Quality of Life of South Asian Older Adults in Hong Kong: Policy Implications for a Multicultural Active Aging Framework

Family, Health and Money Are the Main Constituents of QoL

In this research, 24 people did not understand what QoL was or had never heard of the term before. The research participants were also asked what a good life meant to them, where more people chose to answer the question, and similar answers were given. In the interviews, participants listed things that were important to them for a good life. Family, health, and money were the most commonly mentioned components across all three nationalities. Thirty-two people mentioned family; 15 mentioned health, 12, money; and 6, people mentioned happiness and basic needs. Table 2 summarizes the constituents of QOL among the participants.

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Table 2.

Constitutes of Quality of Life among the South Asian Older Adults (N = 58) N (%).

Good life component	Pakistani	Indian	Nepalese
Basic Needs	2 (3)	3 (5)	1 (2)
Family	11 (19)	3 (5)	12 (21)
Friends			4 (7)
Health	2 (3)	4 (7)	9 (16)
Health services		2 (3)	1 (2)
Happiness	5 (9)	1 (2)
Job	1 (2)
Life	1 (2)	2 (3)	2 (3)
Money	2 (3)	7 (12)	3 (5)
Peace	1 (2)
Religion	3 (5)	1 (2)
No definition		1 (2)

Note. Multiple responses allowed.

Family is one of the most commonly mentioned QOL components across all three nationalities. Fred is a 73-year-old Pakistani man who has been living in Hong Kong for more than 50 years. His QoL was determined by his relationships with his family. He explained, “This life is very good for me. It has been very good. I have my family my kids. It is very and I have been very blessed.” Comparing women from low-income and non-low-income families, this study found that factors such as family, health, and money showed no discernible differences between the two groups of women. Basic needs (e.g., housing, food, and enough income to sustain the household) were only mentioned in the low-income group as key to a good life. Karen, a 76-year-old Indian woman from a low-income family, defined good life as the ability to maintain her basic needs. She said, “I think that if whenever our needs are meet that’s what good life means.” Similarly, Venus, a 74-year-old Indian woman from a low-income family, explained QoL means to her:

Every person has a need as long as you alive, but depends on you how much you can gain from them. Like, you know, sometimes you’re not able to fulfil your needs, so you have to be able to make yourself understand that you can’t get everything in your life. You have to limit yourself and survive with what you have.

All the participants expressed that good health was important for a good life. However, they all suffer from various health problems. Tables 3 and 4 summarize the health conditions of the participants. Hypertension, cholesterol, and arthritis were the most commonly reported health conditions among participants. Previous studies have stressed the importance of health for older adults among the various QoL domains (Seymour et al., 2008). The poor health conditions of South Asian older adults affect their everyday lives. For example, Venus is a 74-year-old Indian woman from a low-income family. She was wheelchair-bound with leg and back pains. When asked how her health affected her daily life, she said the following:

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Table 3.

Health Conditions of South Asian Research Participants (N = 58) N (%).

Health conditions	Pakistani	Indian	Nepalese	South Asian Male	South Asian Female
Arthritis/Knee problem	5 (9)	5 (9)	3 (5)	8 (14)	5 (9)
Asthma	1 (2)	2 (3)	1 (2)	2 (3)	2 (3)
Pain (Back, Chest)	2 (3)	2 (3)	3 (5)	1 (2)	6 (10)
Blood issues	1 (2)	2 (3)		1 (2)	2 (3)
Cholesterol	2 (3)	4 (7)	6 (10)	4 (7)	8 (14)
Dental issues		2 (3)	1 (2)	1 (2)	2 (3)
Depression	1 (2)		1 (2)	1 (2)	1 (2)
Diabetes	12 (21)	5 (9)	5 (9)	8 (14)	14 (24)
Gout			1 (2)		1 (2)
Gynecological issues	1 (2)				1 (2)
Heart condition	3 (5)	1 (2)	2 (3)	3 (5)	3 (5)
Hypertension	4 (7)	3 (5)	15 (26)	4 (7)	18
Indigestion			1 (2)		1 (2)
Insomnia		1 (2)			1 (2)
Intestinal surgery			1 (2)		1 (2)
Liver issues	3 (5)			2 (3)	1 (2)
Thyroid			3 (5)	1 (2)	2 (3)
Uric acid			1 (2)		1 (2)
Vision issues	1 (2)	2 (3)	1 (2)	2 (3)	2 (3)
None reported	3 (5)	2 (3)	1 (2)	3 (5)	3 (5)

Note. Multiple responses allowed.

