Conference on the Well-Being of Asian American Senior Citizens – Session 2B

Ming Chin Yeh: Welcome to Breakout Session 2B: Senior citizens and Research Projects. My name is Ming Chin Yeh, and I’m an Assistant Professor of Urban Public Health at Hunter College, CUNY.

 

Our first presenter is Mr. Yilo Cheng. He’s a licensed clinical social worker, and is currently the Mental Health Project Manager at the Asian American Federation of New York (AAFNY). Today he’ll talk abou, “After 9-11: Building Bridges and Leveraging Assets for Community Recovery.”

 

Yilo Cheng: I’m going to briefly discuss the objectives for this workshop.

First, it’s to provide an overview of AAFNY what we do, and some of our projects. Second, to further our objectives, hopefully we can identify the challenges of providing mental health services to Asian American elders in New York City. So far the AAFNY has been doing a lot of initiatives and projects to address these issues, and I’ll cover some of them today. I‘m going to present a little about AAFNY’s Red Cross Mental Health Project, highlight some of the findings and also discuss what we feel are some cultural competent models of intervention and some things that won’t work. We’ll be reviewing some lessons learned that works and don’t work. You can’t use the same method to work with Asian seniors as you would with the general mainstream population.

The Asian American Federation of New York is a non-profit leadership organization that works to advance, the quality of life for Asian Americans in the New York metropolitan area. Established in 1990, AAFNY supports and collaborates with 39 member agencies to strengthen community services, promote strategic philanthropy within the Asian American community, and conduct research and advocacy concerning critical issues. We have projects and initiatives to strengthen community service organizations. Most of them are member agencies that serve the Asian community, such as the Chinese American Planning Council, Henry Street Settlement House, Hamilton Madison House, Council of South Asians, Council for Social Services and many more.

 

We have a fund to help community initiatives that we can disseminate for various community-based initiatives and projects. We do a lot of policy, advocacy and research. The presentation this morning in General Session 1 of all the stats, Census information, and demographics, we’re the ones that put that information out. We have a census information center, designated by the U.S. Census Bureau, processing all the Asian American data in the tri-state area. All of the information is on our website, such as demographics regarding each Asian ethnic group, education levels, economic situations, circumstances when they came to this country, language proficiency, and so forth. Currently, I’m managing the 9-11 American Red Cross Mental Health Project serving Asian victims, victim’s family, and also Chinatown residents; especially the Chinatown seniors.

 

I’m going to give several examples to illustrate some of the challenges. One challenge of working with Asian elders is language access. Another one is the stigma of mental health, which is a huge factor. It’s a tremendous barrier to what we’re trying to do as we learn in our projects. Asian doesn’t talk about mental health, and they’re very resistant to any type of initiatives or educations, or treatments.

 

I’m going to talk about various services, and capacity issues. I’m starting off with demographics. The largest Asian ethnic groups in the country and in the New York area are Chinese, Koreans, and South Asians. Currently, South Asians are one of the fastest growing groups right now. A lot of times when we talk about Asians, we don’t really think about the South Asian population, and that’s something the Federation is really trying to focus on by educating the community that South Asians are an integral part of the Asian community.

 

Asian Americans make up about 6% of the New York State population and 75% of them live in New York City. 11% of the New York City population are Asian Americans, the fastest growing ethnic group in New York City from 1990 to 2000, which increased by 71%. The Asian elder population over 65 years old, also the fastest growing elder group, increased by 91% between 1990 and 2000. The Asian American population is projected by the New York State Department of Mental Health to grow by 110% by 2010 to 2015. What I also wanted to emphasize is that this is followed by a 70% projected increase for Hispanics and 28% projected increase for Blacks. Asian American older adults in this country will quadruple from 800,000 in 2000 to 3.2 million by 2030. 94% of New York City Asian elders are foreign born, with 54% of them arriving in the last 20 years. This data is the stark evidence of the importance of language access. We need benefits and materials to be translated and also services to be conducted in bilingual languages. If you can’t provide any of the languages, then what is the use? People aren’t going to come and all of these services will diminish.

 

Poverty level is almost 1 in 4 per capita. It’s a model minority myth that Asian Americans are doing well. If you look at the Federation data and our Census information , Asians overall aren’t doing well. There’s a large influx of immigrant population, especially seniors, since a lot of them came in the last 20 years. We think that Asian Americans are smart and do well, that they go to grad school and become doctors. Again, that’s a myth. Overall we’re not doing that well, especially elders. 49% have less than a 9^th grade education, and 59% didn’t complete high school. And if you process this data in Chinatown, it’s even worse because of the influx of immigrants. It’s an explosion of that population.

