HealthEmpowermentAmongImmigrantWomenin.pdf

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

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: [email protected]

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- 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

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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- 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).

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).

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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 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.

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

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program. 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.

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.

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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Yang et al. Health Empowerment Among Immigrant Women

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
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:

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Health Empowerment Among Immigrant Women Yang et al.

My mother-in-law won’t let my children get close
with me. They [in-laws and husband] say I am a
foreigner. They try to persuade the kids their mother
is an ignorant person, don’t ask me questions because
I know nothing. Now, I have learned lots of things. I
have more knowledge to manage my life. I can teach
my children.

Some of the participants experienced physical abuse by
their husbands and, in some cases, their in-laws. In the
special section workshop on domestic violence preven-
tion and management, participants learned about rescue
resources, their legal rights, and the hidden health prob-
lems related to abuse. After attending the workshop, the
women described feeling more self-empowered and more
confident in dealing with and overcoming domestic vio-
lence. For example, one participant mentioned:

Now I know my human rights, that nobody can beat
me. I can call the 113 protection hotline for help. They
[mother-in-law and husband] have no right to beat
me. Before attending the workshops, I thought I was
stupid. If I do something wrong, my mother-in-law
will slap me, and my husband will kick me when he
is drunk.

Building Psychological Resilience

The participants felt burdened with the stress of accul-
turation and its psychological effects, such as emotional
distress. This form of distress was reflected in the follow-
ing statement from one of the women:

I can’t sleep very well, and I often cry in the middle of
the night. I miss my home town. Immigration marriage
in Taiwan is a challenge and a bet. Our lives are filled
with hardships, such as no money in my pocket most
of the time. If I fight with my husband, I have nowhere
to go.

Attending the HEP, however, helped the participants
transform their life distress into a more positive outlook.
They resolved to make a greater effort to successfully
adapt to their new home in Taiwan. During the work-
shops, they discussed the need to increase their ability
to endure the difficulties in life by accepting the chal-
lenges as their destiny and focusing on their children’s
future. Successfully caring for and raising their children
became the women’s main purpose in life. For example,
one participant stated:

I have learned this for my children. I can bear the
hardships in life. Sisters, we must stay in Taiwan,
because this is our home, now we are mothers and
daughters-in-law. In the future, we will be other

women’s mother-in-law. So we keep going and take
care of our kids; they are our roots in Taiwan.

Discussion

The findings from our study not only confirm the
disadvantaged status of marriage immigrant women
in Taiwan and their vulnerability to health risks, but
also demonstrate the effectiveness of PAR as a useful
strategy to empower these women to make sustainable
and beneficial changes in their health and well-being.

The study participants had poor health literacy and
limited knowledge about medical care resources. This
finding is consistent with previous studies that found
immigrant women tend to have low levels of health
literacy, which acts as a barrier to seek out and access
appropriate health care (Kreps & Sparks, 2008; Lee
et al., 2013; Tsai et al., 2014). The women in our study
were unaware of such helpful resources as Taiwan’s
NHI, migrant welfare program, free services and medical
checkups provided by the local health centers, and
the telephone hotline number for domestic violence
protection. Findings from previous studies showed
that health literacy is vital for promoting health and
health-promoting behaviors (Speros, 2005; Von, Knight,
Steptoe, & Wardle, 2007). However, the health literacy
of the marriage immigrant women in our study was
poor. Therefore, we recommend that health promotion
strategies and interventions for migrant women focus
on improving their health literacy. Strategies can include
the development of comprehensive, translated health
information media for distribution to the women.

The study participants’ difficulties with language and
communication created another barrier to their ability
to effectively seek out and use Taiwan’s healthcare ser-
vices and resources. This finding supports similar results
from other studies that examined the health concerns of
marriage immigrant women (Hsia, 2010; Hung, Wang,
Chang, Jian, & Yang, 2012). Having difficulties in learn-
ing to speak and understand a new language often pro-
hibited the women from effectively communicating with
healthcare providers.

The study participants were further isolated by the ac-
tions of their husbands and in-laws who intentionally
prevented the women from going out alone and making
social contacts for fear the women might try to run away
and return to their homeland. This form of marginaliza-
tion and oppression is evident in other studies that focus
on health and social issues of marriage migrant women
in Taiwan (Yang & Wang, 2003). Our results are consis-
tent with previous …