J75 Domestics Aging and Society (2011)

Foreign live-in domestic workers ascaretakers of older Kuwaiti men andwomen: socio-demographic andhealth correlates

NASRA SHAH*, HANAN BADR* and MAKHDOOM SHAH†

ABSTRACTAgeing of the population is posing new challenges for caretakers. This paper aims toexamine: (a) age and gender differences in care provided by a domestic worker versusa family member in the performance of activities of daily living (ADL); (b) socio-demographic correlates of care during illness; and (c) self-reported physical, func-tional, and psychological health status in relation to care-giver. A cross-sectionalhousehold survey was conducted among , Kuwaiti nationals aged years orolder. This paper focuses on persons aged or more. We found that domesticworkers provided care to per cent of men and per cent of women who neededassistance with ADL; and to per cent men and per cent women during illness.These respondents ranked poorer on several health indicators and reported higherdepressive symptoms score than those looked after by a family member. Logisticregression indicated that care by a domestic worker was approximately seven timesmore likely for women than men, about . times more likely for those without co-resident children compared with those who had three or more co-resident children,and per cent less likely for the poorest compared with the richest persons. Itappears that reliance on domestic workers is increasing and such reliance will remainnecessary in the absence of culturally acceptable alternative institutional arrange-ments.

KEYWORDS – live-in domestic helpers, older population, caretaker, Kuwait, genderdifferences, women’s health.

Introduction

During the last century, countries all over the world have been goingthrough demographic transitions typified by declining mortality as well asfertility. Lower infant as well as adult mortality has resulted in larger

* Department of Community Medicine and Behavioral Sciences, Faculty ofMedicine, Kuwait University, Safat, Kuwait.

† GLOBE Consultancy, Kuwait, Kuwait.

Ageing & Society , , –. f Cambridge University Press doi:./SX

numbers of persons surviving to older ages reaching years or higher.With lower birth rates, the age structure of populations has beenchanging. The proportion of younger persons has been declining whilethat of older persons has been increasing, thus resulting in more agedpopulations than in the past. Different countries in the world are atdifferent stages of the demographic transition; more developed countriesare generally further ahead in the transition than the less developed ones.At the same time, an epidemiologic transition has occurred wherebymany elderly people suffering from chronic disease conditions such ashypertension, diabetes, heart disease and arthritis, can survive for severalyears. The above is also true for persons with functional, cognitive andother disabilities. All the above factors have resulted in exacerbating theamount of care needed by elderly people (Legare and Martel ;Tomassini ; World Health Organization ; Yount and Khadr).The growth in number of elderly people, some of whom may be diseased

or disabled, is posing new challenges for caretakers. Historically, the familyacted as the major caretaker of elderly people in most countries, includingKuwait. These traditional arrangements have been changing with theforces of modernisation, urbanisation and the increased educational levelof populations, including that of women. Residential arrangements wherefamily members were traditionally the main caretakers of elderly peoplehave been changing, with increasing numbers of elderly people living alone,or without any co-resident children, in higher- as well as lower-incomecountries (Legare and Martel ; Mehio-Sibai, Beydoun and Tohme; Yount and Khadr ).Alternative arrangements for care have been instituted by various

countries, such as the establishment of public or private old-age carefacilities. Formal institutional care typically is scarce, expensive, and oftenviewed as an unacceptable form of care for older adults in some societies(Sinunu, Yount and El Afify ). A less expensive and increasinglycommon alternative to formal care is reliance on foreign live-in domesticworkers as major caretakers of older, non-institutionalised persons. Theabove trend has been facilitated by the availability and willingness offoreign workers, especially from Asian countries such as the Philippines,Sri Lanka, Indonesia and others, to travel overseas and take up the caringroles in the homes of strangers. While this is a growing phenomenon,very few research studies have looked at the extent and effects of relianceon domestic workers for care of elderly people. The goal of the presentpaper is to add to the knowledge on the subject by analysing thecaretaking role of live-in foreign workers in homes of older Kuwaiti menand women.

