Culturally Sensitive Long-Term Healthcare Services for Japanese Canadians - Understanding the needs of care recipients a

1. Culturally Sensitive Long-Term Healthcare Services for Japanese Canadians-Understanding the needs of care recipients and family caregivers- Naoko Metz NET Master’s Trainee MA in Counselling Psychology, Trinity Western University Thesis Supervisors Dr. Marvin McDonald, Trinity Western University Dr. Maria Cristina Barroetavena, BC Cancer Agency NET Research Day June 6, 2006

2. Background: Seniors in BC • BC has one of the most rapidly aging populations in Canada • It is estimated that seniors (65 years and older) will make up approximately 24 percent of the total population of BC in 2031 • 13.3 percent of BC’s total population is over 65 years and • Immigrants made up a total of 36 percent of senior population (2001) • Large number of seniors whose mother tongues are other than English, especially Asian languages are prominent in BC • Race and ethnicity continue to function as systematic barriers to accessing and providing health services including long-term care services (A profile of seniors in British Colombia)

3. Background: Japanese-Canadians (JCs) • Approximately 37,300 of Japanese-Canadians reside in BC (total JC population 73,300) • About 65% of Japanese were born in Canada, the highest proportion of all visible minority groups • The percentages of intermarriage are the highest of all the ethnic groups (95%)

4. Background: Japanese-Canadians, cont. • The number of Japanese immigrants has remained constant (~1300/yr) but the number of people with mixed Japanese ancestry has nearly doubled in 10 years • Exhibit high level of social integration • High percentage of them holding professional and/or managerial jobs • Low unemployment rate and high educational level (Statistics Canada, Census 2001)

5. Background: Japanese-Canadians (JCs), Cont. Inter-group differences among Asian cultures in conflict resolution • Japanese infrequently use assertive mediation techniques such as criticism, education, and disputant separation • Japanese are more apt to rely on nonassertive techniques such as gathering information from the disputants, listening to opinions, and relaying these between disputants • Japanese approach is significantly less assertive than that used by the Chinese or the South Koreans (Callister and Wall, 1997)

6. Characteristics of Traditional Japanese Culture Giri : refers to obligation/duty, the expectation that all help would be provided from within the family may result in resistance to obligating oneself to an external help Gaman: refers to perseverance/self-control Enryo: refrain from imposing self-interest or needs, self-restraint/reserve Haji : refers to shame/disgrace (Kobayashi, 1999)

7. Traditional Japanese View for Caregiving • “Oya koh koh” -filial obligation/piety (Kobayashi, 1999; Hashizumi, 1998; Young, McCormick and Vitaliano, 2002) • “Sekentei” -conformity to the society/community in general and how it relates to specific norms (filial obligation) or more general norms such as self-sacrifice, endurance • “Obasuteyama”- the legend in old Japan in rural poor area that they used to leave elders in the mountain to starve them to death. Obasuteyama is also used as a symbol of self-sacrifice from elders’ point of view, in order to avoid being a burden to others (Young et al, 2002 and Saldov & Kakai, 2004) • “Shikataganai”-refers to the view that the situation cannot be helped and nothing else can be done. (Flanagan, 2003)

8. Study Overview • Purpose: This qualitative study was designed to investigate issues faced by Japanese- Canadian (JC) family caregivers and care recipients and to explore culturally distinctive adjustment and coping behaviours in the context of long-term care services • Study location: Vancouver lower mainland, BC • Recruitment: Local news papers and community centres

9. Study Overview, cont. • Participants Adult Japanese-Canadians who are/were family caregivers, care recipients, or professional caregivers in a long-term care setting • Interview Procedure Demographic, confidentiality and consent form, followed by individual semi-structured interview (JP/EN) • Data Analysis Phenomenological analysis-Primary and shard themes were identified

10. Definitions • Japanese-Canadians: Those who consider themselves as “Japanese” or “Japanese-Canadian”, including 1st and 2nd generation • Family Caregivers: Those who consider themselves as primary family caregivers who are currently or have provided care in the past for their family members at home and/or at a care facility • Care Recipients: Those who are currently receiving care either at home or at long-term care facility due to old age related health concerns, chronic and/or life threatening illness. Anticipated future care recipients were also included in the study

11. Family Caregivers Demographics • Total of 6 family caregivers, all females • Age ranged from 40s (3) and 60s (3) • All born in Japan with the length of residency 5 to 48 years • Married with child(ren) (4), widow (1), divorced (1) • English proficiency: bilingual (3), mid (1), beginner (2) • Education: high school diploma (1), collage diploma (3), university degree (2)

