The Gerontologist
Vol. 48, No. 1, 16–24

Copyright 2008 by The Gerontological Society of America

Globalization, Women’s Migration, and the
Long-Term-Care Workforce
Colette V. Browne, DrPH,1 and Kathryn L. Braun, DrPH2
With the aging of the world’s population comes the
rising need for qualiﬁed direct long-term-care (DLTC)
workers (i.e., those who provide personal care to frail
and disabled older adults). Developed nations are
increasingly turning to immigrant women to ﬁll these
needs. In this article, we examine the impact of three
global trends—population aging, globalization, and
women’s migration—on the supply and demand for
DLTC workers in the United States. Following an overview of these trends, we identify three areas with
embedded social justice issues that are shaping the
DLTC workforce in the United States, with a speciﬁc
focus on immigrant workers in these settings. These
include world poverty and economic inequalities, the
feminization and colorization of labor (especially in
long-term care), and empowerment and women’s
rights. We conclude with a discussion of the contradictory effects that both population aging and globalization have on immigrant women, source countries,
and the long-term-care workforce in the United States.
We raise a number of policy, practice, and research
implications and questions. For policy makers and
long-term-care administrators in receiver nations such
as the United States, the meeting of DLTC worker
needs with immigrants may result in greater access to
needed employees but also in the continued devaluation of eldercare as a profession. Source (supply)
nations must balance the real and potential economic
beneﬁts of remittances from women who migrate for
labor with the negative consequences of disrupting
family care traditions and draining the long-term-care
workforce of those countries.
Key Words: Aging, Elder custodial care, Filipino
Americans, Geriatrics, Globalization, Health services
We gratefully acknowledge Dr. Jeanette Takamura, Columbia
University; and Drs. Meda Chesney Lind and Pamela Arnsberger,
University of Hawai’i, for their critical comments and suggestions.
Address correspondence to Dr. Colette Browne, School of Social
Work, University of Hawai’i, 1800 East West Road, Honolulu, HI 96822.
E-mail: cbrowne@hawaii.edu
1
School of Social Work, University of Hawai’i, Honolulu.
2
John A. Burns School of Medicine, University of Hawai’i, Honolulu.

16

for the aged, Immigration, Long-term care, Poverty,
Social justice, Women, Workforce

Three trends—population aging, globalization,
and women’s migration—are gaining momentum
concomitantly. Population aging and globalization
are heralded with both enthusiasm and caution.
Population aging represents progress in public health
and medicine, but growing pension and health care
costs are challenging nations. Globalization, a key
theme of contemporary international political economy, promises improved efﬁciency in the distribution of resources and higher standards of living
for some; but for others—especially in developing
nations—it means increasing inequality and poverty
(Stiglitz, 2006). One feature of the economic impact
of globalization is a third trend—the increase in the
transnational migration of women seeking work.
These trends have far-reaching implications for
the care of aged adults. Long-term-care settings
require a range of workers, and those who provide
direct personal care to dependent elders are at the low
end of the wage scale. In the United States, the longterm-care workforce is heavily dependent on women
from racial/ethnic and minority backgrounds, and
increasingly on immigrant women, to ﬁll lowpaying, direct-care positions (Montgomery, Holley,
Deichert, & Kosloski, 2005; Redfoot & Houser,
2005). In this article, we examine the impact globalization and population aging have on immigrant
women in the direct long-term-care (DLTC) workforce. Increasing numbers of older adults, especially
those older than 85, are in need of these workers,
who are critical to their well-being and in short
supply (Paraprofessional Healthcare Institute [PHI],
2005). We suggest that ignoring these international
trends may lead to lack of preparedness for meeting
the escalating needs for these workers.
We begin with a brief proﬁle of the long-termcare workforce in the United States and explore
the impact of population aging, globalization, and
women’s migration on supply and demand for
DLTC workers. We extend the discussion by drawThe Gerontologist

