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Migrant carers

Professional and informal carers

Whereas practically all migrants might identify with a minority ethnic group, many people from minority ethnic groups would not consider themselves as migrants. It has been difficult to obtain information about issues related to health and social care professionals who are clearly from minority ethnic groups (but not necessarily migrants). In some of the studies about migrant and live-in carers mentioned in this and the next sub-section, it is not clear whether a) they are solely about people having recently (e.g. in the last 10 years) moved to a country and become a carer or b) also include people from minority ethnic groups who have lived for long periods in a particular country, were born in that country (e.g. second or third generation) or have no migratory background. Some of the issues described in the section below may apply to professional carers from minority ethnic groups but it cannot be assumed that they do. As elsewhere in this report, we will use the terms used by the researchers whose findings we are reporting.

Reasons for and issues surrounding migration

Migrant carers are likely to have different reasons for having moved to another country to take up paid employment. Not all necessarily set off with the aim of becoming a carer. Some may have arrived as asylum seekers. Most Iranian migrants in Sweden, for example, came as a result of the 1979 Revolution, the Iran–Iraq war of 1980–1988 or to seek a higher education (Antelius and Kiwi 2015).

Migrant carers are not just part of the workforce but also people with lives and families of their own (Kröger and Zechner 2009). People (usually women) who leave their countries to work elsewhere as carers sometimes leave behind them children, disabled or older relatives who also need care. This is sometimes referred to as the ‘global care chain concept’ which highlights the relationship between globalisation, migration and care, whereby a need for care in one part of the world is resolved through the employment of migrant carers which results in a shortage of care in another part of the world (Weicht 2010).  Zontini (2007) and Yeates (2009) (see Kröger and Zechner 2009) warn against stigmatising migrant carers who have care responsibilities at home or the families or organisations who employ them, pointing out that migrants are not victims of circumstances beyond their control and have not ‘abandoned’ their own relatives (as they make arrangements for care and continue to provide emotional support). They suggest instead that policies should be developed to better support them.

In Bulgaria, the Alzheimer Association reports a situation consisting of working age adults leaving the country to work abroad (not necessarily as carers) resulting in people with dementia being left responsible for the care of children and also vice versa. Migrants with a higher level of education tend to be better able to provide for the care of those they leave behind than those with lower levels of education or skills. Some formal care arrangements are not ‘all or nothing’. Ungerson (2003, 2004) describes a situation in Austria where Hungarian and Slovakian carers are employed on a two-weeks-on/two-weeks-off basis. It is not known whether this facilitates care arrangements in the country of origin.

There are sometimes obstacles to gaining employment as a carer such as having to undergo training (sometimes at their own cost) and to work initially on a voluntary basis in order to gain experience (Doyle and Timonen 2009). Language may also be a big obstacle with certain jobs necessitating a high level of proficiency in the official language of a country. Some migrant carers find that their professional qualifications are not recognised in the country where they are working and are obliged to take less-qualified jobs.

Racism, stereotyping and prejudice

Once in employment, migrant carers may experience racism and prejudice. Migrant carers often face the worst conditions in the care market, resulting in a ‘racialised’ divide between the tasks given to migrant and non-migrant carers and the types of contract and working hours offered (McGregor 2007). In a qualitative study of the experience of the multi-cultural care workforce in Ireland (Doyle and Timonen 2009), almost all African carers reported having experienced some form of racism or prejudice. In most cases, perceptions of unfairness and discrimination were not, in that study, associated with the person to whom they were providing care but rather to their co-workers and managers. In another study, migrant dementia carers reported prejudice and stereotyping from residents as well as colleagues (Egede-Nissen et al. 2016).

