Occupational Health Challenges for Immigrant Workers
Summary and Keywords
Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.
Introduction: Migrants and Migrations
According to the International Organization for Migration (2015b), a migrant is
any person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is.
Directional distinctions are made depending on the location of the speaker; an emigrant is a person who leaves the place of the speaker for another, while an immigrant is a person who arrives to settle where the speaker is from another place.
Because migration is necessarily tied to place and perspective, terminology related to the circumstances that drive migration (e.g., labor migration, forced migration) and the type of movement (internal or cross-national border) in documentation on the subject varies by the circumstances described. For instance, a large volume of the published research on the health of foreign-born workers comes from the United States, Canada, and western and southern Europe, places that have long-standing status as countries that receive migrants (Moyce & Schenker, 2018). Literature about the circumstances of foreign-born laborers in the Middle East is growing. In both literatures, the term “immigrant” is most commonly used. In other parts of the world, however, large internal human movements mean the most relevant “newcomer” groups are native-born; for instance, in China, massive rural–urban migration is the focus of migrant occupational health literature (Mou, Griffiths, Fong, & Dawes, 2013). Here, the term “migrant” is used to refer to all possible motivations for and types of human movement for several reasons. First, people in a variety of circumstances may find themselves working in a new place of residence, making consideration of their specific occupational safety and health (OSH) needs important. Second, human movement is often complex, multifaceted, and embedded in sociopolitical and historical context, and migrant trajectories frequently involve both transnational and internal movement (King & Skeldon, 2010; Schapendonk & Steel, 2014). Considering all forms of movement allows the recognition of blurred reality and the relevance it may have for occupational well-being but does not impede greater specificity as needed. In keeping with this thinking, in order to recognize that terms like “migrant” and “immigrant” may hold specific local and legal meanings, when a more specific term is pertinent, that term is used.
The number of people living in a country other than the one in which they were born reached the highest numbers on record in the first few decades of the 21st century, and human movement has grown substantially in certain regional flow areas and, particularly, between countries of the Global South (International Labour Organization, 2015). Overall numbers have been on the rise since 1990, when United Nations Population Division estimates put the number of people living outside their origin country at 152,542,373; 2017 estimates at mid-year suggest the number had grown to 257,715,425. Because total population is also growing, however, the proportion of the world population that is migrant has been relatively stable, hovering around 3% (International Organization for Migration, 2015). If numbers of international and internal migrants are combined—that is, all people who have moved—one in every seven people worldwide falls under this classification (International Organization for Migration, 2015).
The majority of migrants definable as labor migrants are found in the wealthy economic regions of North America and Europe, excluding eastern Europe (International Labour Organization, 2015). While the balance is shifting along with changes in migrant flows, most of the published literature on the OSH concerns of migrant workers thus also originates in those global areas. The terminology used to describe migrant workers in the published literature varies considerably by research context, however, and this complicates efforts to succinctly summarize the state of knowledge about OSH concerns for migrant populations. In some research, for example, populations studied are identified with individual-level characteristics or social categories rather than by their migrant or nonmigrant status, though the people studied may also be migrants. For instance, research originating in the United States often uses an ethnic designation present in existing data sources (“Hispanic”) and its subclassifications (e.g., Mexican-American, Chicano, Mexican) in studying migrant people, since many migrants in the United States come from Latin America and the Caribbean (see, e.g., De Anda, 2005). The term “Hispanic,” however, is not synonymous with foreign-born or migrant, so this sort of strategy can make it difficult to understand whether to consider the results of these studies to be about migrant people. Similarly, research in Canada often uses the terms “visible minority” or “linguistic minority” in ways that may cloud the fact that migrants are under study. As these examples highlight, the words “migrant” and “immigrant” encompass a broad variety of people who all have individual and social categories that overlap (e.g., foreign-born, female gender, linguistic minority) and shape the experiences people have both as migrants and as workers in ways that reflect the societal power structures of their sending and receiving locations (Bowleg, 2012). These issues are discussed further in sections on occupational impacts on migrant well-being and future directions for migrant occupational health and safety.
