Health Problems of Nepalese Labor Migrants

A Scoping Review

Abstract

Labor migrants (LMs) often work in precarious work environments and are exposed to various health risks. There is a lack of information on the health of international Nepalese LMs (NLMs). This scoping study was conducted to assess the health problems of international NLMs based on the six-stage scoping review process of Arksey and O'Malley. A literature review and stakeholders consultation related to NLMs' health information were conducted. A total of 455 studies were identified of which 38 studies were potentially relevant based on title and/or abstract screening, and a total of 16 studies were finally included and assessed. The literature showed that the health problems incurred by NLMs are mainly mental health problems; accidents, injuries, and infectious diseases. The Foreign Employment Board is the main public stakeholder which records deaths and disabilities of NLMs. The record showed that there were a total of 3,752,811 labor permits approval, a total of 7467 deaths, and a total of 1512 disabilities among NLMs during the 11 years from 2008-2018. There is a need to have a better investigation of causes of death and disability among NLMs to assign scientific causes of death. Predeparture orientation on mental health coping strategies, labor rights, health-care accessibility options in destination countries, traffic safety, and infectious diseases should be instituted.

Introduction

The common destinations of Nepalese Labor Migrants (NLMs) are India, Malaysia, and the Gulf Corporation Council (GCC) countries. Labor migration to countries other than India is termed “foreign employment” in Nepal. Out of the total absentee population in the 2011 census of population and housing, 37.6% were reported to be in India. Since 2008/09, there have been more than 4 million labor approvals from the Department of Foreign Employment, Ministry of Labor, Employment and Social Security, Government of Nepal with a record of 354,098 and 236,208 approvals of labor permits in the fiscal year 2017/18 and 2018/19, respectively.[¹]

Labor migration can lead to both good and bad health outcomes for the general population of the country of origin. LMs themselves can be vulnerable to various health risks because they are usually casual, unskilled, and uneducated workers for temporary employment which residents of host countries are unwilling to take on. They often work on jobs characterized by low wages, poor occupational safety measures, job insecurity, lack of control over work processes, and exclusion from protective legislation. Health accessibility is also affected by the lack of linguistically or culturally appropriate health services in destination countries as well as the lack of readily available personal health records for the LMs. As a result, LMs are likely to incur various diseases and injuries during employment in destination countries.

The 72^nd World Health Assembly acknowledged the health of refugees and migrants as a global priority through the acceptance of the World Health Organization's global action plan to promote their health.[²] The National Health Policy 2019 of Nepal seeks to minimize public health risks due to migration, particularly by ensuring the accessibility of health services for Nepalese migrants abroad. It is necessary to better understand the health status and its determinants of NLMs. In this context, the objective of this study is to document the health problems of NLMs.

Methods

This scoping study was carried out as per the six-stage methodological framework developed by Arksey and O'Malley for scoping review study.[³] This scoping study was further enriched by mapping and consultation of key stakeholders.

Identifying the research question

The research question for this review was: What are the health problems of NLMs?

Identifying relevant literature and sources of data

PubMed, EMBASE, PsycINFO, and Google Scholar databases including general Google were searched for relevant studies describing the health problems of NLMs. Keywords used to identify the underlying concepts were: (1) work/employment (labor/migrant/immigrant*/worker/domestic/construction/manufacture/agriculture/restaurant/hotel); (2) health (health/disease*/illness*/morbidity/mental/psychology*/injury*/accidents/hazards/occupational health/death/suicide/mortality); (3) Population (Nepal*). The literature search was initially conducted by combining the first two keywords in the title and abstract field using Boolean terms and word truncation. Later, the population referring to Nepal was added to the search. The websites of the following organizations were consulted to find grey literature and current statistics: the International Organization for Migration, the International Labor Organization, the World Health Organization, the Ministry of Labor, Employment and Social Security, Government of Nepal.

