Older migrants’ use of elderly care in Sweden: family affects choice between home help services and special housing

ABSTRACT

Swedish elderly care consists mainly of two forms of care: home help services and special housing. The aim of this paper is to investigate and analyse how and to what extent older migrants use different forms of elderly care and to explore whether, and if so why, this is the case. The article uses a mixed method that combines a quantitative and a qualitative research approach. The study comprises statistics on the total population of elderly persons using home help services and special housing, and 10 telephone interviews with care managers. The results show that while Nordic migrants have similar patterns access to elderly care to Swedes, older migrants from the Middle East and Africa use home help services to a similar extent to older Swedes, but refrain from use of special housing due to the greater accessibility of home help services and the help they receive from family and relatives. To understand this disparity, the study highlights the role of filial piety and family obligation, which prescribe how the family should take care of elderly family members. The results show that the family significantly influences an elderlýs choice of public forms of care in ways that fit its preferences.

SAMMANFATTNING

Den svenska äldreomsorgen består huvudsakligen av omsorgsformerna hemtjänst och äldreboende. Syftet med denna artikel är att undersöka och analysera i vilken grad äldre migranter nyttjar de olika omsorgsformerna. Vidare är syftet att förklara om och i så fall varför de använder omsorgsformerna på olika sätt. Artikeln kombinerar kvantitativa och kvalitativa forskningsmetoder och omfattar samtliga äldre som har hemtjänst och äldreboende i Sverige samt 10 telefonintervjuer med biståndsbedömare och socialsekreterare. Resultatet visar att nordiska migranter nyttjar hemtjänst och äldreboenden lika mycket som svenskar. Däremot skiljer sig äldre migranter från Mellanöstern och Afrika från svenskar. De nyttjar lika mycket hemtjänst som svenskar, men avstår från att nyttja äldreboende tack vare tillgången till hemtjänst och hjälp från familj och släktingar. Förklaringen finns i filial fromhet och familjens skyldighet att ta hand om sina äldre familjemedlemmar. Familjen påverkar genom att se till att de äldre får hemtjänst och hjälper de äldre, något passar deras preferenser och normer. De kan nyttja hemtjänsten samtidigt som de lever upp till föreställningen om filial fromhet och skyldigheten att ta hand om äldre familjemedlemmar.

KEYWORDS:

• Elderly migrants
• family support
• filial piety
• forms of care
• migration

NYCKELORD:

• Äldre migranter
• filial fromhet
• omsorgsformer
• familjestöd
• migration

Introduction

The findings of existing research indicate that older migrants use less elderly care than the majority population in Germany and Sweden (Hovde, Hallberg, & Edberg, 2008a; Steinbach, 2018). Similar results can be found in Switzerland. Elderly services are not always accessible to older migrants because of inadequate provision of information and a lack of policy integration on older migrants (Bolzman, 2012). Non-European older migrants are particularly vulnerable. In Denmark, migrants are less likely than Danes to use elderly care (Hansen, 2014) but the greatest differences were found between Danes and migrants from non-Western countries, who were also more likely to be cared for by their relatives and families than Danes. Older migrants, and migrants from Turkey in particular, expect that support and care will come from their families to a greater extent than native Germans (Steinbach, 2018, p. 297). In the Netherlands, research (Schoenmakers, Lamkaddem, & Suurmond, 2017; Suurmond et al., 2016) show that lack of knowledge about the home care system meant that non-European elders do not use care services or psychosocial help as much as the host population. In Sweden, non-Nordic migrants complained about their health, and felt exposed and deserted (Hovde, Hallberg, & Edberg, 2008b). They were vulnerable and use less elderly care due to communication difficulties and cultural differences. Like other researchers, Hovde et al. (2008b) called for greater awareness of older migrants’ situation in the elderly care system. Although increased ethnic demand and cultural awareness have led to different care solutions, Forssell and Torres (2012, p. 122) argue that elderly migrants still use public care less than native born Swedes. They are also underrepresented in special housing because migrant families having little knowledge of the elderly care. Researchers have labelled the situation of older migrants double jeopardy (Bengtsson, 1979; Markides & Mindel, 1987) or even triple jeopardy (Norman, 1985). They argue that older migrants have lower social status because they are old and discriminated against as migrants, and that care services are not available to them. A more recent study confirms the notion of discrimination against elderly migrants in different areas of life because of their age and background (Dolberg, Sigurðardóttir, & Trummer, 2018).

