Occupational Health and Safety of Immigrant Workers in Italy and Spain: A Scoping Review

The main aim of the present study was to summarize the available literature on the topic of occupational health and safety (OH&S) among immigrant workers (IMWs) in Italy and Spain. We conducted a scoping review, searching Medline, Social Sciences Citation Index, PsycINFO, CINAHL Plus, SciELO, and EMBASE for peer-reviewed articles, published in English, Italian, or Spanish, between 1999–2018. 34 studies were included, 28 with quantitative methodology and 6 with qualitative. Main findings were that, compared to natives, IMWs in Italy and Spain showed higher prevalence of low-skilled jobs and of perceived discrimination at work; higher physical demands, poorer environmental working conditions, and more exposure to occupational risks (e.g., ergonomic and psychosocial hazards); a greater risk of occupational injuries; worse general and mental health; and a plausible worsening of their health status, especially in Spain, as a result of the economic crisis. The findings of the present scoping review constitute warning signs that indicate the need for a holistic global response to ensure that adverse OH&S outcomes among IMWs workers are improved and that equitable access to health care is guaranteed. Such a response will require a concrete and evidence-based approach to prevent and monitor occupational risk factors and associated outcomes in the workplaces.


Introduction
According to the International Labour Organization (ILO), there are 164 million migrant workers throughout the world; 95.7 million are men and 68.1 million are women. These migrant workers (i.e., international migrants, currently employed or unemployed, and seeking employment in their present country of residence) constitute 4.7% of all workers and present a high labour force participation, particularly in Europe [1]. It has been estimated that international migrants represent almost 10% (90.7 million) of the population in the 53 countries of the World Health Organization (WHO) European Region and that around 12% of all workers in this Region are migrants [2]. 1.
were more often hired on precarious contracts and mainly employed in manual, low-skilled jobs; 2.
were concentrated in the most dangerous jobs; 3.
presented a higher risk of occupational injuries and diseases; and 4.
experienced a worsening of their working conditions during the international economic crisis of 2008-2014.
As in the rest of the world, there is an increasing female presence among immigrant workers, boosted by a large demand for often private and informal domestic workers and caregivers, likely a consequence of a shift of the burden of elderly and child care on the families and without full access to social protection and rights [6].
The aims of this study were 1. to summarize the available literature through a scoping review; 2.
to identify research gaps; and 3.
to make recommendations for future research on occupational health and safety among immigrant workers in Italy and Spain.
We decided to focus on these two countries for the following reasons: 1. previous systematic and scoping reviews on the topic of migrant workers' health and safety did not cover specifically this geographic area [7,9,[11][12][13]; and 2.
these two countries are characterized by a similar immigration regimen-both encountered a deep economic crisis during 2008-2014 [3,4,14].
The crisis, in fact, changed the economic and employment prospects of immigrants in Italy and Spain by affecting the degree of labor market competition with native workers, especially for temporary and precarious jobs in the service sector. This situation forced many immigrants to leave the host country [3,4].

Search Strategy
From October 2018 to March 2019, we searched Medline (through PubMed), Social Sciences Citation Index, PsycINFO, CINAHL Plus, SciELO Citation Index, and EMBASE databases. We searched for articles published in 1998-2018 in order to see how the occupational health and safety of immigrant workers in Italy and Spain developed over time, particularly before, during, and after the international economic crisis of 2008-2014.
We searched on terms related to immigration, then on terms related to occupational health and safety, and then related to the country of immigration: String 1: Immigration descriptors "Emigrants and Immigrants" OR "Emigration and Immigration" OR "Transients and Migrants" OR "Ethnic Groups" OR "Minority Groups" OR "Labour migrants" OR "Migrant workers" OR "Immigrant workers" String 2: Occupational health and safety descriptors "Work" OR "Employment" OR "Job" OR "Workload" OR "Occupational Exposure" OR "Occupational Risk" OR "Occupational Hazard" OR "Occupational Health" OR "Occupational Safety" OR "Occupational Medicine" OR "Occupational Diseases" OR "Occupational Accidents" OR "Accidents, Occupational" OR "Occupational injuries" OR "Economic recession" OR "Economic crisis" OR "Financial crisis" String 3: Receiving country "Europe" OR "European" OR "Italy" OR "Italian" OR "Spain" OR "Spanish". Other potentially relevant sources were searched for in the Medline (through PubMed) database, starting from a reference list provided by the Editorial Office of the International Journal of Environmental Research and Public Health in July 2018.

