Introduction
Regarding the care of older people, there are two categories of available assistance, namely formal and informal care, where the former includes services that are paid for and delivered by healthcare institutions or individuals for the elderly (Li & Song, 2019). The availability of these services is not a definite indicator of utilization by the target population and particularly minority groups such as the Asian-Canadian Elderly. Considering that the difference between formal and informal care is the cost aspects and, in some cases, the quality of care delivery, this adds to the many possibilities that may affect the Asian Canadian elderly population and their families in making the decision regarding paying for various forms of elderly care.
For Asian Canadians, the underlying factor that distinguishes them in pursuit of formal services for the elderly is their immigrant status and how it affects access to and delivery of healthcare. Studies indicate that immigrants, overall and depending on the specific group, are 13.7% more likely to experience aggressive care (Chu et al., 2021) as compared to supportive care. This is a statistical representation of situations where the population of interest only relies on family care for conditions that require aggressive care and fails to translate similar attitudes toward supportive care, which is essential, especially for the aged population. In most cases, the decision lies largely with the family of the elderly more than the opinion of the patient.
Despite the availability of formal care in the country, utilization may be affected by various factors, which either include those that encourage the elderly to seek them or that hinder access. First is the obvious question of accessibility which may include either home-based, community-based, or residential care in nursing homes(Li & Song, 2019). The cost of care is another commonly considered reason for the pursuit of formal care, although it is minimally addressed as a limitation or facilitator of utilizing services among this population (Cheng et al., 2020). As suggested, the input of the patient is rarely considered, and various facilitators of utilization may mainly rely on the perceptions of the family rather than the needs of the patient.
Accessing formal services is a crucial part of health for the elderly population and especially the target population in this paper due to the migrant status and its implications on social determinants of health. Utilization of healthcare services is dependent on social determinants of health as much as delivery is considering that language and cultural differences or geographical and availability of access may hinder the possibility of considering formal services as an option (Wang et al., 2019). Cultural limitations are a key issue even in social determinants of health, and subsequently, this approach to considering barriers and facilitators among the population could also highlight why the realization of Health Services among the elderly in this specific population is not considered in the general ideal framework.
An ideal framework for the utilization of formal services is one that means the population is well-educated and equipped in terms of pursuing formal services readily available for their needs. The Asian Canadian elderly population particularly relies on culturally competent and professional care for the quality of elderly care. The intention to use long-term care and formal care services arise from the family members of the elderly, and an exploration of the Anderson behavioral model, as well as the experiences of this population, provides a paradigm through which an analysis of barriers and facilitators can be achieved (Qiao, 2020). In light of independent case studies and the myriad of factors that affect the consideration of formal services, this research mainly considers the extent to which a real or perceived barrier and facilitator affect the final decision.
Barriers to the utilization of formal services are anticipated as the reasons why an elderly individual or the family would not resort to formal services and instead consider informal care considering that dependency is available at this stage in life (Li & Song, 2019).On the other hand, facilitators are deemed as other provisions of the Healthcare system or government policy that encourage Asian Canadian elderly to pursue services available to them and enhance their quality of life. Regardless of the reasons for and against seeking payable services for this population, the ultimate choice remains with the patient or family, but research can only illustrate the extent to which these barriers and facilitators influence the choice. The main question addressed here is, “to what extent do the barriers and facilitators of the utilization of formal services by Asian Canadian elderly affect access and outcomes ?”
The various sections of this paperwork describe the theoretical basis, previous work, a compilation of information, and conclusions drawn on limiting and driving factors of Asian-Canadian Older people seeking formal services. The theoretical or conceptual framework is the first section, and it outlines the Anderson and Newman behavioral model as it explains practices of Healthcare utilization, followed by a literature review of available studies regarding utilization is are generally or within the specific Asian Canadian elderly population. The discussion section will compile the main findings and key points of the research that are related to the current research question and potentially identify gaps that could be better addressed in the future. In conclusion, this paper will address how the theoretical framework literature and discussion come together to form an actionable basis for the pursuit of formal services among this population.
Theoretical Framework
According to the Andersen and Newman Behavioural Model (ANBM), the probability that an individual will seek out available healthcare options for them is not random but rather a systematic compilation of three classes of factors. The three classes of factors that influence whether an individual will seek medical attention include predisposing, enabling, or need factors (Tesfaye et al., 2018). The classes can be described in various situations depending on the sort of care that is being pursued, either elderly care or antenatal, and for the purposes of this research, the three classes will focus on smaller populations within the greater than-honorable elderly population.
