Author: Lorenzo De Min
Last update: 25/09/2019
According to projections elaborated by the United Nations (UN), the proportion of the world population over 60 years of age will nearly double between 2015-2050, rising from 12% to 22% (UN, 2015). At the same time, due to migration, the number of older persons ageing outside their country of origin is increasing (Barenfeld, Dahlin-Ivanoff, Wallin, & Gustafsson, 2018). Approximately 30 million people aged 65+ are now counted outside of their countries of birth, a number that is almost double compared to 1990 (UNDESA, 2017). Such a trend may represent a challenge for national health systems, which are called to recognise and address the complex web of needs and expectations of culturally-diverse populations as they face the transition into later adulthood (WHO, 2016).
A frequently-used operational cut-off to define old age is 60 to 65 years. However, defining old age is not straightforward. As pointed out by Foucart (2003), old age is a cultural concept, socially constructed. Its definition is arbitrary and varies between nations and latitudes, influenced by life expectancy, local norms and values, social roles, and policies. The concept of “getting old” may be linked to job retirement for example, or to becoming grandparent in certain cultures, while being associated with the degree of disability in others (Foucart, 2003; Glascock & Feinman, 1980; Gleason, 2017). Perception of ageing, therefore, differs widely. Being aware of this difference is relevant when considering migrants’ individual experience of growing old outside their country of origin, as perceptions of ageing influence needs and expectations (Dubus, 2018).
Getting older outside the country of origin implies challenges that have to be recognised by policy makers and health practitioners in order to promote the rights and quality of life of elderly migrants, preventing the creation of health disparities. This article provides a brief overview of the current health trends among senior migrants and the factors that hinder healthy ageing within this subgroup. The conclusion will include a number of recommendations for policy makers and health care workers.
Overview of current NCD trends among migrant populations
As an individual ages, progressive deterioration of health may occur, often in line with increased risk of disease or other health problems such as mobility decline. The most common health problems found in the older adult population fall into the noncommunicable diseases and mental health clusters and include, among the others, cardiovascular diseases, cancer, chronic pulmonary diseases, dementia and depression. A recent technical guidance published by WHO Europe (WHO, 2018) has highlighted that elderly migrants (i.e., persons aged 65+ who are living outside of their countries of birth) tend to have similar disease patterns as senior natives, but the progression of disease over migrants’ life courses is more frequently negatively influenced by disadvantaged socioeconomic status and migration-related risk factors.
Studies focused on cardiovascular diseases among elderly migrants living in Europe are limited and show contrasting findings, describing lower, equal or higher cardiovascular risk among migrants compared to natives, which are influenced by disease prevalence in the country of origin and lifestyle habits (Byberg, Agyemang, Zwisler, Krasnik, & Norredam, 2016). These findings suggest that elderly migrants are not a homogenous group, yet there is relatively more consensus around the finding that elderly migrants from South Asia seem to be at higher risk for cardiovascular diseases and diabetes compared to elderly Europeans (WHO, 2018). Similar findings regarding diabetes are described in studies looking at individuals with South Asian origins living in the United States (Chan, De Souza, Kobayashi, & Fuller-Thomson, 2019) and at Filipino migrants living in New Zealand (Maneze et al., 2018). The last two studies were not specifically focused on elderly migrants but on migrants in general, but as prevalence of the described conditions increase with age, the findings will likely hold for the older migrant population. Research conducted among large populations in Australia showed a higher chronic disease risk factor for immigrants from Middle-Eastern, North African, and European origins compared to locals, yet individuals from Central/South Asian and sub-Saharan African origins showed lower risk of chronic diseases compared to non-migrant Australians. The same study also indicated that the risk of developing chronic diseases among migrant populations tends to converge with that of locals the longer the immigrant has resided in Australia (Sarich, Ding, Sitas, & Weber, 2015). Such a finding is in line with the “healthy migrant hypothesis”, which states that newly-arrived immigrants are overall healthier than the local population – probably due to self-selection – but that over time their risks of poor health outcomes tend to increase due to the change in lifestyle and/or exposure to precarious life conditions (Kennedy, Kidd, McDonald, & Biddle, 2015). A study of older immigrants living in Canada described a higher rate of self-reported chronic conditions among elderly migrants compared to elderly Canadians (L. Wang, Guruge, & Montana, 2019). There is a lack of data specific to senior migrants living in Africa. One recent survey conducted in rural South Africa points out the vulnerability of elderly migrants with high blood pressure living in this context (Jardim et al., 2017).