Inclusion/Exclusion Criteria and Assessment
Titles and abstracts were primarily screened by three of the authors, to exclude those not meeting the following inclusion criteria: original articles published in peer-reviewed scientific journals (i.e., systematic and non-systematic literature reviews, commentaries, editorials, letters, conference abstracts or proceedings, theses, dissertations, books or book chapters were excluded), published in English or Italian or Spanish, mentioning immigrant populations and occupational health or occupational safety as central issues, and focused on immigrants (from any country of origin) employed in Italy and/or Spain.
Then, all potentially relevant papers were read in full by the first author, and a second selection was performed, applying the following inclusion criteria: papers reporting qualitative or quantitative studies addressing (a) the relationship between migration, work, and health; (b) occupational health and safety among immigrant workers; (c) the health status of immigrant workers or (d) preventive programs/activities performed among employed immigrants; (e) social, occupational, cultural, and/or economic determinants of health and safety among immigrant workers; or (f) access to and use of health services among immigrant workers.
Finally, each of the included articles was assessed by one of the authors and then the first author, using a set of predefined parameters, including main characteristics of the article (authors, year, and journal); country, aim, design, and period of the study; information-gathering technique, features of the participants (e.g., sample size, sex, age, criteria of inclusion/exclusion, comparison-group if any); main results; limitations (if any); and conclusions.
On the basis of the research question, we can distinguish the following seven main groups of studies: (i) 10 studies addressing the association of working conditions (i.e., employment conditions and/or specific work-related exposures) and health (i.e., self-reported health problems, sick leave and disability) [61,62,[65][66][67][68]70,75,77,78]; (ii) two studies evaluating the association of discrimination in the workplace and health [63,92]; (iii) five studies dealing with migrant workers' mental health [69,71,86,91,94]; (iv) one study assessing factors associated with a low risk perception of zoonoses in immigrant workers compared with natives [87]; (v) one study aimed at identifying migrant workers with hazardous drinking problem [73]; (vi) six studies addressing whether the risk of occupational injuries is higher in immigrant workers than in natives [72,76,[88][89][90]93]; and (vii) three studies examining the effect of the economic crisis on migrant workers' working conditions and on their health [64,74,79].
(i) Working conditions and health (n = 10 studies) In general, compared to natives, immigrant workers in Spain showed higher prevalence of manual work or low-skilled jobs; temporary or informal employment and low wages; more exposure to physical demands; poorer (i.e. "unhealthy", "risky") environmental working conditions; and a greater risk of injury [66,67,70,75,77]. Therefore, immigrant workers in Spain, compared to Spanish-born workers, reported poorer self-reported general and mental health [67,68,78], worse adherence to dietary recommendations [65], and greater absence from work due to health problems [62]. In particular, undocumented foreign-born workers who lived in Spain ≤ 3 years showed the highest risk of both poor self-rated health and mental health problems [78].
It was also showed that immigrant workers had a greater sickness presenteeism as compared with Spanish-born workers, especially those who had lived in Spain for less than two years [61]. Also, the condition of immigrant decreases the probability of developing disability, probably due to better initial health status (in turn, due to the "healthy migrant effect" or to the fact that healthy people are more likely to migrate) [77].
(ii) Discrimination in the workplace and health (n = two studies) In Spain, Moroccans showed the highest prevalence of perceived discrimination (answering to the question: "Have you ever felt discriminated against?"-Yes/No). Immigrant workers who felt discriminated presented a significantly higher risk of reporting both general and mental health problems [63].
In Italy, perceived discrimination (answering to the question: "Have you ever felt to be exposed to bullying or discrimination phenomena in your work environment?"-Yes/No) was higher among immigrant compared to Italian males, regardless of the geographical areas of origin, particularly for construction and other industrial workers. Among female workers, only Latin Americans and Africans had a higher occurrence of perceived discrimination as compared to Italians [92].
(iii) Mental health (n = five studies) Two Spanish studies showed that immigrants who experienced bad atmosphere at work (low possibility of talking about problems and/or of being treated with respect), high quantitative and emotional demands, low development possibilities, and low support from co-workers reported worse mental health [69,71]. In particular, possible psychiatric case prevalence was higher in Ecuadorian women compared to Spanish-born ones, the main risk factors being having children, work dissatisfaction, and low salaries [69].
An Italian cross-sectional survey showed that migrant workers with high work demand perception tend to report high levels of both anxious-depressive and interpersonal disorders [86]. An Italian clinical case list reported some cases of work-related psychopathological conditions (i.e., stress and mobbing) among migrant workers, as well as some cases of fitness for work with limitations/prescriptions/recommendations due to psychiatric disorders (anxious-depressive disorders, schizophrenia, or other psychotic disorders) [91]. An Italian cohort study on patients diagnosed with a psychotic disorder showed that, compared to natives, a significantly higher number of migrants returned to work. Being occupationally active at the onset was a strong predictor of being working or studying at a 12-month follow-up [94].
(iv) Factors associated with a low risk perception of zoonoses (n = one study) An Italian cross-sectional survey among workers in the agro-livestock and agro-food industry revealed significant differences in risk perception of zoonoses between immigrants and natives. Asian immigrants were the group with the highest prevalence of at risk behaviours and the lowest level of knowledge about zoonoses [87].
(v) Identification of migrant workers with hazardous drinking problem (n = one study) A Spanish cross-sectional survey performed among migrants from North Africa, South America and India-Pakistan, without a comparison group, showed that the factors most closely associated with hazardous drinking were being a man, working in the construction industry or agriculture, being resident in Spain longer than seven years, and sharing a house with friends [73].
(vi) Occupational injuries (n = six studies) Two Spanish studies reported a higher risk for fatal and non-fatal occupational injury in foreign workers compared with Spanish workers, especially in industrial activities and among women [72,76].
Four Italian studies showed an overall higher risk for occupational injuries in immigrant workers compared to natives, particularly among unskilled, temporary workers from strong migratory pressure countries, working in the mechanical engineering and metallurgic sectors or in construction [88][89][90]93].
(vii) Effect of the economic crisis on working conditions and health (n = 3 studies) Three Spanish studies showed that the economic crisis caused an increase in risk of poor mental health among immigrant workers, specifically those who lost their job, whose number of working hours increased, with low salaries and reporting family burden [64,74], as well as a greater risk of job loss/insecurity and of psychological and physical job demand [79].

