1. Mental Health Issues and Use of Health Care Services Among Older Immigrant Women in California by Eronmwon Linda Olanisa School of Social Work California State University, Long Beach May, 2012

2. Introduction  In the last 40 years, the United States has attracted immigrants from all around the world. (Department of Homeland Security [DHS], 2011).  According to the Department of Homeland Security in 2008, California had the largest number of immigrants, which was 27.4% of the total number of immigrants in the United States. (DHS, 2011).  Fifty-six percent of these immigrants were female and Eight percent of the immigrant population in California consists of older women, age 65 years and above. (DHS, 2011).  Although the number of women immigrating is on the rise, little emphasis is laid on the well- being of these immigrant women and how they adjust to the foreign society. (Marsella & Ring, 2003).  The intent of this study was to examine and understand mental health issues and health seeking behaviors of older immigrant women, in addition to exploring how they utilize healthcare services.  What demographic characteristics (age, marital status, and education) are associated with issues of mental health and health seeking behaviors of older immigrant women?  Is there a relationship between mental health issues and health seeking behaviors?

3. Social Work Relevance Older adults are among the fastest growing groups in the United States, and immigrant women are inclusive in this population. (Migration Policy Institute 2009), The immigration process requires many changes in the lives of those who emigrate; consequently, these elderly immigrant women are more susceptible to difficulties and challenges in everyday life due to the change in homeland as a result of relocation. By having a better understanding of mental health issues and factors that may affect how older immigrant women utilize professional health services, social workers would be able to educate and serve the needs of this population. This study is relevant in equipping social workers with the knowledge and awareness of the needs of this population so that social workers will develop culturally sensitive programs that will positively impact the health seeking behaviors of older immigrant women.

4. Multicultural Relevance The influx of immigrants in to the United States is increasing, which means that they will continue to be a part of the population that will be seeking services from the healthcare system. This means that social workers should be culturally competent and sensitive in identifying sets of values or belief systems in order to better serve clients. It is also important for social workers to remember that many immigrant women will not come forth with personal or family information, or admit to personal challenges; many women fear they may be criticized or judged, not only by service providers, but also by members of the ethnic group that they identify with. It is important for social workers and other healthcare professionals to have an understanding that most immigrant women, especially those 65 years of age and older, do not have as much education as American born women, and therefore may not be able to express themselves clearly. This may obstruct the way they get services. However, it is important that each case should be assessed individually.

5. Methods Sampling The CHIS (2009) data were collected by telephone interviews in five languages: English, Spanish, Chinese, Vietnamese, and Korean. The sample in the CHIS (2009) was randomly selected. In order to achieve random selection, the state was divided into 44 geographic sampling strata. Within each geographic stratum, telephone numbers were sampled randomly using a random-digit dial method. Data Collection The CHIS (2009) encompassed information on health and mental health behaviors of adults and older adults living in California. For the purpose of this study, the target population was restricted to immigrant women 60 years and older by using a nonprobability, purposive sampling procedure. Moreover, data about immigrant women within the ages of 60 years and above years were selected. This research analyzed the responses of 129 immigrant women.

6. Methods Variables and Instrument This research was conducted utilizing secondary data. There was no administration of questionnaires or surveys. The variables utilized for this study were derived from the 2009 California Health Interview survey data files. Only elderly immigrant women between the ages of 65 years and above were selected for the study. The data retrieval form outlined the questions that were utilized for the purpose of the study; data for 24 questions were retrieved. Data Analysis The Statistical Package for Social Science (SPSS) 19.0 software was used to analyze the data for this study. The univariate statistics such as frequencies and percentages were reported for each variable. Frequencies were performed to describe the characteristics of the sample. A correlation analysis was performed to measure the magnitude and direction of linear correlation between the feelings scale, the emotions scale, psychological distress, and the number of visits to the doctor. Independent groups t- tests were used to answer research questions.

7. Results The study sample consisted of 129 respondents who were of diverse racial descent and were all immigrant women. The respondents ranged in age from 60 years and above. More than one third (62.8%; n = 81) were between the ages of 60 and 65, and 37.2% (n = 48) were 66 or older. Regarding marital status, 48 respondents (37.2%) were married, while 81 (62.8%) reported that they were separated or divorced, widowed, or never married. In regard to education, 61 (47.3%) of respondents had a high school education or less, while 68 (52.7%) had a college education or more. In reference to English fluency, more than half (n = 65; 50.4%) did not speak the English language well or not at all, 22 (17.1%) spoke only the English language, and 42 (32.6%) spoke the English language well or very well. The majority (n = 101; 78.3%) of the respondents were naturalized citizens of the United States while 28 (21.7%) were non-citizens of the United States. The average age of the respondent was 64.31 year. There is a statistically significant relationship (t = 2.484, p =.014) in the emotions score between those who had difficulty going outside the house (mean = 3.5385) and those who did not (mean = 2.6117). There is a statistically significant relationship between those who have difficulty learning, remembering, and concentrating (t = 3.116, p <.002); those who had difficulty going outside the home alone (t = 4.753, p<.001); and those who have conditions that limits physical abilities (t = 3.457, p <.001) and in their relation to psychological distress.

8. Results contd There is a statistically significant relationship between education (t = - 3.970, p <.005), citizenship status (t =--2.060, df = 127; p <.041), language (F = 11.469, df = 2; p <.005), and race (t = 5.625, p <.001) in relation to their psychological distress score. Those who had high school education or less (mean = 9.3594), non-citizens (mean = 9.3929), those who do not speak English well (mean = 9.6308 and those who were Latino (mean = 9.7674) had higher psychological distress than their counterparts Those who had a higher score in the feelings scale (r =.257; p <.003), the emotions scale (r=.211; p<.016), and psychological distress (r =.187; p <.034) saw the doctor more often. In addition, feelings scale scores are positively correlated with emotions scale scores (r =.257; p <.05) and psychological distress score. The emotional scale score is positively correlated with psychological distress scale score (r =.211; p <.05). The relationships between the variables are weak to moderate.

9. Discussion and Implication for Social Work The purpose of this study was to understand mental health issues among older immigrant women and explore how they utilize health services. When examining the influence of demographics on the feeling scale, it seems feelings of depression differ between those who are married and those are not. In addition, there seems to be a relationship between education and emotional state, indicating that those who had some college education were more likely to seek healthcare services than those who had high school education and less. Other factors in this study that were found to be associated with psychological distress include delay in seeking medical care and use of emergency room as source of healthcare. Implications Immigrant women often do not have a clear understanding of how to navigate the mental health care system in the United States. Therefore, they are less likely to utilize the services. This population is very aware of the stigma that is associated with mental disabilities, and will compromise their own health in order to live up to societal expectations and remain within expected cultural roles. By providing a better understanding of mental health issues amongst immigrant women, social workers would be able to educate and serve the needs of this population. When policies are being made regarding immigrants, professionals who have adequate knowledge and understanding of the factors that could be barriers should be consulted.

10. References California Health Interview survey data files (2009) Marsella, A. J., & Ring, E. (2003). Human migration and immigration: An overview. In L. L. Adler & U. P. Gielen (Eds.), Migration immigration and emigration in international perspective (3–22). Westport, CT: Praeger. Migration Policy Institute [MPI] Data. (2009). http://www.migrationinformation.org/USfocus. United States Department of Homeland Security. Yearbook of Immigration Statistics: 2010. U.S. Department of Homeland Security, Office of Immigration Statistics. Washington, D.C.