Challenges to summarizing the state of migrant occupational health and safety notwithstanding, the first section provides a brief overview of working conditions and occupational hazards for migrants, along with work-related health impacts. In the second section, a discussion about the challenges, practical and conceptual, that impede progress on work-related health for migrant groups is presented. Recognizing that real progress must be evidence informed, the narrative first highlights difficulties in monitoring and studying the health of migrant populations and trade-offs involved with certain design choices. A discussion of ongoing conceptual tensions involved in acting on the needs of migrant workers follows, and the article ends with priorities for advancing study and action on behalf of the OSH concerns of migrants.
Occupational Safety and Health Concerns for Migrant Workers
Classically speaking, occupational health concerns are conditions in the workplace and hazardous factors to which workers may be exposed in the workplace that can lead to chronic or acute injury, distress, or illness (World Health Organization, n.d.). But work is not only an important physical determinant of health; it is also a social determinant of health for all people, including migrants. To reflect this reality, here the term “work” is used to encompass a variety of factors that are relevant to health, including employment arrangement and conditions, job characteristics and tasks, working conditions, and the ways work is organized. More precise terms are used when pertinent.
Migrants participate in the labor force at higher rates than their nonmigrant counterparts. This is especially true of migrant women relative to women in the receiving locale (International Labour Organization, 2015). High labor force participation makes an understanding of the occupational health concerns of migrant populations especially important.
Descriptions of working conditions for migrant populations often highlight the presence of hazards in the physical environment. In many places in the world, migrant populations are concentrated in specific kinds of work. Jobs in which migrants are highly present, such as agriculture, domestic labor, restaurant and food service, sex work, manufacturing, and outdoor construction and landscaping, are sometimes referred to as “3 D” jobs, meaning dirty, demanding, and dangerous. The work involved in such jobs has characteristics that can result in exposure to heavy physical demand, repetitive ergonomic exertion (Ahonen et al., 2010; Jayaraman, Dropkin, Siby, Alston, & Markowitz, 2011; Neitzel, Krenz, & de Castro, 2014; Siqueira & Roche, 2013), biologic agents (Ford & Chamratrithirong, 2008; Goldenberg et al., 2016; Goldenberg, Shoveller, Ostry, & Koehoorn, 2008) or vectors (Crawshaw et al., 2017), and extremes of temperature and solar exposure (Kearney, Phillips, Allen, Hurtado, & Hsia, 2014). In addition, within the same type of work, migrant people are more likely to report hazardous exposures (Seixas, Blecker, Camp, & Neitzel, 2008) and more onerous work for less pay (Hurtado, Sabbath, Ertel, Buxton, & Berkman, 2012; Reid & Schenker, 2016) than nonmigrant people.
Much of the literature on workplace chemical hazards and migrants is focused on agricultural workers and exposure to pesticides, and this concern is long-standing. Despite laws intended to limit pesticide exposure in many countries, reports suggest that migrant agricultural workers still experience inadequate protection (Anthony, Martin, Avery, & Williams, 2010; Arcury et al., 2014; Esechie & Ibitayo, 2011; Gorman Ng, Stjernberg, Koehoorn, Demers, & Davies, 2011). In decades of the aughts, researchers have increasingly employed biological markers of both exposure to and effects of pesticides, in acute and long-term exposure (Arcury et al., 2010; Bahrami et al., 2017; McCauley, Lasarev, Muniz, Nazar Stewart, & Kisby, 2008; Quandt et al., 2010; Raymer et al., 2014; Robinson et al., 2011; Sunwook, Nussbaum, Quandt, Laurienti, & Arcury, 2016; Thetkathuek, Yenjai, Jaidee, Jaidee, & Sriprapat, 2017). Chemical exposures are not limited to agricultural work, however; they have also been reported in migrant workers employed in construction and manufacturing (Chuang et al., 2008; Lee, Chae, Yi, Im, & Cho, 2015; Pechter, Azaroff, Lopez, & Goldstein-Gelb, 2009; Siqueira & Jansen, 2012; Tan, Teo, & Tseng, 2014) and in domestic labor (Ahonen et al., 2010).
As understanding of the multiple ways the work people do influences their health has grown beyond physical conditions, research on these concerns in migrant groups has also expanded to include the social interactions people have at work and the ways in which work is organized (Fernandes & Pereira, 2016; Panikkar, Brugge, Gute, & Hyatt, 2015; Ronda Perez et al., 2012; Ronda-Perez, Agudelo-Suarez, Lopez-Jacob, Garcia, & Benavides, 2014). For instance, migrant employees may experience more social stressors in the workplace (Hoppe, 2011), such as lack of support or social divisions along ethnic lines (Hviid, Smith, Frydendall, & Flyvholm, 2012); physical, verbal, and sexual abuse (Ahonen et al., 2010; Malhotra et al., 2013); lack of control (Hurtado et al., 2012); and undesirable work schedules (Font, Moncada, Llorens, & Benavides, 2012; Moyce & Schenker, 2018). For a variety of reasons, including difficulty in transferring credentials, language, and stereotyping, migrants also frequently work below their educational level (Agudelo-Suarez et al., 2009) and in jobs where they may have little opportunity to grow in their work (Font et al., 2012). Beyond physical and social circumstances in the workplace itself, there is evidence from a variety of national contexts that migrant workers are also especially likely to be employed in poorer arrangements, such as without a formal contract (Ahonen, Baron, Brosseau, & Vives, 2018; Bover et al., 2015; Moyce & Schenker, 2018), leading them to experience a greater sense of job insecurity (Landsbergis, Grzywacz, & LaMontagne, 2014; Ronda Perez et al., 2012).
While research has made visible the working conditions of migrant workers, other factors have been less well studied. Employment arrangement and quality and work organization are particularly absent, with several exceptions (Porthe, Ahonen, Vázquez, Pope, & Garcia, 2010; Premji, 2018). This may be due, at least in part, to the often implicit assumption that most migrant workers do manual labor, making immediate concerns for safety appear to be the more pressing research need. Regardless, the emphasis in migrant OSH literature has been on physical job demands, physical working conditions, and the potential for acute injury in occupations commonly filled by male migrant workers and from the perspective of public health professionals in the receiving country. This has several important consequences. First, there is no nuanced picture of all the ways in which migrants may work and the ways these might matter for health. Second, the circumstances of migrants in high-income countries are better described in the literature than those of migrants in places in the world with less monitoring and research infrastructure. Third, studies most frequently relate to circumstances in identifiable workplaces associated with more organized monitoring, such as agriculture, industry, and manufacturing. Focus on these areas means that the concerns of service workers are less well described in the literature. Because service work, and especially domestic service work, is dominated by women, this also means that the occupational health circumstances of women migrant workers are insufficiently described. Finally, the positionality of research from the stance of the receiving country limits understandings of the ways in which health and safety concerns in workplaces come to be because it leaves out the social context, as well as experiences and understandings migrants have from their sending countries (Flynn, Castellanos, & Flores-Andrade, 2018; Friis, Yngve, & Persson, 1998; Kasl & Berkman, 1984). Rather than suggesting that OSH concerns for migrants are “imported,” the argument here is that if the stance of researchers does not acknowledge that social interactions in the workplace are shaped by both the sending and receiving contexts, they may miss opportunities to highlight both potential hazards and potential preventive measures that could be taken.
Impacts on Migrant Health and Well-Being
Poor conditions lead to disproportionate representation of migrants in occupational fatality events (Al-Thani et al., 2015; Cha & Cho, 2014; Fitzgerald, Chen, Qu, & Sheff, 2013; Landsbergis et al., 2014; Lopez-Jacob, Ahonen, Garcia, Gil, & Benavides, 2008; Schenker, 2010). This can be true over shorter periods of time being “exposed” to the workplace than native workers (Byler & Robinson, 2018), as researchers in the United States have found. In multiple geographic locations, migrant groups may shoulder a growing burden of fatal injury in high-risk industries even as occupational fatalities are declining for the population as a whole (Mekkodathil, El-Menyar, & Al-Thani, 2016).
While results can be mixed depending on the other variables included (e.g., length of residence, industry, region of origin—see, e.g., Biering, Lander, & Rasmussen, 2017), migrant populations have also been found to suffer a greater burden nonfatal acute injuries (Cha & Cho, 2014; Fitzgerald et al., 2013; Salem, Jaumally, Bayanzay, Khoury, & Torkaman, 2013; Schenker, 2010; Tiagi, 2016). In addition, researchers have examined specific forms of injury, such as occupational eye trauma (Ngo & Leo, 2008), general trauma (Al-Thani et al., 2015), and heat-related events (Hansen, Bi, Saniotis, & Nitschke, 2013), finding them to be frequent outcomes in migrant workers.