ing from the writings of a number of gerontology,
globalization, and immigration scholars who have
grounded their work within a feminist and gender
analysis. We raise questions in three areas—world
poverty and economic inequalities, the feminization
and colorization of labor, and empowerment and
women’s rights—with embedded social justice issues
that expose the contradictory effects of these global
trends on women. Figure 1 presents a framework
that identiﬁes issues among the three social justice
issues, international trends, and the DLTC workforce in the United States. Finally, we raise practice,
policy and research questions around reliance on
compensatory migration to meet DLTC workforce
needs. We deﬁne international migrants as persons
born in a country other than that in which they
reside. Our discussion on migrants focuses on legal
labor migration; unless otherwise stated, this excludes refugee movements and human trafﬁcking.

DLTC workers are the lowest paid workers in
long-term care (Bureau of Labor Statistics, 2003;
National Clearinghouse on the Direct Care Workforce, 2006). Many work part time, and the median
hourly wage for DLTC workers in 2005 was signiﬁcantly lower than that of the average U.S. worker,
$9.56 compared to $14.15 (National Clearinghouse
on the Direct Care Workforce, 2006). As a result of
low wages and part-time work, 19% of home care
aides and 16% of nurse aides are poor by the U.S.
Census deﬁnition (Montgomery et al., 2005). Few
jobs offer health insurance or other beneﬁts, or
chances for advancement. As a result, there is high
turnover, ranging from 40% to 100% (U.S. General
Accounting Ofﬁce, 2001). This increases the motivation to fast-track people, including immigrants,
into this ﬁeld and decreases opportunities to develop
a stable, high-quality long-term-care workforce (U.S.
Department of Health and Human Services [DHHS]
and U.S. Department of Labor, 2003). The passage
of the Nursing Relief for Disadvantaged Areas Act of
1999 aimed to address the shortage of trained nurses
in speciﬁc locales by easing immigration restrictions
(Hoppe, 2005), but no similar legislation has been
aimed at the recruitment of the DLTC worker. Instead, those who hope to migrate to the United States
to work in DLTC must ﬁrst abide by the stringent
U.S. immigration laws. Temporary work visas offer
a partial solution but may deny the visa holder the
ability to become a citizen (Novelli, 2005).

The DLTC Workforce
With the aging of the world’s population comes
the rising need for DLTC workers. These include
nurse aides, nursing assistants, personal care attendants, home care workers, and other paraprofessional workers who provide hands-on care to
consumers in hospitals, nursing homes, communitybased services, and private homes. A recent study
found that about 90% of these workers in the United
States were middle aged and female, more than half
were non-White, and about 20% were foreign born
(Montgomery et al., 2005). Researchers have documented similar gender and age proﬁles in other
developed countries (Korszyk, 2004); others have
found an increasing reliance on immigrants to
provide this care (Polverini & Lamura, 2004).
The United States, as with other developed
countries, has a critical shortage of workers in longterm care, especially DLTC workers (PHI, 2005;
Stone & Wiener, 2001). There is no national data set
on these shortages; instead, data on shortages are
extrapolated from studies from individual states and
professional associations (PHI, 2005), projections
on job growth compared with demographic changes
(Bureau of Labor Statistics, 2003), and what is
known about vacancies and job turnover (Better
Jobs, Better Care, 2006a; U.S. General Accounting
Ofﬁce, 2001). DLTC work is one of the fastest
growing service occupations in the United States; the
demand is expected to increase by 63.5%, or about
900,000 new jobs, between 2005 and 2010. To ease
this labor shortage, program administrators are
turning to immigrant women as potential employees
in long-term care (Hagan, 2004; Lowell & Gerova,
2004; Redfoot & Houser, 2005). In fact, the percentage of foreign-born nurses aides in long-termcare settings increased from 6% in 1980 to 16% in
2003 (Redfoot & Houser, 2005).
Vol. 48, No. 1, 2008

