Examining the Role of Immigrant Carers in Care for Older People at Home: The Case of Istanbul

In the modern period, the prevalence of chronic diseases has increased among old people due to the extended lifespans. Accordingly, older people who need for continuous care support has received much more focus. This study examines the experiences of immigrant female carers who are employed in home-based long-term older people care. Specifically, this study evaluates immigrant carers’ daily life practices and relationships with older people. In addition, this study explores the scope of the immigrant carer model as an alternative to caring for older people in traditional and institutional care models. In the study, a qualitative case study has been used. Care takers who immigrant Uzbekistan and Turkmenistan have been interviewed between 15 September and 15 October 2018. Snowball sampling method has been used to select interviewees from the abovementioned countries. All of the participants consist of women. The data has been analyzed in categorical content. The results show that a strong emotional bond has developed between immigrant caregivers and elderly people receiving care. At the same time, financial concerns were found to be the main factors contributing to the cares’ motivation. In this respect, it could be said that this model bears traces in both aspects of home-based older people care. This model could actually be considered to be an intermediate (buffer) mechanism that holds the characteristics of both traditional and modern care together.


Introduction
In the 21 st century, population aging is one of the major trends (WHO, 2007). Advances in health and technology areas have led to increases in peoples' lifespans (UNDESA, 2015). With the extension of life, the number of older people in the total population continues to grow (Klie & Durak, 2018: 91). In many countries older people are the most vulnerable and fragile as compared to other age groups. The prolongation of human life, which has been a significant milestone of the modern period, brings with it a number of problems. Among them is the growing burden of older people who chronic diseases. This makes the issue of caring for older people more important.
The number of Turkish older people continues to increase. This is happening most rapidly unlike the developed countries (Kurtkapan, 2019). The rapid increase in the proportion of older people within Turkey's total population has been one of the main issues of social policy. Organizing services within an infrastructure, which is kind to them, is an important agenda.
Within this framework, many events are organized in both political and scientific circles. The 1 st Council on Ageing, which was held in Ankara on 20 April 2019 under the auspices of the Presidency of the Republic of Turkey is a good example of these organizations.
The main problem that needs to be addressed for older people is who will be responsible for their care (Kurtkapan, 2018b). For older people, the need for supporting basic needs is also increasing due to the loss of ability to carry out the activities of daily life (Klie & Durak, 2018: 90). Should care of older people continue to be the family's responsibility in the traditional sense, or should long-term-care be shifted from family to institutional settings? There seems to be a lot of focus on this issue for the upcoming period because of the demographic and institutional changes expected in Turkey. In one of the studies on immigrant older people, individuals who are older and volunteer indicate that they work voluntarily to look after older and needy people (Palaz & Adıgüzel, 2016: 444).
In a dictionary published by the Turkish language institution, care is defined as an act of meeting and fulfilling a need. Older people care, on the other hand, includes support for the basic needs of older people such as protection, nutrition, dressing, and health. Long-term older people care includes individuals who have experienced physical and mental loss of power or are ill aged (Reichert, Naegele & Durak, 2018: 116). The social, economic and physical support individuals aged 65 and over needs are provided through older people care services (Canatan, 2018: 190).
A significant proportion of older people in Turkey need care (Şentürk & Ceylan, 2015). The results of the Turkey's Family Structure Survey show that 6.3% of households in the country are in need of older people care (TAYA, 2011: 358). Older people care is the family's priority (Özmete & Hussein, 2017;Bilge et al., 2014;Görgün-Baran, 2005;Kalaycıoğlu, 2003). Several mechanisms related to family provided care have also been developed (Bilgili, 2000: 2). The most common model of home-based long-term older people care is the informal care service model (Oğlak, 2017: 76).
There are different types of home-based older people care models available. These include family provided care, hiring relatives and private individuals who have retained these services with paid. Some of these individuals are educated and professionals, while others are not trained in the care of older people. Domestic and immigrant carers are employed in paid older people care. Paid and unskilled immigrant female carers in home-based older people care are becoming more and more prevalent.
In Turkey, home-based older people care model is preferred both by older people and the public. In this regard, it is argued that older people want to spend the last stages of life in the houses they are used to (Klie & Durak, 2018: 90;Kurtkapan, 2018a;Kalınkara, 2012, Şentürk & Altan, 2015. Here, all aspects of older people care need to be taken into consideration. Because of there are both social and health dimensions of home-based older people care (Güven & Seval, 2016: 295). The care requirements of older people need to be resolved in cooperation with other institutions of the community, especially the family. Older people care in Turkey is mostly provided at home and mostly by the immigrant women (Canatan, 2018: 200).
There is need for social policy to solve the problem of elderly care in Turkey. Working conditions for the carers of aged people need to be improved. More work should be done on homebased older people care (Özkul & Kalaycı, 2018: 18). In this sense, policies on home-based older people care in unrecorded older people care model need to be urgently developed (Oğlak, 2013: 83). If necessary measures are not taken, the social security and health system will be inadequate for the aging population (Eryurt, 2014: 90). In this context, more academic work on home-based older people care is needed.
What will be the future of the informal immigrant carer institution? The current situation of countries with a high population rate and the level of development may provide insight into our future scenario. In Italy, the proportion of immigrant carer in the care sector is quite high (Klie & Durak, 2018: 92). Considering the rate of aging is 20% and the level of development higher than us, this country may shed light on our 30 years from now. In addition, the fact that it is a Mediterranean country shows the example of a model that we will encounter more frequently in the future because there are some cultural similarities between the two countries. Although unemployment is high in Italy, more immigrants are employed in this regard. In the European Union, 7% of all workers in 27-member countries are non-citizen workers (European Commission, 2013: 24). İmmigrant carer is common in Italy, Greece, and Spain, which are referred as Mediterranean countries (Lamura et al., 2018: 134). Older people care work, in areas near the Germany border, is provided by illegal immigrant workers, for whom no social security contribution is paid. It is estimated that only about 150,000 workers come from Poland (Reichert & Naegele, 2018: 119). Considering all these aspects, it is seen that immigrant employment for the care of Turkish aged people, will continue to increase. Therefore, the shortcomings and deficiencies of this issue should be identified and short and medium-terms solutions should be developed.
The income inequality between the target and source country motivates the carers to send the fixed portion of their income to their country (Lamura et al., 2018: 136). It is underlined that an immigrant carer correlates more emotionally and socially with aged people individual's family (Lamura et al., 2018: 137). Women, who come to work as care takers, are known to work in older people care sector (Canatan, 2018: 200).
Various studies have been carried out on older people care around the world, and these have identified several problems for carers in older people care. Among these, it was first found that carers in care service were not economically adequately rewarded. Secondly, because women in the family has a primary responsibility in care; women have not able to take part in the wage labor market. Finally, it is said that no common language has been developed between older people care at home and at the institution. (Wellin & Jaffe, 2004: 293).
In Turkey, families are expected to take care of older people (Şentürk & Altan, 2015). Older people care in Turkey, from the past to the present, has traditionally been arranged through family members. To let this happen, several factors function as facilitators. Particularly, the shortage of older people population, the short life span of women, and the fact that they could assume responsibility for care are some of these factors. Yet today, women's participation in the social life outside their home undermines the traditional caring role of women (Canatan, 2018: 191). Providing elderly care to close family members increases the burden of care. But the level of religious coping reduces that burden (Balcı, Atılgan & Bulut, 2016).
Due to changes in the family, social and economic factors, families may need support in older people care. In addition, this need comes to the fore with the increase in older people population (Canatan, 2018: 192). In some families, older people care is provided to third parties for a fee. A significant proportion of these carers are immigrant women from Turkic Republics, who do not have work permits. This study has address the issue of immigrant female carers providing home-based older people care.
In this context, the daily life practices of immigrant carers, the relations they have developed with older people and their family, the reasons for choosing this job are examined. The importance of older people care will increase in Turkey. In this study, it is aimed to make a modest contribution to the institutionalization of the immigrant carer model, which is a part of the solution for older people care.

