People aged 60 or older represent the fastest growing portion of the world’s population, increasing at a rate of 3.25 per cent per year (United Nations Department of Economics and Social Affairs (UN DESA), 2015). In Canada, seniors will account for an increasingly larger share of the total population, growing from 15.6 per cent or over 6 million in 2014 to 23 per cent by 2030 or over 9.5 million as the majority of the “baby boom” generation (born between 1946 and 1965) reaches age 65 and older (Government of Canada, 2014). In conjunction with this aging population, the Canadian demographic landscape is changing rapidly with a significant increase in ethnocultural diversity. Immigrants accounted for more than 6.5 million or 20 per cent of the Canadian population in 2006, and this proportion is expected to continue to rise, reaching between 25 to 28 per cent of the population in 2031 (Statistics Canada, 2010).
As a result of recent changes in the immigration sources from traditional Anglo-Saxon European countries to non-European countries, the proportion of visible minorityFootnote 1 persons among immigrants is also projected to increase to 71 per cent in 2031, compared to 54 per cent in 2006 (Statistics Canada, 2010). For example, the proportion of Asian-born immigrants has steadily increased from 14 per cent in 1981 to 41 per cent in 2006 while the proportion of immigrants born in European countries has declined from 67 per cent to 37 per cent (Statistics Canada, 2010). Within two decades, more than two out of three immigrants living in Canada are projected to belong to a visible minority group with neither English nor French as their mother tongue (Statistics Canada, 2010). This change will have important implications in programs and policies that support growing ethnic senior populations.
Because advanced age is associated with the likelihood of chronic health conditions (Decady & Greenberg, Reference Decady and Greenberg2014), improving older adults’ quality of life while maintaining their health and functional independence has become a priority issue in both the public and private sectors (Public Health Agency of Canada, 2010; Ramage-Morin, Shields, & Martel, Reference Ramage-Morin, Shields and Martel2010). In Canada, federal, provincial, and territorial governments have identified healthy aging as a policy focus which has necessitated the creation of supportive environments as a means to achieve this goal (Ndegwa, Reference Ndegwa2011; Public Health Agency of Canada, 2010; Plouffe & Kalache, Reference Plouffe and Kalache2011). To date, all 10 provinces have joined and have implemented the Age-Friendly Community Initiatives, developed by the World Health Organization in 2006, to promote and develop policies, services, and structures to support seniors to lead active, socially engaged, independent lives (Public Health Agency of Canada, 2015). Increased community engagement is sought through multiple streams, such as in-service provision and the promotion of local projects through government funding (Ndegwa, Reference Ndegwa2011; Public Health Agency of Canada, 2010; 2015).
These government and provincial initiatives are especially promising as ethnic organizations have a greater role to play in reaching out to vulnerable minority immigrant populations who face barriers to existing programs and services. Multiple barriers to accessing health and social care exist, most notably lack of fluency in English, cultural beliefs and practices, and immigrant status itself (Ahmad et al., Reference Ahmad, Shik, Vanza, Cheung, George and Stewart2004; Jang, Kim, & Chiriboga, Reference Jang, Kim and Chiriboga2005; Lai & Chau, Reference Lai and Chau2007; Pourat, Lubben, Yu, & Wallace, Reference Pourat, Lubben, Yu and Wallace2000; Weerasinghe, Reference Weerasinghe2012). Such barriers not only hinder immigrant older adults’ ability to seek and receive necessary care but also reduce social interactions (Kang, Basham, & Kim, Reference Kang, Basham and Kim2013; Kim, Reference Kim2013; Lai & Surood, Reference Lai and Surood2008; Schaie & Pietrucha, Reference Schaie and Pietrucha2000). These barriers and other stressors, such as acculturation, make elderly immigrants particularly vulnerable to poor psychological and physical health (Kang, Domanski, & Moon, Reference Kang, Domanski and Moon2009; Min, Moon, & Lubben, Reference Min, Moon and Lubben2005; Mio, Barker-Hackett, & Tumambing, Reference Mio, Barker-Hackett and Tumambing2008). In particular, older Korean immigrants have been identified as a high-risk group with higher levels of depression and suicidal ideation than other senior groups (Jang & Chiriboga, Reference Jang and Chiriboga2010; Min et al., Reference Min, Moon and Lubben2005; Mui & Kang, Reference Mui and Kang2006).
In light of recent government efforts through community involvement in developing supportive environments to enable healthy aging, there is a need to better understand the impact that community-based programs can have on the well-being of immigrant seniors (National Advisory Council on Aging, 2005). The role of ethnic communities is vital in achieving psychological and physical well-being in their new, adopted culture (Ahmad et al., Reference Ahmad, Shik, Vanza, Cheung, George and Stewart2004; Barrio et al., Reference Barrio, Palinkas, Yamada, Fuentes, Criado, Garcia and Jeste2007; Lai & Surood, Reference Lai and Surood2008; Stewart et al., Reference Stewart, Shizha, Makwarimba, Spitzer, Khalema and Nsaliwa2011; Weerasinghe & Numer, Reference Weerasinghe and Numer2011). The National Advisory Council on Aging (2005) has recommended proactive approaches to prevent social isolation, as cultural and linguistic barriers can be reduced through innovative programs to engage ethnic minority seniors more fully in group activities. Community-based programs targeting ethnic seniors have been effective in reaching out to various ethnic groups and have had numerous positive impacts on the participants’ health outcomes (Hau et al., Reference Hau, Reid, Wong, Chin, Botto, Eliasziw and Fielding2016; Kim, Reference Kim2016; Kim, Reference Kim2013; Koehn, Habib, & Bukhari, Reference Koehn, Habib and Bukhari2016). One noteworthy program is the Seniors Support Services for South Asian Community (S4AC) program implemented in collaboration with the non-profit local United Way agency in British Columbia to improve access to existing facilities for South Asian older adults.