Domestic workers as caretakers of older Kuwaitis

Growth in the foreign domestic worker population

The employment of foreign live-in domestic workers has become a trulyglobal phenomenon during the last two to three decades. At the beginningof this century, an estimated . million Filipinos were employed overseas;more than half were women of whom two-thirds were employed as domesticworkers in more than countries (Parrenas ). Between

and June , , Indonesian women left their country to workoverseas as domestic workers (International Organization for Migration). In receiving countries, the number of women domestic workersexceeded , in Hong Kong. Italy had an estimated one milliondomestic workers, and of all migrant women in France, about half wereengaged in domestic work (International Organization for Migration ).Singapore had more than ,migrant domestic workers amounting toone such worker per eight households in (Yeoh, Huang and Gonzalez). Israel reportedly has , documented and , undocumen-ted foreign home-care workers (Ayalon a). Canada has had a live-incare-giver programme since to facilitate the migration of domesticworkers (Chang ). It is estimated that the United States of Americahosts . million domestic workers, many of whom are reportedly workingillegally (International Trade Union Confederation ).The oil-rich Middle Eastern countries are among the largest recipients

of migrant workers. Non-national foreign workers and their families out-number nationals in several of the oil-rich countries (Shah ). In the sixGulf Cooperation Council (GCC) countries, the percentage of domesticworkers among all expatriates is substantial. There are an estimated .million domestic workers in Saudi Arabia and about , such workers inthe United Arab Emirates (Human Rights Watch ). Kuwait had about, domestic workers in June (Public Authority of CivilInformation ).

Effects of care by foreign domestic workers

Despite the rising number of foreign domestic workers in a wide rangeof countries, research on the old-age care provided by such workers isscant. Existing research on this topic centres on two themes. The firstfocuses on the effects of care by domestic workers on the health, hap-piness, and satisfaction of elderly people and their families. The secondtheme focuses on the social, psychological and health effects for thedomestic workers and their families, who often remain in the country oforigin.

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Research on the effects of care by domestic workers raises severalquestions about the impact on wellbeing of elderly people. In a qualitativestudy of totally impaired persons cared for by live-in Filipino caretakersin Israel, many of the impaired participants experienced violations of trustthat resulted in perceived abuse and neglect of the older person, andintensified the family’s fears about this care-giving arrangement (Ayalona). In another study that looked at the perspective of social workersinvolved in the process of care of elderly people by live-in Filipino caretakersin Israel, four major challenges were identified. They included the pro-minent differences between the cultures of the sending and receivingcountries, as well as legal, social and economic disparities inherent in thecare relationship (Ayalon, Kaniel and Rosenberg ). Satisfaction withlive-in versus live-out caretakers was evaluated through face-to-face interviewsin a study of elderly people in Israel. Recipients looked after by live-in(N=) caretakers reported a higher level of satisfaction than those lookedafter by a live-out caretaker (N=) (Iecovich ).Studies on the effects of live-in domestic work on the workers themselves

consistently suggest that such work is often undervalued and is invisible untilsome problems arise (Brush and Vasupuram ; Chang ; Jureidini; Jureidini and Moukarbel ; Loveband ; Parrenas ).A majority of the studies on domestic workers consist of small-scale surveysusing qualitative methodologies. It has been reported that domestic workersare subject to exploitation throughout the migration process and thearduous nature of their labour is often poorly compensated. Residencein private homes makes them vulnerable to verbal, physical and sometimessexual abuse (Human Rights Watch ; Shah and Menon ). Per-ceptions about such workers range from ambivalent to negative in somereceiving countries such as Singapore, as judged from qualitative researchwith employers (Yeoh, Huang and Gonzalez ).

The Kuwait context: domestic workers in a society undergoing rapidsocio-demographic and epidemiological change

Kuwait is a small oil-rich country with a population of .million persons in. Only . per cent of the total population comprised Kuwaiti citizens,while the remaining . per cent consisted of temporary foreign workers,including domestic workers (Public Authority of Civil Information ).The heavy reliance on foreign workers has been a defining characteristicof Kuwait’s history, especially following the discovery and development ofthe oil industry. Kuwaiti citizens and highly paid foreigners are allowed tosponsor a domestic worker. Recruitment of such workers is usually arranged


through private companies following permission granted by the Ministry ofLabour and Social Affairs and Ministry of Interior. Households with a largernumber of residents are allowed to hire more workers. Domestic workers arenot covered by the country’s labour laws that regulate the employment ofother private-sector workers. A majority of domestic workers in Kuwait arefrom Sri Lanka, Philippines, Indonesia and India. The usual monthly salaryof a domestic worker ranges between KD and (US $ and ) inaddition to food and lodging (Shah b).Domestic workers became an increasingly larger percentage of the

population during the last three decades. Their number went up from onlyabout , in to , in , comprising . and . per centof the country’s population in the respective years (Table ). A majorityof domestic workers are employed by Kuwaiti citizens who numbered,, in June . Thus, the country had about . citizens for everydomestic worker in (Public Authority of Civil Information ).According to a national survey in , per cent of the , sampledhouseholds had no domestic workers, per cent had one, and per centhad two or more. Households with multiple workers were relatively richerand hadmore residents who were children or older persons aged ormore(Shah et al. ).Kuwait is undergoing fairly rapid demographic and epidemiological

transitions. During the last four decades, life expectancy at birth for Kuwaiticitizens increased from . to . years for men and from . to .years for women (Shah a), accompanied by a rise in chronic illnesses.In a survey of older Kuwaitis conducted in –, the prevalence ofdoctor-diagnosed diabetes, hypertension and heart disease among those

T A B L E . Number and percentage of male and female domesticworkers in Kuwait’s population

Year Males (%) Females (%) Total

Domestic workersas per cent ofpopulation

a – – – .

a . . , .a . . , .a . . , .a . . , .a . . , .a . . , .a . . , .b . . , .

Note : . Female domestic workers only.Sources : a. Shah (a). b. Public Authority of Civil Information ().

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aged ormore was reported to be ., . and . per cent, respectively(Shah, Behbehani and Shah ). Increasing life expectancy of elderlypeople, many of whom suffer from long-term illnesses, results in the need forgreater care of this subgroup than was true in the past.At the same time, several major socio-demographic changes are taking

place that are likely to reduce the family’s ability or willingness to take care ofelderly people, thus increasing the reliance on foreign domestic workers.First, literacy and educational levels of both sexes have increased rapidlyduring the last four decades which may have generated attitudinal changesregarding care of the elderly. In , more than per cent of men as wellwomen were literate, while per cent of men and per cent of womenamong all persons aged – had attained a high school or higher level ofeducation (Shah a).Second, massive changes have occurred in the labour force participation

rate of women which may be associated with attitudinal and behaviouralchanges. From only per cent in , the percentage of women aged +participating in the labour force increased to per cent in . Amongthe younger women aged –, who might be expected to provide majorcaretaking functions for elderly people, about per cent were economi-cally active in , and were occupied in roles outside the home and family(Shah a).Third, fertility of Kuwaiti women has declined from about seven children

in to about four children in (Department of Vital Statistics andHealth Records ; Shah a). The percentage of potential childrenas caretakers has therefore declined, although a vast majority of men andwomen have at least one living child. Furthermore, the percentage of nevermarried women, as well as divorced persons, has been increasing during thelast four decades (Shah a). Unmarried and divorced persons do nothave a child or spouse to co-reside and seek assistance from, and may seeksuch assistance from domestic workers.Fourth, rapid changes have also taken place in living arrangements of

elderly people during the last few years. In a comparison of the living ar-rangements of persons aged or more in two surveys conducted in

and – (on which the present paper is based), it was found that thepercentage of those living without any co-resident children increased fromapproximately per cent to about per cent, respectively. The percentageof those living alone increased from to . per cent (Shah et al. ).Perhaps as a result of the expected traditional role of the family in looking

after elderly people, the country does not have any alternative formalarrangements for this group. The only exception is an institution run by theMinistry of Social Affairs where elderly people without adequate familysupport may reside. Residence in the Ministry of Social Affairs institution is a


source of social stigma. Also, there are no privately organised institutions orold-age homes for persons who are not able to reside with their families. Inthe case of persons needing long-term medical care, patients are sometimesleft in the government hospitals by the family, since this is considered morerespectable. The problem of long-stay patients in government hospitals hasbeen increasing over time.

Objectives

Given the heavy reliance of Kuwaiti citizens on domestic workers outlinedin Table , the paper has three specific objectives: (a) to examine the ageand gender differences in the amount of care provided by domestic workersversus various family members, (b) to assess the socio-demographiccharacteristics of elderly people that affect the probability of care by adomestic worker rather than a family member, and (c) to assess whether ornot care by a family member versus a domestic worker is related to thephysical, functional and psychological health status of older men andwomen. We hypothesise that those with poorer health outcomes would bemore likely to be looked after by live-in domestic workers rather than byfamily members as a result of their greater need for care and assistance.

Methods

Sample

A cross-sectional survey of Kuwaiti households was conducted during April to December , and Kuwaiti adults years or older were eligible toparticipate. Non-Kuwaitis, consisting of foreign workers and their families,were not included in the study. Kuwait is divided administratively into sixdifferent areas (governorates). Our survey was conducted in two governor-ates: Capital and Ahmadi. Capital (Kuwait City in Figure ) was chosen torepresent the most urbanised governorate and Ahmadi to represent one ofthe two least urbanised governorates. In January , these two governor-ates had , persons aged or older, about per cent in Capital and per cent in Ahmadi. A proportionately representative sample was there-fore chosen from each governorate. Our objective was to interview a total ofabout persons from each group aged –, – and or older. Thetarget number was chosen to give us reliable estimates of the prevalence ofgeneral health status, major chronic illnesses, living arrangements, disabilityand functional health.A multistage cluster sampling technique was used. Within each governor-

ate, residential areas (mantaqas) were randomly selected. Each mantaqa

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consists of sub-areas or qitaas, which were randomly selected at the nextstage. Within each selected qitaa all households were visited, and householdswith at least one person aged ormorewere included. Of the , eligiblehouseholds, , (. per cent) agreed to participate. These householdshad , persons aged or more, of whom , (. per cent)participated in the study. Thus, per cent of the population aged ormorewas covered in our survey. A proxy respondent, usually a close relative, wasinterviewed in . per cent of the cases where the respondent was not able toanswer, primarily due to old age or functional impairment.The Ethics Committee of the Faculty of Medicine, Kuwait University,

approved the study. Verbal consent was obtained from each respondentbefore interviewing him/her.

Data and methods

A questionnaire to measure psycho-social health, physical health, disabilityand social support was developed by the authors in English and translatedinto Arabic. Trained Arabic speakers conducted face-to-face interviews. Ahousehold listing was done for each resident of the eligible household thatagreed to participate (N=, households). A total of , persons wereresiding in the , sampled households of whom , (. per cent)were domestic workers.

Study areas

Figure . Map of Kuwait showing the study areas.


Variables

Care. Assistance of domestic workers was measured for two differentsituations, first in terms of activities of daily living (ADL) performedroutinely by the respondent, and second in terms of illness, by asking thefollowing questions.

. Six questions on whether or not the older person needed assistancein conducting his/her routine activities and, if so, who assisted most of thetime with ADL (eating, dressing, bathing), and with shopping, managingmoney, using transportation, cooking and cleaning. The two questionson cooking and cleaning were asked only for women since participationin this type of activity is considered to be culturally inappropriate for themajority of men, especially in the older age groups analysed by us.

. A question on who usually takes care of him/her whenever he/she getssick. The frequencies of usual care during illness were examined for thewhole sample aged or more. The rest of the analysis was restricted tothose aged or more because there were very few under this age groupwho needed help with these activities.

Men and women were compared throughout the analysis.

Socio-demographic explanatory variables. Five socio-demographic character-istics of the respondent were used as explanatory variables, namely gender,marital status (currently married versus widowed/divorced/separated), levelof education (some schooling versus never been to school), Bedouin or non-Bedouin cultural background, and the number of co-resident children.In addition to the above, total monthly income of the household was alsoused as an explanatory variable, since household income was expected to beassociated positively with the presence of domestic workers who mightprovide care to older members of the household.

Health status. Health status was measured through several self-reportedindicators, including perceived health status, prevalence of doctor-diagnosed chronic illnesses, presence of various types of disability (visual,hearing and functional) and psychological health. A scale of depressivesymptom experience from the Mexican Health and Aging Study (Soldo,Wong and Palloni ) was used. The scale consists of ten items measuredon a Likert scale ranging from ‘Never’ to ‘Most of the time’ used to assessthe depression symptoms indicating psychological health. For example, aquestion was asked on whether the respondent had poor appetite during theprevious seven days, and whether this occurred most of the time, sometimes,seldom or never. A weight of three was given to the item if it occurredmost ofthe time and a weight of zero was given if it never occurred. The ten items

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were summed to arrive at a composite score of depressive symptomexperience, with a range between zero and .

Analysis

The significance of bivariate associations between type of care-giver(domestic worker versus family member) and health outcome variableswere tested by using Chi-square test and Student’s t-test. Multivariate analysiswas conducted by using binary logistic regression in order to ascertain therelative strength of association between socio-demographic characteristicsand care by a domestic worker, rather than a family member, during illnessamong those aged or more. In the logistic regression, care by a domesticworker was defined as (.%) and by family members as (.%). Ap-value of <. was considered to be significant.

Results

Domestic workers in our sample

Domestic workers comprised per cent of all residents in our sampledhouseholds. Of the , households, . per cent did not have anydomestic workers, . per cent had one such worker, and . per cent hadtwo or more. The availability of domestic workers was higher among theolder men and women aged or more (N=) compared with the totalsample; . per cent of them had no domestic workers, . per cent hadone and . per cent had two or more. As reported by their employer,most (.%) domestic workers were women, andmore than half were aged– with a mean age of . years.

Care-giver for older Kuwaitis

Among the men and women aged or more, and per cent,respectively, needed assistance to carry out their ADL such as eating,changing clothes and bathing. Among those who needed assistance, about per cent of men and per cent of women received such assistance,most of the time, from domestic workers (Table ). About one-fifth of menand women who needed assistance with shopping relied on domesticworkers, and about one-quarter relied on them for using transportation.However, in the case of those needing assistance withmanaging their money,relatively few (%men and %women) relied on domestic workers whilethe remaining got such assistance from family members. Among womenneeding assistance with cooking and cleaning a large majority ( per centor more) received such assistance from domestic workers, as expected.


