Introduction
The primary motivation behind this study was the lack of specific research on aging South Asian immigrants. The influx of immigrants to Canada has sparked an increase in the cultural diversity in Canada’s population composition. The demographic structure of Canada is changing rapidly, a trend that is expected to continue. As a multicultural nation, one in five Canadians are foreign-born (19.8%), the highest proportion in 75 years (Statistics Canada, 2007). In 2001, 5,448,480 immigrants accounted for 18.4 per cent of the Canadian population. The number of immigrants increased by 13.6 per cent to a total of 6,186,950 in 2006 (Statistics Canada, 2007). In 2006, 58.3 per cent of all immigrants in Canada were born in Asia.
Among the various culturally diverse aging populations, the Chinese in Canada have received the most attention in gerontological research (Lai, Reference Lai2001a, Reference Lai2001b; Lai & Chau, Reference Lai and Chau2007; Tam & Neysmith, Reference Tam and Neysmith2006). There is a lack of research on the adjustment and challenges that older adults face in other ethno-cultural communities in Canada. For instance, the South Asian population in Canada has become the largest visible minority group according to the 2006 Census with a total population of 1,262,865. According to Statistics Canada (1996), South Asians refer to people originating from Bangladesh, India, Pakistan, Sri Lanka, and Nepal. In Canada, they accounted for 24.9 per cent of all visible minorities who are defined as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour” (Statistics Canada, 2006, 2008). However, little published empirical research findings can be found on the older adults in the South Asian population.
A major limitation on most of the few published research studies on older immigrant adults are that some tend to group all immigrants into one large group (Markides, Salinas, & Sheffield, Reference Markides, Salinas and Sheffield2008; Mui & Kang, Reference Mui and Kang2006; Treas & Mazumdar, Reference Treas and Mazumdar2002). This creates an erroneous assumption that all immigrants, despite their ethno-cultural background and country of origin, are the same. Although focusing on one group of immigrant older adults who share a common ethno-cultural origin may be perceived as too narrow a focus, this approach does serve to provide more details about the uniqueness of immigrants of similar ethno-cultural origin, backgrounds, or characteristics.
Barriers to service utilization often play an important factor in the adjustment of aging immigrants and ethno-cultural minorities (Choudhry, Jandu, Mahal, Sohi-Pabla, & Mutta, Reference Choudhry, Jandu, Mahal, Sohi-Pabla and Mutta2002; Kuo & Torres-Gil, Reference Kuo and Torres-Gil2001; Lai & Chau, Reference Lai and Chau2007). This speaks to the importance of paying attention to the types and forms of barriers faced by various aging groups. However, previous studies usually lumped together all the different immigrant groups or ethno-cultural communities, resulting in inadequate attention paid to the challenges faced by different sub-groups of aging immigrants and ethno-cultural minority communities.
The focus of our study was on understanding aging South Asian immigrants for three reasons. First, South Asians belong to Canada’s largest visible minority group but research findings on the aging population in this ethno-cultural community have been scant. For building a truly multicultural gerontological knowledge base in Canada, research that includes the aging population in this ethno-cultural community is needed. Second, most of the previous studies on immigrant seniors tended to group all the different immigrant groups or ethno-cultural communities into one unit, resulting in a shallow understanding of whether the challenges that aging South Asians face are the same as others.
Third, the South Asian immigrant communities in Canada bring with them unique cultural values and beliefs that are very different from many of the other immigrant groups. For example, more South Asian immigrants use English because it is the major official language in the Indian subcontinent. When compared with immigrants from China or other Southeast Asian countries, many of the South Asians hold uniquely different cultural and religious beliefs, some of which are similar to those in the Middle East. Therefore, grouping South Asian cultures into one “Asian” group does not allow the values and beliefs of the various South Asian communities to be accurately represented in research findings.
Fourth, as the South Asian communities also represent people of a range of cultural, language, and religious backgrounds, a step toward gaining a more in-depth understanding of these communities is to conduct research on them. Although the scale of this current study and the resulting sample size may not have been sufficient to allow an in-depth intra-group analysis, the attempt to begin focusing on aging immigrants in South Asian communities is a positive move to build an initial knowledge base that can be used for future larger scale and more in-depth studies.
Finally, no Canadian study has ever used a quantitative approach to examine and verify the types of barriers and the structural factors for health services utilization as reported by aging South Asian immigrants. This study has the potential to form the building block of empirical research knowledge on aging South Asian immigrants living in Canada.