In their case study of over a hundred Punjabi-speaking seniors, Koehn et al. (Reference Koehn, Habib and Bukhari2016) found health benefits that accrued to seniors attending exercise classes offered by the S4AC program. The reported health benefits not only pertain to physical health such as reduced hypertension and improved balance and flexibility but also extended to mental health and well-being through enhanced social interactions resulting from the program (Koehn et al., Reference Koehn, Habib and Bukhari2016). Another community-based exercise and health education program, the Boston, Massachusetts-based Healthy Habits Program (Hau et al., Reference Hau, Reid, Wong, Chin, Botto, Eliasziw and Fielding2016) targeting elderly Chinese immigrants, found clinically meaningful improvements in mobility and cognition of the participants at the end of the 6-month intervention period. As well, the researchers found statistically significant improvements in executive function, lessened depressive symptoms, and reduced perceived disability. More importantly, 78 per cent of Chinese seniors achieved the goal of performing exercises three or more times a week during a 6-month period (Hau et al., Reference Hau, Reid, Wong, Chin, Botto, Eliasziw and Fielding2016).
As exemplary as these programs are, the majority of them are structurally implemented with an extensive collaboration with community partners and/or institutions. However, limited research has been conducted on the programs within grassroots from the ethnic community itself. One example of an ethnic community that developed its own program can be found in the work of Kim (Reference Kim2013) who investigated Korean senior schools in North America. His qualitative study of a Korean senior school in the United States reported psychological benefits from the perspective of 10 Korean seniors (Kim, Reference Kim2013). Attending senior school positively influenced their psychological well-being by providing the participants opportunities to meet friends and helping them to deal with the psychological distress associated with immigration (Kim, Reference Kim2013).
There are many references to senior schools or “silver colleges” offered by Korean ethnic churches across North America (Hurh & Kim, Reference Hurh and Kim1990; Hwang, Reference Hwang2008; Kim, Reference Kim2016; Lee & An, Reference Lee and An2013; Sin & Hirsch, Reference Sin and Hirsch2013), and yet the impact of senior schools has not been fully explored by both quantitative and qualitative means. To Korean immigrants, the ethnic churches are “a core source of various social interactions” (Hwang, Reference Hwang2008, p. 214) that provide social network and resources via a wide range of services and scheduled programs including senior schools that offer various educational classes and recreational activities to elderly Koreans (Kim, Reference Kim2016; Kim, Reference Kim2013; Sin & Hirsch, Reference Sin and Hirsch2013). The senior programs have a wider reach as they are not only for church congregations but also extend to Korean seniors in the community as a whole (Kim, Reference Kim2016; Kim, Reference Kim2013). Thus, these sites can serve as a venue for further exploration into the community of Korean seniors.
Koreans accounted for 0.5 per cent of the total Canadian population or over 160,000 people in 2011 (Statistics Canada, 2013a). Of the total Korean population, seniors make up about 7 per cent (Statistics Canada, 2013b). Similar to other immigrant groups, most Koreans settled in Canada’s three census metropolitan areas: Toronto, Montreal, and Vancouver. Toronto has by far the largest Korean community, accounting for 42 per cent of the total Korean population in Canada in 2011, where ethnic enclaves (“Korean towns”) offer cultural resources and support (Lindsay, Reference Lindsay2007). Across the Greater Toronto AreaFootnote 2 alone, there are at least 11 Korean ethnic churches that offer senior colleges advertised through local Korean newspapers (Garden Kyohae … , 2014; Gunganghago … , 2016).
Korean communities may be a good case in point for research into the influence of cultural community programs on the physical and psychological well-being of ethnic immigrant seniors. First, a relatively short immigration history of Koreans in Canada in the 1960s means that most, if not all, seniors are first-generation (Korean-born) immigrants (Kim, Noh, & Noh, Reference Kim, Noh, Noh, Noh, Kim and Noh2012; Lindsay, Reference Lindsay2007). The findings will be highly relevant to foreign-born minority immigrants including a growing number of late-life immigrants who are adjusting to a new country with a culture and language distinctively different from their own. Second, by understanding the experience of elderly Korean immigrants as a singular population, researchers can better understand the ethnic diversity of minority senior populations and fill a gap in defining and analysing the context and cultural uniqueness of Koreans as an individual ethnic group (Hwang, Reference Hwang2008; National Advisory Council on Aging, 2005). Most of the published gerontology research has focused on a single ethnic group, mainly Chinese, or Asian as a single group (Durst, Reference Durst2005), and yet variations in subgroups of Asian seniors exist as evidenced by their utilization of local services.