In terms of care-giving when the older person is sick, we found a strikinggender difference (Table ). Wives were a major care-giver in the case ofmen; more then per cent of the men aged – years were looked afterby their wife when sick. The wife’s role in caretaking seemed to decline withage, however. Among men age or more, only about per cent werelooked after by their wife while per cent were looked after by a daughter

T A B L E . Percentage distribution of assistance provided by familymembers versus domestic worker in performance of various activities amongKuwaiti men and women aged or more (N=), among those whoneeded assistance

Activities ofdaily living

Men (N=) Women (N=)

Needassistance

(N)

Assistance provided by

Needassistance

(N)

Assistance provided by

Domesticworker(%)

Family/others(%)

Domesticworker(%)

Family/others(%)

Eating,dressing,bathing*

. . . .

Shopping . . . .Managingmoney

. . . .

Transportation . . . .Cooking – – – . .Cleaning – – – . .

Significance level: * p<. (gender difference).

T A B L E . Percentage distribution of person who usually takes care ofolder men and women during illness

Age group Spouse DaughterDomesticworker Others

Men– (N=) . . . .– (N=) . . . .+ (N=) . . . .Total (N=) . . . .

Women– (N=) . . . .– (N=) . . . .+ (N=) . . . .Total (N=,) . . . .

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and per cent by a domestic worker. Among women, on the other hand,the husband played a negligible role in taking care of a sick wife at all ages.Among women aged or more, only about per cent of the husbandslooked after the wife when ill. A daughter or a domestic worker were themain caretakers of older women aged or more during illness, providing and per cent of such care, respectively. As women got older, thepercentage looked after by a daughter declined while the percentage lookedafter by a domestic worker increased. Among women aged –, aboutone-quarter were looked after by a domestic worker when sick, while amongthose aged or more, per cent were looked after by a domestic worker.Thus, domestic workers are playing a central role in the care of older womenin Kuwait, both in terms of assisting with ADL and looking after themwhen sick.The role of the domestic worker was especially large among those aged

or more living alone (N= out of ), where almost per cent reportedthat they were looked after by a domestic worker when sick. The percentagewas also very high in case of couples living without any co-resident children,especially so in the case of wives. About per cent of the women living witha spouse only were looked after by a domestic worker when sick (dataavailable on request).Among the respondents aged or more, (.%) were bedridden

of whom (.%) were women. About per cent of the bedriddenwomen were living with their children. During illness a domestic workerlooked after them in per cent of the cases, a daughter in per cent, anurse in per cent and another relative in the remaining cases. In terms ofADL, a domestic worker provided them with assistance in about per centof the cases (data available on request).

Socio-demographic correlates of caretaking by a domestic worker

Unadjusted and adjusted odds ratios of being looked after by a domesticworker when sick are given in Table in relation to several socio-demographic characteristics and household income of elderly peopleaged or more. Controlling for other variables, gender was highly sig-nificant with women being seven times more likely than men to be lookedafter by a domestic worker when sick (p<.). Also, those living withoutany co-resident children were . times more likely to be looked after bya domestic worker when sick compared with those who had three or moreco-resident children. Neither marital status nor educational level norBedouin/non-Bedouin background was significantly associated with car-etaking by a domestic worker. Household incomewas directly associated withbeing looked after by a domestic worker when sick. That is, those who had a


T A B L E . Logistic regression of the socio-demographic correlates of being cared for by a domestic worker during illnessamong Kuwaiti men and women aged or more (N=)

Variables N

Unadjusted OR Adjusted OR

β OR % CI β OR % CI

Gender: ***Men (RG) Women . .*** .–. . .*** .–.

Marital status:Married (RG) Not married . .*** .–. . . .–.

Level of education:Some schooling �. .*** .–. �. . .–.No schooling (RG)

Bedouin background:Non-Bedouin (RG) Bedouin �. . .–. �. . .–.

Co-residing children: *** *** . .*** .–. . .*** .–. . . .–. . . .–. �. . .–. �. . .–. or more (RG)

Total monthly income: *** **Low (4KD ) . .** .–. �. .** .–.Moderate (KD –,) �. . .–. –. .*High (>KD ,) (RG)

Notes: OR: odds ratio. CI: confidence interval. RG: reference group.Significance levels: * p<., ** p<., *** p<..

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household income of KD (£,) or less were about per cent lesslikely to be looked after by a domestic worker when sick compared with thosewho had a household income of KD , (£,) or more.