Research model
Home-based care service is an older people care practice that has gained prominence in recent years and is becoming increasingly prevalent. Carers play a key role in this model. The aim of this study is to evaluate the immigrant carer model in line with the experiences of immigrant carers who provide home-based care. For the target group and objectives of the research, it was deemed appropriate to conduct research with the case study pattern, which is one of the qualitative research methods. In the case study, the researcher examines a limited case at a specific time with multiple data aggregation tools (Creswell, 2009;Neuman, 2014: 42). The research aims to explore in-depth the status of immigrant carer in home-based long-term care. The result of the study includes both the description and themes that the researcher has revealed (Creswell, 2009). In this research, the findings are described and evaluated on the basis of certain themes.

Working group
The research data was collected from a group of women carers of Turkmenistan and Uzbekistan, who provide home-based care to older people in need of permanent home care in İstanbul. A total of 14 participants were interviewed. Participants are thought to have sufficient experience with the subject and to answer questions sincerely. Interviews were conducted in homes -where older people care was provided. The participants were reached by snowball sampling method. All of the female participants were of age ranging between 27 and 47 years with a minimum experience of 6 months and a maximum of 7 years. Among the interviewed women, all of them were married and mothers, except one participant.

Data collection
In the study, the interview technique was applied as it provided flexibility to the researcher. The data was collected with a semi-structured interview form. In the preparation of this form, the literature on elderly care and the sociology of old age was used and the opinions of the experts on the subject were given. The data were collected from 15 September to 15 October 2018. Interviews were conducted by the female care takers at homes of the old people in Istanbul. The interviews were kept short so as not to disturb the older people. All but one of the interviews were audio recorded.

Data analysis
In the study, categorical content analysis was used for analyzing the data obtained from the interviews. Before the analysis, interview notes, audio recording transcriptions were combined. Interview analyses were first divided into codes and then categorized and finally analyzed on a theme axis (Creswell, 2009).

Ethical issues in the research
In order to comply with the ethical requirements, participants were informed about the purpose, scope and identity of the researcher. Participants were asked to identify a pseudonym before the interview. These pseudonyms were used in all types of recordings, audio files, and observation notes. Attention was paid to the confidentiality and the privacy of personal data. Audio recordings and transcriptions were stored on the researcher's laptop and encrypted.

Findings
There are many models in which people are cared for at home. Among these models, the most common one is family provided care, which is an informal older people care provided by the family members. However, due to the growing burden of care and the impact of urbanization in the family structure, different models of home-based long-term care also appear. In this sense, the paid carer model is becoming increasingly preferred. Some traditional families have progressively been used to hire paid carers. Immigrant women are preferred in this regard for various reasons.
One participant acknowledges the leading role of the family in elderly care, but says that the bride and the girls were inclined to engage the migrant carer model as they could not fully fulfil their elder care responsibilities because of the new conditions and responsibilities that emerged with urbanization: "Our expectation is that we see him as the person who will help us. In fact, we need to take care of the elderly as a bride, but we see them as helpful personnel who could stand next to the elderly 24/7 to help us in cases where we can't keep up." (Miss Hanife,45 years old) In this model, family members pay to obtain the support services for the care of their elders. Carers are constantly checked by other members of the family. "If something bothers us, we warn him or her. If he does well, we appreciate the work he does. He is constantly observed'' (Miss Hanife, 45 years old). Family members live in the same apartment or site, although they are not in the same house. There may be various reasons for the transition from the traditional aged care model to a new model. These include the challenges of urban life and the housing situation, the transformation in the responsibilities of the family, and the economic conditions and lifestyles. This changing situation makes the change inevitable in older people care. In this sense, the paid carer model is being developed. In this context, there are migrant care takers, who are immigrants and work in the country. The family that feels the social pressure at first can accept this situation, especially when there are similar cases in their daughter-in-law's families. Participants, especially those with older relatives, may have difficulty in accepting this fact in the first place.
