Accidents disrupt integration into the labour market and affect health of migrants and refugees

The Migrant Health Clinic (MHC) was established at a Danish university hospital in 2008 to increase equality of access to and benefits from highly specialised hospital services for ethnic minority patients. An unpublished observation from the MHC in connection with a health technology assessment showed that 11% of all referred patients had an occupational accident as a significant contributory factor to deteriorating health or unexplained pain complaints.

47% of international migrant workers are estimated to have experienced an occupational illness, 22% have experienced an occupational accident, and compared with local workers, they have a higher risk of fatal occupational injury [1, 2]. A Danish study shows that migrant workers, especially from non-Western countries, have an up to five times higher risk of sustaining a lethal and non-lethal occupational injury than native Danish workers, and they generally experience poorer working environments [3, 4]. Little is known about the incidence of occupational injuries among migrant workers in Denmark, and reported accidents might be underreported. However, there is a general lack of data on this population concerning occupational accidents, particularly in Europe [2]. In addition to occupational accidents, many patients referred to the MHC reported other accidents, such as traffic accidents, acute illness and abuse, as decisive life course-changing events impacting their health.

Methods

A qualitative, retrospective, multiple-case study was conducted from March 2018 to November 2021. A total of 58 referred patients from the MHC were purposively selected from the 610 referred patients overall during the same period. Selection was based on qualitative descriptions of an accident in the patient’s medical record. We defined an accident as an adverse event that causes a decisive social, mental or physical change in a patient's level of functioning. Patients were enrolled if a clinician at the MHC documented an accident in the patient's history. Six patients were excluded because they could not be found in the journal system or because their medical records lacked an accident description. We reviewed the medical record for each included patient and prepared a qualitative in-depth case description. The case description included characteristics of the accident and its mental, physical and social consequences. Information on examinations and treatment was included, based on available medical records.

By reviewing all case descriptions, common themes were identified regarding the general types of accidents patients experienced and the consistent outcomes they faced afterwards. The aim of the study was to describe the various outcomes of an accident in an ethnic minority and migrant patient population in relation to physical and mental health.

Patients provided written consent for the anonymised use of their patient information from their medical records in research activities at the MHC.

Results

A total of 52 case descriptions of accidents were included, and we characterised eight categories of accidents. We distinguished between occupational and non-occupational accidents and divided them into categories relating to the character of the accident (Table 1). Six patients suffered two separate accidents at different times and therefore fell into various categories. We quantified the most common accident outcomes (Table 2) and identified dominant themes.

Themes

Occupational accidents

Several patients who experienced occupational accidents had not reported them and were unaware of the rules for reporting such incidents. Furthermore, interpretation in the reporting process was seldom utilised and varied in quality, which could provide a misleading impression of the causal connection between the accident and symptoms. For one patient, this meant that the accident report was not completed because the reporting deadline had expired. For another patient, it resulted in missing or inaccurate documentation in the medical record. This affected the basis for recognition of the occupational injury. One patient described a lack of introduction to the tasks that led to occupational injury, and another also described language barriers as contributing to the lack of instruction. Patients described that they often worked without breaks and continued to work after accidents despite advice on physical relief, as they felt financially compelled to do so as providers for their families. One patient expressed concerns about reporting an occupational accident due to concerns that it might negatively impact his chances of extending his residence permit.

Post-traumatic stress disorder in relation to accidents and cognitive impairment

Nine (17%) out of a total of 52 patients were diagnosed with PTSD before the accident, and 29 patients (56%) reported PTSD symptoms or re-traumatisation after the accident. Some cases described manageable PTSD symptoms after traumatic war events before their accident, which then aggravated after the accident. Patients described problems such as anxiety, depression and psychotic symptoms either as accompanying symptoms to PTSD or as self-contained symptoms.

Reports indicate that the debut and reactivation of PTSD symptoms after an accident are not diagnosed or recognised by healthcare professionals. Symptoms such as difficulty concentrating, forgetfulness and personality change, as well as language and speech difficulties, are described after accidents, as well as loss and impairment of already acquired Danish language skills (Table 2).

Acute illness

Two patients (4%) described an acute or life-threatening illness, such as acute heart disease, which caused deterioration of their physical and mental health, as well as socio-economic challenges. Patients described a significantly lower level of functioning and unexpected cognitive challenges.

Occupational accidents as an interpreter

One occupational accident involved professional interpreters in the health and justice systems. Prolonged exposure to others' narratives of trauma resulted in PTSD in a professional interpreter with a refugee background. Danish Labour Market Insurance did not recognise any occupational disease related to stress, PTSD and depression.

Racism, bullying and discrimination

Four patients described bullying in the workplace, in some cases of a racist nature. One patient tried to address the problem with his manager but was unable to reduce the harassment. One patient was subsequently fired due to poor collaboration. Two patients described that they had attempted, through hard work, to separate themselves from prejudices about immigrants in Denmark, but after the accident, seemingly confirming these prejudices, they had been fighting in their own integration process.

