Mar 02, 2020
By Susana Caxaj , Katrina Plamondon

Nurses’ role in improving health care access for migrant agricultural workers

Shutterstock.com/Colin Dewar

Take away messages

  • Thousands of migrant workers arrive in Canada each year to work in agriculture. They face many barriers to accessing health care.
  • Nurses can mitigate some of these barriers at the point of care by knowing more about the context and challenges faced by these workers.
  • Five simple things nurses can do to to improve health care access and outcomes for migrant workers include identifying them, providing translation, offering opportunities to disclose workplace injuries, upholding confidentiality, and collaborating with community partners.

In 2018, roughly 70,000 temporary migrants entered Canada to work in the agricultural sector (Government of Canada, 2019a). As 75% of the agricultural workforce, these men and women are key to getting food onto Canadian tables (Burt & Meyer-Robinson, 2016). They pay income taxes and unemployment insurance fees, and contribute to the Canada Pension Plan; yet many struggle to access basic services or make claims to these public programs.

Nurses encounter migrant agricultural workers in various practice settings. Our research and experiences with these men and women show that nurses can play an important role in supporting this group as they navigate our health care system.

The challenges

By definition, migrant agricultural workers in Canada are “temporary” (Government of Canada, 2019b). Their status creates unique health care access challenges, including difficulties registering for public health insurance and navigating private insurance coverage (McLaughlin, Hennebry, & Haines, 2014; Sikka, Lippel, & Hanley, 2011). Workers also must navigate language barriers, limited knowledge of their rights and entitlements as workers in Canada, and limited understanding of how the health and legal systems work.

Low literacy, insecure housing, fear of retribution

Because direct billing is uncommon, workers may have to pay upfront for medical services. Low literacy levels, and transient housing that is often on an employer’s property, can complicate an injured or sick worker’s ability to get the reimbursement and follow-up that they need.

Furthermore, workers’ livelihoods are often tied to a specific employer, so that they are not free to find work on a different farm if they lose their employment (Caxaj & Cohen, 2019). For this reason, workers may not want their employers to know about their medical challenges, yet nonetheless, often depend on them to access services.

Workers also must navigate language barriers, limited knowledge of their rights and entitlements as workers in Canada, and limited understanding of how the health and legal systems work.

Both a worker’s temporary status and being tied to a specific employer create barriers to seeking necessary medical treatment, disclosing symptoms, and even staying safe on the job. Research in Ontario and British Columbia indicates that migrant workers justifiably fear medical repatriation, loss of hours/payment, bullying, or other punitive consequences if they seek medical care or refuse to work under unsafe conditions (Orkin, Lay, McLaughlin, Schwandt, & Cole, 2014).

Isolation and intimidation

Research with migrant agricultural workers and direct care providers also indicates that they face significant geographic and social isolation, privacy concerns, and inadequate legal oversight that complicate their access to various health, social, and legal services (Caxaj, Cohen, & Marsden, in press).

Housing conditions can also cause difficulties. Many workers live on the same farms where they are employed. With farms often located outside of centralized urban services and amenities, men and women in these programs can become socially isolated. This isolation makes workers vulnerable to increased complications and worse health outcomes (Caxaj & Diaz, 2018; Keung, 2019).

In our research, we learned about a worker who requested a change to better protect his health and safety in the workplace. Concerned about potential loss of productivity, the employer retaliated. He berated the worker in front of his co-workers and sent him home before the end of his contract. Such intimidation tactics send a message that workers are expected to accept risk to their health in order to keep their jobs.

Denial of care

Some workers have reported that their bosses have dissuaded them from seeking medical attention and significantly delayed or even refused taking them to a hospital or clinic. One worker who was severely ill requested repeatedly that his boss take him to get treatment. After several days without medical attention, the man despaired and opted instead to go home to Mexico. Within days of arrival back home, he died from a treatable medical condition.

In another case, a worker was injured on the job and immediately reported the injury to a supervisor. The worker was taken to a clinic, but unfortunately, without an unbiased translator, the injury was dismissed by the employer. The injury persists, but the worker was reluctant to pursue further action for fear that it may threaten his job status.

Unfortunately, these experiences are not unique; they have been documented in both research and the media (Keung, 2019) and reflect a pattern of disadvantages faced by this group in accessing and navigating health care.

What can nurses do?

Nurses can join their voices with those of migrant farmworkers to advocate for fairness and justice. Changes in policy and regulations will ensure that workers have a better chance to protect their health and safety. But in the meantime, there are five ways in which you can make a difference at the point of care.

1. Identify who may be a migrant agricultural worker in order to plan appropriate care
By confirming that an individual is participating in a temporary work program, you can identify the unique health care coverage issues they may have. You can directly ask your patient if they work in agriculture and for how long they will be in Canada.

Even if the hospital or clinic where you work does provide direct billing to migrant farmworkers’ private insurance provider, there may be hidden costs (e.g., lab work). By helping workers understand potential costs, you can support them to make a more informed decision about the care they receive, and your institution can better anticipate ways to work with these individuals to address these costs.

Ask if they have a reliable way to get back to your clinic for follow-up. Explore their capacity to read and to follow written instructions. If they should be assigned modified work duties, ask whether they need help explaining their need for accommodation to their boss. Keep in mind, however, the risk of disclosure alongside the risk of resuming regular work tasks. Design a plan together with your patient.