Three Global Trends Impacting Long-Term Care
Population Aging
We turn now to the ﬁrst of three international
trends that shape long-term care and the DLTC
workforce issue—global population aging. In 2006,
nearly 500 million people around the world were
aged 65 years or older. Projections estimate that by
2030 the number will reach 1 billion, or 1 in every 8
persons (U.S. Department of State and U.S. DHHS,
2007). By 2050, the number of people aged 85 and
older—those most at risk for needing long-term
care—will increase by 350% (Kinsella & Phillips,
2005; Wiener & Tilly, 2002). Europe has felt the
impact of an aging population sooner than other
parts of the world, in part due to its high economic
standing and generous social policies (Kinsella &
Phillips, 2005). Japan will experience the most striking increase: By 2030, 24% of all older Japanese
citizens will be aged 85 years or older (U.S. Department of State and U.S. DHHS, 2007). In the United
States, the number of older adults is projected to
increase by 135% between 2000 and 2050 (Wiener &
Tilly, 2002). By 2050, a new demographic shift will
occur, when 80% of the world’s projected 1.5 billion
people older than age 65 will reside in the world’s
developing regions (Kinsella & Phillips, 2005).
Global aging is gender imbalanced. Women out17

Figure 1. Conceptualization of population aging, globalization, migration, and the long-term-care workforce. GNP = gross
national product.

number men in every age group, most notably in the
later years, and in nearly every country. Biological
and social sciences have identiﬁed numerous reasons
for gender differences in longevity (Hooyman &
Kiyak, 2006). This gender differential impacts health
status and functioning, marital status, family caregiving, living arrangements, economic and poverty
status, and the workforce (Kinsella & Phillips 2005;
United Nations, 2005). Additional barriers to opportunities for women emerge when gender intersects
with race, ethnicity, sexual orientation, and other
statuses (Hagan, 2004; United Nations, 2005).

Globalization
Globalization, the second trend, is a complex
world transformation whereby the mobility of capital, organizations, ideas, discourses, and peoples has
taken an increasingly global or transnational form
(Moghadam, 1999). Studied from various perspectives, globalization has economic, political, and cultural components. As deﬁned by Joseph Stiglitz
(2006), economic globalization refers to the ‘‘closer
18

economic integration of the countries of the world
through the increased ﬂow of goods and services,
capital, and even labor’’ (p. 4). People are becoming
increasingly interdependent on one another in what
they produce and what they purchase, although
not equally across borders. Numerous aspects of
globalization impact the DLTC workforce, including
poverty in developed, developing, and transitioning
economies and the use of immigration policy to
alleviate shortages in particular occupations.
Any discussion of globalization must acknowledge
the international debt crisis and payment conditions
directed at debtor nations by the World Bank and
the International Monetary Fund. Strategies deﬁned
to alleviate the debt of poor nations include the enforcement measures of ﬁscal austerity, retrenchment
of social and health care spending, and international
trade agreements that rarely if ever beneﬁt the
developing nations (Blim, 2005; Stiglitz, 2006). This
‘‘crisis of development’’ distributes the economic
beneﬁts of such policies unequally to some parts of
the world, leaving others with high social and environmental costs and disproportionately impacting
women in their role as caregivers (Rankin, 2004). To
The Gerontologist

help meet their debts to international institutions,
many third-world nations encourage women into
four gendered production networks: export production, sex work, domestic service, and microﬁnance
income generation (Pyle & Ward, 2003). Growing
numbers of immigrants are seeking a better life in another country; increasingly, they are women (Arya &
Roy, 2006; George, 2005).

