Elizabeth K. Boyd, HBSc1, Idrissa Beogo, RN, MBA, PhD2, Barbara Liu, MD, FRCPC, FRCP(Edin)3,4,5, Fabien Schneider, RN, MPH6, Mireille Norris, MD, FRCPC, MHSc3,4
1Temerty Faculty of Medicine, University of Toronto, Toronto;
2School of Nursing, University of Ottawa, Ottawa;
3Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto;
4Division of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto;
5Regional Geriatric Program of Toronto, Sunnybrook Health Sciences Centre, Toronto;
6Centre d’Accueil Héritage, Toronto, ONDOI: https://doi.org/10.5770/cgj.28.861
ABSTRACT
Background
Canada is a bilingual country; however, outside of Quebec, health-care services are predominantly offered in English. With the increasing older adult population and stretched health-care resources, Francophone older adults may face significant challenges in accessing care due to their linguistic minority status. This study explores the experiences of caregivers of Francophone older adults in the Greater Toronto Area (GTA).
Methods
Using a convenience sampling strategy, caregivers of patients who had undergone geriatric assessment at the Centre Francophone du Grand Toronto (CFGT) were recruited. Participants underwent 45-minute, semi-structured interviews and completed demographic questionnaires. Three independent reviewers conducted qualitative content analysis of the interview transcripts, using the socioecological model of health and NVivo12.
Results
Nine participants were primarily female (n=5), with age ranges of 40–49 (n=2), 50–59 (n=3), and 60+ (n=4). They originated from North America (n=5), Africa (n=3), and the Middle East (n=1); about half preferred English over French. Thematic analysis identified three key themes: 1) Barriers Accessing Health Care in the French Language; 2) The Need for Interpreter Support; 3) Importance of Comprehensive Francophone Community Services.
Conclusions
Despite the presence of organizations (e.g., CFGT), this study reveals a significant gap in French-language services for older adults in the GTA, leading to increased challenges for their caregivers. Due to linguistic barriers, caregivers must act as interpreters to mitigate the risks associated with miscommunication and potentially worse health outcomes. Addressing these issues requires increasing bilingual health-care providers, enhancing funding for Francophone community services, and improving support systems (e.g., interpreters).
Key words: language barrier, language discordance, bilingual, interpretation, French, caregiver, older adults
Canada’s aging population is rapidly growing, with individuals aged 65 and older now representing nearly one in five Canadians,(1) placing increasing demands on the health and social care systems.(2) As older adults increasingly rely on a range of services to support their health, autonomy, and quality of life, ensuring equitable access to care becomes a pressing concern.
Francophone older adults living in the Greater Toronto Area (GTA) may face challenges in accessing appropriate care. Although French is one of Canada’s official languages,(3) French speakers represent a linguistic minority, comprising just 2.6% of the GTA population.(4) This group is culturally diverse, with 43.9% being immigrants and 19% refugees, and representing more than double the proportion of Black residents in the region.(4) This intersection of linguistic and cultural minority status makes Francophone older adults a critical population to consider in health equity research.
Extensive evidence shows that language discordance between patients and providers causes delays in access to care, impedes the development of trust in clinical relationships, and is associated with poorer health outcomes.(5–11) These effects are particularly concerning for Francophones living outside of Quebec, who often face systemic barriers to accessing care in their preferred language.(6,11,12) To address these disparities, Francophone community organizations, like the Centre Francophone du Grand Toronto (CFGT) and the Centres d’Accueil Héritage (CAH), collaborate to fill critical gaps in the health system. These organizations provide linguistically and culturally appropriate services and health care to Francophone older adults and their families in the GTA.(13,14)
Given the increasing linguistic diversity of the GTA and the central role of caregivers in supporting older adults, this study aimed to explore the experiences of francophone caregivers in the region, emphasizing the importance of culturally sensitive and accessible health-care services.
This qualitative study used a phenomenological approach to explore the experiences of caregivers supporting Francophone older adults in the GTA, focusing on two community organizations: the CAH, which provides French services including housing, day programs, and in-home support; and the CFGT, a family health team offering specialized geriatric services, including a French-language memory clinic.(13,14)
The interview guide was informed by the socio-ecological model, which considers the influence of individual, interpersonal, organizational, and policy-level factors.(15) Questions were co-developed by MN, a geriatrician, and IB, a nurse-researcher, in consultation with clinical and community stakeholders, and iteratively refined during early interviews to ensure clarity and relevance (Appendix A). Ethics approval was granted by the University of Toronto Research Ethics Board (#00044651). This study adheres to the Consolidated Criteria for Reporting Qualitative Studies (COREQ).
