The Role of Acculturation in Health Status and Utilization of Health Services among the Iranian Elderly in Metropolitan Sydney

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1 J Cross Cult Gerontol (2011) 26: DOI /s z ORIGINAL ARTICLE The Role of Acculturation in Health Status and Utilization of Health Services among the Iranian Elderly in Metropolitan Sydney Mahtab Alizadeh-Khoei & R. Mark Mathews & S. Zakia Hossain Published online: 11 October 2011 # Springer Science+Business Media, LLC 2011 Abstract The present study explores the impact of acculturation on health status and use of health and community aged care services among elderly Iranian-born immigrants to Australia. Three hundred two Iranian immigrants aged 65 years and over who had lived in the Sydney Metropolitan area for at least six months participated. Data were collected using a written survey instrument, face-to-face interviews, and telephone interviews. Iranian immigrants had higher levels of psychological distress, more limited physical function, greater need for help or assistance with activities of daily living, lower feelings of wellbeing, and were much less likely to use aged care services than the general population of older Australians. Participants who did not speak English at home were more likely to experience psychological distress and had greater limitations in their physical functioning. Elderly Iranians with better English proficiency had lower levels of anxiety and depressive symptoms and reported less need for help and supervision in activities of daily living; they were also more likely to access health care services. Elderly Iranian immigrants experience higher levels of psychological distress and lower levels of physical function than the general population of older Australians; those with limited proficiency in English are at greatest risk. These findings contribute to the enrichment of multicultural policy, social fairness, access, and equity for ethnic aged people. Keywords Acculturation. Elderly. Health status. Health service utilization Introduction Acculturation is a process by which one cultural group adopts the beliefs and practices of a host culture. The degree of immigrant acculturation is influenced by the length of time and M. Alizadeh-Khoei : R. M. Mathews (*) : S. Z. Hossain Faculty of Health Sciences, University of Sydney, 75 East Street, P.O. Box 170, Lidcombe, NSW 1825, Australia m.mathews@usyd.edu.au M. Alizadeh-Khoei Ministry of Health and Medical Education, Tehran, Iran

2 398 J Cross Cult Gerontol (2011) 26: the degree of proficiency in the language spoken in that country (Aranda and Knight 1997). Rich acculturation has been associated with a range of healthy behaviours (Leybas-Amedia et al. 2005). For example, highly acculturated Hispanic women were less likely to fear cancer and more likely to seek out screening and other health care services, compared with their less acculturated peers (Lantz et al. 1994). Elderly Asian immigrants who were more acculturated to thehostsocietyalsotendedtohavebetter mental health than those who were less acculturated (Stokes et al. 2001). In contrast, poor acculturation has been linked to poor mental health. For example, poor acculturation in immigrants from the former Soviet Union to Sweden was associated with psychological distress and depression (Blomstedt 2007). Similarly, less acculturated elderly Hispanic immigrants to America were more likely to be depressed than those who were more acculturated (Gonzalez et al. 2001). Elements of acculturation are among the correlates of depression identified in elderly minority groups in the United States: shorter lengths of residency, poor health, life stresses, financial difficulty, poor proficiency in English language, dependency on children, social isolation, and lack of social support (Cassado and Leung 2001). Elderly immigrants depression may be due to migration stress and grief, adaptation difficulties, poverty, illness, and weakening family support (Mui et al. 2001). Acculturation can be very demanding for immigrant elderly because they usually have less support, such as income, education, and language proficiency, to assist them in adapting to their new life condition (Cassado and Leung 2001). The feeling of being alone and different in the new country, worries about separating from traditional family, selective mistrust, and anger are common among elderly Iranian immigrants in western countries (Barnes 2003). Emami and Ekman (1998) found that Iranian elderly who migrated late in life to Sweden had limited social networks and experienced social isolation and loneliness due to significant cultural differences and the immigrants lack of Swedish language proficiency. Employment and language competency were some of the important elements that influenced their adjustment to a new culture. Although Iranian immigrants often have high levels of education and income, recent statistics indicate that 31% reported limited proficiency in English. In fact, 16.4% lived in linguistically isolated households (Tahmaseb et al. 2001). Further understanding of the relationships between acculturation, stress, and mental health may inform the design of effective intervention programs for older immigrants. The aim of this study is to investigate the association between acculturation, mental health and use of health care services among Iranian elderly living in Sydney metropolitan area. Iranians in Australia Migration of Iranians to Australia has occurred in several waves starting in the 1960s. Periods of increased migration occurred following the Iranian Revolution in 1979 and the war with Iraq during the 1980s. While the Iranian population of Australia was a mere 3669 in 1981, it became more than three times (12,914) in 1996 (Australian Institute of Health and Welfare 2001). Iranians came to Australia as political and economic refugees and by the latter half of the 1990s many came under the skill and family reunion migration programs (Migration Information Centre 2004). Almost half of the participants in this study (46.4%) migrated to Australia between 1985 and 1994; only 9.6% migrated to Australia less than five years ago. Average age of the participants is 67 years. Majority (46%) of the participants were in the age group of years.