Selection of literature and charting the data

All studies extracted were then exported to EndNote for the identification of relevant articles. Selected studies were those: (i) conducted between January 2000 and July 2020; (ii) related to NLMs; and (iii) assessed or analyzed any health issues of NLMs. We excluded review studies and studies on internal LMs. The full texts of the relevant studies were retrieved and read for the relevant information. The relevant information was extracted and charted in a table by headings including main health or occupation problems assessed, study design, sample size, data collection methods, and key findings. There is no global consensus on the definition of LM. The working definition of LMs in this study was: a population living in a country or area other than their country of origin, who are seeking work, are employed in the host country, or were previously seeking work or were employed but are unable to continue working and remaining in the host country.[⁴]

Collating, summarization, reporting

The literature review included few documents and articles related to NLM data maintained by stakeholders, and the information collected from the literature review and stakeholders were collated and compared.

Stakeholders mapping and consultation

A total of 16 relevant governmental and nongovernmental stakeholders [Table 1] who are directly or indirectly involved in assessing health or maintaining health records of NLMs were physically visited and any documents or information were collected in July and August 2020.

Table 1: Name of stakeholders consulted with information providers

Results

Figure 1 shows the process of inclusion of 16 studies (see https://links.lww.com/WSEP/A12) which were qualitatively analyzed to identify health problems of NLMs. Table 2 summarizes these health problems which can be categorized into three types: (i) mental-health problems; (ii) infectious diseases; and (iii) accidents, injuries, and deaths. Among returnee migrants from India, older age, women, religious minority, security guards, factory workers, and having existing health problems and difficulty in accessing health care in India were found to have a higher risk of psychological morbidity. Among the communicable diseases such as malaria, dengue, TB, toxoplasmosis, and HIV were common.

Figure 1: Flow diagram of studies selected for review

Table 2: Characteristics and main findings of included studies on health problems of Nepalese Labour Migrants (LMs)

Workplace-related injuries and accidents (cuts, fall, road traffic accidents, faint/heat stroke, and fractures) were common among NLMs in GCC countries and Malaysia. The records of Foreign Employment Board (FEB) showed that there was a total of 3,752,811 labor permits approval, a total of 7467 deaths, and a total of 1512 disabilities registered among NLMs during the 11 years from 2008/9 to 2018/19 [Table 3]. The causes of death as per the FEB databases were categorized into eight groups: cardiac arrest, heart attack, traffic accident, workplace accident, suicide, murder, natural cause, and other/unidentified causes.

Table 3: Deaths and disabilities of Nepalese labor migrants abroad during the period from 2008/2009 to 2018/2019*

The study conducted by the International Labor Organization found an average death rate of 0.16% (4322 deaths out of a total of 2,723,587 labor permits) in the 7 years from 2008/09 to 2014/15.[¹⁴] The major causes of death, as reported, were cardiac arrest (941 cases or 21.8%), natural causes (847 cases or 19.6%), and other or unidentified causes (795 cases or 18.4%). Suicide was the major causes of death among female NLMs (33% of all female migrant worker deaths). Almost 97% of these deaths occurred in GCC countries and Malaysia with the highest being in Malaysia followed by Saudi Arabia, Qatar, and United Arab Emirates.

The largest number of cases of cardiac arrest and heart attack among NLMs was reported from Qatar. In Qatar alone, 1,354NLMs died in the period 2009–2017 (150/100,000 migrant workers) out of which 571 (42%) were due to cardiac arrest and heart attack. There was a strong correlation between average monthly afternoon heat levels and these deaths. The most likely underlying cause of these deaths was heatstroke. The majority of NLMs in Qatar reported working at more than 31°C each working day during hot months.[⁶]

Discussions

The literature showed that the health problems suffered by NLMs are mainly mental health problems; accidents, injuries, and infectious diseases during their employment in host countries. Such health problems are common among migrant workers as found by a previous review of health issues among Nepalese migrant workers in the Middle East.[⁷] These health problems are caused by a variety of risk factors including lack of basic amenities in accommodation, work-related hazards such as lack of safety measures at work or safety training, long working hours, high workload, poor communication, and the reluctance of employers in prompt treatment of work-related accidents.[^8,9]