those women who immigrate for employment
(United Nations, 2005).
Turning to the limited data on international
workers and immigrant women employed in the
DLTC workforce, Redfoot and Houser (2005) identiﬁed the primary source (or supply) nations for
DLTC work in the United States as Jamaica,
Mexico, Haiti, Puerto Rico, and the Philippines.
Most researched is the Republic of the Philippines,
which has emerged as a major resource for the longterm-care workforce in the United States, Canada,
Europe, Asia, and the Middle East (Chang & Ling,
2003; Oxman-Martinez, Hanley, & Cheung, 2004).
Reasons for Filipina predominance in foreign longterm-care industries include the continuing high
levels of poverty in the Philippines and the country’s
response to changing world labor markets and national pressures for foreign exchange (Tyner, 1999).
It was estimated that in 1994, a third of Filipinos
lived on less than U.S. $1 per day, the standard for
abject poverty (Balisacan, 1994). In 2001, the
government of the Philippines announced that the
poverty rate had declined to 24%, but this was
primarily due to the lowering of the poverty cut-off
rate to U.S. $0.69 per day. The solution for many in
the Philippines is migration. Of the country’s 89
million people, 10% live abroad (DeParle, 2007).
Supporting a family member to work outside the
country so that he or she can send home foreign
currency is a common way to prevent poverty,
supplement a family’s income, and afford education
and property.
The Philippine government relies heavily on foreign
currency sent home by Overseas Filipino Workers,
and governmental policies and training programs
have been established to encourage the exportation of
Filipino labor (Chang & Ling 2003; Marchand &
Sisson Runyan, 2003; Tyner, 1999). In the domestichelper trades, more than 150 training centers funded
by the 1994 Technical Skills Development and Education Act now operate to train and channel Filipinas
to be internationally exported caregivers for children
and elders (Liban, 1999). Currently, about 8 million
Overseas Filipino Workers (including about 5 million
women) work in 140 countries. Together they remit
more than U.S. $7 to $8 billion each year, representing
about 10% of the Philippine gross national product
(Laquian, 2005; Marchand & Sisson Runyan, 2003;
Pratt, 1999).
In the absence of a national database on DLTC
immigrant workers, a number of smaller studies
provide us with a picture, albeit limited, of the lives
of Filipina domestic workers in the United States. In
California, where 52% of U.S. Filipinos reside, Tung
(2000) found an extensive network of Filipina migrant workers as providers of in-home eldercare,
estimated to comprise 75% of all such providers in
Los Angeles. These women, even if legally residing in
the United States, were not licensed or registered to
provide eldercare, thus adding to the challenges of

Women’s Migration
Migration across international borders is the third
trend. As of 2000, about 159 million persons were
classiﬁed as voluntary migrants, and refugees composed another 16 million (United Nations, 2003).
Over the past decade alone, more than 1.5 million
persons crossed international borders. The United
States is the largest recipient of international
migrants, with 35 million migrants in 2000, followed
by the Russian Federation (13 million), Germany
(7 million), the Ukraine, France, and India (United
Nations, 2005). In addition to globalization forces,
reasons for migration include world poverty; readily
accessible/affordable transportation; the revolution
in communications; growth in transnational communities; increased demand for workers; changes in
immigration policies; and growing worker networks
composed of families, communities, and institutions.
Of the 159 million international migrants, about
90 million (49%) are women or girls (United
Nations, 2005). The proportion of female international migrants is 51% in more developed regions
and 54% in the United States (United Nations, 2003).
Women historically migrated as dependent family
members but today are increasingly part of transnational worker ﬂows, moving to earn more money
(United Nations, 2005).
Immigration data usually are not published by age
or gender, making it difﬁcult to assess the full implications of international migration for women and
their employment picture. Migration research on the
speciﬁc livelihoods of migrant women has only recently received more focus (Arya & Roy, 2006;
George, 2005; Oishi, 2005; Olwig & Sorensen, 2002).
Existing data tell us that most women migrants are
employed in traditional female occupations of domestic work, health care, and teaching (United Nations, 2005). Looking speciﬁcally at health care and
long-term-care employment in the United States,
Ong and Azores (1994) found that Asian immigrants
represented nearly a quarter of the health care providers in public hospitals in major U.S. metropolitan
areas. Paral (2004) estimated that immigrants employed in health care in the United States compose
17% of the DLTC workforce but only 12.4% of the
total population. In general, immigrants are employed in low-paying and insecure jobs. Women’s
unemployment rates are higher than men’s everywhere, leading to a feminization of poverty among
Vol. 48, No. 1, 2008

