How to Support Health When Aging at a Place Called Second Home?

Abstract

Today, we live in a world where migration is a fact. Due to this, in this context, we have a group of persons who will age in a context that differs from their country of birth. It is important to identify the opportunities and obstacles that these persons face when they age in the context of migration. This chapter will highlight how aging is described and what it means to grow old in a migration context. What makes the life worth living? What creates meaning in everyday life when aging far away from “home”? One way to explore this is to see it from the perspective of health promotion and salutogenesis, where the meaning derives from the sense of coherence.

1. Introduction

It is crucial to understand and broaden the view of health in everyday life among older persons aging in migrations. By doing so, it is possible to reveal how to promote health and enable the persons to have a sense of coherence and well-being, despite the fact that they are aging at a place that is not their origin home. Even if the older persons have been living in the host country for ages, the bond to their country of birth is tight. The connections to country of birth are an important part of the sense of well-being in daily life. Therefore, the everyday life in host country will always be experiences as the “second home.”

The meaning of home is a complex phenomenon. It has a central place in every person’s life since a lot of time is spent there. The concept of home and the meaning of it may vary between different persons, but mostly home is connected to feeling of safety, security, and relaxation. Home is place where many memories are kept, it could also be a place that reflects our identity. It is also a place that is connected to important and meaningful activities. Home is much more than an objective physical place. There is always an emotional dimension connected to home.

2. Aging and migration

We all get older, and the aging process is a normal part of life. The aging process can be described from different aspects such as physical aging, social aging, and psychological aging [1]. How the aging process continues is connected to heritage, environment, and the person’s life style [2]. A concept often used in the area of aging is the concept of successful aging, which means to have the opportunity to engage in daily life, experience good health, seen from an individual perspective. Other important part is to have the possibility to be in charge over one’s daily life [3]. This means that when a person has the possibility to continue to manage daily life by using one’s own capacity, the life satisfaction will maintain even if the physical status declines.

The perspective and how we relate to aging and old persons are connected to cultural contexts with its values and norms. According to Fung [4], perspective on aging is influenced by the cultural differences in different countries. Most persons make sense of their life through the values and norms in the specific cultural context, and by that it will also create differences in how aging is perceived. For example, in some cultures, aging persons are respected due to their life experiences and older persons are considered as wise and prudent. In other cultures, aging is seen as a decline. Thus, the respect for older persons is lower, and older persons might be seen as nonproductive and a cost for healthcare services in the society. This kind of differences in how aging is perceived has an impact on aging in the context of migration. As persons age in migration, they have their original culture with them. At the same time, they have to adapt to the new environment and culture in the host country. How the person experiences the aging in the new context is dependent on how the person can interact with others, how they are treated, and if they have the possibility to continue to engage in important and meaningful activities, which they have performed in their country of birth. The experience and the response from the environment, and the possibility to find meaning in life, can be seen as important issues on how the person is able to create a sense of coherence, SOC, in everyday life.

3. The impact of migration on sense of coherence

Sense of coherence, SOC, can be described as a person’s understanding of his or her situation in life [5]. According to Antonovsky, [6] SOC includes three parts, which promote SOC: comprehensibility, manageability, and meaningfulness. Comprehensibility relates to an assumption that things in one’s daily life happens for a reason and that it is in some way predictable. For persons aging in migration, comprehensibility can mean that the person understands the things happening in daily life, understands external structures in society, which may affect daily life. For example, understanding how healthcare services work and how to contact the health service or any other authorities. Additionally, knowledge about the norms and understanding of cultural-related activities in host country may either decrease or increase the sense of comprehensibility.

The second part in SOC is the manageability, which means that the older person is confident in his or her skills and other resources needed to be able to cope in challenging situations in daily life. When aging, there will be decline in functioning, both physical functioning and psychological functioning. This will have an impact on the everyday life and the person’s possibilities to cope with daily activities. Seen from a migration perspective, manageability can be negatively affected if the environment does not recognize the remaining resources the person has and which can be used to manage everyday life in host country. If the resources are not recognized, the resources are not fully utilized to support health. On the other hand, if the expectations from environment are too high in relation to person’s capability, then it might cause a stress reaction and, in that way, have a negative impact on health [7]. The third part in SOC is meaningfulness, which means that the person finds life meaningful, can find a purpose in daily life, and that he or she is prepared and motivated to invest one’s energy to cope with situations in daily life. Meaningfulness has also a cultural dimension since meaning derives from the signs and symbols in the culture [8]. Therefore, for older persons aging in migration, it might be difficult to find meaning in daily life if there are difficulties in interpreting these signs and symbols. All of the parts that build up the sense of coherence are vital for the possibility to experience health in daily life when aging in migration. Social and psychological factors, and also the cultural context, can be seen as cornerstones of a strong SOC. A strong SOC can diminish stress on physiological functions [9] and, by doing so, support experience of health in daily life.