During economic crisis (2008-2014)
Agudelo-Suárez et al. [61], Spain, 2008Spain, -2009 To assess the extent of sickness presenteeism in a sample of Spanish-born and foreign-born workers.  Agudelo-Suárez et al. [62], Spain, 2008 To describe the migratory process (reasons for migrating, time of residence), legal status and personal, working and health characteristics of immigrants with work experience in Spain.
• Cross-sectional questionnaire-based survey. • The immigrants were working in jobs that were below their educational level and reported problems concerning the type of contract, salaries, and the length of the working week, which was often more than 40 hours.
Agudelo-Suárez et al. [63], Spain, 2008 To analyze the relationship between immigrants' perceived discrimination and various self-reported health indicators.
• Cross-sectional analyses from a prospective cohort study.  López-Jacob et al. [72], Spain, 2005 To compare the incidences for both fatal and non-fatal injuries in foreign workers to that of Spanish workers.
• Longitudinal analysis on injury data (from the accident registry of the ministry of labor and social issues). • Longitudinal analysis on injury data (from "New Informative Flows" database set up by Italian National Institute of Insurance for Occupational Injury).
• Occupational accidents among immigrant workers gradually rose and peaked in 2002.

•
The sectors with high rates of accidents were the mechanical engineering and metallurgic sectors and the construction industry. • Accidents occurred mainly among young people (18 to 34 years old), and there was a prevalence of men (83.3%).

•
The number of occupational accidents with a prognosis of 8-30 days fell progressively for workers in general but gradually rose for immigrant workers with a peak in 2001.

•
The overall number of occupational accidents that caused permanent invalidity fell by 52.3% for the workforce in general, and by 25% among immigrant workers.  To evaluate the influence of changes in employment conditions on the incidence of poor mental health of immigrant workers in Spain, after a period of 3 years, in context of economic crisis. • There was an increased risk of poor mental health in workers who lost their jobs (aOR = 3.62, 95%CI: 1.64-7.96), whose number of working hours increased (aOR = 2.35, 95%CI: 1.02-5.44), whose monthly income decreased (aOR = 2.75, 95%CI: 1.08-7.00) or who remained within the low-income bracket.

•
This was also the case for people whose legal status (permission for working and residing in Spain) was temporary or permanent compared with those with Spanish nationality (aOR  • They were mainly employed in metal (35%) and manufacturing (15%) industry, followed by health (20%), catering/hospitality (15%), metal casting (10%), and transport (5%) sectors. To analyze the influence of employment conditions on adherence to dietary recommendations.

Qualitative Studies
The main features of the six qualitative studies [80][81][82][83][84][85] are shown in Table 4. These studies used individual in-depth interviews and/or focus groups to collect their data; participants were immigrant workers and/or key informants living in Spain.
Overall, they compared immigrants and Spanish workers. Immigrants reported discrimination in their community and working life, precarious/poor working conditions, low pay, and health hazards. Exposure to occupational risks (e.g., ergonomic and psychosocial hazards) appeared to be worsened in immigrant workers, owing to their greater presence in low-skilled jobs and their economic need to prolong working hours. Immigrant workers' health status seemed to be influenced by their working conditions; perceived discrimination seemed to affect their quality of life, with consequences on both their mental and physical health (e.g., stress, depression, sleep disturbances, diffuse muscle pain, headaches, gastric discomfort). Moreover, key informants described some difficulties in having health problems recognized as work-related, mainly because of irregular and precarious employment, employers' and insurance companies' reluctance, and lack of knowledge. Finally, immigrant workers in Spain experienced a deterioration in their quality of life and health during times of economic recession, which they interpreted as consequences of a worsening of employment and working conditions as well as of a significant reduction of investments in occupational health and safety measures. Moreover, in a context of economic crisis, many factors influence the occurrence of presenteeism, to which some musculoskeletal, respiratory, and mental problems appeared to be related.
With respect to migration status, two qualitative studies performed in Spain before the economic crisis reported that documentation status was relevant in terms of empowerment and bargaining but did not appear to influence work tasks or exposure to hazards directly [80]. Undocumented workers described poorer working conditions [82].

