Culturally Sensitive Long-Term Healthcare Culturally Sensitive Long-Term Healthcare Services for Japanese CanadiansServices for Japanese Canadians

--Understanding the needs of care recipients and family caregivers-Understanding the needs of care recipients and family caregivers-

Naoko MetzNaoko MetzNET Master’s Trainee NET Master’s Trainee

MA in Counselling Psychology, Trinity Western UniversityMA in Counselling Psychology, Trinity Western University

Thesis Supervisors Thesis Supervisors Dr. Marvin McDonald, Trinity Western University Dr. Marvin McDonald, Trinity Western University

Dr. Maria Cristina Barroetavena, BC Cancer AgencyDr. Maria Cristina Barroetavena, BC Cancer Agency

NET Research Day NET Research Day June 6, 2006June 6, 2006

Background: Seniors in BCBackground: Seniors in BC

Race and ethnicity continue to function as systematic barriers to Race and ethnicity continue to function as systematic barriers to accessing and providing health services including long-term care accessing and providing health services including long-term care servicesservices

(A profile of seniors in British Colombia)(A profile of seniors in British Colombia)

Large number of seniors whose mother tongues are other than Large number of seniors whose mother tongues are other than English, especially Asian languages are prominent in BC English, especially Asian languages are prominent in BC

13.3 percent of BC’s total population is over 65 years and 13.3 percent of BC’s total population is over 65 years and Immigrants made up a total of 36 percent of senior population (2001)Immigrants made up a total of 36 percent of senior population (2001)

It is estimated that seniors (65 years and older) will make up It is estimated that seniors (65 years and older) will make up approximately 24 percent of the total population of BC in 2031approximately 24 percent of the total population of BC in 2031

BC has one of the most rapidly aging populations in Canada BC has one of the most rapidly aging populations in Canada

Background: Japanese-Canadians (JCs)Background: Japanese-Canadians (JCs)

Approximately 37,300 of Japanese-Canadians reside in Approximately 37,300 of Japanese-Canadians reside in BC (total JC population 73,300) BC (total JC population 73,300)

About 65% of Japanese were born in Canada, the About 65% of Japanese were born in Canada, the highest proportion of all visible minority groups highest proportion of all visible minority groups

The percentages of intermarriage are the highest of all The percentages of intermarriage are the highest of all the ethnic groups (95%) the ethnic groups (95%)

Background: Japanese-Canadians, Background: Japanese-Canadians, cont.cont.

The number of Japanese immigrants has remained The number of Japanese immigrants has remained constant (~1300/yr) but the number of people with mixed constant (~1300/yr) but the number of people with mixed Japanese ancestry has nearly doubled in 10 yearsJapanese ancestry has nearly doubled in 10 years

Exhibit high level of social integration Exhibit high level of social integration

High percentage of them holding professional and/or High percentage of them holding professional and/or managerial jobsmanagerial jobs

Low unemployment rate and high educational level Low unemployment rate and high educational level

(Statistics Canada, Census 2001)(Statistics Canada, Census 2001)

Background: Japanese-Canadians (JCs), Background: Japanese-Canadians (JCs), Cont.Cont.

Inter-group differences among Asian cultures in conflict resolutionInter-group differences among Asian cultures in conflict resolution

Japanese infrequently use assertive mediation techniques such Japanese infrequently use assertive mediation techniques such as criticism, education, and disputant separationas criticism, education, and disputant separation

Japanese are more apt to rely on nonassertive techniques such Japanese are more apt to rely on nonassertive techniques such as gathering information from the disputants, listening to as gathering information from the disputants, listening to opinions, and relaying these between disputantsopinions, and relaying these between disputants

Japanese approach is significantly less assertive than that used Japanese approach is significantly less assertive than that used by the Chinese or the South Koreans (Callister and Wall, 1997)by the Chinese or the South Koreans (Callister and Wall, 1997)

Characteristics of Traditional Japanese CultureCharacteristics of Traditional Japanese Culture

GiriGiri : : refers to obligation/duty, the expectation that all help refers to obligation/duty, the expectation that all help would be provided from within the family may result in would be provided from within the family may result in resistance to obligating oneself to an external helpresistance to obligating oneself to an external help

Gaman: Gaman: refers to perseverance/self-control refers to perseverance/self-control

Enryo: Enryo: refrain from imposing self-interest or needs, self-refrain from imposing self-interest or needs, self-restraint/reserve restraint/reserve

HajiHaji : refers to shame/disgrace ( : refers to shame/disgrace (Kobayashi, 1999)Kobayashi, 1999)

Traditional Japanese View for Caregiving Traditional Japanese View for Caregiving