Predisposing factors are mainly social and cultural issues leading up to the need for professional help, in this case, for the Asian-Canadian elderly. With older people, there is a high likelihood of developing single or multiple health conditions hence use, the need for guided care cannot be completely eliminated (Petrovic & Blank, 2015). The predisposing factor is old age and increased probability of complications in line with cultural issues that are associated with the status of Asian Canadians as migrants under consideration in barriers and facilitators of utilization, considering that they also form a precursor to various enabling factors such as availability of resources.
Enabling factors under the ANBM, much like facilitators, are the logistics and resources available for an individual to seek out the available options for professional care. In select instances, the logistics and resources are not as obvious as expected, considering that, to some extent, attitudes among the family of the patient can affect the likelihood of accessing available services (Tesfaye et al., 2018). The availability of resources and the logistics of accessing formalized care actively affect Asian Canadians and also form a framework for understanding the relationship between paid services and informal ones that may be provided by the members of the family and the extent to which a family or community may consider formal services as a need.
Need factors, as the name suggests, are mainly those that categorize the pursuit of formal services according to the level of importance that an older adult and their family attribute to it. The main distinction of formal services is that they require a form of payment; therefore, there is a likelihood that its analysis as a financial need or want is a possibility for the Asian Canadian elderly. Passive informal care as a financial need or want is an aspect of utilization that may be affected by various kinds of barriers, such as personal attitudes, circumstantial challenges, cultural incompetence, or administrative problems within the facility where people seek care (Lai & Surood, 2010). In the presence of proper care, as I need, any issues with care delivery act as a barrier to the utilization of available services.
Applying ANBM to the choice to access formal services by the Asian Canadian elderly explores predisposing, enabling, and need factors that result in barriers and facilitators of using the services. All these factors function independently and collaboratively to influence family decisions on whether to pursue paid services for the elderly, and often a combination of factors is necessary to determine a barrier or facilitator (Qiao, 2020). The cultural aspect can also not be ignored, considering that it may make the difference between considering formal and informal care, especially in the case that a family may have access to professional help through members of the family and not require the assistance of a third party. Next is a literature review that looks at available studies describing the specific Asian Canadian population in light of this theoretical framework.
Literature Review
The mainstream idea is that utilization of formal services is a no-brainer, but in many instances, there are many factors that either encourage or discourage the practice, and they can either be internal or external influences. Literature addresses the various theories and conceptual frameworks that describe habits of health care utilization and specifically the practices among Asian Canadian elderly to provide a foundation for understanding barriers and facilitators of accessing formal services. While some studies are direct on the input regarding the issue of using health services in the population (Lai & Surood, 2010), some studies suggest a more complicated and integrated approach to understanding barriers and facilitators.
Formal Services as a Non–Negotiable
The main determinant for seeking formal services among the elderly, regardless of their demographics, is the sociology of aging, which predisposes this group to multiple comorbidities and makes them dependent. Petrovic & Blank (2015) provide the example of older people with cardiovascular diseases and HIV and the Anderson and Newman behavioral model of Health Service utilization which makes the relationship between a patient and a provider paramount. Furthermore, the observation of crucial services such as antenatal clinics in a different study highlights that the model of utilization is greatly dependent on all three factors rather than individual (Tesfaye et al., 2018). Regardless of the reasons for or against the pursuit of formal service, it remains non-negotiable for the quality of life, especially for the current population.
The pursuit of formal services can also be analyzed as a requirement regardless of the country in which an older adult resides. The study of the utilization of healthcare services, especially in rural areas of China, indicates that chronic diseases are a major factor that encourages using Healthcare services, and in some cases, physician visits or family size may influence the pursuit of paid care (Li et al., 2016). This angle of the literature proposes an alternative perception of living for more services as one that is not affected by geographical locations but rather the condition of the patient and, as a result, may also enhance their understanding of the need for various classes of formalized care either hospitalization or home-based care. In some cases also, hospitalization may be unavoidable, indicating that most services remain to be non-negotiable when considering care for the elderly in various settings.