Training on how to deal with negative remarks and actions from care recipients may be helpful but the discrimination from co-workers and management may nevertheless affect morale and self-esteem, especially where there are no official channels for complaint (Doyle and Timonen 2009). In a study of migrant carers in Ireland and the UK (Walsh and Shutes 2013), carers reported cases of older people refusing to be cared for by a ‘black’ or ‘foreign’ care worker. Often such refusals came at the first encounter but sometimes in the context of an existing relationship of care. Sometimes, care workers were shocked by the attitudes and behaviour of the clients but looked for explanations such as the lack of experience of the clients with other nationalities. The European migrant workers in this study reported much lower levels of racism and prejudice.

Employers and care recipients are sometimes influenced by cultural stereotypes when taking on or appraising migrant care workers, with some carers being perceived as being particularly caring or warm. According to Doyle and Timonen (2009), this leads to the perpetuation of racial and ethnic stereotypes, the consequences of which are not yet fully understood and may well be extended to minority ethnic groups. Romero (2012) suggests that in Spain, in the context of employing migrant workers, women are “considered as natural (biological) caretakers for dependent older people par excellence”. Walsh and Shutes (2013) report references to a ‘caring culture’ in the Philippines and India and to a ‘hard working culture’ in Eastern Europe.

Such stereotypes are an obstacle to seeing the real person and whilst on the surface, they may seem positive, they may also lead to negative stereotyping about other assumed characteristics and towards other migrant carers who are perceived as lacking the valued characteristics. Negative stereotyping is part of the process of stigmatisation which also involves devaluation and discrimination (Link and Phelan 2006). Migrant workers may be reluctant to make a formal complaint about working conditions or attitudes and behaviour towards them if they are in a vulnerable legal position (i.e. their residency rights being dependent on the care recipient or employer being satisfied with their work, being dependent on the employer for accommodation and their right to seek alternative employment being limited or non-existent) (Doyle and Timonen 2009, Walsh and Shutes 2013).

Developing a positive relationship with care recipients

Despite many migrant carers experiencing racism, prejudice, negative stereotyping and discrimination, many report a positive experience of caring and describe the importance of a positive relationship with the people for whom they care. Migrant carers of older people (including people with dementia) in Ireland and the UK emphasised the importance of developing a reciprocal relationship with the older person and of feeling that they were making a difference (Walsh and Shutes 2013) and migrant carers of people with dementia in Norway also reported enjoying their work and finding it rewarding (Egede-Nissen et al. 2015). Clients with neurodegenerative diseases such as Alzheimer’s disease were considered by some migrant carers as being more abusive which may indicate the need for better dementia training and more support so as to enable migrant carers to manage certain situations, practically and emotionally, and to maintain a good care relationship with clients who have dementia (Walsh and Shutes 2013).

Cultural awareness and language proficiency

The ability to develop a positive care relationship with clients can be hindered by the lack of a shared cultural outlook with residents such as being aware of significant historical events that they have lived through, sharing or at least understanding their religion, being able to prepare traditional food and drink properly and understanding humour, gestures, accents and colloquial expressions. Walsh and Shutes (2013) conclude that the ability to communicate, understand cultural norms and deliver care in a culturally appropriate manner is fundamental to the development of relational aspects of care which both clients and migrant carers in their study considered to be a core determinant of quality of care.

Sometimes cultural awareness can be as basic as knowing about certain food that people from the host country like, how to greet visitors and dress codes and this can probably be picked up quite easily through observation and interaction. Within increasingly multi-cultural societies, it should of course not be assumed that there is just one culture and with regard to religion, it may be more difficult to understand people’s beliefs and religious practices as they are rarely explained.

Language can be a considerable obstacle in that a high level of langue proficiency is not only a question of vocabulary and grammar but also of understanding accents, medical terminology, slang, colloquialisms, humour and non-verbal communication (such as facial expressions, gestures and body language). Language is therefore extremely important but it is not always sufficient to perfect one language. As mentioned earlier, in some countries, such as Luxembourg, Switzerland, Belgium, Spain and Italy, there may be more than one national language and in parts of the UK and Ireland, Gaelic and Welsh may be spoken in addition to English. Added to this, the people with dementia receiving care may speak other languages, being themselves migrants or from minority ethnic groups with different languages.