Caretaking by a domestic worker versus family member in relationto health outcomes

Several health indicators were compared for the respondents who reportedto be looked after by domestic workers versus family members when sick.In general, a larger percentage of those looked after by domestic workersperceived themselves to be in worse health, and ranked lower on manyhealth indicators (Table ). Significantly smaller percentages of men as wellas women who were looked after by a domestic worker perceived their healthto be good/very good compared with those looked after by a family member.The percentage that reported doctor-diagnosed hypertension or diabeteswas significantly higher among men as well as women looked after by adomestic worker than a family member. Also, those looked after by domesticworkers had a significantly higher mean score on the depressive symptomsscale than those looked after by family members (mean=. versus .among men, and mean=. versus . among women).Among men, a significantly larger percentage of those looked after by a

domestic worker had hearing or vision disability compared with those lookedafter by a family member. Also, a larger percentage of men looked afterby domestic workers reported severe levels of disability (%) than thoselooked after by family members (%). Contrary to men, disability dif-ferences according to type of caretaker were not statistically significant forwomen.Multivariate analysis was conducted to assess the net association of health-

related factors with caretaking by a domestic worker versus a family member,after controlling for socio-demographic characteristics and household in-come of respondents. The strong associations of care by a domestic workerwith female gender, lack of co-resident children and higher family incomepersisted after the addition of all the health-related variables shown inTable . Two health-related factors emerged as significant correlates of careby a domestic worker, namely perceived health and the score for depressivesymptom experience. Those who perceived their health to be fair (odds ratio(OR): .; confidence interval (CI): .–.) or poor (OR: .; CI: .–.)weremore than twice as likely to be cared for by a domestic worker comparedwith those who considered their health to be good or very good. Also, theunit increase in reported depressive symptom total score increased thelikelihood of a respondent being looked after by a domestic worker ratherthan a family member by per cent.


T A B L E . Association between selected health status variables and care-giving by domestic workers versus family membersduring illness among Kuwaiti men and women aged or more (N=)

Men (N=) Women (N=)

Domestic worker Family/others Domestic worker Family/others

Frequencies (%)Total (.) (.) (.) (.)Self-perceived health:Present health status:Very good/good (.) (.) (.) (.)Fair (.) (.) (.) (.)Poor (.)** (.) (.)*** (.)

Chronic illnesses:Hypertension (Yes) (.)* (.) (.)** (.)Diabetes (Yes) (.)* (.) (.)** (.)Heart disease (Yes) (.) (.) (.) (.)Stroke (Yes) (.) (.) (.) (.)Arthritis (Yes) (.) (.) (.) (.)Cataract (Yes) (.)* (.) (.)* (.)

Psychological health:Depression symptoms (N, mean and SD) , .±.*** , .±. , .±.** , .±.

Disability:Disabled vision (with aids) (.)* (.) (.) (.)Disabled hearing (with aids) (.)** (.) (.) (.)Disability:No (.) (.) (.) (.)Mild/moderate (.) (.) (.) (.)Severe (.)** (.) (.) (.)

Note : SD: standard deviation.Significance levels: * p<., ** p<., *** p<. (difference between domestic worker versus family/others in the same sex).

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Discussion

During the last three decades domestic workers have become an in-creasingly larger segment of Kuwait’s population. They comprised per cent of all residents in our sampled households and were playingvery important roles in providing assistance in performance of ADL and inlooking after elderly people when sick. The likelihood of being lookedafter by a domestic worker had strong positive associations with being awoman, living without any co-resident children, and in richer households.Respondents who were looked after by a domestic worker ranked poorer onseveral health indicators than those who were looked after by a familymember when sick.Among those aged + who needed assistance with ADL, about

per cent of men and per cent of women were assisted mostly bydomestic workers. Furthermore, per cent of women and per cent ofmen were looked after by domestic workers when they were sick. Amongthose living alone, more than per cent were looked after by a domesticworker when sick. The shift of care from a family member to a domesticworker, as illustrated by our findings, is a relatively recent phenomenonamong the Kuwaiti population. Prior to the massive inflow of domesticworkers in the last three decades, family members were the traditional care-givers, with women playing pivotal roles.Several socio-economic changes within the Kuwaiti society, described in

the introductory section, may explain the shift away from traditional care-taking practices. Rising educational level, increased participation of womenin the labour force, and changing attitudes towards co-residing with childrenare likely to be central among these factors. Employment outside the home isbound to place heavy demands on a woman’s time and her ability to take careof an older parent or parent-in-law and she is therefore likely to depend onsubstitute caretakers in the form of domestic workers. At the same time, careof an older person by a domestic worker in a household, especially where theyounger women are employed, seems to have become socially and culturallyacceptable, despite the deviance from traditional norms.The proportion of elderly people living without a co-resident child

