Overlooked by nurses: A scoping review on health stressors, problems and coping of migrant domestic workers

1 INTRODUCTION

Since Hoschschild introduced the concept of the global care chain as “a series of personal links between people across globe based on the paid or unpaid work of caring” (Hochschild, 2000, p. 131), migrant domestic workers (MDWs) have become a major international target population for issues of human rights. MDWs are an emerging group of caregivers in high-income countries and a vulnerable group of ethnic minorities facing extreme health inequity (Gallotti, 2015; Ho & Smith, 2020). An MDW can be defined as a full-time worker who is tied to an employer either through a regulated work permit or an underground contract that allows him/her to work for a single household (Basnyat & Chang, 2017). There are an estimated 11.5 million MDWs in the world, of whom 75% are female (Gallotti, 2015). Studies of MDWs have uncovered systemic inequity based on gender, economic class, ethnic group and legal status (Palenga-Möllenbeck, 2013), exacerbating the health inequalities they face (Chung & Mak, 2020). Examples of health inequalities of MDWs included poor accessibility to health and social care services and poor mental health (e.g. loneliness, depression, anxiety) (Ho et al., 2022). Tackling the health inequalities and inequity of MDWs requires collaborations between health and social care professionals (e.g. nurses and social workers) at the research, practice and policy level (Cheung et al., 2019; Ho & Smith, 2020). Therefore, we reviewed stressors, problems and coping surrounding health issues of MDWs to propose possible strategies to intervene.

Generally, the work of MDWs includes household chores and caring (Ho et al., 2019). People from Poland have been employed as domestic workers in Germany to take care of older adults (Palenga-Möllenbeck, 2013). In Scandinavia, Sweden provides tax reductions for older adults to pay for “top-up” care services from migrant workers (Gavanas, 2013). Filipina domestic workers have been employed to care for older adults in Cyprus (Panayiotopoulos, 2005) and Israel (Ayalon & Roziner, 2016). Approximately 14% (n = 183,000) of Hong Kong older adults are reportedly cared for by MDWs (Ho et al., 2021). The number of MDWs hired to specifically care for older adults was projected to increase from 198,000 in 2011 to 300,000 by 2030 in Singapore (National Population and Talent Division, 2012). Around 12.8% of frail older adults in Taiwan were under the care of migrant domestic workers (Chou et al., 2015) and 17.4% of Israeli older adults received government subsidies to hire MDWs (Ayalon & Roziner, 2016).

The role of MDWs has a unique nature, as both employees and caregivers of their employer or the family members of employers, requiring MDWs to employ heavy emotional labour in their relationships with care recipients (Ho et al., 2019). As such, the mental health of MDWs is a major issue. Half of the MDWs in China reportedly found it difficult to manage negative emotions (Wang & Wu, 2017). MDWs were reportedly highly vulnerable to abuses by employers (Ho et al., 2022). In fact, abusive behaviours by employers, such as physical and verbal abuse, sexual harassment and economic exploitation were identified as common stressors that trigger negative emotions among MDWs (Wang & Wu, 2017). Due to their live-in working arrangements, MDWs provide round-the-clock care to recipients, potentially having an impact on their physical health status. For example, 52% of MDWs complained of a lack of sleep and 73% reported not having regular mealtimes, due to the constant demands of their caregiving work (Mission for Migrant Workers, 2018).

Both social sciences (e.g. Ayalon & Roziner, 2016) and medicine (e.g. Cheung et al., 2019) have independently investigated the health issues of MDWs. While nurses have an important responsibility to promote and protect the mental and physical health of vulnerable groups (e.g. ethnic minorities and caregivers) (Douglas et al., 2014), there are no examples of input from nurses. It has also been highlighted that healthcare professionals (e.g. nurses) and current healthcare services and policies were unable to meet the needs of MDWs (Cheung et al., 2019; Ho & Smith, 2020). Given the increasing global trend of hiring MDWs, coupled with a lack of systematic information on the health issues of MDWs (Gallotti, 2015), this is the first scoping review on health stressors and health problems affecting MDWs worldwide in order to suggest potential interventions for nurses to mitigate the health inequity faced by MDWs.

2 METHODS

We employed Arksey and O'Malley's (2005) five-stage framework and followed the advice of Levac et al. (2010) to synthesize and analyse a wide range of literature. Arksey and O'Malley (2005) proposed five stages to conduct a scoping review: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting the results. Underpinned by the framework (Arksey & O'Malley, 2005), this study is reported according to PRISMA reporting (Page et al., 2021). Steps one to five of this five-stage framework (Arksey & O'Malley, 2005) are described below.

