I. Introduction

Canada continues to become an increasingly diverse society through immigration. Also, Canada receives immigrants from every part of the globe, with the largest flows coming from countries in South, East and Southeast Asia. With the influx of mainly Asian immigrants, Vancouver has experienced dramatic changes in its ethnic composition. Population aging is a complex phenomenon among elderly persons, encompassing important issues for general public health, especially in the delivery and availability of services [11]. As of 2010, Statistics Canada data indicate that B.C. has over 1 million persons aged over 55 years, which translates into about one-quarter of the provincial population [3]. The problem of access is not unique to older Korean immigrants. Many older immigrants are unfamiliar with the Canadian health care system and as a consequence may find it difficult to understand how that system works; often they are not fully aware of their rights to service, the role of practitioners, the management of appointments, and the expectations of providers [16]. When there are communication problems, clients are both fearful that their description of their health condition may not be fully understood, and worried that they themselves may not fully understand the information that is being provided. Leduc and Proulx [17] noted that in some cases, these fears are so strong that patients report repeated visits or the use of other health services for the same problem. In the United States, Sohn and Harada [20] identified a second concern: when immigrant groups have inadequate access to primary health care they experience delays in treatment. There is also evidence that because they are not connected with primary health care services they may use emergency services for non-emergency situations, thereby contributing to crowding and increased wait times in emergency departments [17]. A number of studies undertaken in Canada have shown that Asian immigrant groups, particularly those who do not speak English, face barriers when accessing health-information and are less likely to use preventative health services such as cancer screening [1,4]. Primary health care is the foundation of Canada’s health care system. It provides both an individual’s entry point of contact with the health care system and continuity of care based on health promotion, illness and injury prevention, and diagnosis and treatment of illness and injury [2]. At the time of this study, primary health care in Canada is delivered by family physicians, and general medical practitioners, who focus on the diagnosis and treatment of illness and injury [2].

As a result of the growth of the Korean population, which includes a considerable number of persons over 60 years of age, the demand for health care services for older Koreans, especially within the primary health care sector, has increased significantly in British Columbia (B.C.) over the last 10 years. Although the health care system has developed strategies to meet the health care needs of immigrant populations such as establishing interpretation services and providing guidelines and education to healthcare providers [2,10], there is evidence that many immigrants still face considerable barriers when accessing health care services [8,10,18]. In order to offer appropriate health care services to immigrant populations, particularly older Korean immigrants, it is important for us in the health care industry to first gain knowledge about the characteristics of such immigrants. Although many older immigrant adults face barriers to accessing health care in Canada, very little is known about the experiences of older Korean immigrants in the Canadian health care context.

The purpose of this study is to explore the issues related to primary health care access by older (60 years and older) Korean immigrants. Expected outcomes included developing an understanding of the perspectives and experiences of older Korean immigrants when accessing primary health care services. The results of this study will assist health care providers to plan and deliver better, more culturally sensitive care.

II. Methods

The research design chosen for this study was non categorical interpretive description, as articulated by Thorne, Remier-Kirkham and MacDonald-Emes [22]. The interpretive descriptive approach is appropriate in part because it draws upon principles of the nursing profession as its philosophical underpinnings [22], and in part because it enabled to draw upon the perspectives and experiences of older Korean immigrants in accessing primary health care. This method provides guidance for the researcher attempting to interpret phenomena of interest to the discipline for the purpose of capturing themes and patterns. This method includes knowledge identifying common patterns found within experiences that represent the core of nursing practice, knowledge and practical application of principles [22]. As Gillespie [9] emphasizes, interpretive description is suitable when examining previously unexplored experiences, allowing the researcher to move beyond participants’ descriptions and engage in interpretation of the participant’s experiences from their perspectives. This approach supports the development of a description of individuals’ perceptions of an experience and interpretation of that experience to uncover meaning(s) for nursing knowledge. An interpretive description, informed by the concept of cultural safety, is used to understand older Korean immigrants’ experience in accessing primary health care. Interpretive description aims to understand how participants’ experiences intersect with social structural factors to influence access to primary health care services in the Korean immigrant community. Through studying the participants’ experiences, new knowledge is gained and this new knowledge can be used for action and change not only at the individual level but also in a broader context at the social and political levels. The main research question for this study is “What are the experiences of older Korean immigrants in accessing primary health care services?” This primary question includes the following secondary questions: (a) How do older Korean immigrants understand primary health care in order to access the services? (b) What are older Korean immigrants’ knowledge and expectations with respect to primary health care?

