Qualitative Health Empowerment

CLINICAL SCHOLARSHIP

Health Empowerment Among Immigrant Women in Transnational Marriages in Taiwan Yung-Mei Yang, PhD, RN1, Hsiu-Hung Wang, PhD, RN, FAAN2, Fang-Hsin Lee, PhD, RN3, Miao-Ling Lin, MN, RN4, & Pei-Chao Lin, MSN, RN5

1 Assistant Professor, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan 2 Professor, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan 3 Assistant Professor, Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan 4 Section Head, Department of Health, Kaohsiung City Government, Kaohsiung, Taiwan 5 Doctoral Candidate, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan Qualitative Health Empowerment

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Key words Marriage migrant women, health

empowerment, participatory action research

Correspondence Dr. Hsiu-Hung Wang, Professor, No. 100,

Shih-Chuan 1st Rd., Kaohsiung 80708, Taiwan.

E-mail: hhwang@kmu.edu.tw

Accepted: August 31, 2014

doi: 10.1111/jnu.12110

Abstract

Purpose: The aim of this study was to develop, implement, and evaluate a theory-based intervention designed to promote increased health empower- ment for marriage migrant women in Taiwan. The rapid increase of interna- tional marriage immigration through matchmaking agencies has received great attention recently because of its impact on social and public health issues in the receiving countries. Design and Methods: A participatory action research (PAR) and in-depth interviews were adopted. Sixty-eight women participated in this study. Eight workshops of the health empowerment project were completed. Findings: Through a PAR-based project, participants received positive out- comes. Four outcome themes were identified: (a) increasing health literacy, (b) facilitating capacity to build social networks, (c) enhancing sense of self- worth, and (d) building psychological resilience. Conclusions: PAR was a helpful strategy that enabled disadvantaged migrant women to increase their health literacy, psychological and social health, and well-being. Clinical Relevance: The findings can be referenced by the government in making health-promoting policies for Southeast Asian immigrant women to increase their well-being. Community health nurses can apply PAR strategies to plan and design health promotion intervention for disadvantaged migrant women.

The rapid increase of international marriage immigration through matchmaking agencies has received great atten- tion recently because of its impact on social (e.g., demo- graphic structure and culture) and public health (e.g., healthcare services) issues in the receiving countries. The U.S. Citizenship and Immigration Services (2013) reported that the “mail-order bride” business results in 4,000 to 6,000 marriages between U.S. men and foreign women each year. In Asian countries, an increasing num- ber of women from Mainland China, Vietnam, Indone- sia, the Philippines, Thailand, Malaysia, and Cambodia have migrated through international marriage to Taiwan,

Singapore, Japan, South Korea, and Hong Kong (Hsia, 2010). In Taiwan, the immigration of Southeast Asian brides started in 1987 in rural areas of Taiwan (Yang & Wang, 2012). However, the number of undocumented international marriage immigrant women is often under- estimated. According to Taiwan’s Ministry of the Inte- rior (2012), there has been an influx of 410,000 foreign spouses in Taiwan, including 140,000 from Southeast Asia and approximately 260,000 from Mainland China. The Ministry of the Interior (2012) reported that the overall immigrant population in Taiwan has grown dra- matically, especially immigrants from Mainland China

Journal of Nursing Scholarship, 2015; 47:2, 135–142. 135 C© 2014 Sigma Theta Tau InternationalQualitative Health Empowerment

Health Empowerment Among Immigrant Women Yang et al.

(318,390; 67.45%), Vietnam (87,274; 18.49%), Indone- sia (27,648; 5.86%), Thailand (8,333; 1.77%), and the Philippines (7,468; 1.58%), making the influx of racial or ethnic immigrant minorities an increasingly challenging social and public health issue.

For many women in developing countries, interna- tional marriage immigration has emerged as a way to escape poverty and achieve a better life by marrying men from more financially developed countries. For men in East Asia who experience difficulties finding a wife, matchmaking agencies can arrange a trip to al- low men to locate a partner in a few days and return to their homeland with a new bride. The bridal candi- dates, however, are called by many derogatory terms, such as “mail-order brides” or “foreign brides,” and are often treated with disrespect and derision in the receiving country (Choe, 2005).