"In fact, when I first heard it, I was a little nervous. It was as if I had not to hand over to other hands when there were so many children and grandchildren. It touched me and made me think. "I was worried that he might not be comfortable. After all, he's a stranger and a person he never knew, can we trust him? On the one hand the unease caused by it, on the other hand the conscientious responsibility because of his sons and grandchildren not being able to take care of him." (Miss Sema,35 years old) The participant, who is aware of the fact that the responsibility of the family has changed in older people care states that there should be a long-term and boarding carer in older people care as a result of this imperative. She also states that it is inevitable to take home-boarding carers for the elderly, who those with a vulnerability and dependence on self-care and health care. "Today, family member can't agree on elderly care, and they don't look after older people. They can't stay permanently for care at older peoples' home. It would be better if someone from the outside stayed with him", said Miss Sema (35 years old).
As far as the participants' motivations for coming to Turkey as care takers is concerned, two aspects are important to mention here: (i) firstly, the daily routines of the carers providing home-based care, and (ii) secondly, the symbolic interaction between the carers and the older people.
Participants, who take care of the older people reveal that they have economic motivation to come to Turkey. It can be stated that they view the job of older people's care as an opportunity to make savings. For example, Mrs Gill (32 years old) states that "the purpose of us is always the same. It's about making money, for buying houses and cars after returning to the our country.'' Unemployment and a lack of job opportunities in their home countries are forcing them to work. Another interviewee said that: "We have a pretty small chance of getting a job in our country so we are coming here and doing this job. We don't have much choice (either working in the workplace or carer in care services).'' (Miss Nagihan, 27 years old). ''I needed work and money, there were no convenient jobs in our country." (Mrs. Mayıs,47 years old) This study reveals financial circumstances and unemployment in the interviewees' countries as the key reasons of their migration to Turkey and to adopt the care taking profession. In the study, some problematic areas of immigrant carer model in home-based long-term older people care have been identified. These problems directly stem from immigrant carers' less education, skills and experience to provide care to the aged people in Turkey. All these factors negatively affect the quality of older people's care service.
In terms of the older people's care routines, participants assert that they plan a regular life for old people. This is carried out through the doctor's advice and routine drug purchases and exercises. Breakfast and morning conservations are scheduled as a routine practice in order to begin the day. Daily health care takes an important place in the old people's daily plan. Sometimes welcoming guests are considered as part of this job: "When we get up in the morning, we talk about how s/he slept, after then we have breakfast and tidy the house, and after that I have the older people do sports. Sometimes I take him/her out and walk. I do the daily and health care, like cream putting on ointment, taking meds, etc." (Mrs. Gül, 32 years old) "I walk with him/her through in the morning, clean up, cook together if s/he is awake. We move during the day so that s/he could sleep comfortably in the evening without disrupting his/her sleep. Although some of these movements are recommended by the doctor, sometimes I do so that they sleep comfortably at night." (Mrs. Firuze, 41 years old) Old people may be sometimes physically active at night in case of need. For instance, an interviewee reveals that "they could wake up 2-3 times a night, just like a baby. I accompany him/her when s/he gets up'' (Miss Nagihan, 27 years old). This shows that older people care is done 24/7 and very abrasive. Probably that's the reason that local caregivers avoid providing home-based care. The changes in the social structure of Turkey show that the place and importance of migrant carers in the future of older people care will continue.
In order to contribute to formalization and development of home-based immigrant older people care service, studies should consider perspectives of the immigrant caregivers, shown in Table 1. Findings in this study indicate that immigrant carers do this work for their regular income and to have some moral and ethical values in their personality such as love, respect, and conscience. All the participants in this study mention that they have developed an emotional connection with the older people in a short time. In fact, they highlight that older people care service is difficult and they could overcome this difficulty by adding psychological and emotional elements into their work. All the immigrant carers, who took part in the study, state that they call the older people as "mother" to show respect. "They may like to be called like this", says Miss Negihan (27 years old). In one of the houses observed, one of the older people's close relatives said that the immigrant carer called the older people a more sincerely than his/her own son.
The participants state that they have done this work temporarily. Many of the participants do this by traditional methods in the way they learn from their own families. They state that they have no experience. For example, one interviewee says: "I have been working for 7 months, and I had no previous experience." I have to finish paying off my house, I will quit this job when I get paid to go to university and I become set in my way." (Mrs. Gül, 32 years old) Similarly, another interviewee suggests that "I have little work experience in older people care, and I do not know exactly what to do in this care" (Mrs. Firuze, 41 years old).
Considering that migrant carers are already being used effectively in older people care in countries like Germany and Italy, it can be said that migrant carers will be an important part of Turkey's vision for the future of older people care. The long-term home-based immigrant carer model is a model open to development. The results and recommendations, developed in light of the aforementioned findings, are thought to contribute to the field of sociology of aging.