Previous research has made important contributions to our understanding of the care of elderly migrants. Too much of the research, however, has been focused on the vulnerability of older migrants (Torres, 2006). The role of the family in elderly care has been interpreted only as a consequence of failed public provision. This article challenges the previous research and argues that elderly migrants and their families are not merely a vulnerable group. They also have social and family resources, such as filial norms and duties, that should be highlighted in relation to the different forms of elderly care.

After the aim of the study, I describe Swedish elderly care and the distinction between home help services and special housing to provide insight into the context surrounding elderly migrants. This is followed by examining concepts of filial piety and family obligations to highlight the significance of the family for elderly migrants in relation to elderly care. Thereafter the data and method are presented. The results are then presented in two sections: one on home help services and one on special housing. Finally, I discuss and conclude my results.

Aim of the study

Swedish elderly care consists mainly of two forms of care: home help services and special housing. The aim of this paper is to investigate and analyse how and to what extent older migrants use the various forms of elderly care and to explore whether, and if so why, they use these forms of care differently from Swedes. The study takes an explanatory approach to understand and explain the role of family in the lives of older migrants and their use of different forms of elderly care. I analyse the extent to which migrants’ notions of filial piety and family obligation are significant in relation to different forms of elderly care. The article contributes a nuanced perspective on existing research by highlighting the interaction between the family and the use of different forms of elderly care. Although the significance of family support is not new, the perspective on the significant of family dynamics and the priorities behind the choice of different types of elderly care service is, as this article highlights.

The setting: Swedish elderly care

The goal of Swedish elderly care is to provide good and equal care regardless of ethnic, cultural, religious or national background. The elderly care is provided according to need rather than ability to pay. The elderly care consists mainly of home help services and special housing. All persons aged 65+ are entitled to apply for elderly care from the municipality. Social workers assess the elderly person’s needs. Home help services can potentially be offered around-the-clock in the elderly’s home. The elderly can receive assistance with tasks such as shopping, house cleaning, cooking or providing meals, laundry and health care services, as well as help with personal care such as bathing, showering, toileting, dressing or eating. In contrast, special housing for older people whose needs cannot be met at home. The elderly rent a small room with a toilet and shower. Family members are not allowed to live with them. The elderly receives 24-hour help with all kinds of home care services and help from nurses, doctors, occupational therapists or physiotherapists.

Elderly care is mainly funded by taxation. The elderly pay a small fee to municipality depending on their income. Fees are calculated by the National Board of Health and Welfare (NBHW). The highest monthly fees in 2016 were 1772 (€160) SEK for home help services and 1846 (€167) SEK for special housing. Older people are protected from excessively high fees (Socialstyrelsen, 2015). Moreover, elderly on low incomes or a pension are entitled to welfare and social security benefits set in accordance with a national standard and living costs in Sweden.

Swedish elderly care has undergone extensive changes in recent decades. In 2018, the population of Sweden was about 10,175,213, of which 2,035,711 (20%) were 65 or over. About 268,277 (13%) elderly in Sweden were born in another country (SCB, 2019). Between October 2007 and October 2018, the number of elderly people in special housing decreased from 97,494 to 88,044 while elderly people receiving home help services increased from 198,877 to 236,360 (Socialstyrelsen, 2019, table 9, 10).

Filial piety, family obligations and care of the elderly

The concept of filial piety in this paper refers to the cultural rights, beliefs and duties that shape the family’s and children’s attitudes to providing support, care and respect for elderly parents when they are in need (Canda, 2013, p. 215; Zhan & Luo, 2012, p. 71). It prescribes how family members are expected to care for and provide support to elderly family members. Filial piety exists in almost all cultures, but social changes such as population mobility, urbanisation and shrinking family size are ongoing processes that have implications for filial piety and family obligation in different cultures or families (Canda, 2013, p. 225). Nonetheless, the fundamental essence of filial piety is more or less the same among all cultures: to help and support elderly parents when they are in need. The expectations are that children should tend to the parents who raised them when they are old and frail.