 

Mental health issues among Asian adults with mental health disorders are projected to triple by 2030, according to the U.S. Surgeon General’s report. We know that Asians under-utilize mental health services, but by how much? In New York State, we make up 6% of the population, but we actually only represent less than 1 percent of the actual usage. What happened to the other 5%? That’s the discretion, with a lot of implications there.

 

Asian women over 65 have the highest suicide rate among all female groups. Even scarier, for Chinese women over 65, the suicide rate is over 10 times higher than the general population. This is another fact that most people do not know. According to AAFNY research, New York City Asian elders experience depressive symptoms at a higher rate than the general senior population. A study that AAFNY has done in 2003 is “Asian American Elders in New York City, Study of Health, Social Means, Quality of Life, and Quality of Care. A lot of the data came from here, and we actually worked with Brookdale Center on Aging. The second one is the assessment of all the data on Asian American post mental health 9/11. Asian elder adults have a high rate of all types of dementia.

 

Barriers are important to know for any policy recommendations, when designing projects, and for funding purposes. If you can’t document the needs, you don’t have a case for funding or policy. At AAFNY, we initiate these researches, so that other organizations can use this information and get more funding for further research, and design programs better fit the needs of this population.

 

So, number one, there’s lack of knowledge about mental health. It is a concept that is extremely foreign to many Asian Americans. Most Asian seniors don’t know what services are available, when it is needed, or where to go. This is a great contributing factor to low level usage of services, and the under-utilization of services. Many older Asian Americans understanding of health don’t separate the body from the mind. Look at the Chinese culture, the concept Ying and Yang. It’s a balance, if there’s something wrong, an imbalance, then you go for acupuncture, to an herbalist, or to the temple. These are their cultural ways of getting help for. Plus, the stigma of mental health is extremely prevalent, and pervasive in this population, especially for older Asian adults. They have the disbelief that mental illness can be treated. Most people, when someone says to them that they’re depressed, they think, 1) What is that? 2) I’m going crazy. 3) I’ll never tell anybody about it, therefore I’m never going to get help.

Just to give you an example, Mrs. X, a Chinese elder in her 60’s came to me at Hudson Guild Counseling Service in Lower Manhattan. She presented symptoms of depression, common anxieties, disorders, acculturation problems, and Post Traumatic Stress Disorder (PTSD), because she was held up at gun point during a robbery at take-out in Brooklyn where she worked. A common practice for a clinician is to do a “Red House” assessment, a bio-psychosocial assessment. You go through the person’s history, family history, medical history, and you make a diagnosis. For the first month, I wasn’t able to get anything done because there was a great deal of trust building. It helps that I’m Chinese, but even though I am, it’s still hard, just because mental health is such a stigma. The first month, all she did was trying to convince me that she wasn’t crazy and not to send her to Bellevue. Asians believe that mental health is biological can’t be treated.

 

Another barrier is lack of linguistic and culturally compatible services. I have an incredibly hard time recruiting bilingual workers. In the field, bilingual providers in Chinatown are a revolving door. People steal each other’s staff. Bilingual workers go from one place to another, and you’re not getting the supply and demand over strict supplies. Part of what we’re doing at AAFNY is workforce development to recruit more students to go into the field. There aren’t that many in social work schools right now who are in counseling programs. Even if they’re Asian, they’re not necessarily bilingual. The second challenge is that if they are bicultural and bilingual, they may not go into services or agencies that are surveying Asian Americans. A lot of agencies that serve Asians are very under-funded, so salaries tend to be lower, and become an issue.

 

In Chinatown we did a survey on Asian elders in 2003. Chinatown is the highest concentration of Asians, mostly Chinese. Chinatown has the greatest concentration of mental health providers, however from our census information, there’s approximately 10,000 Chinese elders living in Chinatown. You would assume that there would be a great concentration of services, case management, and mental health providers. According to our survey, our 2003 study, there were only 122 slots open for seniors. There is a capacity issue at hand. You can’t get enough providers and funding, plus limited language access.

 

I always try to refer my patients whenever it is necessary, but I can’t get the best of the Asian focused mental health units. The biggest ones are Bellevue, Elmhurst, Gracie Square. They have Chinese, South Asians, and Korean language psychiatrist programs, social workers, and mental health professionals that are always operating at 100% overcapacity. A lot of times, Asian seniors and patients on the waiting list have to go to other settings, such as English speaking only psychiatrics, and a lot of times they don’t even get admitted. Many times outpatient mental health clinics have waiting lists as long as three to four months. How do you tell someone to wait that long? According to research, documentations, literature, Asian Americans enter mental health services the latest. They enter the latest, and they wait the longest. This is because, one, they’re the most resistant and two, there aren’t many places to go, so therefore they’re the most costly to treat because they get help the latest. If you look at their diagnosis, it’s usually the most severe. The entry point of these services is usually through the ER. That gives you the severity of the problems due to a lack of bilingual providers.