19

studying them. Most were paid ‘‘under the table,’’
a few had health insurance, none owned homes in
the United States, and all planned to return to the
Philippines. On average, these women remitted 75%
of their income to families in the Philippines to
increase their own family’s standard of living.
In Hawai’i, Filipina immigrants compose 95% of
care home operators (licensed long-term-care providers who care for frail elders in their own homes).
When asked why they chose this ﬁeld, most noted
that eldercare ﬁt with their cultural values of respecting and caring for elders. They also noted economic
reasons: They had limited opportunities for other
work, and this job helped them buy a house and
educate their children. Cultural values aside, they did
not wish for or expect their children to continue in
DLTC work because it was physically demanding
and low paying (Browne, Braun, & Arnsberger,
2007).
Broadening the Discourse Around Long-Term
Care as a Global Issue
The global trends of population aging, globalization, and gender migration individually and
together expose the growing demand for a longterm-care workforce in the United States and other
nations. As noted previously, numerous factors
inﬂuence the supply of DLTC workers, including
economic conditions that inﬂuence employment
choice; demographic factors such as gender and
fertility rates; and political decisions about immigration policy, social funding, and occupational
training options (U.S. DHHS and U.S. Department
of Labor, 2003). Still, most nations continue to
approach long-term-care workforce issues individually, with scant attention to the effects of global
aging and globalization.
What are the advantages and disadvantages of
relying on immigrant women to provide needed care
to a growing frail older adult population? What
about the women who migrate and provide this
care—what are their opportunities and challenges?
And what are the effects on source nations that are
providing workers for DLTC? To shed light on these
questions, we turn to the insights of a number of
gerontology, globalization, and immigration scholars who have grounded their work within a feminist
and gender analysis. The common theme in these
analyses is the quest for gender justice and the elimination of power inequities inherent in present
structures for men and women, both within nations
and across international borders. In gerontology,
scholars have applied these critiques to issues of
family care across the life course (Calasanti &
Sleven, 2001; Hooyman & Gonyea, 1997), long-term
care (Nussbaum, 2002; Olson, 2003), social welfare
policies (Browne, 1998; Estes, 2000), retirement
(Richardson, 1999), and ﬁnancial security (Gonyea &
20

Hooyman, 2005). Likewise, a number of globalization and immigration scholars have integrated their
feminist and gender analyses into critiques of the
varied and intersecting relations of global power on
women’s well-being (Beneria, 2003; Eschle, 2004;
Espiritu, 1999; Marchand & Sisson Runyan, 2003;
Parrenas, 2001; Pessar 1999; Pyle & Ward, 2003;
Rao & Kelleher, 2003; Tyner, 1999).
Fundamental to a feminist analysis of long-term
care and work policies is the understanding that
caring work—whether paid, low paid, or unpaid—
cuts across the personal and political boundaries of
family, employment, and government and economic
policy (Beneria, 2003; Chang & Ling, 2003; Eschle,
2004; Hooyman & Gonyea, 1997). Nussbaum
(2002), in her well-framed essay Long-Term Care
and Social Justice, reminded us that caring is considered women’s work and, although necessary for
society, is poorly compensated (if at all) and undervalued. In devoting time to caregiving, women are
hindered in education, employment, and political
participation. Noting an ‘‘acute’’ lack of justice in
long-term care, Nussbaum stated that ‘‘care must be
supplied to those who need it, without exploiting
the givers of care . . . at present, in all nations of the
world, this difﬁcult social problem has not been
solved’’ (p. 39). Moghadam (1999), in turn, is a
globalization scholar who has examined the socialgender effects of globalization with attention to their
contradictory effects on immigrant women in the
workforce. For good or bad, Moghadam argued,
women’s involvement in the global economy has
modiﬁed gender relations and ideologies, ‘‘leading to
the co-existence of both vulnerabilities and sources
of empowerment for immigrant women in home,
work, and community settings’’ (p. 386). Borrowing
ideas from Moghadam and other scholars, we
discuss three thematic areas and their relationships
to the international trends of population aging,
globalization, and immigration that have import for
the long-term-care workforce. These are world
poverty and economic inequalities, the feminization
and colorization of labor, and empowerment and
women’s rights.