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Table 4.

Self-identification of South Asian Older Adults.

Identity—Pakistan	N = 21 N (%)
Pakistani	16 (76)
Chinese	1 (5)
Pakistani Chinese	1 (5)
Hong Kong and Pakistani	1 (5)
No answer	2 (9)
Identity—India	N = 19 N (%)
Indian	9 (47)
Hong Kong	3 (16)
Indian Hong Kong	1 (5)
Punjab	2 (11)
Punjabi Hindi	2 (11)
British	1 (5)
No answer	1 (5)
Identity—Nepalese	N = 18 N (%)
Nepalese	15 (83)
Hong Kong Chinese	3 (17)

Because I have leg problems, my nervous system has some problems with the legs. I don’t really leave my house. I try to do housework as much as I can but I have a lot of limitations because I can’t walk.

Venus’s health severely affects her QoL, as her inability to walk confines her to her house, and she rarely travels anywhere without the aid of her husband. She lives in public housing with one living area that acts as a bedroom and a living room, which is not big enough for a wheelchair to comfortably move in. She has to sit on the floor and move herself by sliding on the floor. She is trying to purchase an electric wheelchair, but currently cannot afford it. Similarly, Fathi, a 77-year-old Pakistani man, described his health as troubling.

I have knee pain. I am stuck in this health problem for many years. It is not getting any better even after years of medication. I found it painful whenever I go downstairs to buy things. My son needs to work, so I have to go alone and walk slowly. The health issue is very frustrating, always on my mind for 24 hours. I don’t feel comfortable.

Money is another component of QoL. Among the research participants, 17 were receiving Comprehensive Social Security Assistance (CSSA), with an average of $5,368 (US$688) per month; five, an old-age living allowance, of $3,800 (US$487) per month; one, the Working Family Allowance of $8,000 (US$1,026) every 6 months. Full reliance on social welfare is insufficient to sustain the high cost of living in Hong Kong (fourth among 178 cities worldwide) (The Standard and Bloomberg, 2022). Older adults are unable to meet their basic needs. Large households are especially vulnerable to poverty because there may not be enough earning members to support the entire family. Karen, a 76-year-old Indian woman and her husband, also received CSSA at $4,000 (US$513) each; however, she said it was not enough to sustain both:

Every time I just go to supermarket, the minimum I spend is $200 (US$26) or $300 (US$38). Even when I try to save a lot of money, fruits are expensive and our diet is really important. So, most of the time welfare is not sufficient.

Language Barrier Hinders Access to Health Services

Language barriers are a major challenge faced by older South Asian adults in Hong Kong. They all attend regular medical checkups at public hospitals. Interpretation services are available at public hospitals; however, owing to the COVID-19 pandemic, this service was temporarily suspended. In this study, most participants attended their medical appointments with a family member, usually their children or grandchildren, who could speak both English and Chinese. Only four research participants utilized the interpretation services provided by hospitals and had an interpreter accompanying them to appointments. Nora, a 67-year-old Indian woman, has eye problems. She noted that not all hospitals provide this service, which may cause problems for people with communication difficulties. She said:

I requested them many times, but they told me that they are unable to provide any because, uh eye hospitals don’t provide any interpreters. So I’m not sure why they have stopped all of the sudden, but other hospitals still provide me with this service.

Ben, a 78-year-old Nepalese man, states that he is concerned about why doctors take large amounts of blood during his blood test but is unable to ask why due to the language barrier:

One concern is that whenever I go for the blood test, they get so much blood that it means three to four small bottles, so I am wonder why it is necessary. Because of language problems, we could not ask anything.

A lack of communication between doctors and patients creates confusion and can lead to undiagnosed or misdiagnosed underlying medical conditions. In the interviews, many participants expressed their frustration at not being understood, and in turn, not understanding the doctor’s actions, which builds mistrust between the two and could deter them from seeking professional medical help in Hong Kong in the future.

Cultural Practices and Family Values Shape South Asians’ Aging Experiences

Cultural food practices play a role in what South Asians eat. For example, fried and oily food (such as samosas) and sweet deserts are served in most meals in the South Asian community in Hong Kong. All female participants stated that they had to use traditional cooking methods to maintain the authenticity of South Asian dishes. One Indian female older adult said, “we need to use ghee, butter, coconut, or palm oil in cooking so that the taste is good’.” Although cholesterol was a common health problem among the participants, they were not aware of the consequences of the daily intake of cooking ingredients high in saturated fat.

