Understanding Aged Care Use by Older Chinese-Speaking Immigrants in

Dolly Hsiao-Yun Huang

Submitted in total fulfillment of the requirements of the degree of Doctor of Philosophy.

December 2016

Department of Social Work School of Health Sciences Faculty of Medicine, Dentistry & Health Sciences The University of

Abstract

The world’s population is ageing rapidly, so how to provide quality health and aged care to an increasing elderly population has become a critical issue facing many countries. In Australia, one in four persons is born overseas. With a significant number of older people from diverse ethnic backgrounds, it is even more challenging to provide quality care that can meet their specific cultural needs. Evidence suggests that older people from culturally and linguistically diverse (CALD) backgrounds are more likely to be socially and financially disadvantaged and to under-use aged care services. However, there is a lack of detailed information on individual ethnic groups in relation to their specific care needs and service utilisation.

This thesis sought to examine the characteristics of older Chinese-speaking immigrants, particularly those who migrated at an older age, and explore the experiences of aged care service use by this population in Melbourne, Australia. The Andersen Behavioural

Model was the analytic framework utilised to understand factors associated with aged care use by this population, focusing on the concepts of predisposing, enabling, and need factors. This model was applied using an intersectionality perspective, highlighting how the interaction of various differences among older Chinese-speaking immigrants created unique experiences of ageing and aged care use. An interviewer- administered survey was conducted with 120 older Chinese-speaking immigrants between December 2009 and January 2011. Participants were recruited from four

ii metropolitan areas in Melbourne using a quota sampling method to ensure representativeness.

The study found that older Chinese-speaking participants used significantly more social support services and significantly less allied health and home care support services, compared with older . The use of aged care services was best explained by predisposing and enabling factors, rather than need factors. Filial piety (a predisposing factor) and the availability of family carers (an enabling factor) were found to have negative effects on use of aged care services, while other enabling factors such as social support, adaptation of Australian culture, retention of Chinese culture, and awareness of existing services were found to be positively associated with aged care use. Having a lower score on activities of daily living (a need factor) was also found to increase the likelihood of using aged care services.

The findings suggest that older Chinese-speaking Australians who are relatively recently arrived immigrants have a greater need for social support services. To improve the uptake of aged care services, policy makers and service providers need to better understand the effects of filial piety and family resources on aged care use, as well to encourage them to strengthen links with both local Chinese communities and the wider

Australian society. This study contributes to a greater understanding of the influence of culture and recency of immigration on aged care use by the older Chinese-speaking population in Australia, and assists service providers and practitioners in better planning and delivery of culturally appropriate aged care services.

iii

Declaration

This is to certify that:

i. the thesis comprises only my original work towards the PhD,

ii. due acknowledgement has been made in the text to all other material used,

iii. the thesis is less than 100,000 words in length, exclusive of tables, maps,

bibliographies and appendices.

Signed:

Dolly Hsiao-Yun Huang

iv

Acknowledgements

My eight years of doctoral studies has been a long but fruitful journey. While conducting this research and writing the thesis, as an immigrant myself, I have also experienced the birth of two children, the start of my first social work job, and voluntary participation in the establishment of two not-for-profit organizations. Without the people and support given to me, I do not think that I could have survived.

First and foremost, I would like to express my sincere gratitude to my three supervisors for their continuous support, encouragement and guidance during my PhD journey.

Professor Daniel Fu Keung Wong, now working in the University of , accepted me as his first and last PhD student at the University of Melbourne. I was honoured and blessed to have the opportunity to be supervised intensively by Daniel in the first one and a half years of my doctoral studies. His knowledge and determination helped me to move productively toward confirmation of candidature and approval of my ethics application, which laid the foundations for this thesis.

I am heartily indebted to Professor Elizabeth Ozanne and Professor Louise Harms for their immense patience, constant support, and invaluable advice. The writing process has been the most difficult part of my studies, not only because I had to write the thesis in a second language that satisfied academic standards but I also had to learn to take ownership of my writing and be more confident and authoritative about it. Elizabeth offered great assistance in improving my English skills and motivated me to become proficient in academic writing. Lou taught me that writing a thesis is like telling a story

v and you as an author have to guide your readers through it. This may sound simple and easy but it took me a couple of years to gradually grasp how to achieve it. In addition, their invaluable and constructive feedback on the initial approach I took in interpreting the data encouraged me to rethink my arguments and theoretical and conceptual framework. This is evident in the methodology and discussion chapters of the thesis. I am deeply grateful for Elizabeth and Lou’s supervision and wisdom that have supported and inspired me to grow and develop as a writer and a researcher.

I would like to extend my gratitude and appreciation to the advisory committee Dr.

David Ross for his advice, support and encouragement, and The University of

Melbourne which awarded me a Faculty Research (trust funded) Scholarship during candidature. My special thanks must go to the participants who kindly offered their time and energy to complete the survey and the gatekeepers of the Chinese seniors clubs, social service organisations, and associations where participants were based. Without their assistance and generosity this research would not have happened. I heartily thank all my fellow PhD students, work colleagues, and close friends for their encouragement, friendship and support, which have made this journey less lonely and more inspirational.

Finally, but most importantly, I thank my parents, parents-in-law, dear husband and two beautiful daughters for their sacrifice, tolerance, and endless emotional and practical support. They are the ones that have kept me going when I was down and did not believe in myself. There are no words to express my gratitude for their immense contribution to my PhD journey. I love you and thank you for always being there for me.

vi

Table of Contents

Abstract ...... ii Declaration ...... iv Acknowledgements ...... v Table of Contents ...... vii List of Tables ...... ix List of Figures ...... xii List of Appendices ...... xii Chapter 1: Introduction ...... 1 1.1 Motivation for this study ...... 2 1.2 Ageing in multicultural Australia ...... 4 1.3 Ethnicity and aged care use...... 8 1.4 Research aims and questions ...... 12 1.5 Terminology used in this study…………………………………………... ….15 1.6 Structure of the Thesis ...... 156 1.7 Summary ...... 17 Chapter 2: The ageing experience of older Chinese-speaking Australians ...... 19 2.1 Defining Chinese ethnicity: ancestry, language, or nationality?...... 19 2.2 Trends in growth of the older Chinese population ...... 23 2.3 The impact of migration on the ageing experience ...... 27 2.4 Cultural and family influences on the ageing experience ...... 35 2.5 Summary ...... 42 Chapter 3: Understanding aged care use by people from diverse ethnic backgrounds ...... 43 3.1 The aged care of older Australians from a CALD background ...... 43 3.2 Models and frameworks for understanding aged care use by ethnic minorities ...... 49 3.3 Review of the empirical evidence on aged care utilisation by older Chinese-speaking people ...... 58 3.4 The integration of the Andersen Behavioural Model and intersectionality ..... 74 3.5 Summary ...... 77

vii

Chapter 4: Research methods...... 79 4.1 Methodological approach and research questions ...... 79 4.2 Ethical considerations in research involving older people from CALD background ...... 83 4.3 Research participants and sampling ...... 87 4.4 Survey method ...... 90 4.5 Procedures and data analysis ...... 109 4.6 Summary ...... 115 Chapter 5: The demographic profile of older Chinese-speaking participants ...... 116 5.1 Demographic characteristics ...... 116 5.2 Migration background ...... 119 5.3 Social and economic status ...... 125 5.4 Health ...... 133 5.5 Summary ...... 135 Chapter 6: The socio-cultural profile of older Chinese-speaking participants ..... 137 6.1 Predisposing factors ...... 137 6.2 Enabling factors ...... 145 6.3 Need factors ...... 160 6.4 Summary ...... 166 Chapter 7: Use of aged care services by older Chinese-speaking participants ..... 168 7.1 Types of aged care services used ...... 168 7.2 Characteristics of users and nonusers ...... 172 7.3 Predictors of aged care use ...... 175 7.4 Summary ...... 179 Chapter 8: Discussion and Conclusion ...... 181 8.1 Addressing the research questions ...... 181 8.2 Strengths and limitations of the study ...... 197 8.3 Implications ...... 199 8.4 Conclusion ...... 203 References… ...... 204 Appendices...... 218

viii

List of Tables

Table 2.1 Comparison of the Australian Chinese population by three different definitions ...... 20 Table 2.2 Older Australians who speak Chinese at home by age, 1996-2026 ...... 25 Table 2.3 English proficiency and year of arrival of three groups...... 27 Table 3.1 Usage rates of selected aged care programs, by age, cultural and linguistic background ,2010-2011 (per 1,000 people) ...... 48 Table 4.1 Quota sampling frame ...... 89 Table 4.2 A summary of Language Equivalence and Content Validity Index of the Survey Questionnaire ...... 94 Table 4.3 Measurement and Operational Definition of Predisposing Variables ...... 97 Table 4.4 Factor Loadings for Items of Modified Community Service Attitude Inventory ...... 104 Table 4.5 Factor Loadings for Items of Vancouver Index of Acculturation...... 105 Table 4.6 Factor Loadings for Items of Duke Social Support Index ...... 106 Table 4.7 Factor Loadings for Items of Barriers to Service Use ...... 107 Table 4.8 Cronbach’s alpha of HFRS, MCSAI, VIA, DSSI, BSU, MBI, LIADLS, and GDS-SF ...... 108 Table 5.1 Comparison of the sample with the older Chinese-speaking population by three age groups ...... 117 Table 5.2 Comparison of the sample with the older Australian population by three age groups...... 117 Table 5.3 Comparison of the sample with the older Chinese-speaking population and the older Australian population by sex ...... 118 Table 5.4 Comparison of the sample with the older Chinese-speaking population in Melbourne by location, 2011 ...... 119 Table 5.5 Birthplaces and languages spoken by participants at home ...... 120 Table 5.6 Comparison of the sample with the older Chinese-speaking population by language spoken at home ...... 121 Table 5.7 Comparison of the sample with the older Chinese-speaking population by year of arrival...... 122 Table 5.8 Comparison of the sample with the older Chinese-speaking population by English Language proficiency ...... 123 Table 5.9 Immigration circumstances of participants (N=120) ...... 124 Table 5.10 Comparison of the sample with the older Chinese-speaking population by marital status ...... 125 Table 5.11 Comparison of the sample with the older Australian population by marital status...... 126

ix

Table 5.12 Comparison of the older China-born population with the Australian population by living arrangements ...... 126 Table 5.13 Comparison of the sample with the older China-born population by living arrangements ...... 127 Table 5.14 Living arrangement preference of participants (N=120) ...... 128 Table 5.15 Comparison of the sample with the older Australian population by religion ...... 128 Table 5.16 Comparison of the sample with the older Chinese-speaking population by religion ...... 129 Table 5.17 Comparison of the sample with the older Australian population by education ...... 130 Table 5.18 Comparison of the sample with the older Chinese-speaking population by education ...... 130 Table 5.19 Comparison of the older Chinese-speaking population with the older Australian population by income ...... 131 Table 5.20 Financial circumstances of participants (N=120) ...... 132 Table 5.21 Medical insurance of participants (N=120) ...... 133 Table 5.22 Comparison of the sample with the older Australian population by self-assessed health ...... 134 Table 5.23 Comparison of the Sample with the older Australian population by need for assistance ...... 135 Table 5.24 Comparison of the Sample with the older Chinese-speaking population by need for assistance ...... 135 Table 6.1 Comparison of the sample’s filial responsibility level with the older Netherland sample in the Van der PAS et al.’s study ...... 138 Table 6.2 Mean, Standard Deviations, Actual Range, and Potential Range of 4 Factors of Modified Community Service Attitude Inventory ...... 141 Table 6.3 Comparison of participants’ intention to use formal aged care services if an aged care need was low ...... 144 Table 6.4 Comparison of participants’ intention to use formal aged care services if an aged care need was high ...... 144 Table 6.5 Mean, Standard Deviations, Actual Range, and Potential Range of 2 factors of Duke Social Service Index ...... 146 Table 6.6 Comparison of sample and older Australian women on the Duke Social Support Index ...... 147 Table 6.7 Mean, Standard Deviations, Actual Range, and Potential Range of 2 factors of Vancouver Index of Acculturation ...... 150 Table 6.8 Summary of Carers and Availability of Care Time ...... 152 Table 6.9 Number and Percentage of aged care services heard of by participants.. 155 Table 6.10 Mean, Standard Deviations, Actual Range, and Potential Range of 4 Barriers to Service Use ...... 156 Table 6.11 Barriers to accessing and using aged care services ...... 157

x

Table 6.12 Correlations of service use attitudes and service barriers ...... 159 Table 6.13 Number and Percentage of participants who can perform activities of daily living independently ...... 161 Table 6.14 Number and Percentage of participants who can perform instrumental activities of daily living independently ...... 162 Table 6.15 Comparison of the sample with the older Chinese in Canada and in by depressive symptoms ...... 164 Table 7.1 Type of HACC services used by participants ...... 169 Table 7.2 Frequencies of use of HACC services by participants ...... 169 Table 7.3 Comparison of the sample with older China-born Victorians across three service types ...... 171 Table 7.4 Comparison of the sample with the older Victorians across three service types ...... 172 Table 7.5 Characteristics of the users and non-users of HACC aged care services . 173 Table 7.6 Logistic regression analysis in relation to the participants’ use of aged care services (N=120) ...... 176

xi

List of Figures

Figure 2.1 Number of Australian residents from China, Hong Kong, , , , and , 1947-2011 ...... 30 Figure 2.2 Chinese languages spoken by Australians at home, 1991-2011 ...... 32 Figure 3.1 The conceptual framework used for this study ...... 73 Figure 4.1 Recruitment procedures for this study ...... 110

List of Appendices

Appendix I Permission to use instruments ...... 219 Appendix II Questionnaire ...... 220 Appendix III Certification of translation ...... 250 Appendix IV Expert committee review ...... 251 Appendix V E-mail correspondence with A/Prof. Andrew Ryder...... 264 Appendix VI Poster ...... 266 Appendix VII Newspaper advertisement ...... 268 Appendix VIII Radio advertisement...... 270 Appendix IX Plain language statement ...... 271 Appendix X Consent form ...... 275 Appendix XI One way ANOVA summary...... 277

xii

Chapter 1 : Introduction

Populations worldwide are ageing rapidly. How to provide quality health and aged care has become a major issue facing many countries (Brega, Goodrich, Powell, & Grigsby, 2005). In

Australia, a quarter of the population is born overseas (Australian Bureau of

Statistics (ABS), 2012a). Immigrants come from over 200 countries and speak more than 200 languages. It is therefore even more challenging for the Australian

Government and service providers to provide quality care that can meet specific needs of older people from culturally and linguistically diverse (CALD) backgrounds.

One of the largest CALD groups in Australia is the older Chinese-speaking1 population; however, there is limited information on this population in relation to its aged care use. This thesis seeks, firstly, to explore the ageing experience of this large and diverse population from an intersectional perspective, in particular those who arrived in Australia later in life; and secondly, to investigate the factors associated with the use of aged care services using the Andersen Behavioural Model.

This introductory chapter sets the scene for the thesis. It begins by outlining my research experience and practice observations, which prompted me to undertake this study. This is followed by an overview of the older Australian population from a CALD background and

1 Reference to Chinese-speaking rather than Chinese is discussed further in Chapter 2.

1 their diverse needs. It provides a contextual understanding of how the older Chinese- speaking population is placed in multicultural Australia. Issues in the study of the relationship between ageing, ethnicity, and service use are discussed. The research aims and questions are also presented and the overall approach to the study elaborated. The chapter concludes with an outline of the thesis.

1.1 Motivation for this study

My interest in this topic started about ten years ago, when I was an international student from

Taiwan undertaking a Master of Social Work in Australia. The focus of my Masters thesis was a comparison of the aged care systems in Taiwan and Australia. Despite the fact that both countries have similar aged care services, the findings suggested that there was a much higher level of aged care use in Australia than in Taiwan (Huang, 2007). Two particular questions arose out of my Masters degree, namely, “Do the different welfare systems and aged care policy development in these countries contribute to this difference?” and “If yes, why do older Australians from Chinese-speaking background have lower service use than their older Australia-born counterparts?” These questions drew my attention to why there was such differential use of aged care services by host and immigrant Chinese older people and provided the impetus for further investigation.

After starting my PhD, I also took up a part-time position working in an ethno-specific community organization, assisting older Chinese-speaking immigrants to access and navigate aged care services. From this professional experience, I witnessed many difficulties that my older Chinese-speaking clients encountered, particularly those who came from China

2 recently and/or had migrated at an older age. The majority of older Chinese immigrants were unable to understand and speak English even those who had lived in Australia for more than fifteen years. Many of them had minimal social support networks, relied on adult children for the provision of income and accommodation, and were dependent on government for assistance. For those who were not entitled to any government benefits, their financial dependency on adult children made them particularly vulnerable if relationship with their children became problematic. The lack of basic English language skills diminished their ability to seek help from mainstream service providers and obtain critical information, which had a negative impact on their health and mental wellbeing.

In addition, some traditional values and beliefs my older clients possessed seemed to influence their decisions to use or not to use aged care services. I found that the notions of family harmony and filial piety were deeply entrenched in some of my clients, particularly those who lived with their adult children. For example, one 85 year- widow was very reluctant to use any home care services because she expected that her co-resident son would look after her even though he often left her at home without any food and support.

Another also refused any home care services because she worried that her daughter would be unhappy to have strangers coming to her house. Many older Chinese-speaking people seemed to have mixed and ambivalent feelings toward their adult children. On the one hand, they wanted care and love from their children and expected to be looked after as they became frail. To be reunited with their adult children’s family is one of the main reasons they were willing to leave China in old age and move to Australia. On the other hand, the reality is that living together caused many family conflicts and they could no longer expect that their busy working son or daughter could help when they were in need.

3

Since then, I have been working with older Chinese-speaking Australians on different projects, such as the Community Partners Program, Social Connectedness, and Active and

Fulfilling Ageing, as well as conducting the current study. Based on my research experience and practice observations, I have found that older Chinese-speaking immigrants in Australia appear to be socially and financially disadvantaged and tend to under-use aged care services.

The intersection of various social identities such as age, class, and immigrant status creates the unique ageing experience of older Chinese-speaking immigrants, particularly those who moved to Australia in later life. I have also noticed that there is differential use of aged care services among older Chinese-speaking immigrants, and that service use is not uniformly low across all different types of aged care services. For example, I found that programs and services that provide transportation and language-specific social activities are very popular among frail Chinese-speaking immigrants. Factors that impact on older Chinese immigrants’ use of aged care services are complex and often interwoven, including their individual circumstances, cultural influences, family resources, and care needs. Therefore, I believe that older Chinese-speaking immigrants’ access and use of aged care services can be enhanced if factors that influence their use are better known and their ageing experience better understood.

1.2 Ageing in multicultural Australia

Given the focus of this study, it is important to start with a broad understanding of

Australia’s ageing and culturally diverse population to locate the older Chinse population.

According to the latest Census, approximately 14% of the Australian population aged over 65

4 years and more than one quarter (27%) of the general population were born overseas (ABS,

2012a). Over the last decade, the aged population from culturally and linguistically diverse

(CALD) backgrounds has increased significantly not only in terms of size but also in terms of proportion relative to the total Australian aged population. In 1996, the older population from CALD backgrounds numbered 392,800 people, or 17.8% of the total older Australian population (Gibson, Braun, Benham, & Mason, 2001). It increased to 827,921 people, or

27.5% of the total older Australian population in 2011 (ABS, 2012a). This was a 111% growth rate over a 15-year period, compared with only a 17% growth rate for the Australian- born population. The Australia Institute of Health and Welfare has predicted that, by 2026, one in four people aged 80 and over will be from CALD backgrounds and their age profile will be considerably older than those born in Australia (Gibson et al., 2001).

The ethnic composition of the older population from CALD backgrounds has also changed dramatically, reflecting different waves of immigrants from different countries. Between the

1950s and 1960s, immigrants were mainly from European countries, such as Ireland, Italy, the Netherlands, Germany, Greece, Poland and Yugoslavia, while in the 1990s Asian countries, including Hong Kong, China, Vietnam, the , Malaysia and were more significant migrant source countries (DIMA, 2001). In recent years, the number of older people from Eastern European countries have gradually declined, whereas older people from Southern European and Asian countries have progressively increased their representation (ABS, 2012a).

The older Chinese-speaking population in Australia has increased dramatically since the late

1990s when a large number of ageing Chinese came to Australia on family reunion programs

5 following earlier waves of skilled and business migrants (Ip, Lui, & Chui, 2007; Marino,

Minichiello, & Macentee, 2010). Chinese now follows Italian and Greek as the third most common language spoken by older Australians. The growth rate for this population was

150% over a 15-year period from 1996 and 2011, a much higher rate than that for the overall aged CALD (111%) group and the Australia-born (17%) population (ABS, 2013; Gibson et al., 2001). It is projected that the number of the older Chinese-speaking population in

Australia will be more than ten thousands by 2026, and the rapid growth of this population will continue over the next few decades (Gibson et al., 2001). For this reason, it is critical that the experiences of older Chinese-speaking immigrants are more fully understood.

With an increasingly large and diversified ageing population, the Australian government, policy makers, and service providers are now facing greater challenges to meet the specific cultural needs of this population. Evidence shows that Australian research on older people from CALD backgrounds has been sporadic and there is a lack of understanding about how to provide culturally sensitive care (Federation of Ethnic Communities' Councils of Australia

(FECCA), 2015). Despite the acknowledgement of diversity, the aged CALD community in

Australia is still treated as a homogenous category in research. Many studies have indicated that older Australians from CALD backgrounds as a group have poorer socio-economic status, higher levels of disadvantage and vulnerability, and lower levels of health and aged care services use than older Anglo-Australians (Australian Institute of Health and Welfare

(AIHW), 2007; Benham, Gibson, Holmes, & Rowland, 2000; FECCA, 2015; Khoo, 2012;

Lister & Benson, 2006). However, very little is known about the differences between and within the older CALD population.

6 This lack of contextual information on individual ethnic groups in relation to their ageing experience can hinder service providers from addressing special needs and delivering quality care that is culturally sensitive and responsive. For example, a recent study by Khoo (2012) investigated the social and economic wellbeing of older Australians from 25 birthplaces using a number of indicators from the 2006 Census. Older Australians from Vietnam and

China are reported to have the lowest English proficiency among all immigrant groups, have lower weekly income and home ownership rates than other older European immigrants, and are more in need of assistance with daily activities than their counterparts from other Asian countries. Although the Khoo study demonstrated that older immigrants differ by county of birth, it is not clear what contributes to these differences and how they are associated with each ethnic group’s cultural and migration experience.

A review study of Australian research on the older CALD population (FECCA, 2015) has identified several research gaps and five groups of older CALD Australians that have not been well researched. One of the identified groups is people who arrive in Australia at an older age. Different from those post-World War II migrants from Italy and Greece who have been living in Australia for more than thirty years now, the new Asian immigrants, who arrived in old age, may have unique needs and face additional challenges which are not well understood. Other groups that require further investigation include new and emerging communities, older people from refugee backgrounds, people from smaller ethnic population groups, and those CALD people who live in regional, rural or remote areas.

The review also indicated that there were research gaps in planning and service delivery. One related to this study is a lack of information about specific ethnic communities and how the

7 effectiveness of programs and services meet their needs. The review found that a great deal

of Australian research has focused on identifying barriers aged CALD groups have in

accessing and using services. While it is important to understand these challenges as a

starting point, there is a need to go beyond that and to understand how individual ethnic

communities actually use available services, what the pathways to access are, and how

effective existing services are meeting care needs. It is also important to understand how the

needs and experiences of older people from CALD backgrounds differ within and between

CALD groups and from the older population in general (FECCA, 2015). This thesis

examines these questions in relation to older Chinese-speaking Australians.

1.3 Ethnicity and aged care use

Because of this considerable growth and diversity in the older population, the issue of racial

and ethnic disparities has now become a major issue facing Australia and many western

countries. It has been documented in the literature that there are racial differences in the use

of health and aged care services in the United States (Akincigil, Olfson, Siegel, Zurlo,

Walkup, & Crystal, 2011; Weinick, Zuvekas, & Cohen, 2000), the United Kingdom (Willis,

Price, & Glaser, 2013), Canada (Koehn, Neysmith, Kobayashi, & Khamisa, 2013; Quan,

Fong, De Coster, Wang, Musto, Noseworthy, & Ghali, 2006), and Australia (AIHW, 2007;

Johnstone & Kanitsaki, 2008). Evidence shows that older people from ethnic backgrounds

use less health, mental health, social and aged care services, experience greater barriers in

accessing these services, and are more likely to be socially and financially disadvantaged.

8 Previous studies have attempted to understand this issue by comparing different ethnic groups and examining whether it is ethnicity that predicts lower take-up. However, studies show inconsistent and inconclusive results. Some found no or minimal relationship between ethnicity and service use after controlling socio-demographic variables (Lun, 2004; Miller,

Campbell, Davis, Furner, Giachello, Prohaska, Kaufman, Li, & Perez, 1996; White-Means &

Rubin, 2004), suggesting the differences in service use maybe the result of poor education, and low socio-economic status. However, some reported that the effect of ethnicity persists even after other key variables are controlled (Cagney & Agree, 1999; Lee, Peek, & Coward,

1998; Wallace, Levy-Storms, Kington, & Andersen, 1998; Webster, Curry, McGraw,

Buckser, & Bradley, 2004). These studies suggest that beliefs, values, cultural preferences and norms, and family structure may contribute to differences in service use.

There are several reasons, however, why findings are inconclusive. First, the effect of ethnicity on health and aged care use is multifaceted. Ethnicity as a predictor interacts with a wide range of other factors that may influence service access and use, such as demographics, socioeconomic and health status, values, preferences, family structure and informal resources.

The findings of these studies can vary considerably in terms of how ethnicity as a variable is defined and what other variables are included and controlled. Second, these studies interrogated the relationship between ethnicity and service use in a range of settings and with a variety of ethnic populations. Differences in the characteristics of ethnic groups, service types, and delivery system between countries may account for the different results. In addition, the sampling methods and recruitment strategies that each study adopted can also contribute to differences in findings.

9 In response to the limitations of ethnicity as a predictive factor or a single analytical category, some scholars have suggested that gerontologists should broaden their understanding of ethnicity and examine the issue of ageing and ethnicity from a social constructionist and intersectional perspectives (Koehn et al., 2013; Torres, 2014; Zubair & Norris, 2015). Torres

(2014) argues that ethnicity should not be understood as a fixed category or an independent variable that merely distinguishes one “individual” from “others” based on appearance or nationality. Rather, it should be viewed as a fluid concept determined by the interaction of both attribution (what others ascribe to us) and self-assertion (who we claim to be). The boundaries between “us” and “others” are seen as negotiable and contextually dependent. In other words, the significance of ethnicity on ageing experience and service use can vary depending on how ethnicity is constructed and understood.

In line with this argument, Koehn et al. (2013) suggests that the experiences of accessing health care by people from different ethnic backgrounds should not be merely understood as the effect of one fixed category, like ethnicity, but the reciprocities between several social identities, including age, gender, class, and immigrant status. This is where the term

“intersectionality” becomes relevant. Intersectionality was first coined by the legal scholar

Kimberlé Crenshaw in 1989 to address the intersection of race and gender that black women experienced as mutually inclusive and unable to be analysed separately (Crenshaw, 1989,

1991). The concept has been since developed and adopted in various fields of study to address overlapping social identities and related systems of oppression and discrimination.

Unlike the double or multiple jeopardy theory that stresses the additive linear effects of disadvantage (Rowland, 2007), intersectionality draws attention to the interaction effects of multiple systems of oppression. For example, the disempowering experience that older

10 Chinese immigrants have in accessing and using aged care services should not be simply seen as the subsumed disadvantage of being old and a minority. Rather, it should be understood from the perspective of how various social identities of older Chinese immigrants interact simultaneously and leads to a disempowering experience in service access (Koehn et al., 2013). Using the concept of intersectionality, discussed further in Chapter 3, is useful in understanding these relationships.

Despite advances in the understanding of ethnicity as well as the notion of intersectionality, many current ageing studies still adopt a one factor view of ethnicity and overlook the intersectional relationships between several categories of difference that are contextually dependent. These studies compared several ethnic groups with the mainstream population and attempted to demonstrate that ethnicity is a main predictor of low service use. This thesis therefore only focuses on one group, older Chinese-speaking immigrants to explore how differences among this population influence their ageing experience and service use.

There have been some studies conducted in Canada and the United States investigating older

Chinese immigrants’ use of aged care services (Aroian, Wu, & Tran, 2005; Kuo & Torres-

Gil, 2001; Lai, 2004a; Liu, 2003; Zhan, King, Kim, Zhang, & Whittington, 2004). The findings of these studies confirm that older Chinese immigrants as a group are internally diversified and their service needs and utilisation vary in relation to their cultural background, personal circumstances, values, beliefs, and care resources. However, many Chinese seniors in these studies were earlier settlers from Taiwan, Hong Kong, China or South-East , and the majority speak and migrated during the 1970s and 1980s. Their migratory circumstance, cultural backgrounds and beliefs may therefore be different from those

11 mainland Chinese seniors who came to Australia in the 1990s and 2000s as ageing parents. In addition, these studies were conducted in countries where the welfare system and service delivery model was different from Australia.

As mentioned earlier, many Australian studies still treat the ethnic aged population as a single group (Cioffi, 2003; Orb, 2002; Rao, Warburton, & Bartlett, 2006; Ward, Anderson, &

Sheldon, 2005). In contrast to its fast growing number and needs for support services, there is much less information about the older Chinese-speaking population in Australia. In the last two decades, a number of Australian studies have focused on older Chinese as an individual group, examining quality of life, social isolation, family care, palliative care, and fall prevention (Hsu, Lee, & O'Connor, 2005 ; Ip et al., 2007; Lo & Russell, 2007; Tsang,

Liamputtong, & Pierson, 2004; Yang, Haralambous, Angus, & Hill, 2008). However, there is currently no detailed investigation of aged care use by this population. This thesis sets out to examine older Chinese-speaking Australians’ use of aged care services and factors associated with that use.

1.4 Research aims and questions

The overall aim of this study was to understand the ageing experience of older Chinese- speaking immigrants in Australia, and explore the patterns of and factors associated with aged care service utilization by this population. This study was positioned within a pragmatist paradigm (see Chapter 4 for detailed discussion), using both the Andersen

Behavioural Model and intersectionality as analytical frameworks.

12 The Andersen Behavioural Model (Andersen & Newman, 1973; Andersen, 1995; Andersen

& Davidson, 2001) was used to examine aged care use by older Chinese-speaking immigrants and investigate possible factors associated with that use. The wide range of factors that determine the use of aged care services, described in greater detail in Chapter 3, are theoretically categorized as “predisposing”, “enabling” and “need” factors. Predisposing factors refer to people’s inclination towards service use, such as demographics, social structures, and beliefs. Enabling factors facilitate use or act as barriers impeding uptake, and need factors refer to users’ perceived and evaluated need for care. The model proposes that the predisposing, enabling and need factors have different explanatory application depending upon the type of service sought, and differences in service utilisation are considered inequitable if socioeconomic variables or enabling factors are dominant determinants

(Andersen, 1995; Andersen et.al, 2001; Mitchell & Krout, 1998).

The notion of Intersectionality was used to understand how various categories of difference among older Chinese-speaking immigrants may interact to influence their aging experience and aged care use in Australia, particularly for those who migrated at an older age. Instead of merely summarising the intra-diversity of the elderly Chinese population, this study aimed to explore the intersectional effect of multiple social identities such as age, social class, gender, and immigration status and how that creates the unique ageing experience of this population.

This study aimed to investigate which variables in the Andersen Behavioural Model contribute the most in determining older Chinese-speaking immigrants’ use of aged care services, and to understand whether their access to service is equitable through the lens of intersectionality. In order to explore and examine the intradiversity of older Chinese-

13 speaking immigrants, a cross-sectional survey design was adopted to collect a wide range of individual and other characteristics that were associated with the ageing experience and use of aged care services. The survey was interviewer-administrated and conducted in

Melbourne’s four metropolitan regions.

Given the overarching research aim was to understand the experience of ageing and aged care use by older Chinese-speaking Australians, this study sought to answer three specific research questions:

1. What were the various categories of difference (eg age, class, and immigration)

amongst older Chinese-speaking immigrants, and how did these differences interact

to influence their aging experience and general wellbeing in Australia, particularly for

those who migrated at an older age?

2. What was the pattern of aged care use by older Chinese-speaking immigrants in

Australia applying the Andersen Behavioural Model of predisposing, enabling and

need factors, and which factors predominantly determine their use of aged care

services?

3. What was the contribution of the Andersen Behavioural Model and intersectionality

to understanding aged care use by older Chinese-speaking immigrants?

By answering these questions, this thesis addresses the gap in understanding the needs of older Chinese-speaking immigrants by exploring use patterns and factors associated with this use. From a practice and policy perspective, the findings of this research provide Australian-

14 based evidence to enhance understanding of this population and the provision of culturally appropriate aged care services. From a research perspective, this study enhances knowledge through the application of intersectionality and Andersen Behavioural Model to understand aged care utilisation by diverse ethnic minorities.

1.5 Terminology used in this study

Older Chinese-Speaking Immigrants — Overseas-born Australians who are over 65 years old and speak a Chinese language at home. The rationale of focusing on older “Chinese- speaking” immigrants is discussed in the next chapter.

Aged Care Services — The Australian Government subsidises services that help older people stay independently at home or are provided in aged care homes. Various services range from home nursing, delivered meals, home help and home maintenance to transport, shopping assistance, allied health services and respite care.

CALD —— An acronym which stands for Culturally and Linguistically Diverse. In the

Australian context, CALD communities are those which comprise people for whom English is not their primary language, or who were born into a culture significantly different to the dominant Australian culture.

1.6 Structure of the Thesis

15 The thesis is divided into nine chapters. This first chapter sets the scene for this thesis.

Chapter Two provides a contextual background to this study in relation to the older Chinese population in Australia. It begins with a definition of who is considered Chinese, followed by an historical account of Chinese migration to Australia and the impact of that migration on older ’s ageing experiences. The growth of the older Chinese-speaking population and their need for aged care is also explored.

Chapter Three focuses on exploring the current state of knowledge about aged care utilisation by older people from ethnic backgrounds. It begins by examining existing evidence on ethnic differences in aged care use among older Australians from culturally and linguistically diverse backgrounds. It presents several models and frameworks used to understand aged care use by different ethnic groups. A review of empirical evidence on factors influencing aged care utilisation by older Chinese people is examined. The chapter concludes by summarising how aged care use by older Chinese-speaking immigrants has been conceptualised for the purposes of this research.

Chapter Four begins by discussing the overall methodological and ethical considerations relevant to this study, including philosophical position, cultural sensitivity, and other ethical challenges. It addresses the three main research questions that this study has attempted to answer. Data collection methods and processes are described and background information on the construction of the questionnaire provided. This chapter concludes with a discussion of the ethical issues presented by the research and how these issues were managed.

16

Chapters Five to Seven present the results of the study. Chapter Five compares the sample with the 2011 Census data in terms of demographics, immigration status, socioeconomic background, and health. Chapter Six presents the statistical analysis of the questionnaire in light of predisposing, enabling and need factors. The relationships between these factors are also discussed. Chapter Seven then describes the aged care utilisation of older Chinese who participated in this study. Type of aged care services used by the participants, characteristics of users and non-users, and the main factors that impacted on aged care utilisation are presented. Finally, Chapter Eight discusses the research findings in the context of the three research questions and the strengths and limitations of the thesis. The possible directions for future research on aged care use by the ethnic aged are identified, and recommendations for future service development made.

1.7 Summary

This chapter has outlined my research experience and practice observations, which prompted me to undertake this study. This is followed by an overview of the older Australian population from a CALD background and their diverse needs. Issues in the study of ageing, ethnicity, and service use are discussed. The research aims and questions are presented and the overall approach to the study elaborated. The chapter concludes with an overview of the thesis.

17

18 Chapter 2: The ageing experience of older Chinese-speaking Australians

This chapter aims to provide the contextual background related to older Chinese-speaking immigrants in Australia, the study population of this research. It begins with consideration of definitions, who is considered a Chinese immigrant, followed by discussion of the current growth of the older Chinse population in Australia and increasing needs for aged care. The ageing experience of older Chinese-speaking immigrants in Australia is understood and examined through an intersectional lens. The impact of migration on older Chinese-speaking

Australians in relation to different periods of arrival, country of origin, and migration program are explored. This chapter ends by discussing cultural and family influences on the ageing experience of older Chinese immigrants and how that may have an impact on aged care use.

2.1 Defining Chinese ethnicity: ancestry, language, or nationality?

As stated in the Chapter 1, a quarter of the Australian aged population comes from culturally and linguistically diverse backgrounds. The Australian Bureau of Statistics (1999) identified a set of variables to define cultural and linguistic diversity, with the aim of developing a more accurate, effective, and consistent estimate of the CALD population. This included four core variables: Country of Birth of Person, Main Language Other than English Spoken at

Home, Proficiency in Spoken English, Indigenous Status, and eight additional variables:

Ancestry, Country of Birth of Father, Country of Birth of Mother, First Language Spoken,

19 Language Spoken at Home, Main Language Spoken at Home, Religious Affiliation, and

Year of Arrival in Australia. Each of these indicators, to some degree, represents the cultural preference and language competence of the CALD population, which can have an impact on their wellbeing and access to services.

Despite this overview, it is still quite challenging to define and estimate the older Chinese population in Australia because of several factors. The word “Chinese” can be used to describe a person’s identity, ancestry, language, and/or nationality. Different criteria therefore can identify several different Chinese populations. According to the 2011 Census, there were 57,532 older Australians claiming Chinese ancestry, 48,811 older Australians who spoke a Chinese language at home, and 31,578 older Australians who were born in China

(ABS, 2013). Table 2.1 shows a comparison of population characteristics by these three different categories.

Table 2.1 Comparison of the Australian Chinese population by three different definitions, 2011 Ancestry Languages spoken Birthplace (Chinese Asian) at home (Chinese(a)) (China) n % N % n % Language spoke at home: English 6,451 11.2 1,976 6.3 Chinese(a) 46,822 81.4 48,811 100.0 27,329 86.5 Country of Birth: China 27,773 48.3 27,330 56.0 31,578 100.0 Malaysia 7,525 13.1 6,019 12.3 Vietnam 4,678 8.1 3,487 7.1 Hong Kong 3,971 6.9 3,798 7.8 Australia 2,761 4.8 543 1.1 Singapore 1,862 3.2 1,204 2.5 Taiwan 986 1.7 974 2.0 Other countries 7,976 13.9 5,456 11.2 Total 57,532 100.0 48,811 100.0 31,578 100.0 (a) Includes Cantonese, Hakka, Mandarin, Wu, Min Nan, and Chinese (not further defined)

Source： (ABS, 2013)

20

Blignault and Haghshenas (2005) reviewed 44 national health data collections and found that the most commonly used indicator to identify the CALD population in Australia is country of birth, followed by language, and year of arrival, or period of residence in Australia. Although country of birth is the most commonly used indicator for cultural and linguistic diversity in

Australia, it may not be the best way to identify the older Chinese population in terms of service planning and delivery. As Table 2.1 highlights, older China-born Australians account for only 48% of the older self-identified Chinese and 56% of the older Chinese-speaking population in Australia. Many older Australians who were born in Hong Kong, Taiwan, and

Macau, and other Southeast Asian countries also identify themselves as Chinese and/or speak a Chinese language at home. Using the birthplace of a person to identity the older Chinese population can underestimate the number of people who require Chinese-specific aged care services, and may result in inappropriate service matching. For example, older people born in

Vietnam may identify themselves as being Chinese and speak Chinese rather than

Vietnamese at home. If culturally appropriate services are arranged based on their birthplace, they could wrongly be provided with a Vietnamese-speaking interpreter or Vietnamese worker with whom they may not feel comfortable.

Ancestry is used as another indicator to identity the Chinese population but it can overestimate the number who need specific cultural and language support. As shown in Table

2.1, 5% and 11% of older Chinese Asians were born in Australia and spoke only English at home. For those older Australian-born or English-speaking Chinese, they tend to assimilate into the mainstream culture and have no difficulty communicating with service providers.

However, it is important to note that some older self-identified or English-speaking Chinese

21 may not need language-specific aged care services but may still require culturally sensitive aged care in which their preferences and needs are attended to.

Language spoken at home was recommended by Howe (2006) in the Victorian Government report the “Cultural diversity, ageing and HACC” as a more appropriate indicator for identifying cultural and linguistic needs of the elderly population. Language is an essential element of culture and an important part of identity. People use language every day to communicate, express thoughts and feelings, exchange information, and maintain social relationships. This is all important in shaping one’s lifestyle as well as choices about aged care. There are more than 10 different Chinese dialects spoken by Australians from Chinese backgrounds. The majority speak either Mandarin or Cantonese. Some understand both but a few only speak their own dialect.