““Oya koh kohOya koh koh” ” -filial obligation/piety (Kobayashi, 1999; -filial obligation/piety (Kobayashi, 1999; Hashizumi, Hashizumi, 1998; Young, McCormick and Vitaliano, 2002)1998; Young, McCormick and Vitaliano, 2002)

““Sekentei”Sekentei” - -conformity to the society/community in general and conformity to the society/community in general and how how it relates to specific norms (filial obligation) or more general it relates to specific norms (filial obligation) or more general

norms such as self-sacrifice, endurance norms such as self-sacrifice, endurance

““ObasuteyamaObasuteyama”-”- the legend in old Japan in rural poor area that they the legend in old Japan in rural poor area that they used to leave elders in the mountain to starve them to used to leave elders in the mountain to starve them to

death. death. Obasuteyama is also used as a symbol of self-sacrifice from Obasuteyama is also used as a symbol of self-sacrifice from elders’ point of view, in order to avoid being a burden to elders’ point of view, in order to avoid being a burden to

others others (Young et al, 2002 and Saldov & Kakai, 2004)(Young et al, 2002 and Saldov & Kakai, 2004)

““ShikataganaiShikataganai””-refers to the view that the situation cannot be -refers to the view that the situation cannot be helped and nothing else can be done. (Flanagan, 2003)helped and nothing else can be done. (Flanagan, 2003)

Study OverviewStudy Overview

Purpose: Purpose: This qualitative study was designed to This qualitative study was designed to investigate investigate issues faced by Japanese-issues faced by Japanese-Canadian (JC) family caregivers and care Canadian (JC) family caregivers and care recipients and to explore culturally recipients and to explore culturally

distinctive distinctive adjustment and coping behaviours in adjustment and coping behaviours in the the context of long-term care servicescontext of long-term care services

Study location: Vancouver lower mainland, BCStudy location: Vancouver lower mainland, BC

Recruitment: Recruitment: Local news papers and community centres Local news papers and community centres

Study Overview, Study Overview, cont.cont. ParticipantsParticipants

Adult Japanese-Canadians who are/were family Adult Japanese-Canadians who are/were family caregivers, care recipients, or professional caregivers, care recipients, or professional caregivers in a long-term care settingcaregivers in a long-term care setting

Interview ProcedureInterview ProcedureDemographic, confidentiality and consent form, Demographic, confidentiality and consent form, followed by individual semi-structured interview followed by individual semi-structured interview (JP/EN)(JP/EN)

Data Analysis Data Analysis Phenomenological analysis-Primary and shard Phenomenological analysis-Primary and shard themes were identifiedthemes were identified

DefinitionsDefinitions Japanese-Canadians: Those who consider themselves as Japanese-Canadians: Those who consider themselves as

“Japanese” or “Japanese-Canadian”, including 1“Japanese” or “Japanese-Canadian”, including 1stst and 2 and 2nd nd

generationgeneration

Family Caregivers: Those who consider themselves as Family Caregivers: Those who consider themselves as primary primary family caregivers who are currently or have family caregivers who are currently or have provided care in provided care in the past for their family members at home the past for their family members at home and/or at a care and/or at a care facilityfacility

Care Recipients: Those who are currently receiving care either at Care Recipients: Those who are currently receiving care either at home or at long-term care facility due to old age related home or at long-term care facility due to old age related

health health concerns, chronic and/or life threatening illness. Anticipated concerns, chronic and/or life threatening illness. Anticipated future care recipients were also included in the studyfuture care recipients were also included in the study

Family Caregivers DemographicsFamily Caregivers Demographics Total of 6 family caregivers, all females Total of 6 family caregivers, all females

Age ranged from 40s (3) and 60s (3)Age ranged from 40s (3) and 60s (3)

All born in Japan with the length of residency 5 to 48 All born in Japan with the length of residency 5 to 48 years years

Married with child(ren) (4), widow (1), divorced (1) Married with child(ren) (4), widow (1), divorced (1)

English proficiency: bilingual (3), mid (1), beginner (2) English proficiency: bilingual (3), mid (1), beginner (2)

Education: high school diploma (1), collage diploma (3), Education: high school diploma (1), collage diploma (3), university degree (2)university degree (2)

Family Caregivers DemographicsFamily Caregivers Demographics

Occupation: Homemakers with retired spouses (3), part-Occupation: Homemakers with retired spouses (3), part-time job (1), family-owned business (1), writer (1)time job (1), family-owned business (1), writer (1)

Religion: Christian (5) and none (1)Religion: Christian (5) and none (1)

Relations to the CR: mother-in-law (2), parent (2), Relations to the CR: mother-in-law (2), parent (2), spouse (2)spouse (2)

