Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Canada
Received date: 12 September 2007 Accepted date: 10 December 2007
Canada’s immigration policy favours family reunification, and many elderly parents follow their adult children into new lives in Canada. In particular, the population of elderly immigrant women living with adult children is growing rapidly. Todate there are few theoretical models to guide research in this area although this subgroup ofimmigrants has been identified as having unique characteristics that warrant urgent research attention.The limited research that exists links immigration, acculturation and communication problems with negative physical and psychological health for immigrant women. One paradigm that holds promise for understanding and responding to the health needs of older immigrant women is that of occupational science. Occupational science proposes that ‘humanengagement is integral to everyday living as people of all ages plan, structure and use their time doingthe things they need and want to do’. Occupational deprivation is a subconstruct of occupational scienceand refers to situations in which people’s needs for meaningful and health-promoting occupations go unmet or are institutionally denied. Currently we do not understand the impact of occupational deprivation on the health of older immigrant women and how this influences their healthcare utilisation. It is probable that the needs of this unique, and growing, group of elderly women have important implications for health planning and resource utilisationthat are only just beginning to be recognised.
ageing, immigration, occupation, wellbeing, women
This paper is intended to show that older women who immigrate to rejoin families in developed nations like Canada not only face the resettlement issues common to all immigrants, but also experience additional and unique aspects consequent to being women and being old. Although this discussion is set in a Canadian context the concern is relevant to other industrialised countries where, as in Canada, there is an increasing reliance on foreign-born immigrants to fill critical workforce gaps. This paper will first discuss why older women are seen as a group with unique issues consequent to immigration. The paper will conclude by presenting an emerging theoretical framework, occupational science, as a possible route forward to understanding these older women’s needs and guiding subsequent intervention and policy initiatives.
The need for theory and models of practice to guide evidence-based programme development and evaluation in the area of immigrant health is only just starting to be recognised. This recognition, driven by Canada’s and other developed nations’ increasing dependence on immigrants to fill high-skilled and technical positions (Conference Board of Canada, 2007), has not yet extended to the needs of immigrant workers’ elderly family members. In particular, it has not addressed the issues of older female family members who are no longer candidates for wage-labour employment. As Im and Yang (2006) point out, ‘there exist very few theories guiding research on immigrants’ health, especially immigrant women’s health’. They concluded that existing theories are overly general and, consequently, fail to satisfactorily explain immigrant women’s health within the context of their daily lives. Theorists call for a targeting of research in this area to guide programme development and service delivery for this growing segment of the Canadian population (Anderson, 1991; Choudhry, 2001; Imand Yang, 2006). This paper proposes that we need to move one level deeper and examine the issues of older immigrant women who, unlike young immigrant women, are no longer active in paid employment.
Elderly female immigrants to Canada have unique health issues with important public policy implications for health planning and resource utilisation. Additionally, these women’s issues relate to the wellbeing and productivity of their employed adult children. For example, the needs of elderly immigrant female parents impact on Canadian workers who form the ‘sandwich generation’, a generation of people who are caring for their ageing parents while supporting their own children. While the concerns of Canadians with ageing parents have received a great deal of public attention in the last decade, less is known about how these concerns are compounded for recent immigrant families by the problems of unfamiliarity with available resources and less extensive informal support networks. There are direct implications for Canada’s labour force when these issues result in conflicting family and work demands that will have an adverse effect on job performance and satisfaction with the choice to immigrate.
Canada’s immigration policy favours family reunification and consequently there are many elderly parents who follow their adult children into new lives in Canada. Of the more than 200 000 immigrants to Canada every year, it is estimated that 18 000 (9%) will be parents and grandparents who have moved, not primarily for employment opportunities, but to be reunited with their adult children (Citizenship and Immigration Canada, 2005). Many of these immigrants, taking up residence in their adult children’s established households, experience a range of losses related to changes of previously held roles, resources and autonomy (City of Toronto, 1990).