Facing different challenges, prayers are both psychologically and theologically important, as they relate to an improved sense of well-being, social connectedness, emotional management, and dealing effectively with anger (Spilka & Ladd, 2012). Turning to faith was essential for older South Asian adults to cope, heal, and adjust to their new surroundings, accompanied by a strong belief that God could solve their problems. Almost all Pakistanis and Indians expressed that aging does not matter, as it is a natural process that cannot be stopped and is in God’s hands. Norman, an 81-year-old Indian man, said,

Basically, we think that, you know, we don’t really think about getting old a lot because, you know, if you say you won’t die ever, that’s impossible. And whenever the God needs you back, he will return you.

Another defining characteristic of South Asian culture is its values, which place importance on the family and family based systems. It is almost always assumed that adult children take care of their aging parents. They act as their parents’ translators, financial support providers, and primary caregivers, especially when their parents are new to Hong Kong. Of the 23 participants who received social welfare support, 18 received pocket money from their children. There is no set sum of financial support that their children provide; in most cases, whenever they need money, they will ask their children. Children would provide both personal and household expenses. The participants would ask for $300 (US$39) or up to $3,000 (US$385) at one time. Rebecca, a 64-year-old Indian woman, stated that it was a child’s duty to take care of their parents as they grew older:

The government also has a duty but when the children are supportive why go at least they are liable to take care of their parents. As a culture also but as human being also if the children are well off why should they not take care.

When questioned about their thoughts about care homes, all participants rejected the idea of care homes and instead planned to grow old at home. In accordance with cultural norms, the concept of sending aged parents to care homes is almost nonexistent and looked down upon, with some saying it is a sin. All of them were confident that as they grew older, their children would take care of them. Nora, a 67-year-old Indian woman, said,

Like, typical Chinese families in the old days, the kids will take care of them. If their kids are not, then their brother’s kids because they have big houses.

Value of Social Relations and Networks

The social relationships of all 58 participants were primarily composed of people from their own communities. Some were friends made before their migration to Hong Kong, whereas others were friends made in religious places, ethnic communities, or NGOs after their arrival. Nikki, a 75-year-old Pakistani woman, described how she made friends with Pakistani women in Hong Kong.

I knew my Pakistani woman friends from the mosque nearby my house. We meet almost every day. We talk about children’s education and where to buy food at low prices. I also often invite my friends to my house. They also invite me to their houses. And then we have food and drinks and chit chat.

Most research participants have a lot of free time, as many no longer work. When not completing household chores or performing caretaking, they often seek the company of friends. Simon, a 68-year-old Pakistani man, spent time with friends:

Every morning, I go to the park downstairs, sit with my friends and talk to them. There are many Pakistani men in the park talking to each other. When it is time to pray, we go to the small mosque. After praying, we go back to the park and spend time together.

While the female research participants discussed family and children when they met people from the same community every day, the male research participants talked about social issues in their home country. All participants stated that they felt relaxed when interacting with their fellow ethnic members in Hong Kong because they could speak their native languages. Nikki, a 75-year-old Pakistani woman, added “Speaking and listening to Urdu here [Hong Kong] make me feel I am in Pakistan! I have the feeling of familiarity.” Ethnic network plays an important role in their old age experience because the main channel of information in their communities was word-of-mouth, especially at the beginning of the COVID-19 pandemic.

Nevertheless, almost two-thirds of the research participants expressed that they attempted to establish social networks with Hong Kong Chinese who they met regularly in places such as wet markets and parks. Gloria, a 72-year-old Nepalese woman, described this as follows:

We meet some Chinese old people in the park every morning. We teach them to say Namaste and they teach us to say zou san (Good morning). That’s how we greet each other every morning. Although we are not real friends, it is good to have friendly relationships with the locals.

While social relationships with Hong Kong Chinese remain peaceful and friendly, they still lack the vitality and dynamics that a bond with fellow ethnic minorities could bring through an understanding and appreciation of their shared culture.