Utilization as a Migrant Issue
Migration and health are considered call issues in healthcare, especially when it affects the accessibility and utilization of available services for the elderly population. Although utilization affects the entire population of immigrants in the country, and there is a confirmed difference among Canadian-born individuals, the elderly population is much more vulnerable (Wang et al., 2019). With modernized care and increased awareness of culturally competent care among medical professionals, the conversation on the cultural or language limitations that affect the utilization of care is mostly considered an afterthought, although, in literature, it is still evident that it is a key determinant. One can either look at the utilization of formal services as a migrant issue where immigrants are less likely to utilize services because they are disadvantaged or, on the other hand, consider that utilization is a universal problem that is still evident in their home countries of the migrants.
An alternative perception of the utilization as a migrant issue in Canada examines the utilization behaviors in China for the representation of Asian communities in their home countries. There is still a persisting and evident issue with utilization especially considering factors such as the expenditure on healthcare and the inconvenience of formal services, which disputes the arguments that immigration and cultural issues limit Asian Canadian elderly utilization (Li et al., 2016). This perspective is an eye-opening assertion to the barriers and facilitators of utilization because it indicates that even in the absence of cultural diversity or in the comfort of their home country, there is still a limitation with how people perceive formal care. Alternatively, this approach is also an indication that the perceptions of formal care may be a social or cultural issue whereby the Asian Canadian population prefers to take care of its own rather than seek external help.
The Real Barriers and Facilitators to Utilization
The actual barriers identified to the realization of human health services among the elderly are largely cultural differences and the structural aspect of health service delivery among the Asian Canadian population. As presented by Qiao (2020), some of the limiting factors may not be associated with the current status of health services in the country extensively as a result of consideration of conveniences and cultural expectations from the families of the elderly. Some of the barriers that will be deemed emotional limitations as to why a patient or family would pursue formalized care, for example, in the case of loneliness in using Primary Care (Sirois & Owens, 2020). The process of pinpointing barriers is as complicated as establishing facilitation to utilize informal services within this population due to the representation of factors from a professional rather than an experience perspective.
Facilitators are extensively discussed as situations that encourage patients to seek paid services for the elderly, but in some cases, some facilitators are a result of unavoidable circumstances. An example of a negative situation that results in the facilitation of utilization is the prevalence of neurological conditions that require specialized assistance that cannot be delivered via informal care (Cheng et al., 2020). Observation of patient responses to free clinics and the possibility that a patient would consider free services is largely associated with patient satisfaction and the differences in care delivery design as compared to formal services (Petrilli et al., 2022). From these observations, the real facilitators of the utilization of human services among the Asian Canadian population first depend on the context of the patient and especially if there is an undeniable need for professional care that can only be obtained through payment. The following discussion will attempt to eliminate each factor and establish which ones remain definite barriers or facilitators of utilization.
Discussion
The main identifiable barriers that are affecting the utilization of multi-services by immigrants in Canada range from literacy to structural circumstances. As outlined by Wang et al. (2019), there is a distinction across the focus areas, such as access and utilization of health promotion or utilization of mental services when reviewing care for older migrants in Canada. The difference in the barriers that affect the utilization of care is mainly associated with whether they need to be addressed at the patient level through education or through policy implications in the case of structural barriers to access and benefits of formal care. Other factors, such as loneliness and how it affects the care of older adults, are minimally addressed, although they remain a key concern affecting elderly migrants (Sirois & Owens, 2020). This discussion anticipates how eliminating various barriers and facilitators can provide insight and what is the root cause for or against the utilization of family services within this population.
Although the cost of service provision constantly arises as a reason for many families not considering formal service, there is evidence that patient care relies a lot on other factors and not just cost dependence. According to Petrilli et al. (2022), there is a generalized perception that free clinics have a different design, especially in the design of care delivery that may not provide proximity or efficiency in care as compared to services that are paid for. This perception could be an active hindrance to the comparison between available informal and formal services for the elderly and a subsequent preference for formal care due to the assurance of better health outcomes. This observation of free clinics highlighted cost as an issue, maybe a weak barrier to the utilization of health services. Also, it definitely facilitates formal services as patients and families may trust their formal services more.
The trust between a patient and physician as it dictates the possibility of older adults with chronic conditions pursuing formal services is not adequately addressed, although it is a key determinant in the case of Asian Canadian elderlies. According to Petrovic & Blank (2015), the care of the elderly is not just limited to the general practitioner or specialist doctor that handles them but also the show’s social workers, surgeons, and multidisciplinary teams that they may interact with. This theme rarely arises in the discussion of the utilization of care, considering that it is a general expectation that a formal setting will provide all the needed support and specialized care for a patient. The relationship that a patient and their family have with medical providers can also influence your perceptions of the community regarding the worth of formal services in caring for the vulnerable elderly population especially considering the cultural differences.
