Socialinė teorija, empirija, politika ir praktika ISSN 1648-2425 eISSN 2345-0266
2023, vol. 27, pp. 100–120 DOI: https://doi.org/10.15388/STEPP.2023.27.6
Perceptions of Older Immigrants About Health Care in the Host Countries: A Narrative Review
Aysegul Ilgaz
Akdeniz University, Faculty of Nursing, Department of Public Health Nursing
07058, Antalya, Turkey
aysegul_ilgaz@hotmail.com
https://orcid.org/0000-0003-0640-2820
Summary. Older immigrants may have different needs regarding health and care services compared to other age groups. There are suggestions for adapting health services to the elderly and even immigrant elderly in order to provide equal service to everyone. There are studies indicating that with advancing age chronic diseases increase and functional capacity decreases, resulting in poorer physical and psychosocial health in immigrant elderly than in the general elderly population. It is stated that immigrants’ use of health services is lower than that of general population. Cultural and social factors influence health behaviors, opportunities, wishes and barriers for patients to access and use health and care services. Studies stated that elderly immigrants not knowing how to apply for health services, having language problems and being ineffective in communication with healthcare professionals, and experiencing lack of/insufficient social, community and family support, are lead to isolation and inadequate use of health services. In the narrative review, it is aimed to explore the existing research which was conducted on the experiences and perspectives of older immigrants, formal and informal caregivers and healthcare workers regarding health and care services and as well as interventions for better adaptation of health and care services among older immigrants.
Keywords: older people, migration, health care, perception, experience
Vyresnio amžiaus imigrantų požiūris į sveikatos priežiūrą priimančiosiose šalyse: apžvalga
Vyresnio amžiaus imigrantai gali turėti kitokių sveikatos ir globos poreikių nei kitų amžiaus grupių atstovai. Atitinkami yra siūlomi politiniai sprendimia kaip pritaikyti sveikatos priežiūros paslaugas pagyvenusiems žmonėms ir net pagyvenusiems imigrantams taip, kad paslaugos būtų prieinamos. Tyrimai rodo, kad senstant auga lėtinių ligų skaičius ir mažėja funkcinis pajėgumas, tačiau dėl prieinamumo prie paslaugų skirtumo pagyvenusių imigrantų fizinė ir psichosocialinė sveikata yra prastesnė. Kultūriniai, socialiniai veiksniai daro įtaką pacientų sveikatos elgsenai, galimybėms gauti ir naudotis sveikatos priežiūros ir globos paslaugomis. Tyrimai rodo, kad vyresnio amžiaus imigrantai, nežinodami, kur kreiptis dėl sveikatos paslaugų, nemokėdami gerai kalbos, gaudami nepakankamą socialinę, bendruomenės ir šeimos paramą, susiduria su iššūkiais prieinant prie sveikatos ir globos paslaugų. Šioje apžvalgoje siekiama apžvelgti esamus tyrimus, kurie buvo atlikti siekiant išsiaiškinti vyresnio amžiaus imigrantų, formalių ir neformalių slaugytojų bei sveikatos priežiūros darbuotojų patirtį ir požiūrį į sveikatos ir globos paslaugas bei intervencines priemones, skirtas geresniam vyresnio amžiaus imigrantų sveikatos ir priežiūros paslaugų pritaikymui.
Pagridniniai žodžiai: vyresnio amžiaus žmonės, migracija, sveikatos apsauga, požiūris, patirtis
Received: 2023-11-16. Accepted: 2024-01-02.
Copyright © 2023 Aysegul Ilgaz. Published by Vilnius University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Introduction
Worldwide migration has been increasing in recent years, as wars and political unrest have increased in many parts of the world, causing people to be forcibly displaced from their own countries, or as people leave their home countries to work voluntarily or to live with family members living in foreign countries (United Nations, 2018). According to the World Migration Report (2022), there were approximately 281 million international migrants globally in 2020. It is stated that this makes 3.6% of the global population. The estimated number of international migrants overall has increased over the last fifty years (IOM, 2022).
According to World Bank data, the main target countries include the USA, Saudi Arabia, United Arab Emirates, Germany and France. Other countries such as Australia, Canada and the United Kingdom have naturalized large numbers of immigrants over time (World Bank, 2023). While Scandinavian countries such as Sweden, Norway and Denmark have many political and social similarities with European countries, immigration to these countries is also increasing, although at different rates in each country. There is migration mobility from South to North and from East to West. In a systematic review, the majority of immigrants in Europe originate from Turkey and Morocco, while the majority of immigrants to Canada, New Zealand and Australia are from China (Hestevik et al., 2022).
