Migrant workers’ health presents a unique set of challenges for OH practitioners. Tristi Brownett draws on personal experience to offer practical advice.
The number of migrants working in the UK is estimated to be 825,000 (ONS, 2016). Of these, 76.4% come from the EU.
Migrants, although often highly skilled, work in “low-skilled work” such as process operative work in manufacturing, domestic services, hospitality, elementary construction and labouring roles (National Migration Observatory, 2015).
It is generally understood that initially these documented economic migrants are healthy upon arrival (Rechel et al, 2013). However, a combination of social and economic disadvantage, including employment type, are confounding factors that specifically affect them (Robinson and Reeve, 2006).
These aspects become determinants of health, which in the longer term have a negative outcome on wellbeing throughout the life course of migrants (Marmot et al, 2012).
The purpose of this article is to highlight a range of health factors that potentially affect such employees and to consider the role of the occupational health professional in managing these issues. It is written from the perspective of an OH nurse with experience of providing OH support for a predominantly migrant workforce.
Rechel and colleagues (2013) cite evidence indicating that occupational exposures are an important factor specifically affecting migrants’ health and wellbeing.
The author’s own experience is that those working in blue-collar workplaces face particular challenges, which include physical, psychological and emotional injury at work.
To illustrate with an example: language barriers affect personal relationships with colleagues, understanding of safety briefings, influence psychosocial workplace engagement negatively and can result in undetected bullying, where team leaders and managers speak a different language to their teams.
Furthermore, migrants are often willing to do the work that others will not, rendering them vulnerable to a range of stresses (Weishaar, 2008), sometimes injury through taking risks to get the job done (HSE, 2007), and potential exploitation (Janta et al, 2011). Also, people working in low-skilled work often receive low pay with limited or no sick pay. This increases the likelihood that they will present for work even when they are not well enough (Williams, 2013).
Although documented migrants tend to have good health at the point of arrival, when they become unwell, in the author’s experience, they don’t necessarily access healthcare services to address their health need, including sexual health. In England, anyone can register with a GP and does not need to be “ordinarily resident” to have access to a consultation without charge (NHS England, 2015). The recent Immigration Act (2014) affected who can access NHS healthcare and secondary services.
Health services and self-medication
For those living, working and paying taxes in the UK as residents, the NHS in England is available without charge at point of use.
However, anecdotal evidence and a Kings Fund report (2015) suggests that migrants don’t always access these services as much as their UK counterparts. Cultural and language barriers may be a prime contributing factor (Hargreaves et al, 2006).
Additionally, a small-scale UK study identified that the experience of being a migrant in a waiting room can be intimidating (Franks et al, 2007), especially for those experiencing mental health difficulties.
Consequently, migrants, who might also personally experience negative cultural attitudes to their mental ill health, are likely to avoid seeking help.
Employees who are not registered with a GP and who speak poor English have a number of innovative, but not necessarily effective, coping strategies.
In the author’s observations of a large migrant workforce, self-medication using illicit drugs, alcohol, traditional remedies and remedies purchased from the internet, as well as overdosing on analgesics and opioids, appeared to be common practice on a manufacturing site.
The sharing of medication on the production line resulted in a stay in hospital for one employee, with the side effects of cardiac medication she would otherwise not have needed. An additional public health challenge observed in this particular setting is the practice of antibiotics being bought abroad and returned to the UK. These antibiotics appeared to be medicating a range of ailments in some of the workforce, although the illnesses did not necessarily appear to be microbial in nature.
Obviously, side effects notwithstanding, this practice is a potential contributor in the challenge of rising antimicrobial resistance across the globe (Kelesidis et al, 2007; PHE, 2016). The other concern is that these drugs, much like some of the cigarettes observed in that particular workplace, could be counterfeit and potentially harmful (Blackstone et al, 2014; MHRA, 2015).
The author recollects that the local A&E units appeared to bear the brunt of the employees not registered with a GP. The use of emergency rooms seemed to result when minor conditions were ignored or pain deteriorated to such an extent that the person could no longer cope.
Employees often reported that they would prefer to have minor health problems assessed and addressed in the country of origin, where they understood how the local health system operated, how to access it and where they spoke the language fluently to understand how to manage any condition.
Broader social and cultural issues
So far this article may have put the experiences of migrant employees in low-skilled work in a negative light, but the issue deserves greater understanding.