Another angle to pursue would be to eliminate the aspect of migrant status and how it affects the utilization of health services by comparing utilization habits within the home countries. According to Li et al. (2016), the Anderson behavioral model, as applied to the elderly population in China, indicates that despite the availability of health services, there continues to be a significant difference between predisposing and enabling factors in terms of how it predicts the possibility of pursuing formal care. In most instances, the main facilitator of formal care is the need factor which process the family and patient to utilize the option. With the need factor prevailing above predisposing and enabling factors, it is easier to perceive utilization mainly as a result of the health care needs that force utilization of healthcare services or, on the other hand, become a barrier for those that direly need professional help.
In some instances enabling factors of pursuing formal services are directly associated with social and economic capabilities and the perceived importance of care in enhancing the quality of life (Tesfaye et al., 2018). Social and economic capability is a key determinant in most aspects of healthcare, and this is not unique when addressing formal services for the Asian Canadian elderly. While cost as a stand-alone issue can be eliminated, the social-economic capability is a different analogy that combines both the capability of a family to take care of the elderly on their own depending on their awareness or literacy levels. This social and economic capability may also be directly linked to cultural issues when compared across various migrant groups and the care of the elderly.
Despite similar limitations among immigrants in seeking formal care for the elderly, there is a significant difference between Asian Canadians and other categories. According to Chu et al. (2021), southeast Asians in Canada are less likely to pursue supportive care as compared to white Western Europeans. This observation in relation to the probability of receiving aggressive care might explain the preference for aggressive care relative to supportive care. The observation that aggressive care is more prominent as compared to supportive care, as well as the comparison between migrant groups, indicates a possible cultural implication in the utilization of formal services. Although not directly employed, there might be a difference in perceptions between Asians and western Europeans that affects the perceptions of using formal services.
The finalized compilation of information retrieved through this research indicates that there is an influence on the utilization of formal services that are affected by migrant status and the need for professionalized care depending on the condition of the patient and the affordability of the service. The family setting and the possibility of home care costs, especially in cases of neurological conditions, result in a burden of healthcare that affects the barriers and facilitators much more than any other Factor (Cheng et al., 2020). Beyond the need for formal care with me for some families to pursue the options, the other services, such as migrant status and affordability of the service, cannot be addressed independently, considering that various cases depend on a combination of factors. The Anderson model of behavior is adequate to predict the utilization of health services, considering that need factors take precedence over predisposing and enabling factors for this population.
Conclusion
The barriers and facilitators of utilizing formal services among the Asian Canadian population, as outlined in this research, are largely dependent on specific case studies, and in some cases, a facilitator may be something perceived as a barrier in other instances. It is evident from the available literature that many limitations exist, especially those associated with cultural competence and linguistic challenges, which prevent the pursuit of formal services in many parts of the country. Regardless a large number of factors, especially those that encourage utilizing formal care that is the facilitators, are usually a result of a lack of options, especially in cases where the health of the patient is largely dependent on the formal care. There is a significant gap in the quality of evidence provided for barriers and facilitators to utilization which can further be enhanced by considering the input of the affected population in addition to professional opinion.
The barriers and facilitators identified in this paper are most similar to social determinants of health, indicating that awareness and education are key in ensuring that formal care is available to those that may need it and provisions are made to make it more convenient. The responsibility of utilizing formal services depends on the patients and their families as much as the healthcare professionals due to the culture of relating the cost-benefit of formal services to the needs of the patient and, in most cases, downplaying the need for multidisciplinary care. Ultimately the barriers and facilitators affect the choice to either take up formal or informal care for the elderly among the Asian Canadian population and for this reason, it is crucial to address each barrier and facilitator independently.
Future Research
The limiting and driving factors of exploring formal services by Asian Canadian elderly can further be examined, especially with studies that specifically investigate this population and obtain feedback from them. This extensive study will contribute to the reality-based understanding of evidence and possibly include more information that is left out in generalized studies of minority populations. Another limitation in the currently available research regarding access and utilization of elderly services is the geographical distribution and representation of other Asian Canadians that do not fall under the Southeast or East Asia regions.
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