The need to perfect at least the main language or languages of the host country is important for the provision of quality care and for good relationships with residents, co-workers and employer but also for migrant workers to integrate into a new society, make friends and become active members of the community. Migrant carers are not always aware of the availability of language lessons or of how to access them (Egede-Nissen et al. 2016). They may also find it difficult to fit the lessons into their working schedule and might not be able to afford them. Efforts should be made by local governments and employers to ensure that migrant carers have the opportunity to improve their language skills. Brooke et al. (2018) suggest the need for open access training and education to cover the broader aspects of communication such as accents, behavioural and facial communication etc.

Cultural differences in the perception of dementia and dementia care

Migrant carers may have very different attitudes towards the care of older people, including people with dementia, to those of most of the people they are caring for. However, migration also influences this view. Similar to the beliefs about filial piety amongst some minority ethnic groups, some migrant carers consider it the moral duty of families to care for their older relatives and that the relatives of people in residential care homes have abdicated their moral responsibility by leaving the care of their parents, for example, to people they do not know and are being paid to provide care. Dementia carers from a Middle Eastern background in Sweden (caring for people with dementia from the same background) emphasised that people from their native countries consider the care of older relatives as a religious obligation which is enforced by relatives as well as through pressure from mosques, churches, associations, distant relatives and even neighbours (Antelius and Plejert 2016). On the one hand, some migrant carers may be critical of families of people with dementia in residential care based on their own beliefs about filial piety; on the other hand, some migrant carers may need a better understanding of filial piety but also to be aware that families which have migrated to Western cultures may have adapted their beliefs through the process of acculturation (Antelius and Kiwi 2015, Brooke et al. 2018). This has been reported with regard to families of Middle Eastern descent in the Netherlands who may have a more positive view of professional care, and who may interpret caring as ensuring that care is provided rather than providing it all themselves (Van Wezel et al 2016).

Migrant carers may use the term dementia in the care setting but are nevertheless usually aware of the beliefs about dementia in their country of origin where in some cases, the term dementia is not used at all (or at least not by lay people) and if used may have a different meaning because there is no concept of dementia. Iranian carers in Sweden, for example, used the Swedish terms for dementia or memory loss when interviewed but explained that in Iran the term Alzheimer’s would be used but not necessarily with the same meaning. In Kurdish, a term would be used which means crazy or lunatic. Other terms mentioned included ‘fool’ and ‘senile’ (Antelius and Kiwi 2015). In some cases, it is the cultural perceptions of ageing rather than dementia which influence how migrant carers respond to the needs of people with dementia (Brooke et al. 2018). Behaviour may also be attributed to daydreaming or to the person just being ‘burdensome’ and ‘troublesome’, sometimes with the assumption that they have always been like that (Antelius and Kiwi 2015). In the study by Antelius and Kiwi, migrant carers highlighted a general lack of understanding about dementia.

“Shervin, 52 years old: I honestly do not know if either staff or relatives have any idea what dementia is.

Ayeh, 57 years old: Frankly, none of us know what dementia is” (Antelius and Kiwi 2015, p. 86).

A good understanding of cultural differences between migrant carers, people with dementia receiving care and their families is important in ensuring that people with dementia receive good care, that families receive appropriate support and understanding and to avoid judging and making assumptions about desired care arrangements. 

The concept of residential care is not always familiar to migrant carers prior to them taking up their work (McGregor 2007, Antelius and Kiwi 2015, Antelius and Plejert 2016). Some have never heard of nursing homes and residential care. When they realise what is involved, some carers find the work ‘dirty’, ‘low’ and ‘cheap’ and feel ashamed of being part of that process (McGregor 2007) even though they may decide to continue with the work (sometimes as a perceived stepping stone to a better job). Ow Yong and Manthorpe (2016) also highlight the ambitions of some migrant dementia carers to move from the residential care setting to take up a more qualified post.