Migrants provide insights into the bigger challenges that they have to overcome. Underuse of employees’ skills is recognised to be a contributory factor to stress.
This has been observed in migrants, particularly those who previously worked as skilled or professional employees prior to migration (Reid, 2012).
Some appear to experience a loss of cultural and personal identity, occasionally coupled with a loss of status (for example, training and working in a role such as nurse or teacher), resulting in low self-worth or cultural bereavement.
The loss of social and support networks can be challenging or isolating, and this is particularly onerous when migrant employees become unwell or have young children or others to care for.
Some employees may bear a double burden, in that they are required to do both paid work and also take responsibility for household chores and childcare or care of family members (Habib and Fathalla, 2012).
Transition to life in the UK can be challenging beyond cultural difference and language barriers. Some migrants report feeling isolation after leaving families behind to come to the UK to work; and they may develop negative coping strategies such as increased alcohol and tobacco use (Carballo et al. 2008).
In the author’s experience, low-paid work and zero hours contracts result in some workers holding more than one job to be certain that they can afford to survive. This potentially results in employees working one shift, before heading straight to another.
Many of these employees will have travelled a distance to reach work. They travel because affordable housing isn’t always in the same area as their work. They sometimes skip meals because they want to make sure that their children eat or bills can be paid.
While a number of these factors apply to all employees in low-paid work, when coupled with aggravating factors such as an inability to communicate, loss of social capital, loss of identity, low self-worth or complex migration histories (for example, escaping war or torture), it is argued that these employees are rendered extremely vulnerable.
Employees may also experience feelings of helplessness or guilt when negative events continue, when they are bereaved, or a natural disaster strikes in their home country (Raphaely and O’Moore, 2010).
Anecdotally, there may be increased crime where low-paid employees live. Anxiety may rise through fear. While working with a large migrant workforce there were three occasions where employees were assaulted, sustained serious head injuries and were robbed in the town where they lived. Each sustained substantial injury, one was hospitalised and experienced complications associated with that type of injury. A wider group experienced fear and anxiety.
Furthermore, throughout July and August 2016, the UK media have reported an increase in hate crimes against migrants since the referendum vote to leave the EU. Again, this highlights additional vulnerabilities and stressors that affect the physical and mental wellbeing of migrant workers.
Migrant workers and the role of OH
These experiences highlight the challenge of managing the good health and wellbeing of employees.
Yet the consequence of these external factors and wider determinants on individual health is further compounded by the biggest of the public health challenges to be overcome in the UK, that of non-communicable diseases (Fenton, 2016).
Migrants often work in an environment where work is predominantly sedentary, and cultural normative behaviour includes smoking tobacco, and drinking strong caffeinated or energy drinks, as well as eating carbohydrate and sugar-rich foods.
Few opportunities are provided to encourage lifestyle adaptions and behaviour change among migrant staff, and the challenge might seem overwhelming for the occupational health professional.
In order to address the health of employees in the broadest context, it is recommended that a psychosocial approach be adopted. This means taking a social history from the employee, and thinking about how their thinking and behaviours might be influenced by social aspects and vice versa.
Take time to build a rapport, use empathy, and develop understanding and insights into the challenges of their lives.
This understanding can help the practitioner build a picture, which may be invaluable when doing a health assessment, but also develops a professional relationship of trust. In the author’s experience, this approach also aided the cessation of human trafficking and slavery in one organisation.
Additional strategies for the occupational health adviser working with migrants in low-skilled work are highlighted below.
- Be patient when communicating. Learn a few key words in the employee’s language such as “hello”, “goodbye” and “thank you”.
- Find out whether or not there are translation services available, to enable you to conduct the interview. Be aware that sometimes employees bring their children to communicate on their behalf. Remember that not only are many work sites unsafe places for children, the presence of children might also inhibit the employee or they might misinterpret information the employee gives the OH practitioner. For these reasons, this is not a recommended strategy.
- Ensure that if an employee brings a colleague from the workplace to translate on their behalf, that they are willing to openly discuss their health in front of them.
- Use leadership to make a business case for English for speakers of other languages (ESOL) courses; it assists safety briefings, retention and productivity (HSE, 2016).
- Try to avoid using Google Translate as this can lengthen consultations and leave both parties very confused.