Studies that consider a broader definition of migrant work–related well-being are less present in the occupational health and safety literature but nonetheless suggest concerns. Prevalence of disability has been found to be higher in foreign-born members of the Hispanic ethnic population in the United States (Seabury, Terp, & Boden, 2017), many of whom are migrants. Sickness presenteeism has been found to be higher in migrants than in native worker groups (Ronda-Perez et al., 2014) and is probably related to employment arrangements frequently experienced by migrant groups that leave people feeling insecure. Studies suggest migrants also may not use or may not be offered occupational supports, infrastructure, and programs that take various forms in different places but that are meant to rehabilitate and sustain workers who have been injured or become ill as a result of their work. Researchers have reported the troubling combination of barriers to rehabilitation after injury (Cote, 2013) and hurdles to accessing medical treatment (de la Hoz et al., 2008; Jayaraman et al., 2011) and workers’ compensation benefits (de la Hoz et al., 2008; Kosny et al., 2012; Smith, 2012).
None of these factors function in isolation, and multiple health concerns and supports may be present in the employment arrangements and workplaces. (Ahonen, Fujishiro, Cunningham, & Flynn, 2018). For instance, perceived lack of job control has been associated with lower likelihood of reporting pesticide exposure in migrant farmworkers (Levesque & Arif, 2014), and injured migrant agricultural workers in another study were found to be more likely to be depressed than noninjured workers (Ramos, Carlo, Grant, Trinidad, & Correa, 2016). Furthermore, these factors may interact with each other, with social category, and with migrant status in nuanced ways. In one example, using national injury and illness surveillance data, Steege, Baron, Marsh, Menendez, and Myers (2014) found that foreign-born workers were disproportionately likely to be in occupations defined as high risk. However, foreign-born individuals were not at increased risk for occupational fatality or occupational homicide for the time period studied. In a study of hotel room cleaners (Premji & Krause, 2010), the relevance of ethnicity (Hispanic or not Hispanic), English-language status (as first language or not as first language), and nativity (foreign-born or native) was different depending on the outcome—experience of pain, severity, and the likelihood of reporting it. In a final example, in a community-based study of immigrant workers (Panikkar et al., 2012), researchers examined OSH outcomes by country of origin, length of time in the United States, and level of English-language proficiency. The authors found that duration of residence in the United States and English proficiency explained the experience of health risks at a level of statistical significance but that national origin best explained the experience of injury. They thus argued that their results show that it is the combination of national origin (not just migrant status), length of U.S. residence, and English-language proficiency that explain the experience of immigrant workers in their community. Such results point to the need to consider that both work and the experience of migrant status are complex and ought to be considered together for their effects on health (Flynn & Wickramage, 2017; Flynn, Eggerth, & Jacobson, 2015; Porru, Elmetti, & Arici, 2014).
The health and well-being impacts most frequently studied in migrant workers are those for which there is more consistent and available data—namely, occupational injury and use of occupational supports that generate administrative data—with scattered studies on other ways work interacts with health for migrants. This leaves an incomplete understanding of the way in which work impacts the health of migrant people. One place to begin to fill in this hole is to work toward greater understanding of the interaction of various forms of service work and health, since the majority of migrant workers are employed in this sector (International Labour Organization, 2015). Since women are also more likely to be employed in service work, such a focus should also enable a better understanding of the occupational health needs of women migrant workers, which are understudied. A second logical place for emphasis is on mental health, such as intermediate states such as distress or particular states of mental ill health such as depression. Study is also warranted of the ways in which the process of migration and the experience of migrant status may mediate the relationship between work and mental health states. Mental health impacts of work are underresearched, in general, and the same is true for migrant workers. Yet, poor employment conditions and work organization, factors that are prevalent for migrant workers and also in service work, are particularly likely to impact mental health (Benach, Muntaner, Chung, & Benavides, 2010; Benach, Vives, Tarafa, Delclos, & Muntaner, 2016).