Mental health problems including depression, anxiety or loneliness are frequent in south Asian LMs in GCC countries and are mainly attributed to the new environment, poor social life, poor arrangement of accommodation, new work pressure, human rights violations, abuse, high expectations from family, family separation.[¹⁰] Another scoping review found that migrants are at an increased risk of developing psychotic disorders and death by suicide but are less likely to use psychotropic medication and mental health-related services.[¹¹] A cross-sectional study of 5000 migrant workers in Shanghai revealed that 21% had mental disorders such as obsessive-compulsive disorder, anxiety, and hostility.[¹²]

Population mobility might contribute to the spread of infectious diseases. Infectious diseases which are endemic in the home or host countries are likely to be transferred during the migration process. Infectious diseases such as malaria and dengue are common to the returnee migrant workers from India where it is endemic. HIV/AIDS is another common infectious disease recognized among LMs because of several risk factors including socio cultural context (cultural norms, family separation, and low social support), mental health (substance abuse, mental health problems, and needle use), and sexual practices (limited condom use, multiple partnering, clients of sex workers, low HIV knowledge, and low perceived HIV risk).[¹³] A study from Singapore reported relatively high prevalence of malaria, hepatitis and TB among migrant workers.[¹⁴] Another study from Bangladesh reported a high HIV positivity (75%) among adults who had a history of migrant work or was the spouse of a migrant worker.[¹⁵] Risky sexual behaviour increases in individuals separated from their usual sexual partners and are away from their communities and families.[⁹] NLMs had poor risk perceptions and low awareness of HIV/AIDS.[¹⁶]

The NLMs in GCC countries and Malaysia are commonly employed in unskilled manual labour in higher-risk sectors such as heavy industries, construction, and agriculture[¹]; the frequent occupational injury or accidents include falls from heights, fractures and dislocations, ocular injuries, and cuts, which are consistent with the findings by a systematic review studies of occupational injuries of migrant workers worldwide.[¹⁷] Such health outcomes are due to the low level of work skills of migrants, illiteracy, language or cultural barriers, poor access to health care and hazardous occupational environment.[^18,19] These types of injuries were reported more by migrant labors who were employed in Malaysia and GCC countries. The severe form of injuries, accidents and occupational hazards have fatal outcomes resulting in a significant proportion of NLMs deaths during employment as revealed by the data from FEB of Nepal. Death of NLMs in road traffic accidents indicates a lack of adequate driving skills or lack of adequate traffic and road safety regulations in destination countries.

The description and categorization of causes of deaths in FEB database, for example, cardiac arrest, heart attack, natural cause and other or unidentified causes, are not scientific as per classifications of deaths by the International Classification of Diseases and do not explain the actual or underlying cause and the circumstances that resulted in the death or fatal injury.[⁵] The natural cause is the manner of dying “due solely or nearly totally to disease and/or the ageing process.” Thus, it is not clear what this means as the cause of deaths of young fit NLMs. Cardiac arrest is also the manner of dying and is inevitably what happens when a person dies.[²⁰] Most cardiac arrest related deaths, as categorized by FEB of Nepal, in Qatar were related to heat stroke-related cardiovascular diseases.[⁶] The geographical features and climatic conditions (a mixture of sub-tropical, temperate, and arctic) of Nepal is quite different from those in Qatar and other GCC countries. Lack of underlying causes of death hinders the key epidemiological information for preventive strategies.

This review included only those studies which assessed any aspect of the health of NLMs. The qualities of included studies were not assessed, and inclusion and exclusion criteria were developed post hoc. The quantitative assessment of the included studies was not done. This study included only international NLM and health-related information and its management for other categories of migrants needs further investigation. Since all approved labor migrants (LMs) might not have departed to foreign employment; and there is no record of total LMs in host countries year-wise, the death rate among NLMs could not be calculated.

Conclusions

The main health problems incurred by NLMs are mental health disorders; accidents, injuries, suicides, and deaths; and infectious diseases, particularly HIV and malaria. The FEB classification of causes of death is not scientific and does not provide the underlying causes of death. Awareness and training on mental health coping strategies, labor rights, health-care accessibility options in destination countries, traffic safety, and infectious diseases are needed before the departure of NLMs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.