The sample for the study was obtained using purposive sampling techniques. Thorne and colleagues [22] point out that the use of purposive sampling allows selection of participants according to the needs of the study, based on the desire to obtain maximum variation in the phenomenon being studied. In this study, sampling was aimed at finding participants to help answer researcher questions in order to understand their experience in accessing primary health care, regardless of their gender. Eligible participants for this study had the following characteristics: Korean immigrants, 60 years of age and older, resident in Canada for at least 5 years, non-English speaking, residing within Greater Vancouver, willing to share their experience, and prepared to give written permission to participate.

III. Data Collection & Analysis

The data were collected by means of in-depth semi structured interviews with a total of ten participants. Open-ended interviews and field notes were used to collect data. Interviews were digital recorded with participant permission, and lasted between 23-60 minutes. Interviews were transcribed verbatim in Korean. There were translated into English. Seven interviews occurred at the participant’s home and three at a fast food restaurant. Participants were encouraged to indicate when the interview was completed, and thereby to retain control of the process. At the beginning of the interview, trigger questions were asked to get an overview of the situation or experiences. Trigger questions were utilized as a tool to facilitate the research process and as a means of refocusing the discussion. Data analysis occurred concurrently with data gathering, using a process of inductive analysis. The aim of the data analysis was to understand older Korean immigrants’ experiences in accessing primary health care, and to explore the impact of the primary health care system on access to health care services in general. Content analysis was used to understand the influences of social and political forces in constructing access experiences and was defined as analysis by topic, and each interview is categorized according to topic. Codes identified the content of each interview, and category labels were used as descriptive names for each group of data. The interpretive description was constructed by repeated review of the transcripts and immersion in the data. Data were broken down into units of information that were inductively coded into the initial three broad idea categories, namely, i) the position of the elderly in the family, ii) significance of the health care relationship with providers, and iii) participant perspectives on health and illness. The properties of components of the idea categories were then identified from the data. From these categories the information was synthesized into themes that provided a coherent description of participant experiences. Three steps of data coding were used: transcription and translation of the data, open coding, and coding following initial data analysis. Thorne and colleagues [22] state that when analyzing data it “becomes important to move in and out of the detail in an iterative manner asking frequently, what’s happening here?”. Using this technique of moving between microscopic and macroscopic views, the date were inductively coded into small and more specific categories. In this process data was refined from three broad categories into many categories that provided a beginning description of the experience. Also, this analysis produced categories that were more specific and provided a greater of information about the experience of accessing primary health care. The first three broad categories were refined after reviewing the progress of the analysis, and the final three dominant themes emerged: i) the shifting social positioning of older Koreans within families, ii) perspectives the primary health care and iii) barriers in navigating the primary health care system.

IV. Findings and Discussion

The findings are presented three dominant themes describing the older Korean immigrant’s experience of access primary health care. These themes were emerged from the narratives of ten older Korean immigrants. As unique as each participant’s story is, certain commonalities among the narratives emerged which are presented by the following themes: a) the shifting social positioning of older Koreans within families, b) perspectives on primary health care system c) barriers in navigating the primary health care system. The findings reveal that older Korean immigrants have experienced many difficulties in gaining access to appropriate primary health care services because of the shifts in their social positioning and other barriers. Such barriers resulted in an inappropriate use of primary care services and reliance on the emergency department for conditions that could be addressed elsewhere, which contributed to the delay in seeking health care services and lack of continuity in service delivery. Also the date reveal that although there are a multitude of primary health care services in place, those services are not well effective to the needs of older Korean immigrants. Three key themes were identified and discussed to draw additional implications in relation to some of the literature in this area: health care providers’ limited understanding of older Koreans’ lives, shifts in older Koreans’ social position and its influence on access to health care, and relationships between older Korean clients and health care providers and their influence on health.