Perceptions of traditional gender roles may also lead to feelings of shame. In societies where the provision of care is still considered ‘women’s work’, some male migrant carers feel ashamed of their work, feeling that it challenges their masculinity and this may result in conflict or re-negotiation of gender roles at home (McGregor 2007). Romero (2012) highlights the feminised and ethnified nature of much of the care provided to dependent older people in Europe, calls for social workers to challenge the situations and inequalities that are inherent in public policies and advocates for a higher level of social justice.

Brooke et al. (2018) suggest the need for all care workers to understand dementia from a biopsychosocial perspective, that it is not a natural consequence of ageing and to understand the importance of preventive interventions, early diagnosis and that symptomatic treatments are available. Whilst the emphasis may often be on migrant dementia carers adapting to the culture of the host country, it should not be overlooked that there is not a single culture but many cultures within any country.

The process of acculturation

The process of acculturation (mentioned earlier) means that migrant care workers from a particular country and carers from minority ethnic groups will not necessarily have the same values and perceptions as people who migrated from a particular country many years ago. Antelius and Plejert (2016) argue that it is important to try to understand dementia care, in a migratory context, more in relation to the healthcare system and culture within thenewsociety (i.e. how people feel about dementia and dementia care in their current setting). This could apply to migrant care workers as well as to migrants with dementia. Brooke et al. (2018) suggest the need for migrant dementia care workers to adapt both to the new country and to the workplace culture and point out that validated, robust tools to understand the process of acculturation in relation to the provision of culturally competent person-centred dementia care are lacking. However, understanding and openness to different cultures is perhaps also needed from members of the host country. In their review of the intersection of culture in the provision of dementia care, Brooke et al. (2018, p.10) conclude:

“Successful acculturation is essential to enable migrant care workers to provide culturally appropriate person-centred dementia care, understanding care workers’ culture is equally important and needs to be considered when developing care provisions for people living with dementia.”

Cultural and ethnic matching

Being a professional carer from the same minority ethnic group as person with dementia can sometimes be challenging.  Professional carers who share some of the same cultural values might find that these are in conflict with their professional knowledge, training and identity, and with established care philosophies, procedures and time constraints. The demands of the profession may make it impossible to respond to the wishes and expectations of people with dementia and their families and result in inner conflict as well as conflict with the person with dementia and his/her family. Some professional carers are one of a few, if not the only person, in an organisation who is either from a minority ethnic group or who just speaks the language of some of the residents.

Sometimes, this results in professional carers from minority ethnic groups being given sole responsibility for the care and support of people from minority ethnic groups and having to deal with special requests from relatives, which at times go beyond their professional responsibilities. As was mentioned earlier in relation to informal carers, people who have adapted to the culture of a particular country, through the process of acculturation, or were born and brought up in that country, may find themselves in an awkward position with assumptions being made about their values and traditions which may not correspond fully or at all to them as an individual. This practice also reflects an attitude that all minority ethnic groups are the same and that by virtue of belonging to a particular minority ethnic group, a person would be able to better understand or relate to a person from any other minority ethnic group. It could also be interpreted as implying that a professional carer from a minority ethnic group is less able to work with people from the majority ethnic group. The following quote highlights some of these issues.

“The employment of minority ethnic staff applies across services (Akpaffiong et al., 1999; Alzheimer’s Disease Society 1998; Department of Health, 1998). However, Patel et al., (1998) highlight the potential of such staff being ‘dumped on’, e.g. in having to see all non-White or non-English speaking service users. It is important to stress, as Patel et al., (1998) do, that employing minority staff is only part of an overall strategy, and just because a worker is of the same ethnicity as the target group, it does not necessarily follow that they will be accepted by the target community (Alzheimer’s Disease Society, 1998)” (Daker-White et al. 2002, p.105).

 

 
 

Last Updated: Monday 08 April 2019

 

 
  • Acknowledgements

    This report received funding under an operating grant from the European Union’s Health Programme (2014-2020) and from the Robert Bosch Stiftung. The content of the report represents the views of the author only and is his/her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains
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