Another non-communicable disease associated with ageing is cancer, where again contrasting results emerge related to the risk of disease onset between migrant and non-migrant populations. Several migrant groups in the European region have been found to have a lower a lower risk of developing cancer, an advantage that is lost over time in association with change in lifestyle. An exception is represented by stomach and liver cancer, whose aetiology correlates with infectious diseases (helicobacter pylori and hepatitis B and C, respectively) and whose prevalence tends to be higher among certain subgroups of migrants compared to natives (WHO, 2018).
Mental health issues are frequently reported among elderly immigrants. Several studies indicate that elderly migrants have higher rates of depression, anxiety and post-traumatic stress disorder. However, this finding should not be generalised across all populations given important discrepancies in reported results across sample destination countries and between migrant groups of different origins (WHO, 2018).
Due to the ongoing ageing of the population worldwide, dementia represents a growing health issue. Evidence gathered within the WHO European region indicates that dementia is often diagnosed late among older foreign-born individuals and associated with the phenomenon of loss of the second language (WHO, 2018). Late diagnosis can be associated to different health beliefs, in particular in communities in which dementia is perceived as a normal consequence of ageing or associated with stigma (van Wezel et al., 2018).
As an individual ages, physical and mental health challenges may compound each other. A study conducted in Tanzania among refugees from Rwanda, for example, highlights the problem of nutritional vulnerability among elderly persons living in refugee camps. Limited food supply in emergency settings is described as the main factor contributing to poor nutritional status, which in turn affects people’s ability for self-care. The authors state that, even when access to food is granted, elderly people might struggle with food preparation if not assisted (Pieterse, Manandhar, & Ismail, 1998).
Lower self-perceived health status has also been found among elderly migrants living in different parts of the world, including Europe, North America and Middle-East (Du & Xu, 2016; B. J. Kim et al., 2017; Strong, Varady, Chahda, Doocy, & Burnham, 2015; WHO, 2018). In this context too, there are divergent findings in the literature. A study conducted in the Chinese city of Hainan shows that elderly Chinese internal migrants report better health than local-born elderly persons (W. Wang, Wu, Yang, He, & An, 2017), while another study conducted in China shows lower reported mental health issues among elderly Chinese migrants (Li, Zhou, Ma, Jiang, & Li, 2017).
As highlighted in this section, even though the diseases that most frequently affect elderly persons tend to be the same worldwide, migrants may be exposed to different risk factors before and after the migratory journey that can have an impact on disease prevalence and outcome. Consequently, there may be health gaps between migrants and non-migrants. The next section will explore more in detail the factors that contribute to the creation of disparities between elderly immigrants and local seniors.
What the literature teaches us
Despite common misperceptions of elderly migrants as a burden for societies in countries of destination, elderly migrants can be a resource: such migrants may be socially active, economically productive, and a source of knowledge for their communities. However, several obstacles and barriers challenge the healthy ageing of migrants. Among others, factors such as language barriers, low socio-economic status, low health literacy, lack of available information, and health beliefs (different explanatory models of illness) play a key role in enhancing an individual’s health vulnerabilities (Chung, Seo, & Lee, 2018; Klok, van Tilburg, Suanet, Fokkema, & Huisman, 2017; Schoenmakers, Lamkaddem, & Suurmond, 2017). Next to the migration-related barriers listed above, common age-specific obstacles to health include reduced mobility, hearing impairment, and vision loss (Leung, Bo, Hsiao, Wang, & Chi, 2014; Strong et al., 2015).