For example, a study in the Greater Vancouver Regional District found that Korean seniors are less likely to use local services and amenities than are Chinese seniors and rely on ethnic churches as a resource (Hwang, Reference Hwang2008). Research also shows that Korean seniors have a strong desire to maintain ethnic ties and surround themselves with familiar cultural touchstones, including in their choice of ethnic foods (Hurh & Kim, Reference Hurh and Kim1990; Lee, Reference Lee2007; Son & Kim, Reference Son and Kim2006). Moreover, there are generational differences within the Korean population. According to the Ethnic Diversity Survey by Statistics Canada (2003), first-generation immigrants were less likely than second- or third-generation Korean-Canadians to participate in sports clubs or service clubs or to be involved in charitable organizations. The only areas in which participation rates were higher among first-generation immigrants, compared to subsequent generations, were religious-affiliated groups and ethnic or immigrant associations (Statistics Canada, 2003). These findings highlight the importance of these organizations and their associated services for Korean immigrant seniors.
This study stems from an ethnographic case study of Canada Enoch Senior’s College (CESC) that explored the experience of Korean immigrant older adults in a culturally sensitive community program in the Greater Toronto Area (Jo, Veblen, & Potter, Reference Jo, Veblen, Potter and Cohen2014). Our earlier explorative study, utilizing a quantitative survey, suggested positive health effects of the program on participants. The purpose of this current investigation is to further evaluate the impact of CESC in improving the health-related quality of life (HR-QOL) of older adults using both quantitative and qualitative measures and to explore the nature of the outcomes and how they were achieved.
Background on the CESC
Canada Enoch Senior’s College is a cultural community program for Korean immigrant older adults centred in a Korean ethnic church in the Greater Toronto Area. It was the first of its kind offered in Ontario for Korean seniors and has served approximately 3,000 seniors over 13 years and currently enrols an average of 150 participants each term. The program is offered twice a year, in spring and fall, and each term lasts between 8 and 11 weeks. CESC is offered free-of-charge to all seniors and is run mostly by volunteers. Except for the director of the program, who is a part-time pastor at the church in which CESC operation is one of her responsibilities, all staff are volunteers. Staff consists of class instructors, kitchen staff, and others who help with day-to-day activities from class setup to cleanup at day’s end. Many of the volunteers are also members of the church. The number of volunteers per term varies depending on the number of elective classes offered during the term or number of kitchen staff available to prepare meals in a given week. On average, there are about 12 to 14 instructors, about 8 to 10 kitchen staff, plus three extra staff for remaining activities. Some instructors are current or retired professionals sharing their skills or expertise with seniors, and their time commitment during the college term is one to two hours.
The CESC program runs weekly and is conducted in Korean. Each day is divided into four time slots, beginning at 10:00 a.m. and finishing at 2:30 p.m., with a traditional Korean style congregate meal at lunchtime. The morning session is organized as an assembly, consisting of singing and short lectures on topics such as Korean history, literature, and life stories with occasional special events, like birthday celebrations. The afternoon session is followed by an elective class and small group gathering. Typical electives include singing classes (art songs, popular songs, and folk songs), dancing (aerobics, Korean traditional dance, worship dance, and line dance), harmonica ensemble, arts and crafts, calligraphy, saxophone, smartphone 101, and Chinese medicine. The electives can vary depending on seniors’ interests and availability of instructors.Footnote 3
Methods
This study used a mixed methodology to evaluate the effects of the CESC program on the HR-QOL and well-being in senior Korean participants. The evaluation of the program included documentation, qualitative inquiry, and a quantitative survey. We used semi-structured interviews with the CESC participants, self-reported health measure questionnaires, and field notes as our main data collection tools.
The quantitative evaluation used a repeated measures design with no control group. The baseline measures (Time 1) occurred during the first two weeks and the end line measures (Time 2) occurred during the last two weeks of each term. Although a true pre- and post-test design would have been ideal, based on the CESC schedule and director’s recommendation, a decision was made on pragmatic grounds to give study participants an option to complete the questionnaire at home and return it the following week to allow for flexibility and reduce potential barriers to participation since the first week at the college is very busy with orientation. For similar reasons, we administered the post-test survey during the next-to-last week of the program. This means that there were some variations as to how many weeks participants would have participated in the program (i.e., 7 to 10 weeks) based on the timing of questionnaire completion.
The Short Form 36 version 2 (SF-36v2), a measure of health status derived from items used in the Medical Outcomes Study, was what we used to assess the HR-QOL of study participants as it has proven reliable and valid in a variety of populations (Walters, Munro, & Brazier, Reference Walters, Munro and Brazier2001; Ware & Gandek, Reference Ware and Gandek1998; Ware & Sherbourne, Reference Ware and Sherbourne1992), including older Korean adults (Han & Lee, Reference Han and Lee2009; Han, Lee, Iwaya, Kataoka, & Kohzuki, Reference Han, Lee, Iwaya, Kataoka and Kohzuki2004). The SF-36 measures eight domains of HR-QOL, including physical function (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role-emotional (RE) and mental health (MH). These were scored using a scale ranging from 0 to 100, with higher scores indicating a higher HR-QOL. The SF-36v2 survey was translated into Korean by a researcher who is proficient in Korean and English, and the translation and adaptation procedures focused on maintaining conceptual equivalence while remaining culturally appropriate (Wagner et al., Reference Wagner, Gandek, Aaronson, Acquadro, Alonso, Apolone and Ware1998). For example, the questionnaire used the term “four weeks”; this was translated to “one month” to mirror the more common usage in Korean culture. After completion of the first draft, the translation was evaluated by a bilingual Korean speaker to ensure that the interpretation and translation of the survey items were clear and appropriate. The researcher distributed the questionnaires and was available to answer clarifying questions on three different occasions – in the morning before classes, during lunch, and after classes – in order to gather complete data from as many participants as possible. Some people chose to complete the questionnaire at home and brought it back the following week. The participation was voluntary, and ultimately, 79 CESC participants out of 165 eligible participants (25 in the spring term; 54 in the fall term) completed the SF-36v2 questionnaire on two occasions and provided informed consent to permit the use of their data for evaluation purposes.
