Health and wellbeing of older Chinese immigrants

The health and wellbeing status of immigrants has attracted the interests of many governments and scholars. Table 1 compares the three largest health problems (diabetes, hypertension and physical inactive) (Chiu et al., Reference Chiu, Austin, Manuel and Tu2010; Bloom and Black, Reference Bloom and Black2016; Jin et al., Reference Jin, Neubeck, Gullick, Koo and Ding2017) among Chinese immigrants and the overall population in the USA, Canada and Australia. The results show that compared to the overall population, Chinese immigrants have a similar rate of diabetes. However, the rate of Chinese immigrants who have hypertension is higher than their local counterparts, and Chinese immigrants are physically less active than other local groups. These data indicate that more attention needs to be paid to the health status of Chinese immigrants.

Table 1. Health status of Chinese immigrants in the United States of America (USA), Canada and Australia

Source: Bloom and Black (Reference Bloom and Black2016); Chiu et al. (Reference Chiu, Austin, Manuel and Tu2010); Jin et al. (Reference Jin, Neubeck, Gullick, Koo and Ding2017).

In this review, health and wellbeing are always coupled together, representing a complete state of physical, mental and social wellbeing (World Health Organization, 2007). Older Chinese immigrants warrant more attention to their health and wellbeing, as they are less resilient, less likely to adapt to changes and potentially exposed to more challenges in their local environment (Chow, Reference Chow2010; Tsoh et al., Reference Tsoh, Sentell, Gildengorin, Le, Chan, Fung, Pasick, Stewart, Wong, Woo, Burke, Wang, Mcphee and Nguyen2016). Previous studies have used health assessment scales to measure health and wellbeing status. These assessments include (a) health-related quality of life (Kwon et al., Reference Kwon, Wyatt, Kranick, Islam, Devia, Horowitz and Trinh-Shevrin2015); (b) Medical Outcomes Study Short Form (SF-36; Mui et al., Reference Mui, Kang, Kang and Domanski2007); (c) four wellbeing indicators: depression, anxiety, loneliness and quality of life (Lin et al., Reference Lin, Bryant, Boldero and Dow2016); and (d) self-rated health (Chow, Reference Chow2010; Tsoh et al., Reference Tsoh, Sentell, Gildengorin, Le, Chan, Fung, Pasick, Stewart, Wong, Woo, Burke, Wang, Mcphee and Nguyen2016). The results of these assessment tools show that older Chinese immigrants are more likely to, one, rate their health as poor, and two, suffer from depressive symptoms and loneliness (Tsoh et al., Reference Tsoh, Sentell, Gildengorin, Le, Chan, Fung, Pasick, Stewart, Wong, Woo, Burke, Wang, Mcphee and Nguyen2016).

Previous research focused on the health and wellbeing measurement tools rather than the impact of neighbourhood environments in shaping the health and wellbeing of this group of people. Among the reviewed studies, the provision of health-care services, which can be regarded as one element of neighbourhood environments, has been the attention of some scholars and policy makers. Poor health and wellbeing among older Chinese immigrants is often linked to their under-utilisation of the health-care system and social services (Miltiades and Wu, Reference Miltiades and Wu2008). Lai and Chau (Reference Lai and Chau2007a) suggested that older Chinese immigrants refrain from accessing health and social service providers due to: language barriers, transportation, service costs, long waiting times for appointments and treatments, cultural norms/value impediments between service providers, fear, traditional folk medicines and the lack of knowledge about health-care services. Research on the use of health services and the effects this has on the health and wellbeing of users currently has not been translated into policy. In the USA, Canada and Australia, no health and wellbeing-related policies specifically relating to older immigrants are available. Most public health systems only cover individuals who have permanent residency.

Research methods

A systematic quantitative literature review method was undertaken to collect and analyse secondary data for this research. This approach contrasts with the more traditional narrative literature review, in which authors use their own understanding of the subject matter to select and judge representative literature. This more traditional review emphasises what is known, rather than what is unknown. The narrative literature review method used for literature selection is internalised and selective, rather than being standardised, reproducible and transparent in comparison with a systematic literature review (Petticrew and Robert, Reference Petticrew and Robert2006). This systematic quantitative method addresses publication bias, and is used for the collection of literature that is explicit and reproducible (Pickering et al., Reference Pickering, Grignon, Steven, Guitart and Byrne2015). The systematic literature review method provides a framework on which to organise the literature systematically, making the review ideal for multi-disciplinary research. Although this method is suitable for use in quite narrowly defined research questions, the result of such a systematic review can be comprehensive (Kamler, Reference Kamler2008).