 

Another problem is that Asians consist of approximately over 85% to 90% of prescription medication prescribed by primary physicians. Unfortunately, most of the physicians aren’t trained for mental health assessments and depression screenings. Honestly, Asian elders don’t have a lot of time. Just think of the last time you went to a network doctor. Symptoms are often missed, and people don’t ask. A lot of times the problem is how Asian seniors and Asian Americans in general manifest. Symptoms are very different. Sometimes my patient, Mrs. X, her symptoms was gastrointestinal problems and headaches, but she never says depression. It comes out differently for every culture. She talked about joint pains, and would go to primary care physician or a specialist to do ab MRI only to find out nothing was wrong. That’s the importance of culturally competent training to recognize these symptoms. Also, research shows that Asian symptoms and the way our body processes medications is different. The psycho-pharmacology is different, so the amount of medication is different for Asians. Sometimes they are over-prescribed and over-medicated.

 

The other problem being faced is the exploding cost of mental health care. One in four Asian seniors lives in poverty. Some have documentation problems, so they can’t qualify for Medicare or Medicaid. A lot of times for these benefits, you have to be in the country for a certain amount of years as a legal resident. Also they may not know what benefits are available for them. Again, it goes back to language access of benefits and materials. When they need to ask about benefits, or call the Department for the Aging, a lot of times no one speaks their language. Who are they supposed to go through?

 

Less than 3% of individual family members who asked us about overall benefits took advantage of mental health services. That’s underutilization. Less than 5% of victims or their family of 9/11 took use of the service.

 

Limited cultural outreach in the community is consistent with the barriers and services that I mentioned, lack of trained professionals appropriate for linguistic cultural competency. There aren’t enough places to go to, and there’s a lack of service coordination. A lot of times people don’t know who to refer or duplicate services they don’t need.

 

Our objectives is to design programs to address these issues and to provide direct mental health services to Asian American victims and Chinatown elders. We have Asian Lifenet, which is a mental health association in New York, and is one of our partners that’s provides outreach in Chinatown. They do outreach in senior centers, conduct screenings for Chinatown seniors, and organize support groups. For South Asians, we basically have partners in South Asian agencies that do actual direct counseling, psychiatric medication management, and psychiatric services. There are a lot of South Asian groups and they have South Asian family days.

 

AAFNY goes out to promote media campaigns, translations, and connecting individuals with appropriate service providers. We try to make a service directory of providers listed by languages. We basically survey each setting, try to see how many openings they have, and what languages they provide.

 

Help has to come from within the community. We recommend recreational activities, social groups, Tai Chi, or classes on health. We try to get agencies to sign up for our trainings and training programs. Many of them say that our seniors are doing fine, but four years after 9/11, long term care is still a big need.

 

If we can’t recruit enough licensed mental health professionals, we recommend using frontline professionals who are already out there and are bilingual. Train them on how to do health assessment, when to refer, how to refer, and use them as links. Integrate mental health and primary care, because people will naturally come to primary health care services to get help in this population. Start with general questions and work up to more specific ones. Talk about what benefits they have, their physical ailments, and then talk about depression.

 

Thank you very much.

Min Chin Yeh: Our second presenter is Nina Parikh from the Brookdale Center of Aging at Hunter College.

 

Nina Parikh: Good afternoon. I’m happy to be here today to discuss with you all two emerging trends, urban aging and the relationship implication of health and health status. In addition I’ll outline some of the projects that are underway and in development. Finally, I’ll present some data from a large longitudinal study of Chinese immigrants in New York City, specifically focusing on the older adults in our sample.

 

The older U.S. population grew rapidly in the 20^th Century from 3.1 million in 1900 to 35 million in 2000. Over this ten year period there was a 12% increase in the number of older adults, with the exception of 1990, the growth of the older population outpaced that of the total population. With the first wave of baby boomers turning 60 this year, we’re under the cuff of a significant growth among the older adult population. People age 65 and older are projected to represent 20 % of the total U.S. population in 2030, compared with 12 % in 2003. Those 85 years and older shows the highest percentages increase. It’s expected that by [2005], those 85 and over, will reach 19 million, making them 5% of total Americans, apposed to 1% today.