The complexities involved in defining who is considered “Chinese” show the diversity within this population. A group of people may all identify themselves as Chinese but at the same time they possess several sub-identities in relation to country of birth, spoken Chinese language, and immigration status. This study aims to explore how the various categories of difference among older Chinese immigrants interact to influence their ageing experience and service utilisation. In this study, speaking a Chinese language was used as a key criterion to identify the older Chinese population for the following reasons. Firstly, older Australians who speak a Chinese language at home came from a variety of birthplaces at different periods of time, and brought various cultural beliefs and practices to Australia. Using a language to identify the study population can capture the major categories of difference among this population such as birthplace, time of arrival, and cultural orientation. Secondly,

22 for older Chinese immigrants, language is one of the most important factors forming their personal identity and building community connections in Australia. Language is also an important tool when accessing information, navigating resources, and negotiating service contracts or agreements with providers.

Given the importance of language in daily life and aged care use, this study therefore focuses on older Chinese-speaking Australians as the target group, particularly those who arrived in

Australia at an older age. “Language spoken at home” was used as the key criterion to draw data from the Census for comparison purposes, which helps to understand the differences within and between the older Chinese-speaking population and the general older Australian population.

2.2 Trends in growth of the older Chinese population

According to all the different definitions used above, the number of older Chinese has increased dramatically over the last few decades and it is projected that this will continue for the next two decades. In 1996 there were 18,000 older Australians who were born in China

(0.8% of the older Australian population), and China ranked sixth among the birthplaces of older immigrants from CALD backgrounds (Gibson et al., 2001). By 2011, China became the fifth largest group of older people from CALD backgrounds. The number of the older China- born population increased to 31,578 (1.0% of the older Australian population), with a growth rate of 75% over a 15-year period to 2011 (ABS, 2013). Between 2011 and 2026, the older population born in China is projected to grow by 79%. China is projected to move into fourth

23 place, with 50,600 people constituting 1.1% of the older Australian population (Gibson et al.,

2001).

The Chinese-speaking aged population is also growing rapidly. In 1996, there was a total of

20,644 older Australians speaking a Chinese language at home, including 14,792 Cantonese speakers, 3,750 Mandarin speakers, and 2,102 who spoke other Chinese languages (Gibson et al., 2001). This elderly Chinese-speaking population more than doubled by 2011, with a growth rate of 92% in the Cantonese group, 325% in the Mandarin group, and 112% in the other Chinese languages group (ABS, 2013; Gibson et al., 2001). Cantonese is now the third most commonly spoken language by older people from CALD backgrounds, while Mandarin is the seventh most commonly used foreign language among the CALD aged population. The report on the projections of older immigrants in Australia (Gibson et al., 2001) revealed that the numbers of older people who speak Cantonese and Mandarin at home will continue to rise substantially between 2011 and 2026, in particular those speaking Mandarin at home.

With the fast-growing number of older Chinese in Australia, it is expected that there will be increasing demand for care and support services for this population, particularly those aged over 85 years old. Table 2.2 (overleaf) shows the age distribution of older Australians who speak a Chinese language at home between 1996 and 2026. In 1996, there were only 1,319 older Chinese-speaking seniors who were over 85 years and the number increased to 4,603 by 2011. It is projected that approximately ten thousand older Chinese-speaking seniors will be aged 85 years and over in 2026.

24 Table 2.2 Older Australians who speak Chinese at home by age, 1996-2026 1996 2011 2026 (projections) n % n % n % 65-69 7,748 37.5 15,070 30.9 33,585 34.1 70-74 5,643 27.3 12,854 26.3 28,201 28.6 75-79 3,832 18.6 10,075 20.6 18,671 19.0 80-84 2,102 10.2 6,209 12.7 8,378 8.5 85+ 1,319 6.4 4,603 9.4 9,677 9.8 Total 65+ 20,644 100 48,811 100 98,512 100 Source：(ABS, 2013; Gibson et al., 2001)

In a Victorian Government report (Howe, 2006), CALD communities were grouped into three clusters in relation to their patterns of ageing and needs for culturally oriented community care. The Chinese-speaking community in was identified as one of six communities with a growing need for culturally oriented community care because it had much larger numbers aged 45-64 compared to the present number aged over 65, and high proportions not proficient in English. Dutch, German and Polish communities were seen as having a waning need for culturally oriented aged care as old established immigrant groups.

There were seven communities such as the Greeks with a sustained need because their migration had peaked earlier with large middle aged cohorts that were now moving into the older age range.

For the purpose of service planning and policy development, Rowland (1999, 2007) argues that not all people from non-English speaking countries are equally likely to have ethno- specific needs in aged care. The newly-arrived and those with little or no English are considered to be more vulnerable and have higher probability of having special needs, while those with good English and speaking only English at home are considered to be less vulnerable and less likely to have special needs. However, some have commented that using only recency of arrival and proficiency in English to assess the needs of older people from

25 CALD backgrounds is oversimplified (Petrov & Arnold, 2000). They argue that the length of stay and language proficiency does not necessarily equal cultural integration, and it is possible to live in a country and become quite fluent in its language but still be isolated and not culturally integrated.

According to the 2011 Census data, approximately 67% of older Chinese-speaking

Australians reported that they cannot speak English well or not at all, and close to 7 % arrived in Australia less than five years ago (ABS, 2013). This indicates that the majority of the Chinese-speaking elderly would fall into the more vulnerable group and have higher probability of needing ethno-specific aged care services. Mandarin-speaking seniors are particularly vulnerable. As Table 2.3 highlights (overleaf), they are more likely to be recent arrivals, born in , and have lower levels of English proficiency than their

Cantonese-speaking counterparts. On the other hand, the Cantonese-speaking population has an older age profile and greater numbers of them are aged over 85 years; therefore they are more likely to require aged care support services.

Given the rapid growth of the older Chinese-speaking population and their vulnerability, demands for those specific aged care and support services are expected to increase significantly. As the majority are identified as being more likely to use ethno-specific services, governments and service providers will face increasing challenges in the provision of culturally and linguistically appropriate aged care services for Chinese-speaking seniors in

Australia. More research is needed to provide detailed information for governments, policy makers and service providers to understand ageing issues of the older Chinese-speaking community and to meet their diverse needs for aged care in Australia.

26 Table 2.3 English proficiency and year of arrival of three Chinese language groups Cantonese Mandarin Other Chinese(a) 2011 n % n % n % Age: 65-74 15,663 55.1 9,705 60.9 2,556 57.2 75-84 9,610 33.4 5,317 33.8 1,360 30.4 85+ 3,129 11.0 922 5.8 549 12.3 English Proficiency: Very well 5,599 19.7 1,512 9.5 1,070 24.0 Well 4,862 17.1 2,246 14.1 623 14.0 Not well 9,020 31.8 6,272 39.3 1,406 31.5 Not at all 8,714 30.7 5,756 36.1 1,319 29.5 Year of Arrival: After 2007 859 3.0 2,109 13.2 198 4.4 1997-2006 2,620 9.2 4,083 25.6 443 9.9 1987-1996 8,353 29.4 5,361 33.6 1,373 30.8 1977-1986 8,293 29.2 2,082 13.1 1,518 34.0 1967-1976 3,135 11.0 550 3.4 389 8.7 Before 1966 3,073 10.8 461 2.9 247 5.5 Country of Birth: China 14,670 51.6 11,257 70.6 1,402 31.4 Total 28,402 100.0 15,944 100.0 4,465 100.0 (a) Includes Hakka, Min Nan, Wu, and Chinese (not further defined).

Source: (ABS, 2013)

2.3 The impact of migration on the ageing experience

The aged Chinese-speaking community has now become one of the largest and fastest

growing ethnic groups in Australia. As described earlier in this chapter, this group has come

from dozens of countries, speaks more than ten different dialects at home, and has arrived in

Australia at different times under various migration programs. From an historic perspective,

Chinese can be briefly divided into three phases, the restricted

period (before 1970s), Chinese immigrants from a diverse range of countries (1970s-1990s),

and more recent mainland Chinese migration (after 1990s). Evidence suggests that the

circumstances of people at the time of their migration and years of residency determine their

psychosocial wellbeing and economic status in the host country (Liu, 2003; Rao et al., 2006 ).

27 Most importantly, it can further affect their ageing experiences and care needs in later life

(Rowland, 2007), and so for the purpose of this thesis, a brief overview is provided.

The restricted period (before 1970s)

The history of Chinese migration to Australia can be traced back to the mid-1800s when large numbers of Chinese people came to Victoria and later to , hoping to strike gold (Wang, 1988). The enactment of the Immigration Restriction Act in 1901 officially banned the intake of migrants from non-European countries, and accordingly the number of the Chinese population in Australia declined (Yuan, 1988). Although the White

Australia policy was not lifted until the mid-1970s, numbers of new Chinese arrivals began to increase slowly in the post-war period. Some of these immigrants came to Australia as refugees from the Chinese Diaspora and others arrived in Australia as students under the

Colombo Plan from South and (Williams, 1999).

According to the 2011 Census, approximately 10% of the older Chinese-speaking population today arrived in Australia between 1930 and 1970. As many were very young at the time of arrival, they established families and grew old in Australia. Compared with those who migrated later in life, these earlier immigrants had opportunities to develop their English language skills and accumulate financial and social capital through many years of studying, working and living in Australia. The majority of older Chinese-speaking immigrants arriving before 1970 were Cantonese speakers and claimed in the Census that they could speak

English well or very well (ABS, 2013).

28 Chinese immigrants from a diverse range of countries (1970s-1990s)

A new wave of Chinese migration to Australia began during the mid 1970s when the

Australian government formulated a policy on the intake of refugees and abolished the White

Australia policy. Between 1976 and 1995, there were large numbers of Indochinese refugees arriving in Australia from Vietnam, Cambodia and Laos (Castles, 1991; Viviani, 1996).

Because of wars, these people were forced to leave their homelands and seek asylum in

Australia. An analysis of Indochinese immigration to Australia between 1975 and 1995 showed that 25% of those from Vietnam, half of those from Cambodia, and 10% of those from Laos were ethnic Chinese (Viviani, 1996).

In addition to refugees from Indo-China, there was an influx of Chinese immigrants from a variety of countries during the 1970s and 1980s due to changes in Australian immigration policy and shifts in socio-economic and geopolitical circumstances in the Asia-Pacific

Region (Ip, Hibbins, & Chui, 2006). Figure 2.1 (overleaf) maps the number of Australians from the six main birthplaces for Chinese-speaking immigrants between 1947 and 2011.

The late 1970s and mid 1980s saw a steady rise in immigration of the China-born population, which was attributed to the abolition of the Immigration Restriction Act, the relaxation of

Chinese government controls in relation to overseas study, and the introduction of the

Australian-Chinese Family Reunion Agreement (DIMA, 2001). Immigration from Malaysia was strong during the 1970s and 1980s, and Malaysia was one of the ten top source countries for immigration to Australia in the same period (Mak & Chan, 1995). The Singapore-born

29 population in Australia also grew rapidly in the 1980s, with a 104.8% increase from 1981 to

1986 and a 56% increase from 1986 to 1991 (Collins & Reid, 1995).

350

300

250

200

150

100

50 Number of Australian Numberresidents (1000) 0 1947 1954 1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011

China Hong Kong Taiwan Malaysia Signapore Vietnam

Sources: (ABS, 1947, 1954, 1961, 1966, 1971, 1976, 1981, 1986, 1991, 1996, 2003, 2008, 2013)

Figure 2.1 Number of Australian residents from China, Hong Kong, Taiwan, Malaysia, Singapore, and Vietnam, 1947-2011

In the 1980s numerous Hong Kong middle class people entered Australia as skilled labour and business migrants because of the uncertainty of Hong Kong’s economic and political future after 1997 (Lui, 2006). In the four year period from 1989 to 1993 Hong Kong was second only to the United Kingdom as a source of Australian immigrants (Mak et al., 1995).

There was also a significant increase of the business immigrant population from Taiwan during the late 1980s and early 1990s due to loosening political controls and soaring economic development (Lui, 2006).

30 According to the 2011 Census, close to 45% of the older Chinese-speaking population arrived in Australia between 1970 and 1990. Although many spoke Cantonese at home, they were very diverse in relation to their country of birth, migration circumstances, and socio- economic status. A review of Chinese migration to Australia between 1945-1994 (Collins et al., 1995) suggests that those born in Cambodia, Vietnam, Laos, and China were more likely to have entered under the family or humanitarian programs, whereas those born in Hong

Kong, Singapore, and Malaysia were more likely to have come under skilled or business migration categories. Because of these different migration characteristics, the former group tended to have considerable English difficulty, worked as unskilled manual laborers in factories, and experienced a high rate of unemployment and low income (Collins et al., 1995;

Martin, 1998a). On the other hand, the latter group was more likely to have a good command of English, work as professionals or semi-professionals, and have higher levels of income and education (Collins et al., 1995; Lui, 2006; Martin, 1998a).

Most recent mainland Chinese migration (after 1990s)

The number of mainland China-born population in Australia only started to increase rapidly when the Australian Government began actively marketing its educational services overseas in the mid-1980s (see Figure 2.1). After the Tiananmen Square protests in 1989, the

Australian government granted four-year entry permits to more than ten thousand Chinese students, giving them also the right to apply for family members to enter Australia. In the late

1990s and 2000s, the Australian Government announced several changes to the General

Skilled Migration Programme, including the provision of bonus points for former overseas students and the introduction of the Migration Occupations in Demand List (Koleth, 2010).

31 These changes strengthened the link between the overseas education program and the skilled migration program, and also promoted the flow of recent skilled migration of mainland

Chinese to Australia. Once these skilled immigrants settled and started a family, many sponsored their ageing parents to come to Australia for family reunion and childcare provision.

Figure 2.2 indicates the number of the population from Chinese-speaking backgrounds and languages they spoke at home between 1991 and 2011. Mandarin speakers have grown significantly during the past two decades, increasing from 21% to 52% of the total Chinese- speaking population, while the proportion of Cantonese speakers and people who spoke other

Chinese languages at home have decreased gradually by 22% and 9% respectively. Mandarin is now the most common language other than English spoken by Australians at home, followed by Italian, Arabic, Cantonese, and Greek (ABS, 2012a). However, Cantonese is still the most commonly used language among the older Chinese-speaking population in Australia because a large number of earlier Chinese immigrants were Cantonese speakers.

700 600 8% 500 7% 52% 400 9%

44% 300 14% 35% 17% 27% 200 21% 56% 49% 40% 100 62% 59% home (1000) home 0

1991 1996 2001 2006 2011 spokeChinese langugaes at Number ofAustralians Numberwho Cantonese Mandarin Other Chinese Languages

Sources: (ABS, 1996, 2003, 2008, 2013; Castles, 1991)

Figure 2.2 Chinese languages spoken by Australians at home, 1991-2011

32 Approximately 38% of the older Chinese-speaking population today arrived in Australia between 1991 and 2011 (ABS, 2013). They are more likely to be Mandarin speakers, coming from Mainland China through the parent immigration category. There are two main types of parent migration category, namely Parent (non-contributory) Visa and Contributory Parent

Visa. Because of limited numbers for Parent Visa applicants each year and a very long waitlist, the Contributory Parent Visa was introduced in 2003, aiming to fast track applications for Permanent Residence by parents of Australian citizens or Permanent

Residents who were prepared to pay a significant application fee and security bond (DIBP

(DIBP, 2015). In 2011-2014, there was a total of 12,259 Chinese immigrating to Australia via the parent (both contributory and non-contributory) category. People from mainland

China have been the main recipients of Parent Visas since 2008-2009, receiving almost half

(48.5 per cent) of all Parent Visas granted in 2013–14 (DIBP, 2014).

The main criteria for both visa applications are the same but the benefits that they are entitled after arriving in Australia are different. For those who apply for the Contributory Parent Visa, their adult children who are the Australian residents (the assurer) have to sign an agreement

(Assurance of Support-AOS) with the Australian Government to ensure that their parents (the assuree) do not need to rely on government payments for 10 years. If the parent receives any government payments during the AOS period, the assurer must repay this money. Some older

Chinese who apply for the Contributory Parent Visa have to transfer their overseas assets to pay for this visa but cannot access any other government assistance and payments because of the 10 year AOS period and residence requirement for the Australian aged pension. For those who hold a Parent Visa, they are entitled to apply for public housing and can access other benefits, such as Special Benefit and Widows Allowance after 2 years of residency in

33 Australia even though they still need to meet the 10 year residence requirement for the

Australian aged pension.

This group of older Chinese-speaking people who were relatively recent migrants and arrived in Australia at an old age through the parent immigration category is particularly vulnerable because of financial insecurity and social isolation. The majority of these older Chinese immigrants cannot drive and speak very little or no English; therefore they have to rely on public transport and others for transport and communication. They are highly dependent on their adult children who may see them as a ‘financial liability’ (Ip et al., 2007). Many of them live with their adult children due to social and financial considerations. They also may experience loneliness and social isolation even though they are living with family.

Compared with earlier settlers, these recent Chinese-speaking immigrants who arrived at an older age face many more challenges than younger immigrants. They have to cope with a different culture and language at an age when they are less open to adjustment and less motivated to learn (Thomas, 2003). At the same time, they face age-related changes and challenges in an unfamiliar cultural context. The literature suggests that those who had come to Australia recently as older persons can have feelings of ‘aging out of place’ or ‘in the wrong place’ because they are not ageing in their “normal” surroundings (Atwell, Correa-

Velez, & Gifford, 2007; Hugman, Bartolomei, & Pittaway, 2004). This group is often underrepresented in Australian ageing research (FECCA, 2015) and more research is needed to explore their ageing experiences and special care needs.

34 2.4 Cultural and family influences on the ageing experience

Despite the differences in their migration circumstances and age of arrival, it has been noted

that many elderly Chinese-speaking immigrants share noticeable similarities in their

traditional Chinese values, beliefs, customs, and practices that have been passed down from

generation to generation (Chan & Leong, 1994; Chau, Yu, & Law, 2014; Kimba & Carew,

1990; Mak et al., 1995; Martin, 1998a). Many studies have found that the intersection of

culture and family plays an important role in determining older Chinese immigrants’

everyday lives and influence their beliefs and behaviours in relation to ageing and help-

seeking behaviours (Fan, 2007; Hsu, O'Connor, & Lee, 2009; Kwok & Sullivan, 2006; Lai,

2009 ; Smith & Hung, 2012; Yang et al., 2008). These cultural and family factors are now

considered.

The impact of culture: traditional values and cultural practice

Taoism, , and are the three main philosophies or religions in China,

which have a profound influence on traditional Chinese culture and thought. Many of the

beliefs that arise in these three traditions influence understandings of health and well-being,

and in turn, beliefs about health care interventions and services. Given this, a brief overview

of these three philosophies or religions is presented. including the concepts of yin

and yang emphasises the importance of maintaining harmony with nature. It is of particular

relevance to Chinese people’s views on health, illness, treatment and medical care ( Kwok &

Sullivan, 2006; Kwok & Sullivan, 2007; Lai & Surood, 2009; Yeo, Meiser, Barlow-Stewart,

Goldstein, Tucker, & Eisenbruch, 2005; Yip, 2004, 2005), and therefore their views on aged

35 care services. Many Chinese, including those living in western countries prefer non-invasive and natural remedies such as food supplements and traditional Chinese medicines to treat illness before considering western treatments (Kong & Hsieh, 2011; Lai et al., 2009).

Western medicine and treatment are seen as strong and quickly effective, but potentially harmful to the body and having unpleasant side-effects (Kwok et al., 2007). Taoism also promotes self-transcendence, self-preservation, non-interference and inaction which have a crucial impact on Chinese older people’s fatalistic attitudes and help-seeking behaviours

(Kwok et al., 2006; Yeo et al., 2005; Yip, 2004, 2005).

Buddhism has had a significant influence on Chinese culture for thousands of years. Chinese who are strongly influenced by Buddhist beliefs prefer self-endurance and tolerance in facing pains and hardships because they believe that suffering is a normal part of human existence

(Yamashiro & Matsuoka, 1997). In addition, Buddhists believe in karma which embodies the consequences of individual deeds and decides their fate in the present or next life (Hsu et al.,

2009). Misfortunes and illness are viewed as the result of past or current misdeeds and individuals are encouraged to endure suffering and transcend these conditions to acquire wisdom and inner peace (Lai et al., 2009; Yamashiro et al., 1997; Yeo et al., 2005).

Confucianism emphasises the importance of social rules for proper social conduct and family as the foundation of morality in society (Kimba et al., 1990; Mak et al., 1995; Martin, 1998a).

Individual identities are defined in terms of roles and interpersonal relationships within the family rather than by the individual’s sense of self (Kimba et al., 1990; Mak et al., 1995). For instance, between husband and wife, women are generally expected to play a subservient role while men are seen as head of the family. Between parent and child, there is affection and

36 reciprocity. Parents should care and sacrifice for their children, and in return adult children are obligated to respect and look after their ageing parents (Canda, 2013).

Compared to their western counterparts, Chinese-speaking seniors under these cultural influences may have different understandings of what constitutes ageing well and successfully. For example, in a comparative study of successful aging, Tan, Ward & Ziaian,

(2011) found that older Chinese-speaking Australians regard heredity as a relatively important factor to successful ageing compared to their English-speaking and Anglo-

Australian counterparts. In another Australian study by Kwok et al. (2006), Chinese-

Australian women were found to be heavily influenced by their traditional culture, believing that contracting disease is inevitable and that there is no way to prevent it. Evidence also shows that older Taiwanese women believe in karma and cause and effect so that doing good deeds and being satisfied with what you have are seen as important to achieve successful ageing (Chen, 2007). Older Chinese in Hong Kong view their family’s willingness to meet their needs as a sign of successful ageing and successful agers were thought to be tolerant, easy-going, and not troublesome (Torres, 1999). These interdependent and sometimes fatalistic views of Chinese-speaking seniors may well affect the way in which they comprehend the ageing process and seek formal help.

Cultural background has an important influence not only on beliefs and values but also on behaviours and lifestyle. Evidence shows that older Chinese immigrants have tried to maintain their language and cultural heritage by speaking Chinese at home and with their offspring, reading Chinese newspapers, watching and listening to Chinese radios and television shows, preparing Chinese meals and dining out at Chinese restaurants, frequently

37 visiting their hometown, using traditional Chinese medicine, celebrating Chinese festivals, and joining Chinese seniors clubs for social activities (Chappell, 2005; Mak et al., 1995;

Martin, 1998b). All these behaviours not only represent a lifestyle but have symbolic and social meanings that shape older Chinese immigrants’ ethnic identity and impact their quality of life in a host country (Lai, 2012; Li & Chong, 2012).

For example, dietary habits are established early in life so traditional food is often associated with feelings of belonging, identity and heritage (Hanssen & Kuven, 2016). Being served unfamiliar dishes may lead to disappointment and a feeling of being betrayed and unloved. In a study exploring older Chinese immigrants’ views on food in relation cancer care, many participants complained about the lack of Chinese food and the poor quality and unsuitability of western food offered in hospitals (Alison Payne, Seymour, Chapman & Holloway, 2008).

Older Chinese people regard food as therapeutic, supportive, and comforting so being able to eat Chinese food is important particularly when they are ill. Another study conducted by

Chan and Kayser-Jones (2005) also found that the dislike of western food was one of the biggest challenges faced by those terminally ill Chinese who live in a nursing home. These older Chinese residents lost appetite and felt hungry after being served with western food.

They preferred Chinese meals—rice with several dishes, and enjoyed hot beverages so they had to rely on food brought by their family from home. Besides food, culturally-related activities are equally important for older Chinese immigrants to reaffirm their cultural identity and maintain their psychosocial wellbeing. Whether these factors are taken into account in aged care provision becomes really critical.

38 Although the evidence suggests that Chinese-speaking elderly may have unique cultural attributes, it is important to acknowledge that diversity also exists among the older Chinese- speaking community. The degree of cultural identity and the retention of cultural practices may vary considerably depending on country of origin, duration in a host country, exposure to mainstream society, ability to speak English, and many other factors (Gee, 1999). This diversity within the aged Chinese community is often overlooked in research and how migration and culture interact to impact on aged care use by older Chinese immigrants remains unclear.

The impact of family: intergenerational relations and family care

As part of the culture, the family is of central importance for Chinese people. It is the core unit and the main source of security, economic sustenance, family care, and social contact.

Traditional Chinese family values include respect for elders and filial piety, the maintenance of harmony within the family, and achieving financial security and prosperity to demonstrate family success (Mak et al., 1995). These family values are heavily influenced by the abovementioned three philosophies, and in particular, the teachings of Confucius have a profound impact on Chinese family relationships and aged care provision. As mentioned earlier, in a traditional Chinese family, elders have a great deal of authority and ageing parents are expected to be looked after by their adult children. The progress of modernization and the impact of international migration however have modified these traditionally defined social roles and family values (Chan et al., 1994; Mak et al., 1995), and shaped the experience of these older Chinese immigrants in their host country.

39 Recently, a small amount of literature has started to look at the influence of ageing and immigration on intergenerational families. Because of the importance of family and collectivist cultural orientation, many Chinese elderly parents are willing to travel or migrate to a Western country to help their skilled immigrant children’s family despite speaking no

English and having to face many other challenges (Xie & Xia, 2011; Zhou, 2012, 2013). It is very common for newly-arrived older Chinese individuals to live with their adult children’s family in the same household; however co-residence has been found to have both positive and negative effects on older Chinese immigrants’ physical and psychological wellbeing.

One of the main reasons older Chinese immigrants live with their adult children is to share economic resources and human capital. Elderly parents assist their skilled migrant children by looking after their grandchildren and doing household chores. Co-resident adult children in turn provide financial and instrumental assistance to their parents such as taking them to medical appointments, reading letters, and completing official forms, etc. Three generational families also increase the frequency of contact with children and grandchildren and provide a sense of security, fulfillment and joy for older Chinese immigrants. This seems to work perfectly in principle, but evidence suggests that co-residency can trigger or exacerbate intergenerational family conflicts which affect older Chinese immigrants’ physical and psychological wellbeing (Lo et al., 2007).

The power dynamics of intergenerational Chinese families are significant. Older Chinese immigrants may feel the loss of parental authority in the family because their knowledge and ideas are not considered by their adult children to fit into a new society. They have also lost their traditional social roles as independently living ageing parents and find their needs

40 subservient to those of their children. Some Chinese parents who lived in their children’s homes even bitterly joked about their ‘three nots identity”: not a master (because they cannot make independent decisions); not a guest (because they have to do all the housework and take care of grandchildren); and not a servant (because they do not get paid despite all the jobs they have done in the house) (Zhou, 2012). These older Chinese immigrants feel that they have to accept the fact that they are no longer the master of a household. This imbalance of power can put Chinese aged parents at risk of being abused or having unmet needs if family relationships break down (Ethnic Communities' Council of Victoria (ECCV), 2013).

Such power dynamics have a long-term impact on their intergenerational relationships, their social participation, their choice of care, and on their quality of life as a whole.

Compared to older family parent migrants, skilled or business migrants who came at a younger or middle age, relationships with adult children and the power dynamic within families appear quite different (Zhang, 2014). These skilled and business migrants who were pioneers in their families may have more challenges settling down, finding a job, looking for accommodation, and establishing social relationships. However, over the long term they gradually established themselves and achieved more autonomy, independence, and power.

Different migration cohorts engender different power relations within families, which can impact profoundly on the care older Chinese immigrants receive and their general wellbeing.

A detailed discussion of these influences of culture and family on aged care use, including values, beliefs, and family care resources, is presented in the Chapter 3.

41 2.5 Summary

This chapter has highlighted that defining who is considered “Chinese” can be difficult

because it involves many different factors. Given the focus of this study, older Australians

who speak a Chinese language at home was chosen as defining the target population. The

size of the older Chinese-speaking population in Australia is increasing dramatically and is

expected to continue to grow in the next few decades. This population is internally

diversified in relation to their characteristics. However, the majority cannot speak English

well or at all, and a significant proportion of them are recent arrivals. Given the rapid growth

of this population and their vulnerability, there is a growing need for aged care support

services that can meet the particular needs of older Chinese-speaking immigrants.

This chapter also reviewed how migration, culture, and family relations interact to impact on

the ageing experience of older Chinese-speaking immigrants. The circumstances of older

Chinese people at the time of their migration and years of residency impact their financial

and social wellbeing in a host country. Those who came to Australia later in life under the

parent migration program often experience financial insecurity and social isolation.

Traditional cultural influences and changes in family values and interactions have further

shaped the ageing experience of these Chinese immigrants. Those who retain traditional

values and Chinese lifestyles may find themselves face additional challenges when they need

support and care which cannot be provided by their family. The intersection of various

contextual and psychosocial factors has therefore led to the unique experience of ageing and

aged care use by this population.

42 Chapter 3: Understanding aged care use by people from diverse ethnic backgrounds

This chapter explores conceptual understandings of aged care use by the ethnic elderly, including older Chinese-speaking Australians. It begins with a review of aged care policy development for older people from CALD backgrounds in Australia, followed by a discussion of differential use of aged care services among aged CALD communities. Next, models and frameworks for understanding service use by the ethnic elderly are examined, utilizing the Andersen Behavioural Mode and intersectionality. The empirical evidence on the key influencing factors of aged care use by older people from Chinese-speaking backgrounds was reviewed. This chapter concludes with presentation of the conceptual framework for this study.

3.1 The aged care of older Australians from a CALD background

It is increasingly recognised that there are significant differences in care needs and service utilisation of minority ethnic older people (Blakemore, 2000; Damron-Rodriguez, Wallace,

& Kington, 1995; Johnstone et al., 2008; Khoo, 2012; Rao et al., 2006 ; Wallace et al., 1998).

The factors contributing to this are complex and vary between countries where different welfare and aged care systems, heterogeneous policies and services supporting elderly minorities exist. As mentioned in Chapter 1, older Australians from a CALD background are often treated as a homogenous group in research and policy and there is a lack of detailed information on individual ethnic groups in relation to aged care use. It is therefore important

43 to have an overview of the development of Australia’s aged care policy for older people from culturally and linguistically diverse (CALD) backgrounds before interrogating possible factors influencing their use of aged care services.

Aged care policies that respond to CALD population ageing

In Australia, the provision of aged care services is mainly regulated and guided by the

Commonwealth Government’s 1997 Aged Care Act, which sought to ensure the planning, provision of and access to appropriate and fair care services for the aged population. This Act identifies several population groups as having ‘special needs’, including older people from non-English speaking (CALD) backgrounds. As a result, a number of policies and strategies have been introduced and implemented to improve delivery of services to the ethnic aged, such as promoting cultural sensitivity in mainstream services, developing language and communication services, providing ethno-specific aged care services, and promoting ethnic clustering in residential aged care (AIHW, 2007).

The Commonwealth Government devised an Ethnic Aged Care Framework in 1997, which sought to improve partnerships between aged care providers, CALD communities, and the

Government and ensure that the special needs of older people from CALD backgrounds were identified and addressed. The Partners in Culturally Appropriate Care (PICAC) Program and the Community Partners Program (CPP) were two specific initiatives under the Ethnic Aged

Care Framework. The former program was developed to fund one organisation in each State and Territory to assist aged care providers to better respond to the differing needs of the ethnic elderly, and the later program was designed to promote and facilitate older people

44 from CALD communities to access aged care (DoHA, 2009). However, both programs are now defunded. The Access and Support (A&S) Program (Department of Health (DoH),

2013), currently funded by the Victorian Government, is another important initiative, aiming to assist older CALD clients in accessing aged care services. Even though there has been some progress in relation to better support of CALD communities, the implementation of these policies and programs is still greatly constrained by cost, the complexities of responding to a diverse range of ethnic groups, and insufficient knowledge about individual target populations and their needs (Rowland, 2007).

In 2012, the Australian Government announced the Living Longer Living Better aged care reform package in response to the growing population of older people and the challenges facing the aged care system (DoHA, 2012a). This reform package involved a comprehensive

10 year plan, seeking to reshape aged care and give older people more choice, more control and easier access to a full range of aged care services. To ensure the needs of aged CALD communities were addressed in the reform, a National Ageing and Aged Care Strategy for

People from Culturally and Linguistically Diverse Backgrounds was also developed, including five key principles (inclusion, empowerment, access and equity, quality, capacity building) and six strategic goals (DoHA, 2012b). These goals were assisting older people from CALD backgrounds to exercise informed choice in aged care, increasing their confidence in accessing and using the full range of services, monitoring and evaluating the delivery of services, enhancing the CALD sector’s capacity to provide aged care services, and achieving better practice through improving research and data collection mechanisms.

45 It is not yet clear whether changes that the reform package proposed have had a long-term impact on aged CALD communities in relation to access and use aged care services.

However, there have been some concerns raised by the Federation of Ethnic Communities’

Councils of Australia (FECCA) (a national peak body representing Australians from CALD backgrounds), particularly in relation to the most recent initiative of Consumer Directed Care

(CDC) and implementation of new Aged Care Gateway (aka My Aged Care). Although these new reforms offer the potential of more choice and control for older consumers, they also require more skills and knowledge to negotiate the complex process of accessing home care packages and understanding the range of services, fee structures, and legal arrangements associated with them. FECCA comments that without sufficient information and assistance, older consumers from CALD backgrounds may have greater difficulty in making informed choices and will encounter more barriers to access services (Migliorino, 2012, 2013), this especially so for recently arrived immigrants who have very limited English capacity and minimal understanding of Australian welfare systems.

Aged care service use by older Australians from CALD Backgrounds

The aged care system in Australia consists of two main forms of service delivery, namely residential and community care. Community Care includes Home and Community Care

(HACC), Community Aged Care Packages (CACPs), Extended Aged Care at Home (EACH),

Extended Aged Care at Home Dementia (EACHD), National Respite for Carers Program

(NRCP) as well as a variety of associated aged care programs. Aged Care Assessment Teams

(ACATs), working under the Aged Care Assessment Program (ACAP), were responsible for assessing older people for their access to aged care services. As a part of the most recent

46 reforms, the CACP, EACH, and EACHD packages have been replaced by the Home Care

Packages Program (HCPP) on a consumer directed care (CDC) basis from 1 August 2013, with four levels of care from High to Low. The HACC program was previously jointly- funded by the Commonwealth and State Governments. Services provided to people aged 65 years and over are now called the Commonwealth Home Support Program and are administered and funded solely by the Commonwealth Government from 2016. Services provided to those aged under 65 years are either continuously funded by each State

Government or the National Disability Insurance Scheme.

There is differential use of these services by older people from culturally and linguistically diverse backgrounds. Representing 21% of the older population, older people from non-

English-speaking countries in 2007 made up about 18% of older HACC clients, 18% of older

ACAP clients, 23% of older CACP recipients, 27% of older EACH and EACHD clients, and around 15% of older permanent residents in aged care homes (AIHW, 2007). One-third of older Australians are now from culturally and linguistically diverse (CALD) backgrounds

(ABS, 2012). In 2014-15, 27% of Home Care recipients aged 70 and over were from CALD backgrounds, while the number was 19% for residential aged care (and 18% of all HACC users were from CALD backgrounds) (AIHW, 2016). Overall, CALD clients are more likely to make use of home-based package care than residential care.

The usage rates of aged care services by older people from CALD background have increased over the past few decades, particularly for those aged 85 and over. In 2001, the usage rates of HACC, CACP and residential care services for the oldest age group (85 years and over) were 221, 43, and 115 per 1,000 (AIHW, 2002). These figures increased to 511, 50,

47 192 respectively by 2011 (see Table 3.1). The rate of EACH and EACHD use for the oldest age group also increased from 4 to 10 per 1,000 between 2006 and 2011 (AIHW, 2007,

2014). Compared with those born in Australia or English-speaking countries, older people born in non-English-speaking countries had higher usage rates of home-based service programs but lower usage rates of assessment services and residential aged care services.

Table 3.1 Usage rates of selected aged care programs, by age, cultural and linguistic background (a) , 2010-2011 (per 1,000 people)

Overseas-born Non-English-speaking Main English-speaking Australian-born countries countries 65–74 75–84 85+ 65–74 75–84 85+ 65–74 75–84 85+ HACC 101.5 296.2 511.1 73.5 266.9 469.7 111.8 322.9 482.5 ACAP 10.7 56.6 147.0 9.7 59.1 168.3 3.1 65.4 164.6

CACP 3.3 18.0 49.9 2.3 13.8 43.6 3.9 15.7 39.6 EACH & EACH Dementia 1.1 4.6 12.7 1.1 3.6 10.3 1.1 3.5 7.4 Permanent residential care 6.6 41.2 191.8 6.3 44.8 232.9 10.2 53.8 233.5 (a) The cultural diversity classification is based on country of birth. Overseas-born people from the main English-speaking countries are those born in New Zealand, United Kingdom, Ireland, United States of America, Canada or South Africa. People from non-English-speaking countries are those born overseas in other countries.

Source: (AIHW, 2014)

Among the older CALD population, people born in Eastern and Southeast Asian countries appear to be less likely to use aged care services. A New South Wales study by Lister et al.

(2006) stated that the lowest users of ACAP services by older immigrants were recently arrived migrant groups such as the Vietnamese and Chinese. Representing around 1.8% of the older population, older people speaking East Asian Languages at home (including

Chinese) make up only 0.8% of residential aged care clients (AIHW, 2012). Evidence also suggests that people born in South East and North East Asia were significantly less likely to be HACC clients, and were less likely than other HACC clients to use home-delivered meals

48 and transport services but more likely to use centre-based day care (Jorm, Walter, Lujic,

Byles, & Kendig, 2010).

The review of aged care policy development in Australia shows that the implementation of a range of policies and services supporting older people from CALD backgrounds only occurred in the last two decades. Even though efforts have been put into providing interpreter services, promoting cultural sensitivity and offering culturally appropriate care, evidence suggests that health inequalities and under-use of some aged care services still persists for many older Australians from Asian (including Chinese) backgrounds. In Australia, very limited empirical research has been conducted to investigate Asian populations (including

Chinese) aged care use. To enhance the accessibility and equity of aged care for the ethnic elderly, there is a need to understand the diversity of the elderly Chinese-speaking population and evaluate aged care use patterns and factors influencing these.

3.2 Models and frameworks for understanding aged care use by ethnic minorities

Ethnic disparities in health and aged care use are not restricted to Australia (AIHW, 2007;

Johnstone et al., 2008) but apply in many developed western countries, including the United

States (Akincigil et al., 2011; Weinick et al., 2000), the United Kingdom (Willis et al., 2013), and Canada (Koehn et al., 2013; Quan et al., 2006). Several models and frameworks have been developed in an attempt to understand and explain differential use of social and aged care services by older people from diverse ethnic backgrounds.

49 3.2.1 The Andersen Behavioural Model

The Andersen Behavioural Model (Andersen et al., 1973; Andersen, 1995; Andersen et al.,

2001) is one of the most frequently used models to study service access. It postulates that people’s use of health and aged care services is determined by individual as well as contextual characteristics. Individual determinants, the main component of the Andersen

Behavioural Model, are categorised as predisposing, enabling and need characteristics.

Contextual determinants, including societal and environmental characteristics, as well as provider-related factors then act on individual characteristics to determine whether a person will use or not use services.

Predisposing factors refer to people’s inclination towards service use. Andersen and his colleague (1973) believe that some individuals have a propensity to use service more than others. Such individual characteristics, including demographic, social structure, attitudes, and beliefs exist prior to the use of service and may predispose people to use services. Enabling factors can be measured by family and community resources. Family resources refer to income, level of insurance coverage, regular source of care, and other sources of support.

Community resources refer to the characteristics of the community where the person or family lives, including availability of aged care personnel and facilities. Lastly, need factors refer to an individual’s perceived and evaluated illness level, which often is the most immediate cause of service utilisation (Andersen et al., 1973). Perceived needs refer to an individual’s self assessment of health and need for service, while evaluated needs refer to the clinical assessment that determines the eligibility for services.

50 Although this model has been widely used in studying health and social service use, it has been criticized for not paying enough attention to social interactions, language and culture, particularly for immigrants’ use of services (Portes, Kyle, & Eaton, 1992). In the Andersen

Behavioural Model, ethnicity was often treated as one of the predisposing factors along with demographics and social structures (Andersen et al., 1973; Andersen et al., 1995). Previous studies reported inconclusive findings in relation to the effect of ethnicity and culture on service use by older people from diverse ethnic backgrounds. Some studies suggest ethnicity was the significant predictor of service use (Quan et al., 2006; Wallace et al., 1998), whereas others reported that there was no effect of ethnicity on service utilisation by older people

(Lun, 2004). One possible explanation is that the effect of ethnicity on service use was offset by the socio-economic and cultural differences among ethnic groups. Using a single variable of ethnicity to represent the role culture plays in determining aged care use can be oversimplified because the influence of ethnicity and culture can impact predisposing, enabling and need factors.

Andersen (1995) responded to this criticism by updating the model to explain how social structure and cultural values might influence enabling factors and perceived need, and further use of services. The model was further expanded and revised by his associates (Gelberg,

Andersen, & Leake, 2000) for the study of vulnerable populations, including ethnic minorities and elderly. By adding another set of the vulnerable domains of predisposing, enabling, and need factors to the original model, the Behavioural Model for Vulnerable

Populations (Gelberg et al., 2000) aims to identify the particular challenges each vulnerable group faces and to improve their access to service use. For example, the predisposing vulnerable domain includes country of birth, immigration status, and psychological resources,

51 while the enabling vulnerable domain includes the ability to negotiate system, receipt of public benefits, self-help skills, and availability and use of information sources.