2. If English is not the person’s first language, provide a third-party translator
Our experience parallels what many researchers have documented: most migrant agricultural workers arrive in clinics and hospitals with a supervisor as their translator (Caxaj & Cohen, 2019; Caxaj et al., in press; McLaughlin et al., 2014).

Don’t assume that your patient is comfortable with this arrangement. Because a supervisor–employer relationship is not an equal power relationship, the onus cannot be on the migrant agricultural worker to request an alternative. Remember that medical repatriation is a real fear and possibility for migrant agricultural workers with temporary status.

Nurses can join their voices with those of migrant farmworkers to advocate for fairness and justice.

Beyond repatriation and dismissal, individuals working under these programs have reported loss of hours of work, bullying, and other punitive actions because of reporting health issues or injuries. To develop an appropriate plan of care, workers need to be in a safe space where they are not worried about the impact of their symptoms on their ability to work in Canada.

3. Give your patient repeated opportunities to disclose a workplace injury
For the same reasons that workers may hesitate to disclose symptoms or illnesses in the presence of their boss, they may be wary of sharing information about workplace injuries. When a worker reports an injury, employers may be concerned about their business, their reputation, or potential financial consequences. Bosses often have a conflict of interest. Giving your patient the chance to speak privately about their injury may facilitate disclosure.

Migrant workers who have been injured on the job need to know the importance of reporting their injuries to the appropriate agency right away (e.g., Ontario WSIB, Worksafe BC). You likely can make this report on their behalf. You can also explain to them the need for continued medical documentation. Workers may not understand that the success of their claim will depend on a clear and consistent medical paper trail that documents their symptoms.

4. Respect the privacy and confidentiality of migrant agricultural workers
As a registered nurse, you know the primacy of maintaining the privacy and confidentiality of your patients. Unfortunately, violations of privacy can and do occur.

Our research has documented instances in which clinicians have disclosed medical information to direct supervisors or bosses. Some clinicians may be motivated by their prior relationship or rapport with an employer or their trust that the employer has the worker’s best interests in mind. Others may unwittingly disclose medical information to a worker’s boss because of a failure to assess the relationship that a presenting translator has to the patient.

Ultimately, it is necessary to take direction from the migran t worker. Providing a third-party translator can facilitate a care plan that respects the dignity and will of migrant agricultural workers who present at our hospitals and clinics.

5. Remember that you don’t have to do this alone
You have colleagues with experience working with migrant agricultural workers both within and beyond the health care system. See the Additional Resources below for a list of organizations that can help. Even if they do not serve your region, staff may be able to provide other recommendations.

Do not underestimate the influence you can have in determining the health and well-being of a temporary migrant agricultural worker. The time and care that you provide to this person may mean the difference between opening a door or slamming it shut. As the famous migrant farmworker advocate Dolores Huerta once said, “Together, we can!” Juntos, sí, se puede!

References

Burt, M., & Meyer-Robinson, R. (2016). Sowing the seeds of growth: Temporary foreign workers in agriculture. Ottawa: Conference Board of Canada.

Caxaj, C. S., & Cohen, A. (2019). “I will not leave my body here”: Migrant farmworkers’ health and safety amidst a climate of coercion. International Journal of Environmental Research and Public Health, 16(15), 2643. doi:10.3390/ijerph16152643

Caxaj, C. S., Cohen, A., & Marsden, S. (In press). (In)access, (in)action and blurred lines: Tensions in support delivery and planning for migrant agricultural workers.

Caxaj, C. S., & Diaz, L. (2018). Migrant workers’ (non) belonging in rural British Columbia, Canada: Storied experiences of marginal living. International Journal of Migration, Health and Social Care, 14(2), 208–220. doi:10.1108/IJMHSC-05-2017-0018

Government of Canada (2019a). Hire a temporary worker through the Seasonal Agricultural Worker Program: Overview.

Government of Canada (2019b). Temporary Foreign Worker Program 2018Q1–2019Q1.

Keung, N. (2019, April 5). This is not what we came to this country for, to live and work like animals: Migrant workers say they endured modern-day slavery in Simcoe County. Toronto Star.

McLaughlin, J., Hennebry, J., & Haines, T. (2014). Paper versus practice: Occupational health and safety protections and realities for temporary foreign agricultural workers in Ontario. Perspectives interdisciplinaires sur le travail et la santé, 16(16-2). doi:10.4000/pistes.3844

Orkin, A. M., Lay, M., McLaughlin, J., Schwandt, M., & Cole, D. (2014). Medical repatriation of migrant farmworkers in Ontario: A descriptive analysis. Canadian Medical Association Journal Open, 2(3), E192–E198. doi:10.9778/cmajo.20140014

Sikka, A., Lippel, K., & Hanley, J. (2011). Access to health care and workers’ compensation for precarious migrants in Québec, Ontario, and New Brunswick. McGill Journal of Law and Health, 5(2), 203–270.

Additional Resources

Canadian resources for migrant agricultural workers

British Columbia

Manitoba

Ontario

Quebec

Saskatchewan

Susana Caxaj, RN, PhD is an Assistant Professor at the University of Western Ontario and affiliate at UBCO. Her research currently explores health access and support services for migrant agricultural workers in British Columbia and Ontario as well as other migration and health equity issues.

Katrina Plamondon, RN, MSc PhD is an Assistant Professor at the University of British Columbia in the Okanagan. Her PhD and ongoing research focuses on practices to advance health equity. She is actively involved in the Canadian Coalition for Global Health Research as co-chair of the University Advisory Council.

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