Literature Review
Very little published literature on barriers to health service utilization by aging South Asians in Canada can be found in the public domain. Some research studies are available to examine service utilization by aging ethno-cultural minorities and immigrants and the barriers they face (Giordano, Reference Giordano1992; Leduc & Proulz, Reference Leduc and Proulz2004), by grouping all aging immigrants and ethno-cultural minority groups into one group. As a result, attention to individual ethno-cultural groups is limited, creating the myth that the challenges and issues that aging immigrants face in different ethno-cultural communities are the same.
Equity in access and the utilization of health care services among immigrants and ethnic minorities is essential for attaining the same health status level as the dominant population. However, health disparities in diverse populations are often reported and linked to personal, cultural, or systemic barriers to service utilization including (a) communication barriers; (b) lack of knowledge about available services; (c) socio-economic inequalities; (d) insensitivity to cultural beliefs, values and practices; (e) prejudice and discrimination; (f) dissatisfaction; and (g) mistrust of the health care profession (Benkert, Peters, Clark, & Keves-Foster, Reference Benkert, Peters, Clark and Keves-Foster2006; Facione & Facione, Reference Facione and Facione2007; Garroutte, Kunovich, Jacobsen, & Goldberg, Reference Garroutte, Kunovich, Jacobsen and Goldberg2004).
Studies have shown that immigrants and ethnic minorities generally have a lower level of health care services utilization despite their higher level of health needs (Aroian, Wu, & Tran, Reference Aroian, Wu and Tran2005). Other researchers have found a similar or higher level of health service use in immigrants and ethnic minorities than in the dominant population (Blais & Maiga, Reference Blais and Maiga1999). These contradictory findings might be due to differences in research methodology, such as sample size, single city or region studied, short or unspecified period of observation, or the structure of the health care system (Blais & Maiga).
A study conducted in Quebec that compared the usage of medical services over a one-year period by ethnic groups and native mainstream Quebecers found that the two groups were using the same level of medical services (Blais & Maiga, Reference Blais and Maiga1999). Because of communication and cultural barriers, general practitioners faced challenges in assessing the health concerns of their ethno-cultural minority patients. As a result, these patients were more often referred to a specialist and therefore had more visits to specialists in private offices (Blais & Maiga). On the one hand, this might indicate possible poorer health status and communication or cultural barriers. On the other hand, the patient’s feelings of dissatisfaction with a diagnosis or of being misunderstood also likely explained why a patient was referred to a specialist more often. These findings provide a concrete example of the role of communication and cultural barriers to health service use experienced by ethno-cultural minority groups.
Many studies have identified barriers encountered by ethnic minorities, especially culturally diverse older populations, in accessing appropriate health care services (Aroian et al., Reference Aroian, Wu and Tran2005; Jang, Kim, & Chiriboga, Reference Jang, Kim and Chiriboga2005; Lima & Allen, Reference Lima and Allen2000; Livingston, Leavey, Kitchen, Manela, Sembhi, & Katona, Reference Livingston, Leavey, Kitchen, Manela, Sembhi and Katona2002; Thomas & Payne, Reference Thomas and Payne1998; Vega, Kolody, Aguilar-Gaxiola, & Catalano, Reference Vega, Kolody, Aguilar-Gaxiola and Catalano1999). identified Communication barriers, lack of knowledge about health care, and the perception of inadequate care were identified as the main barriers among immigrants in Canada (Wu, Penning, & Schimmele, Reference Wu, Penning and Schimmele2005) . In addition, structural (e.g., availability, affordability, accessibility of services) and cultural (e.g., health beliefs, values, attitudes towards health services) barriers have been identified as significant in health services access and utilization by older adults in ethno-cultural minority and immigrant communities (Kuo & Torres-Gil, Reference Kuo and Torres-Gil2001).
