Exploring the Link Between the Hazards and Value of Work,and Overcoming Risk for Community-Based Health Interventions for Immigrant Latinx Low-Wage Workers

Setting and Background

Data from this research originated from two separate formative studies exploring the barriers to health and well-being and hazards of work, respectively, to develop health promotion and protections for immigrant Latinx low-wage workers. Our research used community-engaged approaches to create equitable and collaborative processes in research and intervention design with a trusted community-based organization (CBO) that promotes worker participation allowing health promoting and health protecting perspectives to emerge (Arcury & Quandt, 2017). We partnered with Make the Road New York (MRNY), the largest primarily immigrant Latinx worker-oriented service and advocacy organization with over 24,000 members in the NYC area. The first study arose through a partnership between MRNY, the Barry Commoner Center for Health and the Environment at Queens College, City University of New York (CUNY), and the New York University–CUNY Prevention Research Center. It helped solidify MRNY’s interest in pursuing community-based participatory intervention research about low-wage worker health and led to the second study and partnership with the Icahn School of Medicine at Mount Sinai.

In each study, we employed a consensus-based approach to design research questions, select sampling targets, recruit participants, design data collection instruments, collect data, and interpret findings. Both academic and CBO partners shared viewpoints and iteratively co-created each step to be as responsive as possible to the worker participants, adhere to research objectives, and remain consistent with the mission and vision of the organization. For example, we conducted numerous meetings to design the FG guides to ensure language, tone, and clarity were optimal for the workers. Along with Isabel Cuervo, CBO staff co-facilitated or attended all FGs, conducted in Spanish, and were thus able to make recommendations to adjust FG guides as needed. Such interactions can be adapted to quantitative projects, as in our second study, but an added value of engaging in collaborative qualitative research is that all team members had the privilege of witnessing participants’ retelling of their experiences, which contributed to deeper reflection and interpretation, and analyses. While relationships with team members were congenial, challenges included planning meeting times that fit everyone’s schedules, and selecting topics and questions that met everyone’s interests without burdening the participants with lengthy discussions.

Participants and Research Procedures

This article draws data from 12 FGs conducted between 2016 and 2018 (N = 97) for two different studies: a pilot study for the Workplace Health Research Network (WHRN), funded by the Centers for Disease Control and Prevention, and the “Safe and Just Cleaners” study, funded by the National Institute for Environmental Health Sciences Research to Action program. We chose the FG method in both studies to capture the collective experiences of the targeted worker populations and generate insights that can be used to develop programs (Krueger & Casey, 2015).

The WHRN study held five FGs with domestic, construction, restaurant, home care, and community health workers (N = 45; women, n = 28; men, n = 17) that explored perceptions about how work factors influence workers’ health and well-being, and how these factors could contribute to healthy eating and active living intervention ideas, a programmatic interest of our community partner. We used the associative imagery technique to help elicit meaning-rich data (Gong et al., 2012). FGs were about 1.5 hours in duration and were conducted in 2015 in one of the MRNY’s largest centers in the NYC borough of Queens. Each FG was organized according to occupation with women and men, but women more dominantly represented care-based occupations. The first FG served as a pilot, which helped to revise the interview guide to improve discussion flow for the remaining FGs. Following preliminary analysis of these data, we held a community debrief session with previous and new participants to report back findings, collectively interpret them, and brainstorm intervention ideas.

The Safe and Just Cleaners study held seven FGs with domestic cleaners (N = 52; all women) to understand the work practices associated with the use of household cleaning products. Findings from the FGs were also used to develop a Spanish-language survey for 400 Latinx domestic cleaners working in the NYC metropolitan area. All FGs were conducted between August and December 2018; six FGs were conducted at MRNY’s Queens and Brooklyn centers, and one was held in Manhattan at the offices of one of the project’s advisory partner organizations, National Domestic Workers Alliance. The FGs were about 2.5 hours in duration, and the interview guide was revised iteratively to improve discussion flow. We shared preliminary findings with the project’s community advisory committee comprising research participants.

The institutional review board of Queens College, CUNY approved both studies and informed consent was obtained in written format.

Analytic Strategies

We were informed by Braun and Clarke’s (2012) description of thematic analysis in both the WHRN and Safe and Just Cleaners studies and applied both inductive and deductive stances to the respective data sets. Much of the analysis was informed by a latent, interpretive, approach where we “examine[d] the underlying ideas, assumptions, and conceptualizations—and ideologies—that are theorized as shaping or informing the semantic content of the data” (Braun & Clarke, 2006, p. 84). In the WHRN study, FGs were transcribed in English and Spanish. We and two research assistants read the transcripts in their preferred language, generated analytic memos, and held numerous discussions to achieve consensus of interpretations, often including MRNY staff. We coded the Spanish transcripts using NVivo (QSR International, 2016) using an inductive lens to generate themes. In the Safe and Just Cleaners study, we transcribed the FGs in Spanish, as all team members are bilingual or proficient. FGs on much narrower topics resulted in similar, unelicited talk about the value, meaning, and positive perceptions of work. At that point, we held additional interpretive discussions and generated analytic memos that helped to support joint analysis of data from both studies focused on these topics. We then drafted a codebook that included codes such as, performing well, performing well for job security, working with love, being appreciated by client, valuing oneself for respect, and self-advocacy.