For elderlywomen, the problems are often heightened by the family’s overall decreased adherence to traditional practices, limited opportunities for engagement in activities outside the home and few options for acquiring the language skills necessary to form support networks and function independently in the new environment (Choudhry, 1998).Choudhry (2001) identifies the themes of isolation and loneliness, family conflict, economic dependence and settling in/coping as significant resettlement issues. Additionally, immigrants and their sponsored familymembers are, because of labour force needs, increasingly more often relocated to small, rural communities where the social networks are employment based and the cultural and support resources found in larger communities are not accessible (Baker et al, 1994). We know that employment and social support are important determinants of health (Public Health Agency of Canada, undated). Older, immigrant women who are not employed outside of the home will not have access to the health-related benefits of the workplace and the social network of non-family members it can often provide. Studies have linked immigration, acculturation and communication problems with negative physical and psychological health for immigrant women (Anderson, 1991; Aroian and Patsdaughter, 1989; Im and Yang, 2006). Again, older women who do not go into the workplace cannot benefit from the language practice and exposure to cultural norms that are a secondary benefit for many in paid employment.
Canada has for a number of decades recognised that its ageing population presents an increasing demand on health services. It is projected that one in five Canadians will be 65 years of age or older by the year 2025 (Health Canada, 2002). A number of healthrelated initiatives have been implemented and some very creative research undertaken. However, the prevalence of chronic diseases, like hypertension and diabetes, continues to grown at a rate that challenges the healthcare system’s ability to respond. Of particular concern for both Canadian and foreign-born older women is the increased prevalence of arthritic diseases, chronic pain conditions and multiple chronic conditions compared to males of the same age (National Advisory Council on Aging, 2006). Additionally we know that there are social determinants of health (World Health Organization Europe, 2003) and that these determinants, for example social class, access to food stuffs, education, stress, and transportation, can particularly impact older immigrant women who often assume homemaking and meal preparation roles while the other members of the family are employed outside of the home. When health issues are coupled with the additional challenges faced by immigrant women, the need to understand the dynamic interplay between social determinants of health and illness experiences becomes critical if we are to develop appropriate health policies and intervention strategies.
Historically in Canada, Ontario and British Columbia have had the highest population of people born outside the country (24% and 22%, respectively), and Alberta ranks third with approximately 15% (Stats Canada, 2001). However, this distribution is expected to shift rapidly in the light of Alberta’s acute skill shortage and aggressive international recruitment target of 24 000 new immigrants per year (Alberta Government, 2004). This change will present novel challenges as immigrants to Alberta are likely to find themselves in more rural and isolated settings due to the nature of the labour needs of the province. These settings lack the volume of resources afforded by the large urban settings in Ontario and British Columbia where most elderly immigrant women and their families are traditionally located. Consequently, elderly female immigrants now following families who were employed in the booming energy industries in Canada are at higher risk then ever before of occupational deprivation (defined below) and related health problems. Other developed countries may see similar trends appear when industries, dependent on immigrant workers, are opened up in new geographical locations. These areas will not have established immigrant communities to provide support for those who are newly arrived, and particularly those older women who are not in paid employment and are culturally less likely to make contacts outside of the home.
In summary, there is a growing need for research into what are perceived to be unique and pressing issues for older female immigrants. To date, a theoretical model for this research has been identified as lacking. The following sections of this paper present the theoretical construct of occupational science and build a case for its application in studies of older immigrant women’s health and wellbeing.
One theoretical model that holds promise for understanding and responding to the health needs of older immigrant women is that of occupational science (OS). Occupational science emerged as a field of study in the late 1980s in California under the under the vision of Elizabeth Yerxa (Canadian Society of Occupational Scientists, 2006), and it draws from social and behavioural science disciplines to examine the relationship between people and the things with which they fill their days – notably their occupations. Occupational science theory moves far beyond conceptualising occupation strictly in terms of employment and defines it as goal-directed activities characterising how people use their time both on a daily basis and across the lifespan (Society for the Study of Occupation, 2005). Occupational science proposes that ‘human engagement is integral to everyday living as people of all ages plan, structure and use their time doing the things they need andwant to do’ (Brown et al, 2005). Of particular concern to occupational scientists is the relationship between occupation and health (Molineux, 2004). The evidence base for occupation as a key modifier of health and wellbeing is growing under this new theoretical construct, and the literature contains a diversity of research exploring occupation and health. For example, studies have examined the relationship between favoured versus unfavoured roles and low back pain (Fiscer et al, 2006); participation in community occupations following a stroke and the impact on quality of life (Johansson et al, 2007); and identification of the roles and occupations older people consider to be productive work (Knight et al, 2007).