Bradley, McGraw, Curry, Buckser, King, Kasl, and Andersen (2002) also expand the

Andersen Behavioural Model by adding three types of psychosocial factors as intervening variables between predisposing, enabling, need factors and service utilisation. They argue that the inclusion of beliefs as predisposing factors in the Andersen Behavioural Mode does not adequately capture the complexity and breadth of cultural influence on elderly minorities’ use of aged care services. Their expanded behavioral model posits that the effect of predisposing, need and enabling factors on intended and actual use of long-term care services is mediated by individuals attitudes, social norms, and perceived control of access. These psychosocial factors vary by cultural groups and ethnic background due to differing experiences, norms and attitudes concerning help-seeking and aged care.

Besides individual determinants, contextual determinants of the Andersen Behavioural

Model have also been criticised for a lack of detailed information about how the influence of external environment on service use is defined and constructed, and what components of provider-related factors are included in the model (Phillips, Morrison, Andersen, & Aday,

1998). The model was updated again by Andersen and his colleague in 2001 (Andersen et al.,

2001) to place more emphasis on contextual determinants, and classified them in the same way as individual determinants. Contextual predisposing characteristics include community demographic, ethnic composition, and prevailing social norms and political perspectives that may influence preferred ways for service to be delivered. Contextual enabling characteristics refer to pubic and organisational policies, funding resources, and the characteristics of

52 service providers, and contextual need characteristics refer to general indications of community health.

Several authors have supplemented the Andersen Behavioural Model by providing specific information regarding individual and contextual determinants of aged care use by ethnic minorities, and exploring potential relationships between these determinants. For instance,

Hernandez-Gallegos, Capitman, and Yee (1993) suggests that service use by minority ethnic older people is determined by how provider organisations reach out and respond to individuals’ predisposing, enabling, and need characteristics. The provider organisations in this study are categorised into different groups in light of their strategies and orientation to cultural diversity, namely mono-cultural aging service providers, non-discriminatory aging service providers, multicultural aging service providers, sustaining focus aging providers, and expanding focus aging service providers. Provider characteristics can determine the differential use of aged care services by older people from ethnic backgrounds, depending on how they operate and cater for their ethnic users’ needs and cultural preferences.

Damron-Rodriguez, Wallace, and Kington (1995) emphasise the importance of possible matches and mismatches between individual clients and programs characteristics, addressing appropriateness, accessibility and acceptability of care in relation to elderly minorities. First, services must be appropriate to the health and functional status of the older person; second, they must be accessible given the social and economic characteristics of the group (structural barriers); and third, they must be acceptable to group-specific norms and expectations

(cultural barriers). The failure to match up a program and its target population on any one of these levels can reduce the extent of service use by the ethnic elderly and hinder them from

53 accessing and using needed services. Similarly, Yeatts, Crow, and Folts (1992) focus on barriers that could be more readily altered by service providers in an effort to increase service use, including knowledge related to service (knowledge barrier), access to the service (access barrier) and intent to use the service (intent barrier). A potential client may have a need for care but does not use the service due to one or all of these barriers. There are service-provider strategies however that can intervene to prevent these barriers from inhibiting service use.

Service utilisation is a complex process, involving interaction of multiple factors. Despite some limitations, the Andersen Behavioural Model provides a useful framework to understand the complexity of aged care use by categorising various influencing factors into predisposing, enabling and need factors. The abovementioned adaptations reveal that some components of the Andersen Behavioural Model are of particular relevance to ethnic minorities’ use of aged care services, such as the predisposing components of immigration status and cultural beliefs, the enabling components of resources, knowledge and ability to secure services, as well as the need components of perceived need for care and service.

Because the majority of studies employing the Andersen Behavioural Model use secondary data sets (Babitsch, et al., 2012; Wolinsky, 1994), many factors that affect service use by elderly minorities were either not available or not included. This study therefore adopts the

Andersen Behavioural Model as the conceptual framework, specifically addressing the influence of these components on service use by older Chinese-speaking immigrants.

One of the biggest advantages of using the Andersen Behavioural Model in this study is its flexibility in allowing researchers to choose independent variables related to their specific inquiry (Willis, 2010). The Andersen Behavioural Model does not specify which variables

54 must be used to operationalise need, predisposing and enabling factors (Andersen &

Newman, 1973). Instead, the decision of how to operationalise these concepts should derive from the theoretical relationship between the independent and dependent variables and empirical evidence. Another advantage of using the Andersen Behavioural Model in this study is its potential to address ethnic disparities in health and aged care use. Andersen proposes that the predisposing, enabling and need factors have different explanatory application depending upon the type of service, and whether differences in service utilisation are considered inequitable if socioeconomic variables or enabling factors are dominant determinants (Andersen, 1995; Mitchell et al., 1998).

By categorising various influencing factors into predisposing, enabling and need factors, the

Andersen Behavioural Model allows researchers to examine whether access to service is equitable or not and to understand the different pattern of service use. Evidence suggests that the model has proven to be better suited to understanding the use of home care and community-based services, the focus of the present study, as opposed to more formal, acute medical services use (Calsyn & Winter, 2000; Mitchell et al., 1998). Need factors are found to be more significant in determining the use of least discretionary services, whereas predisposing and enabling factors play more important roles in determining the use of more discretionary services. The details of how the Andersen Behavioural model adopted as the conceptual framework for this study are presented later in this chapter. This study incorporated an intersectionality perspective into the model to better understand aged care use by ethnic minorities, which is introduced next.

55 3.2.2 Intersectionality

As noted in Chapter 1, the term ‘intersectionality’ has been developed since 1990s and adopted in various fields of study to explore the interconnections between traditional background categories, such as ethnicity, gender, sexuality, class and age, and to understand the implications of these categories for people’s lives. In recent years, a growing body of literature proposes an intersectionality perspective on health-risk, biomedical, and population health research to address power inequalities within these categories, and to better understand the cause of disparities in health and service use (Bauer, 2014; Giritli Nygren & Olofsson,

2014; Hankivsky & Christoffersen, 2008; Hankivsky & Cormier, 2011; Kelly, 2009; Koehn et al., 2013).

According to Else-Quest and Hyde (2016a), definitions of intersectionality differ in specific details, however, they share three common assumptions. Firstly, a recognition that all people are characterized simultaneously by multiple social categories; these multiple social categories are interconnected or intertwined, such that the experience of each social category is linked to the other categories. Secondly, embedded within each of these socially constructed categories is a dimension or aspect of inequality or power, and recognition of inequality or power is essential to an intersectional analysis. Lastly, these categories are properties of the individual (i.e., identity) as well as characteristics of the social context inhabited by those individuals (i.e., social structures, institutions and interpersonal interactions construct the categories and enforce the power inequalities); as such, these categories and their significance may be fluid and dynamic.

56 Traditionally, the concept of intersectionality is associated with qualitative research while the

Andersen Behavioural Model, frequently adopted by health care research, is often associated with the use of quantitative methodologies. Some scholars argue that the overreliance on cultural explanations in qualitative literature can overlook the significance of other determinants and barriers, and obscure the impact of structural factors on disparities in health and service use among immigrants (Chiu & Yu, 2001; Giritli et al., 2014; Hankivsky et al.,

2011; Koehn et al., 2013; Viruell-Fuentes, Miranda, & Abdulrahim, 2012). On the other hand, the quantitative literature, using the Andersen Behaviuoral Model suffers from oversimplification of some variables and the absence of primary data that does not capture the complexity of experience in minority groups (Babitsch, et al., 2012; Torres, Sandra,

2014).

The integration of an intersectionality perspective in health and aged care research therefore provides opportunity to reframe the research questions, explores the complexity of service use by older people from diverse ethnic backgrounds from a new perspective, and addresses potential power inequalities in accessing and using aged care use (Koehn et al., 2013; Torres,

2014; Viruell-Fuentes et al., 2012). The concept of intersectionality is adopted in this study in an attempt to better understand the intersecting influences of various social and individual determinants on general wellbeing and service use for older Chinese-speaking immigrants in

Australia. This framework, integrating both intersectionality and the Andersen Behavioural

Model will be introduced later in this chapter, after a review of empirical evidence on aged care use by older Chinese-speaking people.

57 3.3 Review of the empirical evidence on aged care utilisation by older Chinese-speaking people

People’s use of aged care services is a complex process, involving many influencing factors at contextual and individual levels. In this section, factors that impact on aged care use by older people from Chinese-speaking background are examined utilizing the Andersen

Behavioural Model.

3.3.1 Societal and Provider-related Factors

In the Andersen Behavioural Model, contextual determinants including societal and environmental characteristics as well as provider-related factors, act on individual characteristics to influence access and use of aged care services. Racism and institutional discrimination are found to be significant social determinants that contribute to ethnic disparities in social and health care (Blakemore, 2000; Johnstone et al., 2008).

Discrimination in relation to the ethnic aged can lead to problems in planning and delivery of aged care services and result in limited access to, and underuse of services by people from

CALD backgrounds. People from non-English speaking backgrounds encounter many social and structural barriers that can have an adverse impact on their health and wellbeing in old age. Older immigrants may suffer a double disadvantage due to ageism and racism

(Johnstone et al., 2008; Rowland, 2007). Assumptions that minority groups can look after their aged relatives can also be problematic because service planners and providers may overestimate an ethnic family’s ability to provide care and overlook the needs of older immigrants (Chiu et al, 2001). Inadequate provision and funding of support services for older

58 people from non-English speaking backgrounds can be seen as the negative outcome of such assumptions and might be said to be cultural racism (Blakemore, 2000; Tsai & Lopez, 1998;

Warburton, Bartlett, & Rao, 2009).

The provider-related factors, as noted earlier in this chapter, are another important contextual determinant that impacts on access and use of aged care services by people from diverse ethnic backgrounds. An Australian review of service delivery models examined how different models impact on aged care service use by older people from CALD backgrounds

(Radermacher, Feldman, & Browning, 2009). The review found that ethno-specific service providers are able to provide culturally and linguistically appropriate services which are associated with high use rates and satisfaction. However, using only an ethno-specific approach to aged care delivery is not very feasible and can further marginalise aged CALD communities. Mainstream service providers could provide more choice of services that are cost-effective and link older immigrants into the wider community, yet they often fail to meet the special needs of older people from CALD backgrounds. The review concluded that it is not an ‘either/or’ approach and these agencies should work together or in partnership to deliver equitable and culturally responsive aged care services to CALD communities.

Studies of service use by the ethnic elderly found that the characteristics of service providers such as a culturally diverse workforce and management, culturally competent practices and service approaches, targeting specific information and services for ethnic groups, and location of the agency play crucial roles in determining service utilisation by their CALD clients (Hernandez-Gallegos et al., 1993; Lee, Patchner, & Balgopal, 1991). A study of Asian

American elderly (Lee et al., 1991) found that the lack of bilingual and bicultural staff was

59 reported by mainstream providers as the major factor that contributed to their Asian clients’ low use of services. Even though bilingual social workers are recruited, evidence suggests that mainstream providers often fail to provide these workers with the resources and supports needed to work with non-English speaking clients (Engstrom, Piedra, & Min, 2009). Some studies suggest that elderly Chinese can refuse or delay take up of services because there are no Chinese-speaking professionals or interpreters available in their local area (Aroian et al.,

2005; Tsai et al., 1998).

In addition to the availability of bilingual workers, the level of cultural competence and attitudes towards CALD communities can also impact on service use by older immigrants.

Some studies reported that workers and professionals’ discriminatory attitudes and lack of cultural understanding can discourage their CALD clients from accessing and using services

(Chenowethm, Jeon, Goff, & Burke, 2006; Min, 2005; Warburton et al., 2009). Cultural difference between health care workers and their older clients can lead to misunderstandings and result in poor quality of care. Evidence suggests that the cultural competence of aged care workers and health professionals needs to improve to effectively work and communicate with older people from CALD backgrounds (Chenowethm et al., 2006; Min, 2005;

Warburton et al., 2009) .

Compared with mainstream providers, multicultural and ethno-specific organisations have a higher proportion of staff and board members from culturally diverse backgrounds who speak their clients’ languages and share the same cultural identity and values. These organisations target specific ethnic communities so they can develop strategies and design programs that cater for their clients’ specific cultural and linguistic needs. These organisations often locate in or near ethnic enclaves where their targeted clients congregate.

60 Many older Chinese immigrants do not drive, so the location of an agency that is close to them, or has easy access to public transport, becomes important. Although the provision of culturally appropriate aged care to older people from CALD background is current policy in

Australia, as described earlier in this chapter, governments and service providers’ commitment to provide such services can vary depending on their goals, funding, human resources, and service development.

3.3.2 Predisposing Factors

Predisposing factors in the Andersen Behavioural Model refer to the predisposition of the individual to use services, including demographic, social characteristics, beliefs and attitudes, each of which is now considered.

Demographics

For the Chinese elderly, some demographic variables associated with an increasing use of aged care services are found to be similar to those born in the host country, such as advanced age and being female (Kadushin, 2004; Kuo et al., 2001; Lai, 2004a). It is understandable that when people get older and frailer they are more likely to need support and use more aged care services. Women are more likely to live alone, have less access to informal support, and accept services as a result of gender role expectations, thus increasing the likelihood of using aged care services. However a study reviewing home health care use by Kadushin (2004) found that the influences of age and gender on utilisation were uncertain because nearly half of the studies reviewed showed there was no significant difference in age and gender related

61 to service use. Marital status was not found to be a determinant of health and home care service use, although being married could act as a barrier in that living with a spouse might be seen as providing needed support (Kadushin, 2004; Kuo et al., 2001; Lai, 2004a).

Social characteristics

The effect of education on service use by older Chinese immigrants is not clear. Lai’s study

(2004a) found that having post-secondary education was one of the predictors for home care service use among older Chinese in Canada. In a study of health care access and utilisation,

Jang, Lee, and Woo (1998) also reported that with higher levels of education were more likely to have health insurance thus have more access to health care services. However, Kuo et al. (2001) reported that older ’ use of hospitals was associated with lower education. Some suggest that the effect of education on utilisation may be confounded with the effect of income and English language ability

(Kadushin, 2004; Lai, 2004a)

Living arrangement was found to be a significant predictor of service utilisation amongst older Chinese persons. The findings of previous studies suggest that older people who live alone were more likely to use home care services than those living with other family members (Kuo et al., 2001; Lai, 2004a). Several studies have reported that older immigrants from non-English speaking backgrounds are more likely to be living with other family members, usually their children, and are less likely to be living alone when compared with

Australia-born elderly (Benham et al., 2000; Khoo, 2011; Rowland, 1991). It has been reported widely that there is a high co-residency rate among families

(Chappell & Kusch, 2007; Ip et al., 2007; Lin, Bryant, Boldero, & Dow, 2014). However,

62 high levels of financial dependence among older Chinese immigrants may also force them to co-reside with their adult children due to limited other options (Lo et al., 2007; Thomas,

2003).

Country of origin is another possible predictor of service use by older people from Chinese- speaking backgrounds. Evidence suggests that older immigrants from Hong Kong are more likely to use health and home care services than those migrating from Mainland China (Chan

& Quine, 1997; Lai, 2004a). Such differences may be explained by previous understanding of the culture of health and aged care services in their homeland. People from Hong Kong often have some basic understanding of western health care and home care services which may increase the probability of using these services in host countries (Chan et al., 1997; Lai,

2004a). Lai’s study (2004a) also reported that older immigrants from Southeast Asia had the highest probability of using home care services among all Chinese-speaking groups in

Canada. In an investigation into wellbeing of Australia’s top 25 birthplace groups, Khoo

(2011) reported that older people from Malaysia, Singapore, and Hong Kong generally have higher levels of social-economic wellbeing and are less in need of assistance with daily activities than their counterparts from Vietnam and China. However, it is not clear if older

Chinese from Vietnam and China would have higher probability of using aged care services due to a higher proportion needing help with daily activities.

There is evidence that year of residency is associated with service utilisation by people from

CALD backgrounds (Kuo et al., 2001; Scheppers, van Dongen, Dekker, Geertzen, & Dekker,

2006). A study by Kuo et al. (2001) reported that more years since immigration increases the likelihood of hospitalization and home care service use by older Taiwanese in the United

63 States but there is no significant difference in usage of doctor visits. Older Chinese immigrants who had been in the United States for a longer period reported higher levels of social service utilisation, including social security, recreational activities, and housing (Tsai et al., 1998). Length of residency was not found to be the predictor of using home care service in Lai’s (2004a) study, although service users had longer residency in Canada than non-users. The length of residence may be associated with becoming more acculturated, being eligible for assistance, and having increased knowledge of available services, which can have positive effects on service utilisation.

Beliefs and attitudes

There is no empirical evidence that one’s religious affiliation acts as a predictor of service utilisation, however some studies suggest that religious practices of older Chinese immigrants have a positive association with their wellbeing and assists the development of coping strategies (Lee, 2007; Lee & Chan, 2009). Buddhism along with Taoism and

Confucianism are the major religions or value systems in Chinese-speaking countries (Lai et al., 2009). The concepts of self-reliance, self-endurance, self-transcendence, self-control, and non-interference drawn from these religions seem to discourage Chinese from seeking external help and encourage them to use internal resources to solve problems (Yamashiro et al., 1997; Yip, 2004, 2005). Compared with those practicing traditional Chinese religions or having no religious affiliations, older Chinese users of home care services in Canada were more likely to have adopted Western Catholic and Protestant religions (Lai, 2004a). In addition, a study done by Zhang and Zhan (2009) found that Christian participation of older

Chinese immigrants in the United States increased their level of social support and assisted in

64 maintaining ethnic identity, which may result in having more access to information and support services.

In Confucian philosophy, filial piety that expects adult children to show respect and gratitude by taking care of their elderly parents is a major virtue and profoundly influences Chinese society. Numerous studies have attempted to explain the association of filial piety and older

Chinese people’s ageing experiences, such as care arrangements, intergenerational relationships, and psychosocial wellbeing (Chappell et al., 2007; Cheng & Chan, 2006;

Cheung, Kwan, & Ng, 2006; Dong, Chang, Wong, & Simon, 2012; Fan, 2007; Laidlaw,

Wang, Coelho, & Power, 2010; Lan, 2002; Liu, Ng, Weatherall, & Loong, 2000; Ng, Phillips,

& Lee, 2002; Wang, Laidlaw, Power, & Shen, 2009; Li, Hodgetts, Ho, & Stolte, 2010).

A study by Wang et al. (2009) found that high expectation of filial piety is beneficial to older

Chinese’ wellbeing as it is positively associated with their self-esteem and support received from and given to adult children. However, some studies suggest that older parents’ filial expectations have a positive effect on support given to their children but no effect on support received from their children (Chen, Chen, & Adamchak, 1999; Lee, Netzer, & Coward,

1994). Cheung et al. (2006) examined the impact of filial piety on preference for aged care and confirmed the compensatory rather than complementary view of elder care. Findings suggest that when filial support is high, support from other sources including both kinship and government would be low. Aroian et al. (2005) found that certain social services, specifically nursing homes, homemaker services, and home health aids were an affront to filial piety because they were evidence of a shirking of responsibility to take care of parents.

65 In comparison, elder housing, adult day care, and transportation services did not have the same strong negative connotations with regards to filial piety.

However, older Chinese and their adult children’s perceptions of filial piety are not uniform.

The meanings and practice of filial piety may change over time due to the effects of modernisation and length of residency. In fact, some studies have found that there is a trend of departure from the traditional practices of filial piety, to more western patterns of care after the resettlement of Chinese families in a new country (Lan, 2002; Lo et al., 2007). Older

Chinese immigrants have adjusted their expectations of filial piety and begin to put emphasis more on emotional support than daily assistance from children (Cheng et al., 2006). Many studies of older Chinese immigrants show that they would have no objection to moving into aged care homes if it was staffed and managed sensitively and adapted appropriately to their cultural backgrounds (Ip et al., 2007).

Besides expectations of filial piety, some negative attitudes or beliefs that older Chinese immigrants possess towards service use can also impact on their access and use of services.

Their attitudes are associated with personal fears and discomfort with asking for help, mistrust of the system, negative experiences with service providers, and misconceptions about using formal services. Older Chinese people’s reliance on self and family care over professional and formal care are found to predispose them to a lower level of aged care service use as well as delayed assessment and health treatment (Aroian et al., 2005).

Acceptance of formal assistance is often perceived by older people as showing dependence and losing autonomy. Studies have found that the mistrust of the aged care system, negative experiences with service providers, and concerns over others’ opinions can also discourage

66 older people from accessing and using formal services (Lai & Chau, 2007; Pang, Jordan-

Marsh, Silverstein, & Cody, 2003).

Research found that older Chinese people are more likely to have a negative attitude toward ageing than their Western counterparts in relation to physical change and psychosocial loss

(Laidlaw et al., 2010). Therefore they tend to be more accepting of the notion of frailty in old age and not perceive themselves as having a need for help. Chinese elders also perceive

“successful aging” or “ageing well” differently from their Australian counterparts. They view their families’ willingness to meet their needs, having good genes and an active lifestyle as signs of successful ageing while Anglo-Australians see independent living, autonomy, and being able to cope with challenges as the more important elements of successful ageing (Tan,

Ward, & Ziaian, 2010; Tan, Ward, & Ziaian, 2011; Torres, 1999).

3.3.3 Enabling Factors

Enabling factors are the factors that enable use or act as barriers impeding use. Enabling variables reviewed in this study include personal and family resources, knowledge and

English ability, as well community resources.

Personal and family resources

Social networks and informal support are key factors that greatly impact on older Chinese immigrants’ use of aged care services. Lack of informal support is usually considered a predictor of home care service use (Kadushin, 2004), yet in Lai’s study (2004a) social

67 support appears to be a facilitative factor that enables the use of home care services by elderly Chinese in Canada. Findings suggest that if support and care is provided by family members it can reduce older Chinese persons’ probability of using aged care services.

However, when families and friends were unable to provide direct assistance, having a higher level of social support could imply that these immigrants were more likely to have access to and be referred for formal services.

Among types of informal care older Chinese people received, family is the main source of informal support. Spouses were considered to be primary family carers of older Chinese immigrants, followed by their daughters, sons and co-resident daughters-in-law (Pang et al.,

2003; Tsai et al., 1998). Several studies found that there were significant care gaps between what older Chinese parents needed and actual assistance received from their adult children

(Dong et al., 2012). Many older Chinese have restricted social networks, particularly older women. A study by Ip et al. (2007) showed nearly half of older Chinese respondents in

Brisbane reported that they had either no or few close friends and more than one third stated that they seldom or never met with friends. This implies that, if an elderly Chinese immigrant does not have support from family, they may not have sufficient support in general.

Acculturation and enculturation were found to be associated with Asian immigrants’ health status and service utilisation (Salant & Lauderdale, 2003). Studies suggest that increased acculturation to the host society predicts increased help-seeking and better mental health among older Chinese immigrants (Jang et al., 1998; Stokes, Thompson, Murphy, &

Gallagher-Thompson, 2002). Recent evidence found that ‘enculturation’, the adoption and maintenance of one’s heritage cultural norms, also has a significant influence on health and

68 service utilisation. For example, having a higher level of association with the Chinese community, peers, and cultural activities has been reported in many of Lai’s studies as a powerful predictor of a higher level of service use by aging Chinese-Canadians (Lai, 2004a;

Lai, 2007). Several studies suggest that the retention of traditional cultural beliefs and behaviours and the acquisition of new cultural features through acculturation may have qualitatively different effects on health and service utilisation (Salant et al., 2003).

Immigrants who live in the host country longer, have better English ability, immigrated at a younger age, are more likely to adapt to a new society, hence fewer cultural and linguistic barriers are encountered when accessing and using services. Association with their local ethnic community can give older immigrants comfort and a sense of belonging, knowing that they will be well supported by their own community (Lai, 2004b). They may have more access to culturally specific information and services and this increases the probability of using formal services.

Immigrant’s financial status was not found to have a strong association with their use of aged care services. In a study reviewing home health care utilisation, Kadushin (2004) reported that income had an uncertain influence on contact with care and was not associated with the amount of care used. The findings of Lai’s study (2004a) suggested there is no significant effect of personal monthly income on older Chinese’s use of home care services but a higher level of self-rated financial adequacy reduces the probability of using home care service.

Research suggests that the effect of income on aged care utilisation may be associated with immigrants’ health status and the level of discretion they have in accepting formal help

(Kadushin, 2004; Lai, 2004a). If an older immigrant’s care need is high, whether their income is high or low, they are eligible for services, hence more likely to use services. The

69 effect of income on service use is strongest when disability is low and income is high, and older people can purchase services at their discretion to improve their quality of life.

Knowledge and English ability

Lack of English ability is considered as one of the major barriers for older Chinese immigrants in accessing aged care, particularly services provided by mainstream agencies

(Aroian et al., 2005; Ip et al., 2007; Pang et al., 2003). Older Australians from China and

Vietnam are reported to have relatively low levels of English proficiency (Benham et al.,

2000; Howe, 2006; Khoo, 2012). Many of them migrated in old age or stayed in an ethnic enclave during their working life. Their English language level may still be very low even after many years living in Australia (Mak et al., 1995; Thomas, 2003). Recent evidence shows that overseas-born Australians with low English proficiency tended to have poorer self-assessed health, lower overall life satisfaction and lower levels of social participation than those with high English proficiency (AIHW, 2013).

Without sufficient English, older Chinese migrants experience more difficulties in managing everyday affairs, building social networks, obtaining knowledge, maintaining their quality of life, and accessing available health and aged care services. Evidence also suggests that older bilingual migrants may lose their ability to speak English and revert to their first language, particularly those suffering from dementia (Rao et al., 2006 ). Nevertheless, several studies have found that English language proficiency does not predict use of health and aged care services by older Chinese immigrants (Chappell & Lai, 1998; Kuo et al., 2001; Lai, 2004a).

70 Lack of knowledge of available services was reported as another significant barrier to social and health service use by older Chinese immigrants (Ma & Chi, 2005; Tsai et al., 1998). In a study of social support use by Tsai et al. (1998), “do not know about social services” was ranked as the top barrier to service utilisation by 93 elderly Chinese immigrants residing in

California. A study by Ma et al. (2005) also found that would increase their use of social services if they were more aware of the existence of Chinese-specific service agencies, and if they held a more positive opinion of the services provided by these agencies.

Community resources and barriers to access

In addition to personal and family resources, some community resources and barriers can also facilitate or hinder older Chinese people’s access to aged care services. For instance, transport is ranked as the top priority need by older Chinese immigrants in (Ip et al., 2007). Older people are highly reliant on public transport and family for transport so lack of adequate, efficient and frequent public transport restricts their mobility and limits their access to community-based aged care services. The availability of Chinese language services and professionals in their local area were also found to be important enabling determinants of aged care use because of older Chinese people’s preferences for the use of ethno-specific services (Aroian et al., 2005). Other structural factors, such as complicated procedures, unavailability and inaccessibility of services, and long-waiting lists were also identified as barriers that hinder older Chinese people from using aged care services (Lai et al., 2007;

Scharlach, Kellam, Ong, Baskin, Goldstein, & Fox, 2006; Tsai et al., 1998).

71 3.3.4 Need Factors

Evaluated need and health status

Immigrants are generally reported to have better health because of heath requirements prior to migration, and they tend to have higher life expectancies, particularly those born in China and Vietnam (AIHW, 2007). However, this health advantage (healthy immigrant effect) deteriorates with increased length of stay because some migrants adopt the lifestyle of their host country’s population. This has been found in both Australian and overseas studies

(Anikeeva, Bi, Hiller, Ryan, Roder, & Han, 2010). A recent Australian study of social and economic wellbeing of the immigrant aged by Khoo (2012) found that older immigrants from non-English speaking countries have higher proportions needing assistance with daily activities than the Australia-born aged. Evidence also suggests that there are higher rates of admission and utilisation of hospital beds for older people from diverse backgrounds in their last year of life due to poorer health (Rao et al., 2006 ).

Need factors are shown in many studies of using the Andersen Behavioural Model as the major predictor of health and home care utilisation among the elderly (Kadushin, 2004).

Using the 36 item Short Form Health Survey (SF-36) to measure respondents’ health status,

Lai (2004a) found that having poorer physical and mental health significantly predicted home care service use by older Chinese immigrants in Canada. A study of admission to a nursing home found that more than one third of older Chinese immigrants had higher dependence in activities of daily living and nearly three-quarters had cognitive impairments, yet many were not diagnosed (Huang, Neufeld, Likourezos, Breuer, Khaski, Milano, and Libow, 2003).

72

Perceived need and self-rated health

Need for aged care services can be perceived differently by older people, depending on their cultural norms and values and how they view their own general health and functional status.

Older Chinese often perceive themselves as healthy if they are able to function in their daily lives and are not experiencing symptoms. Although other groups of elderly employ similar criteria, Aroian et al. (2005) found it is more pronounced among older Chinese as they do not consider using services if they still can eat, move, and do some housework. Only when their need was significantly high, both Chinese elders and their adult children were willing, albeit reluctantly, to disregard this cultural norm and use services.

Liu (2003) found that different groups of Chinese immigrants have different perceived needs for service which are related to their demographic and migratory characteristics. Recent and old age Chinese American seniors reported having greater need but not using mainstream services, while retired professional Chinese migrants reported not needing services because they often have good health, strong social networks, secure finances, and driving and language abilities. Therefore, the ability for self-care and the availability of informal support may have interactive effects on older Chinese people’ perception of needing aged care services.

73 3.4 The integration of the Andersen Behavioural Model and intersectionality

This section elaborates on the integration of the Andersen Behavioural Model and an intersectionality perspective as the conceptual framework to understand aged care utilisation by older people from Chinese-speaking backgrounds. Figure 3.1 illustrates the framework used for this study.

Individual and contextual determinants

Predisposing Factors Enabling Factors Need Factors

Demographics Personal and Family Resources Perceived Need  Age  Income/ government  Self-rated health  Gender payments  Need for  Availability of family care assistance Social characteristics  Social support

 Education  Years of residency Knowledge and Ability  Religion Evaluated Need  Awareness of existing  Physical health  Marital status services  Country of birth (Activity and  Acculturation/English ability instrumental  Living arrangements activity of Daily Living (ADL and Beliefs and Attitudes Barriers to Service Access  Attitudes toward IADL)  Perceived cultural,  Mental health service use structural, and attitudinal  Filial piety (depression) barriers to access services  Intention to use service

Use of Aged Care Services

Figure 3.1 The conceptual framework used for this study

74 Drawing from the review of frameworks and empirical evidence presented in the preceding sections, the Andersen Behavioural Model used for this study specifically addresses the components of the model relevant to ethnic minorities’ use of aged care services. The predisposing component consists of demographics, social characteristics, beliefs and attitudes.

The enabling component is composed of personal and family resources, knowledge and ability, and barriers to service access, and the need component includes both perceived and evaluated needs for service use. Of the predisposing factors, demographic variables are age and gender. In addition to the conventionally used social structure variables, such as education and marital status, the predisposing factors relevant to older Chinese immigrants’ migratory background and circumstance are also collected, including religion, country of origin, Chinese language spoken at home, year of residency, immigrant status, and migration program. Belief was only treated as one of the predisposing factors in the original Andersen

Behavioural Model. The significance of belief and attitude on service use is emphasised in this study by expanding into the three variables, namely attitudes toward service use, filial expectation toward adult children, and intention to use service.

Beside the enabling factors conventionally collected in the Andersen Model, such as income and informal support, this study also focuses on the additional components that may hinder or facilitate aged care use by older Chinese-speaking immigrants in an unfamiliar cultural context, namely knowledge and ability, and barriers to service access. Acculturation, awareness of existing services, perceived cultural, attitudinal, and structural barriers to access services are examined in this study. Finally, need can be interpreted differently by different cultural or ethnic groups. This study collects data not only on older Chinese immigrants’ evaluated needs but also their perceived needs.

75

Older Chinese-speaking people, as depicted in the Chapter 2, can sometimes be difficult to define because of various categories of difference among this group and their intersectional relationships with each other. Instead of using a one dimensional analysis of ethnicity, this study adopted the intersectionality perspective to examine the three main overlapping dimensions of difference among this population, namely age, immigration, and social class.

The dimension of age is chosen because of its relevance to post-migratory experience and need for aged care use. People at an advanced age are found to be more likely to have multiple health conditions and use more health and aged care services. Age at the time of migration is also relevant to settlement experience and service use. Compared with earlier settlers, the Chinese-speaking immigrants who arrived at an older age face many more challenges than younger immigrants. Older recent Chinese immigrants experience greater difficulty in settling as they have to face aged-related changes and challenges while coping with a different culture and language. Data on participants’ chronological age, age at the time of migration, self-assessed health, physical functioning, and need for assistance are collected in this study to inform the dimension of age.

Immigration is another important dimension that consists of multiple factors. The factors relevant to predisposing variables, including country of origin, immigrant status, year of residency, filial expectation of adult children, and attitude and intention to use service, are examined in this study. Other enabling factors that are related to the dimension of immigration include knowledge of existing services, English ability, acculturation

(acquisition of Australian culture and retention of Chinese culture in Australia), availability of family carers, social support, and perceived barriers to service access. These factors

76 compounded with other social-economic constrains may render recently arrived older

Chinese immigrants dependent on adult children, which therefore may engender intergenerational conflict which may lead to power imbalance within the family and result in an inequitable access to aged care services.

The dimension of social class in this study is informed by the variables such as monthly income, main source of income, income satisfaction, government payment, and private health insurance. These factors can be determined by older Chinese-speaking immigrants’ migration program and family circumstances, which can have a significant impact on their ageing experience and wellbeing in a host country. Given the importance of family as the main source of financial and instrumental support for older Chinese-speaking immigrants, factors such as living arrangements, marital status, and availability of family resources are also investigated.

3.5 Summary

This chapter explored the development of CALD aged care policy in Australia, and the differential use of aged care services by people from CALD backgrounds. The evidence suggests that older people born in Eastern and Southeast Asian countries appear to be less likely to use aged care services. This chapter continues to review the models and frameworks of service utilisation by the elderly ethnic minorities, and identifies possible factors that contribute to the low level of service utilisation by older people from Chinese-speaking backgrounds. These influencing factors are complex and often interacting. The Andersen

Behavioural Model is a useful framework to organise and categorise the different

77 determinants of aged care use by older Chinese-speaking immigrants. Many earlier studies adopting the Andersen Behavioural Model used ethnicity as a single variable and do not include culturally-related predisposing, enabling and need factors. These factors identified in this review of literature are integrated into the framework used in this study. The intersectional perspective is also adopted in this study in order to understand how various social identities of older Chinese-speaking immigrants intersect to impact on the ageing experience and aged care use in the broader social, cultural and political context. To enhance the accessibility and equity of aged care for the ethnic elderly, there is a need to understand the intradiversity of the elderly Chinese-speaking population and evaluate aged care use patterns and factors influencing use.

78 Chapter 4: Research Methods

This chapter discusses my methodological position as a social work researcher and the approach I have taken to studying aged care utilisation by older people from Chinese- speaking background, outlining the three main research questions. Ethical considerations that were relevant to this study, including cultural sensitivity are presented. The study population and sampling methods are described, and the research tool and measures used to address the research questions are also presented. The chapter concludes with a description of how the data were collected and analyzed.

4.1 Methodological approach and research questions

Overall research approach

Before presenting the methods used in this study, it is important to discuss the position I took as a social work researcher and how it shaped my research approach. The classification of paradigms or worldviews is based on assumptions the researcher makes about reality, how knowledge is obtained, and the methods of gaining knowledge. We all bring to our research worldviews or paradigms that influence how we design and conduct our project. Creswell

(2007) proposes that there are four worldviews used in research, namely Postpositivist,

Constructivist, Transformative, and Pragmatic worldviews. The first two worldviews are broadly characterised based on whether knowledge is objective or subjective, while the research in the transformative worldview links political and social action to the issues of

79 social justice and discrimination. The pragmatic worldview then places its central importance on applications-- “what works”, and solutions to problems. Because it is problem-solving centred and real-world practice oriented, researchers who take a pragmatist approach to research use different methods depending on the research question they are trying to answer.

Muijs (2011) suggests in some cases this will lead researchers to quantitative research. For example, they need to give a quantitative answer to a question or generalise findings to a population. In other cases, they will employ qualitative methods to provide depth of understanding or a mixed methods approach combining both quantitative and qualitative methods.

Coming from my research and professional experiences as stated in Chapter 1, this study was driven by inquiry about ethnic disparities in aged care use. Many earlier studies on this issue adopting the Andersen Behavioural Model are within the positivist or postpositivist paradigm, examining whether ethnicity is a significant predictor (Miller et al., 1996; Wallace et al.,

1998; Webster et al., 2004; White-Means et al., 2004). As discussed in the last chapter, the model is very useful in organising and examining various contextual and individual determinants of aged care use but it is criticised for its insufficiency to address the complexity of service use due to primary reliance on secondary data. On the other hand, intersectionality theory, with its focus on examining the intersection of multiple categories that marginalised individuals experience is more congruent with a constructivist paradigm

(Torres, 2014). This latter approach however can also be criticised by positivist researchers for falling to control for the confounding influences of differences among research subjects, rendering research findings unreliable and invalid (Kelly, 2009). Given my intention was to look at “what works” and considering the limitation of each approach, this study therefore

80 took a pragmatic approach to examining aged care use by older Chinese-speaking immigrants, using the conceptual framework presented in Chapter 3 that integrated both an intersectionality perspective and the Andersen Behavioural Model.

A survey research design was employed in this study for several reasons. Firstly, the older

Chinese-speaking population, as a group, are found to be socially and financially disadvantaged and to under-use aged care services in Australia (FECCA, 2015; Khoo, 2012).

Nevertheless great diversity exists within this population. A wide range of individual characteristics such as migration background, socio-economic circumstance, cultural influences and practice, and health conditions can impact on the experience of ageing and aged care use by older Chinese-speaking immigrants, however, how these factors impact on service use remains unexplored. The strength of using a survey research design are its versatility, efficiency, and generalizability (Rea & Parker, 2005). A survey allows data on a diverse range of variables to be collected from a large number of people at a relatively low cost. In addition, it allows data to be compared easily across time, location, and population if a standardised instrument is used.

Secondly, many earlier studies of overseas Chinese elderly mainly adopted qualitative approaches to understand the relationship of culture, ageing, and service utilisation by interviewing older Chinese participants and service providers (Aroian et al., 2005; Lan, 2002;

Liu, 2003; Lo et al., 2007; Scharlach et al., 2006; Zhan et al., 2004). The findings of these qualitative studies have provided a useful account of older Chinese persons’ views of the influence of culture and immigration on ageing experience and service utilisation. However,

81 the sample size in these types of studies is often small, making representativeness and generalisation difficult.

There are limited studies adopting a quantitative approach to investigate the intra-diversity within the aged Chinese-speaking community in relation to ageing experiences and service utilisation (Ip et al., 2007; Kuo et al., 2001; Lai, 2004a). The reviewed literature presented in

Chapter 3 showed that there are many factors associated with aged care use yet the relationships between these factors and the implications and significances of that impact on aged care use by older Chinese-speaking immigrants remain unclear. Using a quantitative approach to study intersectionality is suggested by Else-Quest et al., (2016a, 2016b) to expand the study of intersectionality. By incorporating this concept into health care research, our understanding of the issue of health and service use can be enriched and deepened (Bauer,

2014; Giritli et al., 2014; Hankivsky et al., 2008; Hankivsky et al.; Kelly, 2009; Koehn et al.,

2013).

Research Questions

Based on the literature review and the focus of this study, there were three key research questions that this study sought to answer.

1. What were the various categories of difference (e.g. age, class, and immigration)

amongst older Chinese-speaking immigrants, and how did these differences interact

to influence their aging experience and general wellbeing in Australia, particularly for

those who migrated at an older age?

82

2. What was the pattern of aged care use by older Chinese-speaking immigrants in

Australia and in terms of the Andersen Behavioural Model of predisposing, enabling

and need factors, which of the factors determine their use of aged care services?

3. What was the contribution of the Andersen Behavioural Model and intersectionality

to understanding aged care use by older Chinese-speaking immigrants?

4.2 Ethical considerations in research involving older people from CALD background

Conducting research with older people from diverse cultural background can be challenging.

The key ethical considerations that were relevant to this study are outlined here to ensure that the study was conducted in ways that were culturally sensitive and protected participants from harm. Ethics approval was granted by the Behavioural and Social Sciences Human

Ethics Sub-Committee at the University of Melbourne on the 30th of November 2009 (Ethics

ID: 0932338).

Cultural sensitivity and language issues

Cultural sensitivity in research is referred to as knowing the cultural context of the group with whom the researchers wish to work (Liamputtong, 2008). Cultural sensitivity plays a critical role in study design and implementation processes, including the development of research instruments, recruitment strategies, consent activities, data collection, and analysing and presenting research findings. Without cultural sensitivity, researchers may inadvertently

83 cause harm to prospective participants, and the quality of data collected and the findings of research deriving from the data can also become problematic.