The specific needs of elderly migrants, in general, are at risk of being overlooked from a research, treatment, and policy point of view. This is due to several factors, such as prioritisation of other vulnerable groups (for example women and children), lack of data, and difficulty in applying an inclusive working definition of “old age”. For example, different conceptualizations of “older persons” (i.g. chronological and socially constructed) may inadvertently create the risk of exclusion from policies for those individuals who are considered elderly by social role but who have not reached the age cut-off to be defined as such (Migration Data Portal, 2019).
In addition to the migration- and age-related factors noted above that can challenge healthy ageing among older migrants more generally, several other factors contribute to shaping poor mental health issues among elderly migrants specifically. Depression, anxiety, and post-traumatic stress disorder represent the most relevant mental health conditions among older migrants. Factors such as social exclusion, forced displacement and sexual abuse are highly correlated with the onset of such mental health problems, highlighting how migrant-specific experiences can affect health in later life (R. J. Flores, Campo-Arias, Stimpson, Chalela, & Reyes-Ortiz, 2018). Likewise, marginalisation, poor housing conditions and lack of family and social support are factors often related to lower self-perceived health status, a frequent finding among elderly migrants (WHO, 2018). A study conducted among elderly migrants living in Canada indicates that loneliness tends to be less reported among those migrant groups whose language and culture are closer to those of Canada, whereas it is significantly higher among migrants whose language and culture are more distant from those of Canada (De Jong Gierveld, Van der Pas, & Keating, 2015).
Stigma towards mental health disorders can negatively impact access to care (Steinman, Hammerback, & Snowden, 2015), not only among migrants but among the general population. Kirmayer et al. (2011) describe how stigma affects not only patients but their family as well. Even a neurological condition such as dementia can be associated with stigma, especially within ethnic communities where dementia is interpreted as a spiritual condition or associated with black magic. In general, older migrants who fear being stigmatised by members of their communities or kinship groups may be reluctant to communicate about a disease and may be less proactive in seeking care or assistance for a disease. This example highlights the issue of health literacy within migrant communities. Social networks, including family and friends, can provide emotional, informational and practical support to the elderly. However, in case of low health literacy, the supportive role of social networks can be severely hampered (Schoenmakers et al., 2017).
Other ways in which norms and expectations within family groups can affect healthy ageing relates to coordination of care for older persons. Placing a family member in a nursing home is a decision influenced by cultural norms and values, but it may also reflect lack of access to services due to financial constraints (Mold, Fitzpatrick, & Roberts, 2014). A study conducted in the US among elderly Mexican-origin migrants indicated that migrants and their families had a tendency to postpone the use of nursing homes until late, when an individual’s health status was already compromised (Angel & Berlinger, 2018). Furthermore, a qualitative study conducted in New Zealand on a population of elderly Filipino migrants points out that migrants often lack awareness about the services offered by residential facilities in the destination country (Montayre, Neville, Wright-St Clair, Holroyd, & Adams, 2019).
Culturally adapted home- and community-based residential services are indicated as possible strategies to offer better care and overcome isolation for elderly migrants (Weng, 2017). However, a study focused on Chinese and Korean seniors living in the US discusses how these solutions might not be popular among persons from groups in which older adults expect their children to act as caregivers (I. Kim, Kang, & Kim, 2018). A study conducted in China shows that when older Chinese persons migrate, they generally move to the area where their children live (Liu, 2015), indicating intergenerational caregiving as one of the factors that influence the decision to migrate in older age. Indeed, Gubernskaya and Tang (2017) discuss how seniors from Mexico, Dominican Republic, and Vietnam living in the US tend to co-reside with their children more frequently than in their country of origin, suggesting that co-residence is not always the result of a cultural preference but may also be shaped by policies or migration-specific experiences. In this regard, more restrictive immigration policies may bear negative consequences for multi-generational households in which younger members provide informal care for older members (Angel & Berlinger, 2018).
The role of the family in providing care may also reflect financial challenges older persons experience. Limited access to pension plans is reported as one of the factors undermining financial security for senior immigrants in certain countries, including the US and Canada, with a negative impact on health. Significantly, in the US, Mexican migrants have double the chance of being still employed beyond 65 years of age compared to US-born citizens (Angel & Berlinger, 2018; Curtis & Lightman, 2017; L. Wang et al., 2019).