12. Family Caregivers Demographics • Occupation: Homemakers with retired spouses (3), part-time job (1), family-owned business (1), writer (1) • Religion: Christian (5) and none (1) • Relations to the CR: mother-in-law (2), parent (2), spouse (2) • Type of illness: stroke, cancer, dementia, accident related severe injury including head and/or hip injury • CR’s outcome: death (5) and partial recovery (1)

13. Care Recipients Demographics • Total of 4 care recipients: male (2) and female (2) • Age from 60s (1), 70s (1), 80s (1), 90s (1) • Receiving care at home (1), at the Japanese assisted care home (1) and prospective care recipients (2) • Born in Japan (3)/Canada (1) with residency from 13 to 90 years • English proficiency: Bilingual (1), mid (1), beginner (2)

14. Care Recipients Demographics, cont. • Occupation: All retired (home maker, agricultural business owner and university professor) • Education: high school diploma (2), 2 year collage (1), and graduate degree (1) • Health concerns: cancer, hearing and walking difficulties, heart condition, high blood pressure, and arm/hip/leg pain and diminished usage • Religion: Christian (3) and none (one)

15. Themes

16. Language Barriers Key underling issue affecting the overall long-term care experience of Japanese–Canadians • Primary themes • Communication difficulties with medical/legal personal • Being a liaison, advocate on behalf of a care recipient • Concerns/hesitation for living in a mainstream care home • Limited opportunity for socialization (isolation) • Limited availability in language-matched care services • Inter-generational communication gap

17. Language Barrier, cont. “At the hospital, there was a lack of translator. Everything fell upon us. In the last 3 weeks of my father’s life we were at the hospital 24/7. There were the rounds of doctors to explain the situation but also for the sake of my father’s comfort. We always feared to miss something important. Without our help my father would have signed papers without knowing what they were. So this was a big issue. And I was thinking: Oh my God. What about all of the patients who are alone and do not speak English!” (Family Caregiver) “It is miserable to live in a care home where one can not speak in Japanese. Even those who used to speak English (when they were young) tend to forget English as one gets old. So, language is the most significant aspect of our daily life.” (Care Recipient)

18. Culturally Rooted & Culturally Accommodating Coping Stances Culturally rooted coping stance: • Gaman (self-sacrifice/endurance) • Shikataganai (acceptance) • Enryo (self-refrain/hesitation) Culturally accommodating/ mainstream coping stances • Being assertive and proactive in protecting one’s rights • Being assertive in voicing one’s needs and demanding better service

19. Culturally Distinctive Coping Stances “I don’t want to be too arrogant, you know, then nobody comes near me or be scared of me. So, I don’t want to be too arrogant. I want to keep a low profile. I try not to ask much, I try not to be a burden to anyone.” (assisted care home resident) “I think it’s a Japanese personality trait, we Japanese release stress and tension by crying or do a bit of mumbling, you know somewhat passive. But in the North American main culture, there is a mentality like “be strong and fight back ” when you are faced with adversity. It has more positive and assertive connotations. This is not a typical Japanese way of coping. “ (Family Caregiver)

20. Culturally Accommodating Coping Stances “Caregivers should make sure to write a detailed journal about the treatment the patient is receiving. One should make sure to read and understand all the documents before signing them. If you need a translator, ask for one. It is important to know that one needs to protect the rights of ourselves and family. “ (Family Caregiver) “And also, this can be observed even among Japanese who has been living in Canada for a long time, that they feel shame in expressing when faced with life challenges or hide any problems from outsiders. I don’t think these are good. I think things should be different. When we faced with challenges, it is important that we deal with them in a assertive way.” (Care Recipient)

21. Imprecations for Policy Making and Community Support • Need for a centralized and bilingual (JP/EN) information service regarding the long-term care services • Need for professional medical interpreting services • Need for increased Japanese speaking home visit care professionals with better accessibility

22. Imprecations for Policy Making and Community Support, Cont. • Need for support for family caregivers (i.e helpline) • Education for awareness building concerning depression among elderly and implementation of “check-up” system on elderly persons who live alone • Need for a language/culture appropriate comprehensive long-term care facility

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

24. Question Time For further inquiry, please contact; Naoko Metz Metz_n@hotmail.com Master’s in Counselling Psychology Trinity Western University, Langley BC ~Thank you ~