Making Progress on Occupational Safety and Health Concerns That Affect Migrants
In order to improve and sustain the work-related health status of migrant groups, a clear and evolving understanding of their specific needs must be gained through systematic inquiry. Workplace hazards, occupational injury, and occupational disease are often tracked in public health surveillance systems, which are assessed regularly in order to monitor trends over time to inform ameliorative action. In addition to tracking for monitoring and action purposes, surveillance data may be used to describe patterns in conditions or outcomes by social or demographic categories, which is often a starting point for the development of research questions and for identification of health inequalities. While quality research and surveillance always present challenges, specific difficulties are present if sources of data aim to adequately identify, recruit, include over time, or monitor the health of migrants.
Challenges to Public Health Surveillance and Research on Migrant Occupational Health
Identifying Migrant Workers
One challenge to adequate understanding of the occupational health circumstances of migrant workers is the degree to which migrants are identifiable as such. Some administrative and other sources of data identify foreign-born individuals or indicate place of origin or residency status. However, other sources of data that might be leveraged for surveillance or research do not include such identifiers, and, as a result, analysts must use other proxy ways to identify possible migrant workers. Such practices carry the risk of developing false equivalencies if proxy terms are used without full discussion of their parameters or drawbacks. For instance, ideas of nativity (foreign-born persons), authorization status (whether cross-border movement fell within or outside of national rules about permissibility), language preferences (groups who speak languages other than the dominant one), ethnicity (characteristics of groups that relate to heritage, religion, customs, and factors other than national origin), and even occupation or job title (categories of labor that are associated with immigrant groups) are often conflated with migrant status itself. The realities of imperfect access to data and people mean that such proxy indicators are often necessary, and reports and studies that use them can provide important information. Nonetheless, when these ideas are muddled or incompletely defined and explained, results may at best be less useful to understanding and intervening upon the circumstances of migrants and at worst may contribute to stereotypes about migrant groups (Cooper et al., 2004).
Understanding the health and safety experiences of migrants through surveillance and research is also difficult because migrants are often highly concentrated in certain occupations. Both practices frequently delineate findings by industry or occupation. Research on migrant workers often focuses on an industry or workplace with a high proportion of migrants, such as agriculture, domestic work, home healthcare, or construction. This strategy is a classic one used in occupational health to define a study population, but in the case of migrant workers it can challenge the focus, findings, and use of the analysis because it is difficult to decide whether to attribute findings to the structure of a given industry, to the nature of the work, or to the characteristics of the migrants. While all of these factors are sure to be relevant, more systematic exploration of context is required to get at where the problem actually is. If such exploration is not conducted, there is a risk of problematizing a whole group of people or inadvertently suggesting that improvements to an industry or type of work are not goals to be pursued. Furthermore, while migrants are often employed in jobs with high physical demand and high likelihood of exposure to dangerous circumstances, higher injury rates cannot all be attributed to employment in dangerous industries or work, because morbidity and mortality even within the same industries is sometimes higher for immigrants (Schenker, 2010).
Population-based approaches to research on migrant occupational health come with additional specific challenges. Migrant groups are in general thought to be hard to reach for research studies for reasons that include small numbers within the larger population, geographic dispersion, or sociopolitical circumstances that cause them to be invisible to research or wish to remain hidden out of fear. The migrant research literature highlights the difficulties involved in finding, sampling, recruiting, and maintaining contact with migrant populations for the duration of a study.
For quantitative, population-based studies, a random probability sample provides the greatest assurance that the people sampled for the study represent the broader population from which they are drawn along lines of factors that are important to the study questions. Various enumerations of populations are used to draw a random sample. In some places, population censuses and registries are available that document names, addresses, and other important social and demographic data for the entire population. If indicators of migrant status or plausible migrant status are present in those registries, they may be used to draw a probability sample of individuals or households to contact for recruitment (Reiss et al., 2014). Other times, researchers use a more specific population from which to draw a sample, such as patients in a given health system, lists of people with a certain health condition, or people associated with given schools or workplaces. But in many places, such data are highly sensitive or simply not available, especially in areas that are less accustomed to being destinations for immigrants (Martinez, McClure, Eddy, Ruth, & Hyers, 2012). As such, perhaps the most frequently mentioned problem in quantitative research with migrant populations is the lack of an adequate enumeration of the target population from which to draw a probability sample and provide some level of assurance that estimates of study outcomes will reasonably represent the population from which the sample is drawn.