Looking at health promotion, a frequently reported issue among people with a migration background is the low participation in screening programmes, with a consequent negative impact on disease prognosis (Paszat et al., 2017; Simon, Tom, & Dong, 2017; WHO, 2018).
While much of the literature focuses on factors that compromise the healthy ageing of migrants, there are also factors that correspond to better health outcomes for older migrants. For example, civil society organisations and informal networks may try to address the needs of neglected populations when access to medical care is not granted (Stewart & London, 2015). In a study among members of a Filipino community in Canada, Ferrer, Brotman, and Grenier (2017) describe the concept of reciprocity, which allows older people to be “simultaneously recipients and providers of care, not only in the context of relationships with adult children, but also including care exchanges across multiple generations, borders, communities, and time” (p. 315). Another study conducted in Australia mentions the positive example of a non-profit community based organization called CO.AS.IT.,which supports older Italians and Australians of Italian origin by offering assistance with daily activities such as preparing meals and buying groceries, language courses, and social support through a volunteer network (Basic, Shanley, & Gonzales, 2017). In addition to supporting the explicit health needs of ageing migrants, these examples highlight the importance of providing opportunities for social engagement to older persons. Social interaction can protect individuals from loneliness and support the establishment of social networks in a new country, which may be otherwise difficult for elderly migrants (Jetten et al., 2018).
Recommendations & Conclusions
The challenges described in this article represent a great opportunity for researchers, health workers, NGOs and policy makers to take action and promote the health of elderly migrants worldwide.
It is crucial to collect more data and produce more nuanced knowledge about this group, paying attention to the diversity within different subgroups of older migrants (related to, e.g., different age groups, migration status, country of origin). Most of the literature on elderly migrants’ health comes from the so-called Global North, countries in Europe, North America, and Oceania. A number of studies have been published in South-Asia as well, particularly in China, but there remains a lack of studies focused on the Global South. Conducting more research in low and middle countries is therefore key to detect (and address) the unmet health needs of senior migrants.
As several studies point out, different health beliefs and difficulties in navigating health systems in countries of destination have a deep impact on health. Ad hoc interventions to promote health literacy with information and messaging targeted to the needs and constraints of older migrants are key to empower senior migrants. In particular it is important to provide them with the right information about access to care (including type of services, costs, availability of translators), the existence of primary health care and mental health services, and the importance of screening programmes to identify and treat health conditions along the life cycle (L. Wang et al., 2019). Interventions to develop cross-cultural awareness among health workers in the countries of destination are equally necessary.
Language barriers are also often a major obstacle for elderly migrants’ access to health services, and there is need for medical-translation services. Translations should preferably be provided by professionals, since translation done by family members is often unreliable due to potential lower accuracy and emotional involvement (G. Flores, 2005).
While in many societies nursing home services are seen as the preferable choice to provide care to older people who are no longer self-sufficient, family-based care is the norm in many others. Either due to cultural norms or lack of access to nursing homes, elderly migrants often rely on the care of family members when their health conditions deteriorate and are in need of assistance. Many countries disallow family reunification between an adult and his/her older parents, however, which can make it challenging for older persons to receive family-based care. Promoting family reunification policies or expanding their scope to include older family members in need of care is key to foster family support and intergenerational caregiving. At the same time, developing accessible, culturally-sensitive nursing structures and senior community services can potentially improve the quality of life of elderly migrants, including by reducing loneliness and depression. Co-creation is crucial to develop successful projects, hence senior migrants should be included in the development of community spaces. Similarly, a participatory approach is also essential to adapt health promotion strategies to the different needs and perspectives of elderly migrants. Peer education and the involvement of community health workers from ethnic minorities may be a successful approach to develop tailored health promotion strategies for older migrants.
Financial barriers still hinder access to care for senior migrants in several countries of the world due to healthcare costs and lack of access to social protection schemes intended to reduce risk over the life course. Developing policies that address this issue, including social protection policies related to access and entitlement to both contributory and non-contributory social benefit and insurance programmes, is crucial, as socioeconomic status is a major social determinant of health (L. Wang et al., 2019)
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