Establishment of Language and Cultural Interpreter Training Schemes

Although the Hong Kong Hospital Authority provides interpretation services to ethnic minorities, the accessibility of such services is unreliable. Based on foreign examples such as Australia and the United Kingdom, an accreditation system for interpreters in the main ethnic minority languages should be established by collaborating with academic institutions in Hong Kong. A holistic review of current service provisions should be conducted among all stakeholders, including key ethnic minority groups, social workers, existing interpreters, frontline officers in various government departments, and frontline medical practitioners. The Hong Kong government should ensure the quality of interpretation services by offering professional certification, which includes training on communication skills, interpretation competence, professionalism, and the use of terminology in public services. An accreditation system officially recognized by the government might enhance the professional image of minority language interpreters, thereby attracting more young people from key ethnic groups to become community language interpreters. Interpreters’ codes of ethics (Australian Institute of Interpreters and Translators, 2012) and complaints, and appeal mechanisms should be established. The authorities should also establish a review mechanism to collect comments and recommendations from relevant stakeholders to maintain and improve interpretation services in the long run.

Strengthening Medical Outreach Services to Ethnic Minority Older Adults

In this study, many older South Asian adults were unaware of their deteriorating health. To enhance early diagnosis and management, a holistic care service for older South Asian adults in their neighborhoods is recommended. Medical outreach services allow medical practitioners to gain a better understanding of the living environments of older South Asian adults and facilitate communication with their caregivers. This information is important for patient treatment. As their social relationships are largely composed of people from their own communities, the authorities should collaborate with ethnic community associations, religious bodies, and NGOs in arranging medical outreach services for South Asian older adults in different neighborhoods.

The Social Welfare Department of the Hong Kong government commissioned three NGOs to establish three outreach teams for ethnic minorities to proactively reach out to those in need of mainstream welfare services. To further utilize the functions of these outreach teams, the design and implementation of outreach medical programs should involve family members (in particular, the family caregivers) to understand the caregivers’ needs and concerns in providing care for their aging parents. Family caregiving is a part of active aging, as it allows older adults to age in their homes, alleviating the burden of residential services. If the government aims to adopt an active aging strategy regarding care for its older adult population, it must provide assistance to families who do not have sufficient resources to do so (Equal Opportunities Commission, 2020). Outreach teams should also establish good working relationships with ethnic community leaders and language and cultural interpreters, as well as recruit volunteers from minority communities in the information dissemination process. Most importantly, outreach teams should ensure that the program is located (if home visits are not possible) in ethnic neighborhoods where minority older adults can easily access and congregate.

Promoting Ethnic Minority Older Adults in Social Enterprises

The government should strengthen the promotion of social enterprise funding support in South Asian communities, making leaders of ethnic community associations aware of the funding scheme that can help older adults set up social enterprises to sell their handmade products, such as arts and crafts. Improving coordination among public entities at different levels during project implementation and providing basic business skills training in collaboration with NGOs is a key step toward empowering older adults from ethnic minorities in social enterprises. Active aging highlights the importance of lifelong learning. By promoting older adults from ethnic minorities in social enterprises, this arrangement economically empowers older adults and enhances their social relationships with different people in Hong Kong.

Promoting Ethnic Minority Neighborhood Support Scheme

In South Asian culture, care homes are not acceptable to older adults. Another alternative to care homes is a neighborhood support scheme in which friends or ethnic minorities can live together in a flat and support one another with occasional care visits. This can be in the form of non-subdivided senior housing, where an entire building is for older adults and is staffed with services such as a small clinic, a food hall, and prayer rooms. This allows South Asian older adults to gain independence while receiving support from their own people and professionals. Housing is a major social issue in Hong Kong. Many participants attributed their well-being and happiness to their housing conditions. In South Asian culture, adult children are expected to care for their aging parents and share the same accommodation. However, this might be difficult to achieve in Hong Kong. To support aging in place, when applying for public housing, larger families or older adults of South Asia have the option of being given housing near each other, whether it is flat next to each other, on different floors of the same building, or even adjacent buildings. This allows them to be close to people who can take care of them and ask for help if needed.

Limitations

This study has some limitations. First, the findings did not show gender differences in their old age experiences. For instance, for cultural and religious reasons, South Asian female older adults may spend most of their time at home, which may negatively impact their physical and psychological conditions. Future quantitative studies should be conducted on sex-based differences in health conditions. Additionally, the study only recruited research participants who had existing positive relationships with NGOs, ethnic associations, and religious organizations, thus possibly excluding other South Asian older adults who were relatively more homebound, with more severe problems. Finally, family caregivers were not interviewed; therefore, the discussion lacked a family perspective. Future research should focus on the needs and concerns of adult children when providing care for their aging parents.