Health, Health Service Use and Informal Caregiver Distress among Older Korean Home Care Clients in Canada and Korea
Chang, Byung Wook
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Background: Immigration results in many different changes to life: diet, culture, lifestyle, and language (Hynie et al., 2011; Kim, 2006; Lee Kim, 2001). Immigration later in life is a stressful process for older adults as they are uprooted from their native society and need to readjust to a culturally different society (Hynie et al., 2011; Kim, 2006; Mui, 1996; Mui, 2001; Yoo, 2014). Challenges such as discrimination, language barriers, lack of social resources, and feelings of detachment from the new society may arise especially for elderly Asian immigrants when adapting to host environments (Bernstein et al., 2011; Hossen, 2012; Kiefer et al., 1985; Kim, 2006; Kim, 2010; Lai & Chau, 2007; Mui, 2001; Noh, 2008; Noh & Kaspar, 2003; Noh et al., 2007; Yoo, 2014). Elderly Asian immigrants often lack the information and resources to adjust to major differences between Asian and Western cultural norms and social expectations (Mui, 1996; Mui, 2001). Difficulties coping with the new society and the inappropriate use of resources can increase social isolation, depression, and other health concerns (Kang et al., 2013), which can in turn affect the lives and health of other family members as they become more dependent on these informal caregivers (Chung, 2013; Han et al., 2008; Kim & Knight, 2008; Kwak & Lai, 2012; Lee & Farran, 2004; Yoo, 2014; Wong et al., 2005). However, these struggles are often overlooked as a major issue or concern of immigration policies. Therefore, more studies are required on these Asian immigrants with limited official language proficiency. Koreans have been one of the fastest growing groups of immigrants in Canada, with a growth rate of 42% from year 2001 to 2006 (Statistics Canada, 2006; Statistics Canada, 2007). Of this group, it is estimated that approximately 6% of Korean immigrants are aged 65 and older (Kwak & Hiebert, 2010; Statistics Canada, 2006). In order to examine the possible health disparities faced by minority groups, such as Korean Canadians, an investigation into the quality of care and health service use is vital. However, only a limited amount of research on Korean immigrants has been done in Canada, and fewer than a dozen studies focused on older Korean Canadians. Purpose: This dissertation examined the health disparities in older Korean Canadian home care clients by investigating their health and health service use, informal caregiver distress, and quality of care. More specifically, it compared (1) health and health service use of Korean Canadians, native Koreans, Chinese Canadians, and other Canadians; (2) the risk and protective factors related to the onset of and improvement in caregiver distress; and (3) quality of care using the Home Care Quality Indicators (HCQIs) in Korean Canadians, Chinese Canadians, and other Canadians. Methods: This research was based on secondary data analysis of health information from two different datasets, one from Ontario and the other from Korea. The Ontario health information was based on the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool used to identify a person’s functioning and quality of life that addresses needs, strengths, and preferences in a broad range of domains (Canadian Home Care Association, 2013; Morris et al., 1997; Morris et al., 2009). This health information is managed by the Canadian Institute for Health Information (CIHI) and was made available through the partnership between CIHI and the University of Waterloo. The health information from Korea was obtained using the interRAI Home Care (interRAI HC) assessment tool. The interRAI HC is the updated version of RAI-HC but data from both can be compared with only modest adjustments (Gray et al., 2009; Hirdes et al., 2008a). The research sample was drawn from the population of all long-stay home care clients admitted during the study period between January 2002 and March 2015 in Ontario and between February 2011 and October 2012 in the Republic of Korea. Long-stay home care clients were defined as clients who require more than 60 uninterrupted days of service through a home care agency. The sample only consisted of long-stay home care clients aged 65 and older. Using a variable for primary language, Korean and Chinese home care clients in Ontario were identified. As a result, primary languages other than Korean and Chinese were grouped as ‘others’, referring to other Canadians. For the analyses and results, Korean home care clients in Ontario were referred to as ‘Korean Canadians’, Korean home care clients in Korea were referred to as ‘native Koreans’, Chinese home care clients in Ontario were referred to as ‘Chinese Canadians’, and other Canadian home care clients in Ontario were referred to as ‘other Canadians’. Chapter 5 examined the descriptive profile of the health of older Korean Canadians compared to native Koreans, Chinese Canadians, and other Canadians, by obtaining the descriptive statistics with percentages and frequencies. Chapter 6 investigated the risk and protective factors for caregiver distress accounting for Korean Canadians, Chinese Canadians and other Canadians using bivariate and multivariate logistic regression models, and generalized estimating equations (GEE). Lastly, Chapter 7 used the second-generation HCQIs to explore quality of care by ethnicity in Ontario. Results and Discussions: This dissertation is the first cross-cultural study to examine the health disparities and caregiver distress of Korean older adults in Ontario and in Korea using the RAI-HC/interRAI HC. It is also the first study to use the second-generation HCQIs to explore quality of care by ethnicity. Health disparities were evident from the overall findings in Chapter 5 where both Korean Canadians and native Koreans generally exhibited higher impairments compared with Chinese Canadians and other Canadians. In addition, high caregiver distress was present in the three Asian groups compared to other Canadians. Upon further examination of caregiver distress, results in Chapter 6 demonstrated that being a Korean or Chinese Canadian was associated with lower odds of an improvement in caregiver distress and higher odds of an onset of caregiver distress over time. However, language barriers based on need for an interpreter appeared to be the main explanation for this effect rather than the ethnicity alone. Lastly, Chapter 7 examined quality of care using the second-generation HCQIs and identified different areas where service providers for different groups have opportunities to improve quality. For Korean Canadians, such initiatives should focus on cognitive and psychosocial factors, whereas Chinese Canadians need interventions to target pain, and other Canadians need to improve on the use of hospital, emergency department or emergent care. Most importantly, all groups exhibited an increase in continued caregiver distress over time, though the two Asian groups’ rates seemed to increase more steeply. Overall, the older Korean Canadian home care clients demonstrated substantial health needs and family caregivers had a dire need for additional supports from formal services. However, this clients tended to have a lower use of home care services (i.e., personal support/ homemaking services, and the use of hospital, emergency department or emergent care), and higher levels of caregiver distress indicated that their informal caregivers were struggling. Thus, more practical interventions or resources need to be devoted to this population.