It has been suggested that building rapport and trust are crucial for conducting research with older people from ethnic backgrounds, particularly during the recruitment process (Feldman,

Radermacher, Browning, Bird, & Thomas, 2008; Levkoff & Sanchez, 2003; Sin, 2004;

Yancey, Ortega, & Kumanyika, 2006). Evidence shows that participants are more likely to accept a researcher from the same ethnic background and tend to believe that they share common experiences and viewpoints (Levkoff et al., 2003; Liamputtong, 2008). Being an

“insider” (Irvine, Roberts, & Bradbury-Jones, 2008) who shares a common language and similar culture, I had the advantage of establishing rapport more easily and increasing potential participants’ willingness to participate in the study.

Evidence also suggests that it would be quite challenging and time-consuming to recruit and build up a relationship with participants, if the researchers do not know and are not known by ethnic community members and leaders (Feldman et al., 2008; Levkoff et al., 2003;

Liamputtong, 2008; Yancey et al., 2006). Community leaders and ethnic service providers may act as gatekeepers to deny access or discourage their members and clients from participating in research, even when a researcher shares similar cultural characteristics.

Working in an ethno-specific organisation that is well-known and serves the Chinese- speaking community in Victoria, I had an established network and good access to the community as well as a sound knowledge of cultural beliefs and practices of the study population.

84 In addition, I have a language capability that can facilitate recruitment and participation and ensure cross-cultural equivalence in survey research. It is particularly important as the majority of older Chinese-speaking immigrants in Australia have low English proficiency and some may be illiterate and cannot read Chinese. It was expected that their interest in participation in research would be low if research information was only provided in English and the survey interviews were not conducted in participants’ preferred language. My language skill and work experience also assisted in ensuring the cultural and linguistic adaption of the survey for the study population. Although the survey used existing and well- established instruments, and most have verified Chinese versions available, some translation and adjustments to the Australian context were still required. Details about the translation and cultural adaption process are described later in this chapter.

However, being a cultural insider I needed to be cautious about insider bias. A sound understanding of the cultural backgrounds of the participants can allow insightful interpretation of the research data, yet an over-familiarity with the setting could lead to complacency and loss of objectivity (Irvine et al., 2008). The use of a survey in this study in some ways overcame the insider effect and bias as the analysis of quantitative (numerical) data may be less influenced by the researcher’s own perspectives and viewpoints, compared to qualitative or narrative data collection methods.

Other ethical considerations

Other ethical considerations that influenced the design of the study included issues of informed consent, voluntary participation and possible distress. It is standard practice to have

85 written consent from research participants to ensure that they have an understanding of the research and its risks. However, in some circumstances or with some cultural groups, obtaining a signed consent form can be a challenging task or can be problematic. Evidence suggests that written consent could be intimidating for those immigrants who have negative experiences of living under communist regimes as in Vietnam and Macedonia (Feldman et al.,

2008; Liamputtong, 2008). These participants may have concerns regarding fear of exploitation and the issue of mistrust. In addition, some older participants may be illiterate and unable to read the information and sign the consent form even in Chinese. It is suggested for these participants it would be appropriate and sensible if the details of consent are read out and a verbal consent is secured (Feldman et al., 2008; Liamputtong, 2008).

Participation in this study was completely voluntary. If participants wished to withdraw at any stage, or to withdraw any unprocessed data they had supplied, they were free to do so without prejudice. Because some participants were recruited from the organisations where they received services, the issue of perceived coercion was considered. The participants who received services from the organisations where the recruitment took place were clearly informed that their entitlement to services was not affected if they did or did not participate in this research project. I was particularly mindful of those who received services from the organisation where I worked to ensure that their participation was voluntary.

Most participants in this study were sufficiently fit to attend community activities; however some participants were very frail. Earlier studies with older persons have shown that a phone interview, lasting for 30-45 minutes is viable and a face-to-face interview can be even longer

(Quine & Browning, 2007). As an experienced social worker, I closely monitored

86 participants’ wellbeing during the administration of the survey. If participants felt unwell or became distressed, the interview would be stopped immediately and appropriate support given. With the participant’s consent, I instigated mechanisms for referral to an appropriate counselling or other support service if required.

Older people, particularly those from ethnic communities, are often marginalized in contributing to research because of their limited English (Quinte et al., 2007). This survey conducted in participants’ preferred language offered them an opportunity to be involved in the research and allowed them to be heard and understood. Accordingly, they may feel empowered because their participation in this research can potentially assist the development and improvement of aged care policy and services, and eventually benefit the elderly

Chinese-speaking community in Australia.

4.3 Research participants and sampling

This section defines the research population and describes the sampling framework.

4.3.1 Research population

The research population in this study refers to Australians of Chinese background aged 65 years and older. People who were 65 years and older, self-identified as Chinese descendants, not cognitively impaired, competent to read Chinese or English, or able to speak Mandarin,

Cantonese or English were eligible to participate in this study.

87 Given the focus of this study, language spoken at home was used to determine the size of the research population as discussed in Chapter 2. According to the 2011 Census of Population and Housing, there were 48,811 Australians aged 65 years and over who spoke a Chinese language at home (ABS, 2013). Over half (56%) of them were born in China and 67% cannot speak English well or at all. The majority lived in the capital cities of the States and

Territories, and less than 4% lived in rural areas. Approximately 53% of the older Chinese- speaking population lived in , and 27% lived in Melbourne where the survey was conducted. The highest concentration of the older Chinese-speaking population living in

Melbourne was in the eastern suburbs, including Manningham, Whitehorse, and Monash where many Chinese-specific health and aged care services are located.

4.3.2 Sampling strategies and sample size

To achieve the best representativeness and avoid selection bias, many scholars suggest using probability sampling (Creswell, 2007; Rubin & Babbie, 2007). However, the use of probability sampling in this study was not feasible because the research population was relatively small and not very accessible and visible. In addition, probability sampling can be very costly. Given these limitations, multiple non-probability sampling strategies, including quota and availability sampling were adopted to ensure that the collected sample was representative of the study population.

As Babbie (1990) suggests, quota sampling begins with a matrix describing the characteristics of the target population and the proportion of the population in each cell in light of their demographic and geographic attributes. When such a matrix has been

88 established, data are then collected from persons having the characteristics of a given cell.

All the persons in the given cell are assigned a weight appropriate to their proportion of the total population so the overall data should provide a reasonable representation of that population.

In this study, a quota sampling frame (see Table 4.1) was created by using the 2006 Census of Population and Housing to represent the geographical and demographic distribution of older Australians who speak a Chinese language at home. The 2011 Census data were not yet available when the survey was conducted between December 2009 and January 2011. Age and living areas in Melbourne were used as the main attributes that describe the characteristics of the study population to avoid oversampling those who were younger and lived in the areas where more resources might be available.

Table 4.1 Quota sampling frame (% of older Australians speaking a Chinese language at home by Age) Age EMR(a) of Melbourne SMR(b) of Melbourne NMR(c) of Melbourne WMR(d) of Melbourne (years) N % N % N % N % 65-74 35 29.8 15 12.8 10 9.0 11 9.9 75-84 15 13.0 8 6.5 6 4.8 7 5.8 85- 4 3.6 2 1.8 1 1.1 2 1.9 Total 54 46.4 25 21.1 17 14.9 20 17.6 (a) Eastern Metropolitan Region includes the local government areas of Boroondara, Knox , Manningham, Maroondah, Monash, Whitehorse, and Yarra Ranges. (b) Southern Metropolitan Region includes the local government areas of Bayside, Cardinia, Casey, Frankston,Glen Eira, Greater Dandenong, Kingston, Mornington Peninsula, Port Phillip,and Stonnington. (c) Northern Metropolitan Region includes the local government areas of Banyule, Darebin, Hume, Moreland, Nillumbik, Whittlesea, and Yarra. (d) Western Metropolitan Region includes the local government areas of Brimbank, Hobsons Bay, Maribyrnong, Melbourne, Melton, Moonee Valley, and Wyndham.

Source: (ABS, 2008)

89 Using Cohen’s sample size calculation (Cohen, 1988), with a moderate effect size of 0.02, 18

independent variables were entered for multiple regression analyses. With a desired level of

statistical power of 0.8, and an alpha level of 0.05, the minimum sample size for this study

was 116. Table 4.1 displays the number of participants who should be recruited in light of

their residence and age cohort.

4.4 Survey method

As described in the Chapter 2, the older Chinese-speaking population in Australia is

internally diversified because of differences in the time of arrival, birthplace, socio-economic

status, and value and perspective. These factors can play important role in influencing the use

of aged care services in Australia. The survey design was employed to respond to diversity

and demographic differences within this population. This study used a questionnaire to

collect information of older Chinese-speaking participants. The questionnaire was

constructed from established standardised measures and questions developed specifically for

the current study. To ensure the survey was culturally appropriate to the study population and

cross-culturally equivalent to the original measures, several steps were adopted in its

development (Beaton, Bombardier, Guillemin, & Ferraz, 2000; Sousa & Rojjanasrirat, 2011).

4.4.1 Instrument selection

The selection of research instruments to collect data is crucial to the success of a survey

study. The review of the literature in chapter 3 suggests that some cultural attributes and

behaviours of older Chinese-speaking immigrants may influence their choice of aged care

90 services. As these attributes are often abstract and not easy to measure, this study utilised well-established instruments that have been verified with the elderly and Chinese-speaking populations. The benefit of using existing scales is that these measures have good validity and reliability and have been used with different populations so data collected can be easily used for comparison.

Eight instruments were incorporated into the questionnaire. Six of them, measuring attitudes to community services, perceived barriers, instrumental activities and activities of daily living, acculturation, and depression, had verified Chinese versions, and the remaining two instruments which measure social support and filial expectation only had English versions available. Permission to use all these instruments has been obtained from each respective developer (see Appendix I), and the detailed descriptions of the instruments and their psychometric properties are presented later.

4.4.2 Translation and adaptation of the questionnaire

The questionnaire (see Appendix II) was constructed in seven sections and produced in both

English and Chinese.

Part A：Participants were asked to answer questions regarding predisposing characteristics, including age, gender, marital status, country of birth, years of residency, language, living arrangement, education, and religious affiliation.

91 Part B ： Participants were asked to self-rate their health status and answer questions regarding their activities and instrumental activities of daily living, using the Modified

Barthel Index (MBI) and the Lawton Instrumental Activities of Daily Living Scale (IADL).

Participants were also asked about the availability of informal carers and their own ability to contribute care time.

Part C：Participants were asked to report their knowledge and use of aged care services, using a list of available aged care services in Australia. Participants’ attitudes toward service use and perceived service barriers were also explored, using the Barriers to Service Use

(BSU) and the Modified Community Service Attitude Inventory (MCSAI).

Part D：Participants were asked to answer questions regarding their recent emotional status and level of social support, using the Geriatric Depression Scale Short Form (GDS-SF) and the Duke Social Support Index (DSSI).

Part E：Participants were asked to answer questions regarding their assimilation of the host culture and maintenance of their heritage culture, using the Vancouver Index of

Acculturation (VIA).

Part F：Participants were asked to answer questions regarding their filial expectations of adult children, using the Hamon Filial Responsibility Scale (HFRS).

Part G：Participants were asked to answer questions regarding enabling characteristics, including income, benefits, Medicare and private insurance.

92

The English version of the questionnaire was developed first. For those questions and instruments that did not have Chinese versions available, they were translated into Chinese separately by the researcher who was knowledgeable about research terminology and aware of the concepts being studied, and a Cantonese-speaking volunteer, who was considered as a naive translator but knowledgeable about cultural and linguistic nuance of the study population (Beaton et al., 2000; Sousa et al., 2011). The two forward-translated Chinese versions were then compared and a synthesised version was produced. This synthesised

Chinese version was then back-translated into English separately by two bilingual persons who had similar characterises with the first and second translators in the forward-translation process. All discrepancies and ambiguities were discussed and resolved in a meeting involving all four translators and a bilingual professor who was one of the researcher’s co- supervisors.

To further examine cross-cultural equivalence and cultural adaptation of the questionnaire, an expert committee was formed (Beaton et al., 2000; Sousa et al., 2011). Five bilingual community social workers who have extensive experience working with elderly Chinese immigrants in aged care related settings were selected as content experts to review language equivalence and content validity. Appendix III outlined the qualification and experience of the expert committee, and a certification of translation was signed by the expert panel to validate cross-cultural equivalence between the Chinese and English versions.

Each of the experts was asked to provide comments and rate each survey item in terms of its language equivalence between the English and Chinese version and content relevance to the

93 study population (see Appendix IV). A 4-point scale, ranging from 4 (high degree of equivalence/relevance) to 1 (not equivalent/relevant) was utilized (McGartland Rubio, Berg-

Weger, Tebb, Lee, & Rauch, 2003; Sousa et al., 2011). For each item, an item index was calculated for language equivalence (I-LE) and content validity (I-CV). The average item index of each part of the questionnaire was calculated as a scale index for language equivalence (S-LE) and content validity (S-CV). Using the panel of five experts, an item index of 0.80 and a scale index of 0.90 is considered to have an excellent language equivalence and content validity (Polit, Beck, & Owen, 2007). Table 4.2 summaries the item and scale index of the questionnaire for language equivalence and content validity, suggesting overall good cross-cultural equivalence and content validity. The final Chinese version of the questionnaire was pre-tested on one Cantonese-speaking and one Mandarin- speaking participant to seek their feedback on the length of the questionnaire, response format, and wording of the questions. Both participants stated that questions were easy to understand and answer, and the time taken to complete the survey was acceptable.

Table 4.2 A summary of language equivalence and content validity index of the survey questionnaire Language Content Equivalence Validity I-LE S-LE I-CV S-CV Part A: Demographics 0.88-1.00 0.96 0.88-1.00 0.97 Part B: Physical function and informal care 0.81-1.00 0.92 0.94-1.00 1.00 Part C: Perceptions of aged care use 0.75-1.00 0.94 0.81-1.00 0.97 Part D: Emotional status and social support 0.88-1.00 0.98 0.88-1.00 1.00 Part E: Acculturation 0.88-1.00 0.94 0.88-1.00 0.98 Part F: Filial expectations 0.94-1.00 0.99 1.00 1.00 Part G: Financial status 0.75-1.00 0.95 0.81-1.00 0.98

During the process of translation and adaptation of the questionnaire, two issues were worth- noting. One related to translation--the issue of semantic and conceptual equivalence. On the

94 questionnaire, a list of aged care services available in Australia was used to evaluate participants’ awareness and use. Many of these aged care services such as meals on wheels, home maintenance, allied health services, volunteer friendly visiting, and aged care packages are either unavailable or underdeveloped in the countries where potential participants come from. Direct translations of these services may not make much sense for participants. There was also a lack of consistency in Chinese translations of these services and no unifying terminology. Governments, local councils, and service providers all used slightly different terms to depict these services, depending on translators or bilingual workers involved to produce the translated documents. To resolve this issue, the expert committee suggested giving more explanation for the content of these services. For example, under the direct translation of home maintenance, some examples (eg. installing handrails, changing light bulbs) were provided to help participants understand this service. In addition, these questions on the survey were directly asked of participants to allow the researcher to clarify any ambiguities during the interview.

The second issue was the adaptation of the instrument to a different age group. This study used the Vancouver Index of Acculturation (VIA) to assess participants’ level of acculturation with both heritage and mainstream cultures. This scale assesses ten different aspects of cultural values and behaviours, and it has been found to have good reliability across studies with the Chinese population (Huynh, Howell, & Benet-Martínez, 2009). The samples in most studies using the VIA scale were undergraduate students and young adults

(Tieu & Konnert, 2015). The expert committee suggested that the two questions related to marriage, eg. “I would be willing to marry a person from an Australia/my heritage culture” may be inappropriate and irrelevant to older participants. After email consultation with the

95 scale developer, Associate Professor Andrew Ryder, these two questions were removed from the questionnaire because his colleague had used this scale with older adults and had also deleted these items for the same reason (see Appendix V).

4.4.3 Measurements

This section provides detailed descriptions of measurement and operational definitions of the independent and dependent variables.

The independent variables: Determinants of Aged Care Use

A. Predisposing variables

Age, gender, marital status, education, religion, country of origin, language spoken at home, living arrangements, and years of residency in Australia were examined in this study to help explain differential propensity to use aged care (see Table 4.3 overleaf).

Filial responsibility expectations were conceptually defined as a societal attitude toward the duty of adult children to meet the needs of older parents, specifically addressing parental expectations for filial support (van der Pas, van Tilburg, & Knipscheer, 2005). The Hamon

Filial Responsibility Scale (HFRS) was used in this study to examine older Chinese participant’s filial responsibility expectation of their adult children (Hamon & Blieszner,

1990). Participants were asked to rate their level of agreement with 16 statements using a 5 point Likert scale (1 being strongly disagree and 5 being strongly agree). A higher score indicated a higher level of filial expectation toward adult children. Good reliability scores

96 with a Cronbach’s alpha of 0.85 and 0.92 were reported in earlier studies with older people and immigrants (Rudolph, Chavez, Quintana, & Salinas, 2011; van der Pas et al., 2005).

Table 4.3 Measurement and operational definition of predisposing variables VARIBLE MEASURMENT OPERATIONAL DEFINITION Predisposing Age Interval Age of participant

Gender Dichotomous “1”=male; ”2”=female

Education Categorical “1”= No formal education or primary school; ”2”=Secondary or high school; ”3”=College or TAFE; ”4”=Undergraduate and above

Marital Status Categorical “1”=married; “2”=divorced or separated; ”3”= widowed

Religion Categorical “1”= No religion; ”2”= (Christian and Catholic) ; ”3”=Buddhism; ”4”=Other (Muslim)

Country of Birth Categorical “1”= China “2”=Other (Taiwan, Hong Kong, Malaysia, Vietnam, , Philippines)

Language spoken Categorical “1”= Cantonese; At home ”2”=Mandarin ; ”3”=Wu/; ”4”=Other (, Fuzhou, Hakka)

Year of residence Interval Years that participants have lived in Australia

Living Arrangement Dichotomous “1”= Alone; ”2”= With spouse only; ”3”= With other family members

Attitudes toward service use were defined as feelings of favorableness or unfavorableness toward the use of aged care services. The Community Service Attitude Inventory was originally developed by Collins, Stommel, King, and Given (1991) to measure attitudes of family caregivers toward community services. This scale consists of 25 items and 5 subscales,

97 and has been modified and used in several studies to examine older people’s attitudes toward community service use (Goh, 2007; Guberman, Gagnon, Lavoie, Belleau, Fournier, Grenier,

& Vézina, 2006; Stommel, Manfred, Collins, Clare, Given, Barbara, & Given, 1999;

Zodikoff, 2007). The Cronbach’s alpha ranged from 0.63 to 0.91 in these studies, suggesting acceptable internal consistency levels. This study used the Chinese version of the

Community Service Attitude Inventory modified by Goh (2007). Participants were asked to rate their level of agreement on 17 statements, using a 5 point Likert scale (1 being strongly disagree and 5 being strongly agree).

B. Enabling variables

English ability, social support, acculturation, awareness of existing services, availability of informal carers, perceived service barriers, and financial status were examined in this study to understand factors that facilitate or hinder participants’ use of aged care services. English ability refers to ability of participants to understand and speak English. Participants were asked to rate how well they can speak and understand English (very well, well, not well, not at all).

Social support was measured by using the short form of the Duke Social Support Index

(DSSI) which is abbreviated from the original 35-item DDSI and has been specifically adopted in studies of the elderly (Koenig, Westlund, George, Hughes, Blazer, & Hybels,

1993). The 11-item DSSI includes two subscales, both a subjective evaluation of adequacy of support received as well as an objective evaluation of type and number of social interactions.

Participants were asked to rate on a three point Likert scale, with a higher score indicating

98 better social support. The Cronbach’s alpha coefficients of 0.80 for the overall scale, and 0.6 and 0.8 for the two subscales were reported in a large longitudinal study of older Australian women (Pachana, Smith, Watson, McLaughlin, & Dobson, 2008; Powers, Goodger, & Byles,

2004).

Acculturation in this study referred to changes in the behaviours, attitudes, values and identities of individuals that result from sustained contact between two distinct cultures

(Berry, 2005). The Vancouver Index of Acculturation (VIA) (Ryder, Alden, & Paulhus, 2000) which consists of two subscales (Heritage and Mainstream scale) is one of the widely-used bidimensional measures of acculturation. This study adapted 18 items from the VIA to assess participants’ levels of retention of Chinese culture (heritage scale) and adaptation of

Australian culture (mainstream scale) in the areas of social activities, comfort, entertainment, values, behaviours, humor and friends. Two items related to marriage were deleted given the reason explained in the previous section. Participants were asked to rate their level of agreement on a 5 point Likert scale, from 1 being strongly disagree to 5 being strongly agree.

The Cronbach’s alpha of 0.84 for the VIA heritage subscale, and 0.85 for the mainstream subscale were reported in a study with Chinese Canadian older adults (Tieu et al., 2015), suggesting good reliability of the scale.

Awareness of existing services was measured by the total number of existing aged care services that participants have heard about. The listed aged care services included, planned activity groups, home nursing services, community health centres, home care services, personal care services, home maintenance, meals-on-wheels, respite, friendly visiting, telelink, transport, aged care assessment services, aged care packages, and residential care.

99 Participants scored one point if they answered “yes” for each service that they have heard of, and scored zero if they answered “no”, with a higher score indicating a higher level of awareness of existing aged care services.

Availability of informal carer referred to help with daily living received from family and/or friends. Participants were asked to indicate who are or would be their carers when needed from a list of nine informal carers, and to assess each carer’s availability in terms of care time, ranging from a score 0 being unable to provide care, score 1 being “only occasionally”, score

2 ”for weeks to a half of year”, and score 3 providing help “as long as needed”. The availability of an informal carer score was calculated by adding up 9 of the listed carer items, with the higher score indicating a stronger informal support network.

Service barriers were measured by asking participants to answer either “yes” or “no” to a list of barriers that they might have faced while using aged care services. This list was originally developed by Tsai et al. (1998) and later expanded by Lai et al., (2007) to be used in a national Canadian study with older Chinese immigrants. The scale consisted of 21 items and

4 subscales, namely administrative programs, cultural incompatibility, personal attitudes, and circumstantial challenges. The 16 items were adapted from the scale and 3 more items were added according to the advice from the expert panel. The wording of questions was slightly modified to suit the Australian context with regard to available services. There were no

Cronbach’s alpha scores reported in these studies.

Lastly, participants’ financial status was measured by asking their monthly income, main source of income, and whether they received a government benefit or aged pension. Monthly

100 income ranged from $0-500, $ 500-999, $1000-1499, to $1500+, and the main source of income included government payment, support from adult children, and personal savings.

C. Need variables

Perceived needs were measured by asking participants to self assess their health on a 5 point scale (excellent, very good, good, fair, or poor) and need for assistance with daily living (yes or no). Evaluated needs were measured using the Modified Barthel Index (MBI) (Leung,

Chan & Shah, 2007) and Lawton Instrumental Activities of Daily Living Scale (IADL)

( & Man, 2002). The MBI scale consists of 10 items including feeding, transfers, grooming, toilet use, bathing, mobility (on level surfaces), stairs, dressing, bowel and bladder function. The IADL scale consists of 8 items, including ability to use a telephone, shopping, food preparation, housekeeping, laundry, driving, responsibility for own medications, and handling finances. Participants were then asked if they could perform these tasks without any assistance, with some help or completely depending on others’ assistance, with a higher score being more dependent.

Participants’ mental health was also examined in this study as one of the need factors. The

Geriatric Depression Scale Short Form (GDS-SF) developed by Mui (1996) was used to measure the level of depression, which consists of 15 items. Response of a “yes” was scored one point and “no” equalled “0”.

101 The dependent Variable: Use of Aged Care Services

In this study, the dependent variable was measured by asking participants to answer “yes” or

“no” to a list of 16 available aged care services in Australia that they had used. The listed aged care services included planned activity groups, home nursing services, community health centres, home care services, personal care services, home maintenance, meals-on- wheels, respite, friendly visiting, telelink, transport, aged care assessment services, community aged care packages, extended aged care at home, hostel, and nursing home. The score was calculated by adding up all 16 items, one point for a “yes” and zero for a “no”.

4.4.4 Validity and Reliability

The psychometric properties of the survey instruments used in this study were examined to establish construct validity and internal consistency reliability.

Construct validity

Construct validity refers to the degree to which an instrument assesses the underlying theoretical construct it is supposed to measure. Factor analyses using the principal component method with a varimax rotation were performed on four scales used in this study to examine their construct validity (Thompson & Daniel, 1996). These included the Modified

Community Service Attitude Inventory (MCSAI), the Vancouver Index of Acculturation

(VIA), the Duke Social Support Index (DSSI), and the Service Barriers (BA) Scale. Overall,

102 the result showed robust construct validity across these instruments. The detailed results for each scale are reported below.

A. Modified Community Service Attitude Inventory (MCSAI)

Prior to conducting a factor analysis, the factorability of the 17 MCSAI items was examined.

Correlation and anti-image correlation matrixes were used to identify unsuitable items which did not correlate with other items. Item 12 was removed because its value on the diagonal of the anti-image correlation matrix was less than 0.5, suggesting this item did not relate to any other items. A principal component exploratory factor analysis using a varimax rotation was then conducted. Three more items were eliminated. Item 8 was removed because it had similar loadings between 0.5 and 0.6 on two factors. Item 7 and 15 which loaded on one factor but did not have a theoretical fit with the scale were also dropped. Table 4.4 overleaf shows the final rotated matrix with factor loadings of the retained MCSAI items.

The four factors were similar to the original factors identified by Collins and her colleagues in the studies on caregivers’ community service attitudes (Collins et al., 1991; Stommel et al.,

1999). Three factors, ‘Acceptance of Government Assistance’, ‘Concern for the Opinion of

Others’ and ‘Worry and Fear’ remained largely intact, while one factor ‘Preference for

Informal Care’ had two additional items loaded on. These four factors in total explained approximately 63% of the variance.

103 Table 4.4 Factor loadings for items of Modified Community Service Attitude Inventory

Factor 1 ：Preference for Informal Care (18.72% of variance) I would rather ask my family for help than use these services .746 I think my family should care for me without help from these .712 services I believe in the idea that families should care for their own elderly .704 relative and not ask for outside help I would rather ask my friend for help than use these services .603 Factor 2：Acceptance of Government Assistance (15.41% of variance) I would use more services if the government helped to make them .839 more affordable Government should do more to help families care for their older .821 relatives at home I feel good about using these services to help care for me .614 Factor 3：Concern for the Opinion of Others (14.89 % of variance) People outside my family will have a different opinion to me if I .818 use these services. Families should not use these services to care for an elderly relative. .622 I do not want others to know my condition. .727 Factor 4：Worry and Fear (13.60% of variance) I trust people from these services to care for me (reversed) .775 It is hard to trust someone from these services to care for me .658 I am fearful of having people from these services taking care of me .634

B. Vancouver Index of Acculturation (VIA)

The factorability of the VIA scale was examined before a factor analysis was conducted.

Item 14 was removed because its value on the diagonal of the anti-image correlation matrix was below 0.5. The factor analysis result showed that there were three underlying factors.

The third factor including Item 1, 2, 3 and 8 were removed because these items did not fit conceptually well with the original VIA scale which was a bidimensional scale (Ryder et al.,

2000). The rotated matrix with factor loadings and communalities of the remaining VIA items are reported in Table 4.5 overleaf.

104 The first Factor contained 7 items of maintenance of heritage (Chinese) culture and the second factor contained 6 items of adaptation of mainstream (Australian) culture. These two factors had total explained variance of 54%, which was similar to an earlier study with two

Chinese groups of 59% and 53% (Ryder et al., 2000)

Table 4.5 Factor loadings for items of Vancouver Index of Acculturation

Factor 1 ：Heritage (retention of Chinese culture) (28.4% of variance) It is important for me to maintain or develop the practices of my Chinese culture .758 I believe in the values of my Chinese culture .758 I am interested in having friends from my Chinese culture .742 I often behave in ways that are typical of my Chinese culture .732 I am comfortable working with people of a Chinese background similar to myself .657 I enjoy the jokes and humor of my Chinese culture .657 I enjoy entertainment (e.g., movies, music) from Chinese culture .637 Factor 2：Mainstream (adaptation of Australian culture) (24.41% of variance) I am interested in having Australian friends .758 I am comfortable working with typical Australian people .758 I enjoy social activities with typical Australian people .724 I enjoy typical Australian jokes and humor .674 It is important for me to maintain or develop Australian cultural practices .609 I often behave in ways that are 'typically Australian’ .563

C. Duke Social Support Index (DSSI)

The DSSI satisfied the requirement of conducting a factor analysis. The diagonals of the anti- image correlation matrix were all over 0.5. Item 4 was eliminated as it did not correlate at 0.3 with any other item in the correlation matrix. A principal component factor analysis was performed and Item 10 which had similar loadings to another factor was removed. Table 4.6

(overleaf) summaries the factor loadings of 9 retained DSSI items.

105 Table 4.6 Factor loadings for items of Duke Social Support Index

Factor 1：Satisfaction with Social Support (40.34% of variance) Do you feel that you have a definite role (place) in your family and among .870 your friends? Do you feel useful to your family and friends (people important to you)? .855 Does it seem that your family and friends (people who are important to you) .769 understand you? Do you know what is going on with your family and friends? .736 When you are talking with your family and friends, do you feel you are being .711 listened to? How satisfied are you with the kinds of relationships you have with your .550 family and friends? Factor 2：Social Network (20.44% of variance) How many times did you talk to someone (friends, relatives or others) on the .796 telephone in the past week (either they called you, or you called them)? How many times during the past week did you spend time with someone who .773 does not live with you, that is, you went to see them or they came to visit you or you went out together? Other than members of your family how many persons in your local area do .557 you feel you can depend on or feel very close to?

The final result identified two factors, the first factor (6 items) related to satisfaction with social support and the second factor (3 items) related to social interaction. They were identical to the original DSSI scale (Koenig et al., 1993), except for one item dropped from each factor. The DSSI scale and its two factors explained only 60% of the variance, which was lower than the Powers et al.’s study in which over 80% of the variance was explained

(Powers et al., 2004). However, it still met the general norm that eigenvalues should account for at least 50 % of the variance (Streiner, 1994).

D. Barriers to Service Use (BSU)

The factorability of the BSU was first examined. Item 1, 16 and 18 were eliminated as they either did not relate to any other item at 0.3 or their values on the diagonal of the anti-image correlation matrix were below 0.5. Four factors were extracted from the principal component

106 analysis and the final rotated matrix with factor loadings for each BSU items is displayed in

Table 4.7 below.

Table 4.7 Factor loadings for items of Barriers to Service Use

Factor 1：Cultural barriers (17.54% of variance) Staff and workers are not Chinese .806 Staff and workers do not speak your language .801 Staff and workers do not understand your culture .730 Services are not specialized for Chinese (eg. Meals) .693 There are no other Chinese clients/users .641 Factor 2：Structural barriers (16.11% of variance) The waiting list is too long .832 The procedures of using the services are complicated .777 The office hours are inconvenient .750 The services are too expensive (Cannot afford to pay) .595 Transportation difficulties .457 Factor 3 ：Attitudinal barriers (15.34 % of variance) Feeling ashamed. .931 Feeling awkward to ask for help .860 You worry that you are being seen as having problems .843 Factor 4 ：Self-sufficiency (10.90% of variance) You can take care of yourself well. .840 You are in good health now. .658 Your family can look after you. .589

The first factor, cultural barriers, was related to culture and communication difficulties in accessing and using aged care services. The second and third factors were barriers related to service delivery and personal attitudes, so called structural and attitudinal barriers. These three factors were similar to the original scale. The final factor, self sufficiency, referred to self-care and family independence, which consisted of 3 items that were relevant to aged care use and suggested by content experts. These four factors accounted for 60% of the total variance, which was above the commonly recommended 50%.

107 Internal consistency reliability

Reliability refers to the consistency of a measure and the most common method of assessing reliability is to assess the consistency of results across items within a test, namely internal consistency reliability (Onwuegbuzie & Daniel, 2002). Internal consistency of the HFRS,

MCSAI (4 subscales), VIA (2 subscales), DSSI, BSU (4 subscales), MBI, LIADLS, and

GDS-SF were then examined by calculating Cronbach’s alpha (Table 4.8).

Table 4.8 Cronbach’s alpha of HFRS, MCSAI , VIA, DSSI, BSU, MBI, LIADLS, and GDS-SF Scale Number of Cronbach's Items Alpha Hamon Filial Responsibility Scale (HFRS) 16 0.88 Modified Community Service Attitude Inventory (MCSAI) 13 0.66 Preference for Informal Care 4 0.72 Acceptance of Government Assistance 3 0.69 Concern for the opinion of others 3 0.63 Worry and Fear 3 0.64 Vancouver Index of Acculturation (VIA) 13 0.79 Heritage (Chinese) 7 0.84 Mainstream (Australian) 6 0.79 Duke Social Support Index (DSSI) 9 0.85 Barriers to Service Use (BSU) 16 0.71 Cultural Barriers 5 0.79 Structural Barriers 5 0.74 Attitudinal Barriers 3 0.86 Self Sufficiency 3 0.50 Modified Barthel Index (MBI) 10 0.76 Lawton Instrumental Activities of Daily Living Scale (LIADLS) 8 0.82 Geriatric Depression Scale Short Form (GDS-SF) 15 0.87

For evaluating alpha coefficients, George and Mallery (2003) suggest following rules of thumb：_ > .9 – Excellent, _ > .8 – Good, _ > .7 – Acceptable, _ > .6 –Questionable, _ > .5 –

Poor, and_ < .5 – Unacceptable” (p. 231). However, for exploratory studies, Cronbach

108 suggests that Cronbach’s alpha of 0.6 is still considered acceptable (Cronbach, 1990). In this

study, the Cronbach’s alpha of 8 scales and their subscales were reported between 0.62 and

0.88, suggesting good or at least acceptable reliability. There was only one BSU

subscale, ’Self-sufficiency’ with a Cronbach’s alpha value less than 0.6. Although its

reliability may be considered as questionable or poor, this subscale was retained in the

analysis given the exploratory nature of this study.

4.5 Procedures and data analysis

This section introduces the recruitment process, administration of the survey, secondary data

used for comparison, and the strategies of analysing data.

4.5.1 Recruitment

To successfully recruit participants from ethnic backgrounds, the literature suggests that the

researcher has to establish rapport through knowing and being known by the community

studied and their leaders, as described earlier. Therefore, recruitment of older Chinese-

speaking participants in this study included both passive and active approaches (Lee,

McGinnis, Sallis, Castro, Chen, & Hickmann, 1997; Rao et al., 2006 ; Yancey et al., 2006).

Figure 4.1 overleaf illustrates the recruitment process.

109

Passive Recruitment

The dissemination of information via posters, flyers, local newspaper and radio Active Recruitment

The researcher was present at Interested participants recruitment sites during the data contacted the researcher collection period and made direct contact with potential participants

Consenting Participants

Appointment for a The administration of survey interview survey by the researcher

Figure 4.0.1 Recruitment procedures for this study

Passive recruitment involved the researcher sending a poster (Appendix VI) to libraries,

Chinese senior clubs, Chinese churches and temples, as well as organisations and agencies where aged care services are provided to older Chinese-speaking people in the four metropolitan regions of Melbourne. The researcher also advertised the study in local Chinese newspapers (Appendix VII) and on SBS Chinese radio (Appendix VIII) to increase the participation rate. These recruitment methods aimed to make prospective participants aware of this study and allow them to directly approach me.

110

Active recruitment involved the researcher getting in direct contact with prospective participants. The literature suggests recruitment of minority elderly through a wide range of community organisations and agencies that cater for different social, cultural, and welfare needs can yield a more robust sample (Sin, 2004). The researcher contacted a number of

Chinese seniors’ clubs and Chinese organisations, offering a free talk on aged care services to their members and inviting the community leaders to participate in this study. Fitzroy

Chinese Residents Association, Brotherhood of St Laurence - Coolibah Centre, Victoria Hua

Xin Chinese Women’s Association, Chinese Community Social Service Centre Inc., South

East Volunteers (formerly Monash Volunteer Resource Centre), Chinese Social Center of

North Melbourne, Jing Song Senior Chinese Men’s Incorporation agreed to support this study by facilitating the researcher to introduce this study via talks, giving prospective participants a flyer, and referring them to the researcher. The researcher also visited these organisations and senior clubs at their weekly gatherings to make direct contacts with prospective participants.

4.5.2 Administration of the survey

Before the administration of the survey, participants were given time to read the plain language statement (Appendix IX) and sign the consent form (Appendix X). If participants were unable to read the plain language statement, the researcher read it out to them. Although the researcher was able to obtain written consent from nearly all participants, time was required to explain the purpose of signing a consent form. Some participants required more explanation and assurance relating to anonymity and confidentiality because of their past

111 experiences with the Chinese government or distrust of the Australian authorities. The researcher stressed that their name and contact details were kept in a separate, password- protected computer file and were not linked to their responses. Their responses appeared as aggregate data in the final report and no personal information was disclosed.

If prospective participants agreed to engage in the study, a face to face structured interview was organised that took place either at the recruitment site or the participants’ choice of place such as their home or local library. The survey was administered by the researcher in participant’s preferred language. I can speak fluent Mandarin and Hokkien, and a little

Cantonese. If the interviewee’s preferred language was Cantonese, a Cantonese-speaking social worker was arranged to be present to assist me in administering the survey. Training was given to the Cantonese-speaking assistant and there was a debriefing session with her after each interview. A total of 120 older Chinese-speaking immigrants were recruited and the survey was administered face to face mainly through the active approaches.

4.5.3 Secondary data for comparison

In addition to primary data collected through the survey, two secondary datasets were used for comparison purposes.

2011 Census of Population and Housing

The Census of Population and Housing is the largest statistical collection undertaken by the

Australian Bureau of Statistics (ABS). The Census is conducted every five years and collects

112 a range of demographic, social and economic information from all people and dwellings in

Australia on census night. The most recent national Census was conducted in September,

2016 but data were not yet released. This study used the data drawing from the 2011 Census which were made available on the internet through a wide range of products.

TableBuilder, an online self-help tool developed by the ABS, was used to draw data from the

2011 Census. I completed a one-day training on how to use this tool and registered to access

2006 and 2011 Census data. TableBuilder allowed the purposive building of the tables using different demographic, social and economic information. The two populations from the 2011

Census used for comparison were Australians who were 65 years and above (referred to as the “older Australian population” in this thesis) and Australians who were over 65 years and spoke a Chinese language at home (referred to as the “older Chinese-speaking population”).

HACC minimum data set 2011-2012

The HACC Minimum Data Set (MDS) is a collection of data about client characteristics and the amount and types of assistance being provided to them through the Home and

Community Care (HACC) Program. The data used for comparison was drawn from the national HACC minimum data set 2010-2011 (Department of Health and Ageing (DoHA),

2014), and the Victoria HACC minimum data set 2009-2010 (Department of Health (DoH),

2010).

113 4.5.4 Analysis strategy

The Survey data were entered into Predictive Analytics SoftWare (PASW) Statistics

18 (formerly SPSS Statistics). A two-stage analysis was undertaken. The first stage included an examination of the sample’s predisposing, enabling, and need characteristics. Results including participants’ demographics, migratory background, socio-economic status, and self-rated health are presented in chapter 5. Frequency distributions were used to provide a description of the counts and proportions of these variables. In order to examine the representativeness of the sample, t-tests were used to compare the sample with the older

Chinese-speaking population in Australia, drawing from the 2011 Census data. T-tests were also used to compare the sample and older Australian population to see if there are significant differences in demographics and socio-economic characteristics of these two populations.

Results collected using existing scales are presented in chapter 6, including filial expectation, attitudes toward service use, acculturation, social support, availability of carers, perceived service barriers, physical limitations, and depression. Mean, Standard deviation, and the range of scales were used to provide a description of these variables. To examine the socio- demographic variance of the sample on these variables, one-way analysis of variance

(ANOVA) tests were performed.

The second stage of analysis included an examination of aged care utilisation by older

Chinese-speaking participants. The analysis began with a description of the sample’s use of aged care services by using frequency distributions. The national HACC minimum data set

114 2010-2011 and the Victoria HACC minimum data set 2009-2010 was used for comparison

with the sample’s service utilisation, using t-tests. To examine the predictive factors of aged

care use by the sample, a hierarchical binary logistic regression was conducted. The

predisposing, enabling, and need factors were entered into a stepwise regression model in a

hierarchical fashion as independent variables.

4.6 Summary

In this chapter, the overall research approach and the ethical considerations in research with

older people from ethnic backgrounds have been discussed. The methods used to recruit

participants, collect and analyse data were also reported. The participants were recruited

using quota and availability sampling from various seniors clubs and agencies across the four

Metropolitan areas of Melbourne. This study surveyed 120 participants who were 65 years

and older and spoke a Chinese language at home. The questionnaire was developed, using

existing scales that were reliable and valid to measure participants’ predisposing, enabling

and need characteristics.