- Arrange to have key documents translated into the key languages.
- Be confident to refuse to undertake the assessment until suitable arrangements have been put in place to ensure that you and the employee understand each other.
Assessment and referral
- Equip yourself with a range of skills – such as advocacy, objectivity, empowering language, awareness, empathy and sensitivity.
- Acknowledge employees’ survival skills resilience and cultural bereavement; focus on the positives rather than negatives.
- Be aware of exposures from poor social environment – for example, aspergillus fungus in housing, or the risks involved in living in housing of multiple occupation.
- Be aware of environmental and occupational exposures from life before the UK.
- Develop a deeper understanding of particular health issues affecting specific groups – for example, some Eastern Europeans have increased thyroid cancers due to the Chernobyl incident, while helminth infections, such as hydatid disease, are noted in the Middle East.
- Be alert to the possibility that medication taken by the employee may not have been issued by a doctor or pharmacist.
- Understand the influence that culture, faith and religion may have on health beliefs.
- Signpost services, such as cultural cafés and support networks.
- Assist access to healthcare services; if necessary, work with local GPs and CCGs to ensure that suitable services exist for your staff.
- Don’t assume migrant employees have health literacy or are aware of things UK workers take for granted – for example, that smoking is harmful to health.
Working with employers
- Influence management to invest in translators, ad ensure that key services, such as employee assistance programmes (EAPs), are accessible and promoted in the key languages used on site.
- Provide culturally appropriate meals – promote healthy eating and recognise when employees may fast for religious reasons.
- Don’t assume that all employees from the same country are a community or willing to assist.
- Highlight behaviours that implicitly create difference or discriminate, such as written recruitment opportunities or health and safety briefings, only offered in English. This ensures that English speakers with low literacy also have opportunities afforded to them.
Sources of information
- The HSE webpage for migrant workers
- Migrant Help
- Unison provide leaflets in a range of languages about worker rights and responsibilities in UK
General notes for OH practitioners on managing migrant workers’ health
Understandably, in the modern context of OH provision, this process can be difficult where time and communication are both limited, and where the OH practitioner is not necessarily employed within the organisation.
Migrant populations can also be transient, creating a high turnover in the workforce, which can be a symptom of organisational culture, or caused by the availability of better-paid work elsewhere.
In general, be patient, observe workforce trends, avoid jumping to conclusions and use critical self-questioning to understand whether or not you are noticing specific behaviours or patterns.
Act on your findings and talk to the employer, highlighting some of the specific challenges that migrant employees face.
Give objective, evidenced, creative and low-cost solutions to help address the challenges and ensure continuing fitness to work.
MHRA – Medicines and Healthcare Products Regulatory Agency (2015) Press release UK leads the way with £15.8 million seizure in global operation tagrgeting counterfeit and unlicensed medicines and devices. 18 June 2015.
Medicines and Healthcare Products Regulatory Agency (2015). “UK leads the way with £15.8 million seizure in global operation targeting counterfeit and unlicensed medicines and devices”. Press release:18 June 2015.
National Migration Observatory (2015). Briefing: Migrants in the UK labour market – an overview.
NHS England (2015). Patient registration; Standard operating principles for primary medical care (General Practice).
Office of National Statistics (2016) Statistical bulletin: National migration statistics, quarterly report. May 2016.
Public Health England (2016) Antimicrobial resistance (AMR)
Raphaely N and O’Moore E (2010). Understanding the Health Needs of Migrants in the South East Region. London: Health Protection Agency and Department of Health.
Rechel B, Mladovsky P, Ingleby D, Mackenback JP, and McKee M (2013). Health in Europe 5: Migration and health in an increasingly diverse Europe. Lancet, vol.381 (9873), pp.1235-1245.
Reid A (2012). Underuse of migrant skills linked to poorer mental health. Australian and New Zealand Journal of Public Health, vol.36(2), pp.120-125.
Robinson D and Reeve K (2006). Experiences of new immigration at the neighbourhood level. Joseph Rowntree Foundation.
The Kings Fund (2015). Verdict: What do we know about the impact of immigration on the NHS?
Weishaar HB (2008). Consequences of international migration: a qualitative study of Polish migrant workers in Scotland. Public Health, vol.122, pp.1250-1256.
Williams N (2013). The problem with presenteeism. Personnel Today, 5 December 2013.