Research on Working Conditions and Immigrant Health Elena Ronda M.D., M.P.H., Ph.D. Associate Professor, University of Alicante Principal Investigator, Centre for Research on Occupational Health Co-Chair CIBERESP Summer Institute on Migration and Global Health June, 2015

To introduce the relationships between migration, working and employment conditions, and health and discuss some important and practical concepts related to the challenges faced by researchers. GOAL OF THE WORKSHOP:

Immigration is an global phenomenon One of the largest drivers for immigration is work and economic opportunity. Entry into the labour market is not easy for migrants, and they tend to occupy low-qualified, high-risk jobs, although often their education and work experience would qualify them to work in better posts with better contractual conditions (“3D jobs”: “dirty, demanding and dangerous”): health implications IMMIGRATION, WORK AND HEALTH ILO has estimated that there are million immigrants of economically active age worldwide

The beginning of a project in occupational health: demographic change 8 million jobs were generated (2.5 million were filled by foreign workers). 76% of male migrants were employed in construction and services, while the large majority of women were employed in services (89%)

ITSAL (Spain) Project Articles published (1990 and 2005) (n=48) Most articles on occupational health in immigrant workers came from countries with a long history of migration (Australia, Canada and the United States) (80%) Only 8% came from European countries (Sweden, Italy and Germany): HIGHER RATES OF FATAL AND NON-FATAL OCCUPATIONAL INJURIES AND WORK-RELATED PROBLEMS IN MIGRANTS COMPARED TO NATIVES Common explanations: 1.Assignment of more hazardous tasks to immigrant workers 2.Failure of employers to invest in safety training and equipment 3.Greater risk-taking by immigrant workers 4.Reluctance to complain about unsafe conditions by those with precarious jobs.

1 st case-study. It is You are in charge of designing a research project to assess the health of immigrant workers in Spain: 1.Propose the main topics that you would include 2.Think about the most appropriate design 3.Which groups of migrants would you include? 4.Which definition of migrant would you use? 10 minutes work in groups…

Inmigración Trabajo y Salud: ITSAL (Spain) Project Starting in 2005: the general objectives were to analyze employment and working conditions in immigrant workers and relationships with their health. Funded by the Fondo de Investigación Sanitaria. Instituto de Salud Carlos III in 2005 (PI050497,PI052202, PI052334), in 2006 (PI061701), and in 2007 (PI )

Causal Model in Occupational Health Living Conditions: family and social relations, housing, mobility, etc. Working Conditions: workplaces, equipment, subtances and materials, tasks, organization. Employment conditions : sector and occupation, wages, contract, working hours. Politics, resources, care and preventive activities Job Market Social Protection Productive Structure Behaviours (ppe, smoking…) Wellbeing injuries Illnesses Disabilities Wellbeing injuries Illnesses Disabilities Meso (firms) Micro (workers) Macro (Governments)

Sub study 1: Secondary data analysis Analysis of occupational injuries Sub study 1: Secondary data analysis Analysis of occupational injuries Sub study 2: Qualitative study Interview and focus groups (n=158) Sub study 2: Qualitative study Interview and focus groups (n=158) Sub study 3: Epidemiologic study Migrant workers : n= 2434 Spanish workers: n= 509 Sub study 3: Epidemiologic study Migrant workers : n= 2434 Spanish workers: n= 509 ITSAL Project ( )

Sub study 1: Secondary data analysis Analysis of occupational injuries: work injuries statistics and working conditions survey Sub study 1: Secondary data analysis Analysis of occupational injuries: work injuries statistics and working conditions survey Sub study 2: Qualitative study Interviews and focus groups (n=158) Sub study 3: Epidemiologic study Migrant workers : n= 2434 Spanish workers: n= 509 ITSAL Project ( )

aOR: Adjusted OR by sex, age, educative level, job situation, type of contract, sector and occupation. Adjusted OR of self-reported occupational injuries by country of origin, Spain, 2008 (n=10,927 ) Occupational injuries: injury occurring at work that was serious enough to require time off or medical care

Sub study 1: Secondary data analysis Analysis of occupational injuries Sub study 2: Qualitative study: focus groups and in-depth interviews with 158 documented/undocumented foreign-born workers from Colombia, Ecuador, Morocco, Romania and Sub-Saharan Africa Sub study 3: Epidemiologic study Migrant workers : n= 2434 Spanish workers: n= 509 ITSAL Project ( )

ITSAL Project: Methods Immigrant worker definition: 1.Not Spanish citizens and not married to a native Spaniard 2.Not athletes, artists, graduate students or high-level executives 3.Residing in Spain for more than 1 year 4.Worked more than 3 months in Spain (with or without a contract) 5.Level of Spanish to understand the survey or focus group 6.Born in Ecuador, Colombia, Romania and Morocco (more than 70%) Population sampling: Convenience sample segmented by sex, residency (cities), country of origin, and documentation status Interviewed in their meeting places (call centers, coffee shops, NGOs, employment or regularization queues (lines), town squares, etc.