115 Chapter 5: The demographic profile of older Chinese-speaking participants

This chapter describes the characteristics and circumstances of the 120 older Chinese- speaking immigrants in Melbourne who participated in this study, namely their demographics, immigration history, socioeconomic and health status. These characteristics were categorised under the predisposing, enabling and need factors of the Andersen Behavioural Model as explained in Chapter 3. The predisposing factors presented in this chapter include age, gender, education, religion, marital status, living arrangement, country of birth, and years of residency. The enabling factors are income and English proficiency, while the need factors include self-rated health and perceived need for assistance.

To examine the sample’s representativeness, the data were compared with statistics drawn from the 2011 Census of Population and Housing (ABS, 2013). The two populations from the ABS used for comparison were the “older Australian population2” and “older Chinese- speaking population3”, as noted in Chapter 4.

5.1 Demographic characteristics

Demographic variables examined in this study were age, gender and geographic location.

2 Australians who were 65 years and above 3 Australians who were over 65 years and spoke a Chinese language at home

116 5.1.1 Age

The mean age of this sample was 76.9 years (range from 65 to 92 years old), with a standard deviation of 6.1 years. T-tests were performed to determine whether there were significant differences between the sample and the older Chinese population (see Table 5.1) and between the sample and the older Australian population (see Table 5.2) with respect to age distribution.

Table 5.1 Comparison of the sample with the older Chinese-speaking population by three age groups Sample Older Chinese-speaking t(48929) p population Age N % N % 65-74 40 33.3 27,924 57.2 5.284 0.0000 75-84 68 56.7 16,287 33.4 5.403 0.0000 85+ 12 10.0 4,600 9.4 0.225 0.8221 Total 120 100.0 48,811 100.0

Table 5.2 Comparison of the sample with the older Australian population by three age groups Sample Older Australian population t(3012399) p Age N % N % 65-74 40 33.3 1,627,409 54.0 4.556 0.0000 75-84 68 56.7 982,191 32.6 5.629 0.0000 85+ 12 10.0 402,681 13.4 1.093 0.2745 Total 120 100.0 3,012,281 100.0

Results indicate that the percentage of the sample whose age was between 65 and 74 years old was significantly lower than the older Chinese-speaking population and the older

Australian population. The sample had a significantly higher proportion of people aged between 75 and 84 years, compared to both the older Chinese-speaking population and the older Australian population. However, the percentage of people who were aged above 85

117 years old was not significantly different from the sample and the other two populations.

These findings suggest that the sample had more ‘middle-old’ and fewer ‘young-old’, compared to both the older Chinese-speaking and Australian populations. Given the fact that age is often associated with increasing care need and service utilisation, this sample well represented those at more advanced ages who are more likely to use aged care services.

5.1.2 Gender

The sample consisted of 70% females and 30% males. Table 5.3 compares the gender distribution of the sample, the older Chinese-speaking population and the older Australian population.

Table 5.3 Comparison of the sample with the older Chinese-speaking and Australian populations by sex

Gender Sample Older Chinese-speaking Older Australian population population N % N % N % Male 37 30.8 22,485 46.1 1,378,441 45.8 Female 83 69.2 26,326 53.9 1,633,840 54.2 Total 120 100.0 48,811 100.0 3,012,281 100.0

Analyses using t-tests indicates that the sample had a significantly higher proportion of females and a lower proportion of males, compared with both the older Chinese-speaking population, t(48929)=3.358, p=0.0008 and older Australian population, t(3012399)=3.298, p=0.0010. There is no significant difference between the older Chinese-speaking and older

Australian populations with regard to their gender distribution, t(3061090)=1.320, p=0.1873.

118 5.1.3 Geographic location

The participants were proportionally recruited from four Melbourne Metropolitan areas.

Table 5.4 shows the geographical distribution of the sample and older Chinese-speaking

population in Melbourne. According to the 2011 Census data, approximately 27% of the

older Chinese-speaking population lives in Victoria. Of them, nearly 99% live in the

metropolitan areas of Melbourne and only 1% in regional Victoria.

Table 5.4 Comparison of the sample with the older Chinese-speaking population in Melbourne by location, 2011

Living area Sample Older Chinese-speaking t(13422) p population N % N % Eastern Melbourne 55 45.8 6,611 49.7 0.851 0.3952 Western Melbourne 20 16.7 2,233 16.8 0.029 0.9768 Southern Melbourne 19 15.8 2,694 20.2 1.196 0.2320 Northern Melbourne 26 21.7 1,766 13.3 2.691 0.0072 Total 120 100.0 13,304 100.0

The results of t-test analyses showed that there were no significant differences between the

sample and the older Chinese-speaking population with regards to those located in the

eastern, western and southern suburbs of Melbourne. However, the sample consisted of a

significantly higher proportion of those from the northern suburbs.

5.2 Migration background

Migration background presented here included participants’ birthplaces and languages

spoken at home, years of residency in Australia, English proficiency, and immigrant status.

119 5.2.1 Birthplace and language spoken at home

Table 5.5 shows that 107 participants were born in Mainland China, making up 89% of the sample. There were also 4 born in Indonesia, 3 in Taiwan, 2 in Malaysia and Vietnam, and 1 in Hong Kong and Philippines. In relation to language spoken at home (see Table 5.5), no participants spoke English at home. Mandarin was the most common used language by participants at home, followed by Cantonese and Shanghainese. The remainder spoke the

Chinese dialects of Hokkien, Fuzhou, Hakka, and non-Chinese language of Indonesian.

Table 5.5 Birthplaces and languages spoken by participants at home Language Birthplace spoken at China Malaysia HK Taiwan Vietnam Indonesia Philippines Total home N % N % N % N % N % N % N % N % Mandarin 58 48.3 0 0.0 0 0.0 1 0.8 0 0.0 2 1.7 1 0.8 62 51.7 Cantonese 18 15.0 2 1.7 1 0.8 0 0.0 1 0.8 0 0.0 0 0.0 22 18.3 Shanghainese 21 17.5 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 21 17.5 Hokkien 4 3.3 0 0.0 0 0.0 2 1.7 1 0.8 0 0.0 0 0.0 7 5.8 Fuzhou 4 3.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 4 3.3 Hakka 2 1.7 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 2 1.7 Indonesian 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 2 1.7 0 0.0 2 1.7 English 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0 0 0.0 0 0.0 Total 107 89.2 2 1.7 1 0.8 3 2.5 2 1.7 4 3.3 1 0.8 120 100

T-tests were performed to determine whether there were significant differences between the sample and the older Chinese-speaking population with regards to the languages spoken at home (Table 5.6). Results showed that the sample was comprised of significantly more people speaking Mandarin, Shanghainese, and other Chinese languages at home as well as significantly fewer people speaking Cantonese and other non-Chinese languages. These findings suggest that the sample well represented older Chinese immigrants who were from

Mainland China and understood or spoke Mandarin at home. As described in Chapter 2, older Mandarin speakers are more likely to be recent immigrants from Mainland China,

120 whereas Cantonese speakers are more likely to be established immigrants from Hong Kong,

Malaysia, Vietnam, and other Southeast Asian countries. The sample consisted of a significant number of people speaking Shangainese at home, which is the second most commonly spoken language in China after Mandarin. Most participants who spoke

Shanginese at home can understand Mandarin quite well and the interviews were mainly conducted in Mandarin.

Table 5.6 Comparison of the sample with the older Chinese-speaking population by language spoken at home

Languages spoken Sample Older Chinese-speaking t(48929) p at home population N % N % Cantonese 22 18.3 28,402 58.2 8.848 0.0000 Mandarin 62 51.7 15,943 32.7 4.430 0.0000 Shanghainese 21 17.5 218 0.4 28.206 0.0000 Other Chinese lang. 13 10.8 4,248 8.7 0.815 0.4153 Other 2 1.7 0 0.0 28.807 0.0000 Total 120 100.0 48,811 100.0

5.2.2 Years of residency

Table 5.7 (overleaf) shows that the majority of the participants (92%) arrived in Australia between 1991 and 2011, compared to only 38% of the older Chinese-speaking population who came to Australia after 1991. Participants’ year of arrival varied from 1968 to 2010, with a mean year of residency of 12.5 years (SD=7.0 years) and a mean age of migration of

64.4 years (SD=8.8 years).

121 Table 5.7 Comparison of the sample with the older Chinese-speaking population by year of arrival Year of arrival in Sample Older Chinese-speaking t(48929) p Australia population N % N % Before 1981 2 1.7 12,739 26.1 6.083 0.0000 Between 1981-1990 8 6.7 13,785 28.2 5.231 0.0000 Between 1991-2000 61 50.8 12,343 25.3 6.412 0.0000 Between 2001-2011 49 40.8 6,279 12.9 9.086 0.0000 Not stated 2,201 4.5 Not applicable 1,464 3.0 Total 120 100.0 48,811 100.0

Analyses indicate that the sample had a significantly lower proportion of those who arrived before 1990 and a significantly higher proportion of those who had arrived between 1991 and

2011 in comparison with the older Chinese-speaking population. This suggests that the sample was more representative of relatively recent Chinese immigrants who have lived in

Australia for no more than 20 years.

5.2.3 English Proficiency

The majority of participants (75%) spoke no or little English and only 25% rated themselves as speaking English well or very well (see Table 5.8 overleaf). T-tests were performed to determine whether there were significant differences of English language proficiency between the sample and the older Chinese-speaking population. Results showed that differences in percentages of the sample and the older Chinese-speaking population who rated themselves as speaking English well or not well were not significant. Yet the sample had a significantly higher percentage of participants who spoke English not at all and a significantly lower percentage of participants who spoke English very well. This suggests

122 that the sample had a relatively lower level of English proficiency than the older Chinese- speaking population in Australia.

Table 5.8 Comparison of the sample with the older Chinese-speaking population by English Language proficiency

Sample Older Chinese-speaking t(48929) p English proficiency population N % N % Very well 4 3.3 8,180 16.8 3.954 0.0001 Well 26 21.7 7,730 15.8 1.769 0.0772 Not well 38 31.7 16,700 34.2 0.577 0.5643 Not at all 52 43.3 15,789 32.4 2.548 0.0110 Not Stated 412 0.8 Total 120 100.0 488,11 100.0

5.2.4 Immigration circumstances

The majority of participants were either naturalised Australian citizens (54%) or Permanent

Residents (42%) as shown in Table 5.9 overleaf. Analyses using t-tests indicate that the sample had a significantly lower proportion taking up Australian citizenship, compared with the older Chinese-speaking population, t(48929)=5.750, p=0.0000. Approximately 76% of the older Chinese-speaking population in Australia were Australian citizens in 2011, whereas only 54% of participants were Australian citizens at the time of the interviews.

Most of the participants were parents of Australian citizens or permanent residents. They immigrated to Australia mainly via a Parent Visa (60%) or Contributory Parent Visa (25%).

There was a small proportion of participants (3%) who came to Australia as skilled migrants and business people. Four participants (3%) immigrated as refugees under the humanitarian program because they were victims of wars or people affected by the Tiananmen Square

123 incident in China in 1989. Of those 9 participants whose immigration categories are not listed above, one was a New Zealand citizen.

Table 5.9 Immigration circumstances of participants (N=120) Immigration circumstances N % Immigration status Naturalised Australian Citizen 65 54.2 Permanent Resident 51 42.5 Others 4 3.3 Immigration categories Parent Visa 72 60.0 Contributory Parent Visa 31 25.8 Independent professional immigrant 2 1.7 Business investment 2 1.7 Refugee and Humanitarian Program 4 3.3 Other 9 7.5 Want to return to home country permanently Yes 5 4.2 No 85 70.8 Not Sure 30 25.0

When asked if they would like to return to their home country, the majority answered ‘no’ and gave the reasons that their adult children and families were all in Australia, and they enjoyed the good living environment and high quality social and health care that Australia offered. However, there were a few participants who answered that they would like to return to their home country permanently due to financial insecurity and loneliness. About a quarter said they were ‘not sure’ about it because that would be determined by a combination of factors such as their health, income, relationship with children, and living situation. This may be attributed to the sample consisting of a significant number of recent migrants who were still adjusting to a new life in Australia and were not yet decided as to whether they wanted to stay permanently.

124 5.3 Social and economic status

Participants’ social and economic status including marital status, living arrangement, religion, education, income, Medicare and private health insurance are presented in this section.

5.3.1 Marital status

Nearly 65% of participants were married, 28% were widowed and 7% were divorced or separated, as shown in Table 5.10. T-tests were performed and results show that there were no significant differences between the sample and the older Chinese-speaking population in relation to their marriage patterns.

Table 5.10 Comparison of the sample with the older Chinese-speaking population by marital status Sample Older Chinese-speaking t(48929) p population Marital status N % N % Married 77 64.2 33,356 68.3 0.964 0.3353 Widowed 34 28.3 11,157 22.9 1.406 0.1601 Divorced or separated 9 7.5 3,220 6.6 0.397 0.6918 Never Married 0 0.0 1,078 2.2 1.643 0.1007 Total 120 100.0 48,811 100.0

In comparison with the older Australian population, the sample had a higher proportion of people who were married and lower proportions of those who were widowed, divorced or separated, and never married. However, the analyses indicate that the percentages of people who were married, widowed, and divorced or separated between the sample and the older

Australian population were not significantly different (see Table 5.11 overleaf).

125 Table 5.11 Comparison of the sample with the older Australian population by marital status Sample Older Australian population t(3012399) p Marital status N % N % Married 77 64.2 1731,173 57.5 1.485 0.1379 Widowed 34 28.3 774,646 25.7 0.652 0.5147 Divorced or separated 9 7.5 366,913 12.2 1.573 0.1160 Never Married 0 0.0 139,549 4.6 2.405 0.0163 Total 120 100.0 3012,281 100.0

5.3.2 Living arrangements

Because there was no living arrangement data available for the older Chinese-speaking population, Australians who were over 65 years and born in China (referred to as the “older

China-born population”) were used here to compare with the sample and the older Australian population. The living arrangement pattern of the older China-born population was very different to the older Australian population. Although the most common living arrangement is to live with a spouse, older Australians are more likely to live alone or in residential care compared with China-born seniors who are more likely to live with other family members, as illustrated in Table 5.12 below.

Table 5.12 Comparison of the older China-born population with the Australian population by living arrangements

Older China-born Older Australian t(3043932) p population population Religion N % N % With spouse only 19,053 60.2 1,573,399 52.2 28.437 0.0000 With other family 6,315 20.0 232,970 7.7 81.044 0.0000 Alone 3,583 11.3 719,261 28.5 67.564 0.0000 Others 2,702 8.5 486,651 19.3 48.541 0.0000 Total 31,653 100.0 3,012,281 100.0 Note. Others include living with unrelated people in private dwellings and living in non-private dwelling such as hostels or nursing homes.

126

T-tests were performed to determine whether there were significant differences between the sample and the older China-born population with respect to their living arrangement (see

Table 5.13). Results indicate that the sample had a significantly lower proportion of those who lived with spouse only and a higher proportion of those who lived with other family members when compared with the older China-born population. The possible explanation is that this study recruited more recent immigrants who may not have the resources or confidence to move out from living with their adult children and live independently.

Table 5.13 Comparison of the sample with the older China-born population by living arrangements Sample Older China-born(a) t(31771) p population Living arrangement N % N % With spouse only 45 37.5 19,053 60.2 5.069 0.0000 With other family 55 45.8 6,315 20.0 7.039 0.0000 Alone 20 16.7 3,583 11.3 1.867 0.0627 Others 0 0.0 2,702 8.5 3.338 0.0009 Total 120 100.0 31,653 100.0 (a) Older China-born population does not include China-born people who live in non-private dwellings such as hostels or nursing homes.

The preference of participants’ living arrangements presented in Table 5.14 overleaf suggests that there is a discrepancy between actual and preferred living arrangements. Most participants preferred not to live in the same household with their children due to family conflict or the difference in lifestyle, but half of the participants were living with their adult children when the survey was undertaken. This may be a result of limited family and financial resources and inadequate housing options available to older Chinese-speaking immigrants in Australia (Lo et al., 2007; Thomas, 2003).

127 Table 5.14 Living arrangement preference of participants (N=120) Living arrangement preference N % Prefer to live with children in the same household 29 24.2 Prefer to live nearby children 56 46.7 Prefer to live separately not nearby children 17 14.2 Prefer to live with other seniors 16 13.3 Other 2 1.7

5.3.3 Religion

Table 5.15 shows that the sample had more diverse religious affiliations, compared to the older Australian population. Nearly 60% of participants declared ‘no-religion’ when asked about their religious affiliation, while 22% were Christians and 14% were Buddhists. T-test results indicate the sample had higher proportions of those who claimed to have ‘no-religion’ and to be Buddhists and a lower proportion who claimed to be Christians in comparison with the older Australian population.

Table 5.15 Comparison of the sample with the older Australian population by religion Sample Older Australian population t(3012399) p Religion N % N % No religion 71 59.2 308,476 10.2 17.734 0.0000 Christianity 27 22.5 2,348,764 78.0 14.676 0.0000 Buddhism 17 14.2 35,609 1.2 13.076 0.0000 Others 5 4.1 58,720 1.9 1.765 0.0778 Not Stated 0 0.0 260,712 8.7 3.382 0.0007 Total 120 100.0 3,012,281 100.0

When compared to the older Chinese-speaking population in Australia, the sample shared a similar pattern of religious affiliation (See Table 5.16 overleaf). Both had high percentages of

128 people with ‘no religion’, followed by Christians and Buddhists. T-tests were conducted to examine whether there were any statistical differences. Results show that the sample had a significantly higher percentage of those with ‘no religion’ and a significantly lower percentage of those who adhered to Buddhism.

Table 5.16 Comparison of the sample with the older Chinese-speaking population by religion Sample Older Chinese-speaking t(48929) p population Religion N % N % No religion 71 59.2 17,156 35.1 5.522 0.0000 Christianity 27 22.5 13,454 27.6 1.248 0.2122 Buddhism 17 14.2 15,219 31.2 4.016 0.0001 Others 5 4.1 473 1.0 5.536 0.0000 Not Stated 0 0.0 2,509 5.1 2.668 0.0078 Total 120 100.0 48,811 100.0

This may be due to the greater number of participants from China who had experienced the

Cultural Revolution when religious belief or practice was banned and regarded as being backward and superstitious. Older people from Mainland China were consequently inclined to see themselves as having no religion. As noted in Chapter 2 and 3, religious beliefs and practices of older Chinese immigrants are found to be associated with their psychosocial wellbeing and help-seeking behaviours. Although this study found that a higher proportion of the sample claimed to have no religious affiliation, the influence of traditional values such as filial piety from Confucianism, as well as self-reliance and self-care drawing from Buddhism and Taoism still remained strong among older Chinese-speaking participants, as discussed in later result and discussion chapters.

129 5.3.4 Education

In terms of educational level, the sample was well educated in comparison with both the older Australian population (see Table 5.17) and the older Chinese-speaking population (see

Table 5.18).

Table 5.17 Comparison of the sample with the older Australian population by education Sample Older Australian population t(3012399) p Education N % N % None-Primary 12 10.0 658,950 21.9 3.152 0.0017 Secondary-High school 40 33.3 1,071,450 35.5 0.504 0.6146 College or TAFE 21 17.5 577,912 19.2 0.473 0.6365 Undergraduate and above 47 39.2 261,343 8.7 11.854 0.0000 Not stated 0 0.0 442,626 14.7 4.548 0.0000 Total 120 100.0 3,012,281 100.0

Nearly 40% of participants held a university degree, whereas only 9% of the older Australian population and 18% of the older Chinese-speaking population possessed an undergraduate or postgraduate degree. The Chinese-speaking population had significantly higher proportions of those who held both the lowest and highest qualifications compared to the older Australian population.

Table 5.18 Comparison of the sample with the older Chinese-speaking population by education Sample Older Chinese-speaking t(48929) p population Education N % N % None-Primary 12 10.0 15,535 31.8 5.124 0.0000 Secondary-High school 40 33.3 16403 33.6 0.069 0.9446 College or TAFE 21 17.5 5326 10.9 2.316 0.0208 Undergraduate and above 47 39.2 8637 17.7 6.156 0.0000 Not stated 0 0.0 2910 6.0 2.767 0.0058 Total 120 100.0 48,811 100.0

130 T-tests were then performed to see if there were significant differences between the sample and the other two populations in relation to their educational levels. Results indicate that the sample had significantly higher percentages of those who had an undergraduate or postgraduate degree, yet significantly lower percentages of those who had no formal education or had only attended primary school, compared with the older Australian and

Chinese-speaking populations.

5.3.5 Income and benefits

The older Chinese-speaking population had significantly lower levels of income than the older Australian population (See Table 5.19). T-test results show that the older Chinese- speaking population had significantly higher proportions of those whose weekly incomes were under $199 and between $200-299 and significantly lower proportions of those having weekly incomes of $300-399 and over $400 when compared with the older Australian population.

Table 5.19 Comparison of the older Chinese-speaking population with the older Australian population by income

Weekly (Monthly) Older Chinese-speaking Older Australian t(3061090) p Income population population N % N % 0-199 (0-866) 13,261 27.2 242,379 8.0 152.475 0.0000 200-299 (867-1299) 15,438 31.6 697,655 23.2 43.526 0.0000 300-399 (1300-1732) 9,059 18.6 729,155 24.2 28.692 0.0000 400+ (1732+) 9,384 19.2 1,019,890 33.9 68.175 0.0000 Not stated 1,669 3.4 323,202 10.7 52.008 0.0000 Total 48,811 100.0 3,012,281 100.0

131 The sample also had relatively low levels of income as shown in Table 5.20. Nearly half of older Chinese-speaking participants had a monthly income of less than $1000 and those with a monthly income over $1000, mainly received this from their Australian Government payments. Due to a lack of comparable data, the researcher was unable to examine whether there were statistical differences between the sample and the older Chinese-speaking population in relation to income levels. The majority of participants (70%) received at least one type of government payment, namely Aged Pension, Special Benefit, Widows

Allowance, Carer Payment or Carer Allowance. Thirty percent of the participants did not qualify for any payments so they had to live on savings or rely on their adult children. When asked if they were satisfied with their income, 65% claimed it was adequate for them to live on.

Table 5.20 Financial circumstances of participants (N=120) Financial circumstances N % Monthly Income ($) 0-500 22 18.3 500-999 35 29.2 1000-1499 57 47.5 1500+ 6 5.0 Government payments Australian aged pension 64 53.3 Special benefits 13 10.8 Carer allowance/payment 4 3.3 Other payments 3 2.5 No payments 36 30.0 Main source of income Government payments 82 68.3 Support of adult Children 26 21.7 Personal savings 12 10.0 Income satisfaction Adequate 79 65.8 Inadequate 41 34.2

132 5.3.6 Medicare and private health insurance

Nearly all participants were covered by Medicare, but of them only 21% had additional

private health insurance (see Table 5.21). This coverage was much lower than the older

Australian population. According to the National Health Survey between 2011 and 2012

(ABS, 2016), about half of older Australians were covered by some form of private health

insurance.

Table 5.21 Medical insurance of participants (N=120) Medical insurance N % Medicare Yes 117 97.5 No 3 2.5 Private insurance Yes 26 21.7 No 94 78.3

5.4 Health

5.4.1 Self-assessed health status

The majority of older Chinese-speaking participants (70%) rated themselves as having fair or

poor health, while 72% of the older Australian population considered their health as either

good, very good or excellent, as illustrated in Table 5.22 overleaf. The role poorer self-

assessed health plays in influencing older Chinese-speaking immigrants’ general health and

service use is discussed in the discussion chapter.

133 Table 5.22 Comparison of the sample with the older Australian population by self-assessed health Sample Older Australian population t(2920318) p Self-assessed health N % N % Excellent 3 2.5 347,500 11.9 3.180 0.0015 Very good 11 9.2 794,500 27.2 4.431 0.0000 Good 22 18.3 962,100 32.9 3.404 0.0007 Fair 62 51.7 559,900 19.2 9.039 0.0000 Poor 22 18.3 256,100 8.8 3.673 0.0003 Total 120 100.0 2,920,200 100.0 Note. This data was drawn from the Australian Health Survey, 2011-2012, Australian Bureau of Statistics. The total number of the older Australian population (estimate) was 2,920,200, which was different from the Census data (3,012,281).

T-tests also show that the sample had significantly higher percentages that reported their health as fair or poor compared to the older Australian population. The percentages of those who reported their health as good, very good or excellent were also lower in the sample than in the older Australian population. Participants’ negative view of their health may be attributed to the influence of Chinese culture on their perception of health and being conservative in their answers.

5.4.2 Need for assistance

Compared with both the older Australian and older Chinese-speaking population, the sample had significantly higher proportions of those who claimed that they needed assistance to perform daily activities and/or instrumental activities (see Table 5.23 and Table 5.24). This may be due to their poorer self-assessed health, limited English ability, and inability to drive so they needed some assistance to perform instrumental activities such as going out, shopping for food, keeping track of finances, and managing medication.

134 Table 5.23 Comparison of the sample with the older Australian population by need for assistance Sample Older Australian population t(3012399) p Need for assistance N % N % Does not need assistance 76 63.3 2292,436 76.1 3.288 0.0010 Needs assistance 44 36.7 537,280 17.8 5.412 0.0000 Not stated 0 0.0 182,565 6.1 2.792 0.0053 Total 120 100.0 3,012,281 100.0

Table 5.24 Comparison of the sample with the older Chinese-speaking population by need for assistance

Sample Older Chinese-speaking t(48929) p population Need for assistance N % N % Does not need assistance 76 63.3 36,766 75.3 3.043 0.0024 Needs assistance 44 36.7 11,346 23.3 3.466 0.0006 Not stated 0 0.0 699 1.4 1.305 0.1921 Total 120 100.0 48,811 100.0

It is interesting to note that the older Chinese-speaking population also had a significantly

higher percentage of those who claimed to have need for assistance with the three core

activity areas of self-care, mobility and communication. There was 23% of the older

Chinese-speaking population needing help in one or more of these core activities, whereas

only 18% of the older Australian population had the same need.

5.5 Summary

This chapter reported some of the predisposing, enabling and need factors of the Andersen

Behavioural Model that influenced older Chinese-speaking participants’ use of aged care

services, namely demographics, immigration background, socioeconomic and health status.

135

The sample’s representativeness was examined by comparing with two older related populations from ABS, the “older Australian population” and the “older Chinese-speaking population”. The sample was more representative of the older Chinese-speaking population in Australia although there were some statistical differences in demographics. The sample had significantly higher proportions of females, people aged between 75 and 84 years old, who had arrived more recently (post 1991), spoke Mandarin and Shanghainese at home.

However, their pattern of living arrangements, religious affiliation, level of English proficiency, and financial status were similar to the older Chinese-speaking people’s profile in 2011.

In comparison with the older Australian population, the sample appeared to have some distinguishing characteristics. Older Chinese-speaking participants had a significantly higher level of education and a higher co-residence rate with their adult children. They had poorer self-assessed health, higher level of perceived need for assistance, as well as more diverse religious affiliation than their older Australian counterparts.

136 Chapter 6: The socio-cultural profile of older Chinese-speaking participants

This Chapter continues to report on the remaining culturally-related factors of the adapted

Andersen Behavioural Model, which were measured by survey instruments in this study.

These factors include predisposing variables such as filial piety beliefs, attitudes towards service use, and intention to use services. Enabling variables include social support, acculturation, informal carers, services awareness, and service barriers. Need factors are physical health and mental health, including activities of daily living, instrumental activities of daily living, and depression.

6.1 Predisposing factors

6.1.1 Filial responsibility expectation

The mean score of filial piety of this sample was 58.9 (range from 16 to 80, SD=8.3), suggesting quite strong filial responsibility expectations by participants of their adult children.

Compared to older Netherlanders in the van der PAS et al.’s study (2005), this sample had a higher score on their mean for all items, especially for items 2, 3, 6 and 11 on which the mean was one point higher (See Table 6.1 overleaf).

137 Table 6.1 Comparison of the sample with older Netherlanders on the Hamon Filial Responsibility Scale

Sample Van der PAS et al.’s study t(119) (N=120) (N=1411) Item M SD M SD 1. Children should live (close) with their parents 3.0 1.1 2.7 1.3 3.10** 2. Children should take care of their sick parents 3.8 1.0 2.6 1.2 14.14*** 3. Children should give their parents financial 3.3 1.0 2.1 1.1 12.69*** support 4. Children who live nearby should visit their 3.9 0.9 3.4 1.3 5.57*** parent at least once a week 5. Children should phone their parents on a regular 4.1 0.8 3.8 1.1 3.62*** basis 6. Children should feel responsible for their 4.3 0.8 3.2 1.3 14.67*** parents 7. Children and parents should be together at 4.2 0.8 4.0 1.1 2.92** special occasions, such as Christmas and weddings 8. Parents should be able to talk to their children 4.1 0.7 4.1 1.0 - 0.50 about matters of personal importance that have influence on their lives 9. Children should give emotional support to their 4.2 0.6 3.7 1.1 9.55*** parents 10. Children should be willing to give up free time 3.0 0.9 2.6 1.1 4.31*** for their parents 11. In emergencies, children should make room for 3.8 0.9 2.7 1.2 14.23*** their parents in their home 12. Children should offer advice to their parents 4.0 0.7 3.2 1.1 12.47*** 13. Children should adjust their work situation to 2.9 1.0 2.1 1.1 9.39*** help their parents, for example, by working less overtime or temporarily working less hours 14. Children should monitor the quality of care 3.6 0.9 3.4 1.2 2.83** given to their parents 15. Children should adjust their situation at home to 3.3 1.0 2.4 1.1 10.54*** help their parents, for example, assign activities to others or put activities aside temporarily 16. Children should familiarize their parents with 3.6 1.0 3.7 1.1 -1.05 health care services Note. * p < 0.05, ** p < 0.01, *** p < 0.001

T-tests were then performed to determine whether the items’ mean scores were statistically different between the sample and the older Netherlanders population. Results showed that 14 out of 16 items had significant differences between these two groups. While the older

Netherlander respondents agreed the importance of family connections and communication with children (Item 7&8, M ), older Chinese participants were more inclined to agree

138 that children should feel responsible for their parents, visit or phone them on a regular basis, give them emotional support, and provide advice and care when needed ( Item 5,6,7,8,9 &12,

M ). This finding supports the literature that elderly Chinese have higher expectations for support and care from children than their western counterparts and this remains the same even after migration to the host countries (Jones, Lee, & Zhang, 2011; Laidlaw et al., 2010).

To examine the socio-demographic variance on participants’ scores of Filial Responsibility

Expectations Scale, one-way ANOVA was performed. Results indicated that there were no significant differences in the effects of age, gender, language spoken at home, years of residency, living arrangements, religion, education, and health (Appendix XI). However, the effects of marital status (F(2,117)=3.95, p=0.022, monthly income (F(3,116)=2.95, p=0.036), and main income sources (F(2,117)=3.81, p=0.025) were statistically significant. Post hoc analyses using the Scheffé post hoc criterion for significance indicated participants who were divorced or separated (M=65.11, SD=9.62) had higher filial expectations towards their adult children than those who were married (M=57.70, SD=7.67). The level of filial piety was significantly higher for participants whose monthly income was less than $500 (M=62.36,

SD=10.94) in comparison with those who had an income between $1000 and $1499 monthly

(M=57.33, SD=6.17). In addition, participants who were financially dependent on their adult children (M=62.58, SD=10.59) had the highest filial expectations compared to those whose main source of income was government payments (M=58.33, SD=7.48) and personal savings and investment (M=55.67, SD=5.96).

These findings suggested that there were some variations in filial piety among older Chinese- speaking participants even though their filial expectations of adult children were generally

139 stronger than the older Netherlanders sample in the van der Pas et al.’s study (2005). Married

Chinese couples who had reciprocal support from each other and financially independent elderly Chinese who were capable of supporting themselves expected less from their adult children in this study. This somehow echoed with the literature that ageing parents who had lower socioeconomic status possessed higher expectations for filial support from their children (Lee et al., 1994; Lee et al., 1998). Nevertheless, contrary to the literature, participants who were less healthy and required more assistance did not express significantly higher filial expectations in this study.

6.1.2 Attitudes toward service use

As shown in Table 6.2 2 (overleaf), older Chinese-speaking participants had moderately favourable attitudes toward service use, with a mean score of 37.61 (SD=1.95). The mean scores on the Concern for the Opinion of Others scale and the Worry and Fear scale indicated that on average participants disagreed with statements asking if they felt it was hard to trust service providers and had concern over others’ opinions when needing or using services. As for the Acceptance of Government Assistance scale, half of participants agreed that they feel good about using services to care for themselves, they would use more services if the government made them more affordable, and government should do more to help families care for their older relatives at home. When asking participants if they would rather ask family or friends for help than use services or if they thought family should care for them without help from outside, about half of them disagreed.

140 Table 6.2 Mean, standard deviations, actual range, and potential range of 4 factors of Modified Community Service Attitude Inventory

Actual Potential Scale M SD Range Range (disagree-agree) Factor 1 ：Preference for Informal Care 9.84 2.98 4-16 4-20 Factor 2：Acceptance of Government Assistance 11.78 1.97 3-15 3-15 Factor 3：Concern for the Opinion of Others 7.09 1.98 3-12 3-15 Factor 4：Worry and Fear 7.24 1.95 3-12 3-15 Favourable attitudes toward service use 37.61 6.23 23-53 13-55

T-test and one-way ANOVA analyses were then conducted to examine the socio- demographic variance on participants’ attitudes toward community service use. Results indicated that there were no significant differences in the effects of socio-demographic backgrounds of participants on Preference for Informal Care (Factor 1) and Worry and Fear

(Factor 4) (Appendix XI). However, there was a significant effect of participants’ income satisfaction (t(70.219)=2.259, p=0.027) on Acceptance of Government Assistance (Factor 2).

Participants who thought their income was not very adequate (M=12.37, SD=2.14) had a higher level of acceptance of government assistance than those who thought their income was sufficient (M=11.47, SD=1.81). This may be related to the participants’ eligibility for an aged pension and other government support. Those who had no income, and were ineligible for any government payment due to residency requirements, often perceived their income as inadequate, therefore were more willing to accept government assistance.

The effects of language spoken at home (F(3,116)=4.006, p=0.009) and marital status

(F(2,117)=5.027, p=0.008) were statistically significant in relation to Concern for the

Opinion of Others (Factor 3). Post hoc comparisons using the Scheffé test showed that participants speaking Shanghainese at home (M=8.24, SD=1.70) had a higher level of

141 concern for others’ opinion than those speaking Cantonese at home (M=6.50, SD=2.15).

Participants who were separated or divorced (M=9.00, SD=2.06) also had the greatest level of concern for others’ opinions in comparison with the widowed (M=7.12, SD=1.72) and the married (M=6.85, SD=1.98). This may be a result of the Chinese being a relatively small and conservative community in Australia so older people from the same region, such as Shanghai or those who went through divorce may worry more about what others think of them if they use formal services.

6.1.3 Intention to use aged care services

Intention to use aged care services was measured using two questions. One question was related to low aged care need and another to high care need. When asked to imagine that they were ageing and becoming frail (low care need), 44% of participants claimed that they would prefer not to use any formal aged care services but rely on self-care or their families to provide support. Of those who would consider using formal aged care services, 45% would prefer home and community based services while 11% would choose aged care homes. When asked if their health was deteriorating and they would need a lot of assistance in bathing, toileting and walking (high care need), the percentage of the participants who would consider using formal aged care services increased to 82%. Forty three percent of participants would still prefer to use home and community based services while 38% would like to move into a nursing home. There were 18% of the participants who would not consider using any formal aged care services even though their needs for aged care would have risen substantially.

142 These findings suggest that older Chinese immigrants’ intention to use aged care services can vary depending on the severity of their disability. Generally speaking, they would first use personal strengths and/or family resources to cope with their increased needs. Once the informal support system fails to meet their needs, they would then consider bringing in formal resources. The majority would prefer to use home and community based aged care services; however, the increased number of participants would agree to move into residential care when they required a significant amount of assistance to perform daily living tasks.

Chi square and t-tests were conducted to investigate whether there were significant differences between the participants with an intention and no intention to use aged care services. The findings indicate that there were no significant differences in the effects of socio-demographic backgrounds of participants on their intention to use services if their aged care need was low. However, there were marginally significant effects of participants’ age

(t(70.219)=1.75, p=0.083), marital status (2(2) = 5.90, p = 0.052), and government payment

(2(2) = 3.34, p = 0.064) on their intention to use service if their disability increased (high aged care need). Participants who were younger, widowed and had not received any government payment were more likely to consider using aged care services if their care need was high.

Results also show that there were significant differences in the effects of availability of carers, social support, awareness of services, and depression on their intention to use aged care services in both hypothetical scenarios (see Tables 6.3 and 6.4 overleaf). Participants with an intention to use aged care services were more likely to be those who had a favourable attitude

143 toward service use, fewer informal carers available, a lower level of social support, a better knowledge of existing aged care services, and more depressive symptoms.

Table 6.3 Comparison of participants’ intention to use formal aged care services if aged care need was low

Intention to No intention to t(118) p use of formal use of formal care (N=67) care (N=53) Filial Responsibility Expectation 59.33 58.55 0.54 0.591 Favourable attitudes toward service use 39.42 35.32 3.77 0.000 Acculturation ¤ Heritage (Chinese) 30.31 29.60 1.27 0.208 Mainstream (Australian) 17.64 17.02 0.83 0.411 Availability of Informal Carers 2.57 3.87 -3.08 0.003 Social Support 20.19 22.21 -2.84 0.005 Awareness of Existing Services 11.28 9.81 2.04 0.044 Service Barriers 6.96 6.62 0.57 0.568 Activities of Daily Living 95.09 93.40 0.93 0.356 Instrumental Activities of Daily Living 18.57 17.58 1.44 0.154 Depression 4.69 2.42 3.56 0.001

Table 6.4 Comparison of the participants’ intention to use formal aged care services if aged care need was high

Intention to No intention to t(118) p use of formal use of formal care (N=98) care (N=22) Filial Responsibility Expectation 59.24 57.82 0.73 0.469 Favourable attitudes toward service use 38.13 35.27 1.97 0.051 Acculturation ¤ Heritage (Chinese) 29.92 30.36 -0.78 0.439 Mainstream (Australian) 17.52 16.68 0.87 0.388 Availability of Informal Carers 3.10 3.32 -0.48 0.635 Social Support 20.77 22.50 -2.41 0.020 Awareness of Existing Services 10.93 9.32 1.73 0.087 Service Barriers 6.89 6.45 0.70 0.488 Activities of Daily Living 94.86 92.05 1.04 0.307 Instrumental Activities of Daily Living 18.57 16.18 2.17 0.040 Depression 4.12 1.73 4.68 0.000

144 The overall findings indicate that the participants’ intention to use aged care services were

more associated with their attitudes, perceptions, and available resources than their

demographics. Older Chinese-speaking immigrants with more positive views on service use,

more knowledgeable about existing aged care services, having lower levels of family and

social support, and being more depressed were more likely to consider using formal aged

care services when needed.

6.2 Enabling factors

As noted earlier in the Andersen Behavioural Model, enabling factors refer to personal and

family resources, knowledge and ability, community resources and barriers that can facilitate

or impede service use. Analysis of enabling factors presented in this section are social

support, acculturation, availability of family carers, awareness of existing aged care services,

and barriers to accessing services.

6.2.1 Social support

Participants’ social support level was measured by the Duke Social Support Index (DSSI),

which consists of both subjective (satisfaction with social support) and objective social

support (social network size). Table 6.5 (overleaf) displays the mean, standard deviations,

actual and potential range of the DSSI and its two subscales. Overall, participants were

satisfied with their social support and had a moderately sized social network.

145 Table 6.5 Mean, standard deviations, actual range, and potential range of 2 factors of Duke Social Service Index

Actual Potential M SD Range Range Scale (dissatisfied-satisfied) (small-large network) Duke Social Service Index 21.08 3.98 9-27 6-27 Factor 1 ：Satisfaction with Social Support 15.24 2.95 6-18 3-18 Factor 2：Social Network 5.84 1.57 3-9 3-9

However, when compared to Australian women aged 70-75 years old using the same scale in the study conducted by Powers et al. (2004), results showed that the participants had significantly lower levels of objective and subjective social support (see Table 6.6 overleaf).

Participants had significantly fewer contacts with people outside their household, suggesting family is still their main source of social support. Another important source of supporting network for some older Chinese-speaking participants is regular meeting with other Chinese seniors. Even though there was no statistical difference, as shown in Table 6.6, Item 4 indicates that about 4% of the participants reported attending senior clubs, religious meetings and other regular activities more than 6 times in the past week, whereas only 2% of

Australian women aged 70-75 years old attended such meetings 6 times or more in the past week.