In the spring term, we distributed the questionnaire to a subset of participants (25) as we originally conceived this study as an exploratory pilot. The survey was administered again in the fall term to increase sample size, so we distributed the questionnaire to all participants except those who had completed the survey in the spring term. The study sample consisted of the same population with little turnover between the terms (< 10%). Out of 150 participants in the fall term, 125 were eligible to participate excluding 25 participants who had already completed the survey beforehand. In total, 79 participants completed the questionnaire on the first occasion (Time 1), and 69 completed the questionnaire on the second occasion (Time 2). However, only 54 pairs from the fall term were included in the analysis due to missing identifiers or having completed the questionnaire only once. To analyse the data, paired-samples t-tests let us determine the statistical significance of the difference between Time 1 and Time 2 for each HR-QOL measure.
The qualitative inquiry component of this study drew upon ethnography of the CESC on the basis of fieldwork conducted during two consecutive terms between April and October 2014 by the researcher in both a participant and non-participant capacity. Additionally, the researcher conducted semi-structured interviews with CESC participants. Adherence to the ethnographic study necessitated that the researcher be immersed in the setting (Bresler, Reference Bresler1995; Creswell, Reference Creswell2007; Fetterman, Reference Fetterman1998; Merriam, Reference Merriam2009). Through serving as a volunteer, the lead researcher was able to establish rapport with participants (Bell, Reference Bell2005; Yin, Reference Yin2009). The researcher observed all sessions including lunch breaks and the short informal social gatherings that occurred at the end of each session, with a weekly rotation of elective classes and small group meetings. Multiple sources of information were used as data, including field notes written immediately after observation or participation in classrooms, informal conversations with the participants, and self-reflection (Bernard, Reference Bernard2011; Denzin & Lincoln, Reference Denzin and Lincoln2005). The data supplemented quantitative findings and aided in cross-checking.
A total of 11 participants were interviewed to provide more detailed accounts of the program’s impact as perceived by the participants. The time and place of interviews were chosen by the participants, and most participants chose to meet at CESC before or after the program. The duration of each interview ranged from 15 minutes to two hours. For some participants who chose to meet during lunch hours, subsequent interviews were necessary to continue and conclude their previous conversations. On average, the total interview time per interviewee was an hour. In addition, on these occasions some of the individual interviews became a small group conversation when one or two members sitting nearby joined in to share their accounts. Conversations also continued throughout the term as participants offered their reflections and accounts. Informal conversations were recorded in the field notebook immediately after the conversation took place. The use of email made it possible for the researcher and participants to maintain contact even after the term ended. All interviews and email correspondences were conducted in Korean. Individual interviews were audio-recorded and transcribed verbatim, followed by translation into English. All email communications pertaining to this research were saved and translated into English.
The data were analysed using content analysis (Green & Thorogood, Reference Green and Thorogood2009), beginning with open coding of the transcripts followed by an iterative process of inference and analysis where emerging and recurrent topics were highlighted and combined or collapsed to a distinct and encapsulating theme. We ensured the quality and rigour of the data collection and analysis stages by employing a variety of strategies. Participants reviewed themes that emerged from data analysis by a member-checking process, which ensured that the data was interpreted correctly and in the appropriate context (Green & Thorogood, Reference Green and Thorogood2009). We maintained the credibility/reliability of the data by a back-translation process whereby the lead researcher, fluent in English and Korean, translated a random selection of paragraphs back to Korean. This was followed by validation of the quality and conceptual equivalence of paragraphs by the researcher (Guillemin, Bombardier, & Beaton, Reference Guillemin, Bombardier and Beaton1993). The final stage of the research sought to capture the detailed context through compiling field notes to create a thick description of each theme, supported by verbatim quotes from the participants, as recommended by Green and Thorogood (Reference Green and Thorogood2009). This research has been reviewed and approved by a Western University Ethics Review Board.
Results
Quantitative Evaluation
A total of 79 out of 165 eligible CESC participants completed both pre- and post-questionnaires. The mean age of the participants was 74.1 years, and 77 per cent were female (n = 61) and 23 per cent were male (n = 18). All participants were from the Greater Toronto Area and were first-generation (Korean-born) immigrants with Korean as the mother-tongue language. Analyses across the entire sample using one-tailed t-tests were employed since the previous explorative study indicated positive health effects of participants. Table 1 presents mean differences and standard deviations for each of the eight SF-36v2 HR-QOL domains (physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional or role limitations due to emotional problems, and mental health). Significant differences were found for the two domains of bodily pain and role-emotional. The mean scores for bodily pain (p = .014) and role-emotional (p = .032) for the seniors were significantly higher at Time 2 or after 7 to 10 weeks of program participation. Higher scores refer to better self-rated QOL with regard to each subcategory. The respondents experienced less body pain and had less functional role limitations resulting from emotional issues after participation in the program. Additionally, physical functioning showed marginal, although not significant, improvement. There were no significant differences between Time 1 and Time 2 in terms of role limitation due to physical health problems, general health perceptions, general mental health, vitality, or social functioning in the group.