3 J Cross Cult Gerontol (2011) 26: Age at migration and duration of migration both play significant roles in migrant acculturation as does language proficiency. In Australia and elsewhere, language spoken at home and proficiency in communicating in English are known to have an impact on the utilization of health care services by migrants, particular elderly migrants (Khavarpour et al. 2003). These variables have been included in this study to measure the degree of acculturation of elderly Iranians living in Sydney. As Mahdi (1998) states, Iranians, like their other counterpart immigrants on arrival to host nations, carry with them their Iranian characteristics. An understanding of Iranian socio-cultural norms and values is integral in understanding health service utilisation among the study population. The Iranian value system is centred around family and societal goals. In Iran, the family is the primary source of help and support for its members. Iranians respect their elders and are critical of Australians for abandoning their older people in homes for the aged (Hossein 2008). There are specific roles and responsibilities within the family structure, particularly those placed on sons and daughters to provide care and accommodation for elderly parents. Thus, the socio-cultural issues specific to the community should be taken into consideration when assessing acculturation and use of services, in particular use of basic health and community care services. Methods Participants and procedure Census data estimate that 1,209 Iranian-born immigrants aged 65 and over live in the Sydney Metropolitan area (Australian Institute of Health and Welfare 2001); a total of 302 participated in this study. Power analysis, using Cohen s formula (1988), showed that a sample size of 200 would give 80 per cent chance of detecting correlation ±0.223 at 0.01 level. Thus a sample size of 302 was considered adequate for the purposes of the study. In developing the survey instrument, questions were drawn from the NSW Older People s Health Survey 1999, a state-wide telephone survey with questions designed and validated for telephone data collection (Public Health Division 2000). The survey included a variety of demographic measures in addition to closed-ended and multiple-choice questions about mental and physical health and the use of community health and aged care services. For the purposes of this study, the questions selected were translated into Farsi (the native language of most Iranians) in line with guidelines for cross-cultural adaptation of self-report measures (Beaton et al. 2000). Two people, both fluent in Farsi and English, independently translated the questionnaire from English to Farsi. The two versions were compared at a consensus meeting during which differences were discussed and an agreed version developed. The Farsi version of the questionnaire was pre-tested on 4 participants for internal consistency, test-retest reliability, ceiling and floor effects and responsiveness. Participants for the pre-test were recruited using purposive sampling from the Iranian community living in the Sydney Metropolitan area. Following pre-testing, the questionnaire was refined for better understanding and to make questions simple and readable. Slight modification in wording of questions 4, 8,12,13,18, 26, 41,147, 156 and 182 was required. The modified Farsi version of the questionnaire was re-tested with two elderly Iranians and no further modifications were required. Administration of the Farsi version of survey instrument was carried using three different methods: self-complete, telephone interviews and face-to-face interviews. The