Specifically, language barriers have been identified as one of the primary access barriers to health services among ethno-cultural minority older adults (Choudhry et al., Reference Choudhry, Jandu, Mahal, Sohi-Pabla and Mutta2002; Kuo & Torres-Gil, Reference Kuo and Torres-Gil2001). Researchers have also found other barriers such as lower financial status (Bass, Looman, & Ehrlich, Reference Bass, Looman and Ehrlich1992), transportation problems (Aroian et al., Reference Aroian, Wu and Tran2005; Lai, Tsang, Chappell, Lai, & Chau, Reference Lai, Tsang, Chappell, Lai and Chau2007), limited knowledge or awareness of existing health services (Lindesay, Jagger, Hibbett, Peet, & Moledina, Reference Lindesay, Jagger, Hibbett, Peet and Moledina1997), and long waiting lists (Aroian et al.). Other researchers have shown that health services access can be hindered by a preference for one’s own cultural services, a lack of awareness about the problems, and a poor understanding of existing services (Kuo & Torres-Gil; Lindesay et al.).
Another recent study (Sadavoy, Meier, & Ong, Reference Sadavoy, Meier and Ong2004) identified some key barriers to mental health services use by ethnic seniors in Toronto. Using focus groups, some of the barriers included (a) lack of awareness about mental illnesses; (b) lack of information, understanding, and capacity to navigate the medical system; (c) stigma and fear of rejection; and (d) a lack of ethno-racial services with a special focus on geriatric and psychiatric care. This particular study suffers, however, from three major limitations. First, the study included only Chinese and Tamils, and the analysis was done by mixing the two groups together. As a result, no specific information was provided on barriers that South Asian older adults in Toronto face. Second, the study focused specifically on using mental health services and did not address the use of other health services. Finally, the use of a qualitative method served to identify the types of service barriers that emerged from the data provided by the participants; however, the data obtained cannot be used to generalize to a larger South Asian population, even in the local context.
Methodology
Research Questions
In this study, we were interested in adding knowledge for understanding service barriers that aging South Asians in Canada face when they try to use health services. Specifically, this study sought to answer the question, “What are the major types of barriers aging South Asians face while using health services and what is the factor structure underlying these identified barriers?”
Research Design
This research was conducted using a telephone survey between August 2004 and July 2005. Because an exhaustive list of names for South Asian older adults does not exist, surnames listed in the telephone directory were used as the sampling frame. Using surnames as identification keys for locating Asian participants is well supported and established (Lauderdale & Kestenbaum, Reference Lauderdale and Kestenbaum2000; Rosenwaike, Reference Rosenwaike1994; Tjam, Reference Tjam2001).
To find the sample, we identified South Asian surnames from the local telephone directory. A South Asian surnames list was compiled using published South Asian surnames listed in previous research (Naidoo & Davis, Reference Naidoo and Davis1988) and websites identified through Internet searches by the second author, who is a South Asian and has strong cultural knowledge about the surnames used by the South Asian communities. Afterwards, research assistants who spoke both English and various South Asian languages were hired and trained to call all the randomly selected numbers to identify South Asians 55 years of age or older and invite them to take part in a telephone survey. The inclusion of those 55 years and older was relevant for the study because, on the Indian sub-continent, most public-sector jobs have retirement ages ranging between 55 to 60 years; and persons 60 years and older are classified as seniors. Other researchers such as Ng, Northcott, and Abu-Laban (Reference Ng, Northcott and Abu-Laban2007) have also included participants less than 65 years old in their study of South Asian immigrant seniors in Edmonton, Alberta.
Community interviewers and graduate students in social science disciplines with the skills to speak English and various major South Asian languages were recruited and trained to collect the data. Among the interviewers were those who had the ability to speak Hindu, Punjabi, Urdu, and Gujarati. In addition, interviewers speaking Bengali, Neplai, Tamil, and Telgu were also available to conduct the interviews. Since the interviewers’ languages encompassed most of the languages used by the different ethno-cultural groups in the South Asian countries, where many groups are multilingual, language barriers were not a major issue for the potential study participants. During data collection, the interviewers also ensured that potential participants could choose to take part in the study using the languages or dialects that they preferred. When an interviewer did not speak the preferred language or dialect of a participant, another interviewer with the relevant language skills called the participant back to conduct the interview.
From the local telephone directory, a total of 10,640 telephone numbers listed under 3,241 South Asian surnames were identified. Using version 13.01 of the Statistical Program for the Social Sciences (SPSS), a random list of telephone numbers was generated for this study. Telephone screening was conducted using 4,719 randomly selected telephone numbers, and a total of 329 eligible participants were identified. For any households with more than one eligible person, the person with an upcoming birthday was selected. For the remainder of the telephone numbers, the call team was unable to contact 2,316 individuals; 950 were not South Asian; and 1,124 were South Asians but did not have any persons in the household who met the age criterion. Among the eligible participants identified, 220 completed the telephone survey, representing a response rate of 66.9 per cent, a higher than average response rate in many telephone surveys with older adults (Ford, Havstad, Hill, & Kart, Reference Ford, Havstad, Hill and Kart2000; McFall & Yerkes, Reference McFall and Yerkes1998).