A. Health Care Provider’s Limited Understanding of Older Koreans’ Lives

Despite an increasing number of Korean immigrants to Canada, little is known about the lives of older Korean immigrants, especially the change they experience as a result of immigration. For older Koreans immigrating to Canada may experience increased difficulty in meeting their health needs as a result of having English as a second language and having a very different value system and rules of behavior. In this study, the participants who came to Canada in their late age, may have a more difficult time incorporating the language and culture of Canada into their Korean culture. They also experience the lack of the resources and relevant experiences required to legitimize their authority over the young people. The older Koreans in the new society could be disadvantaged in their intergenerational relations because of their declining control over valued resources, with results in decreasing dependence of their children on them. Wong, Yoo and Stewart’s [23] study with older Chinese and Korean in San Francisco indicated that the older Chinese and Koreans were no longer the center of the family. In this study the participants had similar experiences in that they did not feel as if they were the center of their family. Thus, the older Korean immigrants in this study may exercise little power, and may be granted less status in the family [13]. The position of an elder in the family is ideally a respected one in the traditional Korean society [13]. The concept of filial piety is considered very important in East Asian countries and its practice still remains an ideal among most of Korean families in contemporary Korean society. However, the participants in this study seemed to experience less sense of filial piety from their children because of their changed role in family as a result of immigration. According to the city of Vancouver report [7], which was conducted as a special project to identify the Korean community’s needs, the isolation of many older Koreans and their lack of access to the mainstream service organizations are significant issues among Korean community. Similar to the findings of this study, the report indicates that the isolation of the older Korean immigrants is due to their inability to speak English and the lack of Korean community based organizations.

The changed roles of older Korean immigrants and the changed concept of filial piety in family lives have affected their access to health care providers. They could not depend on their children, who could be the source of their linguistic or economic resource in reaching out to health care services. With their desire of not becoming a burden to their children, the participants in this study have had to figure out how to access to health care services all by themselves. This finding is noteworthy considering that the lack of family support among older Korean immigrants is not well recognized by many mainstream health care providers. With two exceptions, all participants in this study had a chronic health conditions such as hypertension, heart disease, diabetes, osteoporosis, and back pain. Their chronic health condition underscores the need for access and information of health care services and resources. The lack of family support indicates that these older Korean immigrants need supports outside when they reach out to health care services. They need a lot of assistance in understanding Canadian health care systems, reaching out to available health care resources, and visiting their doctors. However, the findings suggest that the health care system may not be meeting their needs well. Their voices imply that they do not get the kinds of support or assistance they expect from health care providers; none of these participants have experienced assistance from health care systems in terms of translation or transportation during their visits to doctors. Most of participants in this study strive to get just some basic health treatments, rarely getting any additional services related to illness prevention and management. The service may be in place, but it has not well mobilized to connect with this certain group of older Korean immigrants. These findings point out that the unique needs of older Korean immigrants, the consequences of their changed role in family lives must be recognized by health care providers, and appropriate intervention needs to be developed by health care systems. Ensure equity of access to care that health care providers can be advocates for the older Koreans to ensure appropriate services are available to meet their needs. Recent studies have emphasized primary health care extends beyond timely access to diagnosis and treatment to be responsive [24,25]. A responsive primary health care includes approaches that take the patients’ social context into consideration. Recent studies also show that the populations that are vulnerable because of their social and material circumstances have benefited from more comprehensive community partnership approaches [24,25].