4 400 J Cross Cult Gerontol (2011) 26: research project was publicized in weekly Iranian newspapers and on radio stations broadcasting in Farsi. In an attempt to reach as many elderly Iranian immigrants as possible, the survey instrument was distributed at places and events likely to be frequented by the target population. However, this resulted in the return of only 70 self-completed questionnaires. The research team decided to change the method of administration to telephone and/or face-to-face interviews. One of the researchers (MAK), fluent in Farsi, attended places of interest to older Iranians in the community and carried out face-to-face interviews or arranged telephone interviews; these two methods were the main sources of data collection. Of the total sample (302), only 23% data were collected through self complete survey. While three methods such as telephone interviews, face-to-face interviews and self administered survey were used to collect data, all used Farsi version of the instrument, therefore question of equivalence of concepts and the linguistic challenges did not arise. Measures The questionnaire used in the present study asked about demographic variables (age, gender, education, marital status, living arrangements, number of children living in Australia, financial status, government benefits, home ownership) and acculturation (language spoken at home, self-assessed English proficiency, and duration of residence in Australia). The survey also included questions to identify participants psychological distress, psychological wellbeing, physical functioning, ability to perform activities of daily living, use of health services, and use of aged care services. Psychological distress was assessed using the Kessler K6 (Furukawa et al. 2003). Participants were asked how much of the time during the last four weeks they felt sad, nervous, restless, hopeless, effort, or worthless. Responses were entered on a 5-point scale: (1) all of the time, (2) most of the time, (3) some of the time, (4) a little of the time, or (5) none of the time. Scores for the six items were summed for each participant and placed in one of three categories: high (6 to 14), moderate (15 to 22), and low psychological distress (23 to 30). Psychological wellbeing was assessed using five questions that asked how often the respondent felt happy, calm/peaceful, bored, lonely, and depressed during the previous four weeks. Responses were entered on a three-point scale: (1) none of the time, (2) some of the time, and (3) most of the time. Responses to the negative emotions were reversed as appropriate, and a total score was derived by summing across the five items. Scores were then classified into the three categories: high (13 to 15), moderate (9 to 12) and low (5 to 8) feeling of well-being. Physical functioning was measured using 10 items from the SF-36 (short form 36) Health Survey (Ware et al. 1993). Participants were asked the extent to which their health limited them in their ability to engage in various activities (e.g., climbing one flight of stairs) on a 3-point scale (a lot, a little, not at all). Scores were summed for each participant and classified as: no limitations (24 to 30), some limitations (17 to 23), or limited physical function (10 to 16). Participants ability to perform activities of daily living (ADL) was assessed with five yes or no questions (Katz et al. 1963). Three questions asked whether respondents could perform various activities on their own (e.g., household duties) and two asked whether respondents needed help or supervision to perform personal care activities (e.g., bathing). Scores were summed for each participant, yielding an ADL score. ADL scores were classified as high (4 or 5), moderate (2 or 3), or low (0 or 1).

5 J Cross Cult Gerontol (2011) 26: Participants were asked if they had received any of three basic aged care services (assistance with household duties, personal care, and meal preparation or delivery) in the last week and any of five supportive aged care services (e.g., transportation for errands or medical appointments) in the past four weeks. A total score for basic aged care services and supportive care services was derived by summing across the three and five items respectively. Participants were also asked to respond yes or no to six questions about their use of health services during the preceding 12 months (e.g., seen by a GP or local doctor, spent at least one night in hospital) and a total score for health service use was derived by adding the scores for those six services. Data analysis The data were analysed using SPSS V15.0. T tests and one-way ANOVAs were used to identify significant variables. Results A total of 302 participants completed the survey with almost equal numbers of men (49%) and women (51%). The largest age category comprised participants aged 65 to 69 (46%); 21% were 70 74; 16% were 75 79; and 17% were 80 or older. Most (65%) were married; 24% were widowed; and 10% were separated or divorced. Nearly all (93%) had one or more children currently residing in Australia. Many (45%) lived with a spouse or partner; 28% lived in the home of one of their children; 7% lived with other family or friends; and 21% lived alone. Only 7% of the participants had arrived in Australia before 1975; 18% immigrated between 1975 and 1984, 46% between 1985 and 1994, and 29% since The majority of participants (74%) had difficulty communicating in English: 28% could not communicate at all in English, and 46% could not communicate well in English. Most of the participants (85%) spoke Farsi at home; only 15% usually spoke English at home. Table 1 provides a comparison of responses provided by Iranian elders participating in this study to the responses of the 8,881 NSW residents aged 65 and older who participated in the 1999 Older People s Health Survey (Public Health Division 2000). The elderly Iranian participants were found to have significantly higher levels of psychological distress, lower levels of wellbeing, more limitations in physical functioning, and greater need for assistance in activities of daily living. Conversely, elderly Iranian participants were less likely to have used any form of basic aged care services (assistance with household duties, personal care, or meal delivery) during the previous week, and used fewer supportive aged care services (e.g., respite, transportation) during the previous month. The majority of Iranian elders (96%) did report using a range of health care services in the previous year. The role of acculturation Table 2 shows that Iranian elders who did not speak English at home were more likely to experience high levels of psychological distress, while Iranian elders who could communicate in English well to very well showed lower levels of psychological distress. English language proficiency also was related to wellbeing, and the language spoken at home similarly had a significant impact on participants feelings of wellbeing. Those respondents who spoke Farsi at home and those who could not communicate in