In common with many Asian cultures, the values of filial piety are embedded in Middle East and African migrants’ cultural backgrounds and social practices. This shapes and structures family relations alongside changing societies not only in the host country, but also in the Middle East and Africa (Apt, 2012; Glicksman & Aydin, 2009; King, 2008). The level of filial piety is also dependent on migrants’ education, gender, religiosity, family relations, length of residence and socio-structural circumstances in the host country (Diwan, Lee, & Sen, 2011; Dykstra & Fokkema, 2012). US studies have shown that Asian parents in Georgia, are more likely to want to move closer to their adult children when they are old rather than move in with them like families do in Asia or India (Diwan et al., 2011, p. 63). Among Taiwanese migrants in California filial piety can be fulfilled by what Lan (2002) calls ‘subcontracting filial piety’. They achieved filial piety by employing home care workers to take care of their parents. Children fulfilled their filial duty of care by using ‘care workers to be their filial agents and fictive kin’ (Lan, 2002, p. 813). Good family relations were maintained among migrants despite the fact that the children were not the direct caregivers.

However, the implications of filial piety and family obligation should be understood not only in relation to family care for the elderly, but also in relation to the forms of public care arrangements in the host country, as this article highlights.

Data and methods

The article uses a mixed method that combines quantitative and qualitative research approaches. I started with quantitative methods. Following analysis of the quantitative data, semi-structured interviews were conducted with social workers. This is according to Bishop (2015, p. 8), ‘ … designs are sequential in that the first component is completed before the second component is begun’. Bishops says that this two-step approach consists of an exploratory and an explanatory approach. In this article the quantitative data explores the extent to which migrants use different forms of elderly care, while the interviews with social workers focus on whether and, more specifically, why older migrants are using different forms of elderly care.

The quantitative data was taken from the NBHW register of elderly receiving home help services (hemtjänst) and special housing (äldreboende) in accordance with the Social Services Act (2001, p. 453). Special housing is sometimes called a nursing home, but I use the term special housing, in line with the NBHW’s translation. Data was collected on all the elderly people receiving home help services and live in special housing from October 2007 to October 2014, excluding 2009 and 2013, for which data was not available. The data was cross-checked with the National Patient Register (NPR) to determine the countries of birth of the service users. The NPR covers all in-patient care in Sweden and details of outpatient visits such as day surgery or psychiatric care from both private and public sector providers. There is a high level of probability that all those who receive elderly care will be on the NPR. The statistics on the total population of elderly people are from Statistics Sweden (SCB).

The statistical data was used to derive a six-year mean value, which provides an overall picture of the use of elderly care. This is one way to minimise the risk that annual changes might distort the picture of elderly people receiving the elderly care, as the average age of migrants in Sweden will differ from year to year. In addition, the 1940s was the largest baby boom in Sweden in the twentieth century and a high portion of that generation of Swedes reached retirement age at the start of the period studied.

The data is presented according to SCB’s country classification: Sweden (native born), the Nordic countries, Europe, the Middle East (including Afghanistan) and Africa. ‘Elderly migrants’ refers to people aged 65+ and born outside Sweden. ‘Elderly Swedes’ refers to people aged 65+ and born in Sweden. Older migrants are not a homogeneous group, but elderly care concerns all of them when they are in need.

The statistical data has some limitations. Care services in special housing are provided around-the-clock. Unlike special housing, the quantity of home help services depends on the need’s assessment (measured in hours of care per week/month) made by social workers. Therefore, the quantitative data tells us only that the elderly person received home help services, but it does not tell us the quantity or quality of these services.

The qualitative data consists of semi-structured telephone interviews with 10 care managers and professionals (called social workers). The aim was to mediate the views on the experience of elderly care for older migrants and their families through interviews with social workers. Social workers have longstanding experience of elderly care for migrants and Swedes. The interview questions were formulated in order to gain an understanding of the results from the quantitative data. I asked participants to reflect on and talk about their views and experiences of the role of families in relation to public elderly care for migrants and Swedes. The information from interviews help us to understand and elaborate on the results derived using quantitative method and family support in relation to home help services and special housing.

I contacted 10 municipalities with a high proportion of migrants, which were mainly in large cities. I interviewed 10 social workers due to their accessibility and proximity to elderly people and their families. Their experience varied from 15 to 40 years in elderly care. The interviews were conducted in January/February 2018. Each interview took about 40 min. All the participants had a university degree in social work or sociology and have been anonymised using pseudonyms. The interviews have some limitations. However, to compensate for the limits of interviewing only 10 social workers, I also refer to literature on the role of the family for elderly migrants to strengthen the understanding of the results from the interviews. Paired the interviews with the literature increases the reliability and trustworthiness of the results.