A convenience sampling strategy was used, with maximum variation to capture demographic diversity. Using a patient list of approximately 50 Francophone seniors who received geriatric consultations at the CFGT, next-of-kin were contacted by phone or email. Inclusion criteria included being a caregiver to an older adult (>65 years) who: 1) speaks French, 2) resides in the GTA, and 3) has a functionally limiting condition (e.g., dementia, visual impairment). Participants were informed about the study’s goals and its aim to improve culturally and linguistically appropriate care. Recruitment was closed once the exhaustion of the small eligible pool was reached.
Participants provided written informed consent prior to—and verbal consent at the time of—their interview. Interviews were conducted in English or French by EB, a female senior medical student fluent in both languages with prior qualitative interviewing experience. Semi-structured interviews were conducted in private (either in person at the CFGT or virtually via Zoom/phone), lasted approximately 45 minutes, and were audio-recorded with consent.
EB transcribed all interviews verbatim, anonymized and cleaned the transcripts, and translated any French content into English. While transcripts were not returned to participants for correction, key themes were summarized during the interviews for member checking. No repeat interviews were conducted, and field notes were not taken. Participant demographics were collected via brief questionnaires.
The first six transcripts were coded by three independent reviewers (EB, IB, NC) using manual coding and NVivo 12 software (QSR International (Americas) Inc., Burlington, MA). Initial coding followed a line-by-line inductive approach, grounded in participants’ language. The team engaged in multi-phase discussions to finalize macro themes, drawing on Braun and Clarke’s reflexive thematic analysis approach.(16) After multiple rounds of discussion to refine and agree upon code definitions and emerging themes, the remaining three transcripts were coded by one investigator (EB) using the agreed framework.
Reflexivity was supported by ongoing dialogue about personal assumptions and positionality, particularly in relation to linguistic and cultural identity, as supported by Lincoln and Guba’s credibility criteria.(17) The research team included a female senior medical student (EB), male nurse-researcher (IB), male health-care executive (FS), female master’s student (NC), and two female practicing geriatricians (BL, MN). The diverse composition of the research team (across race, gender, and disciplinary backgrounds) provided a range of worldviews and lived experiences. FS and MN, who had prior relationships with potential participants through their roles at CAH and CFGT, were excluded from recruitment and analysis to reduce bias. EB had no prior relationships with participants and explained her role as a student researcher.
Of the total caregivers contacted, nine agreed to participate. An additional five declined, with two citing the demands of caregiving as the reason, five expressed interest but did not follow up, four did not meet inclusion criteria, and the remainder did not respond. Table 1 shows caregiver (participant) and older adult characteristics. Caregivers’ ages ranged from 40–49 (n=2), 50–59 (n=3) and over 60 years old (n=4). They originated from North America (n=5), Africa (n=3), and the Middle East (n=1). Most caregivers were female (n=5), religious believers (n=7), were still working (n=7), and have English as their preferred language (n=4). Older adults’ ages ranged from 71–100 years old. Most older adults were female (n=6), had a high school diploma level of education (n=4), and had an income of <$50,000 (n=7). From qualitative data, three themes emerged, as summarized in Table 2: 1) Barriers Accessing Health Care in the French Language, 2) The Need for Interpreter Support, and 3) Importance of Comprehensive Francophone Community Services.
TABLE 1 Characteristics of caregivers (participants) and Francophone older adults
In an Anglophone city, caregivers of older adults frequently faced challenges accessing Francophone health-care services. These barriers were especially pronounced when seeking specialist doctors, optometrists, and dentists, as most services are only offered in English. Caregiver#3, who speaks little English, explained: “There are hospitals where there are people who speak scarcely a word of French [...] practically all the clinics have service in English, with not one person that speaks French. [...] But for the community in Ontario, the most important is the Anglophone community. And that’s normal.” He added, “Help with language, there is none [...] we don’t know how to voice our concerns to the doctors. They need to be able to understand, but that’s not the case.”
Limited availability of Francophone providers restricts options for older adults, often requiring significant travel. Some caregivers reported traveling across the GTA to the two CFGT clinics, which offer some of the only Francophone primary care physicians (PCPs). Caregiver#4 shared: “Yeah, they asked me to come today [for a medical appointment]. It’s tough by commute too. I live an hour north of the city.” Caregiver#9 described having to leave the CFGT and only finding an English PCP after moving their older adult to a distant GTA city. “So there’s the male doctor and then there is the language that obviously — I’m sure that if the doctor was French or francophone, there’d be a lot more trust there. [...] A francophone female doctor is what we need.”