It is stated that immigrants’ use of health services is lower than that of local people. Cultural and social factors can affect health behaviors and individuals’ opportunities, desires and abilities to access and use health and care services (Hestevik et al., 2022). Immigrants may have difficulty explaining their health problems due to differences in their native language and culture, and a translator may be required (Turhan et al., 2021).
Immigrant individuals have poorer physical and psychosocial health than the general population. In addition, chronic diseases that increase with age and the decrease in functional capacity are more common in immigrants compared to the general population (Hestevik et al., 2022). Different age groups migrate and each life stage has different challenges. Old age is a period in which significant changes occur in physical and psychosocial health (Kang et al., 2021). For this reason, elderly immigrants constitute a disadvantaged subgroup among immigrants, who are a fragile group.
Older immigrants do not necessarily have the same needs and preferences regarding health and care services as the majority of the population. In order to provide equal service to everyone, health services need to be adapted to a complex and heterogeneous population (Hestevik et al., 2022). It is important for immigrant elders to have access to health services in order to protect the human rights of individuals of all age groups, leaving no one behind, and to achieve sustainable development goals regarding aging. Supporting immigrant elders will also contribute to the realization of the United Nations Decade of Healthy Aging. 9.3% of elderly people aged 65 and over worldwide are immigrants (Migration Data Portal, 2020).
Older immigrants have poorer physical, mental and social health than the general elderly population and rate their health as worse than older people in their host country (Khan et al., 2015). In a study analyzing data from 25 European countries, it is stated that older immigrants under the age of 75 have more chronic diseases than natives (Jang et al., 2023). In a study conducted in Norway, it is stated that the health and functional capacity of older immigrants are lower than those born in Norway (Qureshi et al., 2022). There are many factors that can affect the health of immigrant elders. Exposure to health risks before and during migration, lower socioeconomic position, linguistic barriers and low health literacy, cultural factors affecting health-seeking behaviors, psychosocial status and discrimination affecting health and quality of life can be counted as variables that may affect health (Kristiansen et al., 2016).
Figure 1. Schematic presentation of older immigrants in view of health care factors, and perceptions & experiences
The health of immigrants is important for the health of the society, and the factors that facilitate and hinder access to health services must be eliminated. Elderly immigrants’ experiences and perceptions regarding health services are important to protect and improve their health. In addition to the perceptions of immigrants regarding health care, the perceptions of caregivers are also among the factors that may affect the health of immigrants. In order to adapt health services to older immigrants, health care models that take into account their experiences and perceptions are needed. In this narrative review, it is aimed to examine in detail the factors that prevent or facilitate elderly immigrants’ access to health services, and the research that addresses the experiences and perspectives of the elderly, caregivers and health professionals. This study is presented in two parts: factors affecting elderly immigrants’ access to health services, and the experiences/perceptions of the elderly, caregivers and health professionals (Figure 1). In the section on experiences of elderly immigrants, what happened during the COVID-19 pandemic is also discussed. Additionally, interventional suggestions are included to improve the adaptation of elderly immigrants to health care services.
Factors that facilitate and hinder elderly immigrants’ access to health services
Access to health services is a human right. However, there are differences in access to health services between immigrant individuals and local people living in the community (WHO, 2018). Situations such as language barriers and cultural differences are the main factors that prevent immigrant elderly people from accessing health services (Ahmed et al., 2016; Rasi, 2020). It is stated that elderly immigrants not knowing how to apply for health services, having inadequate health literacy, experiencing language problems and ineffective communication with health professionals, lack of/insufficient social, social and family support are lead to social isolation and inadequate use of health services (Abood et al., 2021; Hestevik et al., 2022; Jacobsen et al., 2023). A study conducted in Norway states that immigrant elderly people do not seek primary healthcare services like the majority of the population (Spilker & Kumar, 2016). In addition, another study found that immigrants from Poland, Somalia, Sri Lanka and Vietnam generally had lower rates of referral to psychiatric specialists (Abebe et al., 2017).