Results

Use of home help services among elderly migrants and Swedes

Although some differences can be seen between the Nordic countries, Nordic migrants are better integrated into Swedish society and the welfare system than other migrant groups (Hansen & Lofstrom, 2003). This might explain why they use home help services in almost the same proportion as Swedes while older migrants from Europe use home help services slightly less than Swedes. The social workers were unable to offer any explanation for the latter. One explanation might be that some migrants from Europe plan to return to their homeland when they retire (Karl, Ramos, & Kühn, 2017; Klinthäll, 2006) due to a sunnier climate, democratic stability or cheap travel costs (Bjerke, 2017). Although migrants from the Middle East and Africa might initially intend to return, with time their plans tend to change due to their health, care needs and a desire to live near their children (Kristiansen, Kessing, Norredam, & Krasnik, 2015; Liversage & Mirdal, 2017). According to all social workers, they have major difficulties with the Swedish language and communication with staff:

The Swedish language is a big problem. Often, they forget the Swedish language they once knew. They go back to speaking their native language … . We try to recruit staff that speak two languages, but it is not so easy. (Eva)

It is not surprising that language can be a problem, but the interviews also highlight that these obstacles with language are compensated for through help from family members. As Table 1 shows the proportion of older migrants using home help services increased between 2007 and 2014. This is especially the case among older migrants from the Middle East and Africa who, based on the mean values, use the home help service as much as Swedes. Home help services are readily available to the elderly from the Middle East and Africa. However, special housing is still underused (see Table 2). This cannot be explained only by the lack of Swedish language skills or by vulnerability and discrimination. If this were the case, it would also be reflected in use of home help services. In addition, once granted home help services, older migrants are already in the elderly care system. Information is provided about special housing and care needs are reviewed by social workers at least once a year. Some prefer to continue receiving home help services even though they need nursing care. The interviews shows that help from family members compensate for the elderly person’s lack of Swedish language skills. First, the family helps their elderly to apply for home help services. Second, they provide informal additional care to enable their loved one to stay at home with support from home help services rather than opt for special housing.

Table 1. Total population 65+ and the elderly who receive home help services, 2007–2014, by region of birth, year and mean value.

Elderly with home help services compare to total population by region of birth		2007	2008	2010	2011	2012	2014	Mean value, 2007–2014	Mean value, %
Sweden	Home help	138,384	137,657	141,193	143,490	143,138	138,414	140,379	9
	Population	1,425,668	1,456,530	1,535,871	1,575,297	1,610,407	1,677,995	1,546,961
Nordic countries	Home help	6581	6857	7535	7967	8181	8319	7573	8
	Population	84,864	86,773	91,634	94,828	97,776	102,672	93,091
Europe	Home help	4749	5012	5382	5577	5756	5943	5403	7
	Population	69,801	72,274	76,108	78,404	81,100	86,233	77,320
Middle East	Home help	1304	1388	1777	2056	2510	2707	1957	12
	Population	12,834	13,609	15,732	16,887	18,310	22,038	16,568
Africa	Home help	196	222	315	334	405	490	327	9
	Population	2483	2719	3479	3964	4476	5609	3788
Total	Home help	151,214	151,136	156,202	159,424	159,990	155,873	155,639	9
	Population	1,595,650	1,631,905	1,722,824	1,769,380	1,812,069	1,894,547	1,737,729

Note: Population 65+ refers to all older people in Sweden. About 75 429 individuals categorised as ‘Other countries’ was excluded from the table. According to the SCB, there was no data on their nationality.

Table 2. Total population 65+ and the elderly who live in special housing, 2007–2014, by region of birth, year and mean value.