The scarcity of Francophone older adult housing and options for long-term care (LTC) compounds these issues. Caregiver#8 noted:
“Bendale I don’t love because it’s more of a hospital setting. […] The only other Francophone retirement community I found for her is in Penetanguishene, which is not practical because I need to be like a twenty-minute drive from wherever she ends up. So, I think that is truly the biggest thing missing—a French contingency somewhere in a retirement home, but that’s kind of impossible when you’re in an Anglophone province in Ontario.”
The same caregiver also did not meet the income cut-offs for lodging at the CAH, which is a single location facility with limited capacity that allocates 100 of its 135 apartments to subsidized housing for low-income seniors.(14)
Five caregivers often acted as interpreters for their older adults during appointments, particularly when interacting with English-speaking specialists or community health services. For instance, Caregiver#5 described: “When she was being evaluated for her walker, everything was in English. I had to be there to interpret. When she needs her blood work done, it’s all done in English.” Similarly, Caregiver#1 explained:
“Oftentimes, the appointments in English are with specialists, so it’s words that she doesn’t really know, and she finds that they talk too fast. It’s important, not just because of her language but also because of her age, that someone is with her for all the appointments.”
This dual role of caregiving and interpretation often added to the caregivers’ responsibilities, which some found challenging to balance alongside other duties. Caregiver#8 highlighted the ongoing need for interpretation/translation support: “For me, I get to be the interpreter, so I do a lot of that for my mom. [...] But just because of the memory thing and aging, I try to translate a lot of the stuff.” The task of interpreting was particularly significant when older adults experienced cognitive or age-related declines that affected their ability to communicate effectively.
The additional burden of interpreting contributed to caregiver stress. Caregiver#5 explained: “If all the care was in French, I would be less involved and have to spend less time coordinating everything.” This caregiver also described the physical and emotional toll of caregiving: “Physically, now it’s challenging because you have trouble sleeping, and you’re already tired, but you still have to go and do what you gotta do.” Caregiver#7, who does not have permanent residency status, was unable to access personal support workers (PSWs) care expressed much fatigue from caregiving stating, “No, I don’t have help to get rest. I spend all day taking care of him.”
The seven caregivers using the CAH emphasized the importance of the comprehensive services provided for Francophone OAs. Services included PSWs, housekeeping, medication reminders, appointment scheduling, transportation, grocery and meal services, exercise programs, adult day programs, care coordination, and supportive housing. Caregiver#2 expressed appreciation for these services: “He’s in a supportive care building, right? Well, the province needs about 3 billion more. He’s in good hands there, so I don’t have that kind of stress.” Caregivers also praised the tailored care provided by CAH staff. Caregiver#4 described the value of the care coordinator’s role: “[the care coordinator] will touch base with her every month or two. And if my mom needs something, like she needed a doctor because her doctor closed down, [the care coordinator] got her into [the Centre Francophone].” Similarly, Caregiver#6 noted the benefits of the adult day program: “With respect to the French [adult day] program, they’ve been very good. And he absolutely loves it. I’m telling you, that is what is keeping him going.”
While one caregiver described their older adult as bilingual and less dependent on Francophone services, most caregivers stressed the necessity of French-speaking providers. Even bilingual older adults were described as feeling more comfortable, trusting, and safe when care was provided in French. Caregiver#9 explained: “There is a certain trust that gets established as soon as it’s in French. It’s a weird thing. It’s a love of the mother tongue. It’s a comfort.” Other caregivers noted that speaking in the older adult’s first language—whether French or an African language—improved communication, particularly for those experiencing cognitive decline.
Unlike other linguistic minority groups, such as Spanish speakers in Miami or Chinese-speaking populations in Canadian cities who benefit from social enclaves within their communities,(18) Francophones in Toronto are geographically dispersed, with no concentrated area where French language and culture are centred.(19) This lack of an enclave presents unique challenges in accessing French-language health care. Our findings highlight how this lack of language-concordant infrastructure impacts caregivers of Francophone older adults, underscoring the need for more equitable, linguistically accessible services in the GTA.
Caregivers described a lack of French-language health-care services in the GTA, often relying on English care despite challenges. This mirrors findings from Eastern Ontario, where Francophones struggled to access French services, even near Quebec.(6) While most caregivers were bilingual, the two with limited English—both identifying as Black—faced significant barriers, including difficulty expressing concerns to providers. Language discordance, known to increase health-care risks, can be mitigated by expanding interpreter services(20,21) and training more bilingual providers.(6)
Geographic inaccessibility was another barrier. Some caregivers reported long commutes across the GTA to find French services, while others lost access entirely after relocating. This added travel contributes to caregiver stress, which is associated with burnout in dementia caregiving.(22)
Finally, caregivers noted a scarcity of Francophone LTC and housing options, naming only CAH Supportive Housing and Bendale Acres LTC. Language mismatches in LTC negatively affect care and quality of life for Francophone older adults.(23,24) Supportive housing has also been shown to reduce caregiver burden,(25) underscoring the need for more accessible Francophone facilities.