When it comes to satisfaction with social support, there was no significant difference in the sample and the older Australian women respondents when asking if they were satisfied with the kinds of relationships they had with their family and friends (see Table 6.6, Item 11).

However, much lower percentages of older Chinese-speaking participants felt useful and understood by their family and friends, and that they could talk about their deepest problems.

These findings imply that even if the family is the main source of social support for older

146 Chinese-speaking participants they were not very happy with their relationship with family overall.

Table 6.6 Comparison of the sample and Australian women aged 70-75 years old on the Duke Social Service Index

Percentage with highest score Sample Aus. women aged t(12511) (N=120) 70-75 (N=12,393) Social Network 1. Other than members of your family how many persons in 45.0 58.9 3.08** your local area do you feel you can depend on or feel very close to? 2. How many times during the past week did you spend 4.2 55.0 11.12*** time with someone who does not live with you, that is, you went to see them or they came to visit you or you went out together? 3. How many times did you talk to someone (friends, 26.7 42.3 3.44*** relatives or others) on the telephone in the past week (either they called you, or you called them)? 4. About how often did you go to meetings of clubs, 4.2 2.2 1.48 religious meetings, or other groups that you belong to in the past week? Social Support Satisfaction 5.. Does it seem that your family and friends (people who 59.2 88.3 9.77*** are important to you) understand you? 6. Do you feel useful to your family and friends (people 58.3 83.2 7.22*** important to you)? 7. Do you know what is going on with your family and 57.5 75.7 4.62*** friends? 8. Do you feel that you have a definite role (place) in your 57.5 86.3 9.06*** family and among your friends? 9. When you are talking with your family and friends, do 61.7 83.1 6.20*** you feel you are being listened to? 10. Can you talk about your deepest problems with at least 46.7 76.4 7.59*** some of your family and friends most of the time, some of the time, or hardly ever? 11. How satisfied are you with the kinds of relationships you 76.7 81.6 1.38 have with your family and friends? Note. * p < 0.05, ** p < 0.01, *** p < 0.001

Note. Responses to the satisfaction with social support items, ‘hardly ever’, ‘some of the time’ and ‘most of the time’, were scored from 1 to 3. The social network items were also scored from 1 to 3 with the highest score indicating most contact. Response options for the item, ‘very dissatisfied’, ‘somewhat dissatisfied’ and ‘satisfied’, were scored from 1 to 3.

147 T-test and One-way ANOVA analyses were performed to examine the socio-demographic variance on participants’ social support (Appendix XI). Analysis showed that the effects of year of arrival (F(3,116)=5.367, p=0.002), monthly income (F(3,116)=4.008, p=0.009), income satisfaction (t(118)=-3.131, p=0.002), and government payments (F(3,116)=3.660, p=0.015) were statistically significant. Participants who regarded their income as adequate

(M=21.87, SD=3.57) had greater social support than those who perceived their income was inadequate (M=19.56, SD=4.31). Post hoc analyses using the Scheffé test indicated that participants who had a monthly income between $1000 and $1499 (M=22.26, SD=3.76) possessed the highest level of social support compared to those whose monthly income was between $500 and $999 (M=20.37, SD=3.40), and those who had monthly income of less than $500 (M=19.18, SD=4.81). Participants who were aged pensioners (M=22.06, SD=3.58) had stronger social support than those who received no government payments (M=19.81,

SD=4.27). Participants who arrived between 2001 and 2011 (M=19.45, SD=4.32) had a significantly lower level of social support than those who arrived between 1991 and 2000

(M=22.34, SD=3.33). Our findings suggest that the level of social support of older Chinese- speaking participants is principally influenced by their financial status and years of residence in Australia. It is understandable that immigrants who live in the host country longer are more likely to have a larger social network and to be satisfied with their social support. The higher monthly income and satisfaction with their finance means that they have greater economic autonomy which allows for more frequent visits to family and friends as well as attending more social activities.

Even though there were no significant differences, participants who lived with other family

(M=20.49, SD=4.18) appeared to have the lowest level of social support in this study,

148 compared to those who lived with spouse only (M=21.13, SD=3.97), and those who lived alone (M=22.60, SD=3.07). Even though living with their adult children’s family provides one form of social support, it can also hinder those participants from attending other social activates as some are often caught up by housework and caring responsibilities for grandchildren. Additionally, co-residency with their adult children can cause intergenerational conflicts and therefore decrease their satisfaction with family relationships and social support.

To explore the relationships between social support and other factors that impact on aged care use by older Chinese-speaking immigrants, bivariate correlation tests were conducted.

Results indicated that there were no significant correlations between participants’ social support and filial piety, favourable attitudes toward service use, acculturation, and awareness of existing services. Participants’ level of social support were positively associated with availability of carers, r(120) = 0.34, p = 0.000, and negatively correlated with perceived barriers, r(120) = -0.23, p = 0.010, and depressive symptoms, r(120) = -0.64, p = 0.000. The overall findings suggest that participants with a higher level of social support were more likely to be those who lived in Australia longer, had a higher monthly income, received government payments, had more informal carers available, perceived less service barriers, and were less depressed.

6.2.2 Acculturation

Participants’ acculturation level was measured by the Vancouver Index of Acculturation

(VIA), which is a bi-dimensional acculturation measurement, comprising the heritage

149 subscale (retention of Chinese culture) and the mainstream subscale (acquisition of

Australian culture). Mean, standard deviations, actual and potential range of the VIA scale and its two subscales are displayed in Table 6.7. The mean of 30.00 on the heritage subscale and the mean of 17.36 on the mainstream subscale indicated that older Chinese-speaking participants still retained strong connections with their Chinese culture and were not assimilated into the Australian culture.

Table 6.7 Mean, standard deviations, actual range, and potential range of 2 factors of Vancouver Index of Acculturation

Scale Actual Potential M SD Range Range Vancouver Index of Acculturation (VIA) Factor 1 ：Heritage (Chinese culture) 30.00 3.18 15-35 7-35 (Include Item 5,7,9,11,13,15,17) Factor 2：Mainstream (Australian culture) 17.36 4.10 8-28 6-30 (Include Item 4,6,10,12,16,18)

One-way ANOVA were then conducted to examine the socio-demographic variance on participants’ retention of Chinese culture (heritage scale) and acquisition of Australian culture (mainstream scale). Results showed that there were significant differences in the effects of age (F(2,117)=4.289, p=0.016), spoken language at home (F(3,116)=3.799, p=0.012), English proficiency (F(3,116)=9.131, p=0.000), and need for assistance

(F(3,116)=6.800, p=0.001) on the mainstream scale (Appendix XI). Post hoc comparisons using the Scheffé test indicated that participants who were in the youngest age group

(M=18.83, SD=3.76) and could speak English very well (M=19.58, SD=2.91) had higher levels of acquisition of Australian culture. Participants who spoke Cantonese at home

(M=19.14, SD=3.33) and do not need assistance (M=16.11, SD=3.97) also had significantly higher levels of acculturation to Australia than those who spoke other Chinese languages at

150 home (M=14.73, SD=5.22) and needed more assistance (M=18.09, SD=4.3). However, there were no significant differences in the effects of demographics, socio-economic status, and health on the heritage scale (retention of Chinese culture).

To explore the relationships between acculturation and other predictive factors, bivariate correlation tests were conducted. Results showed that participants’ retention of the Chinese culture were positively associated with their filial responsibility expectation, r(120) =

0.42, p = 0.000, and favourable attitude toward service use, r(120) = 0.21, p = 0.021.

However, participants’ acquisition of the Australian culture was negatively associated with their perceived service barriers, r(120) = -0.25, p = 0.005, but positively associated with their knowledge of available aged care services, r(120) = 0.25, p = 0.006, and favourable attitude toward service use, r(120) = 0.20, p = 0.026.

These findings suggest that older Chinese-speaking participants were generally less assimilated to the Australian culture and more adherent to their Chinese culture regardless of their demographic and socioeconomic status. Their level of acquisition of Australian culture appeared to be determined by their age and English ability rather than their years of residency in Australia. In fact, there was no significant difference in the effect of years of residency on their English proficiency (F(3,116)=2.271, p=0.084). The longer they lived in

Australia does not necessarily mean better English or the more acculturated they are. The results also suggest that participants who retained their Chinese culture and lifestyle in

Australia had a higher level of filial responsibility expectation toward their adult children, whereas those who strongly endorsed Australian values and behaviours tended to be younger,

151 perceived fewer service barriers and had a more favourable attitude toward service use, and know more about existing aged care services.

6.2.3 Availability of informal carers

The mean score of availability of informal carers was 3.14 (score ranges from 0 to 9,

SD=2.38), suggesting that the sample received a moderate level of support from informal carers. The majority of participants (82.5%) would have at least one informal carer available when they were in need; however, twenty-one participants (17.5%) claimed that no one would be able or willing to give them any help if they were sick and disabled. Table 6.8 summarises the category of person who would provide help and their availability of care time.

Table 6.8 Summary of carers and availability of care time Availability of care time Informal Carer As long as needed Weeks to half a year Only occasionally Total N % N % N % N % Spouse/Partner 46 38.3 2 1.7 4 3.3 52 43.3 Daughter 22 18.3 8 6.7 26 21.7 56 46.7 Son 8 6.7 7 5.8 21 17.5 36 30.0 Son in law 7 5.8 1 0.8 12 10.0 20 16.7 Daughter in law 2 1.7 0 0.0 7 5.8 9 7.5 Grandchildren 1 0.8 1 0.8 6 5.0 8 6.7 Friends 0 0.0 0 0.0 3 2.5 2 2.5 Siblings 0 0.0 0 0.0 1 0.8 1 0.8 Relatives 0 0.0 0 0.0 1 0.8 1 0.8

Daughter (46%) and spouse/partner (43%) were two types of informal carer most frequently identified by the participants; however spouse carers would most likely provide longer care.

Nearly all spouse carers would be able to provide help to participants for as long as needed, whereas only less than a half of daughter caregivers could do this. Thirty percent of

152 participants also nominated their son as the potential carer, yet they could only be of help for a short time or on occasion. There were 16% and 7% of participants indicating that a son-in- law and daughter-in-law would be able to assist if they needed.

One-way ANOVA were then conducted to examine the socio-demographic variance on participants’ support by informal carers. Results showed that there were statistically significant differences of availability of informal carers on participants’ marital status

(F(2,117)=5.61, p=0.005), living arrangements (F(3,116)=6,217, p=0.003), government payment (F(3,116)=6.308, p=0.001), main source of income (F(3,116)=5.194, p=0.007), and need for assistance (F(3,116)=3.660, p=0.015), but no significant differences on the effects of demographics, self-assessed health, and other social and economic factors (Appendix XI).

Post hoc comparisons using the Scheffé test indicated that participants who were married

(M=3.65, SD=2.33) or lived with family members (M=3.75, SD=2.63) had a significantly higher level of informal care support than those who were widowed (M=2.38, SD=2.28) or lived alone (M=1.65, SD=1.60). Participants who received an aged pension (M=2.77,

SD=1.97) or whose main source of income was a government payment (M=2.70, SD=2.00) had significantly fewer informal carer resources, compared to those who received no payment (M=3.75, SD=2.63) or financially relied on their adult children (M=4.31, SD=2.90).

Participants who needed more help received a significantly lower level of support from their informal carers than those who did not need any help.

To explore the relationships between availability of carers and other factors, bivariate correlation tests were conducted. Results indicated that participants’ availability of carers were positively associated with their level of social support, r(120) = 0.34, p = 0.000, and

153 negatively correlated with their perceived barriers, r(120) = -0.24, p = 0.007, and depressive symptoms, r(120) = -0.36, p = 0.000. The overall findings suggest that being married and co-residency with family are the two important protective factors for elderly Chinese- speaking immigrants to receive informal care, but those who receive a higher level of support from informal carers are more likely to be financially disadvantaged. Participants who had more informal carers available were more likely to receive a higher level of social support, perceived less service barriers and were less depressed.

6.2.4 Awareness of existing services

Participants were asked how many existing aged care services they knew of. The responses to the number of services varied widely from 1 to 17, with the average number of 10.63

(SD=3.98). Table 6.9 (overleaf) shows the existing aged care services ranked by number and percentage of participants who had heard of these services. The most well known service was senior centres or clubs -- nearly all participants were aware of this type of support.

Residential care services including both nursing home and hostel were also well known to participants, even though the distinction between these two was unclear to some participants.

Home and Community Services (HACC), as explained in Chapter 3 now known as the

Commonwealth Home Support Program (CHSP), were familiar to most participants. Of these, the best known services were home and personal care services, followed by meals-on-wheels, and home maintenance. More than half of participants have heard of aged care assessment services, whereas only one third knew about Community Aged Care Packages (CACPs) and

Extended Aged Care at Home (EACH), now known as the Home Care Packages (HCP).

154 Table 6.9 Number and percentage of aged care services heard of by participants Services heard N % 1. Services from senior centre/club 117 97.5 17. Nursing home 108 90.0 5. Home care services 106 88.3 6. Personal care services 104 86.7 16. Hostel 95 79.2 8. Meals-on-wheels 94 78.3 7. Home maintenance 84 70.0 13. Aged Care Assessment Service (ACAS) 78 65.0 2. Adult day program/Plan Activity Group (PAG) 72 60.0 4. Community Health Centre 70 58.3 12. Transport 65 54.2 3. Royal District Nursing Services 60 50.0 9. Respite Care 60 50.0 10. Friendly Visiting 58 48.3 15. Extended Aged Care at Home (EACH) Packages 40 33.3 14. Community Aged Care Packages (CACP) 39 32.5 11. Telelink 26 21.6

One-way ANOVA and independent t-test analyses showed that the effects of years of residency (F(3,116)=5.683, p=0.001), living arrangements (F(2,117)=3.136, p=0.047), and need for assistance (t(118)=5.61, p=0.005) were statistically significant, yet there were no significant differences in the effects of demographics and other socio-economic factors (see

Appendix XI). Participants who arrived in Australia earlier generally knew about more existing aged care services, and the post hoc comparison using the Scheffé test indicated that those who came to Australia between 1991 and 2000 (M=11.77, SD=3.48) were statistically more knowledgeable about aged care services than those who arrived between 2001 and

2011 (M=9.14, SD=4.15). In addition, participants who lived with a spouse only (M=11.78,

SD=3.59) knew significantly more about services than those who lived with other family

(M=9.85, SD=4.33), and participants who needed more assistance (M=11.04, SD=3.40) were also more aware of available services than those who did not need assistance (M=10.05,

SD=4.20).

155 To explore the relationships between awareness of existing services and other factors, bivariate correlation tests were conducted. Results showed that participants’ knowledge of services was negatively correlated with their preference for informal care and was positively associated with their acculturation to Australia (r(120)= -0.22, p = 0.016; r(120) = 0.25, p =

0.006). These overall findings suggest that longer years of residency and a higher level of acquisition of Australian culture will equip elderly Chinese-speaking immigrants with a better knowledge of the Australian aged care system and services, and those who have greater need for aged care or were less inclined to informal care would tend to discover more options, and hence know more about existing services.

6.2.5 Barriers to service use

Participants identified an average of 7.54 barriers to accessing and using aged care services.

There were 4 factors extracted from these barriers, namely cultural barriers, structural barriers, attitudinal barriers, and self-sufficiency. The mean, standard deviations, actual and potential range of scores of these four factors are displayed in Table 6.10.

Table 6.10 Mean, standard deviations, actual range, and potential range of 4 Barriers to Service Use Actual Potential Scale M SD Range Range Factor 1：Cultural barriers 3.47 1.67 0-5 0-5 Factor 2：Structural barriers 2.32 1.75 0-5 0-5 Factor 3 ：Attitudinal barriers 1.02 1.25 0-3 0-3 Factor 4 ：Self-sufficiency 2.27 0.89 0-3 0-3 Barriers to Service Use 7.54 3.31 0-15 0-16

156 As shown in Table 6.11, communication difficulty and cultural incompatibility were the main reason for participants not using aged care services. The majority of participants consider not using services because staff and workers do not speak their language (83%), staff and workers were not Chinese (73%), staff and workers do not understand Chinese culture (68%), and services are not specialized for Chinese clients (68%). The structural barriers including complicated procedures (53%), expensive service fees (50%), long waiting lists (45%) and transportation difficulties (44%) also prevented many participants from using services.

Table 6.11 Barriers to accessing and using aged care services Item N % Factor 1：Cultural barriers 10. Staff and workers do not speak your language 99 82.5 8. Staff and workers are not Chinese 88 73.3 9. Staff and workers do not understand your culture 82 68.3 11. Services are not specialized for Chinese (eg. Meals) 82 68.3 12. There are no other Chinese clients/users 65 54.2 Factor 2：Structural barriers 15. The procedures for using the services are complicated 63 52.5 17. The services are too expensive (Cannot afford to pay) 60 50.0 14. The waiting list is too long 54 45.0 19. Transportation difficulties 53 44.2 13. The office hours are inconvenient 49 40.8 Factor 4 ：Self-sufficiency 2. You can take care of yourself well. 107 89.2 4. You are in good health now. 90 75.0 3. Your families can look after you. 75 62.5 Factor 3 ：Attitudinal barriers 5. Feeling awkward to ask for help 48 40.0 6. Feeling ashamed. 45 37.5 7. You worry that you are being seen as having problems 29 24.2

Self-sufficiency is another important reason for older Chinese-speaking participants not considering using aged care services. Nearly 90% of the participants expressed the view that they can take care of themselves well, and 75% regarded that they are in good health so they did not need to use any services. However, when asking participants about their self-rated

157 health, only 30% regarded their heath as good or very good as reported in Chapter 5. This may somehow suggest that older Chinese-speaking participants have a different standard of health when it comes to aged care service utilisation. Self-reliance and endurance described in Chapter 2 are highly valued in Chinese culture and viewed as a means of overcoming challenges in old age. These values influence older Chinese participants’ view of the need for care, and hence the intention to use aged care services. Even though the majority of the participants rated their heath as fair (52%) or poor (18%), they still perceived themselves as being healthy enough to self-care and have no need for formal services.

To examine the socio-demographic variance on the participants’ scores of the service barrier scale, t-test and one-way ANOVA were performed. Results indicated that there were no significant differences in the effects of age, language spoken, years of residency, living arrangements, monthly income, government payments, and main income sources (Appendix

XI). However, the effects of gender (t(118)=6.590, p=0.012), English proficiency

(F(3,116)=5.124, p=0.002), and self-rated health (F(2,117)=5.461, p=0.000) were statistically significant. Results show that female participants (M=8.05, SD=3.28) experienced a significantly higher level of perceived service barrier than male participants

(M=6.41, SD=3.13). Post hoc analyses using the Scheffé post hoc criterion for significance indicated participants who regarded that they could speak English well (M=5.73, SD=3.16) and rated their health as very good or excellent (M=5.50, SD=3.06) perceived significantly lower levels of service barrier than those who could not speak English at all (M=8.38,

SD=3.27), and rated their health as poor or fair (M=8.71, SD=3.39). Results also show that there were significant differences in the effects of marital status and religion on participants’ perceived attitudinal barriers. Participants who were married (M=65.11, SD=9.62) and

158 Christians (M=65.11, SD=9.62) had significantly lower levels of attitudinal barrier than those

who were divorced or separated (M=65.11, SD=9.62), Buddhists (M=65.11, SD=9.62) or had

no religious affiliation (M=65.11, SD=9.62).

Bivariate correlation tests were then conducted to examine the relationships between

perceived barriers and other predictive factors. Result indicated that the sample’s perceived

service barriers and favourable attitudes toward community service use were found to be

negatively correlated (see Table 6.12). Participants who were concerned more about others’

opinions when accessing services perceived higher levels of cultural, structural, and

attitudinal barriers. Those with a higher level of worry and fear about service use also

perceived higher levels of structural and attitudinal barriers. In addition, participants’ cultural

barriers were negatively correlated with their level of acculturation, r(120) = -0.26, p = 0.004,

while structural barriers were negatively associated with level of social support,

r(120) = -0.22, p = 0.014. Participants who perceived greater service barriers were more

likely to have a higher level of depression, r(120) = 0.40, p = 0.000.

Table 6.12 Correlations of service use attitudes and service barriers Measure Preference for Acceptance of Concern for Worry and Fear Favourable Informal Care Gov. Assistance others’ opinions attitudes Cultural barriers .12 .17 .22** .18 -.13. Structural barriers .06 .07 .19* .18* -.13 Attitudinal barriers .18 -.03 .20* .18* -.22* Self-sufficiency .11 .18 -.03 .03 .00 Service Barriers .13 .07 .30** .25** -.21* Note. * p < 0.05, ** p < 0.01, *** p < 0.001

159 These overall finding suggest that participants who were female, had less favourable attitudes

toward service use, had poorer English and self-rated health, and a higher level of depression

were more likely to perceive greater barriers when accessing and using services. Their

attitudinal barriers were particularly associated with their demographics including marital

status and religious affiliation, whereas cultural and structural barriers were negatively

correlated with their level of acculturation to Australia and social support.

6.3 Need factors

Need factors refer to an individual’s perceived and evaluated illness level. Analysis of

perceived needs, including self assessment of health and need for assistance, was presented

in the last chapter, while evaluated needs using the clinical measurements are presented here.

6.3.1 Activities of daily living

Scores on the Modified Barthel Index (MBI) for this sample ranged from 60 to 100, with a

mean of 94.34 (SD= 9.66), suggesting the sample had relatively sound self-care abilities.

Table 6.13 (overleaf) shows the numbers and percentages of participants who can perform

activities of daily living independently. Nearly all participants can self-feed, use a toilet,

wash and dress without assistance but 15-25 % had some difficulties in moving, walking and

climbing stairs. About 20% of participants had continence issues.

160 Table 6.13 Number and percentage of participants who can perform activities of daily living independently

Dependent Need some help Independent Activities of Daily Living N % N % N % 1. Feeding 0 0.0 0 0.0 120 100.0 2. Transfer 1 0.8 17 14.2 102 85.0 3. Grooming 1 0.8 ▬ ▬ 119 98.2 4. Toilet use 1 0.8 4 3.3 115 95.8 5. Bathing 8 6.7 ▬ ▬ 112 93.3 6. Mobility (on level surfaces) 0 0.0 19 15.8 101 84.2 7. Stairs 9 7.5 19 15.8 92 76.7 8. Dressing 0 0.0 7 5.8 113 94.2 9. Bowels 1 0.8 9 7.5 110 91.7 10. Bladder 1 0.8 25 20.8 94 78.3

One-way ANOVA and independent t-test analyses showed that the effects of age

(F(2,117)=5.683, p=0.001), English proficiency (F(3,116)=4.206, p=0.007), living arrangements (F(2,117)=3.256, p=0.042), the receipt of government payments

F(3,116)=5.761, p=0.001), self-assessed health (F(2,117)=5.111, p=0.007), and need for assistance (t(118)=5.61, p=0.005) were statistically significant (see Appendix XI). Results indicated that participants who were in the oldest age group (M=91.67, SD=12.85), rated their health as fair or poor (M=92.57, SD=10.86), and needed assistance (M=88.30,

SD=12.39) had the lower ADL scores, compared with those who were in the youngest age group (M=97.63, SD=5.06), rated their health as excellent or very good (M=99.29, SD=1.82), and did not need assistance (M=97.84, SD=5.13).

Additionally, participants who can speak English well (M=99.04, SD=2.46), did not receive any government payments (M=96.81, SD=6.78), or live with other family members had the higher ADL scores (M=96.73, SD=7.09), compared with those who could not speak English at all (M=91.37, SD=11.27), received special payments (M=85.00, SD=13.99), and lived

161 alone (M=91.80, SD=11.19). These findings suggest that older Chinese-speaking immigrants who were younger, healthier, financially more dependent, and had better English and lived with their adult children, were more likely to perform activities of daily living without assistance.

6.3.2 Instrumental activities of daily living

Scores on the Lawton Instrumental Activities of Daily Living Scale (LIADLS) for this sample ranged from 3 to 8), with a mean of 6.7 (SD= 1.30), suggesting the sample had basic functional skills to live independently in the community. Table 6.14 shows the numbers and percentages of participants who can perform instrumental activities of daily living independently. The lowest functional skills among the older Chinese-speaking participants were shopping and food preparation, more than half of participants needed help with shopping and 42% needed some assistance to prepare their own meal. About one fifth of participants didn’t travel or only travelled in taxis or on public transportation accompanied by another person.

Table 6.14 Number and percentage of participants who can perform instrumental activities of daily living independently

Dependent Independent Instrumental Activities of Daily Living N % N % 1. Ability to use telephone 0 0.0 120 100.0 2. Shopping 67 55.8 53 44.2 3. Food Preparation 50 41.7 70 58.3 4. Housekeeping 0 0.0 120 100.0 5. Laundry 4 3.3 116 96.7 6. Mode of transportation 22 18.3 98 81.7 7. Responsibility for own medications 8 6.7 112 93.3 8. Ability to handle finances 5 4.2 115 95.8

162

One-way ANOVA and independent t-test analyses showed that the effects of age

(F(2,117)=4.444, p=0.014), English proficiency (F(3,116)=7.709, p=0.000), the receipt of government payments F(3,116)=2.796, p=0.043), source of income (F(2,117)=3.197, p=0.004), self-assessed health (F(2,117)=10.538, p=0.000), and need for assistance

(t(118)=30.197, p=0.000) were statistically significant (see Appendix XI). Results were similar to the previously presented ADL findings, suggesting that older Chinese-speaking immigrants who were younger, healthier, financially more dependent, and had better English were more likely to perform instrumental activities of daily living without assistance.

There was also a significantly positive correlation between ADL and IADL, r(120) = 0.50, p

= 0.000. These indicate that the participants who were older tended to have more difficulties in performing ADL and IADL, and those with more limitations in ADL, such as bathing, showering dressing, eating, walking, using the toilet, were more likely to have IADL impairments, related to shopping, preparing meals, doing housework, and travelling alone.

6.3.3 Depressive Symptoms

Scores on the Geriatric Depression Scale-Short Form (GDS-SF) for this sample ranged from

0 to 14. On average participants reported 3.7 depressive symptoms (SD=3.7). Thirty percent of participants reported having depressive symptoms, with 18% being mildly depressed

(score=5-9) and 12.3% being moderately to severely depressed (score=10-15). Eighty-two participants (67.2%) scored at 4 or below, indicating normal or non-depressed.

163 Table 6.15 shows a comparison of the sample and the two other studies of older Chinese immigrants in relation to depression using the same scale.

Table 6.15 Comparison of the sample with older Chinese people in Canada and in New Zealand on the GDS-SF

Sample Older Chinese Older Chinese in in Canada4 New Zealand5 GDS-SF N % N % N % Non depressive(score=0-4) 83 69.2 1165 75.8 112 73.7 Depressive (score=5-15) 37 30.8 372 24.2 40 26.3 Total 120 100.0 1,537 100.0 152 100.0

T-tests were conducted to determine whether there were significant differences of depression rates between the sample and the two other studies. Results found that there was no significant difference between the sample and older Chinese immigrants in the Canada study

(Lai, 2004c) and between the sample and older Chinese immigrants in the New Zealand study (Abbott, Wong, Giles, Wong, Young, & Au, 2003). According to the results of the

Australian Health Survey (ABS, 2012b), approximately 10% of Australians aged 65 years and older reported having mood (affective) disorders such as depression. A review of depression in populations of elderly Caucasians also suggests that the prevalence of depression ranges between 0.9% and 9.4% in private households (Djernes, 2006). These findings suggest that there were significantly higher rates of depression among Chinese- speaking immigrants in western countries. These Chinese-speaking immigrants even had higher levels of depression than their counterparts in China as the prevalence rates of depressive mood in China were 14.81% (Chen, Copeland, & Wei, 1999).

4 Lai, D. W. L. (2004). Impact of culture on depressive symptoms of elderly Chinese immigrants. Canadian Journal of Psychiatry, 49(12), 820-827. 5 Abbott, M. W., Wong, S., Giles, L. C., Wong, S., Young, W., & Au, M. (2003). Depression in older Chinese migrants to Auckland. Australian & New Zealand Journal of Psychiatry, 37(4), 445-451.

164

To examine the socio-demographic variance on participants’ GDS Scale, one-way ANOVA and t-test were performed. Results showed that there were statistically significant differences in the effects of gender (t(118)=7.039, p=0.009), years of residency (F(3,116)=2.799, p=0.043), monthly income (F(3,116)=2.831, p=0.041), government payment

(F(3,116)=5.198, p=0.002), and income satisfaction (F(2,117)=4.257, p=0.016), self-assessed health, and need for assistance (t(118)=5.805, p=0.018). Results show that female participants and those who had poorer health or needed more assistance were more likely to be depressed than male participants and those who were in good health and did not need assistance. Post hoc comparisons using the Scheffé test indicated that participants who came to Australia earlier and had a lower level of financial resources has the highest proportion of those suffering from depression. It is worth noting that participants’ depressive symptoms had negative correlation with their age, r(120) = -0.19, p = 0.040, availability of carer, (120)

= -0.36, p = 0.000, and social support,(120) = -0.64, p = 0.000. Depression was positively correlated with perceived service barriers, r(120) = 0.28, p = 0.002.

The overall findings suggest that having poorer health and low income can increase the older

Chinese-speaking immigrants’ risk of developing or triggering depression. Participants who suffer from depression tended to be younger, have lower levels of family and social support, and perceived a higher level of service barriers. The sample’s recency of migration may contribute to their lower level of financial independency and social support, which may make these recent immigrants more vulnerable to depression.

165 6.4 Summary

This chapter reported on influencing factors of aged care use by older Chinese-speaking

participants in light of predisposing, enabling and need factors of the Andersen Behavioural

Model. The results indicate that the sample seemed to possess similar cultural beliefs and

attitudes that predispose them to use or not to use services. Regardless of their demographic

and socioeconomic characteristics, older Chinese-speaking participants had a relatively high

level of filial expectation of their adult children, a moderately favourable attitude toward

service use, and a relatively low intention to use aged care services particularly when they

perceive their aged care need is low.

Family was the main source of support for older Chinese-speaking participants as close to

half of the sample lived with adult children. However, the findings imply that many were not

satisfied with the quality of support, particularly the relationship with adult children. This can

impact on health and general wellbeing of the older Chinese-speaking participants as they

had a relatively high filial expectation toward children. Support provided by the family then

acts as a facilitator and barrier simultaneously to influence older Chinese-speaking

immigrants’ use of aged care services. The study found that the sample’s financial status was

associated with their social support level and availability of informal carers. Participants who

had a low monthly income were more likely to have a lower level of social support but a

higher level of family support. The implications of these findings and the intersectional

effects of these factors on older Chinese-speaking immigrants’ general wellbeing and service

use are discussed in Chapter 8.

166 The findings also suggest that participants perceived many barriers to accessing and using services, particularly cultural barriers. The sample had a high level of retention of Chinese culture and a low level of acquisition of Australian culture. Results showed that participants’ awareness of existing aged care services and social support level increased as they stayed in

Australia longer; however, their level of spoken English and acquisition of Australian culture did not necessarily improve even if they lived in Australia for many years. The sample had a moderate level of physical functioning skills but a high level of depression, which was associated with gender, financial status, and social support level. These findings have important implications for policy and service development, discussed in Chapter 8.

167 Chapter 7: Use of aged care services by older Chinese-speaking participants

This chapter reports the findings of actual aged care utilisation by participants, applying the adapted Andersen Behavioural Model presented in Chapter 3. It begins by outlining the older

Chinese-speaking participants’ actual use of aged care services and comparing their level of use with two related older populations in Victoria. The two comparative populations are people aged 70 years and older living in Victoria (hereafter referred to as “older Victorians”) and people aged 70 years and older who were born in China (hereafter referred to as “older

China-born Victorians”). Because there is no national dataset available for users from non-

English speaking countries, data drawn from the Victorian HACC minimum data set 2009-

2010 were used for comparison. This chapter concludes by reporting on the main cross correlations that impacted on aged care utilisation and examines the predictive predisposing, enabling and need factors.

7.1 Types of aged care services used

Of the 120 participants, 65 participants (54.2%) reported having used at least one Home and

Community Care (HACC) service, while 55 participants (45.8%) reported never using any

HACC services. Table 7.1 overleaf shows the types of HACC services used by older

Chinese-speaking participants. Community health centre services were the most frequently used service type by the sample, followed by home maintenance, transport, planned activity groups, home care, and home nursing.

168 Table 7.1 Type of HACC services used by participants Yes No Home and community care services (HACC) N % N % 1. Community Health Centre 44 36.7 76 63.3 2. Home maintenance and modification 28 23.3 92 76.7 3. Transport 15 12.5 105 87.5 4. Day Care Centre/ Plan Activity Group (PAG) 14 11.7 106 88.3 5. Home care services 14 11.7 106 88.3 6. Royal District Nursing Services 13 10.8 107 89.2 7. Telelink 4 3.3 116 96.7 8. Respite Care 3 2.5 117 97.5 9. Friendly Visiting 3 2.5 117 97.5 10. Personal care services 1 0.8 119 99.2 11. Meals-on-wheels 1 0.8 119 99.2 Total (used at least one HACC service) 65 54.2 55 45.8

The majority of participants who were users of HACC services only used one or two types of service, accounting for 43% and 29% of total users (see Table 7.2). This is similar to the

Victorian figure in 2010-2011 of 52 % of HACC clients receiving only one kind of HACC service and about 20% of HACC clients using two types of service (DoH, 2014).

Table 7.2 Frequency of use of HACC services by participant

Frequencies of use of HACC services N % 1 28 43.1 2 19 29.2 3 4 6.2 4 9 13.8 5 4 6.2 6 1 1.5 Total users 65 100.0

In addition to HACC services, most of the participants (84%) had attended or visited Chinese seniors’ clubs before, while 11 participants (9%) had received an Aged Care Assessment. Of

169 the 11 users of Aged Care Assessments, 5 took up Community Aged Care Packages (CACP), and the others used 1 to 4 types of HACC services.

To examine the pattern of HACC services used by older Chinese-speaking immigrants, the

Victoria’s HACC minimum data set 2009-2010 was used for comparison with the sample.

Eleven HACC services were grouped into three main service types in light of classification by the Department of Health in Victoria, namely Home Support Service, Allied Health and

Nursing Services, and Social Support Services. T-tests were performed to determine whether there were significant differences between the sample and the older China-born Victorians in relation to their use of HACC services (see Table 7.3). Results indicate that the percentage of these participants who used social support services was not significantly different from older

China-born Victorians. However their use of Home Support Services and Allied Health and

Nursing Services were significantly higher than older China-born Victorians. These higher service utilisation rates were associated with the participants’ higher use of community health centres, and home maintenance and modification services.

There are several explanations for these results. Firstly, a number of participants were residents of public housing where grab and shower rails had already been installed in their bathrooms. Those participants would then answer ‘Yes’ when asked if they had used home maintenance and modification services. Secondly, many participants may use community health centres for GPs or dental services, particularly those who lived in public housing where the GPs at the nearby community health centre services were very accessible to them.

This therefore results in a higher utilisation rate of community health centres by the sample.

If community health centres and home maintenance and modification services are excluded

170 (see Table 7.3), the results show that there were no significant differences between the sample and the older China-born Victorians in their use of HACC services.

Table 7.3 Comparison of the sample with older China-born Victorians across three service types Sample Older China-born t(4666) p Victorians Service No. of Users as % No. of Users as % service of the service of the users sample users population Home Support(a) 32 26.7 461 10.1 5.849 0.00 (Excluded Home 15 12.5 461 10.1 0.859 0.39 Maintenance and Modification Services) Allied Health and Nursing(b) 50 41.7 426 9.4 11.525 0.00 (Excluded Community 13 10.8 426 9.4 0.518 0.60 Health Centres) Social Support(c) 20 16.7 693 15.2 0.451 0.65 (a) Home support includes the services of Home maintenance and modification, Home care services, Respite Care, Personal care services, Meals-on-wheels. (b) Allied Health and Nursing includes the services of Community Health Centre and Royal District Nursing Services. (c) Social Support includes the services of Transport, Day Care Centre/ Plan Activity Group (PAG), Telelink, and Friendly Visiting.

Source: (Department of Health, 2010)

When compared with the older Victorian population, the participants’ use of home support services was not statistically different, but their use of allied health and nursing services, and social support services were significantly higher (see Table 7.4 overleaf). If home maintenance and modification services and community health centres are excluded, the results show that the sample used significantly more social support services, yet significantly less home support and nursing services in comparison with older Victorians. These findings suggest that older Chinese-speaking immigrants’ use of aged care services was not universally low and their pattern of aged care utilisation was distinctly different from their older Victorian counterparts.

171

Table 7.4 Comparison of the sample with older Victorians across three service types Sample People aged 70+ t(437819) p in Victoria Service No. of Users as % No. of Users as % service of the service of the user sample user population Home Support 32 26.7 116,383 26.6 0.025 0.98 (Excluded Home 15 12.5 116,383 26.6 3.495 0.00 Maintenance and Modification Services) Allied Health and Nursing 50 41.7 77,539 17.7 6.886 0.00 (Excluded Community 13 10.8 77,539 17.7 1.980 0.05 Health Centres) Social Support 20 16.7 29,745 6.8 4.306 0.00

Source: (Department of Health, 2010)

7.2 Characteristics of users and nonusers

As presented earlier in this chapter, about 54% (65/120) of participants reported having used

at least one HACC service. Chi square and t-tests were performed to determine whether there

were significant differences in the characteristics of the users and non-users. The findings

indicate that there were no differences in their behaviours based on gender, marital status,

language spoken at home, religious affiliation, education level, filial responsibility

expectations, community service use attitudes, self-rated English, acculturation level,

perceived service barriers, and depressive symptoms (see Table 7.5 overleaf).

172 Table 7.5 Characteristics of the users and non-users of HACC aged care services Non-users Users t test/ p (N=55) (N=65) chi square mean/ mean/ percentage percentage Predisposing Factors Age (in yrs) 75.7 77.8 t=-1.84 0.069 Sex Male 51.4 48.6 ϰ2=0.66 0.418 Female 43.4 56.6 Years of residency (in yrs) 10.0 14.6 t=-3.68 0.000 Immigration Visa Parent 36.1 63.9 ϰ2=7.45 0.024 Contrib. Parent 64.5 35.5 Others 52.9 47.1 Marital status Married 48.1 51.9 ϰ2=0.76 0.684 Divorced 33.3 66.7 Widowed 44.1 55.9 Living arrangement Alone 30.0 70.0 ϰ2=10.51 0.005 Spouse only 33.3 66.7 Other family 61.8 38.2 Filial Responsibility Expectation 60.3 57.9 t=1.60 0.113 Community Service Attitude (Favourable) 38.2 37.1 t= 0.96 0.340 Preference for Informal Care 9.8 9.9 t= -0.27 0.792 Acceptance of Government Assistance 12.1 11.6 t=1.40 0.166 Concern for the Opinion of Others 7.0 7.2 t=-0.72 0.472 Worry and Fear 7.2 7.3 t=-0.50 0.624 Intention to service use-low need Yes 46.3 53.7 ϰ2=0.01 0.914 No 45.3 54.7 Intention to service use-high need Yes 48.0 52.0 ϰ2=0.97 0.324 No 36.4 63.6 Enabling factors Monthly income $0-500 72.7 27.3 ϰ2=12.45 0.002 $500-$999 54.3 45.7 $1000+ 31.7 68.3 Government payments No 77.8 22.2 ϰ2=21.14 0.000 Yes 32.1 67.9 Acculturation Heritage (Chinese) 30.0 30.0 t=0.00 1.000 Mainstream (Australian) 16.7 17.9 t=-1.63 0.106 Availability of Informal Carers 3.6 2.8 t=1.80 0.074 Social Support 20.3 21.7 t=-1.98 0.050 Awareness of Existing Services 10.3 13.8 t=-2.87 0.005 Perceived Service Barriers 7.5 7.6 t=-0.04 0.965 New perceived barriers 7.0 6.6 t=0.61 0.542 Cultural barriers 3.5 3.4 t=0.25 0.800 Structural barriers 2.6 2.0 t=1.79 0.076 Attitudinal barriers 0.9 1.2 t=-1.31 0.192 Need factors Need for assistance No 55.3 44.7 ϰ2=7.42 0.006 Yes 29.5 70.5 Self-assessed health Excellent/Good 58.3 41.7 ϰ2=3.24 0.072 Fair/Poor 40.5 59.5 Activities of Daily Living 97.1 92.0 t=3.12 0.002 Instrumental Activities of Daily Living 7.0 6.5 t=1.95 0.053 Depression 3.6 3.7 t=-0.13 0.901

173

However, the effects of years of residency in Australia, immigration visa type, living arrangements, monthly income, receipt of government payments, social support, awareness of existing services, need for assistance, and activities of daily living were statistically significant. The effects of age, availability of informal carers, self-assessed health, and instrumental activities of daily living were marginally significant (p <0.1).

These results indicate that typical users of HACC services were those who were relatively older, had resided in Australia longer, migrated under a Parent Visa, lived alone or with spouse only, had a monthly income of more than $1000, received government payments, and reported having need for more assistance and having poorer health. They also tended to have fewer available family carers, received a higher level of social support, knew more about existing aged care services, and had poorer functional ability.