Health Care Among Immigrant Women in Transnational Marriages

The growing number of immigrant women has be- come a significant global concern in the social and public health sectors. According to the United Nations’ Commit- tee on the Elimination of Discrimination Against Women (2009), immigrant women may not only be subject to sex discrimination in their receiving country but also face specific health challenges. Indeed, one of the primary goals outlined in Healthy People 2020 is to eliminate health disparities among different segments of vulnera- ble populations, such as immigrants (U.S. Department of Health and Human Services, 2013). Studies showed that immigrant women in Taiwan not only tended to be more vulnerable to illness but also experienced more barriers to their health care than nonimmigrants. A cross-cultural comparison indicated that Vietnamese immigrant women in Taiwan had a generally lower health-related quality of life than native Taiwanese women (Yang & Wang, 2011a). Lin and Wang (2008) investigated Southeast Asian pregnant immigrant women and found they had irregular prenatal examination behavior.

Immigration is a stressful, unexpected life event in which immigrants experience a complicated process of re-adaptation in the host society (Meleis & Lipson, 2004). To cope with the challenges of living in a new coun- try, marriage migrant women in Taiwan are also vulnera- ble to psychological distress, which can negatively impact their health and well-being (Yang, Wang, & Anderson, 2010). Moreover, greater acculturative stress increases the risk for developing psychological problems, partic- ularly in the initial months of immigrating to the new host society (Berry, 1997). The lack of true friendships,

personal relationships, and social support in their host country intensifies their loneliness and social isolation (Yang & Wang, 2011b).

Marriage migrant women’s marginalized status and dif- ficulties in accessing adequate health care indicate a lack of empowerment to effectively seek the resources they need to improve their health and well-being. Shearer (2007) asserted that health empowerment may increase one’s awareness in health and one’s own healthcare decisions. Ensuring health empowerment among mar- riage migrant women may improve their ability to access health care, achieve better health, and overcome their marginalized status in their receiving country. The aim of this study was to develop, implement, and evaluate a theory-based intervention designed to promote increased health empowerment for marriage migrant women in Taiwan.

Methods

Design and Theoretical Framework

Action research is an interactive research process that equalizes problem-solving actions implemented in a col- laborative framework with data-driven analysis or an in- quiry to understand underlying causes enabling future expectations about personal and organizational change (McNiff, 2013). Participatory action research (PAR) is based on critical social theory; it is conducted to realize and transform the world, collaboratively and reflectively (Reason & Bradbury, 2008)Qualitative Health Empowerment.

PAR was used to develop the intervention of this health empowerment project (HEP). The bottom-up approach of PAR was chosen as the most appropriate method to develop and evaluate an intervention program designed to empower an especially marginalized and oppressed population (Minkler & Wallerstein, 2010). Previous researchers have documented PAR as an empowerment-based inquiry methodology that bridges the gaps between knowledge and daily lives and equal- izes the power between researcher and participants (Tapp & Dulin, 2010). It promotes the research participants’ ability to identify their own problems, make their own priorities, handle their own solutions, and control their own progress. In addition, Etowa, Bernard, Oyinsan, and Chow (2007) considered PAR a user-friendly framework for community-based inquiry and provided the model for researchers and community members to work together to identify problems, take action, and achieve the goal. The essential elements of PAR are collaboration, partici- pation, and reflection, which take place during multiple cycles of planning, acting, and reviewing (Koshy, 2005).