The difference between having a strong SOC and a weak SOC lies in what kind of resources the person has and which can be used to meet the challenges in daily life. Antonovsky [6] calls these resources for General Resistant Resources, GRR. These GRRs can be induvial or resources in the environment, which can be used to combat the stressors or challenges in daily life.

4. Health among older persons in migration

Since the number of older persons aging in migration is expected to increase in the future, it is important to increase our understanding of how health in everyday life is experienced by persons who are aging in a country that is not their country of birth. Older persons are often described as a fragile group, who are particularly vulnerable to illness, have decline in functional capacity and difficulties in coping independently with daily life. A particularly vulnerable group are older foreign-born persons who are now aging in a country that is not their home of origin. Surveys that have been done among these people indicate that they have a weaker health status in comparison with older native-born persons in same age group [1, 4]. With this in mind, this group of older persons is described as a particularly vulnerable group. Efforts are needed to enable this group of older persons to maintain health in everyday life. The efforts should strive for supporting older persons to use and utilize the resources they have. These resources the person can use to create a meaningful and functioning everyday life and thus have a good life during old age. To be able to identify the personal resources and the older person’s view of this, it is important to use a person-centered approach. This approach highlights the older persons’ own perspective of health in daily life and builds the frame for health promotion. By doing so, it is possible for the persons to maintain or improve health when health is examined on the basis of quality of life, participation in activities, and a sense of meaning in everyday life.

5. Dimensions of meaning in daily activities

Yerxa [10] has highlighted the connection between health and engagement in activities. The World Federation of Occupational Therapy (WFOT) defines activities (occupations) as: “…the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do” [11]. Daily activities are also recognized and named by the culture in which they are performed, and therefore, it can be assumed that the daily activities are formed by our cultural background [12]. The meaning and value in activities are strongly connected to the person’s narrative and previous life. When reflecting on older immigrants, the value and meaning derive from their cultural background and in that sense the meaning in daily activities is also connected to this. For this reason, health in everyday life is supported when the older person can use his capacity in various types of activities in daily living, both routine tasks and other meaningful and engaging activities, which gives some kind of self-rewarded value to the person.

There is also a connection between health, meaning, and value in activities, and this meaning derives from different dimensions of activity. According to Wilcock [13], the meaning aspect is connected to the possibility to experience doing, being, becoming, and belonging in daily life. The experience of doing, being, becoming, and belonging is universal among human beings and an important part of the experience of health in everyday life [14]. This is interesting to reflect on from the perspective of SOC, in combination with migration and aging. Obviously, the doing part is tightly connected to manageability. This is because it refers to the concrete doing or performing activities. The experience of being able to engage in activities in daily life adds value into the experience of health and well-being [15, 16, 17]. Therefore, decline in functional skills may have negative impact on manageability. But if the functional limitations can be corrected by environmental adaptations or by health promotion interventions, it might be possible to perform the activity even in future. The relation between health and ability to manage and engage in activities includes all kinds of activities, both productive activities and leisure activities [18]. Characteristic of these activities is that there is a deep emotional aspect, they are performed with passion and are more than just routine activities. Additionally, these activities are absorbed with positive meaning [16, 17], and they should be self-initiated [19].