Literature searches for this study were conducted between November 2017 and February 2018, using scholarly electronic databases (ScienceDirect, ProQuest, Web of Science and Google Scholar) to identify original research papers. Only articles published after the year 2000 were sought in order to identify recent trends. The search topic for this review focused on the ‘health and wellbeing’, as already defined, of older Chinese immigrants. According to the research background and question, the keywords used for the search were grouped into two categories: ageing population (older people, elderly, older adults) and Chinese immigrants. Additional sources were also identified from the reference lists included in the selected papers.

A two-step inclusion process was applied to review the identified literature. Firstly, article titles were screened and examined to exclude non-relevant articles. Secondly, article abstracts were reviewed for relevant content based on the following three criteria: (a) original research papers published in peer-reviewed English-language science journals, (b) the aimed cohorts must be older Chinese immigrants, and (c) the study focused on the health and wellbeing of older people who lived independently. An initial keyword search identified around 885 articles. After removing irrelevant and duplicated articles and screening the titles, 172 papers were selected for abstract evaluation. Excluding the articles which were not related to the topic of neighbourhood environment and health and wellbeing, 52 articles were finally critically reviewed (Table 2). Some limitations were identified in this method. All the research papers included in this review were in English. The omission of relevant articles published in other languages, especially Chinese, may influence the findings of this review. Moreover, only including peer-reviewed articles published in scholarly journals meant that other literature, like grey literature, book chapters and conference papers, were excluded. While these limitations may influence the depth of the findings, the significance of this review lies in its generalisation and transferability.

Table 2. General characteristics and methodological aspects of the included articles

Note: USA: United States of America.

Data were then entered into an Excel spreadsheet and analysed using the following categories: author, year of publication, article title, journal name, the country in which the study was located, study design, the aim of the study, methods, sample size and outcome. The literature review search found that older Chinese immigrants attracted diverse scholarly interest in countries which attracted large numbers of immigrants. The majority of studies (N = 35) were conducted in North America, of which 24 were within the USA and 11 were located in Canada. Nine studies were found in Australia, three in New Zealand and two in the United Kingdom. Two studies were multinational, covering the USA and China.

Critically reviewed papers were published in 42 different journals spanning a wide range of disciplines, which demonstrates a trans-disciplinary interest in the topic and amongst which Ageing & Society published the highest number of articles (N = 4). Two fields, in particular, were dominant: health and social work. Nearly half of the journals concentrated on health-related issues (N = 17) (American Journal of Public Health (AJPH), Australian Journal of Primary Health, Contemporary Nurse, Ethnicity & Health, Health & Social Work, Health Education & Behavior, Health Expectations, International Journal of Public Health, International Journal of Qualitative Studies on Health and Well-being, International Psychogeriatrics, Journal of Community Health, Journal of Health Psychology, Journal of Immigrant and Minority Health, Public Health Nursing, Research in Nursing & Health, Social Science & Medicine, Social Work in Public Health). Twelve journals focused on social aspects (Ageing & Society, International Journal of Social Welfare, Journal of Community & Applied Social Psychology, Journal of Family Issues, Journal of Gerontological Social Work, Journal of Human Behavior in the Social Environment, Journal of Intergenerational Relationships, Journal of Social Work, Journal of the American Geriatrics Society, Management Research News, Social Indicators Research, Social Work). For the remainder of the articles, seven concentrated on ageing (Activities, Adaptation & Aging, Aging & Mental Health, Canadian Journal on Aging, Journal of Aging and Health, Journal of Aging and Physical Activity, Journal of Religion, Spirituality & Aging, International Journal of Aging and Human Development) and six came from journals focusing on gerontology (Archives of Gerontology and Geriatrics, Clinical Gerontologist, Gerontology, Journal of Cross-cultural Gerontology, The Gerontologist, Journals of Gerontology). In this research, none of the journals were found to have published articles relating to urban studies, planning or geography.

