Building Community with African Immigrant Older Adults to Improve Function

Despite their growing numbers, research on the functional health of African immigrants in the U.S. is limited. Two reasons for this include: the aggregation of all Blacks as a group, and the underrepresentation of this population in research.

Increasingly, there have been calls for the disaggregation of data to facilitate understanding of the unique healthcare needs and assets of the different racial/ethnic groups that make up the U.S. population. Also, there have been studies to identify why racial/ethnic minorities are underrepresented in research, especially in research on older adults.

Older adults in these studies often have been classified as “difficult to reach.’’ Might I suggest that this is not entirely true? The reality is they are “difficult to reach” because they are “not often approached.” When inclusion barriers are decreased, and other challenges such as lack of diversity in data collection are overcome, these groups are excited to participate in research.

The Older African Immigrant Health Study

After witnessing a growing number of community-dwelling African immigrant older adults living with physical function limitations, for my dissertation I wanted to adapt an evidence-based intervention for this population. However, this couldn’t be done because there was no data about the burden of this condition in the population.

When inclusion barriers are decreased, and lack of diversity in data collection are overcome, these groups are excited to participate in research.

Therefore, in what became the Older African Immigrant Health study, we sought to examine the relationships among acculturation, racial discrimination and physical function limitations in older African immigrants. Working together with the community, we were able to survey 165 older adults (and interview a subset of 15 older adults) in the Baltimore-Washington Metro area. To the best of our knowledge, this was the first study of functional health in older African immigrants.

The mean age in our sample was 62 years (SD = 8 years), and 61 percent were female. The majority (58 percent) migrated to join their family, 50 percent migrated before the age of 50, and 61 percent had lived in the country for less than 10 years.

High discrimination experiences (i.e., endorsing “sometimes or often” on one or more of the discrimination questions) were endorsed by 64 percent, and the mean physical function limitation score was 45, indicating that the physical function of this sample was 5 points lower than the general adult population.

The study found:

Physical Function limitations: Older adults who have lived in the country for 10 years or longer had more physical function limitations compared with those who had lived here for less than 10 years (b = –2.62, 95 percent confidence interval [CI] = [–5.01, –0.23]).

Compared to lower discrimination, those with high discrimination had more physical function limitations (b = –2.51, 95 percent CI = [–4.91, –0.17]), but this was no longer significant after controlling for length of residence.

As a proxy measure of acculturation, increasing the length of residence assumes that there are increasing opportunities to adapt to more aspects of U.S. culture, which can include unhealthy behaviors that impact health outcomes.

Acculturation also affects perception and experiences of discrimination, and discrimination is associated with numerous medical conditions that are risk factors of physical function limitations.

Discrimination: Three main themes and six sub-themes were identified in older African immigrants’ description of discrimination.

The first theme was related to the three types of discrimination experiences: accent-based, unfair treatment during routine activities and experience with systems.

The second theme explored the consequences of discrimination including both emotional and financial outcomes.

And the third theme described the participants’ strategies to deal with experiences of discrimination: [turning] a “blind eye to it,” reacting to it, or avoiding it.

Depressive symptoms: Clinically relevant depressive symptoms were present in 8.1 percent of these immigrants, and 20 percent reported trouble falling asleep more than half of the time. The level of education, income and reason for migration differed significantly by clinical depressive symptoms, but these were not significantly associated with more depressive symptoms after controlling for covariates.

What Does It All Mean?

Before, during and after their immigration to the U.S., immigrants face stressful life circumstances (e.g., exposure to violence, trauma and separation for caregivers) that may render them at risk for depressive symptoms and other poor health outcomes

Taken together, we found that racial/ethnic and immigrant–related factors such as length of residence, discrimination and reason for migration are associated with poor healthcare outcomes in older African immigrants.

Twenty percent of these immigrants reported trouble falling asleep more than half of the time.

However, more research with longitudinal designs and large diverse samples of African immigrants may further elucidate incidence, correlates and long-term effects of depressive symptoms, physical function limitations and their risk factors in this population. These studies are necessary to inform the development of health interventions and clinical practice. For example, a better understanding of depressive symptom burden and its risk factors can inform timely assessment, referral and treatment of depression.

Additionally, there is a need to identity strategies to improve outreach and collaboration with this community to improve research participation. First, critical evaluation and reduction of potentially unnecessary research inclusion barriers is warranted.

Secondly, increased engagement and collaboration with community partners is needed.

Third, it is important to provide multiple data collection methods (e.g., combination of in-person, phone, mail and in-home).

Finally, other methods for successful collaboration with African immigrant communities include: engaging community gate keepers, religious and immigration factors, maximizing the research team’s cultural competence and promoting altruism through health education. These approaches are essential when conducting community-engaged research that is informed by and with the community. This will also facilitate adequate representation in research that is necessary to improve long-term functional health outcomes in African immigrant older adults.

Manka Nkimbeng, PhD, MPH, RN, is an assistant professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health in Minneapolis.