For persons aging in migration, the opportunities to perform self-initiated activities increase the experience of health in daily life. Other important aspect is the connection between activities and the person’s sense of belonging. Additionally, when the activities are defined and named within a group where the person experiences inclusion and belonging, the meaning in the activity will be even more valuable and rewarding. When a person is a member of a group, and has social support, it can be assumed that the social environment will be a source for supporting both manageability and comprehensibility when aging in migration. Especially, the connections to a group with compatriots have been seen to have an important impact on the sense of well-being [20]. Other important part of being able to experience health is the possibility to have moments of relaxation. In the context of migration, it means to be able to have a daily life without too much stressors, which requires great efforts by the person. Situations that are not comprehensible or manageable create a stress reaction. This will have a negative impact on the sense of coherence in all its parts, but especially comprehensibility and meaningfulness. Consequently, then the person cannot see what point it is in daily life and the things that are happening around him. The person will then not have opportunities for just being, which is an important part of the balance in daily life. When a person has opportunity to relax and have moments of being, it will create time for the person to reflect on life and think about what the future brings and what the person will become [13]. For persons aging in migrations, these reflections might be scary because it is connected to uncertainty in how to manage everyday activities if being dependent on others. Research has shown that some of the thoughts have to do with the challenges to communicate with professional care givers. The concern is that what happens if the older person cannot express his or her needs and wishes due to lack of language skills? The concern has to do with the existential dimension of being a person instead of just an object who needs care [20, 21]. The point is that how does the older immigrant reflect on their own “becoming” in the future? This kind of worries may have a negative impact on sense of coherence, which will weaken the experience of health in daily life.

6. Daily activities and migration

Activities in daily living are often taken for granted, and we do not reflect on how decline, for example, decline in physical functions, may affect the possibility to perform daily activities independently. Different cultures may have different view of which daily activities are the important ones and how these activities should be conducted. For example, it might be that older immigrants have daily activities, which they are used to perform in a specific way, and which are meaningful. In situations where they need care from healthcare professionals, situations can occur where the professionals do not recognize the meaning dimension in the activity. In these situations, the value and meaning in activities will decrease, and there may be a disruption in daily activities [22, 23], which may affect the experience of health in daily life. In addition to physical functions, also the environment where the activities are performed will have an impact on how the person can manage the activities. The environment can be both the physical environment and the social environment. If there are hinders in the environment, it causes decreased possibility for the person to use the personal capacity. This can be related to the concept of capability [24] where the view of human beings is that every person is capable of managing daily life if the personal resources and external surrounding enable the person to use their ability. Robeyens [24] explains that there are different types conversion factors, which influence how the person is able to use the skills and resources he or she has. These conversion factors are connected to the person’s skills and body functions, social norms, and environment. In the capability approach, the environment is described on different levels such as organizational level, which can be interpreted as the political level. There is also the community level, which may refer to healthcare organizations and community. So, it is crucial to create environment that supports the person to use the capability he or she has. Healthcare organization should be responsible for creating structures and services, which are understandable and which enable persons to use their own resources. By this, the person will be able to use one’s capability and create a valuable and meaningful life. How this is realized depends on what real opportunities the person has to engage in those activities and doings, which are meaningful and valuable for the person. Reflecting on this, if the surrounding and healthcare system are difficult to grasp and understand for the older person, it will decrease the person’s possibilities to use the capability needed to manage daily life. Lack of information or knowledge of the system will have a negative impact on person’s comprehensibility. Consequently, it will have a negative impact on the sense of coherence, meaning, and life satisfaction in everyday life.

The basis for engagement in daily activities is the personal motivation [16] and also a personal freedom to choose what activities are valuable and worth investing energy in. The motivation to perform activities is also connected to the possibility to perform activities in a way that is familiar to the person. In other words, to be able to keep up the familiar routines in daily life. How activities are performed has also a cultural dimension. Different dimensions of a culture create meaning to our activities [25, 26]. So, when moving from one cultural context to other, it may affect the meaning in the activity. In migration context, this is visible when older persons want to continue to perform activities in the same way as before immigration. Then the daily routines and meaning aspect in activities could be remained and by that support the meaningful parts of SOC. Professionals working with older immigrants have expressed that activities that are familiar from the country of birth are important for the experience of health and also as a way to keep up one’s connection to the country of birth [20].