B. Older Korean Immigrants’ Social Position and its influence on Access to Health Care

Older Koreans’ social positioning influences ways of accessing primary health care since it explains how social isolation intersects with the process of aging to increase the isolation of those people who do not benefit from the support of kin or members of their families. The stories of participants in this study demonstrate how enormously their particular social status has influenced the quality of health care services they have received. Older Koreans’ social positioning influences ways of accessing primary health care since it explains how social isolation intersects with the process of aging to increase the isolation of those people who do not benefit from the support of kin or members of their families. The social isolation of older Korean immigrants constrains their ability to access health care services and resources. The results of this study suggest that these older Koreans’ social isolation brought about their lack of understanding of primary health care services and resources available to manage their health condition. As shown in the stories, while there are many kinds of primary health care services such as 24 hours BC nurse line, pharmacist and dietitian services, and Nurse Practitioners, the participants in this study did not even know the availability of these services. They also considered physicians as the only health care providers and accessed only physicians. Furthermore, most of participants were poorly informed about programs or resources offered by community health centers. Surprisingly, most of participants in this study did not even know about existence of community health centers.

The findings of this study indicated that one important source of their social isolation and lack of access to health care system intersects with their low economic status. Some participants in the study told that they could not afford to pay for some services such as private interpreter services, which eventually could jeopardize their health conditions. Other sources of older Korean immigrant’s isolated social position were related to their lack of English ability and lack of Korean community organizations. The urgent need of ethno cultural community service is strongly related to the language issue. Participants’ voices in this study indicate that their English barrier made them feel more isolated social position. As a way to overcome this language barrier, some participants relied on their informal networks such as churches or friends, but social isolation still remains an issue for older Koreans.

Kawk’s study [14] on Korean immigrants in Vancouver, indicates that Korean community organization have been too weak to respond to Korean immigrants’ various needs such as housing and settlement services. Seniors’ housing update report by Hwang [12] indicates that Korean seniors in British Columbia are underserved with full range of options. However, this study suggested that the lack of Korean ethnic services is not limited to the issue of housing or general settlement services only. The lack of service is remained in health care service as well: for instance, one female participant in this study who had a heart attack last year, lived alone. She could not walk by herself and she felt dizzy all the times after having a heart attack. Although she was eligible for assisted living service, she was not aware of the service as no one informed her of the availability of services. She still lives an apartment (government-subsidized housing) by herself, not knowing how to get care service options such as house cleaning and meal preparation. Another example, one participant has not had a Medical Service Plan as he did not know how to apply for it upon his immigration to Canada. He says, “no one was around to tell us”. These examples suggested the need for Korean community organizations in order to support older Koreans’ needs and to develop services in Korean. In both cases, Korean community organizations could play a vital role in connecting them to available mainstream services. One participant of this study touched upon this point: “well, there are available services in Chinese, but not Korean.” A Korean community organization should advocate for members of the Korean community, especially for older Koreans with their needs of Korean services. When these services become available and well known to Korean community, Korean elder immigrants could engage in mainstream health care services more effectively.

C. Relationships between Older Korean Clients and Health Care Providers and their influence on health

Several participants in this study described that their perceived remote relationship with health care providers is one of barriers to access to health care services. Their stories showed that most of participants experienced frustration and difficulty when they approached to their health care providers. The findings of this study suggested that, among various cultural differences, difference in communication style is a key obstacle for older Korean populations seeking to build trusting relationships with their health care providers and to manage their health condition. While a number of studies have documented the language barrier problem faced by immigrants [1,8,15,20]. The participants in the study felt that their communication style was different from their health care providers; while they felt important or need to share their emotions or concerns about the symptoms and conditions of their health during their conversation with health care providers, they felt that such needs of theirs were ignored by their health care providers. This created a problem in their building continual relationships with health care providers. From the cultural safety point of view, older Korean immigrants must feel safe in their relationship with the health care providers. The concept of cultural safety requires health care providers’ recognition and respect towards individuals with regard to their cultural identity. Also, it requires older Korean immigrants’ sense of power to define their own safety. However, the participants’ stories indicated that their health care providers did not exhibit enough cultural safety to their Korean clients and that the older Korean immigrants did not possess any power to claim their safety. This study calls for health care providers’ recognition and respect for Korean clients’ expectation in terms of communication style. Viewing health care encounters through the lens of cultural safety would lead health care providers to examine how elderly Koreans are affected by the dominant communication culture. Health care providers must be able to think critically about this Korean group is disadvantaged by a certain communication culture prevalent in health care system. Then, health care providers may make efforts to promote culturally safe environment for Korean immigrant clients. Several participants in the study described that their experience of health care providers was unfriendly. These participants described that the outcome of their interaction with health care providers could have been different if the approach of the health care providers had been more patient and sensitive to the fact that they spoke little or no English. Thus, the findings of this study suggest that the needs of older Korean immigrants would have been fulfilled if their working relationships with their health care provider were improved.

