aging, financial adequacy, service barriers, and ethnic identity could be identified in . By referring to the results of the chi-square tests in Table 1, significant city differences in marital status, education, and country of origin were observed.

Based upon these findings, the poorer health status reported by Vancouver respondents was likely due to their lower level of positive attitude toward aging, lower level of self-rated financial adequacy, higher level of service barriers, higher level of Chinese ethnic identity, lower percentage of being married, higher percentage of having post-secondary education, and higher percentage of immigrants from Taiwan.

Further examination of the results revealed the possibility of some confounding effects among these variables. While there was a significantly higher percentage of immigrants from Taiwan in Vancouver than in Victoria (Table 1), there was also a significantly higher percentage of older Chinese immigrants from Taiwan having a post-secondary level of education than those who were from a different country of origin (58% versus 22.5%; χ2 = 31.52; P< .001). Therefore, the higher percentage of participants in Vancouver having post-secondary education was actually due to Vancouver’s higher percentage of immigrants from Taiwan who reported a significantly higher percentage of having post-secondary education. If the immigrants from Taiwan were excluded from the analysis, the differences between Vancouver and Victoria in the percentage of older Chinese-Canadians with post-secondary education would no longer be significant (24% versus 19.7%; χ2 = 1.72; P = .19), meaning that the differences in education level was indeed not a reason for the differences in health status between the two cities.

In addition, a higher level of Chinese ethnic identity was associated with a lower level of self-rated financial adequacy (R = -.08; P< .05). Because Vancouver respondents reported a lower level of financial adequacy than Victoria respondents, it also means that more individuals in Vancouver would probably have a higher level of Chinese ethnic identity, therefore, the possible confounding effect of financial adequacy should be considered when interpreting the impact of ethnic identity on the poorer health status of older Chinese-Canadians in Vancouver.

Conclusions

The findings of this study demonstrate that many sociocultural factors are significant predictors of health status. The findings also suggest that in order to improve the health status of older Chinese-Canadians, service providers should focus on reducing the negative impacts of certain sociocultural predictors of health: cultural and other related service barriers, poor attitude toward aging, and poor financial status.

Cultural and other related service barriers

Despite the fact that a strong Chinese ethnic identity may have a protective function[30] and contribute to the positive health status of older Chinese-Canadians through the social connection and association with their ethnic community, the cultural incompatibility between older Chinese-Canadians and mainstream society ultimately has a negative impact on mental and physical health.

When health-related services and programs are organized according to a Western perspective, older Chinese-Canadians who maintain a higher level of Chinese cultural values probably have more difficulty connecting with the services they need than those Chinese-Canadians who maintain a lower level of Chinese cultural values. Therefore, it is important for health care providers to take into consideration the cultural uniqueness of the users and to make changes to the delivery system to better meet the needs of users.

The following might serve to reduce the cultural gap between the users and the service delivery system:

• Providing written and verbal health promotion materials in languages that users are familiar and comfortable with.
• Integrating the cultural concepts and beliefs of users in the Western health promotion concepts.
• Training health professionals to understand users of different cultural backgrounds. 
• Recruiting and further developing the skills of health professionals who have knowledge and skills in the culture and language of users.
• Providing ethno-specific or first-language-based services.

It is worth noting that older Chinese-Canadians in Vancouver were less healthy than their counterparts in Victoria, even when all other predicting factors were adjusted, and that Vancouver respondents reported significantly more service barriers than their counterparts in Victoria. Local policymakers and service providers should ponder these results and further examine the strategies to reduce service barriers.

Attitude toward aging

The findings also indicate that a more positive attitude toward aging is a significant predictor of better health status. As a result, strategies to improve the older adult’s attitude toward aging are needed. Older adults from ethnic minority backgrounds often face multiple challenges in addition to the social stigma of being old. Cultural shock, discrimination, and language barriers are examples of these challenges. While interventions to support older Chinese-Canadians in building a positive image about being old and about themselves are appropriate, strategies to reduce discrimination related to culture and ethnicity are also important.

Financial status

The older Chinese-Canadians included in this study belonged to a rather nonhomogeneous population, particularly socioeconomically. As the findings indicate that financial status is a significant predictor of health, future research to further analyze health status of older Chinese-Canadians in these diverse socioeconomic subgroups is recommended.

Competing interests
None declared.

Table 1. Demographic variables and health predicting variables used to study health status of older Chinese-Canadians in Vancouver and Victoria.

Table 2. Health status of older Chinese-Canadians in Vancouver and Victoria as measured by health assessment tools.

Table 3. Regressive coefficients of health predictors for Composite Health Index

* P <.001; † P <.01; ‡ P <.05

Table 4. Results of multivariate analysis of variance using location as the factor.