Type of illness: stroke, cancer, dementia, accident Type of illness: stroke, cancer, dementia, accident related severe injury including head and/or hip injury related severe injury including head and/or hip injury

CR’s outcome: death (5) and partial recovery (1) CR’s outcome: death (5) and partial recovery (1)

Care Recipients DemographicsCare Recipients Demographics

Total of 4 care recipients: male (2) and female (2)Total of 4 care recipients: male (2) and female (2)

Age from 60s (1), 70s (1), 80s (1), 90s (1)Age from 60s (1), 70s (1), 80s (1), 90s (1)

Receiving care at home (1), at the Japanese assisted Receiving care at home (1), at the Japanese assisted care home (1) and prospective care recipients (2) care home (1) and prospective care recipients (2)

Born in Japan (3)/Canada (1) with residency from 13 to Born in Japan (3)/Canada (1) with residency from 13 to 90 years90 years

English proficiency: Bilingual (1), mid (1), beginner (2) English proficiency: Bilingual (1), mid (1), beginner (2)

Care Recipients Demographics, Care Recipients Demographics, cont.cont.

Occupation: All retired (home maker, agricultural Occupation: All retired (home maker, agricultural business owner and university professor)business owner and university professor)

Education: high school diploma (2), 2 year collage (1), Education: high school diploma (2), 2 year collage (1), and graduate degree (1)and graduate degree (1)

Health concerns: cancer, hearing and walking difficulties, Health concerns: cancer, hearing and walking difficulties, heart condition, high blood pressure, and arm/hip/leg heart condition, high blood pressure, and arm/hip/leg pain and diminished usagepain and diminished usage

Religion: Christian (3) and none (one)Religion: Christian (3) and none (one)

ThemesThemes

Common Themes Common Themes

FC and CR FC and CR

Themes Distinctive Themes Distinctive Family CaregiversFamily Caregivers

Themes Distinctive Themes Distinctive Care RecipientsCare Recipients

Language barriersLanguage barriers Physical/Psychological Physical/Psychological strain strain

Maintaining Maintaining independenceindependence

Culturally rooted & Culturally rooted & Culturally accommodating Culturally accommodating

coping stancescoping stances

Sense of accomplishment Sense of accomplishment

and regret and regret

Loneliness Loneliness

Having access to Having access to Japanese cuisineJapanese cuisine

Racism Racism

Interpersonal relationship Interpersonal relationship

Barriers for healthcare Barriers for healthcare service access service access

Change in view towards Change in view towards long-term carelong-term care

Spirituality Spirituality

Language BarriersLanguage Barriers Key underling issue affecting the overall long-term care Key underling issue affecting the overall long-term care

experience of Japanese–Canadiansexperience of Japanese–Canadians

Primary themesPrimary themes

Communication difficulties with medical/legal personal Communication difficulties with medical/legal personal Being a liaison, advocate on behalf of a care recipient Being a liaison, advocate on behalf of a care recipient Concerns/hesitation for living in a mainstream care home Concerns/hesitation for living in a mainstream care home Limited opportunity for socialization (isolation) Limited opportunity for socialization (isolation) Limited availability in language-matched care services Limited availability in language-matched care services Inter-generational communication gap Inter-generational communication gap

Language Barrier, Language Barrier, cont.cont.

““At the hospital, there was a lack of translator. Everything fell upon At the hospital, there was a lack of translator. Everything fell upon us. In the last 3 weeks of my father’s life we were at the us. In the last 3 weeks of my father’s life we were at the

hospital 24/7. There were the rounds of doctors to explain the hospital 24/7. There were the rounds of doctors to explain the situation but also for the sake of my father’s comfort. We situation but also for the sake of my father’s comfort. We always feared to miss something important. Without our help always feared to miss something important. Without our help my my father would have signed papers without knowing what they father would have signed papers without knowing what they were. So this was a big issue. And I was thinking: Oh my God. were. So this was a big issue. And I was thinking: Oh my God. What about all of the patients who are alone and do not speak What about all of the patients who are alone and do not speak English!” English!” (Family Caregiver)(Family Caregiver)

““It is miserable to live in a care home where one can not speak in It is miserable to live in a care home where one can not speak in Japanese. Even those who used to speak English (when Japanese. Even those who used to speak English (when they were young) tend to forget English as one gets old. they were young) tend to forget English as one gets old.