World Poverty and Economic Inequalities
World poverty and inequalities sharply inﬂuence
the consequences of global aging and increasing
demands for DLTC workers (Arya & Roy, 2006;
George, 2005; Tulchin & Bland, 2005). Internationally, the risk and prevalence of women’s world poverty and desire for social and legal rights will
continue to fuel the increase in their motivation for
migration and for work. And although some women
migrants are educated, others with limited skills
work as domestics, in textiles, and in long-term
care. The world’s situation, however sobering, may
The Gerontologist

appear at ﬁrst glance to have a silver lining for those
in developed nations seeking to hire DLTC workers.
Migration, as we have discussed, is a povertyreduction strategy that allows DLTC immigrant
workers to send money home in the form of international remittances; this may be the most effective or
only way to improve the lives of their families.
Living austerely as immigrants, many immigrants
hope to return home to a better life made possible
through their savings. However, the migration of
nurses, nurse aides, and other long-term-care workers, who are primarily women, leaves serious health
care shortages in source countries like the Philippines
(Laquian, 2005).
Would improvements in the economies of source
countries lessen migratory trends? Changes in land
ownership laws in Nigeria and Rwanda now allow
women to inherit land. Women in Bangladesh enjoy
expanded employment opportunities due to the
growth of the export garment industry and have
organized labor unions to strengthen their bargaining power (United Nations, 2005). The Grameen
Micro-Credit Bank in rural Bangladesh is another
positive example. Gender at Work, a knowledgeand capacity-building network for women, cites
examples in India, South Africa, and Latin America
of strategic interventions developed to provide for
better accountability to protect women’s economic
interests (Rao & Kelleher, 2003). This is good news,
but it nonetheless exposes the fact that when conditions within source countries improve, the need and
drive to migrate may diminish.

because of their cultural values to respect and care
for elders. Conservative theorists have posed the
comparable argument that Filipinas are natural nurturers in order to describe women’s similar natural
roles as unpaid caregivers in most male-dominated
societies. In the end, this argument may legitimize
the low pay of DLTC workers by arguing that it is
the nature of women and of certain cultural groups
to provide this work. In contrast, evidence suggests
that many migrant women choose care occupations
because globalization, international economies,
training opportunities, and immigration policy
encourage them in this direction (Oxman-Martinez
et al., 2004; Tung, 2000).
Economic pressures intersect with gender and
cultural expectations to increase migrant women’s
vulnerability to employment exploitation (Chang &
Ling, 2003; Espiritu, 1999; Hagan, 2004; OxmanMartinez et al., 2004; Parrenas, 2001; United
Nations, 2005). Migrant women working as carers
are especially vulnerable to exploitation because
domestic service is often paid under the table and, as
such, local labor laws may not be enforced (Pratt,
1999). Sexual exploitation is not unusual; workers
talk of ‘‘laying down’’ or being ‘‘laid off’’ (Sharma,
2003). Unfortunately, women subject to abusive
employment practices may ﬁnd that supply governments are reluctant to intervene because of their
dependence on overseas worker remittances (Pyle &
Ward, 2003). At the same time, labor market restructuring is developing foreign employment situations
in which immigrants and immigrant women are
denied rights or entitlements of citizenship in some
demand (destination) countries (Oxman-Martinez
et al., 2004; Sharma, 2003). At a microanalysis
level we wonder: Who is responsible for immigrant
women’s social and economic well-being? And at
a more macro level we ask: Do developed nations
owe a debt to those nations whose workers migrate
after receiving health-related training? Who should
pay this debt? A World Health Organization (2002)
report posed this question: ‘‘Is it reasonable to ask
if the multinational corporations that depend on the
natural and human resources in developing countries
have a responsibility to ﬁll the gaps in caregiving
they help to create?’’ (p. x).