Despite the growing availability of interpretation systems either through formal language services (e.g., Voyce) or informal websites and applications (e.g., Google or Apple translate), caregivers did not report being offered interpretation during health-care appointments. Prior research has found that formal interpretation is often underused due to service gaps, assumptions that English will suffice, unwritten rules to reduce costs, or expectations that family members will interpret.(7,9) A study examining low English-proficiency-caregivers’ experiences with interpreters showed overall increase in satisfaction when formal interpretation was used.(26)
In the absence of French-language services, caregivers frequently acted as interpreters. This ad-hoc approach can compromise care quality, especially when conveying sensitive or complex information.(27) Several participants described frustration related to this added responsibility, with one adding that more French services would lessen their involvement in care coordination and reduce their stress. This reflects findings that caregivers of older adults with limited English proficiency experience increased burden.(28) To ensure equitable and safe care, health-care professionals should provide trained interpreter services, and avoid relying on caregivers to bridge language gaps.
Caregivers emphasized the value of community organizations like the CAH, whose programs, ranging from adult day services, to care coordination and supportive housing, help reduce caregiver burden and support older adults’ well-being. Language-concordant services like those at CAH have been shown to ease caregiver stress for those supporting older adults with dementia.(29)
Despite these benefits, structural barriers remain. At the Centre Francophone du Grand Toronto (CFGT), primary care providers must chart in the patient’s preferred language,(30) but most external systems operate in English, requiring time-consuming translations. Expanding incentives for French-speaking providers and increasing French training programs may help address these challenges.
Community organizations like CAH and CFGT play a critical role beyond formal services, fostering culturally safe care and supporting caregivers. Research on Franco-Ontarians supports this, showing that positive care experiences are shaped not only by the availability of services in French, but also by the commitment of providers who understand the importance of linguistic and cultural alignment.(6,12) Together with the active involvement of caregivers, these community-based resources act as key facilitators in improving care trajectories for Francophone older adults.
This study offers important insight into the experiences of caregivers of Francophone older adults accessing community health services in the GTA. However, its findings are limited by a small, convenience-based sample recruited through the CFGT. This excluded caregivers without such connections, who may face greater challenges. Several potential participants declined due to being overwhelmed by caregiving responsibilities, a common issue in caregiving research,(31) potentially skewing the sample toward individuals with more capacity and resources. As saturation of themes was not reached due to the small sample size, this study should be viewed as an initial step toward further research or continuation of research. Due to the weak sample size, the study design and the dispersion of the Francophone community in the GTA,(19) the findings cannot be generalized to other settings or linguistic minority groups (e.g., Arabic speakers in Montreal). Future research should aim to include a broader sample, such as self-referrals from the wider Francophone population, and explore less time-intensive methods like online surveys to reduce caregiver burden and improve participation.
This study highlights significant linguistic barriers that caregivers of Francophone older adults face in accessing health and home care services in the GTA. Expanding the availability of Francophone health-care providers, language concordant housing and LTC facilities, and professional interpretation services are crucial to reducing caregiver burden and ensuring equitable access to care. Addressing systemic disincentives for French-speaking professionals, investing in geographically accessible community services, and supporting existing organizations, such as the CFGT and CAH, will be essential as the older adult population continues to grow. Ongoing collaboration with caregivers and Francophone stakeholders will be essential to ensure services remain responsive and equitable.
Not applicable
We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare the following interests: Dr. Mireille Norris is providing geriatric consultation services under contract for the Centre Francophone du Grand Toronto, and Fabien Schneider is the Deputy General Director of the Centre d’Accueil Héritage. These relationships do not influence the research, and we declare no further competing interests.
Elizabeth K. Boyd was funded by the University of Toronto’s Division of Geriatric Medicine’s Summer Older Adult Research (SOAR) experience award. The project was also partially funded by the University of Toronto Black Research Network’s IGNITE grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Correspondence to: Mireille Norris, MD, FRCPC, MHSc, Division of Geriatric Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., L-Wing, 1,st Floor, Rm. L1-01d, Toronto, ON M4N 3M5, E-mail: mireille.norris@sunnybrook.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 28, No. 4, DECEMBER 2025