has increased almost five times (from to %) during the last decade, asmentioned earlier. The lack of co-resident children is bound to be a majorconstraint in providing assistance with ADL or when elderly people are sick.In our study, multivariate analysis indicated that those without a co-residentchild were . times more likely to be looked after by a domestic workerrather than a family member. It is possible that the easy availability ofdomestic workers has in fact acted as a facilitator of changes in livingarrangements of elderly people. One consequence of this change is that the


caring tasks provided earlier by a family member are now performed by thelive-in domestic worker.In addition to the socio-economic changes mentioned above, the

relatively low cost at which a domestic worker may be hired is probably animportant factor in the growth of reliance on domestic workers. Themonthly wage of a domestic worker amounts to a fairly small percentage ofthe total monthly income of a Kuwaiti household in our survey (medianhousehold monthly income=KD , (US $,). The current affluenceof Kuwaiti households is a relatively recent phenomenon enabled by thediscovery and export of oil, combined with government policies to share thiswealth with nationals in the form of increased salary and allowances, freeeducation and health care, and generous subsidies on many items (Shaha). Our results showed that the adjusted odds of being looked after by adomestic worker were significantly higher among the richer compared to thepoorer respondents.Despite the increased reliance on domestic workers to assist with ADL

and during illness, however, the family continues to play a major role in thecare of elderly people. We found that a family member assisted the oldermen as well as women in the performance of tasks that involved activitiesand spaces outside the house, such as shopping, using transportation to go toplaces, and money management. Thus it seems that there is a greaterreliance on domestic workers for the performance of the routine ‘chores’such as cooking, cleaning and personal care of the older individual and thefamily continues to play the major role in the older person’s interaction withthe public spheres of life. Furthermore, about per cent of the bedriddenpersons lived with their children. Our findings about the continued im-portant role of the family despite the presence of live-in domestic workersare consistent with the experience of Israel where family members continueto play major, though different, roles in the care of elderly people than theones played prior to the domestic worker’s arrival (Ayalon c).Gender was found to be a very significant factor associated with the care of

elderly people by a domestic worker. Multivariate analysis showed thatwomen were seven times more likely than men to be looked after by adomestic worker rather than a family member when ill. A major reason forthis is that women, especially wives, play the caring role in the case of sickmen as is considered socio-culturally appropriate. When the wife falls ill,however, the husband rarely acts as the caretaker. His domain, especiallyamong older Kuwaitis, is generally considered to comprise of activitiesoutside the house, and he is not expected to take care of an ailing wife.Furthermore, fewer women than men in Kuwait have spouses whomay act aspotential caretakers because of the higher frequency of widowhood amongwomen resulting both from their longer life expectancy and the lower

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incidence of re-marriage compared to men (Shah ). Previous researchamong the oldest old in China showed that the role of the wife was a criticalfactor in the health status of a man, and provided the best protectionregardless of the presence of children (Li, Zhang and Liang ). In ourstudy, a significantly larger percentage of men who were looked after by adomestic worker when ill suffered from various disabilities than those lookedafter by a family member (mainly the wife) which further highlights theimportant role a wife seems to play in sustaining the health of the husband.Among the other female members of the household, the daughter was

found to play a major role in the care of elderly people, especially mothers.The central role that daughters play in looking after older parents/relativeshas been reported in previous studies around the world (Fleming ). Aswomen got older, however, the percentage of daughters who were able orwilling to take care of them declined with a concurrent increase in care bydomestic workers. One of the factors related to decline in care by a daughteris the fact that daughters typically leave the parental home once they getmarried. They either move to the husband’s parental home or set up theirown residence. Hence, the number of potential daughters who could act ascaretakers declines as the mother ages. Furthermore, a larger percentage ofwomen thanmen aged + are now living alone (. and .%, respectively)and dependence on the domestic worker is much higher among thoseliving alone.We had hypothesised that those with poorer health outcomes would

be more likely to be looked after by live-in domestic workers rather thanby family members. Our findings were generally consistent with theabove hypothesis. Respondents who were looked after by domestic workersperceived themselves to be in relatively poorer health; larger percentages ofthem suffered from hypertension and diabetes, and reported higherdepressive symptom scores. In the multivariate analysis, perceived healthwas significantly poorer among those looked after by domestic workers andtheir depressive symptom score was significantly higher. Being cared for by adomestic worker rather than a family member might raise the feelings ofsocial isolation, and low emotional support from children and family, whichin turn may enhance the potential of depression in later life as found inprevious research (Djernes ).Previous literature does not provide any guidance on whether we