Instrument
In the telephone survey, a structured questionnaire was used. The questionnaire covered a wide range of topics including (a) socio-demographic information; (b) physical and mental health status; (c) preference for health-related caring arrangements; (d) use of health services and related community support services; (e) barriers to service use; (f) health maintenance methods and practices; (g) cultural values; (h) health beliefs; (i) ethnic identity; and (j) life satisfaction. The interviews were conducted either in English or a South Asian language spoken by the participants. Ethics approval for the protocol of this study was obtained from the research ethics board of the first author’s university. Verbal informed consent was obtained by telephone from the participants before the interview.
In the telephone survey, service barriers were measured by asking the participants to indicate the barriers that they faced in using health services from a list of 21 potential service barriers. The list included service barriers identified in previous research and literature (Aroian et al., Reference Aroian, Wu and Tran2005; Bass, Looman, & Ehrlich, Reference Bass, Looman and Ehrlich1992; Choudhry et al., Reference Choudhry, Jandu, Mahal, Sohi-Pabla and Mutta2002; Kuo & Torres-Gil, Reference Kuo and Torres-Gil2001; Lai & Chau, Reference Lai and Chau2007; Lindesay et al., Reference Lindesay, Jagger, Hibbett, Peet and Moledina1997), and through input from services providers in the South Asian communities in Calgary. Examples of barriers included (a) the waiting list’s being too long, (b) professionals who do not understand the users’ culture, (c) lack of transportation for the users, and (d) professionals who do not speak the users’ languages. The list was included in the questionnaire, and the interviewer read each item on the list to the participant who would then reply either “yes” or “no” to each question about barriers. The participants were also given an option to add barriers that were not covered by the list. The total number of barriers reported by the participants ranged from 0 to 21.
The demographic variables collected included age, gender, marital status, English competency, education, personal monthly income, self-rated financial adequacy, religion, country of origin, and length of residency in Canada. The categorical groupings of most of the demographic variables are listed in Table 1.
Demographic characteristics of telephone survey participants (n = 220)
No objective English testing could be conducted with the participants, and therefore a subjective approach of asking the participants to self-rate their English competency was adopted in this study. Two questions created by the researchers were used. These two questions asked the participants whether they were able to comprehend and speak English. The responses to each question were grouped as “not at all”, “a little bit”, and “very well”. The sum of the two questions led to a score ranging from 2 to 6, with a higher score representing a higher level of English competency.
Self-rated financial adequacy was measured by asking the participants to indicate how well their income and investments satisfied their financial needs, from possible answers of “very inadequate”, “not very adequate”, “adequately”, and “very adequate”, with corresponding scores of 1, 2, 3, and 4 respectively. A higher score represented a higher level of financial adequacy. In Table 1, “Country of Origin” referred to the country that they lived in before immigrating to Canada.
Results
Demographic Characteristics of the Participants
Details of the demographic information are presented in Table 1. Among all the completed interviews, 30.9 per cent were completed in English, 18.2 per cent in Hindu, 9.5 per cent in Urdu, 40.5 per cent in Punjabi, and 0.9 per cent in Gujarati. No interviews were conducted in some of the prominent languages spoken in Sri Lanka (Sinhala and Tamil), Bangladesh (Bengali), and Nepal (Nepali) beca use the random sample did not capture the older people from these countries, probably owing to the relatively small population size of these ethnic groups in Calgary.
The participants’ length of residency ranged from less than 1 year to 46 years. Most participants were from India, while the rest were divided equally between Pakistan and various African countries. It is noteworthy that participants from Africa and other countries identified themselves as ethnic South Asians, although the country they resided in before immigrating to Canada may not belong to one of the South Asian countries as defined by Statistics Canada (1996). For some South Asian immigrants, they may have first immigrated to Africa or other countries, such as the United Kingdom or the United States, before immigrating to Canada.