Occupational deprivation is a concept within the field of occupational science. ‘Occupational deprivation refers to situations in which people’s needs for meaningful and health promoting occupations go unmet or are systematically denied’ (Wood et al, 2005). A review of the scarce literature regarding elderly women’s experiences when immigrating to be reunited with adult children reveals that these women may feel as if they are living ‘in between’, neither completely of their birth culture nor of the new host culture (Donnelly, 2006). Participants in a study of female Vietnamese immigrants carried out in western Canada identified feelings of loss, loneliness and isolation, while at the same time recognising that for the most part their lives were financially more stable. With the benefits of income security for some also came loss of role and meaningful activity. Participants commented that their lives were now circumspect; ‘Just eat and sit ... I knit ... it helps me to forget ... I would sit here alone and cry’ (Donnelly, 2006). A study of older female Iranian immigrants highlighted similar findings. While these participants reported that immigration had resulted in increased financial and personal safety, it was considered to be the lesser of two evils given the significant losses in terms of meaningful roles, status and participation in a familiar society (Shemirani and O’Conner, 2006). These women reported loss of valued roles: ‘it was very hard for me to accept that I could not find a job in my own field ... Now I have lost my independence ... I have not been as productive as I used to be’. A number of the women in this study commented that being an active and contributing member of their new Canadian society was much more difficult because of their age – ‘ I dyed my hair but signs of aging were showing in my face. You can’t dye your age! ... I wish I came here earlier, I was younger; I could work in my own field’. One participant spoke of being refused entry to English as a second language courses based on her ‘advanced’ age of 52 years (Shemirani and O’Conner, 2006). These women, like the Vietnamese women in Donnelly’s study, also commented on the negative emotions triggered by time alone with little to do; for example, ‘I would like to be entertained, busy or occupied a bit more and to spend less time at home and not to think a lot ...’ (Shemirani and O’Conner, 2006). Being denied access to programmes and services based on age is an example of institutionalised occupational deprivation.
Additional issues illustrating factors that contribute to occupational deprivation were identified in a study of ageing Asian and Caribbean women who migrated to Pennsylvania (Patterson, 2004). This study revealed that 60% of the participants did not drive, and the implications of this for participating in meaningful activities, family chores and any efforts to decrease feelings of isolation, given North America’s automobile- centric society, are potentially far-reaching. These women identified how lack of recognition of qualifications from their country of origin and expectations of their families to remain in the home and provide care to grandchildren, as opposed to securing paid employment or increased educational qualifications, contributed to a sense of loss and decreased productivity. Many Asian cultures ascribe to collectivist traditions where one’s value lies in relationships with, and doing for, other family members. In contrast are the capitalist social norms in Canada, where value is integrally related to productivity and earning capacity. These conflicting norms can compound the feelings of confusion and uncertainty elderly immigrant women have about their role within the restructured family post migration (Iwama, 2006).
Mjelde-Mossey and Walz (2006) present a compelling summary of the literature supporting the need for productive activity to achieve successful ageing and explore how volunteer activities can play a role in developing public policy supporting the health needs of ageing Asian female immigrants. Without public policy changes the needs of this group of new Canadians are likely to remain unmet. Policy makers and service providers need to recognise that this group’s unmet needs and the subsequent health impacts may have significant and far-reaching implications for the health and wellbeing of the extended family, affecting members’ current and future economic productivity at the micro-level (family) and the macro-level (community and national). Occupational science has established an evidence base in research involving a diverse range of service users including people with HIV and AIDS, developmentally delayed children, people with chronic mental health disease and incarcerated prisoners (Molineux, 2004). The component features of occupational deprivation, marginalisation, isolation, role deprivation and decreased personal control that these people share are also a risk factor present in the lives of many elderly immigrant women. The successful health promotion and illness management interventions gained by applying an occupational science perspective in their lives can potentially prove highly relevant to the emerging health needs of women confronting the dual challenges of ageing and immigration within their new lives in Canada.
Further information about occupational science and occupational deprivation is available from the Canadian Society of Occupational Scientists (http://occupational sciencecanada.dal.ca/home.html), the International Society of Occupational Scientists (www.isoccsci.org)) and the Society for the Study of Occupation (www. education.wisc.edu/occupational_science).
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