The purpose of this study was to explore how elderly Chinese immigrants acculturate to their host country. We use the example of how Western concepts of oral health and dentistry serve to influence these immigrants’ beliefs and practices as they adapt to their host country. In this section, we discuss different intersecting factors that contribute to the complexity of acculturating to a new country and its health care system.
Acculturation includes a process of ‘enculturation’, by which connections with the original culture are maintained for several generations after the original migration1–3. Policies in Australia and Canada reunite migrant families, although there are suggestions that older immigrants have difficulties acculturating to their new surroundings4,5. In general, elderly people (65–74 years) in Hong Kong6 and in Guangdong Province7 use traditional Chinese medicine (TCM) and have only a limited knowledge of Western dentistry, so the challenge of acculturation probably explains why Chinese immigrants, despite many years in England, retained many traditional beliefs about health care8–10. It probably explains also why elderly Chinese immigrants in Canada increased their knowledge of dentistry as they grew affluent11, and why Vietnamese immigrants in Australia increased their knowledge of oral health and their use of dental services, but did not improve their oral health12,13.
Social values, well-being and health care
There is growing interest in the influence of family re-unification and acculturation of immigrant families14. Elderly members of large extended families in China generally were disposed to a stoical and utilitarian view of health and disability in accordance with the principles of social stability and harmony. Social supports and health influence well-being in Canada and in China, despite different political and socioeconomic systems. Until recently, people expressed less concerns about their health in China, possibly because of their strong social supports15,16. Adjustments to social values are underway in Asia with the large movements from rural to urban life and with improvements in affluence, although not necessarily in health and well-being17,18. For example, families in Asia generally feel social pressure to express their filial piety (xiao), yet this pressure is changing as urbanisation grows. It is not clear how these adjustments influence the cultural identity and behaviour of elders who have emigrated recently, especially when they move occasionally between their adopted and birth countries1. Consequently, there is interest in knowing how immigration and acculturation to the new society influences the traditional expectations of older peoples.
Asian immigrants use TCM, but many prefer Western medical care13,19,20; however, there are indications that older Chinese immigrants use general health services in British Columbia at a rate similar to non-immigrant elders21. In Western culture, body image, including dental appearance, has a strong influence on well-being even in old age22–26, whereas older adults in Hong Kong27 and Guangzhou7, and others who migrated to Australia12, Canada11 or the UK10 seem generally disinterested in the appearance of their teeth.
Dentistry in Australia and Canada
Dental services need to be accessible and culturally acceptable in Australia and Canada where there are large and growing immigrant populations from Hong Kong and mainland China28. Both Canada and Australia provide universal access to health care as a tax-based benefit regardless of ability to pay. Dentistry for the most part is excluded from this benefit, and is purchased mostly through private insurance or directly by the patient. Very few immigrants have dental insurance29,30, but some are entitled to limited dental services in both countries if they have little income, and if they can find a dentist who accepts the relatively low fees paid for these services31. Melbourne, in contrast to Vancouver, has a more extensive government-sponsored dental service through community health centres that enhance access to care for immigrant groups12.
Oral health care beliefs and behaviours of Chinese immigrants
Research in Leeds, England, found that many Chinese immigrants retain their traditional beliefs that gums bleed because of imbalanced body humours, and that, natural teeth in old age cause misfortune9. A more educated group of Chinese immigrants in Montreal accepted Western ideas on caries, but they managed gum problems with traditional herbs to quell the ‘internal fire’ along with antibiotics from China and vitamin C20. Nonetheless, they consulted Western dentists when problems resisted traditional medicine, but were concerned about ‘loosing face’ if they could not afford the treatment.
Theoretical framework for oral health
A theoretical framework or model for oral health based on views of the body, the person and society was constructed from interviews and, subsequently, expanded from focus groups that had previously been conducted among elderly people of European origins in Vancouver32,33. It presents beliefs and behaviours relating to oral health essentially as a combination of oral hygiene, general health and comfort (including eating, appearance and absence of discomfort), and it is supported by theories of personality, personal control, social learning and other affective phenomena dominated by the social environment34,35. Consequently, we used this framework to help interpret how acculturation in Australia and Canada influences the dental beliefs and behaviours of older Chinese immigrants.