Barriers to Utilizing Health Services
According to the data of the telephone survey, aging South Asian immigrants reported an average of 5.9 (SD = 5.1) types of access barriers to health services. Table 2 presents a list of health service barriers reported by the participants. Using the data collected through the 21 service barrier items in the telephone survey, exploratory principal-components analysis with nonorthogonal varimax rotation was performed to explore the underlying factor structure. The eigenvalue-one rule was used, and initially six factors were identified. However, as some of the factors only consisted of one or two items, a subsequent scree plot test was performed showing that a four-factor model better fit the underlying factor structure of the service barrier items. Therefore, another round of exploratory principal-components analysis using nonorthogonal varimax rotation was performed with the number of the underlying factors restricted to four. The results for the factor loadings are presented in Table 3, and they indicate that the items loaded well on the four factors.
Service barriers reported by aging South Asians (n = 220)
Rotated factor structure of service barriers
Extraction Method: Principal Component Analysis; Rotation Method: Varimax with Kaiser Normalization.
“Cultural incompatibility” was the first factor, which accounted for 32.8 per cent of the variance. Examples of the items this factor includes are professionals who do not speak the users’ language, programs that are not specialized for South Asians, and professionals who do not understand the users’ culture. “Personal attitudes” was the second factor. It included items such as feeling ashamed, uncomfortable with asking for help, and not believing that the professionals can help. This factor accounted for 9.6 per cent of the variance. The third factor, “administrative problems,” referred to problems such as long waiting lists, inconvenient office hours, and complicated procedures. This factor accounted for 8.1 per cent of the variance. “Circumstantial challenges” was the fourth factor, including items such as lacking transportation, weather too cold to get out, and not knowing about existing health services. This factor explained 5.9 per cent of the variance.
Discussion
This study identified four major types of access barriers for aging South Asians: (a) cultural incompatibility, (b) personal attitudes, (c) administrative problems, and (d) circumstantial challenges. Barriers related to cultural incompatibility explained most of the variance in the overall factor structure of the barriers reported by the participants. The items appearing under the cultural incompatibility barriers are related to the cultural and language differences between the aging South Asians and the health care providers or professionals. The findings on cultural incompatibility are consistent with studies in previous research in which cultural barriers related to language and cultural values are often cited as the barriers by ethno-cultural minority older adults (Blignault, Ponzio, Rong, & Eisenbruch, Reference Blignault, Ponzio, Rong and Eisenbruch2008; Dohan & Levintova, Reference Dohan and Levintova2007; Pearson, Ahluwalia, Ford, & Mokdad, Reference Pearson, Ahluwalia, Ford and Mokdad2008). Using quantitative data, our study has further verified the access experiences of many ethno-cultural minority older adults who often worry about not being able to communicate with the service providers, or that the service providers are not able to understand them from either language or cultural differences (Liang, Yuan, Mandelblatt, & Pasick, Reference Liang, Yuan, Mandelblatt and Pasick2004).
The findings on barriers related to cultural incompatibility indicate that many of the older South Asians in this study would prefer having health care providers or professionals who are able to communicate with service users in languages with which they are familiar. Therefore, cultural compatibility is more than just language use. The barrier items indicated that many of the South Asian older adults also worry that if the service providers or professionals are not from the same ethno-cultural background as the users, the services provided may not be able to meet their needs. These findings indicate the hidden concerns of older South Asian users about cross-cultural empathy, and about cultural understanding and knowledge that all service providers may not have. The expectation extends beyond language use to the service providers’ cultural competence (Fortier, Reference Fortier2008).
Personal-attitude barriers are related to perceptions on seeking help or using services. Previous researchers have discussed that beliefs regarding use of services often play an important role in determining health services use and access. (Kleinman, Reference Kleinman1980; Rosenstock, Reference Rosenstock1966). The findings in this current study add to earlier findings, indicating the potential role that culturally unique or specific values and beliefs may play in the formation of “internal” or “personal” barriers.
Previous research on access barriers faced by ethno-cultural minority older adults has rarely given attention to access barriers related to the administration of services (Whetten, Leserman, Whetten, Ostermann, Thielman, Swartz et al., Reference Whetten, Leserman, Whetten, Ostermann, Thielman and Swartz2006). This gap in the literature is based on the erroneous assumption that all access barriers of ethno-cultural minority older adults are “culture-related”, resulting in a risk that service providers place too much emphasis on culture uniqueness and pay inadequate attention to basic administrative issues in service delivery. An interesting finding in our study is that administrative barriers were reported by the aging South Asians, and some of these administrative barriers related to long waiting lists, inconvenient office hours, complicated procedures for accessing services, and general satisfaction toward the services. These administrative barriers reported are also commonly related by many other service users in a strained health care system in which resources are tight or limited (Wu et al., Reference Wu, Penning and Schimmele2005).