Table 1: Health impacts of the CESC program: Mean differences in HR-QOL of Korean immigrant seniors at Time 1 and Time 2
Note. HR-QOL = health-related quality of life; SD = standard deviation.
* p < .05.
Qualitative Inquiry
We conducted a total of 11 interviews (six females and five males). The age range for these participants was 70 to 87 years. The following results are discussed in relation to the three main themes that emerged from the data analysis: (1) CESC as promoting health and vitality; (2) CESC as reducing social isolation and exclusion by fostering a renewed perspective on aging and self; and (3) CESC as providing social support and a sense of belonging.
CESC as Promoting Health and Vitality
Participation at CESC helped Korean older adults live healthier lives by increasing their activity levels and motivating them to take better care of themselves.
Several of the participants spoke of how dance classes helped them become physically fit. One participant described the benefits of taking a line dance class:
So I started to take the dance class because our legs become weaker as we get older. At first, the steps were very confusing, and it took quite a bit of time for me to follow them correctly. And then there was music on top of it. So you can see the challenges, but it turned out to be good for my health. My legs have strengthened a lot since the class.
Participants also reported improvement in their appetite and energy levels. Several of the participants, who live alone or with their spouses without their families, stated a lack of motivation or inspiration to cook for only one or two persons. One woman described her cooking and eating habits:
I don’t usually feel like cooking much, so I have a cup of black coffee and a piece of toast in the morning and skip lunch. For supper, I usually make something simple. When I do cook, it is usually for my niece who lives alone away from her family to attend a university nearby.
However, she found herself cooking more frequently at home and adding more variety in her diet due to improved appetite since her participation at CESC. In this regard, the weekly lunch served at CESC may have also played a role. People spoke of getting ideas from the lunch menus and commented that they were eating better at home as a result. Referring to the positive experience of sharing meals with other Koreans, another participant commented, “The lunch here is the best meal of the week!” Several participants echoed her comment about how they enjoy the lunchtime at CESC and stated that their appetites had improved since the school started.
Through CESC, participants were motivated to take better care of themselves since the program provided them with social interaction. One senior mentioned how she ran into another CESC member at a hair salon just a day before CESC’s fall term began; they were both getting “ready” for the school. Another participant described how she finds CESC as an opportunity to dress up. She explained that “there are less social occasions to dress up these days, so I pull out my best ensemble when I go to Enoch College.” This attitude was noted by other participants as well. One senior explained: “Every week, both men and women look polished. You look around and see others paying attention to their looks and attire, so you also become more conscious as to how you look, in a good way.” In this way, the program helped to restore vitality in the lives of older Korean adults.
CESC as Fostering Renewed Perspectives on Aging and Self
Elderly Koreans in the program spoke of increasing feelings of isolation and exclusion and their perceptions of the diminished role and value in society. One senior expressed that she felt like “a second-hand citizen” and another said that he often felt “out of place”, not being able to keep up with the fast-changing society. One later-life immigrant (who migrated to Canada at age 66) pointed out:
Unlike in Korea where there are multiple places for retired seniors to hang out, as immigrants in Canada we have no place to go, no one to talk to, and nothing to do. So it’s important that we have Enoch College where we can meet once a week and socialize with other Koreans.
Even those who have been active members of their community also spoke about changing attitudes towards older adults. “I’ve always been volunteering in the kitchen, but I began feeling awkward amongst volunteers because of my age,” one senior explained and continued: “Since I’ve become one of the eldest, I’ve noticed a younger group of volunteers being more self-conscious around me. I am starting to feel like I might be a burden to them and no longer sure of my place.” Other participants also spoke of invisible tension, especially in a mixed-generation setting that impeded participation, further contributing to their diminished social circles and engagement. This also relates to common perceptions and attitudes shared by the participants. One senior explained, “It is a virtue of old people to step back and let the younger ones take the lead.”
However, participants stated that this was not the case at CESC. Several participants mentioned that they were less restricted by their age and social status. One participant explained, “Here at Enoch College, everyone is the same.” Another senior elaborated:
We all become like children, freed from the concerns of world. It is as if we go back in time to our childhood when we played together regardless of our gender or social status. We have a great time enjoying activities together in which we are reminded of how grateful we are to be living.
This friendly atmosphere appears to encourage participants to explore. One senior described how she got involved in art class:
I’ve always wanted to study art, but never got a chance. In a way, I had given it up because I felt I was too old and embarrassed to start something. I was thinking to myself, ‘What would be the use?’ However, here at Enoch College, from watching others I’ve realized that it is never too late to try, so I took up my courage and have been taking art for two consecutive terms. I found Enoch College to be the place for fulfilling my long-lost dream.
A similar account was related by another participant who was taking a saxophone class; she explained that this was her very first lesson on a musical instrument. Others also spoke of how they expanded their horizons by getting out of their comfort zones, like singing in front of an audience for the first time in life or writing a memoir and getting it published. At CESC, Korean seniors are provided with opportunities to explore and extend their interest, which has helped promote self-awareness and insight in participating seniors.
The overall change in attitude of the group is expressed succinctly in a poem written by one participant:
I won’t give up now just ’cause I am old
Joy comes from serving and sharing
My fellow friends at Enoch College
Let’s shout to the world, our life begins at 80!
