Health Empowerment Among Immigrant Women

The participants were grouped into five groups by ethnicity. Taiwanese dialect and Mandarin were the languages used while conducting the workshops.

Data Collection

Two qualitative methods were used to collect data: participatory observation and in-depth individual inter- views. Participatory observation involved a member of the research team taking field notes to record the in- teractions and activities in each of the eight workshops throughout the entire health empowerment program. The content of these field notes included observations on the setting arrangement, the participants, group dynam- ics, and interactions between participants, group presen- tations, and the premeeting with community partners. At the conclusion of the program, another member of the re- search team conducted in-depth individual interviews to gain a deeper understanding of the personal experience of each study participant. We developed a semistructured interview guide to elicit responses from each participant. The individual interviews were conducted for 60 to 90 min and were tape recorded and transcribed.Health Empowerment Among Immigrant Women

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Ethical Considerations

The institutional review board of Kaohsiung Medical University, Taiwan, approved the research and proce- dures before the study began. The participants in the study did not experience any physical harm, discomfort, or psychological distress. They were fully aware of par- ticipating in a study, and they understood the purpose of the research by giving their informed consent. The study procedures were fully described in advance to each par- ticipant, the participants had an opportunity to decline to participate, and appropriate consent procedures were implemented.

Data Analysis

Following guidelines recommended by Miles and Huberman (2013) for qualitative data analysis, three members of the research team used the transcribed data for a thematic analysis to examine the qualitative data, which were categorized based on prominent theme pat- terns expressed in the text of the individual interviews with participants. First, the researchers applied categories to each transcript code. They read and analyzed all the transcripts in a three-stage process of data analysis and synthesis, as recommended by Rice and Ezzy (2001). The verbatim transcripts of the 68 interviews in our study generated a codebook of 36 units. In the next stage, the same three researchers used the focused coding method

for the second coding cycle. They met together and, through peer discussion and agreement, recategorized the 36 coding units. Finally, on the basis of the coding, the principal investigator of our research team identi- fied themes that integrated substantial sets of the coding units. Data were collected by two trained, bilingual re- search assistants who were proficient in Taiwanese dialect and Mandarin and had each obtained a bachelor’s degree in nursing Health Empowerment Among Immigrant Women

Rigor

Rigor was guided by the process of trustworthiness (Lincoln & Guba, 1985). Prolonged engagement and peer debriefing were used to assess the credibility of the themes. To ensure dependability, the principal investiga- tor conducted an 8-hr training session for the research assistants, advising them on the inclusion and exclusion criteria of the study and instructing them in the use of interviewing techniques, participatory observation skills, and field-study knowledge to ensure reliability. In addi- tion, thick description of text and field notes enhanced research transferability.

Results

Sixty-eight marriage migrant women in Taiwan partic- ipated in and completed this study. Participants ranged in age from 20 to 42 years, with a mean age of 32.4 years (SD = 4.6). Their spouses’ ages ranged from 27 to 72 years, with a mean age of 42.5 years (SD = 4.34). The participants’ original nationalities were Vietnamese (n = 42, 61.8%), Thai (n = 12, 17.6%), Indonesian (n = 8, 11.8%), Filipino (n = 5, 7.3%), or Cambodian (n = 1, 1.5%). The women’s length of residency in Tai- wan ranged from 2 to 12 years, with a mean length of stay of 8.3 years (SD = 2.6). The levels of education for most of the participants before immigrating to Taiwan were elementary school and junior high school (n = 62, 91.2%). The highest level of education for most of the women’s spouses was junior high school or high school (n = 60, 88.2%). Among the participants, 53 (77.9%) were housewives.

Through an inductive thematic analysis, the follow- ing four outcome themes emerged from the data: (a) in- creasing health literacy; (b) facilitating capacity to build social networks; (c) enhancing sense of self-worth; and (d) building psychological resilience.

Increasing Health Literacy

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and

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understand basic health information and services (Speros, 2005). The immigrant women in our study had poor health literacy and, consequently, experienced many bar- riers to accessing and using healthcare services. For in- stance, one woman said she didn’t know “what is Pap smear or cervical cancer screening and how much it cost.” Participants were not aware that the Taiwan’s National Health Insurance (NHI) program in Taiwan offers a free annual cervical screening to women 30 years of age and older. They not only lacked awareness about NHI and affordable medical care resources but also experienced language difficulties that prevented them from learn- ing about illness prevention and health promotion. One woman shared her experience about feeding her baby: “I chose wrong baby milk formula because I cannot read the instruction on milk bottle.” After attending the work- shops for our HEP, the participants reported that they felt more informed about healthcare information and re- sources. For example, one of the participants said:

When I arrived here [in Taiwan], I very quickly became pregnant. Because I am not a citizen, I thought I am not covered by the National Health Insurance. My husband and I didn’t know that we can have free prenatal examinations and obstetrical services provided by primary healthcare centers. We spent a lot of money to visit a private clinic. Now, through this workshop, I know where I can get medical care to help me.

The participants’ increased health literacy and knowl- edge about illness prevention and health promotion prompted them to change their behavior in favor of more healthy choices. For example, one of the par- ticipants decided to change her use of an oral pill to the use of condoms for contraception and safer sex. The increased exchange of health-related information and resources provided in the workshops improved the immigrant women’s decision-making skills and their ability to apply these skills in health-related situations. For example, one of the participants who experienced domestic violence stated:

From the special issue workshop on domestic violence prevention and management, I learned that nobody has the right to hurt another’s body. My husband beat me and the kids. Now, I will call 113 for help and will have free-of-charge medical treatment.

Facilitating Capacity to Build Social Networks

Many of the participants experienced extreme lone- liness and isolation in their community. They missed their friends and family and the familiar culture of their

homeland. Moreover, their husbands and in-laws often forbid them to leave the house, preventing them from developing new friendships with others. The women reported that attending these workshops helped alleviate their sense of loneliness and facilitate their capacity to build social networks in the community. By the end of program, participants had developed small, informal groups that would arrive early to the workshops in order to chat with each other and enjoy the company of other participants. These advantages of attending the program’s workshops are described in the following statements from participants:

To get in touch with other immigrant friends is the happiest thing I have. I look forward to the workshops because this is a chance I can go out and meet friends from the same country. My family is afraid that the “bad friends” might influence me.

The women’s shared ethnicities and personal interac- tions with other participants at the workshops provided them the opportunity to develop friendships that offered strong emotional support, which reduced their feelings of loneliness and social isolation. Attending the work- shops helped them facilitate their capacity to build social networks and communicate with their husbands and in- laws to decrease social isolation. One participant stated that “After the teaching, I have learned to use better way to talk with my husband and mother-in-law, not just al- ways keep silent. They have more patience to communi- cate with me.”

Enhancing Sense of Self-Worth

The participants in our study reported that they suffered discrimination and oppression from their new family. The women’s original culture was ignored, suppressed, and even discriminated against by their Taiwanese in-laws. Moreover, because most of the women spoke Mandarin, they could easily be identified as foreigners by their accent in the eyes of the Taiwanese public. Consequently, the women remained silent and were submissive to their in-laws.

The workshops used role-play activities, team pre- sentations, and group discussions designed to increase the women’s confidence in their ability to speak out for themselves. After attending the workshops, the par- ticipants described feeling more confident in problem- solving and seeking better health care for themselves and their family members. As one participant noted, “I had a better understanding of taking care of myself and my family.” Another participant said: Health Empowerment Among Immigrant Women