6 402 J Cross Cult Gerontol (2011) 26: Table 1 Comparison of Iranian elders to NSW Older People s Health Survey (1999) Iranian Elders NSW Health Psychological Distress High 16% 3% Moderate 44% 30% Low 40% 68% Mean (STD) 20.4 (5.7) 27.1 (3.6) t (9096)= 52.42, p<.001 Wellbeing Low 21% 2% Moderate 58% 25% High 21% 73% Mean (STD) 10.4 (2.9) 13.3 (1.9) t (8911)=26.9, p<.001 Physical Functioning Limited 18% 8% Some limitations 41% 20% No limitations 41% 72% Mean (STD) 22.0 (5.8) 25.3 (4.9) t (8299)=11.16, p<.001 Activities of Daily Living (ADL) High need of assistance 14% 3% Moderate need of assistance 30% 17% Low need of assistance 56% 80% Mean (STD) 3.42 (1.6) 5.76 (1.1) t (9029)=12.62, p<.001 Basic Aged Care Services 7.6% 10.3% Mean (STD) 1.7 (0.7) 1.3 (0.6) t (932)= 3.28, p<.05 Supportive Aged Care Services 7.0% 12.2% Mean (STD) 1.4 (0.7) 1.2 (0.5) t (1106)= 2.15, p<.05 Health Care Services 96.4% 96.4% Mean (STD) 2.3 (1.3) 1.7 (1.0) t (9104)= 9.72, p<.001 English had greater limitations in their physical functioning. Respondents who could not communicate in English were also more likely to have more difficulty with activities of daily living. English proficiency was the only acculturation variable that had a significant impact on respondents health service utilisation. Two other key variables measuring acculturation such as language spoken at home and duration of residence in Australia and use of health care services did not show any significant association for this group. Discussion These results suggest that Iranian immigrants had higher levels of psychological distress, more limited physical function, greater need for help or assistance with activities of daily living, and lower feelings of wellbeing, but were much less likely to use aged care services than the general population of older Australians. Participants who did not speak English at home were more likely to experience psychological distress and had greater limitations in

7 J Cross Cult Gerontol (2011) 26: Table 2 Association between acculturation variables and mental health, well-being, ADL and use of services (N=302) Language Spoken at Home Communicate in English Farsi English Not at all Not well Well or very well Psychological Distress Mean (STD) 20.1 (5.8) 22.1 (4.4) F=4.88* 17.5 (5.8) 21.1 (5.3) (5.0) F=18.27** Wellbeing Mean (STD) 10.3 (2.5) 11.2 (2.0) F=5.56* 9.1 (2.4) 10.7 (2.2) 11.4 (2.4) F=22.34** Physical Functioning Mean (STD) 21.7 (5.8) 24.0 (5.1) F=6.47* 18.9 (5.6) (5.2) 24.4 (5.5) F=22.66** ADL Mean (STD) 3.4 (1.6) 3.8 (1.5) F= (1.5) 3.6 (1.5) 4.0 (1.5) F=20.1** Basic Aged Care Services Mean (STD) 1.6 (.669) 2.5 (.707) F= (.517) 1.7 (.823) 1.8 (.836) F=.088 Supportive Aged Care Services Mean (STD) 1.4(.712) 1.2(.500) F= (.000) 1.5(.776) 1.25(.500) F=1.09 Health Care Services Mean (STD) 2.4 (1.3) 2.1 (1.2) F= (1.2) 2.3 (1.2) 1.9 (1.3) F=6.85** *p<.05; **p<.001 their physical functioning. Elderly Iranians with better English proficiency had lower levels of anxiety and depressive symptoms, reported less need for help and supervision in activities of daily living, and were more likely to access health care services. Further, the results of the present study are consistent with Barnes (2003) findings that feelings of being alone and different in the new country and worries about separation from traditional family and patterns of communication are common psychological distress symptoms among elderly Iranian immigrants in western countries. English language proficiency was a predictor of utilisation of health services among Iranian elderly. These findings support Benham et al. s (2000) suggestion that English language proficiency is an acculturation variable that contributes to high levels of service use and McMaugh s (2001) finding that a non-english speaking background was associated with underutilisation of Home and Community Care (HACC) services by frail aged people in northern Sydney. These results suggest that elderly Iranian immigrants experience higher levels of psychological distress and lower levels of physical function than the general population of older Australians. They are much less likely to access aged care services but have a greater need for health care services. Those with limited proficiency in English are at the greatest risk. English proficiency and language spoken at home did not show any significant association with utilisation of basic or supportive aged care services. This might be attributed to a lack of knowledge about the availability of HACC services. However, as outlined earlier traditional Iranian cultural beliefs suggest that elders should be looked after by their children. Almost one third of the participants lived in the home of one of their children and most of them spoke Farsi at home with their family members. These findings are consistent with Migrant Information Centre data (2004) indicating that there are specific attitudes towards the aged and ageing in Iranian culture. Older people are respected and age is viewed positively and thought of as a sign of wisdom. Older people are often asked for advice and provide emotional and financial support (Hossein 2008).