Country-specific factors such as socioeconomic level, presence of close relatives, intergenerational relationships within immigrant communities, health expenditures in the host country, and communication skills of health professionals have been identified as factors that play an important role in the health and health-seeking behavior of older immigrants (Jacobsen et al., 2023). A review found that despite the desire to ensure equality in access to healthcare, persistent inequalities exist between immigrants and nonimmigrants. In this review, it was determined that especially the needs of mental and dental health services were not met; there were legal obstacles in accessing health services, there were language and communication barriers, overuse of emergency services and inadequate use of primary health care services (Lebano et al., 2020).
Language proficiency
One of the most important factors affecting elderly immigrants’ access to health services is language proficiency (Filler et al., 2020; Abood et al., 2021). It is stated that immigrants with language problems, especially those who do not work in any job, do not have any language proficiency. It is reported that immigrants who do not speak the language of the country they migrate to at all or do not speak at a sufficient level have problems in making an appointment or communicating with health professionals (Luo & Proch, 2018). In addition, it is possible that these individuals are less likely to apply to health services such as hospitals or other health institutions, and may face worse health outcomes because they do not apply to the health institution on time for their health problems (Luo & Proch, 2018; Hestevik et al., 2022). In a study conducted with immigrant elderly people with dementia, it was stated that the most important problem was the language problem. In the same study, agitation and isolation were observed in patients with dementia who were unable to communicate with healthcare professionals (Sagbakken et al., 2020).
Older immigrants may not understand the healthcare system and how to use healthcare services. For a new immigrant, not knowing the language of the country to which he/she immigrated and having a poor English proficiency cause ineffective communication with healthcare professionals (Alizadeh-Khoei et al., 2011; Stewart et al., 2011). Lack or insufficient interpreter support is considered as a barrier for immigrant elderly people to access health services (Aroian et al., 2005; Stewart et al., 2011). A study with immigrants found that language proficiency mostly delayed access to available healthcare and hindered the development of a therapeutic relationship between the patient and healthcare professionals. It has also been determined that there is no effective communication due to the language barrier, which reduces the quality of care, causes dissatisfaction with care, and prevents compliance with treatment and the use of preventive and screening services (Pandey et al., 2021).
Language barriers can delay access to timely care, lead to poor chronic disease management, and ultimately lead to poor health outcomes. A review found a relationship between language proficiency and inadequate use of health services, ineffective communication, and increased use of emergency care. This study states that creating immigrant-friendly solutions such as providing professional translators and providing culturally and linguistically sensitive training can increase the quality of care and access to care (Rasi, 2020). In a systematic review examining the barriers and obstacles to accessing patient-centered care among immigrant and refugee women, two-thirds of the studies stated that immigrants’ lack of language skills is important for health care (Filler et al., 2020). Lack of translators is also an important issue. Access to interpreters and healthcare professionals who can communicate effectively with older immigrants increases healthcare utilization (Nguyen, 2012).
Settlement period and immigration status
The process of settling in the country of migration affects the use of health care services. Newly immigrated older adults differ by age (young and older), gender, race, country of origin, language, literacy, culture, traditions, gender norms, religions, employment history, economic security, and length of residence (Luo & Proch, 2018). The duties of individuals providing health services are as follows: to care for elderly immigrants with a broad understanding, to direct people who need preparation and learning to language schools, to support elderly people who are exposed to mild to serious neglect and abuse, to help elderly immigrants with mild depression who suffer from extreme social isolation (Mandell et al., 2019).
In the study conducted with individuals who have just immigrated to Canada (0–7 years), it is expressed that they face more difficulties in accessing health services compared to individuals who have immigrated earlier It has been reported that some elderly immigrants, who are struggling to improve their English skills, take care of their families or find a job to earn a stable income, become ill due to stress and even suddenly become paralyzed due to stress (Luo & Proch, 2018). A study indicates that the unmet home care needs of individuals who have migrated recently are higher than those who have migrated earlier (Yung, 2022).
The status of immigrants is important in terms of health insurance. Undocumented immigrants’ access to healthcare may be hindered due to medical expenses. In order for these individuals to benefit from health services, they must register to a health institution and pay their own health expenses. Additionally, if they register to health institutions, they may be reported to law enforcement. Since this carries the risk of deportation, these individuals do not apply to health institutions (Danış et al., 2020). One report declares that 50% of undocumented immigrants and 18% of legally registered immigrants living in America do not have insurance. It has been stated that especially undocumented immigrants have obstacles in accessing health services and avoid applying for health services when they experience any health problems (KFF, 2023).