 

Along side with aging, within the past 20 years, the U.S. has experienced the largest wave of immigration in its history. Unlike immigrants who arrived in the U.S. at the turn of the 20^th Century, today, new immigrants are basically non-European, which present significant cultural and economic challenges to the provisions of quality healthcare in this population. Currently, the foreign born population comprises eleven percent of all U.S. citizens, according to the 2000 Census. In New York City, the foreign born population makes up 35% of the total population. Approximately 3 million, or 11%, of foreign born are 65 and over, as reported by the Census. People who are Latin American account for 31% of the older foreign born population right now. 51% of the total foreign born population is Latinos and a younger age.

 

Not part of the current immigration debate are older immigrants with regards to citizenship. That’s because a high proportion of the older foreign born are naturalized citizens compared to the total foreign born, 70% versus 37% in 2000. The lower proportion of naturalized citizens among Asians is partially due to the changes in the immigration law during the late 60s and early 70s, in which a large proportion of Asians came to this country. By combining these two population trends, immigration and aging, we arrived at the conclusion that we’re experiencing one of the largest waves of immigration, and that the proportion of the older adults who are non-White will increase over time. That’s a major distinction to be found in the increasing diversity of racial ethnic groups among the U.S. elderly, is that the elderly immigrants.

 

I want to switch to what we’re doing at the Brookdale Center. One of the major priorities of the research division that I’m a part of is to better understand the determinant of healthy aging, particularly in an urban setting given that well over half of the older adults are currently living in large cities. Currently, we’re involved with a couple of projects, and developing others that are aimed to help us better understand and address the needs of the growing ethnically diverse elderly in New York City.

 

The first project is Health Status of Older Adults Attending Senior Centers in New York City. The second is Healthy Aging in Neighborhoods of Diversity Across the Lifespan, which is HANDLS. And third, the New York City Chinese Health Study.

 

First, I would like to talk about Health Status of Older Adults Attending Senior Centers in New York City. It’s striking that there’s no health data on these seniors who attend senior centers. As city leaders, advocates, and researchers, we need to have a better understanding of the health status and utilization pattern of this vulnerable group to help design better health interventions. We’re working with the Department for the Aging to implement pilot assessments of the health status of older adults attending senior centers throughout the city. We’re collecting data from ten sites, two in each borough, and want to show the diversity in New York City. We have completed four of the ten sites, and have approximately 190 surveys, about 50 surveys per site. The remaining sites will represent older immigrants who are South Asian, Korean, Chinese and Laotian.

 

Second, HANDLS is in development with partners from Baltimore, where the project originated. It’s a community based epidemiological study whose primary goal is to address aging and health disparities in ethnic and poor populations over time. The proposed New York project will evaluate genetics, social, biological, and psychosocial data of Latinos and Asians. The project in Baltimore is currently collecting data on African Americans and Whites. In order to get this genetic, biological, and social data, they conducted surveys at the household level and have their medical assessment go through many tests to finish up the individual data. Community and neighborhood level information is also gathered, such as the number of grocery stores, liquor stores, and parks to help complete the whole picture.

 

Lastly, the New York City Chinese Health Study, is a National Cancer Institute funded longitudinal study to primarily assess smoking cessation among Chinese Americans in New York City neighborhoods. It also includes several health indicators between chronic conditions, ethnic health care, alcohol consumption, and physical activity. The baseline has already been collected, and over 2,500 surveys completed. We’re currently in the field conducting a follow up, so we’ll have additional information soon.

 

To give you a background, the Chinese population is one of the fastest growing immigrant groups in the U.S., from 1.6 million in 1900, through 1990 to 2.4 million in 2000. The Chinese American population is one of the largest segments of Asian Americans in New York City, with a 58% increase since 1990.

 

I will now discuss some of the findings from the New York City Chinese Health Study on the older adults segment of our sample. What I did first was examine the differences that exist between younger, below 55, versus older Chinese immigrants. There were stark differences between younger and older adults in regards to demographic factors. On a socio economic factor, older adults are more likely to have less education, with 60% not completing high school compared to 37% younger adults. In addition, they’re more likely to have income less than $10,000, and less likely to have income higher than $40,000.

 

Turning to acculturation in our study, it is defined as two category variables, a linguistic measure regarding the English language and media use. Relatively few Chinese immigrants spoke English at home. Acculturation, as I said, is a linguistic measure, which includes speaking English at home. It’s not surprising that older adults were less acculturated. It should also be noted that the overall sample isn’t that highly acculturated. In fact, in the regards of number of years in the U.S., younger Chinese immigrants were in the US for shorter period of time. Older adults were more likely to reside in the US for 16 years or more.