Elderly in special housing compare to total population by region of birth		2007	2008	2010	2011	2012	2014	Mean value 2007–2014	Mean value %
Sweden	Special housing	85,333	84,889	81,692	80,556	77,345	71,805	80,270	5
	Population	1,425,668	1,456,530	1,535,871	1,575,297	1,610,407	1,677,995	1,546,961
Nordic countries	Special housing	3959	4188	4439	4475	4589	4446	4349	5
	Population	84,864	86,773	91,634	94,828	97,776	102,672	93,091
Europe	Special housing	2273	2331	2494	2575	2594	2614	2461	3
	Population	69,801	72,274	76,108	78,404	81,100	86,233	77,320
Middle East	Special housing	266	279	346	359	375	381	334	2
	Population	12,834	13,609	15,732	16,887	18,310	22,038	16,568
Africa	Special housing	37	40	52	55	58	68	52	1
	Population	2483	2719	3479	3964	4476	5609	3788
Total	Special housing	91,868	91,727	89,023	88,020	84,961	79,314	87,485	5
	Population	1,595,650	1,631,905	1,722,824	1,769,380	1,812,069	1,894,547	1,737,729

Note: Population 65+ refers to all older people in Sweden. About 75 429 individuals categorised as ‘Other countries’ was excluded from the table. According to the SCB, there was no data on their nationality.

The results from interviews in this article is in line with international studies. A German study (Steinbach, 2013), for instance, shows that older migrants tend to live with family members more than native Germans do. Older migrants, and especially migrants from Turkey, expect more support and care from their family than native Germans do. Another study (Dykstra & Fokkema, 2012) also shows a strong relation between family support and filial norms on obligation among non-European migrants than Dutch natives. As Palmberger (2017) shows in the case of elderly Turkish migrants in Austria, this notion is socially embedded in family relations that are maintained not only by the family, but also by religious, cultural and political associations.

The interviews show that older migrants see the home help service as a good solution while special housing is seen as abandoning the elderly in their solitude. The strong family ties make it possible for the elderly to continue to live at home with the aid of home help services.

They wish to stay with their children. In some cultures, it is shameful to move to special housing. Some children have their older parents living nearby or together with them. They visit and help their parents every day. Being forced to move to special housing is seen as an act of abandonment by one’s children and family. … Migrants from the Middle East and Africa want more home help services, even in situations where more specialised housing and care are needed. (Deniz)

According to Deniz the family ties are strong not only among the elderly from the Middle East and Africa, but also among Swedes. The difference is that Swedes help their elderly relatives in other ways. Swedish families may help by spending more ‘quality time’ together, but leaving heavy household work to staff and care assistants from the municipality. Moreover, Swedes are also more positive about special housing and see it as a solution to their elderly relatives’ needs. Similar findings show Parveen, Morrison, and Robinson (2013) that the British Asian families demonstrated stronger and more explicit norms of filial responsibility, a greater willingness to help their older family members and were more driven by cultural and religious beliefs compare with British. As caregivers, British Asians were more often motivated by a sense of duty or obligation (familism) while British caregivers ‘provided care due to intrinsic motivations (emotional attachment with the care-recipient)’ (Parveen, Morrison, & Robinson, 2011, p. 869). Thus, the willingness to take care of elderly parents is also high in Western culture, but ‘Western culture does not have clear and explicit norms of filial responsibility (…) but they nevertheless provide extensive care to their parents’ (Chappell & Funk, 2011, p. 327). This is highlighted by social workers in the following way:

We [Swedes] do not have the same culture as migrants [from the Middle East and Africa]. For the older migrants, special housing is often seen as a last resort. But for Swedes, special housing is kept open as one of several options. Also, older Swedes do not want to be a burden to their families and relatives. I think this explains a lot about why migrants use more home help services and less special housing. Family help and support is a significant complement to the home help services they receive. (Maria)

It is certainly true that older people from the Middle East and Africa prefer home help services to special housing. Swedish relatives do a great deal for their elders too, but they do it in different ways. We go for coffee [“fikar”], celebrate birthdays, take walks and help with small things, but we don’t do heavy household work. (Emma)

Older people from the Middle East and Africa have so many children and they are always around them. In good times and bad. Most Arabic speaking migrants increasingly use home help services, so they can continue to live in their homes with family support. (Katrin)

When I asked whether social workers are restrictive in granting older migrants special housing because it costs the municipality more than home help services, Katrin noted that home help services can also be expensive to provide. Home help services are perhaps cheaper up to a certain point but in cases of increased needs home help services can also prove costly. This requires a lot of care assistants and nurses to be provided at home. She added that needs assessment decisions are based on the Social Services Act and with regard to the elderly person’s needs, not on the costs of care. On the contrary, they have problems convincing older migrants from the Middle East and Africa to move to special housing even though it may be better for them as they would receive better care there. This can sometimes lead to conflict:

Many times, the old ones live at home with their children. In some cases, this has resulted in issues and conflicts as it is difficult to collaborate with relatives. They think they can take care of their mother 100% by themselves. They want more home help hours. (Victoria)

Migrants from Somalia and Iraq are especially negative about special housing. They usually refer to their culture or religion when they refuse special housing. It is not surprising that the older migrants with access to considerable amounts of help from family and friends are also the ones who use formal social services more, as was seen in a Swiss study (Bolzman & Vagni, 2017, p. 264).

Use of special housing among older migrants and Swedes

As mentioned above, special housing is intended for elderly people who have extensive care needs. Although some migrants may require a lot of care, the social workers pointed out that placement in special housing causes great anxiety among migrants from the Middle East and Africa, which is reflected in the level of use of special housing (see Table 2). They use less special housing than Swedes and migrants from Europe and the Nordic countries. Swedes and Nordic migrants make up the two largest groups in this category. They have similar perceptions of special housing and they expect to be cared for in nursing homes when they need extensive care (Heikkilä, 2004, p. 30 and 41). In the case of families from the Middle East and Africa, however, special housing is associated with ‘shame and guilt’, as one of the social workers put it. They think about their reputation in Sweden and their homeland and are afraid of being accused of abandoning their elderly relatives.

Many think: What would our relatives say? What would the neighbours say? Everybody helps their old ones and they want to help all the way to the end. It is amazing how much they are willing to help but, in some situations, it is difficult to handle. Sometimes we think a person should live in special housing because he or she has needs that require special skills to meet, but it can be difficult to convince the relatives. Somalis in particular … do not want their elderly in special housing. I have only seen a single Somali in special housing in my six years here, even though many Somalis live in this district. This is also the case with families from the Middle East. (Irina)

The interviewees mentioned that families support their elderly based on feelings not only of obligation and cultural background, but also of emotional reciprocity and love. However, they were clear that families take collective responsibility for their elderly.

They often live in the same household. I think the combination of having the municipality’s home help services and help from the family makes it so that they don’t have to apply for special housing. (Sofia)

In this district there are many migrants. Many of them come from non-European countries. It is mostly Arabic speaking migrants here. I think everyone helps their older parents and relatives. I think older migrants prefer to receive care at home. (Monica)

Burholt, Dobbs, and Victor (2018) believe that this is linked to the strong collectivistic culture that they found among six non-European migrant groups in England and Wales. The authors traced this back to the collectivistic culture in migrants’ countries of origin. Although they found differences in their study, help from the family played an important role in care of the elderly in all six migrant groups. Similar results have been found in South Asian communities in the UK (Victor, Wendy, & Zubair, 2012).

Even in Sweden non-European migrants believe that the family is better at taking care of the elderly (Forssell, 2004). Turkish migrants (Naldemirci, 2017) hoped that their children would opt for family care rather than formal care. However, there is also a concern that they should not become a burden to their children. This conflicting attitude could also be found among Arabic speakers (Ajrouch, 2005) in the USA, where the elderly feared being placed in a nursing home and often rejected the idea of moving into one. At the same time, however, they had a desire to live with other elderly Arabs and expressed the need for social interactions with other Arabs. They believed that social relations with other elderly people would reduce feelings of loneliness and facilitate social and emotional support beyond their family and children.

According to Katrin there are also some practical problems linked to special housing. The families visit very often and spend a lot of time with their elderly relatives in special housing, and this has sometimes been disturbing for other elderly residents. Other residents can become concerned and may be fragile and easily worried by visitors, who sometimes stay late into the evening. The strong family ties could come into conflict with the idea of special housing.