Social and economic decline after the accident

Several cases described severe consequences to the physical, mental and financial challenges that patients experienced after an accident. Some experienced losing their jobs after sick leave and, in turn, their sense of identity at work. Other patients described working from an early age and finding joy in supporting themselves and their families in a new country. The loss of work identity and economic consequences, however, resulted in isolation and psychological problems. Some patients even distanced themselves from their families and ended up in divorce.

Discussion

Occupational accidents account for 64% of all accidents, supported by previous studies that indicate how migrant workers face a more stressful and hazardous work environment with a higher risk of accidents, musculoskeletal pain, long working hours and psychosocial stress [5, 6]. This study shows that patients are unaware of the importance or right to report occupational accidents and face obstacles in the reporting process, which affects the likelihood of obtaining legal recognition. Furthermore, migrant workers’ tendency to seek diagnosis and treatment after an occupational accident is strongly correlated with their prior knowledge of occupational safety and legislation [7]. Previous studies in the United States show that high-risk working migrants do not feel free to speak up when they feel insecure in their work. In line with this, the present study describes a patient worrying about potentially negative effects of a work accident on his residency permit [8].

Psychological and cognitive consequences after an accident

The experience of high demands, poor control, heavy workload, job insecurity and lack of social support at work, often reported by migrant patients, is associated with mental health issues such as depression, anxiety, burnout, and suicidality [9]. This is reflected in the high prevalence of depression or anxiety, ranging from 20% among working migrants to 40% among refugees, and the fact that individuals with a refugee background are about ten times more likely to develop PTSD than the background population [10, 11]. The risk of developing PTSD after a traffic accident or an occupational accident is increased by lack of social support, long-term physical problems, anxiety disorders and involvement in legal proceedings, which are frequent challenges for this patient group [12]. This study implies that refugee and migrant patients are vulnerable to developing PTSD or re-traumatisation, depression or anxiety in connection with an accident due to their previous trauma, social vulnerability, weak attachment to the labour market and lack of networks and social support. Patients experience the accidents as re-traumatisation events (reliving a previous traumatic experience through a current situation) and develop PTSD symptoms, which are often overlooked. Studies from the MHC show that 40-60% of referred patients have PTSD, whereas 27% have an overlooked PTSD condition [12].

Occupational injury as an interpreter

This study describes the case of a professional interpreter with a refugee background who was primarily traumatised by past war experiences and secondarily traumatised by working in the legal and public healthcare system, where he experienced prolonged exposure to other’s traumatic events. Studies indicate that there is a need for separate training and supervision for professional interpreters with refugee backgrounds, as they face critical challenges in their profession, such as confidentiality, personal boundaries and over-identification with the patients they serve [13, 14].

Racism, bullying and discrimination

Studies show that work-related racial discrimination against migrant workers in the workplace predicts chronic health restrictions. Previous discrimination prior to this increases the risk of physical and mental illness [15]. Studies showed that working conditions had a stronger impact on self-reported health for undocumented migrants than changes in legal status, such as obtaining a residency permit. Good working conditions are crucial for participation in the labour market after the age of 50 years [16, 17]. This study leaves an impression that managers, shop stewards and unions have a certain fear of dealing with the problem of racism and discrimination because it is sensitive and evokes strong emotions, and therefore they may tend to downplay the importance of the problem [4]. Communication between employees and management is essential for a successful recruitment process. The combination of language difficulties and uncertainty can hamper communication between employee and management [18]. Migrant workers generally experience more stress due to social factors such as language challenges, cultural differences and sudden upheavals, loss of mother tongue, financial challenges and limited influence on their own work [19] (see Figure 1). A recent European study suggests that a reduction in injury severity among native workers may result from a reallocation of riskier tasks from older native workers to migrant workers [20].

Patients with a migrant and refugee background are vulnerable at the intersection of navigating psychological vulnerability and the prejudice that their challenges are due to a lack of motivation or stereotypical overreaction. The findings of the present study are limited as the data are derived from patient records, and the descriptions of the accident and adverse effects were not systematic. Furthermore, there is a risk of underreporting in patient records, as information is extracted from a broader clinical history. There are no systematic records on legal reporting of occupational accidents in the patient records, which limits the quantification of this issue. Finally, this study is limited in external validity to other migrant populations, as only migrant patients with complex, unexplained health and social issues are referred to the MHC.

Conclusions

Occupational and other types of accidents are particularly important in the context of refugees and migrants – interplay and intersectionality reinforce vulnerabilities.

Workers’ unions can benefit from training their representatives in intercultural competencies and by providing them with bilingual information on rights, duties and assistance options in the event of accidents. Working conditions and environment are of crucial importance to migrants’ work retention.

Healthcare professionals should raise awareness of acute illnesses, traffic accidents and occupational injuries in patients with PTSD or previous trauma, while paying particular attention to the increased reports of PTSD and chronic pain conditions among migrant patients. Interpreters are an overlooked profession in this context. Interpreting agencies and healthcare professionals must recognise the risk of both primary and secondary traumatisation for interpreters and incorporate this into debriefing routines.

Additionally, social case workers should be aware that accidents can trigger a social decline for a migrant patient if prompt action is not taken.