These findings should remind service providers and health professionals that although service users are from ethno-cultural minority backgrounds with different and unique culture values and beliefs, cultural and language concerns are not the only issues. Similar to many non-immigrant aging people, aging South Asians feel that service use experience and administrative issues are important in affecting their access to services. Ethno-cultural minority users with unique cultural backgrounds and different language needs face double-barrelled barriers, a finding consistent with the findings of some researchers who think that ethno-cultural minority older adults face double-jeopardy due to their old age, as well as their ethno-cultural traits as minorities (Silveira & Ebrahim, Reference Silveira and Ebrahim1998).
Circumstantial barriers also emerged as an important type of barrier that older South Asians encountered in this study when accessing health services. Most of the circumstantial barriers reported in this study are actually related to social and material resources. For instance, “services are too expensive” and “do not have transportation” are related to financial resources and vehicle ownership or accessibility. “No one available to take me there” is related to social resources such as social networks and social support, and “do not know about existing health services” is related to knowledge. The detrimental effects of these resource issues are often compounded and can create further problems or barriers for older South Asians when, for example, the weather is too cold for older adults to venture out.
The findings in our study also indicate that except for weather, a factor that is unchangeable by service providers, other resource-related circumstantial barriers could be better dealt with or resolved by appropriate social support or community resources provided to aging South Asians. Previous research has indicated the importance of social support as a key factor for facilitating access to services (Kuo & Torres-Gil, Reference Kuo and Torres-Gil2001; Lai & Kalyniak, Reference Lai and Kalyniak2005). Strategies to create, re-create, and strengthen the social support system of older South Asians could be useful in reducing resource related circumstantial barriers (Kuo & Torres-Gil; Lindesay et al., Reference Lindesay, Jagger, Hibbett, Peet and Moledina1997).
A few methodological limitations of this research are noteworthy. Despite the use of a random sample in this study, our data were derived from a local study collected in only one city. The sample did not include aging South Asian immigrants from all the South Asian countries as defined by Statistics Canada (1996). For example, the sample did not include people from Sri Lanka or Nepal. However, it is important that this study only collected data on the country from which the participants migrated but not necessarily that of the participants’ ethnic origin. It is possible that the sample could have included older immigrants who are Sri Lankan Tamil who moved to India as refugees before arriving in Canada.
The self-reporting nature of the items used for measuring barriers may bring into question some of the results’ validity. The sample size of the ethno-cultural sub-groups (i.e., Hindu, Sikh, and Muslim, etc.) was not large enough to allow the findings to be generalized to larger populations. The relatively small sample size also did not allow analysis to be conducted by examining the differences in barriers reported by the different immigrant cohorts. This leads to the two further issues that this study could not address. One is that acculturation could have affected the manifestation of the barriers by the aging South Asian immigrants. Second, acculturation could also be a correlate of amount and types of barriers reported by the aging South Asian immigrants. The failure to address the first issue arose from the small sample size that limited our ability to subdivide the sample further into different groups representing different levels of acculturation. The second issue was outside the scope of this study but should be further examined in a follow-up study to examine acculturation as an explanatory factor of access barriers of aging South Asian immigrants.
The cross-sectional nature of this research has also limited how the actual effect of time and the length of immigration may have affected the access barriers reported. Future research should consider the use of a multi-site design to include a larger overall sample size as well as a larger sample size for each of the major ethno-cultural sub-groups within the South Asian population. The use of a longitudinal design would also be useful to delineate further the effect of time change on the nature of service barriers reported by aging South Asians.
To conclude, the study has taken an empirical approach to examine the service barriers to accessing health services as perceived by aging South Asians. Consistent with previous literature and research findings, this study has further verified the types of access barriers that challenge aging South Asians in Canada. Previous literature on access barriers for immigrants and ethno-cultural minority groups often focuses on cultural barriers. The findings in our study further delineate the different types of culture-related barriers. Specific barriers such as culture incompatibility, personal attitude, and circumstantial barriers are related to cultural differences, values, beliefs, and the unique socio-cultural background of ethno-cultural minority groups. The findings should form the conceptual basis for understanding and measuring access barriers faced by this aging ethno-cultural population in future research.