Feminization and Colorization of Labor
Occupational segregation by gender and race is an
institutional feature of the U.S. workforce overall,
and long-term care is but one example. In the United
States and other nations, eldercare remains the
charge of women, either as unpaid caregivers or as
low-wage DLTC workers (Friedland, 2004; Stone,
2001). In both developed and developing nations,
a gender-speciﬁc labor supply is produced by gender
and cultural norms and stereotypes, through which
certain occupations, such as nursing, are deﬁned as
more suitable for women. Gender-speciﬁc expectations further encourage immigrant women to send
money back to families via remittances. The present
anti-immigration stance of some Americans also may
contribute to the devaluation of eldercare as a profession, as eldercare so often employs immigrant
women. These factors help maintain relatively low
wages for DLTC workers.
Returning to the case of Filipinas as DLTC
workers, research in ethnogeriatrics has explored cultural values that support family caregiving (Braun &
Browne, 1998; McBride & Parreno, 1996). Findings
can be misconstrued to suggest that women in some
cultural groups, like Filipinas, are natural caregivers
Vol. 48, No. 1, 2008

Empowerment and Women’s Rights
Low pay is but one consequence for migrant
women of being employed in gender-speciﬁc work
(United Nations, 2005). Another may be enhanced
autonomy and empowerment. Nonetheless, and as
we show in Figure 1, empowerment and women’s
rights hold different implications for women in developed and developing nations. Studies have found
that immigrant women choose DLTC work because
it allows them to care for their own families, calling
for a greater theoretical understanding of the com21

plex ways in which home and family are situated
differently by groups of women (Browne et al., 2007;
Collins, 1991; Parrenas, 2001).
Although increasing scholarship and policies have
focused on the provision of cultural competence for
the consumer, limited attention has examined the
need for cultural sensitivities for the DLTC worker
from other nations. Immigrant workers face numerous issues related to acculturation that inﬂuence
their integration into the DLTC workforce and U.S.
society (Hoppe, 2005). Prejudices and discriminatory
behaviors and attitudes based on nationality, race/
ethnicity, class, gender, and other sociodemographic
factors exist in the greater community, and it would
be naı¨ve to think they disappear in the long-termcare setting (Aronson & Neysmith, 1996).
Parker and colleagues (Better Jobs, Better Care,
2006b) identiﬁed a number of problems related to
diversity among staff and residents in long-term care,
such as difﬁculties with communication, discriminatory attitudes and behaviors, and organizational
nonresponse to these problems. Varied cultural competency interventions were implemented and evaluated, with the results linking training to beneﬁcial
effects on employee attitudes. The authors argued
that cultural competence training be mandated for
all staff (including supervisors) and residents and its
delivery monitored by government.
From a strengths perspective, programs that serve
older adults may well ﬁnd that immigrant women, in
contributing to the diversity of their workforce, can
be resources in program delivery, training, and
marketing. By 2050, 1 of every 4 older adults in the
United States will be a member of an ethnic minority
group (U.S. Department of State and U.S. DHHS,
2007). As the nation’s aged population and those who
work in DLTC become more ethnically and culturally diverse, the potential exists for each to teach the
other about cultural awareness. Although few would
argue against continuing education for eldercare
workers or the protection of their legal rights, worker
empowerment may lead to increased awareness of
opportunities to choose another career or work path
as long as DLTC work is poorly paying and stressful.