should expect any association between health status and care by a familymember versus a domestic worker. Despite the significant differences foundin our analysis, the sequential order implicit in the positive associationbetween care by a domestic worker and poorer health is not obviousand remains a limitation of our study. We do not know the extent towhich care by a domestic worker during illness represents a more general


pattern of caring experienced by the respondent in his/her everyday life.If care during illness is representative of a much broader range of situations,this variable is likely to carry considerable weight in health-care outcomesof elderly people. In the Kuwaiti culture, care of elderly people by familymembers is expected, desired and accorded a high degree of social approval,as in many other cultures. An older person looked after by a family memberis likely to feel more satisfied with the care arrangement. A person devoid ofsuch care, on the other hand,may feel neglected, whichmight exert short- orlong-term consequences on health. However, our cross-sectional data do notenable us to establish the possible ‘causal’ pathway inherent in theassociation between the type of caretaker and health outcomes.Satisfaction with care by a live-in domestic worker is another area on which

we do not have any information in our study. If the older person is satisfiedwith such assistance, he/shemay actually feel gratified by the kind of supportreceived, and the caretaking arrangement may not carry any negative healthimpacts. The above perceptions may also be conditioned by the duration forwhich the older person has been cared for by a domestic worker, the qualityof their interactions, trust placed on the caretaker, and the general per-ception about his/her skill level and competence. Each of the precedingfactors has been noted as an important element in the satisfaction of elderlypeople and their families with the caretaking arrangement (Ayalon a,b, c; Keitzman, Benjamin and Matthias ), and should beaddressed in future studies.

Conclusion and implications beyond Kuwait

A survey of older Kuwaitis age or more found that domestic workersplayed a substantial role in providing assistance in activities of daily living andin providing care during illness. The likelihood of being looked after by adomestic worker rather than a family member during illness was significantlyhigher among women, those living without any co-resident children and inricher households. Furthermore, those looked after by a domestic workerrather than a family member reported significantly poorer health on severalindicators. In terms of the implications of our findings for the future, threeexpectations may be highlighted. First, reliance on domestic workers willincrease with continued ageing of the population, high levels of women’sparticipation in the labour force, and the tendency towards more in-dependent living by elderly people, unaccompanied by children. The aboveexpectation presumes that a large majority of elderly people will continue toreside in private homes rather than in formal institutions, as observed in caseof some frail older Egyptians who were placed in long-term care facilities in

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Cairo, despite the norms of family care (Sinunu, Yount and El Afify ).Second, if current gender differences persist, a much larger proportion ofolder women than men will rely on domestic workers for care. Finally, adecline in the perceived as well as psychological health status of the olderperson is likely to increase reliance on domestic workers as a substitutesource of care by the family. The country does not currently have a routinesystem of information that may provide data on the socio-demographic andhealth dynamics of ageing. There is thus an urgent need to regularly conductstudies that would enable health planners to develop a comprehensiveunderstanding of such dynamics to better meet the health needs of elderlypeople in the years to come.The findings of our study may have several implications for other

Arab, as well as non-Arab, countries undergoing rapid social, economic,demographic and epidemiological transitions as Kuwait. With increasinglife expectancy combined with an expansion of chronic illnesses, thenumber of persons requiring assistance from family and non-family sourceswill increase. The proportion of the population requiring such assistancewill be higher in countries where fertility decline is faster and the numberof children as potential caretakers of elderly people is therefore smaller.Among those needing assistance, the proportion of women will be muchlarger than men both as a result of their longer survival and the absence ofa spouse. If the trend towards living without co-resident children continuesto rise, the need for alternate sources of care will exacerbate. Institutionalcare for elderly people that is rarely available in most developing countrieswill need to be developed by the government or private agencies. In themeantime, live-in domestic helpers are likely to fill in the caretakergap at an increasing pace. The observed trend of an increase in live-inforeign workers in a multitude of countries suggests that this phenomenonwill accelerate in the future. The supply of such workers is likely to remainabundant with the addition of more sending countries than in the past.The abundance of such workers is likely to keep their wages low. Ourknowledge about the process of hiring domestic workers, the multipleroles they play in the family and the consequences of their presence inthe household is very weak. There is a need to conduct research on manyaspects relating to the social, economic, and psychological costs andbenefits of the entire process of care by foreign live-in workers, both forthe health and wellbeing of the elderly people and the domestic workers.

Acknowledgement

This work was supported by the Kuwait Foundation for Social Sciences (grantnumber KFAS --).


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Accepted July ; first published online August

Address for correspondence :Nasra Shah, Department of Community Medicine and Behavioral Sciences,Faculty of Medicine, Kuwait University, P.O. Box ,Safat, Kuwait.

E-mail: [email protected]


J75 Domestics Aging and Society (2011)

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