Connection to the target population can be further complicated by both geographic (physical dispersion of migrants) and social distance between the population and researchers. Social distance may take many forms, which can impact connection and trust between researchers and potential participants. Factors such as differing language preferences, religious or nonreligious practices, levels of education, and others can exacerbate power differentials that are always present in research involving people.
As a result of these difficulties, many researchers use quasi-probability sampling, where sampling occurs in two phases, one of which involves random selection and the other some form of quota sampling (Lavange et al., 2010), or nonprobability sampling, particularly convenience snowball or chain sampling, wherein initial contacts are established with the target population or with gatekeepers and those initial contacts help to recruit subsequent study participants until the predetermined sample size is reached or the entire network of the target population is sampled (Johnston & Malekinejad, 2014). While these forms of recruitment can assure contact with the most hidden members of a target population that random sampling may miss, they can result in bias because certain subgroups may be over- or underrepresented depending on how connected or inclined to participate they are, though they may be useful for preliminary studies (Lopez-Class, Cubbins, & Loving, 2016).
Over time, as research on migrant populations and health has grown, researchers have devised alternative sampling strategies for quantitatively oriented studies when full enumeration of a sampling frame is not possible, including projected convenience samples with street-intercept recruitment (Delclos, Benavides, García, López-Jacob, & Ronda, 2011) or respondent-driven or network sampling (Johnston & Malekinejad, 2014), strategies that sample based on venues migrants frequent (Muhib et al., 2001), and complex, multiphase sampling (Kamel et al., 2001; Lavange et al., 2010).
These challenges and the strategies for overcoming them apply to all studies that aim to include migrants and are not specific to occupationally focused ones. In fact, migrant research and OSH research are largely separate endeavors, and much of the migrant research fails to consider the impact that work may have on migrant health at all. In turn, OSH literature concerning migrants also tends to skirt the ways in which the broader experience of being a migrant takes shape both in and out of work and relates to health. The implications for OSH research thus extend beyond concerns about representation and generalizability for migrant health studies described to include the implications that design and sample choices have for the use of the results of applied OSH research. For instance, if people are recruited into a study that intends to examine relationships between work and health from a general population, it is likely that the migrant workers in that population will do a variety of types of work under different employment and working conditions. While such a reality may help elucidate the origins of migrant health inequalities and inform possibilities for general social and policy intervention that will better support migrant workers, it also means that developing appropriate workplace-based interventions will be more difficult because of the different employment and work realities represented. Conversely, recruiting migrants into an industry- or workplace-based study will provide detailed understandings of the circumstances migrants face in that sort of work but may be less useful to inform broader population-based social policy.
Other Phases and Types of Research
If barriers to design and sampling are well known, they are not the end of the challenges to research with migrant groups. Further methodologic challenges that apply equally to qualitative and mixed-method designs include barriers that inhibit participation at the level of the target population, including lack of familiarity with research; limitations to participant time; difficulties with transportation (Katigbak, Foley, Robert, & Hutchinson, 2016); language limitations on the part of study staff; inadequate or inappropriate communication across phases of the study that limits retention; and mistrust. Factors above the level of individual participants or researchers include the existence of institutionalized racism and discrimination against ethnic or foreign-born people and lack of ethnic and national diversity among researchers at the societal level, which may exacerbate study challenges if there is a mismatch in values between the researcher background and the values of the studied population (Katigbak et al., 2016). Several large cohort studies have allowed scholars to highlight, discuss, and summarize successful strategies to overcome barriers to participation for each phase of research: recruiting, enrolling, and retaining participants through the duration of a study (De La Rosa, Babino, Rosario, Martinez, & Aijaz, 2012; Lopez-Class et al., 2016). Even before recruitment begins, several researchers suggest that efforts should be made to address potential mistrust of research, limit the distance between researchers and participants, and tailor research tools and staff to the specifics of the participants being studied. Successful strategies include research team participation and presence in existing community events, developing data collection tools with input from the participant community, and choosing and training field staff with subgroup, gender, and language and idiom diversity at the forefront. Because concerns may appear at any phases of research, a standing community advisory group is a recognized way to center dialogue between researchers and participants across the research endeavor (De La Rosa et al., 2012; Lopez-Class et al., 2016).