Research topics

An increase in the number of Chinese immigrants globally has posed more challenges, not only for the issue of health but also for the environment in which they live (International Organization for Migration, 2018). The steadily increased number in the calculation of literature every five years shows that the research on this group of people has been becoming an increasingly popular topic since 2000 (Figure 2). From 2001 to 2005, three papers concentrated on health problems, three papers studied the social environment and one article focused on family relationships of older Chinese immigrants. Between 2006 and 2010, figures for papers that were published on issues relating to health increased to ten, while three articles focused on social relationships. As for family relationships, sense of home and perceptions on ageing among older Chinese immigrants, each had one article that researched these topics. From the year 2011 to 2015, ten articles concentrated on the issues of health, while research on social environment increased dramatically, showing that seven articles researched social relationships, two articles focused on family relationships and one article concentrated on the perceptions of ageing. Finally, in 2016 and 2017, four articles concentrated on the social relationships of older Chinese immigrants and three articles investigated health issues. There was only one article that focused on family relationships and one article that investigated the sense of home of older Chinese immigrants.

Figure 2. Numbers of articles on different topics.

The relationship between the social environment and health and wellbeing

The neighbourhood social environment has been conceptualised as the interaction of local residents. Social networks (Tieu and Konnert, Reference Tieu and Konnert2014; Park et al., Reference Park, Jang, Lee, Ko, Haley and Chiriboga2015) and neighbourhood engagement (Luo and Menec, Reference Luo and Menec2018) are two dominant themes in the social environment body of literature. Although migration enables older immigrants to reunite with their children, they also face the loss of connection with their friends and neighbours in their home countries (Ryan et al., Reference Ryan, Sales, Tilki and Siara2009). Seventeen of the reviewed studies have critically analysed social networks, and found the existence of severe social pressures (e.g. small social network, restricted social participation, social isolation and loneliness) among this group (Ip et al., Reference Ip, Lui and Chui2007; Wu et al., Reference Wu, Guo, Chi and Plassman2011; Kim et al., Reference Kim, Linton and Lum2015; Luo, Reference Luo2016; Dong and Chang, Reference Dong and Chang2017; Luo and Menec, Reference Luo and Menec2018).

Social networks refer to the web of interpersonal relationships with family, friends and neighbours. Previous research argued that older Chinese immigrants had small and family-oriented social networks (Dong and Chang, Reference Dong and Chang2017; Luo and Menec, Reference Luo and Menec2018). Heavy domestic responsibilities, limited English proficiency and restricted mobility in a foreign country are factors that influence older Chinese immigrants in building social networks, which then influence the sense of wellbeing and social inclusion experienced by this group (Ip et al., Reference Ip, Lui and Chui2007; Diwan, Reference Diwan2008; Da and Garcia, Reference Da and Garcia2015; Luo, Reference Luo2016).

Family relations comprise a large proportion of social networks of older Chinese immigrants (Dong and Chang, Reference Dong and Chang2017). Filial piety is deeply valued in Eastern culture (Lo and Russell, Reference Lo and Russell2007), and adult children generally have responsibilities outside the home and they frequently play core roles in providing informal care to their parents, including financial, instrumental and emotional support (Wong et al., Reference Wong, Yoo and Stewart2005; Wu et al., Reference Wu, Guo, Chi and Plassman2011; Dong et al., Reference Dong, Chang, Wong and Simon2012b). Five articles critically explored family relationships among older Chinese immigrants (Pei-Chia, Reference Pei-Chia2002; Wong et al. Reference Wong, Yoo and Stewart2006; Lo and Russell, Reference Lo and Russell2007; Dong et al. Reference Dong, Chang, Wong and Simon2012b; Lin et al., Reference Lin, Bryant, Boldero and Dow2017). The most frequently cited reasons for the migration of older Chinese people include family and domestic responsibilities, such as taking care of grandchildren and assisting in household work (Da and Garcia, Reference Da and Garcia2015). These findings show that family relations do not always meet the needs of filial expectations of immigrant parents. Older Chinese immigrants frequently feel they are peripheral to the family and no longer have any authority because of their lack of language proficiency and knowledge of Western culture. This often leads to feelings of uselessness in family decision-making (Wong et al., Reference Wong, Yoo and Stewart2006; Ip et al., Reference Ip, Lui and Chui2007). As a result, older Chinese immigrants are more likely to want to live independently, since they are reluctant to live in someone else's home (Wong et al., Reference Wong, Yoo and Stewart2007; Da and Garcia, Reference Da and Garcia2015). This lack of satisfying intergenerational relationships is the main factor influencing the wellbeing of older immigrants (Dong et al., Reference Dong, Chang, Wong and Simon2012b; Luo and Menec, Reference Luo and Menec2018).