Health coverage and medical costs
Medical expenses and insurance coverage can both facilitate and hinder access to healthcare. In many countries, primary preventive health services are provided free of charge to immigrants (Kringos et al., 2013; Marchildon, 2022). In a study conducted with undocumented immigrants living in San Francisco, it was stated that expanding the scope of health services locally facilitated access to health care (Alwan et al., 2021). In another study, it is stated that the existence of a health system that covers all medical intervention and drug costs and provides access to health services when necessary has a positive effect on access to health services. However, in the same study, it was determined that the payment of ambulance fees by individuals is the biggest source of concern and that the elderly avoid calling an ambulance even if they need it (Luo & Proch, 2018). Additionally, in Canada, dental treatment, eye care, private home care and some alternative health services are not covered by public resources (Luo & Proch, 2018; Marchildon, 2022).
Discrimination
Immigrant elders establish better communication with healthcare professionals and members of the society from their own cultural origins. A study indicates that health professionals do not discriminate against immigrant elders, but they are excluded by individuals in society (Luo & Proch, 2018). It is stated that accessing healthcare services is not the same as going to the hospital, and that a healthcare professional’s discriminatory attitude may cause an interruption in healthcare services. Therefore, such attitudes deter immigrants from seeking health services (Danış et al., 2020). In a study conducted with immigrant individuals with dementia and their caregivers, it was stated that there is stigma and discrimination (Chejor et al., 2022). In studies examining the health conditions of immigrants and asylum seekers, it has been stated that as the duration of stay in the host country increases, immigrants are more exposed to discrimination and their health conditions worsen, and their use of health services is less. Studies examining the health status of immigrants and asylum seekers show that as the duration of stay in the host country increases, immigrants are more exposed to discrimination. It has been stated that their health conditions have deteriorated and their use of health services is low (Berchet & Jusot, 2012; Lebano et al., 2020).
Attitude of health professionals
The attitude of health professionals can be a factor that both facilitates and hinders elderly immigrants’ access to health services. In both the clinic and the hospital environment, a facilitating factor is the presence of healthcare professionals who are knowledgeable, reliable, patient, kind, caring, respond quickly to requests of older immigrants, and are willing to answer patients’ questions and explain medical conditions. However, the negative attitude of health professionals, lack of culturally appropriate health care, and the knowledge and treatment of health care providers may prevent immigrants from seeking health care (Luo & Proch, 2018). In a review, clinicians’ lack of training in cultural competence was cited as a factor hindering access to health care. The same study found that establishing a close relationship between healthcare professionals and allocating more time for communication will positively impact patient-centered care (Filler et al., 2020).
Presence of professionals/individuals who know the language and culture
The presence of health professionals who speak more than one language and culture facilitates immigrant individuals’ access to health services (Filler et al., 2020; Alwan et al., 2021). A study with immigrants revealed that communicating with a professional who spoke their native language reduced older adults’ anxiety about undergoing medical procedures and questions about their condition, but it was noted that there are not enough healthcare professionals who speak more than one language. In the same study, it is stated that older immigrants who have migrated earlier also need health professionals who know their language and culture, older immigrants can explain their problems to them more easily and provide better communication (Luo & Proch, 2018). In a review, it is stated that there are cultural differences between immigrant elderly people and health professionals (Mohammady & Namukwaya, 2023).
Delivery of health materials and health information
Older immigrants need health materials in their own language. In a study, it was determined that elderly immigrants received letters reminding them of annual check-ups, new immigrants were informed about the health system, but there was a significant lack of information and education for elderly immigrants. The same study found that older immigrants were not provided with information on how to access health services, even in printed materials in English, even if it was not their own language (Luo & Proch, 2018). It is stated that the literacy rate among older immigrants is low and they cannot read health materials, so it is important to provide health education through a translator (Mohammady & Namukwaya, 2023). Health materials can be translated into the languages of immigrants, and versions of frequently used forms can be prepared in different languages. In addition, videos containing health information can be made available to immigrant individuals via mass media (Luo & Proch, 2018; Ilgaz, 2022).
Support from family and relatives/individuals from the same culture
The presence of family and relatives can be a factor that facilitates immigrant elderly people’s access to health services. The presence of children in the family can make it easier for the elderly to access health services. In a study, it was determined that the family plays the most important role in the access of elderly immigrants to health services, spouses and children are the caregivers of the elderly, they provide transportation of the elderly to health institutions, and especially family members who speak the language translate the conversations with health professionals. However, there are reportedly cases where cultural beliefs prevent older immigrants and their families from accessing healthcare services such as home care or assisted living (Luo & Proch, 2018). In a study conducted with elderly Chinese immigrants who immigrated to the United States, it was reported that family relationships play an active role in the elderly’s use of health services (Guo et al., 2019). It is recommended that health care providers comprehensively evaluate family dynamics to fully understand the resources and barriers to health care use in the elderly immigrant population (Rote & Markides, 2014; Guo et al., 2019).