Compared to the participants who used HACC services, those users of the Aged Care

Assessment Service were much older (M=79.36, SD=4.46), had significantly lower functional abilities in performing ADL (M=79.55, SD=14.57) and IADL (M=4.82, SD=0.98), and had significantly more depressive symptoms (M=6.36, SD=4.43). This suggests that participants who had used the Aged Care Assessment Service were more likely to be older and frailer and required more assistance to perform daily activities and live independently at home.

174 7.3 Predictors of aged care use

To further examine predictive factors of participants’ use of aged care, hierarchical logistic regression analysis was applied. The predisposing, enabling, and need factors were entered into a stepwise regression model in a hierarchical fashion as independent variables. The use or nonuse of aged care services was the dependent variable. In addition, although a p value

(significance level) of .05 is usually treated as the standard for evaluating significant variables, variables at the .1 significance level were also included because of the exploratory nature of the study (Kuo et al., 2001; Noelker, Ford, Gaines, Haug, Jones, Stange, &

Mefrouche, 1998). The results of the logistic regression model for predicting aged care service utilization are shown in Table 7.6 overleaf.

The findings indicated that when only predisposing factors were entered into the model, being in Australia longer (p < .01), and living alone (p <.1) or living with spouse only (p <.1) were factors predicting a higher probability of using age care services. When enabling factors were entered as the second block of independent variables, the effects of years of residency and living arrangements on aged care use became insignificant. Among all the enabling factors entered into the regression model, the receipt of government payments, acquisition of

Australian culture, retention of Chinese culture, and awareness of existing services were the significant predictors. The results show that receiving a government payment (p < .1), having higher levels of acculturation to both their heritage (Chinese) (p < .05) and mainstream

(Australian) cultures (p < .1), and knowing more about aged care services (p < .001) would increase probability of using aged care services.

175 Table 7.6 Logistic regression analysis in relation to the participants’ use of aged care services (N = 120)

Model 1 Model 2 Model 3 B OR B OR B OR Block1：Predisposing factors Age 0.05 1.05 0.08 1.08 0.01 1.01 Gender (Female) 0.71 2.03 0.85 2.34 0.51 1.66 Year of residency 0.11*** 1.11 0.03 1.03 0.06 1.07 Living arrangement (Alone) 1.02* 2.78 1.13 3.10 0.51 1.67 (Spouse only) 0.93* 2.54 0.75 2.11 0.02 1.02 Filial responsibility -0.03 0.97 -0.06 0.94 -0.08* 0.93 Preference for Informal Care -0.02 0.98 0.08 1.08 0.01 1.01 Acceptance of Government Assistance -0.14 0.87 -0.13 0.88 -0.07 0.92 Concern for the opinion of others 0.03 1.03 -0.02 0.98 0.04 1.05 Worry and Fear 0.02 1.02 0.18 1.20 0.34* 1.41 Block2：Enabling factors Monthly income ($0-500) 1.69 5.39 2.09 8.10 ($500-999) -0.79 0.46 -0.84 0.43 Government payments (Yes) 2.07* 7.92 2.02 7.50 Acculturation to heritage culture 0.23** 1.26 0.26** 1.30 Acculturation to mainstream culture 0.13* 1.15 0 .14* 1.15 Availability of Informal Carers -0.14 0.89 -0.33* 0.72 Social Support 0.11 1.12 0.23** 1.26 Awareness of Existing Services 0.34**** 1.41 0.37**** 1.44 Service Barriers 0.07 1.07 -0.03 0.97 Block3：Need factors . Self-assessed health (Poor) 0.89 2.44 Need of assistance (Yes) -0.15 0.86 Activities of Daily Living -0 .08** 0.92 Instrumental Activities of Daily Living -0.26 0.77 –2 log likelihood (-2 LL) 136.87 101.06 91.00 Chi-square 28.65**** 35.81**** 10.06** Nagelkerke R2 28.4% 55.5% 61.8% Note. * p < 0.1, ** p < 0.05, *** p < 0.01, ****p<0.001

In the final model, the effect of government payments became an insignificant predictor, yet retention of Chinese culture (p < .05), acquisition of Australian culture (p <.1), and awareness of existing services (p < .001) remained as significant predictors of using aged

176 care services. The effect of filial responsibility expectation (p < .1), availability of informal carers (p < .1), social support (p < .05), and ADL (p < .05) also appeared to be significant in the final regression model. Table 7.6 showed that having a one unit increase in the levels of filial responsibility expectation and availability of informal carers reduced the odds of using aged care services by 0.93 times and 0.72 times, as indicated in the Model 3 as OR. A one unit increase in the levels of retention of Chinese culture and acquisition of Australian culture raised the probability of using services by 1.30 times and 1.15 times respectively. Having a one unit increase in the level of social support and awareness of existing services also increased the odds of using services by 1.22 times and 1.44 times.

The findings show that each set of variables all have important independent effects on whether these participants use aged care services or not (see Table 7.6). The inclusion of the predisposing factors resulted in a -2 Log Likelihood (-2 LL) of 136.87 (df = 10; p < .001), a reduction of 28.65 from before the independent variables were included. The addition of enabling factors reduced -2 LL by 35.81 to 101.60 (df = 11; p < .001) and the inclusion of need factors further reduced the -2 LL by 10.06 to 91.00 (df = 3, p < .05). The decrease in the

Log Likelihood measure suggests that the model improved its ability to predict aged care use after entering each set of predisposing, enabling and need factors. The final regression model accounted for roughly 62% of the variance, suggesting good predictive effectiveness in aged care use by older Chinese participants. Different from some earlier studies suggesting relatively low predictive effectiveness of the Andersen Behavioural Model at between 20% and 52% (Calsyn et al., 2000; Li, Fann, & Kuo, 2011; Mitchell et al., 1998), the inclusion of more social structural, cultural and attitudinal variables in this study increased its ability to explain aged care use among the ethnic elderly.

177

Results showed that the predisposing and enabling factors contributed much more of variance

(explained 28.4% and 27.1% of the variance respectively) than the need factors (explained only 6.3% of the variance). This finding is different from earlier studies of home-based services using the Andersen Behavioural Model where need factors were often found to have the strongest influence on home care service utilization (Kadushin 2004). One possible explanation is that the sample had a higher level of use of community-based aged care services, such as planned activity groups, transport, and community health centres but a lower level of home-based aged care service use, including domestic and personal care services. The use of community-based aged care services is more likely to be determined by needs for social support and culturally-specific health care rather than physical functioning.

Evidence suggests that need factors play a particularly important role in predicting the use of non-discretionary services, such as high care, emergency and hospitalisation ( ern ndez-

Mayoralas, Rodr guez, & Rojo, 2000; Mitchell et al., 1998). These services to some extent can be classified as discretionary and the importance of need factors in explaining aged care use by the sample is therefore diminished.

Another possible explanation is that there is inequitable access to aged care services among the sample. Andersen (1995) proposes that equitable access occurs when demographic and need variables account for most of the variance in service use. If social structure, health beliefs, and enabling resources determine who gets care, access to service use is considered as inequitable. This study found that immigrant status, filial piety, personal resource, knowledge and ability to secure services seem to play more important roles in influencing access and use of aged care services by the sample. It may imply that older Chinese-speaking

178 people who are more deprived and have less resources would in fact be less likely to access

and use services. A detailed discussion about inequitable access to aged care service is

presented in the next chapter.

7.4 Summary

This chapter reports the pattern of aged care utilisation by older Chinese-speaking

participants. Of all listed aged care services, the community health centres were the most

frequently used service type by participants, followed by home maintenance and

modifications, transport assistance, planned activity groups, and home care services. The

pattern of aged care service use by older Chinese-speaking immigrants was very different

from their Australian counterparts. They used significantly more social support services, yet

significantly less home support and nursing services. This may be partially attributed to the

sample’s relatively sound self-care abilities and physical functioning, as reported in the

previous chapter.

The users of aged care services were those who were older, had resided in Australia longer,

migrated under the Parent Visa Category, lived alone or with spouse only, had a monthly

income of more than $1000, received government payments, reported having a need for more

assistance and having poorer health. They also tended to have fewer available informal carers,

received a higher level of social support, knew more about existing aged care services, and

had poorer functional ability.

179 Using the Andersen Behavioural Model, lower filial responsibility expectations, higher levels of acculturation to both heritage and mainstream cultures, a higher level of social support, and a higher level of awareness of existing aged care services were found to be predictors of use of aged care services. The predisposing factors and enabling factors explained the largest proportion of variation in their aged care use. The implications of these findings and how the

Andersen Behavioural Model contributed to understanding aged care use by older Chinese- speaking people are discussed in Chapter 8.

180 Chapter 8: Discussion and Conclusion

This chapter integrates the findings of this research in relation to the existing literature and draws out the implications of this study. The research findings are discussed in the context of the three key research questions, followed by the strengths and limitations of the research.

Finally, the implications and overall conclusions are presented.

8.1 Addressing the research questions

This thesis sought to establish an understanding of older Chinese-speaking immigrants’ ageing experiences and aged care use in the Australian context by addressing the following three research questions.

8.1.1 Intersection of age, immigration, and social class

The first question this thesis sought to examine was:

“What were the various categories of difference (eg age, class, and immigration) amongst older Chinese-speaking immigrants, and how did these differences interact and intersect to influence their aging experience and general wellbeing in Australia, particularly for those who migrated at an older age?”

This question was examined to provide a picture of diversity within this population and enable an understanding of the key factors that impact on older Chinese immigrants’ ageing experience and psychosocial wellbeing.

181

The findings of this study corroborate earlier research (Benham et al., 2000; Khoo, 2012), which suggests that older Chinese-speaking Australians are more likely to be socially isolated and financially dependent, particularly those from mainland China. The participants in this study experienced greater disadvantaged and disempowerment than the general older

Chinese-speaking population because of their relatively recent residency, age at immigration, and financial dependence. The sample was composed of older Chinese-speaking immigrants who came to Australia later in life to be reunited with their adult children. The intersection of age, immigration, and social class has placed these older Chinese-speaking participants in a unique social location. Unlike the younger immigrants who are energetic and more motivated to learn, these older people came to Australia at an age when they were less capable of learning a new language and less able to adjust. Unlike older people grew up in Australia, these recently arrived immigrants lacked English ability, social support networks and cultural knowledge to help them settle in and age well. Unlike those who are financially better-off, these participants had low or no income and generally did not have sufficient resources to maintain their quality of life independently. The intersecting effect of being of an older recently-arrived immigrant who was financially dependent greatly impacted on their ageing experience and general wellbeing.

Another key finding was a higher co-residence rate among the sample (46% living with other family members) compared with the older Australian population and the general older

Chinese-speaking population in Australia (8% and 20% respectively). Earlier studies suggested that high co-residence rate with adult children among older Chinese-speaking immigrants is a traditional cultural practice (Lai, 2005; Wong, Yoo, & Stewart, 2007).

182 However, the high co-residence rate among the sample in this study was found to be determined by social and/or financial restrictions rather than simply cultural preferences. As documented in Chapter 5 and 6, those who lived with other family members were more likely to have a low monthly income, receive no government payment, and to have arrived in

Australia less than 10 years ago. Several studies have reported that older Chinese immigrants prefer to live separately but nearby their adult children’s families so they can enjoy independent living with family support available, but avoid intergenerational conflicts caused by three generations living together (Dong et al., 2012; Lo et al., 2007; Tsai et al., 1998).

This study found that only a quarter of the sample preferred to live with their adult children.

The discrepancy between actual and preferred living arrangements found in this study supports the evidence that older Chinese-speaking participants may not live with their adult children by choice and cultural preference but because of limited financial and social resources and inadequate housing options. Current evidence suggests inconclusive relationship between living arrangement and psychosocial wellbeing among older Chinese immigrants (Guo et al., 2015; Kuo, Chong, & Joseph, 2008). Some studies found that living alone was a significant predictor of depression (Mui, 1999), whereas more recent evidence suggests that the co-residence in Chinese immigrant families was a trigger for intergenerational tension and associated with a higher level of depression and lower parent- child relationship quality (Guo et al., 2015; Lo et al., 2007; Stokes et al., 2002; Wong et al.,

2007).

This study found that older Chinese-speaking immigrants still possessed quite strong filial expectations toward their adult children. Compared with their western counterparts, these participants, in particular, expected that children should feel responsible for them, give them

183 financial and emotional support, and take care of them when they were sick, as presented in

Chapter 6. This may relate to their motivation to immigrate in old age. But interestingly a significant number of participants explicitly stated during the survey that they could not any longer expect that their children would provide care and support when needed so they had to strive to live independently. Current evidence also suggests inconsistent findings regarding whether filial expectation of adult children is a risk or protective factor for older Chinese people’s mental health and wellbeing. Wang et al.'s study (2009) found that high expectations of filial support is beneficial for older Chinese people as it is positively associated with self-esteem, as well both support received from, and given to adult children.

Nevertheless, some studies suggest that a high level of filial expectation can be detrimental to older Chinese people’s health and psychosocial wellbeing if there is a discrepancy on the perception of filial piety between parent and child (Cheng et al., 2006, Dong et al., 2012).

Another significant finding was a higher level of depression. About 31% of participants reported having mild or moderate depression. This figure is similar to a review of depression among older Chinese immigrants in Western countries, suggesting a 20%-30% prevalence rate (Lin, Haralambous, Pachana, Bryant, LoGiudice, Goh, & Dow, 2015). This prevalence rate for depression is much higher compared to the average prevalence of 13.5% in later life

(Beekman, Copeland, & Prince, 1999). It is not yet clear what is contributing to these differences in depression rates because of wide variation in research methodologies, sample characteristics, and screening instruments (Dong, Chang, & Simon, 2011; Lin et al., 2015).

Some studies however suggest that a higher prevalence of depression among older Chinese immigrants is associated with acculturation stress and migratory background (Dong et al.,

2011; Lin et al., 2015; Mui & Kang, 2006). This study found that being female, living in

184 Australia for a shorter period of time, having a lower level of social support, having poorer self-rated health, and lower income were positively associated with depressive symptoms.

This echoes the evidence that suggests higher prevalence rates of depression for women, and among older people living under adverse socio-economic circumstances (Beekman et al.,

1999; Djernes, 2006). Although this study did not find correlations between depression and filial expectation or living arrangements, having higher filial expectation of adult children, and living with children were found to be significantly associated with financial dependency which is often perceived by older Chinese immigrants as a negative contributor to ageing well (Tan et al., 2010).

It is worth noting that the sample had a significantly lower level of self-rated health than the general older Australian population, as presented in Chapter 5. A study on age-associated changes of perceived health using a meta-analysis suggests that the associations of self- perceived health with mental health were stronger than that with physical and functional health in older samples (Pinquart, 2001). The findings of this study echo the evidence that there were significant associations between participants’ depressive symptoms and self-rated health status whereas the correlations of depression with ADL and IADL among the sample were not significant. Immigrants’ poorer self-rated health was also found in the literature to be associated with recency of immigration and be more likely to transition to poor health outcomes (Newbold, 2005).

The overall findings suggest that the unique social location of older Chinese-speaking participants has rendered them multiply marginalized and placed them at a greater risk of developing depression and poorer health outcomes. Some determinants, such as low social

185 support, are consistently found in the literature to be negatively associated with physical and mental health, but findings regarding the effect of these factors related to immigrant status and cultural values remained inconclusive. At a glance, it may seem contradictory that living alone and living with children were both found in the literature to be associated with older

Chinese immigrants’ depression levels. If we take into account the contextual background and the social location of this population, it is not difficult to understand why such inconclusive results might exist. For older Chinese immigrants, living alone can mean fewer contacts with the outside world and living with children can mean living with conflict. A study by Wilmoth and Chen (2003) also found that the effect of living alone or with family on depressive symptoms is greater for immigrants than non-immigrants. In addition, in the study of Canada’s immigrant population, Dunn & Dyck (2000) suggest that socio-economic factors play a more important role in determining health status and heath care access for immigrants than for non-immigrants. Recent evidence shows that the disparities in health and service access among immigrants can be better explained by the concept of intersectionality

(Giritli Nygren & Olofsson, 2014; Guruge & Khanlou, 2004). The application of this concept in understanding older Chinese-speaking immigrants’ general wellbeing and aged care access is presented later in this discussion, and the implications of these findings for policy and practice are discussed later in this chapter.

186 8.1.2 Aged care use pattern and factors associated with that use

The second research question was:

“What was the pattern of aged care use by older Chinese-speaking immigrants in Australia and in terms of the Andersen Behavioural Model of predisposing, enabling and need factors, which of the factors determine their use of aged care services?

Using the Andersen Behavioural Model enabled a close examination of the interaction of the factors outlined in the previous section, specifically examining the predisposing, enabling and need factors in determining the use of aged care services.

This study found that the pattern of aged care use by the participants was similar to their

Chinese-speaking counterparts but distinct from other elderly Australians. Older Chinese- speaking immigrants used significantly more social support services, yet significantly less home support and nursing services than general older Victorians, as reported in Chapter 7.

This result may be partially attributed to the “healthy migrant effect” (Anikeeva et al., 2010), as the sample, with an average age of 77, still had relatively sound physical function measured by ADL and IADL. However, it does not necessarily mean that older Chinese- speaking immigrants had better heath or required less support and assistance. In fact, the findings suggest that the sample had a significantly lower level of self-assessed health and a significantly higher level of perceived need for assistance compared to the older Australian population, noted in Chapter 5. In the Andersen Behavioural Model, need factor including both perceived and evaluated need is seen as the most immediate cause of service use. It is therefore not difficult to understand that the sample used more social support services and general community health services, rather than domestic or personal care services because

187 their need for services is more around psychological wellbeing and culturally specific health care.

Tsai et al. (1998) found that language, cultural adjustment, transport, health, finances, and loneliness were identified by elderly Chinese immigrants in USA as the top six daily life problems. A study in also found that transportation and social support are the two greatest needs of older Chinese immigrants who were relatively recent arrivals and often quite socially isolated (Ip et al., 2007). Some studies suggest that older Chinese people are reluctant to use domestic or personal care services because these services have stronger negative connotations with regards to filial piety and self-sufficiency, compared with public housing, adult day care and transportation services (Aroian et al., 2005). This study found that older Chinese-speaking immigrants had a moderately favourable attitude toward service use but perceived many barriers in accessing and using services, particularly communication difficulties and complexity of the system. Their intention to access and use aged care services therefore can be influenced by the unavailability of affordable and culturally-specific services.

Of all the predisposing factors, filial expectation of adult children was the only significant predictor of service use, suggesting older Chinese people who had a higher level of filial expectation were less likely to use aged care services. As stated in Chapter 6, the sample had some variations in their perceptions of filial piety; however they generally had stronger filial expectations in comparison to their western counterparts. In a study which examined the impact of filial piety on preference for formal and informal aged care, Cheung et al. (2006) demonstrated that the Chinese endorsed the compensatory view but not the complementary

188 view of elder care. That is, individuals prefer to rely on only one mode of elder care. When filial expectation is high their desire for other sources of support would be low. Another possible explanation for this result is that the study found a negative association between filial expectation and financial independence. The participants with a higher level of filial expectation were more likely to be financially dependent on their children. Financial dependence can be the result of recent residency and ineligibility for government payments, therefore those with low or no incomes tend to live with their adult children. This study found that living with other family members is associated with having more family support and carers available, which again reduces their likelihood of using aged care services.

Of all the enabling factors, there were four significant predictors, namely social support, availability of family carers, acculturation (including acquisition of Australian culture and retention of Chinese culture), and awareness of existing aged care services. Having a higher level of social support and a lower level of perceived family support both predicted the use of aged care services by older Chinese-speaking people. According to the compensatory model as described earlier, it is understandable that the participants who perceived having more family carers were less likely to use formal services. Those who had a higher level of social support in this study were also found to be more likely to use aged care services. This finding is contradicted by some studies using the Andersen Behavioural Model, which suggest that a lack of social support increases the likelihood of using home care services (Kadushin, 2004).

However, a large-scale study on health and wellbeing of aging Chinese Canadians by Lai

(2004a) reported that social support acts as a facilitative factor that enables the use of home care services by elderly Chinese immigrants in Canada. The possible explanation of this result is that those with stronger social support networks were more likely to have families,

189 friends, neighbours, who could provide information and support as well navigate appropriate services for them if needed.

Acquisition to Australian culture and Retention of Chinese culture were both found to be significant predictors of using aged care services in this study. The participants with a higher level of acquisition to Australian culture were more likely to have better English proficiency, know more about existing aged care services, and to be younger. Some studies use English ability, or year of residence as surrogate variables for acculturation (Kuo et al., 2001; Liu et al., 2000; Wong et al., 2007); however the positive effect of acculturation on service use is not simply derived from participants’ better English ability or longer years of residence. In fact, these two variables were not found to be significant predictors of service use in this study. Having more knowledge of available aged care services, which was associated with a higher level of acquisition to Australian culture, better predicted their use of aged care services. This means that those earlier Chinese settlers became more acculturated and more knowledgeable about services, which facilitated their accessing services and removed some perceived service barriers; nevertheless they can still encounter many communication difficulties and cultural compatibility issues when actually using services. For those recently- arrived older immigrants with poor English, they would be multiply disadvantaged because they face the similar challenges when accessing services but they do not have financial resources and familiarity with Australian culture like earlier settlers.

The study found that participants with a higher level of retention of Chinese culture possessed higher expectation of filial piety, yet these two variables have opposite effects on use of aged care services. Having higher retention of Chinese culture increased the odds of

190 using aged care services while having higher expectation of filial piety negatively predicted older Chinese immigrants’ use of services. Lai’s studies (2004b; 2007) found that higher levels of Chinese ethnic identity is a significant predictor of intention to apply to a long-term care facility and use of senior centres among older Chinese Canadians because they know that they will be well supported by their own community and so use services provided by

Chinese-specific agencies. However, having higher expectations of filial piety, which is positively associated with family carers’ availability and financial dependency reduce their likelihood of using formal aged care services.

Previous studies suggest that the retention of traditional cultural beliefs and behaviours and the acquisition of new cultural features through acculturation may affect health outcomes in non-over-lapping ways (Salant et al., 2003). Being acculturated to ones’ heritage culture may act as a protective factor that allows older Chinese-speaking immigrants to feel safe and have a sense of belonging knowing someone from their own community that they can seek assistance from when they are in need, whereas being acculturated to Australian society becomes a facilitative factor of service use because they would have more understanding of the Australian welfare system and be more aware of available aged care services. Awareness of existing aged care services was another important enabler of service use. Older Chinese- speaking people who were more knowledgeable about aged care services and system were more likely to be users. The findings of this study suggest that service knowledge is actually relevant to users’ attitudes and intention to use service. People were motivated to understand more existing services if they perceived themselves having a greater need for assistance, and preferred and intended to use formal care. Finally, a lower ADL score was found in this study to be a significant ‘Need’ predictor of aged care use. Although other ‘Need factors’ such as

191 IADL, self-assessed health and need for help were all associated with aged care use, they were not found in the regression model to be significant predictors.

This study found that predisposing and enabling factors contribute most to variance in explaining aged care use by older Chinese-speaking people, followed by need factors. There are two possible explanations for the need factor not being the most significant contributor of aged care use in this study, namely the nature of the services being used and inequitable access to services, as discussed in the preceding chapter. Several studies of using the

Andersen Behavioural Model also found predisposing characteristics or enabling resources play a more critical role in explaining aged care use by older people from ethnic background.

Lai’s study (2004a) found that older Canadian Chinese’s predisposing characteristics, such as birthplace and Chinese health beliefs were significant predictors of home care service use. A recent study by Lehning, Kim, and Dunkle (2013) also suggests that the key determinant of the use of home and community-based services by the urban African American elders was not need factors but enabling factors, such as financial resources, not driving a car, and social support.

This demonstrates that there is inequitable access to aged care services not only between mainstream and ethnic groups but also among different aged ethnic populations. Interestingly, in Lehning, et al.’s study (2013) the use of home and community-based aged care services was related primarily to the lack of financial and social resources, whereas this study found that older Chinese-speaking people who had more enabling resources in relation to income, knowledge, and social support were more likely to access aged care services. This may reinforce inequalities in aged care use where the rich and dominant mainstream groups have

192 better access and use of aged care services. The implications of these findings for future research and practice are presented later in this chapter.

8.1.3 Integration of the Andersen Behavioural Model and intersectionality in understanding disparities in health and service use

The third question this thesis sought to examine was:

“What was the contribution of the Andersen Behavioural Model and intersectionality to understanding aged care use by older Chinese-speaking immigrants? “

This was to provide a practical application of the integration of the Andersen Behavioural

Model and intersectionality in health and aged care disparities research, using older Chinese- speaking immigrants’ use of aged care services as an example.

It has been well documented that there are disparities in health and service use by older

Australians from culturally and linguistically diverse backgrounds, and factors contributing to this phenomnon are complex and interwoven (Johnstone et al., 2008). The application of the Andersen Behavioural Model assists in exploring multi-dimensional determinants of service use by the sample, while the integration of an intersectionality perspective in this study provides a new perspective on interpreting the findings and understanding these disparities in health and service use. Intersectionality, which is outlined in Chapter 3, emphasises that all people are characterised simultaneously by multiple social categories, such as gender, age, ethnicity, and class; and embedded within each category is an aspect of power and inequality. The predisposing, enabling, and need factors of the Andersen

Behavioural Model were used to represent these categories of difference.

193 For example, in the category of age, the privileged Chinese seniors are those considered as young and healthy. They often held more power and experience less discrimination in the family and society because they are likely to be seen as contributors (breadwinners, taxpayers, childcare and housework helpers) rather than burdens (care and welfare recipients) on family and society. In the category of immigration, power differences can exist between immigrants and non-immigrants, between established and recently-arrived immigrants, and between

English-speaking service providers and non-English-speaking users. The privileged ones were those who were more acculturated to Australia, had a better understanding of existing aged care services, and had a wider social network that can facilitate access to service use. In the category of social class, more privileged participants were those who had more financial resources to secure autonomy and independence, to maintain their quality of life, and to obtain the services they needed. This study found that the older Chinese-speaking participants who were considered as being more privileged or having more power were more likely to use age care services, suggesting inequalities in aged care use among this population.

It is important to note that these categories and their significance can be potentially fluid and dynamic because they are socially constructed (Else-Quest et al., 2016a). For example, if the category of immigration is constructed and defined by years of residency in a host country, more privileged participants were those who had lived in Australia longer and received government payments in comparison to those recently-arrived and ineligible for an age pension who had low or no income. If this category is defined by immigrant status, such as immigrants or non-immigrants, the effect of immigration on aged care use can be divergent.

Those established older Chinese-speaking immigrants who were considered as the privileged in this study can become disadvantaged due to a smaller social network, a lack of English

194 proficiency, and unfamiliarity of Australian culture and system, compared to mainstream

English-speaking Australia-born seniors.

These social categories are not only properties of individuals but characteristics of their social context. The power and inequality that are embedded within these categorises are therefore fostered and perpetuated by their social context. For example, the disparities in health and service use among this population can further be reinforced by institutional oppression such as ageism, racism or stigma and discrimination in care provision (Blakemore,

2000; Johnstone et al., 2008; Johnstone & Kanitsaki, 2010). Immigration policies and the 10- year residence requirement for an age pension can also enforce class and socio-economic inequalities among older Chinese immigrants and further marginalise those who are recently- arrived parent immigrants. Some participants in this study who came under the Parent Visa were eligible for other government benefits and payments after two years of living in

Australia while there were no payments available for those who came under the Contributory

Parent Visa regardless of financial hardship. During the waiting period, they had to financially depend on their adult children and live off their savings, which could cause psychosocial distress due to the feelings of uncertainty and insecurity as well loss of authority and power in their intergenerational family.

The integration of an intersectionality perspective into the Andersen Behavioural Model in this study has contributed to a better theoretical understanding of ethnic disparities in aged care use. In the Andersen Behavioral Model, access to service is considered inequitable if socioeconomic variables or enabling factors are dominant determinants. The issue of disparity in service use is therefore understood as a result of multiple contributors that

195 predispose and enable/impede an elderly minority to use or not to use aged care services.

Coming from this perspective, many researchers endeavoured to identify key determinants and predictors of service use by people from diverse ethnic backgrounds, however, the issue of health and service use disparities remained unsolved (Hankivsky et al., 2008).

Intersectionality, on the other hand, stresses the power inequalities embedded within each traditional background category, such as age, ethnicity, and class, so the interplay of these power inequalities cause disparities in aged care use. Instead of merely identifying the key determinants or predictors of service use by older Chinese-speaking people, this study, by integrating the concept of intersectionality addresses the significance of these factors in the broader Australian context and articulates the power inequalities that older Chinese-speaking immigrants experienced because of their unique social location.

The participants in this study experienced many disadvantages and difficulties in access and using services due to lack of English ability, social support, financial resources, and cultural knowledge. These disadvantages and power inequalities are therefore perpetuated if access to service depends on whether individuals have certain characteristics and/or enabling resources.

As mentioned in Chapter 3, Australia is now undergoing Aged Care Reforms which propose to offer older Australians more choice and control over their care, in a consumer-directed framework. Despite good intentions, these reforms may require older Australians to have more networks and assistance to navigate the service system, more skills and knowledge to negotiate with service providers, and more resources to obtain and secure the services they need. Without sufficient information and assistance, older consumers from CALD backgrounds may therefore have greater difficulty in making informed choices and will

196 encounter more barriers to access services, especially those who came to Australia later in

life. Implications for policy and program development are discussed later in this chapter.

8.2 Strengths and limitations of the study

There are several strengths and limitations of this research that may impact on the findings of

data collected and analysed. This study used a survey method to investigate an inherently

diversified ethnic aged group, older Chinese-speaking immigrants. Due to the diversity

among the older Chinese-speaking population, using a survey method enables the researcher

to collect a wide range of individual information in a relatively effective and efficient manner.

The examination of a single ethnic aged group provides detailed information about one

population and its subgroups. However, it made direct comparison with other ethnic groups

more difficult for lack of compatible data. This study adopted well-developed and widely-

used scales and included some questions drawing from the Census so the findings can be

made comparable with other studies.

This study used a cross-sectional design therefore the long term impact of individual

characteristics on aged care use could not be explored. Some of the predisposing and

enabling determinants of service use by older Chinese-speaking immigrants such as values,

beliefs, social support, acculturation, and knowledge of service may alter as they live in

Australia longer. A longitudinal study would allow for temporal changes to be assessed.

Another methodological limitation of this study is that it used non-probability sampling

techniques, which may limit the making of broader generalisations about the whole older

Chinese-speaking population in Australia. Participants were mainly recruited through

197 Chinese seniors clubs and social organisations that provide a variety of services to older

Chinese-speaking immigrants in Melbourne, Victoria, using the quota sampling frame. The sample consisted of significantly more females, Mandarin speakers, and people aged between

75 and 84 years old who had arrived more recently (post 1991). However, their living arrangements, religious affiliation, level of English proficiency, and financial status were similar to the older Chinese-speaking Australians’ profile in 2011. The sample still well represented the older Chinese-speaking population, particularly those who immigrated to

Australia at an older age for family reunion.

A key strength of the study is the researcher’s language ability and familiarity with the study design and the target population. Unlike many other cross-cultural studies, primary researchers have to rely on others for linguistic assistance, such as translating research materials, recruiting participants, and conducting interviews. The questionnaire, reported to have good validity and reliability, was developed by me as a bilingual researcher and was able to be adapted for older Chinese-speaking people. The fact that the survey was administered by me face to face with participants in their preferred language enhances the consistency and accuracy of the findings. The bilingual researcher facilitated participants to complete the questionnaire and clarified and explained the questions if participants did not understand them. By these processes, missing data in this study was kept to a minimum, possible bias and errors were reduced, and participation was optimised.

198 8.3 Implications

This study carries significant implications for future research, policy development, and practice in aged care use by older people from diverse ethnic backgrounds.

8.3.1 Implications for policy and practice

In the current globalised context, later life migration is a significant social issue which is particularly pertinent to social work practice. Working with older migrants requires a good understanding of the nature of later life migration and its impact on intergenerational family relationships (Park, 2015). The acculturation process can be particularly stressful for these older Chinese immigrants who came to Australia later in life because they had fewer resources to assist them in adapting to the new environment. The intersecting effect of age, immigration, and social class on older recent Chinese immigrants was found in this study to be a negative contributor to mental and psychosocial wellbeing as well aged care use. Social workers and other service providers may be better able to assist elderly Chinese immigrants by working with supportive family members, but must also be cognizant of those elders who have conflicts with their family members, or who have lost family support for other reasons.

Social service agencies could facilitate the ability of family members of Chinese elders to offer adequate support by providing intergenerational services for both the elderly and their offspring.

Another important practical implication of the findings is the elaboration of the role of enabling characteristics in relation to aged care access and use. This study found that having

199 higher levels of social support and retention of Chinese culture in Australia acted as supportive factors of aged care use by older Chinese-speaking immigrant, while having higher levels of acquisition of Australian culture and awareness of existing aged care services were facilitative in determining their use. In a bi-dimensional acculturation framework, the retention of traditional cultural beliefs and behaviours and the acquisition of new cultural features through acculturation can have qualitatively different effects on health and service utilisation. Older Chinese-speaking immigrants and other ethnic groups can improve their health and service utilisation by maintaining their ethnic identities and cultural practices as well as having close connections with local ethnic communities and the wider Australian society.

An additional implication for service delivery regards the fact that the majority of participants did not know what kinds of aged care services were available to them and were concerned about the cultural incompatibility issue. Culturally appropriate informational material should be provided and supplemented by outreach to this population, such as public housing resident meetings and meetings of Chinese clubs and associations. In addition, older

Chinese-speaking immigrants can benefit from having a bilingual representative or a cultural advocator/advisor who understands their cultural needs and preferences as well as the

Australian aged care system. Poor agency location, complicated procedures and insufficient numbers of staff compound barriers to service access. Aged care policy makers and service providers need to devise programs and services that provide additional assistance in narrowing these access gaps.

200 Implications for the policy maker and the practitioner go beyond just this population of elders.

Many diverse, non-English speaking elders are aging along with mainstream Australians.

The unique language, cultural and familial qualities of many elder groups warrant differentiation of their needs and available resources. Particularly within the context of recent aged care reforms, increased cultural sensitivity, additional assessment and support to access, and appropriate outreach assistance should be among those strategies and approaches for future aged care service delivery to this and other immigrant populations.

8.3.2 Implications for research

This study reported a high prevalence of depression among older Chinese-speaking immigrants, which is consistent with the findings reported in the literature over the past two decades (Kuo et al., 2008). This study also confirmed that there is a high level of complexity in Chinese family experience. Living arrangements, filial piety, health condition, financial status, and parent-child relationships all intersect to influence older Chinese-speaking immigrants’ quality of life and psychosocial wellbeing in the host country. Depression is one of the leading causes of disability in Australia and has been documented to be associated with suicide, which is the fourth largest cause of mortality in Australia (Minas, Klimidis, &

Kokanovic, 2007). However, there is very limited empirical evidence to inform the origin of such a high depression rate among older Chinese-speaking immigrants in Australia (Lin et al.,

2015) and virtually no data on quality of mental health service outcomes (Minas, Kakuma,

Too, Vayani, Orapeleng, Prasad-Ildes, Turner, Procter, & Oehm, 2013). The ECCA’s review study on Australian research (2015) also found that older people from CALD

201 backgrounds have a higher risk of mental health issues than other Australians but under-use mental health services. This is an important focus for future research.

Another theoretical implication of the findings is the integration of an intersectionality perspective into the Andersen Behavioural Model in understanding aged care use by ethnic minorities, using a survey method. The questionnaire used in this study was designed in light of the Andersen Behavioural Model, with the aim of identifying key determinants of service use and exploring the issue of inequitable access to aged care services. Intersectionality conceptualizes social categories as interacting with and co-constituting one another to create unique social locations that vary according to time and place. Although the findings have suggested that there are intersecting effects of age, immigration, and class on older Chinese- speaking immigrants’ health and service use, this study did not directly examine these categories of difference and their intersectional effects as they can be fluid and contingent.

This study chose a number of variables to represent each category of difference among this population and attempted to provide another layer of interpretation through the lens of intersectionality.

To advance the application of intersectionality theory into the study of ethnic disparities in health and service use, future studies may consider the development of a questionnaire or scale that specifically addresses the intersectional locations that older people from diverse ethnic backgrounds position and examine the complexity of these intersectional effects on health and aged care, using advanced statistical methods. Future research would benefit from the use of a larger sample that included those who migrated under different immigration programs and came to Australia at different historical periods and chronological ages. Future

202 longitudinal research on the long-term impact of the intersection of multiple social identities on health and service use is also warranted.

On the other hand, more qualitative research, such as in-depth interviews, is recommended to further define and explore these socially constructed categories and related systems of oppression, domination, or discrimination. Future qualitative research with more focus on power inequalities should be undertaken so the dynamic and fluid influences and effects of these intersectional social categories on elderly minorities at both individual and contextual levels can be better understood.

8.4 Conclusion

This is the first study in Australia to examine the older Chinese-speaking population’s use of aged care services, using a conceptual framework that integrated an intersectionality perspective with the Andersen Behavioural Model. The findings of this study suggest that there is inequitable access to aged care services because the key determinants of service use are primarily related to older Chinese-speaking people’s predisposing and enabling characteristics. From the perspective of intersectionality, all people, including elderly minorities are characterized simultaneously by multiple social categories, which are properties of the individual as well as characteristics of the social context inhabited by these individuals. Without addressing power inequalities within these traditional background categories, such as age, gender, immigration, and social class, the origins and root causes of ethnic disparities in health and aged care cannot be understood and equitable access to health and aged care services cannot be achieved.

203 References

Abbott, M.W., Wong, S., Giles, L.C., Wong, S., Young, W., & Au, M. (2003). Depression in older Chinese migrants to Auckland. Australian & New Zealand Journal of Psychiatry, 37(4), 445-451. Akincigil, A., Olfson, M., Siegel, M., Zurlo, K.A., Walkup, J.T., & Crystal, S. (2011). Racial and ethnic disparities in depression care in community-dwelling elderly in the United States. American Journal of Public Health, 102(2), 319-328. Alison Payne, S., Seymour, J.E., Chapman, A., & Holloway, M. (2008). Older Chinese people's views on food: implications for supportive cancer care. Ethnicity & Health, 13(5), 497-514. Andersen, R.M. (1995). Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior, 36(1), 1-10. Andersen, R.M., & Davidson, P.L. (2001). Improving access to care in America: individual and contextual indicators. In Rice T.H., Andersen R.M. & Kominski E.F. (Eds.), Changing the U.S. health care system: key issues in health services, policy, and management (pp. 3-30). San Francisco, CA: Jossey-Bass. Andersen, R.M., & Newman, J.F. (1973). Societal and individual determinants of medical care utilization in the United States. The Milbank Memorial Fund Quarterly. Health and Society, 51(1), 95-124. Anikeeva, O., Bi, P., Hiller, J.E., Ryan, P., Roder, D., & Han, G.S. (2010). Review Paper: The health status of migrants in Australia: a review. Asia-Pacific Journal of Public Health, 22(2), 159-193. Aroian, K.J., Wu, B., & Tran, T.V. (2005). Health care and social service use among Chinese immigrant elders. Research in Nursing & Health, 28, 95-105. Atwell, R., Correa-Velez, I., & Gifford, S. (2007). Ageing out of place: health and well-being needs and access to home and aged care services for recently arrived older refugees in Melbourne, Australia. International Journal of Migration, Health, and Social Care, 3(1), 4-14. Australian Bureau of Statistics. (1947). Census of the Commonwealth of Australia, 1947. : ABS. (Cat. no. 2109.0). Australian Bureau of Statistics. (1954). Census of the Commonwealth of Australia, 1954. Canberra: ABS. (Cat. no. 2108.0). Australian Bureau of Statistics. (1961). Census of the Commonwealth of Australia, 1961. Canberra: ABS. (Cat. no. 2107.0). Australian Bureau of Statistics. (1966). Census of population and housing, 1966. Canberra: ABS. (Cat. no. 2106.0). Australian Bureau of Statistics. (1971). Census of population and housing, 1971. Canberra: ABS. (Cat. no. 2105.0). Australian Bureau of Statistics. (1976). Census of population and housing, 1976. Canberra: ABS. (Cat. no. 2104.0). Australian Bureau of Statistics. (1981). Census of population and housing, 1981. Canberra: ABS. (Cat. no. 2103.0). Australian Bureau of Statistics. (1986). Census of population and housing, 1986. Canberra: ABS. (Cat. no. 2102.0).