Practice, Policy, and Research Implications
For elderly citizens to have access to a quality
long-term-care workforce, the work must adequately
compensate and protect those who provide it. The
issue of compensation is especially critical for
immigrant women who are working not only for
themselves but for their families back home. In all,
22 states have enacted the wage pass-through—
a new policy strategy that allocates additional
Medicaid funds to pay for higher DLTC staff wages.
Data on the effectiveness of this policy are not yet
available, and decisions that individual states are
making about amount the size of the salary increase,
22

to whom it is targeted, and accountability systems
will likely yield different results across states (PHI,
2003). In addition to increased wages, other retention factors include health care beneﬁts, opportunities for career advancement, education about
legal rights, and respectful working conditions
(Better Jobs, Better Care, 2006a; George, 2005). An
international analysis can suggest new policy directions for the United States. For example, Canada’s
government-sponsored Live-in-Caregiver Program
facilitates the migration of workers who live with
and provide care to a child, an elder, or a disabled
person in a government-approved home. The government provides a valid work permit to those eligible,
and workers may apply for permanent residency
after 2 years with the same employer. Although the
program has its supporters, Oxman-Martinez and
colleagues (2004) suggested that the program’s
requirements tie workers to a single employer for 2
years, making them vulnerable to exploitation and
abuse.
In the United States, a new pilot program of the
Department of Labor aims to provide career advancement opportunities via a nursing career ladder
that will link nurse aides to apprenticeships, community colleges, and professional nursing programs
(Chao, 2007). The passage of the Workforce Investment Act of 1998 also aims to provide DLTC
workers with career opportunities for higher wages
and career advancement by connecting workforce
training and development to local and regional
engines of economic growth (Better Jobs, Better
Care, 2006a; Health Workforce Solutions, 2006).
Both offer the potential for better work conditions
and opportunities for some immigrant DLTC workers. Creating safe and respectful working conditions
for these women also requires knowledge about
their legal rights and freedom from prejudice and
discrimination in the work setting and beyond
(American Health Care Association, 2005; Lowell &
Gerova, 2004). The need for legal education and
training in cultural competence, then, must be a twoway street—both the worker and the consumer will
beneﬁt from knowledge on rights and responsibilities
of all workers and increased sensitivities to diversity.
Employers in both public and private long-term-care
organizations must balance their need to recruit
good workers with a consideration of the rights
(e.g., to a comfortable wage) of those who provide
this care.
Macrolevel issues include fairness and unresolved
policy issues around questions of global social justice
for both source and destination nations. There may
be a lack of consensus regarding some of these issues,
and the dictating of policies may be premature.
Nonetheless, we join scholars like Redfoot and
Houser (2005) in raising a number of research
questions that raise our awareness and deserve our
attention. For developing nations such as the Philippines, we ask about the social costs of this migraThe Gerontologist

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tory pattern on workers’ young children and elderly
parents who remain in the source nation. Should
migration policy allow source countries to reduce
their capacity to deliver equitable and accessible
health services? And to what extent will these
migratory patterns jeopardize future generations of
citizens in these source countries? For developed
countries like the United States, can salaries and
beneﬁts for all DLTC workers be increased, and, if
they are, will others (men and women) enter this
profession? Will labor shortages cease to exist? And
how much will increased salaries impact the already
high costs of long-term care? Should destination
countries impose regulations on recruiters who
seek DLTC workers from source nations? And,
ﬁnally, do developed nations who beneﬁt from
securing these workers from developing nations
have a responsibility to address the health care
problems of the countries that are losing these
workers? Most important, more data are needed on
foreign-born DLTC workers, especially those working in home settings where conditions are hard to
monitor.
Conclusion
In this article, we examined the potential impact
of international trends around population aging,
globalization, and women’s migration on the DLTC
workforce. We presented evidence that the increase
in the aging population is unprecedented and global,
that world poverty and immigration are on the rise,
and that the need for DLTC workers is increasing.
We suggest that researchers continue to critically
consider our present strategy of relying on compensatory migration, primarily of women, given these
global trends. We raised questions in three thematic
areas—world poverty and economic inequalities, the
feminization and colorization of labor, and empowerment and women’s rights—suggesting avenues for
practice, policy, and research. In the end, and regardless of the nativity of eldercare providers, it is in each
nation’s best interest to acknowledge that long-term
care has become a global issue and that dignity and
caring belong on both sides of the equation.

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Received January 17, 2007
Accepted May 10, 2007
Decision Editor: William J. McAuley, PhD

The Gerontologist