Individual’s health belief/culture
Perceived personal health beliefs are among the factors that facilitate older immigrants’ access to health services. As the perceived need increases, the need to seek health services increases. Living in the same country for a long time, having a good host country (or English) language level, family support (presence of language speakers in the family, emotional support, transportation support) (Alizadeh-Khoei et al., 2011), knowledge about access to health services (making an appointment, location of the hospital, etc.) are other facilitating factors (Luo & Proch, 2018). In the culture of the elderly immigrant, it may be possible to resort to different methods to solve a health problem, in which case it is possible to delay seeking professional health care (Institute of Medicine (US), 2004). In a study conducted with older immigrants, it was stated that cultural and religious beliefs led to inappropriate professional intervention (Rote & Markides, 2014; Guo et al., 2019). In two studies, the general health status of the elderly and their cultural and personal beliefs are also stated as factors that prevent access to health services (Hadziabdic et al., 2009; Kim et al., 2010).
The culture of older immigrants can be a factor that prevents them from accessing health services. Different medical beliefs and practices in the culture of immigrants may differ from the health practices of the country they migrate to. For example, in some cultures, people believe that health and disease reflect the internal balance of hot and cold forces in the body. Others state that some diseases are caused by spirits or ghosts (Ngo-Metzger et al., 2003; Hawkins et al., 2022). People with such beliefs may try to solve their health problems with different methods instead of applying to health institutions. Some patients use acupuncture or herbal medicine to supplement Western therapies, or simply apply such therapies instead of medical treatment. In a study conducted with immigrant individuals in Taiwan, individuals resorted to symptoms-relieving practices instead of going to the doctor when they are sick. The same study states that delaying seeking healthcare will result in worse health outcomes (Kuan et al., 2020). In a systematic review, it was determined that one of the most important factors in immigrant individuals’ access to health services is the cultural barrier. Regarding the cultural barrier, it has been determined that situations such as the absence of healthcare professionals of the same ethnic origin, healthcare professionals not talking to patients about their cultural practices, and not knowing their cultural practices are obstacles to accessing healthcare services (Ahmed et al., 2016). The fact that health professionals do not know the needs and cultures of immigrant elderly people further complicates these problems (Koehn, 2009). Therefore, in order to effectively care for immigrant elders, healthcare professionals must learn these deeply held health-related cultural beliefs and practices and communicate effectively with their patients.
Perceptions of elderly immigrants and caregivers towards health care services
Immigrant elderly may apply to health institutions in acute and chronic situations that disturb them and are very risky for their health (Luo & Proch, 2018). While psychosocial problems are experienced intensely in the elderly, this may be even more important in immigrant elderly (Aroian et al., 2005; Stewart et al., 2011). Mental health interventions, including counseling and medical treatment, should be implemented to improve the health of immigrant individuals (Luo & Proch, 2018).
Although immigrants are satisfied with the quality of the host country’s healthcare services and patient-centered service approaches, they are concerned about access to specialist doctors and the language barrier (Alizadeh-Khoei et al., 2011; Devillanova & Frattini, 2016). In a study, it was determined that the structure of the health system (referral system), financial and political conditions (bilateral agreements, health insurance) and the advantages and disadvantages of the health system (number of health professionals, physical conditions of health institutions, companionship system) affect immigrants’ perceptions of health services (Korkmaz Yaylagul & Yazici, 2018).
Older immigrants who believe they should not bother anyone for help or that they will not be understood enough to receive adequate care may not be able to access health care even if they need help (Hestevik et al., 2022). In a study examining immigrants’ experiences with healthcare in the United States, it is stated that those who are undocumented, those with lower incomes, those who are Black and Hispanic, and those with limited English proficiency have more difficulty in benefiting from healthcare services. Challenges include access to health insurance, low-wage jobs being less likely to offer health insurance, and health insurance coverage varying across states (Pillai et al., 2023). In a study investigating the experiences of newly immigrated individuals to Canada, it was found that immigrants could not benefit from public services free of charge until they met the minimum residence requirement, therefore new immigrants faced financial difficulties and could not access publicly financed hospitals and medical services when they needed them, which caused vulnerability. It is stated that it results in anxiety and emotional problems (Niraula et al., 2023).