Even in cases where the elderly care is culturally profiled, feelings of obligation and norms of filial piety are very strong among migrants from the Middle East in Sweden. Antelius and Plejert (2016; see even Kiwi, Hydén, & Antelius, 2018) interviewed nurses and care managers with Middle East backgrounds in Sweden. The results showed that the perceptions of disease and cognitive decline had little or nothing to do with Middle East migrants’ views on formal care. Instead, cultural norms, tradition and filial piety played a greater role in the decision to move to residential care. Even in the most difficult cases, such as cases of dementia in older family members, families typically did not want their loved ones in residential care homes. When for example Iranians felt the burden had become too great, however, they would allow a move to culturally profiled residential care for Iranians as one way to live up to Iranian culture, as well as values and norms on filial piety (Antelius & Kiwi, 2015). Even though the families felt that their relatives were safer and better off in residential care, they still felt anxiety, remorse, guilt and shame. A study (Khalaila & Litwin, 2012) of Arabs in Israel showed similar results.

Discussion and conclusions

The purpose of this article was to investigate how older migrants use the different forms of elderly care and analyse whether, and if so why, they use different forms of elderly care. The results show that Swedes and Nordic migrants use home help services and special housing to similar extents. Older migrants from Middle East and Africa use home help services as much as Swedes. However, they use special housing considerably less than Swedes. As the interviews with the social workers showed, this disparity can be explained by the fact that they tend to prefer home help services and to refrain from accessing special housing. They prioritise home help services due to their preferences and expectations of filial obligation. Families and relatives compensate for the need for special housing and make it possible for their elderly to continue to live in their homes with the support of home help services. The family is providing the elderly with positive practical help. They are aware of how to make use of the different forms of care and make deliberate choices in line with their preferences. In this study, filial piety and family obligation have been shown to be expressed not only through migrants helping their elderly, but also by the choice of home help services and rejection of special housing. They use home help services as a means to demonstrate filial piety and fulfil family obligations. The families combine home help services and family support in way that express their preferences and enable families to live up to notions of family obligation.

My results contribute to previous research by differentiating between home help services and special housing in relation to migrants’ own preferences. I highlight that the disparities in the use of special housing cannot be explained only by discrimination, vulnerability or lack of knowledge of the Swedish language or the elderly care system, as previous research seems to suggest. If this were the case, it would also be reflected in patterns of access to home help services. In fact, older migrants who have accessed home help services are already in the elderly care system. They will have their care needs assessed by care managers on a regular basis.

The results of the article should be viewed with some limitations in mind. The elderly in special housing are helped with almost all their needs around-the-clock, but this is not the case with home help services. The level of care would depend on needs assessment decisions by social workers. Therefore, the statistics on home help services tell us only that an elderly is receiving home help services, but do not tell us the quantity or quality of the services. Another limitation is that migrants from Middle East and Africa may choose home help services and refrain special housing due to care structure and the conditions surrounding their preferences. In particular, it could be the case that the elderly person has no family or that they live far away. Finally, mediating the role of the family in care for the elderly through 10 interviews with social workers can also have some limitations. There is a risk that social workers might paint too positive a picture of themselves. On the other hand, there is no doubt that the vast majority do a great job for all the elderly and have no need to exaggerate their roles. It is to be hoped that the use of literature was able to compensate for these limitations. However, future research should consider the personal perspectives of migrants on the different forms of care available. It may also be useful to investigate and analyse each migrant group separately.

Finally, as the number of elderly migrants increases, the debate surrounding their care will increase in many Western countries. Families will probably continue to play a significant role regardless of the form of public care. However, it is important that politicians and professionals think about how to make special housing attractive to elderly migrants and their families. When it comes to home help services, the family can only be a meaningful resource if there is equal access to home help services. If not, there is a great risk that the family and relatives will be unable to cope, and that the burden of care will become too great. In the long run, the family cannot compensate for unequal access to either home help services or special housing. The burden would be too much even for the most committed and motivated families.

Acknowledgements

I thank the National Board of Health and Welfare and Statistics Sweden for help with statistics. I thank the interviewees who shared their valuable knowledge and experiences with me.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

I would like to thank my university, Södertörn University, School of Social Sciences for funding this work.

Notes on contributors

Welat Songur

Welat Songur, as a researcher and lecturer at university and government agencies, worked with the impact of the welfare state on older migrants. Welat Songur has combined research on the welfare state with research on migration and ethnic relations. At university, Welat Songur has been teaching in welfare concerning older migrants and the living conditions of the older people. Another area of Welat Songur's research is within so-called open comparisons at the National Board of Health and Welfare. Welat Songur wrote reports about older people’s satisfaction with elderly care, with respect to gender and ethnicity. Furthermore, Welat Songur wrote a report about Swedish national minorities and elderly care.