V. Limitations

This paper has explored experiences of older Korean immigrant’s perspectives of accessing primary care services. In interpreting the findings of this study, it is important to acknowledge its limitations. The sample size was small. The qualitative and exploratory nature of this inquiry limits the generalizability of the findings. The findings are limited by the selection criteria for participants, i.e. older Korean immigrants who were 60 years and older, and the small sample size (n=10). Participants were all living in the same urban area, so their experience may not represent the experiences of individuals living in other urban, rural or remote areas. However, the findings have considerable importance for health care professionals and the organization of health care services. This study offers insights to assist health care professionals in understanding not only the nature of the challenges and issues older Korean immigrants face when seeking health care, but also how they resolve them. The study’s description of this phenomenon may serve as the basis for proposed interventions that respect the values of older Korean immigrants and improve their access to primary health care. The findings offer preliminary directions for health care professionals to provide primary health care in ways that respect and support older Korean immigrants.

VI. Recommendations

This research offers insights to enhance our understanding of older Korean immigrants’ issues with access to primary health care services. The findings suggest designing strategies to enhance older Korean immigrants’ accessibility to primary health care services. Based on the outcomes of this study, the following recommendations have been formulated. These are suggested to redirect primary health care system to support older Korean immigrants.

  • Recognize the need to inquire about/not make assumptions about older Korean immigrants’ lack of familial and social support. These results suggest that there is social isolation of some older Korean immigrants.

  • Formal health care systems would benefit from establishing partnerships with government funded- cross cultural community agencies or programs for older Korean immigrants- This would enable health care providers (community nurses, Nurse Practitioners and physicians) to connect immigrants to these services by referring their older Korean immigrant clients to appropriate services or by working in liaison with the services. Health care providers could work as advocates for older Koreans by informing the availability of programs and ensuring them to be benefited from the services.

  • Support the Korean Canadian community in developing services for older Korean immigrants. For provincial government and policy-makers, a priority would be to help the Korean Canadian community in developing health care support resources such as volunteering, interpreter services, and home care support. To this end, the provincial government can consult Korean Canadian religious and community leaders to determine the needs of Korean Canadian community needs.

  • Develop health resources in Korean related to prevention and health promotion for older Korean immigrants. For example, translating existing education materials, developing resources specific to the Korean community.

  • Develop activities aimed at encouraging the participation of Korean elders in the community health programs. As an example, Korean Elderly Support Group which can increase the accessibility to services for elderly Koreans who do not speak English can be suggested. It would also promote the notion of equality and the rights of elderly Korean immigrants to be treated fairly in existing multicultural Canadian community settings, thus, fostering connection and engagement could potentially reduce their isolation.

  • Increase the number of Korean interpreters and staff in the community health centers and neighborhoods where older Korean immigrants live. This needs to consider in order to reach out to the Korean elders who could not access other health care services beside family doctors.

VII. Conclusion

Through this study, the issue of access to primary health care from perspective of older Korean immigrants cannot be studied outside of the social, cultural, economic context within which it unfolds. This research must be used as a vehicle to promote social justice in the health care system and this social justice will be translated in delineating interventions aimed at enhancing the accessibility of primary health care services for older Korean immigrants. Moreover, this study offers insights to assist health care professionals to understand the nature of the challenges and issues older Korean immigrants face when seeking health care and how they resolve them. Describing this phenomenon has provided some insights to propose interventions that respect the older Korean immigrants’ values and improve their access to primary health care. The findings this exploratory study give some preliminary direction to health care professionals as they provide care that respect and support the older Korean immigrants. Thus, health care providers need to gain more information and insights about various immigrants group include older Korean immigrants. This is especially important as the number of older adults continues to increase and these older adults are from a variety of cultural, ethnic, and religious backgrounds.