Discussion
The main messages arising from the present scoping review are 1.
Italy and Spain show similar occupational health and safety concerns and patterns of risk for fatal and non-fatal injuries; the overall numbers are impressive and demand interventions; 2.
the parallel economic crisis and the irregular status of many immigrant workers contributed to exacerbate occupational health and safety concerns in Italy and Spain; 3.
the uniqueness of the demographic migration process that happened in these two Mediterranean countries; 4.
our findings are consistent with those of previous reviews investigating working conditions and occupational health outcomes among international migrant workers [7,9,[11][12][13].
A few gaps can be identified, such as 1. many problems have been highlighted, but scant solutions were proposed. No intervention studies are available, which could be very useful to build an evidence-based prevention of work-related injuries and diseases among immigrant workers in the workplaces, as well as to better inform health policy makers; 2.
more observational studies are needed with a longitudinal design, comparing the outcomes of interest in relationship to the different periods (i.e., before, during, and after) of the economic crisis. Such studies should be based on objective data and dealing preferably with occupational diseases instead of occupational injuries; 3.
more studies should analyze the potential role played by the migration status (i.e., documented vs undocumented) in exacerbating poor health and safety outcomes among migrant workers in Italy and Spain; 4.
the great majority of the included studies did not consider the heterogeneity of migrant workforce, with no sub-analyses for ethnic group and for length of stay in the host country; these are possible conditions of different vulnerability to occupational health and safety risks.
Some limitations should be acknowledged. We performed a non-systematic scoping review. Since the amount of relevant peer-reviewed literature surpassed our expectations, we did not include the grey literature (e.g., conference abstracts or proceedings, theses, dissertations, books, or book chapters). Therefore, we may have overlooked relevant documentation published. Relevant differences were observed between the studies in terms of sample size, methods of recruitment, and methods of assessing both working conditions and OH&S outcomes. This heterogeneity restricted our ability to compare and combine the findings. Therefore, the presented results are a simplification, a summary and a selection of information and knowledge available. In addition, we did not summarize the findings per migration group.
With respect to previous reviews, this paper has the following strengths: it presents updated results and comprehensive of quantitative and qualitative studies performed before, during and after the economic crisis; it deals only with migrant workers, not including refugees and asylum seekers; and, to the best of our knowledge, it is the first study specifically on two frontier Mediterranean countries.

Conclusions
The evidence base for migrant workers' occupational health and safety in Italy and Spain is growing considerably. The findings of this scoping review indicate the strong need for a global, response to assure that adverse occupational health and safety outcomes among migrant workers are tackled, preferably with intervention studies. Also, we believe in a strong multidisciplinary call for an equitable access to health care Migration represents a global and increasing challenge that needs more attention. Therefore, a concrete and evidence-based approach will be required to prevent and monitor the occupational risk factors and associated outcomes, as well as for the development of new policies and enforcement of existing ones aimed at protecting migrant workers in the workplaces. There is a need for the following key actions, from the occupational health and safety side: promotion of migrant workers' wellbeing and prevention of migrant workers' disorders in the workplaces, by means of focused and multidisciplinary risk assessments; 2.
concrete and timely responses to migrant workers' health needs, through largely accessible and focused health surveillance, fitness for work, case management and health promotion performed by a qualified, accountable, and motivated occupational physician; 3. more collaborative dialogue with general practitioners; 4. more social protection and compensation opportunities for work-related disorders in migrant workers in general, and for female domestic workers and caregivers in particular; 5.
the already existing and protecting legislation about occupational health and safety of immigrant workers should be regularly and proactively applied in the workplaces; 6.
free access to public occupational health services should be provided to migrant workers, particularly undocumented ones.
The adoption of the above-suggested best practices, according to the principles of corporate social responsibility (also stated by legislation), and within the framework of a more general design of social protection and health care systems for migrant populations [95], would enable migrant workers' effective integration, with relevant benefits for workers, enterprises, and society at large.
Finally, future research should be aimed at a deeper analysis of labor market institutions, gender, language, migrant flows, and status as mediating factors in occupational safety and health outcomes among migrant workers.