204 Australian Bureau of Statistics. (1991). Census of population and housing, 1991. Canberra: ABS. (Cat. no. 2101.0). Australian Bureau of Statistics. (1996). Census of population and housing, 1996：basic community profile. Canberra: ABS. (Cat. no. 2901.0). Australian Bureau of Statistics. (1999). Standards for statistics on cultural and language diversity. Canberra: ABS. (cat. no. 1269.0) Australian Bureau of Statistics. (2003). Census of population and housing, 2001: basic community profile. Canberra: ABS. (cat. no. 2001.0). Australian Bureau of Statistics. (2008). Census of population and housing, 2006: migration. Canberra: ABS. Data retrieved on 20 June, 2009 from TableBuilder. Australian Bureau of Statistics. (2012a). Reflecting a nation: stories from the 2011 Census,2012-2013. (cat. no. 2071.0). Canberra: ABS. Australian Bureau of Statistics. (2012b). Australian Health Survey: First Results, 2011-12. (cat. no. 4364.0.55.001). Canberra: ABS. Australian Bureau of Statistics. (2013). Census of population and housing, 2011: cultural and language diversity. Canberra: ABS. Data retrieved on 4 Feb, 2013 from TableBuilder. Australian Bureau of Statistics. (2016). National Health Survey: Health Service Usage and Health Related Actions, 2011-12. (cat. no. 4364.0.55.002). Canberra: ABS. Australian Institute of Health and Welfare. (2002). Older Australia at a glance (third edition). (cat. no. AGE 25) .Canberra: AIHW. Australian Institute of Health and Welfare. (2007). Special population groups. In AIHW. (Ed.), Older Australia at a glance (fourth edition). (cat. no. AGE 52). Canberra: AIHW. Australian Institute of Health and Welfare. (2012). Residential aged care in Australia 2010- 11: a statistical overview. (cat. no. AGE 68). Canberra: AIHW. Australian Institute of Health and Welfare. (2013). Australia's welfare 2013. (Cat. no. AUS 174). Canberra: AIHW. Australian Institute of Health and Welfare. (2014). Cultural and linguistic diversity measures in aged care: working paper. (cat. no. AGE 74). Canberra: AIHW. Australian Institute of Health and Welfare. (2016). Exploring the aged care use of older people from culturally and linguistically diverse backgrounds:a feasibility study. (cat. no. AGE 77). Canberra: AIHW. Babbie, E.R. (1990). Survey research methods. Belmont, California: Wadsworth Publishing Company. Babitsch, B., Gohl, D., & Lengerke, T.v. (2012). Re-revisiting Andersen's Behavioral Model of health services use: a systematic review of studies from 1998–2011. GMS Psycho- Social-Medicine, 9, 1-15. Bauer, G.R. (2014). Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Social Science & Medicine, 110, 10-17. 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 Australian Institute of Health and Welfare. Berry, J.W. (2005). Acculturation: living successfully in two cultures. International Journal of Intercultural Relations, 29(6), 697-712.

205 Blakemore, K. (2000). Health and social care needs in minority communities: an over- problematized issue? Health & Social Care in the Community, 8(1), 22-30. Blignault, I., & Haghshenas, A. (2005). Identification of Australians from culturally and linguistically diverse backgrounds in national health data collections. Australian Health Review, 29(4), 455-468. Bradley, E.H., McGraw, S.A., Curry, L., Buckser, A., King, K.L., Kasl, S.V., et al. (2002). Expanding the Andersen Model: the role of psychosocial factors in long–term care use. Health Services Research, 37(5), 1221-1242. Brega, A.G., Goodrich, G.K., Powell, M.C., & Grigsby, J. (2005). Racial and ethnic disparities in the outcomes of elderly home care recipients. Home Health Care Services Quarterly, 24(3), 1-21. Canda, E.R. (2013). Filial Piety and Care for Elders: A Contested Confucian Virtue Reexamined. Journal of Ethnic and Cultural Diversity in Social Work, 22(3-4), 213- 234. Cagney, K.A., & Agree, E.M. (1999). Racial differences in skilled nursing care and home health use: the mediating effects of family structure and social class. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 54B(4), S223- S236. Calsyn, R.J., & Winter, J.P. (2000). Predicting different types of service use by the elderly: the strength of the Behavioral Model and the value of interaction terms. Journal of Applied Gerontology, 19(3), 284-303. Castles, I. (1991). Multicultural Australia. Canberra: Australian Bureau of Statistics, Commonwealth of Australia. (cat. no. 2505.0). Chan, F.Y., & Quine, S. (1997). Utilisation of Australian health care services by ethnic Chinese. Australian Health Review, 20(1), 64-77. Chan, J., & Kayser-Jones, J. (2005). The experience of dying for Chinese nursing home residents: cultural considerations. Journal of Gerontological Nursing, 31(8), 26-32. Chan, S., & Leong, C.W. (1994). Chinese families in transition: cultural conflicts and adjustment problems. Journal of Social Distress and the Homeless, 3(3), 263-281. Chappell, N.L. (2005). Perceived change in quality of life among Chinese Canadian seniors: the role of involvement in Chinese culture. Journal of Happiness Studies, 6(1), 69-91. Chappell, N.L., & Kusch, K. (2007). The gendered nature of filial piety : a study among Chinese Canadians. Journal of Cross-Cultural Gerontology, 22(1), 29-45. Chappell, N.L., & Lai, D.W.L. (1998). Health care service use by Chinese seniors in British Columbia, Canada. Journal of Cross-Cultural Gerontology, 13(1), 21. Chau, R.C.M., Yu, S.W.K., & Law, C.S.F. (2014). Culturally sensitive health care services for Chinese people in Britain. Journal of Ethnic & Cultural Diversity in Social Work, 23(3-4), 256-270. Chen, R., Copeland, J.R.M., & Wei, L. (1999). A meta-analysis of epidemiological studies in depression of older people in the People's Republic of China. International Journal of Geriatric Psychiatry, 14(10), 821-830. Chen, S., Chen, D., & Adamchak. (1999). The effects of filial responsibility expectations on intergenerational exchanges in Urban China. Hallym international journal of aging, 1(2), 58-68. Cheng, S.T., & Chan, A.C.M. (2006). Filial piety and psychological wellbeing in well older Chinese. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 61(5), P262-P269.

206 Chenowethm, L., Jeon, Y., Goff, M., & Burke, C. (2006). Cultural competency and nursing care: an Australian perspective. International Nursing Review, 53(1), 34-40. Cheung, C.K., Kwan, A.Y. H., & Ng, S.H. (2006). Impacts of filial piety on preference for kinship versus public care. Journal of Community Psychology, 34(5), 617-634. Chiu, S., & Yu, S. (2001). An excess of culture: the myth of shared care in the Chinese community in Britain. Ageing and Society, 21, 681. Cioffi, J. (2003). Communicating with culturally and linguistically diverse patients in an acute care setting: nurses’ experiences. International Journal of Nursing Studies, 40(3), 299-306. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (second edition). Hillsdale, NJ: Erlbaum. Collins, C., Stommel, M., King, S., & Given, C.W. (1991). Assessment of the attitudes of caregivers toward community services. The Gerontologist, 31(6), 756-761. Collins, J., & Reid, C. (1995). Chinese in Australia 1945-1994 : changing patterns of migration, racialisation and opportunity. Sydney: School of Finance and Economics, University of Technology. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine. Feminist Theory and Antiracist Politics, University of Chicago Legal Forum 1989, 139-167. Crenshaw, K. (1991). Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241-1299. Creswell, J.W. (2007). Research design : qualitative, quantitative, and mixed method approaches (fourth edition.). Thousand Oaks, Calif: Sage Publications. Damron-Rodriguez, J., Wallace, S., & Kington, R. (1995). Service utilization and minority elderly: appropriateness, accessibility and acceptability. Gerontology & Geriatrics Education, 15(1), 45-64. Department of Health. (2010). Use of HACC services across regions, local government areas, and Victoria-wide: 2009-2010 HACC Minimum data set. Melbourne: Department of Health, State of Victoria. Department of Health. (2013). Diversity planning and practice in Home and Community Care services in Victoria: working with HACC Access and Support services. Melbourne: Department of Health, State of Victoria. Department of Health. (2014). Who gets HACC 2010-2011: a statistical overview of the Home and Community Care Program in Victoria in 2010-2011. Melbourne: Department of Health, State of Victoria. Department of Health and Ageing. (2009). Partners in culturally appropriate care (PICAC) program guidelines. Canberra: DoHA, Australian Government. Department of Health and Ageing. (2012a). Living longer living better: aged care reform package. Canberra: DoHA, Australian Government. Department of Health and Ageing. (2012b). National Ageing and Aged Care Strategy for People from Culturally and Linguistically Diverse (CALD) Backgrounds. Canberra: DoHA, Australian Government. Department of Health and Ageing. (2012c). Home and Community Care Program Minimum Data Set 2010-2011 Annual Bulletin. Canberra: DoHA, Australian Government. Department of Immigration and Border Protection. (2014). Australia's migration trends 2013-14. Canberra: DIBP, Australian Government.

207 Department of Immigration and Border Protection. (2015). Parent Visa Queue. Retrieved from https://www.border.gov.au/Trav/Brin/Fami/Capping-and-queuing/Parent-visa- queue. Canberra: DIBP, Australian Government. Department of Immigration and Multicultural Affairs. (2001). Immigration: Federation to Century's End 1901-2000. Department of Immigration and Multicultural Affairs, Commonwealth of Australia. Djernes, J.K. (2006). Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatrica Scandinavica, 113(5), 372-387. Dong, X., Chang, E.S., & Simon, M. (2011). Depression in the Chinese aging population: leveraging cultural humility to improve the quality of care of a vulnerable population. Aging Health, 7(6), 849-863. Dong, X., Chang, E.S., Wong, E., & Simon, M. (2012). A qualitative study of filial piety among community dwelling, Chinese, Older Adults: Changing Meaning and Impact on Health and Well-Being. Journal of Intergenerational Relationships, 10(2), 131- 146. Ethnic Communities' Council of Victoria (ECCV). (2013). Respect and dignity: seniors, family relationships and what can go wrong (a Chinese community education resource kit around elder abuse prevention). Melbourne: Ethnic communities' council of Victoria. Else-Quest, N.M., & Hyde, J.S. (2016a). Intersectionality in Quantitative Psychological Research: I. Theoretical and Epistemological Issues. Psychology of Women Quarterly, 40(2), 155-170. Else-Quest, N.M., & Hyde, J.S. (2016b). Intersectionality in Quantitative Psychological Research: II. Methods and Techniques. Psychology of Women Quarterly, 40(3), 319- 336. Engstrom, D.W., Piedra, L.M., & Min, J.W. (2009). Bilingual social workers: language and service complexities. Administration in Social Work, 33(2), 167 - 185. Fan, R. (2007). Which care? whose responsibility? and why family? a Confucian account of long term care for the elderly. Journal of Medicine and Philosophy, 32(5), 495-517. Federation of Ethnic Communities' Councils of Australia (FECCA). (2015). Review of Australian Research on Older People from Culturally and Linguistically Diverse Backgrounds. Federation of Ethnic Communities' Councils of Australia. ern ndez-Mayoralas, ., Rodr guez, V., & Rojo, F. (2000). Health services accessibility among Spanish elderly. Social Science & Medicine, 50(1), 17-26. Feldman, S., Radermacher, H., Browning, C., Bird, S., & Thomas, S. (2008). Challenges of recruitment and retention of older people from culturally diverse communities in research. Ageing & Society, 28(04), 473-493. Gee, E.M. (1999). Ethnic identity among foreign-born Chinese Canadian elders. Canadian Journal on Aging/La Revue canadienne du vieillissement, 18(04), 415-429. Gelberg, L., Andersen, R.M., & Leake, B.D. (2000). The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Services Research, 34(6), 1273-1302. Gibson, D., Braun, P., Benham, C., & Mason, F. (2001). Projections of older immigrants: people from culturally and linguistically diverse backgrounds, 1996-2026, Australia. (cat. no. AGE 18). Canberra: Australia Institute of Health and Welfare. Giritli Nygren, K., & Olofsson, A. (2014). Intersectional Approaches in Health-Risk Research: A Critical Review. Sociology Compass, 8(9), 1112-1126.

208 Goh, S.N. (2007). Factors affecting the utilization of post acute care by the elderly in Singapore. (Unpublished doctoral thesis), University of Melbourne, Melbourne, Australia. Guberman, N., Gagnon, É., Lavoie, J.-P., Belleau, H., Fournier, M., Grenier, L., et al. (2006). Families' values and attitudes regarding responsibility for the frail elderly. Journal of Aging & Social Policy, 18(3), 59-78. Guo, M., Xu, L., Liu, J., Mao, W., & Chi, I. (2015). Parent–child relationships among older Chinese immigrants: the influence of co-residence, frequent contact, intergenerational support and sense of children's deference. Ageing & Society, FirstView, 1-24. Guruge, S., & Khanlou, N. (2004). Intersectionalities of influence: researching the health of immigrant and refugee women. CJNR (Canadian Journal of Nursing Research), 36(3), 32-47. Hamon, R.R., & Blieszner, R. (1990). Filial responsibility expectations among adult child- older parent pairs. Journal of Gerontology, 45, 3(3), 110-112. Hankivsky, O., & Christoffersen, A. (2008). Intersectionality and the determinants of health: a Canadian perspective. Critical Public Health, 18(3), 271-283. Hankivsky, O., & Cormier, R. (2011). Intersectionality and public policy: some lessons from existing models. Political Research Quarterly, 64(1), 217-229. Hanssen, I., & Kuven, B.M. (2016). Moments of joy and delight: the meaning of traditional food in dementia care. Journal of Clinical Nursing, 25(5-6), 866-874. Haralambous, B., Moore, K. & Tate, R. (2007). HACC Social Support for people from Culturally and Linguistically Diverse (CALD) backgrounds. Melbourne: National Ageing Research Institute. Hernandez-Gallegos, W., Capitman, J., & Yee, D. (Eds.). (1993). Conceptual understanding of long-term service use by elders of color. New York: Springer Publishing Company. Howe, A. (2006). Cultural diversity, ageing and HACC: trends in Victoria in the next 15 years. Melbourne: Department of Human Services Victoria, 2006. Hsu, C.Y., Lee, S., & O'Connor, M. (2005). Issues affecting access to palliative care services for older Chinese people in Australia. Journal for Community Nurses,10 (3), 9-11. Hsu, C.Y., O'Connor, M., & Lee, S. (2009). Understandings of Death and Dying for People of Chinese Origin. Death Studies, 33(2), 153-174. Huang, D.H.Y. (2007). A comparative analysis of community-based aged care policies and practices in Australia and Taiwan. (Unpublished mater's thesis). University of Melbourne, Melbourne, Australia. Huang, Z.B., Neufeld, R.R., Likourezos, A., Breuer, B., Khaski, A., Milano, E., et al. (2003). Sociodemographic and health characteristics of older Chinese on admission to a nursing home: a cross-racial/ethnic study. Journal of the American Geriatrics Society, 51(3), 404-409. Hugman, R., Bartolomei, L., & Pittaway, E. (2004). It is part of your life until you die: older refugees in Australia. Australasian Journal on Ageing, 23(3), 147-149. Huynh, Q.L., Howell, R.T., & Benet-Martínez, V. (2009). Reliability of bidimensional acculturation scores: a meta-analysis. Journal of Cross-Cultural Psychology, 40(2), 256-274. Ip, D., Hibbins, R., & Chui, W.H. (2006). Experiences of Transnational Chinese Migrants in the Asia-Pacific. New York: Nova Publishers. Ip, D., Lui, C.W., & Chui, W.H. (2007).Veiled entrapment: a study of social isolation of older Chinese migrants in Brisbane, Queensland. Ageing & Society, 27(05), 719-738.

209 Irvine, F., Roberts, G., & Bradbury-Jones, C. (2008). The researcher as insider versus the researcher as outsider: enhancing rigour through language and cultural sensitivity. In P. Liamputtong (Ed.), Doing Cross-Cultural Research: ethical and methodological perspectives. Melbourne: Springer Netherlands. Jang, M., Lee, E., & Woo, K. (1998). Income, language, and citizenship status: factors affecting the health care access and utilization of Chinese Americans. Health & Social Work, 23(2), 136-145. Johnstone, M.J., & Kanitsaki, O. (2008). Ethnic aged discrimination and disparities in health and social care: a question of social justice. Australasian Journal on Ageing, 27(3), 110-115. Jones, P.S., Lee, J.W., & Zhang, X.E. (2011). Clarifying and measuring filial concepts across five cultural groups. Research in Nursing & Health, 34(4), 310-326. Jorm, L., Walter, S., Lujic, S., Byles, J., & Kendig, H. (2010). Home and community care services: a major opportunity for preventive health care. BMC Geriatrics, 10(1), 26. Kadushin, G. (2004). Home health care utilization: a review of the research for social work. Health and Social Work, 29(3), 219-244. Kelly, U.A. (2009). Integrating intersectionality and biomedicine in health disparities research. Advances in Nursing Science, 32(2), E42-E56. Khoo, S.E. (2012). Ethnic disparities in social and economic well-being of the immigrant aged in Australia. Journal of Population Research, 29(2), 119-140. Kimba, F.Y.C., & Carew, R. (1990). Confucianism: Its relevance to social work with Chinese people. Australian Social Work, 43(3), 3-9. Koehn, S., Neysmith, S., Kobayashi, K., & Khamisa, H. (2013). Revealing the shape of knowledge using an intersectionality lens: results of a scoping review on the health and health care of ethnocultural minority older adults. Ageing & Society, 33(03), 437- 464. Koenig, H., Westlund, R., George, L., Hughes, D., Blazer, D., & Hybels, C. (1993). Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals. Psychosomatics, 34(1), 61-69. Kuo, B.C.H., Chong, V., & Joseph, J. (2008). Depression and its psychosocial correlates among older Asian Immigrants in North America. Journal of Aging and Health, 20(6), 615-652. Kuo, T., & Torres-Gil, F.M. (2001). Factors affecting utilization of health services and home- and community-based care programs by older Taiwanese in the United States. Research on Aging, 23(1), 14-36. Kwok, C., & Sullivan, G. (2006). Influence of traditional Chinese beliefs on cancer screening behaviour among Chinese-Australian women. Journal of Advanced Nursing, 54(6), 691-699. Kwok, C., & Sullivan, G. (2007). Health seeking behaviours among Chinese-Australian women: implications for health promotion programmes. Health:, 11(3), 401-415. Lai, D.W.L. (2004a). Use of home care services by elderly Chinese immigrants. Home Health Care Services Quarterly, 23(3), 41-55. Lai, D.W.L. (2004b). Predicting factors for intention of use of long-term care facilities by aging Chinese-Canadians. Journal of Social Work in Long-Term Care, 3(2), 31-46. Lai, D.W.L. (2004c). Impact of culture on depressive symptoms of elderly Chinese immigrants. Canadian Journal of Psychiatry, 49(12), 820-827. Lai, D.W.L. (2005). Cultural factors and preferred living arrangement of aging Chinese Canadians. Journal of Housing For the Elderly, 19(2), 71 - 86.

210 Lai, D.W.L. (2007). Predictors of use of senior centers by elderly Chinese immigrants in Canada. Journal of Ethnic And Cultural Diversity in Social Work, 15(1), 97-121. Lai, D.W.L. (2009). Older Chinese' attitudes toward aging and the relationship to mental health: An international comparison. Social Work in Health Care, 48(3), 243 - 259. Lai, D.W.L. (2012). Ethnic identity of older Chinese in Canada. Journal of Cross-Cultural Gerontology, 27(2), 103-117. Lai, D.W.L, & Chau, S.B. (2007). Effects of service barriers on health status of older Chinese immigrants in Canada. Social work, 52(3), 261-269. Lai, D.W.L., & Surood, S. (2009). Chinese health beliefs of older Chinese in Canada. Journal of Aging and Health, 21(1), 38-62. Laidlaw, K., Wang, D., Coelho, C., & Power, M. (2010). Attitudes to ageing and expectations for filial piety across Chinese and British cultures: a pilot exploratory evaluation. Aging & Mental Health, 14(3), 283-292. Lan, P.C. (2002). Subcontracting filial piety: elder care in ethnic Chinese immigrant families in California. Journal of Family Issues, 23(7), 812-835. Lee, E.K.O. (2007). Religion and spirituality as predictors of well-being among Chinese American and Korean American older adults. Journal of Religion, Spirituality & Aging, 19(3), 77-100. Lee, E.K.O., & Chan, K. (2009). Religious/spiritual and other adaptive coping strategies among Chinese American older immigrants. Journal of Gerontological Social Work, 52(5), 517 - 533. Lee, G.R., Netzer, J.K., & Coward, R.T. (1994). Filial responsibility expectations and patterns of intergenerational assistance. Journal of Marriage & Family, 56(3), 559- 565. Lee, G.R., Peek, C.W., & Coward, R.T. (1998). Race differences in filial responsibility expectations among older parents. Journal of Marriage and the Family, 60(2), 404- 412. Lee, J.J., Patchner, M.A., & Balgopal, P.R. (1991). Essential dimensions for developing and delivering services for the Asian American elderly. Journal of Multicultural Social Work, 1(3), 3-12. Lee, R., McGinnis, K., Sallis, J., Castro, C., Chen, A., & Hickmann, S. (1997). Active vs. passive methods of recruiting ethnic minority women to a health promotion program. Annals of Behavioral Medicine, 19(4), 378-384. Lehning, A.J., Kim, M.H., & Dunkle, R.E. (2013). Facilitators of home and community- based service use by urban African American elders. Journal of Aging and Health, 25(3), 439-458. Leung, S.O.C., Chan, C.C.H., & Shah, S. (2007). Development of a Chinese version of the Modified Barthel Index — validity and reliability. Clinical Rehabilitation, 21(10), 912-922. Levkoff, S., & Sanchez, H. (2003). Lessons learned about minority recruitment and retention from the Centers on Minority Aging and Health Promotion. The Gerontologist, 43(1), 1-18. Li, I.C., Fann, S.L., & Kuo, H.T. (2011). Predictors of the utilization of long-term care (LTC) services among residents in community-based LTC facilities in Taiwan. Archives of Gerontology and Geriatrics, 53(3), 303-308. Li, W.W., & Chong, M.D. (2012). Transnationalism, social wellbeing and older Chinese migrants. Graduate Journal of Asia-Pacific Studies, 8(1), 29-44.

211 Li, W.W., Hodgetts, D., Ho, E., & Stolte, O. (2010). From early Confucian texts to aged care in China and abroad today: The evolution of filial piety and its implications. Journal of US-China Public Administration, 7(7), 48-59. Liamputtong, P. (2008). Doing research in a cross-cultural context: methodological and ethical challenges. In P. Liamputtong (Ed.), Doing cross-cultural research: ethical and methodological perspectives. Melbourne: Springer Netherlands Lin, X., Bryant, C., Boldero, J., & Dow, B. (2014). Older Chinese immigrants’ relationships with their children: a literature review from a solidarity–conflict perspective. The Gerontologist. Lin, X., Haralambous, B., Pachana, N.A., Bryant, C., LoGiudice, D., Goh, A., et al. (2015). Screening for depression and anxiety among older Chinese immigrants living in Western countries: The use of the Geriatric Depression Scale (GDS) and the Geriatric Anxiety Inventory (GAI). Asia-Pacific Psychiatry, 8(1), 32-43. Lister, S.M., & Benson, C. (2006). Comparative analysis of dementia and ethnicity in the New South Wales Aged Care Assessment Program: 1996 and 2001. Australasian Journal on Ageing, 25(1), 24-30. Liu, Y.L. (2003). Aging service need and use among Chinese American seniors: Intragroup variations. Journal of Cross-Cultural Gerontology, 18(4), 273-301. Liu, J.H., Ng, S.H., Weatherall, A., & Loong, C. (2000). Filial piety, acculturation, and intergenerational communication among New Zealand Chinese. Basic & Applied Social Psychology, 22(3), 213-223. Lo, M., & Russell, C. (2007). Family care: An exploratory study of experience and expectations among older Chinese immigrants in Australia. Contemporary Nurse, 25, 31-38. Lui, C.W. (2006). Transnational Chinese migration: an Australian profile. In D. Ip, R. Hibbins & W. H. Chui. (Ed.), Experiences of Transnational Chinese Migrants in the Asia-Pacific (pp. 17-39). New York: Nova Science. Lun, W.M.A. (2004). The effects of race and gender on predicting in-home and community- based service use by older adults. Chronic Care, Health Care Systems and Services Integration, 22, 121-139. Lynn Weber, M.E.F. (2007). Race, Ethnicity, and Health: An Intersectional Approach. In Hernán Vera & Joe R. Feagin (Eds.), Handbooks of the Sociology of Racial and Ethnic Relations (pp. 191-218). Ma, A., & Chi, I. (2005). Utilization and accessibility of social services for Chinese Canadians. International Social Work, 48(2), 148-160. Mak, A.S., & Chan, H. (1995). Chinese family values in Australia. In R. Hartley (Ed.), Families and cultural diversity in Australia (pp. 70-95). NSW: Allen & Unwin Pty Ltd. Marino, R., Minichiello, V., & Macentee, M. (2010). Older Cantonese Australians: Issues arising from focus group discussions. Health Issues (103), 29-32. Martin, J. (1998a). Chinese culture and social work. Australian Social Work, 51(2), 3-8. Martin, J. (1998b). Cultural diversity and practice with Australians of Chinese background: Consumer perspectives. Paper presented at the changing families, challenging futures- 6th Australian Institute of Family Studies Conference, Melbourne. McCall, L. (2005). The Complexity of intersectionality. Signs: Journal of Women in Culture & Society, 30(3), 1771-1800.

212 McGartland Rubio, D., Berg-Weger, M., Tebb, S.S., Lee, E.S., & Rauch, S. (2003). Objectifying content validity: conducting a content validity study in social work research. Social Work Research, 27(2), 94-104. Migliorino, P. (2012). The meaning of choice and control in multicultural reality. Paper presented at the National Aged Care Conference : Living Longer. Living Better, Convention Centre. Migliorino, P. (2013). Rights, respect and recognition for older CALD Australians. Paper presented at the COTA National Policy Forum: Rights, respect, recognition: a new deal for older Australians, National Press Club, Canberra ACT. Miller, B., Campbell, R.T., Davis, L., Furner, S., Giachello, A., Prohaska, T., et al. (1996). Minority use of community long-term care services: a comparative analysis. The Journals of Gerontology, 51B(2), 12. Min, J.W. (2005). Cultural competency: a key to effective future social work with racially and ethnically diverse elders. Families in Society, 86(3), 347-358. Minas, H., Kakuma, R., Too, L.S., Vayani, H., Orapeleng, S., Prasad-Ildes, R., et al. (2013). Mental health research and evaluation in multicultural Australia: developing a culture of inclusion. International Journal of Mental Health Systems, 7(1), 1-25. Minas, H., Klimidis, S., & Kokanovic, R. (2007). Depression in multicultural Australia: Policies, research and services. Australia and New Zealand Health Policy, 4, 16. Mitchell, J., & Krout, J.A. (1998). Discretion and service use among older adults: The behavioral model revisited. The Gerontologist, 38(2), 159-168. Morgan, D.L. (2014). Pragmatism as a Paradigm for Social Research. Qualitative Inquiry. Mui, A.C. (1996). Geriatric depression scale as a community screening instrument for elderly Chinese immigrants. International Psychogeriatrics, 8(03), 445-458. Mui, A.C. (1999). Living alone and depression among older Chinese immigrants. Journal of Gerontological Social Work, 30(3), 147 - 166. Mui, A.C., & Kang, S.Y. (2006). Acculturation Stress and Depression among Asian Immigrant Elders. Social Work, 51(3), 243-255. Muijs, D. (2011). Doing Quantitative Research in Education with SPSS (forth edition). London: SAGE Publications Ltd. Newbold, K. B. (2005). Self-rated health within the Canadian immigrant population: risk and the healthy immigrant effect. Social Science & Medicine, 60(6), 1359-1370. Ng, A.C.Y., Phillips, D.R., & Lee, W.K.-m. (2002). Persistence and challenges to filial piety and informal support of older persons in a modern Chinese society: a case study in Tuen Mun, Hong Kong. Journal of Aging Studies, 16(2), 135-153. Noelker, L.S., Ford, A.B., Gaines, A.D., Haug, M.R., Jones, P.K., Stange, K.C., et al. (1998). Attitudinal influences on the elderly's use of assistance. Research on Aging, 20(3), 317-338. Orb, A. (2002). Health care needs of elderly migrants from Culturally and Linguistically Diverse (CALD) backgrounds: A review of literature. : Curtin University of Technology. Pachana, N.A., Smith, N., Watson, M., McLaughlin, D., & Dobson, A. (2008). Responsiveness of the Duke Social Support sub-scales in older women. Age and Ageing, 37(6), 666-672. Pang, E.C., Jordan-Marsh, M., Silverstein, M., & Cody, M. (2003). Health-seeking behaviors of elderly Chinese Americans: shifts in expectations. The Gerontologist, 43(6), 864- 874.

213 Park, H.J. (2015). Ageing in anomie: later life migration and its implications for anti-anomic social work practice. International Social Work, 1-7. Petrov, L., & Arnold, L. (2000). Special needs, special wants. Australasian Journal on Ageing, 19(1), 43-44. Pinquart, M. (2001). Correlates of subjective health in older adults: a meta-analysis. Psychology & Aging, 16(3), 414-426. Portes, A., Kyle, D., & Eaton, W.W. (1992). Mental illness and help-seeking behavior among Mariel Cuban and Haitian refugees in South Florida. Journal of Health and Social Behavior, 33(4), 283-298. Powers, J.R., Goodger, B., & Byles, J.E. (2004). Assessment of the abbreviated Duke Social Support Index in a cohort of older Australian women. Australasian Journal on Ageing, 23(2), 71-76. Phillips, K.A., Morrison, K.R., Andersen, R., & Aday, L.A. (1998). Understanding the context of healthcare utilization: assessing environmental and provider-related variables in the behavioral model of utilization. Health Services Research, 33(3), 571- 523. Polit, D.F., Beck, C.T., & Owen, S.V. (2007). Is the CVI an acceptable indicator of content validity? appraisal and recommendations. Research in Nursing & Health, 30(4), 459- 467. Quan, H., Fong, A., De Coster, C., Wang, J., Musto, R., Noseworthy, T.W., et al. (2006). Variation in health services utilization among ethnic populations. Canadian Medical Association. Journal, 174(6), 787-791. Quine, S., & Browning, C. (2007). Methodological and ethical issues in conducting research with older people. In M. Pitts & A. Smith (Eds.), Researching the margins-strategies for ethical and rigorous research with marginalised communities. New York: Palgrave macmillan. Radermacher, H., Feldman, S., & Browning, C. (2009). Mainstream versus ethno-specific community aged care services: it's not an 'either or'. Australasian Journal on Ageing, 28(2), 58-63. Rao, D.V., Warburton, J., & Bartlett, H. (2006). Health and social needs of older Australians from culturally and linguistically diverse backgrounds: issues and implications. Australasian Journal on Ageing 25 (4), 174-179. Rea, L.M., & Parker, R.A. (2005). Desiging and Conducting Survey Research (third edition). San Francisco: Jossey-Bass. Rowland, D. (1999 ). The ethnic aged population and the likelihood of special needs Australasian Journal on Ageing 18 (3 ), 50-54. Rowland, D. (2007). Ethnicity and ageing. In A. Borowski, S. Encel & E. Ozanne (Eds.), Longevity and social change in Australia (pp. 117-141). Sydney: UNSW Press, 2007. Rubin, A., & Babbie, E.R. (2007). Essential research methods for social work. Belmont, Calif.: Thomson Brooks/Cole. Rudolph, B., Chavez, M., Quintana, F., & Salinas, G. (2011). Filial responsibility expectations among Mexican American undergraduates: gender and biculturalism. Journal of Hispanic Higher Education, 10(3), 168-182. Ryder, A.G., Alden, L.E., & Paulhus, D.L. (2000). Is acculturation unidimensional or bidimensional? a head-to-head comparison in the prediction of personality, self- identity, and adjustment. Journal of Personality and Social Psychology, 79(1), 49-65. Salant, T., & Lauderdale, D.S. (2003). Measuring culture: a critical review of acculturation and health in Asian immigrant populations. Social Science & Medicine, 57(1), 71-90.

214 Scharlach, A.E., Kellam, R., Ong, N., Baskin, A., Goldstein, C., & Fox, P.J. (2006). Cultural attitudes and caregiver service use -- lessons from focus groups with racially and ethnically diverse family caregivers. Journal of Gerontological Social Work, 47(1), 133 - 156. Scheppers, E., van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential barriers to the use of health services among ethnic minorities: a review. Family Practice, 23, 325-348. Sin, C.H. (2004). Sampling minority ethnic older people in Britain. Ageing & Society, 24(02), 257-277. Smith, C.S., & Hung, L.C. (2012). The influence of eastern philosophy on elder care by Chinese Americans. Journal of Transcultural Nursing, 23(1), 100-105. Streiner, D.L. (1994). Figuring out factors: the use and misuse of factor analysis. Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie, 39(3), 135-140. Tan, J., Ward, L., & Ziaian, T. (2010). Experiences of Chinese immigrants and Anglo- Australians ageing in Australia: a cross-cultural perspective on successful ageing. Journal of Health Psychology, 15(5), 697-706. Tan, J., Ward, L., & Ziaian, T. (2011). Comparing definitions of successful ageing: the case of Anglo-and Chinese-Australians. E-Journal of Applied Psychology, 7(1), 15-21. Thomas, T. (2003). Older migrants and their families in Australia. Family Matters, 66 (Spring/Summer), 40-45. Thompson, B., & Daniel, L.G. (1996). Factor analytic evidence for the construct validity of scores: a historical overview and some guidelines. Educational and Psychological Measurement, 56(2), 197-208. Tieu, Y., & Konnert, C. (2015). Measuring acculturation and enculturation among Chinese Canadian older adults. Canadian Journal on Aging/La Revue canadienne du vieillissement, 34(01), 36-46. Tong, A., & Man, D. (2002). The validation of the Hong Kong Chinese version of the Lawton Instrumental activities of daily living scale for institutionalized elderly persons. OTJR, 22(4), 132. Torres, S. (1999). A culturally-relevant theoretical framework for the study of successful ageing. Ageing and Society, 19, 33-51. Torres, S. (2014). Expanding the gerontological imagination on ethnicity: conceptual and theoretical perspectives. Ageing and Society, 35(5), 935-960. Tsai, D.T., & Lopez, R.A. (1998). The use of social supports by elderly Chinese immigrants. Journal of Gerontological Social Work, 29(1), 77-94. Tsang, E.Y. L., Liamputtong, P., & Pierson, J. (2004). The views of older Chinese people in Melbourne about their quality of life. Ageing & Society, 24(01), 51-74. van der Pas, S., van Tilburg, T., & Knipscheer, K.C.P.M. (2005). Measuring older adults' filial responsibility expectations: exploring the application of a vignette technique and an item scale. Educational and Psychological Measurement, 65(6), 1026-1045. Viruell-Fuentes, E.A., Miranda, P.Y., & Abdulrahim, S. (2012). More than culture: structural racism, intersectionality theory, and immigrant health. Social Science & Medicine, 75(12), 2099-2106. Viviani, N. (1996). The Indochinese in Australia 1975-1195 from burnt boats to barbecues. Melbourne: Oxford University Press. Wallace, S.P., Levy-Storms, L., Kington, R.S., & Andersen, R.M. (1998). The persistence of race and ethnicity in the use of long-term care. The Journals of Gerontology, 53B(2), S104.

215 Wang, D., Laidlaw, K., Power, M.J., & Shen, J. (2009). Older people's belief of filial piety in China: expectation and non-expectation. Clinical Gerontologist, 33(1), 21-38. Wang, S.W. (1988). Chinese immigration 1840s-1890s. In J. Jupp (Ed.), The Australian People: An Encyclopedia of the Nation, Its People and Their Origins (pp. 298-304). North Ryde, NSW: Angus& Robertson. Warburton, J., Bartlett, H., & Rao, V. (2009). Ageing and cultural diversity: policy and practice issues. Australian Social Work, 62(2), 168-185. Ward, B.M., Anderson, K.S., & Sheldon, M.S. (2005). Patterns of home and community care service delivery to culturally and linguistically diverse residents of rural Victoria. Australian Journal of Rural Health, 13(6), 348-352. Webster, T.R., Curry, L.A., McGraw, S., Buckser, A., & Bradley, E.H. (2004). The role of intended use on actual use of home care: Is race a factor? Home Health Care Services Quarterly, 23(3), 57-68. Weinick, R.M., Zuvekas, S.H., & Cohen, J.W. (2000). Racial and ethnic differences in access to and use of health care services, 1977 to 1996. Medical Care Research and Review, 57(4), 36-54. White-Means, S.I., & Rubin, R.M. (2004). Is there equity in the home health care market? Understanding racial patterns in the use of formal home health care. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 59(4), S220-S229. Williams, M. (1999). Chinese settlement in NSW: A thematic history. NSW: Heritage Office, State of NSW. Willis, R., Price, D., & Glaser, K. (2013). Ethnicity as a determining factor for instrumental support in mid and later life in England and Wales. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 68(2), 278-289. Wilmoth, J.M., & Chen, P.C. (2003). Immigrant status, living arrangements, and depressive symptoms among middle-aged and older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 58(5), S305-S313. Wolinsky, F.D. (1994). Health services utilization among older adults: conceptual, measurement, and modeling issues in secondary analysis. The Gerontologist, 34(4), 470-475. Wong, S.T., Yoo, G.J., & Stewart, A.L. (2007). An empirical evaluation of social support and psychological well-being in older Chinese and Korean immigrants. Ethnicity & Health, 12(1), 43-67. Xie, X., & Xia, Y. (2011). Grandparenting in Chinese immigrant families. Marriage & Family Review, 47(6), 383-396. Yamashiro, G., & Matsuoka, J.K. (1997). Help-seeking among Asian and Pacific Americans: A multiperspective analysis. Social Work, 42(2), 176-186. Yancey, A.K., Ortega, A.N., & Kumanyika, S.K. (2006). Effective recruitment and retention of minority research participants. Annual Review of Public Health, 27(1), 1-28. Yang, X.J., Haralambous, B., Angus, J., & Hill, K. (2008). Older ' understanding of falls and falls prevention: Exploring their needs for information. Australian Journal of Primary Health, 14(1), 36-42. Yeatts, D.E., Crow, T., & Folts, E. (1992). Service use among low-income minority elderly: strategies for overcoming barriers. The Gerontologist, 32(1), 24-32. Yeo, S.S., Meiser, B., Barlow-Stewart, K., Goldstein, D., Tucker, K., & Eisenbruch, M. (2005). Understanding community beliefs of Chinese-Australians about cancer: Initial insights using an ethnographic approach. Psycho-Oncology, 14(3), 174-186.

216 Yip, K.S. (2004). Taoism and its impact on mental health of the Chinese communities. International Journal of Social Psychiatry, 50(1), 25-42. Yip, K.S. (2005). Taoistic concepts of mental health: Implications for social work practice with Chinese communities. Families in Society, 86(1), 35-45. Yuan, C.M. (1988). Chinese in white Australia 1901-1950. In J. Jupp (Ed.), The Australian People: An Encyclopedia of the Nation, its People and Their Origins (pp. 304-307). Sydney: Angus and Robertson. Zhan, H.J., King, S.V., Kim, J.H., Zhang, G., & Whittington, F.J. (2004). Double-bind: The experience of aging and being an ethnic minority in the U.S. among Chinese and Korean American elders. Hallym International Journal of Aging, 6(2), 119-137. Zhang, G., & Zhan, H.J. (2009). Beyond the Bible and the cross : a social and cultural analysis of Chinese elders' participation in Christian congregations in the United States. Sociological Spectrum, 29(2), 295-317. Zhang, J. (2014). Enhancing quality of life: The social support of elderly Chinese migrants in New Zealand (Doctor of Philosophy ), The University of Auckland, Auckland. Zhou, Y.R. (2012). Space, time, and self: Rethinking aging in the contexts of immigration and transnationalism. Journal of Aging Studies, 26(3), 232-242. Zhou, Y.R. (2013). Toward transnational care interdependence: Rethinking the relationships between care, immigration and social policy. Global Social Policy. Zodikoff, B.D. (2007). Gender differences in the community service use attitudes of older spousal caregiver-care recipient couples. Home Health Care Services Quarterly, 26(2), 1-20. Zubair, M., & Norris, M. (2015). Perspectives on ageing, later life and ethnicity: ageing research in ethnic minority contexts. Ageing & Society,35(05), 897-916.

217 Appendices

218

Minerva Access is the Institutional Repository of The University of Melbourne

Author/s: Huang, Dolly Hsaio-Yun

Title: Understanding aged care use by older Chinese-speaking immigrants in Australia

Date: 2016

Persistent Link: http://hdl.handle.net/11343/148408

File Description: Understanding aged care use by older Chinese-speaking immigrants in Australia

Terms and Conditions: Terms and Conditions: Copyright in works deposited in Minerva Access is retained by the copyright owner. The work may not be altered without permission from the copyright owner. Readers may only download, print and save electronic copies of whole works for their own personal non-commercial use. Any use that exceeds these limits requires permission from the copyright owner. Attribution is essential when quoting or paraphrasing from these works.