 

Right now, I’m going to go through some of the health indicators again. There are significant associations between several health indicators and age. Poor health status and increase problem with chronic conditions exist among older adults at a higher proportion. We do see some trend in the positive direction. For example, older adults are less likely to be current smokers, and less likely to drink alcohol. They’re also more likely to exercise in moderate amounts compared to younger adults.

 

Finally, they have better access to care. 79% of older adults have health insurance, compared with 68% of the younger adults. Older participants were more like to see a health care provider in the last 12 months, compared to the younger group, 81% versus 70%.

 

We can see that age is significantly associated with several demographic Socio-economic Status (SES) and health indicators among Chinese immigrants. Older adults with lower SES, and stronger social support, are less acculturated, have lived in the US longer, have greater access to healthcare, engage in fewer risky behaviors, and have more chronic conditions. Our next step is to further examine the determinants of selected health indicators, such as chronic conditions, smoking, or alcohol consumption.

 

Another topic of discussion is some of the differences among Chinese immigrants by age, and to take a closer look at whether demographics and health indicators among older adults differ based on the number of years in the US. For those who are over 55, the number of years in the U.S. does not differ by much. There are fewer women among those who are over 65 compared to our main sample. Over 65 comprised of 35% women while the main sample comprised of 45% women.

 

Most older Chinese adults are married, 93% of them were born in mainland China, 95% don’t speak English at home, and 91% were considered not acculturated. With regards to access to healthcare, the same trend sort of exists. Those who are over 65, 96% have the usual source of care, 89% have health insurance, and yet their health status isn’t good. 52% reported either having fair or poor health, which isn’t overly surprising given the population. Many Chinese adults have stated that they were usually involved in moderate amounts of physical exercise. Less than half had a high knowledge about smoking, and most was aware that second hand smoke was bad for you.

 

Now I’ll get into my analysis of demographics of health indicators by the number of years in the United States. There are several factors and complex interactions of demographics, social, and behavioral characteristics that are associated with healthy urban aging for the immigrant population. Health status deteriorates with increasing residence in the United States among older Chinese Americans. With mental health, respondents were asked if they felt down or blue and the finding showed an increase based on length of residence here. Adults who lived in the U.S. for less than five years reported being blue, 7% of the time, as apposed to those who were here for fifteen years or more reporting, 12%. What’s interesting is that the folks who have been here for 6 to 15 years are reporting higher, as high as 16%. When folks initially moved here, they might have a better support system, such as family being close to them. As they continue to live in the U.S., their social support system might diminish; family members might have moved away. After fifteen years, they might have adjusted to living here, but nonetheless, they’re still at risk for depression.

 

With regards to healthcare and access, individuals who are here for a longer period of time have better access. They have a less unusual source of care, which is more of a problem for those who are here for less than five years, compared to those who are here for more than sixteen. It might be because those who lived here longer may have become naturalized and be eligible for Medicare as they approach 65 or older.

 

With regards to chronic conditions, there’s a sharp increase for those who’ve been here for a prolonged period of time, going from about 2% to nearly 7%. We don’t see major clear trends for all the conditions that support the notion that the longer one lives in the U.S. the more one’s health deteriorates, in terms of increased problems of chronic conditions. There are some health impairments that are worth knowing, specifically high blood pressure. Only 7% of older adults who lived in the U.S. for less than five years reported high blood pressure, compared with 50% respondents who lived here for more than fifteen years. With some of the other chronic conditions, we don’t see a clear trend. For example, problems with heart disease and diabetes are a little higher for those who lived here for less than five years, in contrast to problems of fractures which is higher among older adults who lived here for 6 to 15 years. Other chronic conditions we’re concerned with is arthritis, with 40% of the population reported having arthritis, which is higher than the general U.S. population of 34%. Heart disease is another chronic condition we’re concerned about, which tops diabetes.

 

To conclude what we’re discussed today, in addressing health and social needs of our most vulnerable population, the elderly immigrants. As the intersection of immigration and aging is in its infancy, we need better intervention and policy measures in place for older adults. We can enact better economic and housing policy through the findings from this report, as well as others, that have found that many older Chinese Americans’ incomes are less than $10,000 a year. As mentioned, social isolation is often assumed that for many ethnic groups, including the Chinese, that family plays a huge role in adaptation and well being of elders. Recent research suggests that there’s a change in the expectation of caregivers and our elders, so I think that needs to be explored a little bit more in terms of how we move forward. We need to look at individual social and contextual factors when we talk about healthy aging. Finally, culturally competent targeted interventions are needed for specific ethnic and racial groups, to better understand the complexity of healthy and successful urban aging, particularly for an older immigrant population. Thank you.