Nursing homes for elderly immigrants need to be adapted to suit the culture. In a review, some studies indicate that nursing homes are not suitable for the culture of elderly immigrants, so the elderly do not want to choose nursing homes. This situation may be a danger to the health of the elderly living in the community, especially the elderly living alone (Hestevik et al., 2022). Therefore, a care model that suits individual and cultural needs should be created (Ilgaz, 2020; Hestevik et al., 2022). In a study conducted in Norway, health care services that adopted Norwegian culture created a feeling of alienation and exclusion in immigrants (Sagbakken et al., 2020).
In a study of newly immigrated individuals to Canada, they expressed dissatisfaction with the effectiveness of medications, the time spent at appointments, and the way healthcare professionals communicated health information. Referral processes and waiting times are cited as barriers to accessing specialists, diagnostics, and acute care, and individuals worry that appropriate healthcare may not be available when they need it (Pandey et al., 2022). A study of immigrant individuals found that some immigrants, particularly Black, Hispanic, and Asian immigrants, experience unfair treatment when seeking health care and have difficulty accessing respectful and culturally competent care (Pillai et al., 2023). In a study consisting of Turkish elderly immigrants, it was found that Turkish physicians were preferred for rapid diagnosis and treatment, but the host country’s healthcare professionals were more humane and reliable. The same study found that older people were often satisfied with their family physicians in their host country (Yazıcı et al., 2018).
It is also important to investigate caregivers’ experiences (Hestevik et al., 2022). A systematic review examining the experiences of older immigrants living with dementia and their caregivers identified a lack of culturally appropriate dementia services, language barriers, and dementia stigma as factors that prevent older immigrants from accessing dementia care (Chejor et al., 2022). It is important to ensure that older migrants with dementia and their families from culturally and linguistically diverse backgrounds have information, training and support to access dementia services (Kovaleva et al., 2021; Chejor et al., 2022).
In a study examining the experiences of caregivers of immigrant elderly individuals, it is reported that not providing culturally sensitive services and the services not meeting the needs of caregivers and immigrant elderly people increase the burden of care. In the same study, it is stated that there should be nonjudgmental health and care services appropriate to language, culture, religion and lifestyle (Shrestha et al., 2023). In another study examining the experiences of caregivers of elderly immigrants with dementia, it was determined that they endured a higher level of stress and burden compared to families from the main culture, and they decided not to use services, thinking that their loved ones could not be provided with linguistically appropriate care (Nurunnaher et al., 2023).
COVID-19 pandemic and the health experiences of older immigrants
The COVID-19 crisis has had a disproportionate impact on immigrants (OECD, 2022). While the COVID-19 pandemic has severely strained healthcare systems around the world, countries with large numbers of refugees have experienced problems in providing preventive and therapeutic services to refugees. Since undocumented immigrants cannot fully access health services, providing access to health services to the entire immigrant population, regardless of legal status, is very important in combating the COVID-19 epidemic (Angawi, 2023). In addition, the lack of national disaggregated databases during the COVID-19 epidemic prevented obtaining information about the health of immigrant individuals and immigrant elderly people. According to the literature, COVID-19 exposure, infection and death rates are higher among immigrants.
During the pandemic period, immigrants are more likely to contract the disease and develop serious symptoms and have higher mortality rates than natives (OECD, 2022). Even during the most critical period during the pandemic, when cases increased, immigrants continued to work in high-risk environments. It is also stated that they have less access to health services and economic assistance and are exposed to discrimination (Đoàn et al., 2021). Lack of housing conditions suitable for social distance or isolation from individuals at home during the pandemic period for immigrant elderly people negatively affected their health. Low socioeconomic status, low health literacy, and multigenerational living conditions make them more likely to be exposed to the virus (Turcotte & Savage, 2020). In the first months of the pandemic, many deaths occurred in long-term care homes and nursing homes due to the COVID-19 outbreak. Medical staff in these institutions faced a high risk of infection (Canadian Institute for Health Information, 2020). In a study, immigrants lacked access to information in their native language during the pandemic period, had a higher risk of infection because they lived in close proximity to family members, had worse health conditions because resources were less, and had a lifelong disadvantage due to systematic discrimination (Calvo, 2020).