Relationships of friends constitute a minor component of the social networks of many older Chinese immigrants (Dong and Chang, Reference Dong and Chang2017). Friends usually offer general information or advice (learning English, applying for citizenship or using health services) and some level of companionship (Wong et al., Reference Wong, Yoo and Stewart2005; Tieu and Konnert, Reference Tieu and Konnert2014). Apart from social networks, community engagement, as an important domain in the neighbourhood social environment, also influences the health and wellbeing of older Chinese immigrants. Tan et al. (Reference Tan, Ward and Ziaian2010) found that in Chinese cultural norms, participation in social activities and community work is regarded as ‘ageing’ successfully. However, a previous study found that the rate of civic and social participation by older Chinese immigrants was low, and higher participation in inappropriate civic activities may even result in stress and anxiety (Luo and Menec, Reference Luo and Menec2018). This demonstrates the need to understand the social environments of older Chinese immigrants specifically because these environments contribute to their health and wellbeing (Tan et al., Reference Tan, Ward and Ziaian2010; Van Cauwenberg et al., Reference Van Cauwenberg, De Donder, Clarys, De Bourdeaudhuij, Buffel, De Witte, Dury, Verte and Deforche2014; Tiraphat et al., Reference Tiraphat, Peltzer, Thamma-Aphiphol and Suthisukon2017; Luo and Menec, Reference Luo and Menec2018).

The relationship between the physical environment and health and wellbeing

Apart from the dramatic shifts in the social environment, physical environment also dramatically changes after migrating to a foreign country. Although the impact of the built environment on the wellbeing of older people has been well documented (Van Cauwenberg et al., Reference Van Cauwenberg, De Bourdeaudhuij, De Meester, Van Dyck, Salmon, Clarys and Deforche2011; Timmermans et al., Reference Timmermans, Schaap, Visser, van der Ploeg, Wagtendonk, van der Pas and Deeg2016; Soma et al., Reference Soma, Tsunoda, Kitano, Jindo, Tsuji, Saghazadeh and Okura2017), there is a relatively small body of literature that casts a geographic lens on the relationship between older Chinese immigrants’ health and wellbeing, and the effects of their built environments (green space, street, facilities, and safety and accessibility, for instance). Living in a strange built environment can be extremely distressing. Only two studies by Da and Garcia (Reference Da and Garcia2015) and Selvarajah (Reference Selvarajah2004) were found which suggested good traffic management could improve the quality of life of older Chinese immigrants. In addition, research on the physical environment for other ethnic minority groups was also scarce. Sawchuk et al. (Reference Sawchuk, Russo, Bogart, Charles, Goldberg, Roy-Byrne, Buckwald and Forquera2011) investigated physical environment barriers and facilitators of walking and physical activity among older Indian immigrants, and found that better accessibility to interesting places, shopping places and parks would encourage more physical activity. Physical activities are important in understanding how the built environment influences the health and wellbeing of older Chinese immigrants, which is a crucial research topic in gerontology geography (Van Cauwenberg et al., Reference Van Cauwenberg, De Bourdeaudhuij, De Meester, Van Dyck, Salmon, Clarys and Deforche2011; Barnett et al., Reference Barnett, Barnett, Nathan, Van Cauwenberg and Cerin2017; Tuckett et al., Reference Tuckett, Banchoff, Winter and King2018). More research is needed to understand this area.

In relation to the natural environment, there are relatively few studies on the impact the natural environment has on the wellbeing of older immigrants. Some studies mentioned that fresh air, a healthy environment and clean water are factors that influence the wellbeing of older immigrants (Da and Garcia, Reference Da and Garcia2015; Ip et al., Reference Ip, Lui and Chui2007). However, no literature was found which critically investigated how the change in the natural environment influenced the wellbeing of older immigrants.

The relationship between place attachment and health and wellbeing

Place attachment for older Chinese immigrants was a recurring topic in the literature reviewed. Migrating to another country requires a redefinition of what place means, and transnational migration exposes the fluid and dynamic nature of the place and its meanings, which does not mean abandoning attachment to the place of origin but building a sense of place within the destination. Older Chinese immigrants were a special group who left their home country and settled in foreign countries in their later lives. The experience of trading-off between two lives in two countries influences the wellbeing of older Chinese immigrants (Li et al., Reference Li, Hodgetts and Sonn2014). In addition, Zhan et al. (Reference Zhan, Wang, Fawcett, Li and Fan2017) provided insight into the factors that may influence the sense of home among elderly Chinese Americans, and suggested that English proficiency, favourable family relationships and social policies will influence the sense of home as well as health and wellbeing. However, studies seemed to need further research to study the physical aspects of place attachment and its relationship with health and wellbeing for older Chinese immigrants.