2.3 Study selection

In total, 2,377 references were obtained for literature in English, Chinese or Indonesian, of which 1,511 were eliminated as duplicates. A study team of seven members screened the titles and abstracts of the remaining 866 articles using the Covidence software platform. Each article was screened independently by two team members with disputes resolved by a third team member. After reviewing titles and abstracts, 82 full-text relevant articles were retrieved and screened again. Articles were screened based on the following inclusion criteria: (1) only international peer-reviewed studies and original articles; and (2) research design was quantitative, qualitative or mixed methods studies. Studies were excluded if they: (1) only mentioned social construction of exploitation or abuse on MDWs, (2) involved participants who were migrant workers but not engaged in domestic work or (3) not focussed on the health and well-being of domestic migrant workers. We also excluded commentaries, discussion papers, editorials, literature reviews and book chapters (Cheung et al., 2021). Monthly meetings were carried out to clarify the study selection eligibility criteria. No Chinese or Indonesian literature met the inclusion criteria. In total, 25 articles were included, and an additional two articles were retrieved by searching on Google. Therefore, 27 articles were included in the final scoping review. The search process is provided in Figure 1.

3 RESULTS

The 27 included studies encompassed qualitative (n = 8), quantitative (n = 14) and mixed methods studies (n = 5). Twenty-one studies focussed specifically on workers from the Philippines (n = 14), Indonesia (n = 2), Ethiopia (n = 2), Nepal (n = 1), Burma (n = 1) and Russia (n = 1). Other studies included a mixture of participants from Philippines, Indonesia, Colombia, Morocco, Senegal, Romania, Sir Lanka, Burma, Vietnam, Sri Lanka, India and Bangladesh. We discuss below the key themes, which comprised stressors impacting health, physical and mental health problems and coping strategies.

4 DISCUSSION

This is the first scoping review and synthesis of literature related to the health issues of MDWs involving 16 countries or cities globally. It indicates that MDWs' health is a global issue and provides a valuable addition to the literature on the health inequity of MDWs. From a human rights perspective, identifying stressors and subsequent coping strategies used by MDWs to address their health problems is merited. Human rights issues are meant in the first instance to guide the actions of governments and have implications for health policy and practice (Gruskin et al., 2007). One systematic review identified that common stressors, which triggered emotional and psychological problems in MDWs included, abusive behaviour by employers, sexual harassment, economic exploitation, demanding working environment and recurrent financial hardships (Wang & Wu, 2017), all consistent with the findings of our review.

The “healthy immigrant effect” was originally employed to permanent migrants in migrant studies (Anikeeva et al., 2010). For example, a review of permanent migrants in Australia showed that the migrant health advantage generally deteriorates with increasing duration of residence (Anikeeva et al., 2010). A similar situation of the general deterioration of health stats was also experienced by MDWs in our findings. Indeed, the “healthy immigrant effect” was shown to be experienced by temporary foreign workers as well (Vahabi & Wong, 2017). This scoping review identified a range of physical problems, such as chronic pain, fatigue, sleeping difficulties, gambling behaviour and suicide, indicating the potential of somatization of mental problems faced by MDWs. High levels of stress, anxiety and depressive symptoms were common in MDWs across all geographical regions. However, these problems were largely reported in qualitative studies, in which systematic survey data on physical and mental problems, inclusive sexual and reproductive health, faced by MDWs are lacking in this scoping review. A recent survey using summary scores on physical health and mental health showed that MDWs suffered poorer physical and mental health status when compared with the general population in Hong Kong (Chung & Mak, 2020), further providing solid evidence on the health inequalities of MDWs. However, the types of physical and mental problems faced by MDWs were not identified by Chung and Mak (2020). As such, our findings highlight the importance for health and social care researchers to systemically assess the physical and mental problems of MDWs, actively listen to their concerns and demonstrate commitment to support and follow-up.