During the pandemic period, the risk of developing psychosocial problems in the elderly increased due to visiting restrictions in institutions that care for elderly individuals and curfews to protect elderly people living in the community from the virus (Johnson et al., 2021). In a review, it was determined that social isolation and loneliness increased as the social connections of older immigrants were interrupted during the pandemic, and anxiety and depression increased in those with high levels of loneliness. Using technology to connect with others and provide health care, outdoor group activities and culturally adapted social programs during lockdown periods are recommended (Sidani et al., 2022).
Experiences of health professionals regarding health care services for elderly immigrants
The immigrant population is aging rapidly. Healthcare professionals will likely encounter increasing numbers of older adult immigrant patients (IOM, 2020). The experiences of healthcare professionals regarding immigrants are also important. Communication-related problems such as lack of communication, inability to obtain informed consent, inability to empathize, and inability to effectively carry out the diagnosis and treatment process may occur (Turhan et al., 2021).
Traditionally, the health of immigrants, especially those from developing countries, has been improved by living conditions in their destination countries (Lebano et al., 2020). Social relationships through neighborhood relationships, religious involvement, and family and friends are key to helping immigrants age healthily. It is important for healthcare professionals to evaluate the daily lives and social relationships of older immigrants (Rote & Markides, 2014).
In a study examining the experiences of professionals working with elderly immigrants in Finland, professionals stated that elderly immigrants living at home try to preserve their own culture and origins (Thyli et al., 2014). A systematic review examining the experiences of health professionals in mental health services for immigrants and refugees found a system that was under-resourced, stigmatized immigration status, and lacked universal access to health care (Peñuela-O’Brien et al., 2023). In a study examining the attitudes of healthcare professionals who care for migrants, it was found that some of the migrants thought that they were aggressive and dangerous, doctors and nurses had more positive attitudes towards migrants than other workers, and most healthcare workers felt that their knowledge and skills in caring for migrants were at low and medium levels (Dias et al., 2012).
In a study evaluating the care and perceptions of health care providers, there are differences in cultural beliefs and language differences, time and resource constraints, conflict between professional ethics and laws restricting immigrants’ right to access health services. In the same study, it was stated that healthcare professionals partially ignored the risky legal situations of immigrants and tried to solve them by using methods such as asking for help from civil society groups in order to carry out their clinical practices (Suphanchaimat et al., 2015). In a study conducted in Norway, it was investigated how elderly immigrants were discursively constructed as patients by nurses, and it was determined that elderly immigrants were constructed as marginalized patients by nurses, and that they were perceived as different and foreign by nurses (Vestgarden et al., 2023).
Interventions for better adaptation of health and care services among older immigrants
In order to provide sensitive health care to immigrants, holistic health services that cover individual and cultural needs are needed. The presence of linguistically and culturally diverse health professionals may represent an important resource, potentially reducing some communication-related problems (Sagbakken et al., 2020; Chejor et al., 2022). At the structural level, interpreter support, more time and resources should be allocated when assessing immigrants with different linguistic and cultural backgrounds (Sagbakken et al., 2020).
It is necessary to provide services adapted to language and culture, to add bilingual personnel to primary health services and to provide cultural awareness and sensitivity training to health personnel in these services (Gönderen Çakmak et al., 2020; Sagbakken et al., 2020). In addition, preparing different language versions of forms and health materials commonly used in health institutions in host countries can help establish effective communication. A study of immigrants with dementia reported that lack of access to certain types of food and the ability to listen to songs, music, literature or TV programs that are familiar or representative of the home environment hinder the use of public dementia care (Sagbakken et al., 2020).
There is a need for interventional studies that will facilitate elderly immigrants’ access to and use of health services. There is a particular need for research examining the impact of such interventions/programs and how they are experienced by older adults and their caregivers/relatives. In order to adapt these services to elderly immigrants, studies need to be conducted to evaluate the interventions/programs implemented by health and care services (Luo & Proch, 2018; Alwan et al., 2021; Chejor et al., 2022; Hestevik et al., 2022).
In a study investigating the experiences of elderly immigrants in Sweden, it is stated that elderly immigrants are fragile while receiving public care, and the reason for this is previous life events, cultural differences and communication difficulties (Hovde et al., 2008). In a study conducted in Norway, the care expectation of older immigrants is that the younger generation takes on the responsibility of caring for them. For this reason, it is recommended that nurses implement the family-oriented care perspective (Thyli et al., 2014).