Investigators have used various strategies for making contact with the participant community, including word-of-mouth individually and through community-based social service or health agencies, fliers posted in places frequented by the participant group, and mailings with follow-up telephone calls or home visits. While in-person strategies seem to be most effective (Reiss et al., 2014), especially if enrollment is possible at first contact with a member of the target research population, researchers have also suggested that the existence of a range of strategies provides a broader level of community awareness about the study that may encourage participation. Once recruitment is underway, investigators should continue to attend to issues of mistrust and power dynamics, personalize recruitment materials and pitches to the individual potential participant, and emphasize and promote the aspects of belonging and contribution to the collective that can come through participation in research (De La Rosa et al., 2012; Lopez-Class et al., 2016).
Complex challenges to participation are typical of migrant studies and apply equally to research studies that adopt quantitative, qualitative, and mixed-method designs. But these challenges may be particularly difficult to overcome for researchers trained in clinical or technical aspects of OSH, because such training may have placed less emphasis on socially constructed power dynamics, social science research design, or community-based research strategies. However, this reality may provide impetus for collaboration among social scientists, community health researchers, clinicians, and OSH researchers that has the potential to enrich understandings of the influences of both migration and work on health through a variety of pathways.
Conceptual Tensions in Acting Upon Identified Migrant Needs
Surveillance and research on the experiences and needs of migrant workers is a basic part of providing appropriate support for migrant well-being. But much like conceptual and practical challenges to monitoring and understanding the influences of work on the health status of migrant workers, there are tensions to be balanced inherent in addressing needs that may be identified. The place that migrant workers occupy in broader populations, and the implications of that placement for intervention, are chief among them.
How migrants are considered to fit within the population in a broader public health sense is an important issue to consider. Much discussion of supports for migrant groups treats them as a special subpopulation within the overall population. There may be good reason for this stance, given that migration itself has implications for health and the experience of migrants in a new location may be economically, politically, legally, and socially distinct from the nonmigrant population; all of these differences of experience can matter to health (Zion, Briskman, & Loff, 2010). Difference of experiences notwithstanding, an insistence on difference through research and subsequent interventions—the “special populations” approach—in the name of public health may also inhibit the ability of migrant groups to be viewed (and to view themselves) as part of the broader population (Hankivsky & Christoffersen, 2008), therefore reinforcing social determinants of health that may disadvantage migrant people. The idea of inclusion is all the more complex when considering the large numbers of migrant minors who, given their age, may grow up and become workers in the receiving country. How long are they migrant special subpopulations, and how do they become part of the general population if they are always viewed separately?
Key to understanding and intervening upon challenges that may particularly burden migrant workers are structural forces that create the conditions under which safe, high-quality employment and work are likely to be available, and to whom (Ahonen & Benavides, 2016). Both work and immigrant status are considered to be social determinants of health—meaning conditions that are determined at a social or structural level and shape health above the domain of individual characteristics (Flynn, Eggerth, & Jacobson, 2015). Several aspects of structural disadvantage may be especially relevant to migrants and to work-related health (Flynn, 2018). Feeling the need to prove oneself and gain security (Landsbergis et al., 2014; Ronda Perez et al., 2012) may lead to migrant workers accepting dubious safety and health circumstances, or even engaging in less than safe behaviors at work (Flynn, 2018). Such behaviors, and the perception of the need for them, are always rooted in a broader context (Smith, Chen, Mustard, Hogg-Johnson, & Tompa, 2015). To illustrate, the distinction between migrants who are authorized to live and work in the receiving country and those who are not may influence the quality of work available to migrant persons in general (Moyce & Schenker, 2018). The influence of the broader context may be related to safety and health concerns, as well as to qualities of work that are health promoting, such as skill use and creative decision-making. Negative stereotypes about migrants that result from factors as varied as appearance (e.g., racialization), views and rules about education and preparation in other nations, and familiarity with the way things work in the receiving country may mean that many have difficulty finding work at the highest level of their ability and training. Work or residential authorization may also be tied—in reality or in perception—to access to other health-supporting resources (e.g., workers’ compensation; social and economic safety net resources). In some areas of the world, unauthorized status is criminalized, which may lead to a lack of empowerment about speaking up to influence occupational and broader social, economic, and personal circumstances.