136 Journal of Nursing Scholarship, 2015; 47:2, 135–142. C© 2014 Sigma Theta Tau International

 

 

Yang et al. Health Empowerment Among Immigrant Women

Intervention

Planning cycles. During the planning phases of our PAR-based HEP, the specific health concerns of the participants had been identified based on the previous literature (Lee, Wang, Yang, & Tsai, 2013; Tsai, Cheng, Chang, Yang, & Wang, 2014; Yang & Wang, 2011b), in- cluding social isolation, acculturative stress, lack of health information, and lack of health literacy. Investigators established a collaborative relationship with community partners, and integrated community resources. The re- search team met with community partners several times to discuss the appropriateness and effectiveness of the health promotion strategies presented in the workshops. Investigators established a preliminary curriculum.

To recruit participants, the research team established community partnerships such as the local neighborhood managers (the heads of the subdivisions of the districts), the local Christian church, the primary healthcare center, and the Management of Assistance Center for Foreign Spouses. The community of interest was considered and the appropriate consent procedures were implemented for participants who were involved in the design of the curriculum. We formalized an arrangement with community leaders to establish contacts with community partners, to build a trusting relationship between par- ticipants and our research team, and to agree on a time frame for the HEP.

Acting cycles. The goal of the various acting cycles of our PAR project was to develop an HEP, implemented as a series of eight workshops, in order to generate pos- itive psychological and social changes among the partici- pants. A major component of the HEP’s curriculum was a holistic health concept, which included physical, psycho- logical, and social well-being. The curriculum addressed the following six topics: reproductive health (maternal health and family planning); disease prevention (human immunodeficiency virus, sexually transmitted illnesses, cancer screening); healthcare system utilization (health information and health insurance); cultural competence (social support and acculturation); mental health (inter- personal relationships and stress management); and the special issue (domestic violence prevention and manage- ment). The study’s principal investigator designed and developed the preliminary curriculum based on previ- ous studies (Lee et al., 2013; Wang & Yang, 2002) and discussion with community leaders, and two instructors presented the health information by means of various activities conducted in the workshops, such as lectures, demonstrations, drama, role-play exercises, group discus- sions, and group presentations.

Reviewing cycles. During the multiple reviewing cycles of the PAR project, the research team worked with community partners to evaluate and reassess the HEP during intermittent periods and at the final stage of the program. Participatory observations and group dis- cussions during the workshops, as well as in-depth indi- vidual interviews with each participant at the conclusion of the program, provided the participants’ points of view and reflections during the PAR process. Feedback from the participants was ongoing. For example, many partic- ipants complained their husbands beat them after quar- rels, so the special session on domestic violence in the curriculum was in response to participants’ feedback in the reviewing cycles.

Data generation and analysis occurred concurrently and began in the early stages of the HEP, which enabled the use of emerging themes and issues to guide group dis- cussions in the workshops. The researchers’ role through- out the reviewing cycles was to explore and stimulate the participants’ reflections on their experience during the HEP Qualitative Health Empowerment.

Participants and Setting

Among the 87 women who were invited to participate in this study, 68 completed the eight workshops of the HEP. The reasons of those who did not complete the study included transportation problems, being forbid- den to go outside by their mother-in-law, taking care of young children, or moving out of the community. Eligible participants were women who fit the following criteria: (a) were marriage migrants from Vietnam, Indonesia, the Philippines, Thailand, or Cambodia; (b) were married to a Taiwanese man; (c) had a basic conversation ability in Taiwanese or Mandarin; and (d) were willing to partic- ipate in the study. Although immigrants from Mainland China comprise the majority of the marriage migrants, they were not included as part of the inclusion criteria. This is because Mainland China migrants share the same culture and speak the same language (Mandarin) with Taiwanese. They can access more information by themselves with no language barrier and have better acculturation in Taiwan. The women from Vietnam, Indonesia, the Philippines, Thailand, or Cambodia who were included have all learned a new language since immigrating. They need to learn Mandarin or Taiwanese dialect to communicate with their husband and in-laws. From June 2009 to February 2010, eight workshops with 1-month intervals were held in a local church located in Pingtung County, southern Taiwan. Each workshop lasted approximately 3 hr, for a total of 24 hr of contact time with study participants throughout the intervention Qualitative Health Empowerment