7. Health promotion as means to support everyday life when aging in migration

The goal with health promotion is to empower persons to maintain or improve their health and well-being in everyday life [27]. The traditional way to support health has been based on a deficit model, meaning that the focus has been more on decline and illness than the health resources the person has. Antonovsky’s [6] perspective, with health as a continuum instead of a dichotomy where health and disease are opposites, has been highlighted as a more useful way of defining health promotion. Eriksson and Lindström [28] have created a metaphor for this perspective, which they call for “Health in the river of life.” This perspective highlights the importance of changing the perspective from the traditional view in medicine, where the focus is on care and treatment, to a more holistic perspective where the core is on prevention and promotion. A similar view has been highlighted by Morgan and Ziglio [27], and they have stated that in health promotion, more resources and research need to be focusing on health resources as a way to promote health. Morgan and Ziglio present a model they call for the Health Assets model. In this model, the resources that could be used to promote health include resources on individual level, group level, and communities, populations, and social systems. When using all these resources through cross-border activities, it is possible to utilize more capability resources for individuals. When it comes to resources, more attention should be on identifying the individual resources that older persons aging in migration have. To be able to identify these resources, we have to combine perspective of salutogenesis with a person-centered approach in health promotion. A salutogen perspective draws a picture of what kind of situations in everyday life have an impact on sense of coherence among older immigrants. Furthermore, with a person-centered approach, it is possible to identify these resources together with the older person, with the aim to enable a meaningful life in the context of migration. Thus, a possible way to enable and support health among older immigrants is to create person-centered health promotion programs. The starting point in a person-centered approach health promotion is the concrete situations where the person is at the moment. The goal for person-centered health promotion is to empower the person to utilize his or her capabilities, including the resources the person has. This means to use the person’s previous experiences and potentials. The focus should be on those life tasks that the person perceives as important and meaningful from a personal level. In everyday life, this means that the person has the opportunity to engage in those everyday activities, which creates meaning and value in life. This will also support the sense of coherence in daily life. Research has shown that even if the SOC is quite stable later in life, it is possible to influence SOC by using person-centered health promotion intervention [29].

The core of the person-centered approach is to have the person in center and involve the person as an active partner in both planning and implementation of health promotion activities. In person-centered health promotion, the relationship is based on equal interest, understanding, and importance. It is important to have the focus on the whole person, to find a common ground but also to find realistic frame for the intervention. Thus, when planning for health promotion from the perspective of salutogenesis and migration, the starting point should be to encounter the person in his or her specific context. This means, to be able to create a relationship with the person, which creates a trustful situation. When doing so, it creates an opportunity to be familiar with the person’s narrative. The narrative will reveal the range of valuable and meaningful activities in everyday life. The mapping of the narrative, in combination with an authentic dialog with the professionals, is a way to empower the person to actively take part and responsibility for health promotion activities. An authentic dialog builds up a trustful relationship with the person, and it creates a mutual understanding for the planned health promotion intervention. The person is then seen, heard, and respected. The intervention is based on cooperation and mutual understanding where the person is an equivalent partner in the situation. It creates opportunities for the person to reveal thoughts and fears about issues that have an impact on comprehensibility, manageability, and meaningfulness in everyday life. A person-centered approach to health promotion, as a mean to support sense of coherence, can be argued to be a suitable and useful approach when aiming to support health among older persons aging in migration. It will also move toward a view of positive health along the ease/disease continuum [6]. Additionally, it supports opportunities to create a meaningful everyday life and by that support a successful aging in the context of migration. Health promotion programs, which are designed and based on a person-centered approach, adapted to fit persons who are aging in migration, seem to support capability in daily life among older immigrants [30]. This kind of health promotion interventions can preferable be conducted as group interventions consisting of persons representing similar migration background. Promising results have been revealed on this concept [31]. When older persons with immigrant background have the possibility to come together and discuss challenges in daily life, they have peer support from each other. This is a resource that supports experience of health and well-being in everyday life.

8. Conclusion

It is necessary to take a holistic view of health when discussing health in everyday life among older persons aging in migration. This is because persons are a product of their past lives. The person’s narrative will give guidance on what kind of everyday life the older person wishes for when aging at a place called second home. The daily life should consist of activities that give meaning to life. Additionally, the situations in daily life should be comprehensible and manageable. For this reason, an important part is the environment and context around the person. Structures in healthcare organizations, such as health promotion, should be based on a person-centered approach. In this way, the person’s wishes can be the starting point for health promotion interventions. A person-centered approach in health promotion enables both respect for the person and utilize the person’s capability. This is the base for supporting and creating a meaningful daily life in migration context. Humans are able to create a meaningful life after migration when the daily life includes parts from the person’s life before migrating, in combination with the routines and activities developed in the host country during resettlement. This means that older persons aging in migration can, with their own actions and wishes, be actively involved in shaping their daily life even in the context of migration. In this way, the migration does not have to be a negative influence on the experience of health or have a negative impact on sense of coherence.

Acknowledgments

This work was supported by The Finnish Ministry of Education and Arcada University of Applied science within the project AI Driven Nordic Health and Welfare.

Conflict of interest

The author declares no conflict of interest.