Immigrant workers present greater health vulnerability than native workers, as a consequence of their economic needs, job insecurity, legal status, increased job hazards exposure, and lack of knowledge of their rights and resources. Immigrant women workers are a vulnerable group, especially if they work in domestic services. Immigrant workers experience discrimination and have little capacity to influence their working and employment conditions. Some results from the qualitative ITSAL

Sub study 1: Secondary data analysis Analysis of occupational injuries Sub study 2: Qualitative study Interviews and focus groups (n=158) Sub study 3: Epidemiologic study Based on a convenience sample using a questionnaire (74 items) of 2,434 interviewees from Colombia, Ecuador, Morocco and Romania. A complementary convenience sample of 509 Spanish workers between 20 and 40 years from the same cities and in neighborhoods. Sub study 3: Epidemiologic study Based on a convenience sample using a questionnaire (74 items) of 2,434 interviewees from Colombia, Ecuador, Morocco and Romania. A complementary convenience sample of 509 Spanish workers between 20 and 40 years from the same cities and in neighborhoods. ITSAL Project ( )

Complex interactions among legal status, type of contract, and time living in the country. The worst health outcomes were observed in documented immigrants without job contracts and living more than 3 years in Spain. Women immigrant workers, especially in domestic services, have the highest exposure to adverse working conditions. Immigrant workers show a higher risk of sickness presenteeism. Some results from the quantitative ITSAL

Comparison of Sickness Presenteeism between Foreign- born and Spanish born workers by different variables ORcIC95%ORa**IC95%ORcIC95%ORa**IC95%ORcIC95%ORa**IC95% Sex Males Females Age (years) Educative level Without studies/Primary studies Secundary Universitary Type of contract Permanent Temporaty No contract Income last 3 months* <= > N.A Total Foreign-born and time in Spain >= 2 yearsForeign-born and time in Spain < 2 yearsVariables Sickness presenteeism Foreign-born Presenteeism: “going to work in ill health or with a medical condition that would require sick leave”

1.A clear and operative definition of immigrant worker must be adopted. 2.Legal status, type of contract and time in the country are key variables to explaining the association between work and health, and they must be properly collected in any survey. 3.Given difficulties accessing the immigrant population (hard-to-reach groups), convenience samples, carried out by trained (immigrant) interviewers, might be the best way to survey immigrant workers. Some lessons from the ITSAL Project

ITSAL II: From the boom to the crisis Source: Spanish Labor Force Survey % Wage variation ( )

Emerging research questions What happens with the migrants who come to Spain to work? How is the economic crisis affecting these workers?

2 nd case-study. Based on ITSAL I, What do you think is the best approach to this new scenario? (study design, immigrant definition, methodology etc.)

ITSAL I To analyze working and employment conditions of immigrants and their relation to health ITSAL II To analyze how the economic crisis has affected immigrants’ working and employment and the impact on health ITSAL Project

ITSAL Project ( ) Sub study 5: Qualitative study Interview and focus groups (n=158) Sub study 5: Qualitative study Interview and focus groups (n=158) Sub study 6: Epidemiologic study Re-contact through telephone Sub study 6: Epidemiologic study Re-contact through telephone

Method: Study design and participants 1.Six focus groups (3 men and 3 women) n= 44 participants: Colombia, Ecuador, Morocco 2.Two semi-structured interviewers: key informant working with Romanian Associations 3.Theoretical sample design National group with substantial presence in Spain. Time of residence since 2007 minimum Employment status (employed and unemployed)

Decreased employment opportunities and lower salaries Reduced health and safety measures The most frequent health-related complaint are related to mental health problems which impact on their physical health, leading to diffuse pain, headaches and gastric discomfort, and the practice of self-medication to cope with the situation Increase in presenteeism

ITSAL Project ( ) Sub study 5: Qualitative study Interview and focus groups (n=158) Sub study 5: Qualitative study Interview and focus groups (n=158) Sub study 6: Epidemiologic study Re-contact through telephone Sub study 6: Epidemiologic study Re-contact through telephone

t0t0 t1t1 3 years ITSAL I (2008) ITSAL II (2011) n = 2434n = 318 ITSAL Project Survey design: Follow-up survey n= 1129

Increased PMH among those who: lost their employment (ORa=3,62; IC 95%: 1,64-7,96) Increased number of working hours(ORa=2,35;IC95%:1,02-5,44) Mensual salary decreased (ORa=13,61 IC 95%:1,49-124,35) Continue to have irregular status (ORa=36,59; IC 95%:2,47-541,17) Decreased PMH among those who became affiliated to social security (ORa=0,10; IC 95%: 0,02-0,48)

3rd case-study. 1.What do you think is the best way to transfer these research results? 2.To whom should they be transferred?

Immigrant CBOs: Their experience with ITSAL results and need to follow this topic For Community-based Organizations:

Seminar and Policy Briefing at the Ministry of Health Madrid, 2011 For Policy Makers:

EPICOH 2011: Minisymposium on Migration and Occupational Health For Researchers:

Thank you For more information about the ITSAL Project: