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Population Health for Nurses

27.4 Migrant Workers

Population Health for Nurses27.4 Migrant Workers

Learning Outcomes

By the end of this section, you should be able to:

  • 27.4.1 Define the term migrant workers.
  • 27.4.2 Discuss the health barriers migrant workers face.
  • 27.4.3 Describe the health needs of the migrant worker population.
  • 27.4.4 Identify the nurse’s role in caring for migrant workers.

According to the World Health Organization (WHO) (2022), millions of migrants worldwide work dangerous, low-skilled jobs and live and work in substandard conditions. Migrant workers are often mobile, moving frequently to locations that offer work, most often in a seasonal pattern. A migrant farmworker, also commonly called a migratory seasonal agricultural worker (MSAW) or mobile worker, is an individual who is required to be absent from a permanent residence to seek paid employment in agricultural work (Migrant Clinicians Network [MCN], 2023b, para 1). In contrast, immigrants lawfully move to another country to live there permanently.

Globally, migration has evolved and changed. Migrants are now working in industries and communities that never before relied on migrant workers, such as Alaskan salmon fisheries or Wisconsin industrial dairy farms (MCN, 2023c). A few migration patterns have emerged: migrants moving back and forth between their home country and country of migrant work; agricultural workers moving frequently within one country following seasonal changes in work opportunities; and new immigrants searching for opportunity and more stable conditions (MCN, 2023c). In 2020, 281 million people were living outside of their country of birth, and in the United States, over 51 million people were born outside of the country (MCN, 2023c).

An estimated 2.9 million farmworkers reside in the United States, a large majority of whom are immigrants. Sixty-three percent of all U.S. agricultural workers were born in Mexico, and 36 percent lack authorized work status (Farmworker Justice, 2023). Education and literacy are limited among farmworkers, who often have an average formal education ending at ninth grade (Farmworker Justice, 2023). Approximately 15 percent of farmworkers travel long distances to find work, some traveling across the U.S.–Mexico border and some in the United States, especially to Florida, Texas, Arizona, and California. Communities of farmworkers have high levels of poverty as few have benefits such as sick leave, paid vacation, unemployment insurance, or health insurance. Despite this poverty, most farmworkers do not receive federal benefits such as food stamps, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), or Medicaid. Women comprise 34 percent of the agricultural workforce and face additional obstacles such as sexual harassment, fear of reporting sexual harassment, and lack of appropriate health care (Farmworker Justice, 2023; National Center for Farmworker Health [NCFH], 2022).

Health Barriers Experienced by Migrant Workers

Migrants are among the most susceptible and overlooked members of society (WHO, 2022). For many reasons, migrant workers have poorer health outcomes than typical individuals in their host communities (WHO, 2022). They often lack access to health and dental care due to economic instability, lack of health insurance, migratory lifestyle, language barriers, cultural differences, geographic location, and a lack of familiarity with the health care system (MCN, 2023a). Because this population tends to move frequently, they often cannot establish a primary care home or develop relationships with providers and nurses, inhibiting their ability to receive appropriate health screenings, education, and follow-up care. Language and cultural differences are also barriers to overall health and dental care. The complexities of navigating unfamiliar health care facilities, policies, and insurance requirements lead some migrant workers to delay care or avoid the system altogether.

Migrant farmworkers in the United States legally can receive health insurance under the ACA and Medicaid if their annual income is below 138 percent of the federal poverty line. Due to farm labor shortages, the United States created the H-2A guest worker program to bring in temporary agricultural workers. In 2021, the U.S. Department of Labor approved 317,619 H-2A visas (NCFH, 2022). Workers with an H-2A visa can receive health insurance under the ACA, but due to their temporary status, employers are not required to provide them with health insurance, so they may need to pay for it themselves. Co-pays and deductibles often present barriers to low-income migratory workers seeking medical care. In 2021, almost 80 percent of MSAWs were considered low-income, with an income at 200 percent of the federal poverty level, and nearly half had no insurance (NCFH, 2021c). Farmworkers in the United States illegally cannot receive health insurance either privately or through the ACA.

The Migrant Health Act of 1962 authorized primary and supplemental health services to migrant and seasonal farmworkers. Today, 177 federally funded Migrant Health Centers (MHCs) are run by either community-based organizations or by governmental entities such as state and local health departments, serving MSAWs and their families. In 2021, there were nine migrant health–only programs in Maine, Massachusetts, North Carolina, South Carolina, Georgia, Minnesota, Kansas, Iowa, and Montana, providing care irrespective of ability to pay (NCFH, 2021c). Despite the availability of MHCs in some geographic regions, economic instability remains a health barrier due to a lack of transportation and the inability to afford to take a day off from work.

Case Reflection

Stories from the Field

Stories from the Field is a collaboration between the nonprofit Farmworker Justice and photojournalist David Bacon that gives farmworkers and their families a voice to talk about their experiences and the challenges they face.

Read Teresa’s story and Ramona’s story, and then respond to the following questions.

  1. What health conditions do Teresa and Ramona experience? How are these conditions related to their work?
  2. In your view, do communities have an ethical duty to do more to protect the rights of these individuals? Why or why not?

Health Needs of Migrant Workers

Hazardous work and living conditions place migrants at risk for adverse health outcomes. In the legal and occupational regulatory systems, a history of agricultural exclusions has resulted in inadequate job protections for farmworkers (MCN, 2023a). The Migrant and Seasonal Agricultural Worker Protection Act (MSPA) of 1983 established employment standards regarding wages, housing, and transportation, among others, but exclusions remain (MCN, 2023a). Health issues occurring more frequently in this population include diabetes, heart disease, arthritis, and TB (MCN, 2023a). Dangerous working conditions often result in musculoskeletal strains, falls, trauma, lacerations, and illnesses related to chemical, pesticide, extreme temperature, and allergen exposures (Figure 27.6) (MCN, 2023b). Workers’ families who travel with them are at increased risk for similar adverse health outcomes. For these reasons, migrant farmworkers have higher morbidity and mortality rates than the majority of the U.S. population (MCN, 2023b).

A group of people bend over in the dirt on a farm. Sweet potatoes are in mounded rows on the top of the soil.
Figure 27.6 These migrant farmworkers harvest sweet potatoes in the fields. Exposure to the hot sun, strenuous manual labor, and pesticides are just a few health risks they face. (credit: Lance Cheung/USDA/Flickr, Public Domain)

Maternal child health care among this population is a considerable health need. Of the estimated 2.5 to 3 million migrant and agricultural workers in the United States, more than 25 percent are women, and more than 50 percent are parents. Studies have found that fewer than half of pregnant agricultural workers accessed prenatal care within the first 3 months of pregnancy compared to 76 percent of women who access prenatal care early nationally. Half of the agricultural worker women monitored gained less weight than recommended during their pregnancies, and close to 24 percent had undesirable birth outcomes (NCFH, 2018).

Barriers to oral health include lack of dental insurance, the cost of dental repair, long travel times to receive dental care, and cultural and linguistic barriers. This has both physical and psychosocial effects. Oral disease is very visible, marking individuals as “second-class citizens” and increasing social exclusion (NCFH, 2018c).

Theory in Action

How Building a Community of Care Can Improve Farmworkers’ Health

This short video highlights the Community of Care program in Southeast Arizona as a way to improve farmworkers’ health.

Watch the video, and then respond to the following questions.

  1. What barriers to accessing health care do the farmworkers experience?
  2. What is the role of the promotoras de salud described in the video? Why are they effective?
  3. In your view, will building this “community of care” improve the health outcomes of farmworkers and their families? Why or why not?

Social Determinants of Health Affecting Migrant Workers

Structural factors, including political, commercial, economic, and social factors, directly impact migrant workers’ health and well-being globally. Lack of migrant worker rights and protections negatively affect the health of these individuals and their families. Because employers can pay migrant workers minimal compensation for difficult labor performed under suboptimal conditions, these individuals cannot seek appropriate care for their illnesses or injuries or leave their jobs due to their precarious economic situation.

The health inequities migrant workers experience are a direct result of individual and structural SDOH (Evagora-Campbell et al., 2022). The WHO’s World Report on the Health of Refugees and Migrants reports that migrants’ ill health compared to their host communities is the result of suboptimal individual determinants such as income, education, housing, and access to services, exacerbated by linguistic, cultural, legal, and other barriers (WHO, 2022). According to this report, compared with non-migrant workers, migrant workers are more likely to have occupational-related injuries and less likely to use health services. Limited or restricted access to health services exacerbates these health problems (WHO, 2022). Table 27.5 demonstrates how the SDOH are directly related to migrant workers’ health concerns.

SDOH How It Occurs Negative Outcomes
Economic insecurity
  • Performing low-wage work
  • Being born into generational poverty
  • Lack of social or political influence
  • Lack of legal status in the host country, in some cases
  • Beginning migrant work at an early age
  • Limited access to reliable, safe housing and neighborhoods
  • Limited access to health or dental care
  • Limited access to an adequate variety of healthy foods
  • Limited access to transportation
  • Limited access to educational opportunities

Neighborhood and Built Environment
Food insecurity
  • Lack of access to an adequate variety of healthy foods because of economic circumstances
  • Lack of transportation to grocery stores
  • Consumption of highly processed, easily stored foods related to a lack of a means to store and cook fresh food appropriately
  • Food insecurity leads to poor nutritional status and potential adverse health outcomes like obesity, diabetes, hyperlipidemia, and hypertension.
  • Food insecurity is linked to learning disorders in children, and symptoms of depression in children and adults.
Substandard housing
  • Using unsafe drinking water for drinking, cooking, bathing, and cleaning
  • Living in an overcrowded environment
  • Experiencing inadequate sanitation
  • Living in an unheated or inadequately heated structure
  • Living in an unsafe substandard structure with a substandard electrical system
  • Inhaling or absorbing pesticides in the home via application drift
  • Contaminated drinking water and inadequate sanitation are associated with many negative health outcomes, including infectious diseases.
  • Overcrowding is associated with increased communicable diseases, food insecurity, and poorer mental health.
  • Substandard heating and electrical systems are associated with hypertension and respiratory issues.
  • The unsafe conditions in substandard buildings and structures create health hazards.
Environmental conditions
  • Inhaling or absorbing pesticides through their skin while on the job
  • Inhaling or absorbing pesticides in the home via application drift
  • Inhaling or absorbing toxic household and industrial cleaners and industrial chemicals
  • Working outdoors in extreme weather, poor air quality related to wildfires or high humidity, and disease-carrying vectors
  • Working outdoors without an adequate supply of drinking water
  • Pesticides may affect the nervous and endocrine systems, act as carcinogens, or cause skin or eye irritation.
  • Children exposed to pesticides are at increased risk for learning delays and long-term disabilities.
  • Extreme heat may lead to heat exhaustion, sunburn, and dehydration.
  • Accumulated sun exposure places individuals at higher risk for skin cancer.
  • Poor indoor and outdoor air quality puts individuals at increased risk for respiratory illnesses.
Educational environment
  • Migrating between May and November interrupts schooling.
  • Children working in agriculture can work an unlimited number of hours outside of school hours, starting at ages 10 to 11.
  • Children 12 and older can work on tobacco farms, a practice banned in many other countries due to the work’s toxic nature.
  • This population’s high school dropout rate is four times the national rate.
  • Children exposed to pesticides are at increased risk for learning delays and long-term disabilities.
Table 27.5 Intersectionality of Migrant Workers with the SDOH (See MCN, 2023a; NCFH, 2018a; NCFH, 2021a.)

The Nurse’s Role in Caring for Migrant Workers

Migrant health needs are often managed in community settings where community health nurses can make a lasting positive impact. To ensure better health outcomes, nurses need to advocate for the health of migrant workers, who have very little economic or political power. Nurses can help these individuals navigate the complex health system and push for more access and affordable care options. To address transportation barriers, public health nurses can advocate for mobile health units to visit migrant housing centers, a great upstream intervention. School and community nurses have a duty to advocate for the health and welfare of the children in the community. These nurses can advocate for fair labor laws and policies that govern other nonagricultural work, free school breakfasts and lunches, and appropriate health screenings and care.

MSAW clients frequently experience chronic diseases such as hypertension, diabetes, asthma, and eczema, being overweight or obese, and mental health disorders like anxiety and depression (NCFH, 2021c). Community and public health nurses can tailor nursing interventions to address these health issues. For example, education and advocacy efforts can target improving policies, providing healthy food options at little to no cost, and funding accessible telehealth mental health services. Community nurses can work with local businesses, officials, and community food programs to address food insecurity. Nurses can also partner with migrant and seasonal head start programs or farm-to-preschool programs to help provide children with appropriate education, health resources, and food (NCFH, 2021a).

Community health centers (CHC) are a resource for populations with limited access to health care, such as migrant workers. These community-based organizations are classified as CHCs rather than MHCs because they do not receive federal migrant health funding. Community health workers (CHWs) often play a key role in promoting migrant health by facilitating health promotion and disease prevention activities and programs to increase access to services, provide translators, and enhance the cultural competency of health programs (Emery et al., 2022). Community and public health nurses should become familiar with local migrant and community health centers, especially in rural areas, to spread awareness of their services and help migrant workers access and coordinate care. Nurses have a role in primary, secondary, and tertiary prevention for caring for migrant workers (Table 27.6).

Primary Prevention
  • Educate migrant workers on measures to reduce pesticide exposure
  • Educate clients on the benefits of immunizations and administer them as appropriate
  • Teach migrant farmworkers how to stay hydrated and avoid heatstroke
  • Educate clients to wear sunblock while working outdoors in addition to hats and clothing that covers skin
  • Provide prenatal care as necessary for pregnant clients
Secondary Prevention
  • Screen for TB
  • Screen for skin cancer
  • Screen children for anemia
  • Screen for pesticide exposure
  • Screen for communicable diseases
Tertiary Prevention
  • Treat for pesticide exposure and TB
  • Promote rehabilitation following occupational-related musculoskeletal injuries
  • Provide referrals as appropriate for obstetric care, mental health care, or other specialty care areas
Table 27.6 Nurses’ Role in Primary, Secondary, and Tertiary Prevention for Migrant Workers

Theory in Action

Migrant Clinicians Network

In this video, a community outreach nurse discusses what it is like to care for migrant farmworkers in Maine.

Watch the video, and then respond to the following questions.

  1. What different roles does Beth Russet, the nurse in the video, play?
  2. In your view, is this type of health care effective in managing the health needs of migrant workers? Why or why not?
  3. What alternatives to this type of nurse-led health care for migrants could reach more individuals?

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