CESC as Providing Emotional Support and a Sense of Belonging
All participants expressed how they look forward to coming to CESC every week and rarely missed an opportunity to do so. CESC attendees suffer from various chronic illnesses including diabetes, arthritis, and cancer as well as age-related health declines such as vision and hearing loss. Health-related issues did not prevent them from attending CESC. One participant, who came despite having sprained her back the day before, explained:
As long as I am able, I will be here. Attending Enoch College is good for me, it makes me feel better. Now, I will have to take an extra precaution and won’t be able to participate in some of the activities but I won’t miss Enoch.
Participants described how they prioritize CESC. One senior commented, “I have a pretty busy schedule with several commitments with family and church, but I make sure that Thursday is free for my friends at Enoch College.” Being able to communicate in Korean and meeting other Koreans appear to be important parts of CESC that older adults value. Another participant remarked, “Where else can we meet Korean people?” Others also commented that attending CESC and seeing familiar faces alone is often enough to make them feel better and helps them forget about worries of life. Still another CESC student summed up the experience by saying, “We have such a good time together at Enoch College; we are busy laughing, learning, and sweating from exercising – the day goes by before you know it.”
Through the CESC program, participants extended social ties and networks that went beyond the confines of school terms or activities. All of the participants described how they stay connected with other CESC members throughout the year in one form or another, many using cell phones and text messages. These connections were likely strengthened by small groups which may be unique to CESC. Referred to as homeroom (“Ban” in Korean), each student participant was assigned to a small group where two representatives or leaders (“Ban-jang” in Korean) assumed responsibilities related to their homeroom such as taking attendance and facilitating homeroom/group activities. This system was modeled after the traditional primary and secondary school system in Korea. In the CESC setting, it allowed for better communication and created a sense of group belonging as well as opportunities for participants to get to know one another at a more personal level. For example, Ban-jang would follow up by a phone call when a member was absent the previous week. (See earlier exposition of CESC program; Jo et al., Reference Jo, Veblen, Potter and Cohen2014.)
Participants also found enjoyment from sharing stories or YouTube videos with each other via email. One participant explained: “I keep a list of friends from Enoch College whom I often send or forward emails that contain either interesting stories or videos and useful living tips.” Another participant added: “Occasionally we meet up with each other to exercise at a nearby mall and have a cup of coffee afterwards.” These opportunities can also lead to meeting new people, such as when an elderly Korean was introduced to a local hiking club by a fellow CESC member.
Participation at CESC not only enhances social connections but also provides emotional support for older adults. One woman described a time that she came to CESC straight from an eye specialist’s appointment despite blurred vision due to eye drops used in the examination: “I was planning to go home initially after the doctor’s appointment, but I changed my mind. I knew if I go home I would be alone and feel blue so I came here.” Several participants also shared how they were able to overcome difficulties in life, such as bereavements, family issues, or suffering ill health, through their association with CESC. One participant, who suffered depression after a sudden loss of her husband, described her experience:
I remember my first day at Enoch College. Another participant, whom I’ve never met before, approached me to say hello as I was a new face here. For some reason, I told her about my husband. Without any words she held my hands tightly and I felt like she understood my pain. Her genuine gesture opened up my heart and since then I’ve tried to offer the same kind of support to others who lost their loved ones.
Supported by the care and friendship experienced at CESC, another participant described how he found strength to overcome the pain and loneliness that troubled him, which often kept him up all night. He stated, “Pain shed light out of my life but I regained hope and joy through Enoch College. It gave me something I look forward to.”
Participants not only found solace through CESC relationships but also from various CESC activities. Specifically, group singing seems to have a positive impact on mood and enhances a sense of belonging in CESC members. One participant shared her experience: “When we sing songs from our schooling days, even though it was long ago and forgotten, quite surprisingly the songs come back to you. It brings us back to the joyful time when we were in school.” Another senior shared a similar experience: “The art song class is my favourite class. Singing the songs from past is soothing and I find my mind at peace when we sing together.” This psychological comfort is also noted in the attitudes of other participants. Another senior observed: “You can see people closing their eyes listening to the tunes and humming when we sing together because we are familiar with them. They remind us of good old days of our youth.” Through reminiscence and strengthening bonds, music seems to be a source of comfort among older Koreans.
Discussion
This study sought to evaluate the impact of the CESC program on Korean immigrant older adults’ health and well-being, and to explore, through the use of a mixed-methods approach, the nature of the outcomes and how they were achieved. The results of the quantitative evaluation demonstrated that participation at CESC was associated with improvements in HR-QOL for physical and mental health domains. Statistically significant results were found for two variables, bodily pain and role-emotional or role limitations due to emotional problems. In the case of self-rated physical health, the program reduced perceptions of bodily pain among respondents and led to a marginally significant improvement on physical function. For the mental health domain, respondents had fewer issues or limitations in carrying out daily activities due to emotional status. The results of qualitative evaluation align strongly with these findings except for the social function variable. Overall, the CESC program encouraged Korean senior participants to live actively and helped them feel physically and emotionally stronger while reducing social isolation.
There are multiple ways in which the program could have influenced the positive health outcomes observed in the participants, including lessened bodily pain and improved role-emotional. One way is through increased activity levels. As a result of participating in the CESC, seniors reported that they were generally more active whether it was through program-related activities like dancing classes or social gatherings/outings outside of CESC. Previous research has shown that individuals who engage in higher levels of physical activity tend to have higher HR-QOL scores (Anokye, Trueman, Green, Pavey, & Taylor, Reference Anokye, Trueman, Green, Pavey and Taylor2012; Hand, Cavanaugh, Forbes, Govern, & Cress, Reference Hand, Cavanaugh, Forbes, Govern and Cress2012; Moore-Harrison, Johnson, Quinn, & Cress, Reference Moore-Harrison, Johnson, Quinn and Cress2009; Okamoto, Nakatani, Morita, Saeki, & Kurumatani, Reference Okamoto, Nakatani, Morita, Saeki and Kurumatani2007). In particular, moderate-intensity, low-impact aerobic activity, including dancing and brisk walking (similar to the exercise program at CESC), have also shown to reduce pain related to musculoskeletal conditions that are common in older adults, such as osteoarthritis, and to improve physical function, moods, and quality of life (Krampe et al., Reference Krampe, Wagner, Hawthorne, Sanazaro, Wong-Anuchit, Budhathoki and Raaf2014; Hughes et al., Reference Hughes, Seymour, Campbell, Pollak, Huber and Sharma2004; Okamoto et al., Reference Okamoto, Nakatani, Morita, Saeki and Kurumatani2007). It is interesting to note that physical functioning did not change despite many references to improvements. One explanation might be that the participants are already a high-functioning group. A comparison to the norm data shows that the physical function (PF) score for the group was above the population norm. In Canada, the norm for PF is 75.5 (SD 22.2) for adults aged 65 to 74 (Hopman, Towheed, Anastassiades, & Tenenhouse, Reference Hopman, Towheed, Anastassiades and Tenenhouse2000), whereas the study group had an average of 77.1 (SD 18.8) at baseline examination and 78.9 (SD 18.9) at final examination (p = .089). This high baseline score may have created a ceiling effect, thus making any improvements difficult to observe.
Physical activity also may affect HR-QOL through the effects of self-esteem. Previous studies show that exercise is an effective means to enhance self-esteem in older adults (Li, Harmer, Chaumeton, Duncan & Duncan, Reference Li, Harmer, Chaumeton, Duncan and Duncan2002; McAuley et al., Reference McAuley, Elavsky, Motl, Konopack, Hu and Marquez2005; Opdenacker, Delecluse, & Boen, Reference Opdenacker, Delecluse and Boen2009). One possible explanation is that physical activity can help maintain a sense of self-worth for those who have experienced a decline in perceived self-worth due to changes in health or physical abilities. Self-esteem, in turn, has a positive association with QOL. A comparative study of QOL between Korean older adults and Korean-American older adults found that, for both groups, self-esteem and the ability to perform activities of daily living or instrumental activities of daily living (ADLs; IADLs) were strong predictors of QOL (Kim, Jeon, Sok, Oh, & Kim, Reference Kim, Jeon, Sok, Oh and Kim2009). Increased opportunities for self-achievement also contributes to self-esteem. Participants spoke of trying new activities/exercises at CESC and how they were able to overcome various physical and mental challenges. One senior described how she gained confidence from taking an aerobics class for the first time:
It was so confusing at first because I’ve never done anything like it, moving so fast you know. I thought of giving it up, but slowly I followed the dancing sequences one by one and eventually I was able to do them all. It made me feel so good that I did it! I learned I can do anything once I put my mind to it.
This participant shared that she joined a choir for the first time prompted by her positive experience from aerobics, illustrating that success breeds other successes.
The CESC program contributed positively to Korean older adults’ well-being through social support. The individual interviews found an emphasis on the social aspect of the program – for example, how important it was for participants to be able to interact with other Koreans and to communicate in Korean. Previous studies on arts-based community programs also found social connectedness or sense of community to be an important part of a program that contributed to participants’ well-being and the main reason for continued participation by the seniors (Phinney, Moody, & Small, Reference Phinney, Moody and Small2014; Teater & Baldwin, Reference Teater and Baldwin2014). Similarly, the social aspect and learning were the central parts of the CESC experience which likely contributed to a high participation/retention rate as well as to participants’ health. Previous research has suggested that interaction with members of the same ethnic group is positively associated with psychological well-being among ethnic minorities (Frable, Prat, & Hoey, Reference Frable, Pratt and Hoey1998; Sanchez & Garcia, Reference Sanchez and Garcia2009). Members of the same ethnicity can easily develop group cohesion and experience psychological comfort (Otten & Moskowitz, Reference Otten and Moskowitz2000) because of familiarities in customs and culture.
The field note data made broad-ranging reference to the emotional benefits experienced by the participants: People were generally happier; they stated that they felt appreciated and valued. Many seniors called Enoch College “heaven”, reflecting their Christian beliefs, because of the joyful time they had together. They spoke of a supportive and encouraging environment, from the volunteers to instructors to participants, which helped create a positive experience and also put newcomers at ease. In particular, people spoke of music as something dear to them: bringing back childhood memories, comforting them, lightening their moods, increasing connectedness, and strengthening a sense of membership. Psychological comfort experienced by the participants can also be explained through music (Hays, Bright, & Minichiello, Reference Hays, Bright and Minichiello2002; Lally, Reference Lally2009) helping to manage emotions, change moods, increase positive feelings, experience spirituality (Hays & Minichiello, Reference Hays and Minichiello2005; Lee, Reference Lee2013; von Lob, Camic, & Clift, Reference von Lob, Camic and Clift2010), improve bonding and co-operation, and create a sense of belonging (Bailey & Davidson, Reference Bailey and Davidson2002; Reference Bailey and Davidson2005; Blaine & Fels, Reference Blaine and Fels2003; Clift, Nicols, Raisbeck, Whitmore, & Morrison, Reference Clift, Nicols, Raisbeck, Whitmore and Morrison2010; Livesey, Morrison, Clift, & Hancox, Reference Livesey, Morrison, Clift and Camic2012; Silber, Reference Silber2005).
Although the program demonstrated a significant influence on the measure of emotional well-being, namely, role-emotional, there was no improvement in the mental health variable. It is possible that this relates to emotions at a deeper level perhaps requiring a longer duration and/or targeted intervention to make a difference. For Asian older adults in general, identifying depressive moods and anxiety carry a stigma (Baker, Marryshow, Poteau, & Sutin, Reference Baker, Marryshow, Poteau and Sutin2015; Conner et al., Reference Conner, Copeland, Grote, Koeske, Rosen, Reynolds and Brown2010; Gary, Reference Gary2005). When identifying and rating self-health with psychological labeling such as “depression”, Koreans are likely to refrain from expressing itFootnote 4 (Kim, Reference Kim2010; Kim et al., Reference Kim, DeCoster, Chiriboga, Jang, Allen and Parmelee2011; Sin, LoGerfo, Belza, & Cunningham, Reference Sin, LoGerfo, Belza and Cunningham2004). Our participants also confirmed similar views towards mental health, referring to a feeling of uneasiness answering questions on the mental health domain. One commented: “Confronting that I’ve been depressed or whatever, makes me feel like I am depressed or I will get depressed.” Moreover, questions associated with negative feelings such as nervousness, fatigue, and depression – as well as positive feelings like serenity, energy, and happiness – may be less relevant to older adults as inconsistent responses may result from a misinterpretation of negative or positive questions (e.g., Did you feel worn out? Did you have a lot of energy?) (Kim, Jo, & Lee, Reference Kim, Jo and Lee2013). This might help explain why the vitality scale did not show significant change in the participants, which also may have been affected by seasonal variations in mood and behaviour (Jia & Lubetkin, Reference Jia and Lubetkin2009).
Although there were many references to increased social contacts or relationships and ties within Enoch College community and beyond in the interviews, the social functioning measure did not show significant change over time. This may be due to cultural differences in conceptualization of social functioning in Korean seniors. Similar to the findings reported for other Asian countries (Gandek et al., Reference Gandek, Ware, Aaronson, Alonso, Apolone, Bjorner and Sullivan1998; Lim, Seubsman, & Sleigh, Reference Lim, Seubsman and Sleigh2008; Tseng, Lu, & Gandek, Reference Tseng, Lu and Gandek2003; Wang et al., Reference Wang, Wu, Ma, Zhao, Yan and He2011). S. H. Kim et al.’s (2013) evaluation of the SF-36 in a Korean population suggested that the social functioning variable should be interpreted with caution. Compared to individualistic Western society, Asian cultures with collectivist values tend to conceptualize social roles and social functioning differently. For example, avoidance of social activities due to health problems may be less acceptable for Koreans than for people from other Western countries (Kim et al., Reference Kim, Jo and Lee2013). Indeed, it was observed throughout the school year that weekly attendance to CESC was determined by self-motivation rather than having optimal health, as explained by high participation rates and interview data where participants chose to attend CESC despite having pains from injuries or other health issues.
Although this study provides support for the health and social benefits of the CESC program, there are limitations. Unlike a randomized controlled trial, our study design has known limitations related to the internal validity of results. These limitations include seasonal variations in health status and mood, lifestyle factors, and self-reporting and self-selection biases. For example, there may be an important difference between those who completed the questionnaire on two occasions versus those who did not. The reasons for non-participation were not sought out and would need to be considered in future studies. The detailed socio-demographic information on the study participants was not collected as pre-testing of the survey questionnaire with a sample of seniors found it unduly long, making it a barrier to participation. For future studies, this should be better planned. For a qualitative research component, we used a relatively small convenience sample of participants who volunteered to be interviewed but whose experience may not have been representative of all CESC participants. However, the results of this evaluation confirm findings of earlier research (Jo et al., Reference Jo, Veblen, Potter and Cohen2014), and we have gone a step further through the use of quantitative measures of health and well-being in the context of real-life settings.
In conclusion, this study provides evidence of the effectiveness of CESC in improving quality of life of Korean immigrant seniors. Considering that CESC is rooted in the ethnic community and run by volunteers, it has great potential – as an economical and effective program – for conferring health and social benefits to other elderly community-living adults. Partnership with ethnic organizations can be a valuable starting point as they may be better positioned to provide more culturally relevant and accessible services to minority immigrant seniors through the knowledge of shared cultural heritage and established networks. Future research might focus on (1) programmatic components of CESC such as an ethnic organization’s capacity, commitment, and potential route for partnerships; and (2) an exploration of perspectives from the volunteers and organizers of this program. Because relatively few grassroots programs like this exist, it would be useful to identify essential implementation elements that contributed to the program’s overall success in order to replicate the program in various cultural contexts. Similar research on the community-based cultural programs throughout the minority immigrant senior population would provide further methodological context to validate this evidence. Nevertheless, there is no doubt that CESC has made a lasting impact on the life of Korean immigrant seniors. In the words on one CESC member: “Many activities at Enoch College may seem a bit childish, but for us this is a loving nest that fills us with life’s joy and happiness that are meaningful because we create our lasting memories together.”