Discussion and recommendations
The family has an important role in the in-house care of older people. However, due to urban conditions, families are no longer able to afford care takers for the aged people. For this reason, people from outside the family are used to look after the aged people. It is seen as difficult to maintain older people care at home with an established sense of care (Klie & Durak, 2018: 90). For this purpose, various care model applications are being introduced, one of which is the home-based immigrant older people carer model.
When looking at the professional qualities of immigrant carers, it is seen that their professional qualities are just like family members. In fact, it can be said that this kind of care functions like the buffer mechanism that Kıray proposes for urban development. The concept of the ''buffer mechanism'' refers to an intermediate mechanism that connects the various elements of the social structure and includes the elements of both the old and new structure in terms of both structure and function Since (Kaçmazoğlu, 2017: 406). Family members are unable to fulfil their older people care responsibilities in a changing social structure, home-based immigrant older people carer model serves to support the family's older people care responsibility. In this model, neither complete professionalism nor complete volunteering is essential. It functions as an intermediate mechanism in the transition from the traditional to the modern older people care model.
Through this limited study, older people care model can be looked at from the perspective of Turkey. As such, we could not been able to fully urbanize and modernized older people care in Turkey (Kurtkapan, 2018b). However, it is obvious that we cannot maintain traditional elderly care. In older people care the family is forced because of urban conditions and traditional values. There is neither a fully modern/urban nor a fully traditional model in the older people's care.
With increased older people's care programs in Turkey, more professionals will be involved in older people care in the future. Until then, however, unqualified immigrant carers will continue to work as intermediaries. With this in mind, immigrant carers need to be included in the formal care system. In this context, the necessary training and courses should be given to these carers and it should first take place the adoption of immigration legislation.
This study has aimed to shed light on the fact that immigrant carer older people care is becoming increasingly common in Turkey. Further work needs to be done on migrant carers and to improve the quality of older people care in the country.