So, So, language is the most significant aspect of our daily life.” language is the most significant aspect of our daily life.” (Care Recipient)(Care Recipient)

Culturally Rooted & Culturally Rooted & Culturally Accommodating Coping StancesCulturally Accommodating Coping Stances

Culturally rooted coping stance: Culturally rooted coping stance: Gaman (self-sacrifice/endurance) Gaman (self-sacrifice/endurance) Shikataganai (acceptance)Shikataganai (acceptance) Enryo (self-refrain/hesitation)Enryo (self-refrain/hesitation)

Culturally accommodating/ mainstream coping stances Culturally accommodating/ mainstream coping stances Being assertive and proactive in protecting one’s Being assertive and proactive in protecting one’s

rightsrights Being assertive in voicing one’s needs and Being assertive in voicing one’s needs and

demanding better servicedemanding better service

Culturally Distinctive Coping StancesCulturally Distinctive Coping Stances

““I don’t want to be too arrogant, you know, then nobody comes near me I don’t want to be too arrogant, you know, then nobody comes near me or be scared of me. So, I don’t want to be too arrogant. I want to or be scared of me. So, I don’t want to be too arrogant. I want to keep a low profile. I try not to ask much, I try not to be a burden to keep a low profile. I try not to ask much, I try not to be a burden to anyone.” anyone.” (assisted care home (assisted care home resident)resident)

““I think it’s a Japanese personality trait, we Japanese release stress I think it’s a Japanese personality trait, we Japanese release stress and tension by crying or do a bit of mumbling, you know somewhat and tension by crying or do a bit of mumbling, you know somewhat passive. But in the North American main culture, there is a passive. But in the North American main culture, there is a mentality like “be strong and fight back ” when you are faced with mentality like “be strong and fight back ” when you are faced with adversity. It has more positive and assertive connotations. This is adversity. It has more positive and assertive connotations. This is not a typical Japanese way of coping. “not a typical Japanese way of coping. “ (Family (Family Caregiver)Caregiver)

Culturally Accommodating Coping StancesCulturally Accommodating Coping Stances

““Caregivers should make sure to write a detailed journal about the Caregivers should make sure to write a detailed journal about the treatment the patient is receiving. One should make sure to read treatment the patient is receiving. One should make sure to read and understand all the documents before signing them. If you need and understand all the documents before signing them. If you need a translator, ask for one. It is important to know that one needs to a translator, ask for one. It is important to know that one needs to protect the rights of ourselves and family. “protect the rights of ourselves and family. “

(Family Caregiver)(Family Caregiver)

““And also, this can be observed even among Japanese who has been And also, this can be observed even among Japanese who has been living in Canada for a long time, that they feel shame in expressing living in Canada for a long time, that they feel shame in expressing when faced with life challenges or hide any problems from when faced with life challenges or hide any problems from outsiders. I don’t think these are good. I think things should be outsiders. I don’t think these are good. I think things should be different. When we faced with challenges, it is important that we different. When we faced with challenges, it is important that we deal with them in a assertive way.”deal with them in a assertive way.”

(Care Recipient)(Care Recipient)

Imprecations for Policy Making Imprecations for Policy Making and Community Support and Community Support

Need for a centralized and bilingual (JP/EN) information Need for a centralized and bilingual (JP/EN) information service regarding the long-term care services service regarding the long-term care services

Need for professional medical interpreting servicesNeed for professional medical interpreting services

Need for increased Japanese speaking home visit care Need for increased Japanese speaking home visit care professionals with better accessibility professionals with better accessibility

Imprecations for Policy Making Imprecations for Policy Making and Community Support, and Community Support, Cont.Cont.

Need for support for family caregivers (i.e helpline)Need for support for family caregivers (i.e helpline)

Education for awareness building concerning depression Education for awareness building concerning depression among elderly and implementation of “check-up” system among elderly and implementation of “check-up” system on elderly persons who live aloneon elderly persons who live alone

Need for a language/culture appropriate comprehensive Need for a language/culture appropriate comprehensive long-term care facilitylong-term care facility

AcknowledgmentAcknowledgment

Study ParticipantsStudy Participants Dr. Marvin McDonald (Trinity Western University) Dr. Marvin McDonald (Trinity Western University) Dr. Maria Cristina Barroetavena (BC Cancer Agency)Dr. Maria Cristina Barroetavena (BC Cancer Agency) New Emerging Team, BC Cancer AgencyNew Emerging Team, BC Cancer Agency National Association of Japanese-CanadiansNational Association of Japanese-Canadians Trinity Western University Trinity Western University Tokachi & Kirin Japanese Restaurant Tokachi & Kirin Japanese Restaurant

Question TimeQuestion Time

For further inquiry, please contact;For further inquiry, please contact;

Naoko MetzNaoko MetzMetz_n@hotmail.comMetz_n@hotmail.comMaster’s in Counselling PsychologyMaster’s in Counselling PsychologyTrinity Western University, Langley BCTrinity Western University, Langley BC

~Thank you ~~Thank you ~