8 404 J Cross Cult Gerontol (2011) 26: These findings have public policy implications in that more needs to be done to ensure that elderly migrants, especially those from culturally and linguistically diverse (CALD) backgrounds, have equitable access to health and community services. Further, recognition of the relationship between the migration process, acculturation and mental and physical health outcomes should inform the provision of, and access to effective intervention programs to address these issues. Acknowledgments The authors gratefully acknowledge NSW Department of Health s Centre for Epidemiology and Research for access to data collected in the New South Wales older people s health survey 1999 and to Dr Michael Giffin for his feedback and suggestions. References Aranda, M. P., & Knight, B. G. (1997). The influence of ethnicity and culture on the caregiving and coping process: a socio-cultural review and analysis. The Gerontologist, 37, Australian Institute of Health and Welfare. (2001). Projections of older immigrants: People from culturally and linguistically diverse backgrounds, Canberra: AIHW. Barnes, D. (2003). Asylum seekers and refugees in Australia. Issues of mental health and wellbeing. Paramatta: Transcultural Mental Health Centre. Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. (2000). Guidelines for the process of crosscultural adaptation of self-report measures. Spine, 25, Benham, C., Gibson, D., Holmes, B., & Rowland, D. (2000). Independence in ageing: The social and financial circumstances of older overseas-born Australians. Canberra: Department of Immigration and Multicultural Affairs and the Australian Institute of Health and Welfare. Blomstedt, Y. (2007). Self-reported health among immigrants from the former Soviet Union: Quantitative and qualitative studies in Sweden. Stockholm: Karolinska Institute. Cassado, B. L., & Leung, P. (2001). Migratory grief and depression among elderly Chinese American immigrants. Journal of Gerontological Social Work, 36, Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: L. Erlbaum Associates. Emami, A., & Ekman, S. L. (1998). Living in a foreign country in old age: life in Sweden as experienced by elderly Iranian immigrants. Health Care in Later Life, 3, Furukawa, T. A., Kessler, R. C., Slade, T., & Andrews, G. (2003). The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well- Being. Psychological Medicine, 33, Gonzalez, H. M., Haan, M. N., & Hinton, L. (2001). Acculturation and the prevalence of depression in old Mexican Americans: baseline results of the Sacramento area Latino study on aging. Journal of the American Geriatrics Society, 49, Hossein, A. (2008) Iranians in Australia. Lecturer in Sociology, School of Social Science, Queensland University of Technology. availablehttp://escholarship.usyd.edu.au/journals/index.php/ssr/article/viewfile/ 695/676. Katz, S., Ford, A., & Moskowitz, R. (1963). Studies of illness in the aged. Journal of the American Medical Association, 185, Khavarpour, F., Hosseinipour, S. M., Pourmand, D., Gholamshahi, S., & Nesvandarani, B. (2003). Mental health and service utilisation among the Iranian community in metropolitan Sydney the Needs, Transcultural Mental Health Centre, Iranian Mental Health Sub-Committee, Sydney, Australia. Lantz, P. M., Dupuis, L., Reding, D., Krauska, M., & Lappe, K. (1994). Peer discussions of cancer among Hispanic migrant farm workers. Public Health Reports, 109, Leybas-Amedia, V., Nuno, T., & Garcia, F. (2005). Effect of acculturation and income on Hispanic women s health. Journal of Health Care for the Poor and Underserved, 16, Mahdi, A. (1998). Ethnic identity among second-generation Iranians in the United States. Iranian Studies, 31 (1),

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