These realities do not only affect migrant populations. That is, poor employment and working conditions are not migrant-specific, but the forces that distribute groups of people into jobs with perpetually poor conditions may be stronger on migrants if migrant groups lack adequate power and protection. Migrant status is a socially designated status along which the availability of resources can be inequitably sorted (Flynn et al., 2015). While important as part of the pursuit of health equity (Braveman, 2014), a focus on those groups of workers at “high risk” for adverse outcomes could obscure a vision of the roots of that risk. Concerns for health related to work ought to be addressed through the work itself—by making employment arrangements and working conditions safer and more health-supportive and occupational and social supports stronger. Moreover, because migrants are part of broader worker and community populations, poor conditions for immigrant workers undermine conditions for all workers (International Labour Organization, 2016a).
A structural perspective on risks to migrant well-being will also necessitate recognition of the importance of linkages among work and other socially distributed resources and their ties to broader social, economic, and political circumstances as drivers of health. For example, in addition to occupational injury and disease (those conditions that can be tied directly to the work a person does), the work people do can bring with it “nonoccupational” concerns (Ahonen et al., 2018). For instance, access to quality housing and built infrastructure, as well as healthful food and adequate nutrition, are heavily determined by financial resources gained from work. A focus on the structural drivers of health, and how those factors function to determine the employment and working conditions in which migrants find themselves, is central to the ability to make improvements. Work-related vulnerabilities may evolve and accumulate over time in combination with non-work factors, which are nonetheless heavily impacted by work. The ways in which work and non-work-related perspectives on migrant well-being could be enriched with the consideration of migration and work as experiences over time, as sources of both advantage and disadvantage, and as links to larger structures that impact health (Corna, 2013) are considerable. Migrant status itself is unlikely to be the cause of disparate occupational injury and illness in migrants; such a view assumes that all groups of workers find themselves in similar circumstances. Such thinking is a mistake, because, structurally, “things are never equal” (Gron & Knudsen, 2012, p. 96).
Future Directions for Migrant Occupational Health and Safety
The suggestions made here, such as adopting a broad perspective on who is a migrant worker, considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, making careful choices about using a population-based or high-risk perspective, and engaging with the ways in which structural influences act on health through work, whether in research or through workplace or policy intervention, is more a more complex endeavor than taking a more narrow perspective. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the OSH concern in the first place—the characteristics of the work people do. In addition, a broader perspective provides the possibility of uniting people across social and professional disciplinary boundaries behind the common cause of more healthful work for all.
Surveillance and Research
Keeping in mind several ideas would advance the state of surveillance, research, and action in support of migrant worker health and promote an integrated perspective.
• Occupational surveillance systems and monitoring efforts should include details that allow an understanding of migrant OSH, such as the ability to identify people as migrant and socioeconomic status. They should expand the notion of work-related health beyond physical diagnosable diseases. They should also include a broad range of factors related to work (e.g., shifts worked, duration of employment, benefits eligibility), in order to understand areas where further exploration through research may be warranted (Benach, Muntaner, Solar, Santana, & Quinlan, 2010; Friis et al., 1998; National Academies of Sciences, 2018; Kasl & Berkman, 1984).
• Public health and OSH professionals should work to expand monitoring of exposure conditions in the service sector, where the majority of migrants worldwide work, including greater monitoring of mental health.
• Research should engage an interdisciplinary and mixed-methods strategy where appropriate to answer complex questions about the interactions among work, migration and migrant status, and health.
• Research about the OSH of migrant populations should consider broader theories about how health, and health inequalities, are created. This will encourage researchers to look at populations as a whole and articulate the ways in which migrant status may be a social fault line along which uneven accumulation of the causes of injury and ill health accumulate (Masters, Link, & Phelan, 2015).
Evidence from a variety of places and contexts suggest that migrant workers face disadvantage that requires attention and priority (Ahonen & Benavides, 2016). Such attention should frame occupational health challenges broadly, looking beyond exposure to hazards to consider the full range of work’s influences on health. Nuanced research and specific surveillance are necessary to understand where that disadvantage comes from and remedy it as close to the structural drivers as possible. Since migrant workers are part of the broader population of people, strategies should be pursued that improve conditions for all workers, while being especially attentive to the structural sources that create disadvantage for migrant people.
The author thanks Rachel Hinrichs for her efficient and excellent reference support; Kaori Fujishiro for providing clarifying critique on an earlier draft; and two anonymous reviewers whose critiques helped fine-tune the arguments.
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