In a study in which a health promotion program was applied to elderly immigrants, it was found that person-centered interventions supported a sense of individual consistency. It is recommended to use such programs to make daily life more understandable and manageable and to cope with the difficulties in daily life caused by aging (Arola et al., 2018). In two studies conducted with immigrant women with dementia, psychosocial therapy interventions were applied to immigrants via phone and text messages, but it was determined that the participation of older women was low because they had difficulty in using technology (García et al., 2019; García et al., 2020).
In a study conducted with older Korean immigrants who immigrated to Florida, it was found that a telecounseling intervention reduced depressive symptoms in immigrant elderly women. The same study recommends telecounseling for linguistically isolated populations (Jang et al., 2014). Peer-based intervention has been implemented to reduce loneliness, social isolation, and improve psychosocial well-being of Chinese elderly immigrants. This intervention reduced loneliness, increased resilience, reduced barriers to social participation and depressive symptoms, and increased life satisfaction and happiness (Lai et al., 2020).
Language barrier and cultural differences were identified in a study examining the experiences and perceptions of healthcare professionals from 16 European countries for good examples in the provision of healthcare to immigrant individuals. There are also problems in providing care to immigrants without health insurance, different understandings of disease and treatment, negative attitudes among staff and patients, and lack of access to medical history (Priebe et al., 2011). In order to solve these problems, it has been suggested that there should be sufficient time and resources and institutional flexibility, including individualized care, translation services, provision of facilities for the treatment of undocumented immigrants (such as financial support of nongovernmental organizations), and the creation of databases containing medical histories. In addition, it is necessary to work with families and social services, increase the cultural awareness of staff, prepare training programs for health professionals and information materials for immigrants, and create clear guidelines regarding the care rights of different immigrant groups (Priebe et al., 2011; Luo & Proch, 2018; Hestevik et al., 2022). In a systematic review evaluating the perspectives of healthcare professionals providing palliative care to patients from different cultures, it was determined that healthcare professionals have communication difficulties and fear of acting in a culturally insensitive manner, and that the family has an important role in the care and death process. It has also been stated that there is a universality of needs as we approach the end of life and the need for training of healthcare professionals (Burke et al., 2023).
Conclusion
Old age is a critical period and immigrant elderly may be more disadvantaged. It is crucial to identify the factors that facilitate and hinder elderly immigrants’ access to health services and to plan initiatives to eliminate the hindering factors. While the factors that mostly hinder access to health services are language and cultural barriers, the presence of family members and translators makes it easier. Health professionals have difficulty providing care to immigrant individuals. Therefore, they should be given cultural awareness and sensitivity training. It is also reported that during the pandemic period, elderly immigrants have a higher risk of exposure to the virus, problems with transportation to health institutions, and psychosocial problems. Caregivers and healthcare professionals have also had negative experiences. While providing care to immigrants, health professionals face some difficulties such as lack of communication, inability to obtain informed consent, inability to empathize, and inability to effectively carry out the diagnosis and treatment process. It may be useful to create policies and review some guidelines to overcome these difficulties. Providing culturally sensitive care is needed in institutions where elderly care is presented and in the services provided to community dwelling older immigrants. There is a need for more research on how older immigrants experience healthcare, assessing their satisfaction with healthcare, and how healthcare can be well tailored for them. It is important to conduct multidisciplinary research that focuses on facilitating elderly immigrants’ access to health services and improving their health.
Implications for practice
Factors that facilitate elderly immigrants’ access to health and care services should be taken into account and solutions should be developed for the factors that hinder them. It is stated that the language and cultural barriers prevent immigrants from accessing health services the most. In this regard, policies should be created to solve the language and culture problem in health institutions in countries where immigrants are concentrated. It is also recommended to establish clear guidelines regarding the care rights of elderly immigrants from different cultural backgrounds. Creating care models suitable for individual and cultural needs can also contribute to the solution of this problem. Another recommendation is to create training programs so that health professionals can effectively provide care to immigrant elderly people. Additionally, strategies for society should be developed to prevent negative attitudes and stereotypes in health services. In order to improve the quality of health care in institutions providing health care to older immigrants, reduce health inequalities, and achieve positive health outcomes, policies should be developed to improve the skills of health professionals in dealing with immigrant populations with different cultural backgrounds. Moreover, taking into account the disruptions in health services provided to immigrants during the pandemic period, precautions should be taken against any crisis that may occur in the future. For this purpose, national and international strategies should be developed, including the creation of databases and facilitating access to health services, especially for undocumented immigrants.
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