In coping with stressors and health problems, numerous socio-cultural disadvantages (e.g. social isolation, marginalization from health and social care systems, language barriers) contributed to their poor accessibility to health services and limited health literacy in host countries (Weng et al., 2021). As such, they faced challenges in accessing and understanding health-related information and services (Ho & Smith, 2020). In our findings, MDWs identified employers as a major source of social support (Heng et al., 2019; Kantaris et al., 2014; van der Ham et al., 2015). However, our findings also showed that employers were a possible source of abuse for MDWs. It was shown that employers could be a source of stress because of the unequal employer-employee power relationship (Ho et al., 2019). While the live-in arrangement prevented law enforcement in the private sphere to protect MDWs, MDWs are at the same time dependent on their employers for instrumental support, informational support and emotional support (Ho et al., 2019). This complex situation exacerbates the vulnerabilities of MDWs, in which nurses in the community need to partner with social care professionals in order to address health issues within a marginalized social environment.

As an advocate of clients, providing health literacy support to clients is a core nursing skill (Wittenberg et al., 2018). Our findings on peer support and participating in religious activities shed light on the possible way for nurses in community settings to mitigate the health inequity of MDWs, particularly addressing the issues of structural exclusion from healthcare system and limited health literacy. MDWs mainly shared information and advice by establishing social networks and contacts with peers (Anbesse et al., 2009). However, providing or receiving mutual aids among peers was not always entirely positive because they shared similar problems with limited resources (Hall, Garabiles, & Latkin, 2019). Building on MDWs' preference to seek help from peers, in which mutual aids may not be always effective, training peer leaders to be para-professional peer counsellors was shown to be a feasible and potentially effective intervention to promote the mental well-being and mental health literacy of MDWs (Wong et al., 2020). Wong et al. (2020) showed that peer support coupled with training of CBT was effective to improve the mental health literacy of MDWs, and a potential bridge between formal healthcare services and MDWs. However, the study of Wong et al. (2020) was a pilot study with 37 participants. Meanwhile, it was commented that CBT might be too intensive for MDWs, as such mental health first aid training could be an alternative (Ho et al., 2022; Hung et al., 2021). Further large-scale randomized controlled trial is needed for strong empirical evidence of the effectiveness of para-professional training of MDWs to improve their mental health.

According to our findings, MDWs were marginalized from health and social care services. This will certainly present a challenge to nurses in secondary prevention settings to identify MDWs in distress. A recent study has shown potential in training up peer support workers and including them in interprofessional teams for more egalitarian service provision for people with mental health issues (Ehrlich et al., 2019). Given nurses bears the role of coordinator, this may be particularly helpful to actively involve marginalized MDWs. On the other hand, our findings have also shown that MDWs performed religious activities in church. As such, collaborating with faith-based organizations is a possible way for nurses in the community to collaborate with social care professionals to provide peer support programmes for MDWs in the community. As an example, a community engagement forum in Hong Kong led by nurses was shown to be feasible to engage the MDW community to co-create peer support with the non-government organization (The Nethersole School of Nursing, The Chinese University of Hong Kong, 2022).

Small sample size and non-probability sampling were common in quantitative studies, highlighting a research gap in current literature to produce a more rigorous design to ensure better generalization. Several mixed methods research studies included in this review were designed to capture experiential aspects of the health-related consequences of working as an MDW. We further advocate for a participatory action research approach to actively empower MDWs through the co-construction of a peer support programme. Bhuyan et al. (2018) demonstrated an excellent example of advocacy for migration policy changes for MDWs in Canada, using a participatory action research approach. The changes were deemed to be important to ameliorate the structural violence of migrant labour (Bhuyan et al., 2018).

5 CONCLUSIONS

Narrowing health inequity has long been the heart of helping professions. As advocators, nurses have the responsibility to improve the accessibility of MDWs to healthcare services and their health literacy. Our review findings illustrate MDWs as a vulnerable group with extreme health inequity, for whom marginalization requires nurses to reach out to the community and to include them in interprofessional teams. Taking approaches to train para-professional peer leaders with CBT can be a possible way to support the health and well-being of MDWs. To reach migrant domestic workers who are systematically marginalized from health and social care services, engaging faith-based organizations could be potentially effective. Employing a participatory action approach will be a feasible way to co-create a suitable peer support programme for MDWs.

AUTHOR CONTRIBUTIONS

Ken, Ingrid, Janet and Graeme drafted the manuscript. Sonia, Lisa and Ferry reviewed and revised the manuscript. All authors have reviewed the submitted manuscript and approved the manuscript for submission. All the team members participated in the screening of articles.

CONFLICT OF INTEREST

We declare no conflict of interestPreprint version.