Hazards of Work

Workers described negative and often overlapping hazards that are highly consistent with existing literature about the negative health effects of low-wage work (Clouser et al., 2017; Lipscomb et al., 2006; Steege et al., 2014). While some participants in the first study described decent working conditions in some cases, fear of job loss and widespread negative experiences dominated the discussions in both studies. The focus of this article is not on the hazards of low-wage work per se, it is nevertheless important to provide the context that gave rise to the ways in which workers found value.

Many participants reported the need to work quickly and limited time to conduct their duties often as a result of inadequate staffing (time pressure). Most workers used public transportation to commute, and interestingly, many described work-related time pressure as beginning before the official workday due to delays. A home health attendant said,

I take care of a person that depends on me, and I have to be there to make him breakfast, if I’m running late then he eats late. So, all of that stresses me out: transportation, buses, trains . . . I have to leave at noon . . . he says, “Make me lunch” 10 minutes before I have to leave . . . because I have a job in the afternoon . . . So I say, “Oh no.” Because sometimes they pay you by the hour, so if I say yes and stay there with him, I lose an hour that no one is paying me for. So, it’s really stressful.

Most employers did not inform them about job safety and their rights, including providing personal protective equipment (PPE; lack of worker protections). A domestic cleaner shares about an experience where the client denied her PPE, “Sometimes, they gave me products to clean the tile in the bathroom that were really strong, and they didn’t let me use gloves.”

Most participants’ occupations required that they undertake physically demanding activities, such as heavy lifting of boxes, materials, and repetitive motions, often causing chronic sensations of fatigue and pain (physically demanding work). A construction laborer said,

Perhaps one or two bags don’t affect you, but when it’s some 10 bags, the repetitive process of bending down and standing up, that can surely affect your spine . . . You can’t lose a day’s work. With or without pain you have to work and continue with the same repetitive process.

Multiple barriers to healthy eating were shared, including accessibility of fast food, and employers controlling what workers were able to eat. Inconsistent or lack of meal breaks were a major complaint (constrained food access). Domestic and home care workers experienced the most notable eating-related challenges. A domestic cleaner shared,

I couldn’t bring any food in because those people had allergies. And because my food had a different smell that could penetrate the apartment . . . until I left the apartment, I couldn’t eat. So, when I got out, and if I was hungry and saw a food cart, or I would grab a slice of pizza or something which is the fastest thing you can eat. Or I would have to wait until I got home to eat.

Domestic cleaners, although not exclusively, were exposed to the most chemical hazards (chemical hazards). Most expressed the inability to choose the cleaning products that they used. The most commonly used products also contain toxins known to cause respiratory and dermal effects over short and long terms: “I feel all those chemicals in my esophagus. If I use too much chlorine, I get this tingling all the time on this side [gestures to her body] and soon afterwards I get sick with a cold.” Many domestic cleaners also mixed products, particularly influenced by the need to work quickly.

Finally, the most widely experienced hazards were relational problems between employers and coworkers. Participants shared stories about tense relationships, humiliation, envy, and favoritism, which often involved wage theft, but also implicated their job performance, their job tenure, and overall sensation of stress (lack of employer and coworkers social support). A construction cleaning worker shared,

You have your boss—perhaps, we have families, children, we have to send money [back home] . . . I didn’t want to quit that job, and I put up with a lot of humiliation during all four years because I didn’t want to lose it.

Women, mostly, related heartfelt stories about being accused of thievery, laziness, and being sexually harassed. Feelings of overall stress were reportedly “brought home” at times by most workers, impacting their relationships with their families.

Value of Work

Participants made positive remarks despite our intention to focus on ways to ameliorate negative health impacts originating from low-wage work. Workers were clear that the most positive aspect about work is the income they received. Nevertheless, participants described two additional ways in which they value work—work is health and performing well.

Building Agency to Overcome Risk

As indicated prior, workers in both studies raised more direct concerns about the diverse ways in which their work negatively impacted their health and overall well-being. Yet, they also spoke about learning to protect one’s health and how they tried speaking up with employers and coworkers about their exposures to make changes.

Linking Pride to Worker Self-Efficacy

Neurological research has found that high self-esteem could be protective of physical health (Lu et al., 2018). Self-efficacy, a related psychological factor to self-esteem, is tied to changing unsafe and unhealthy working conditions (DeJoy, 1996). Taking the latent approach to thematic analysis (Braun & Clarke, 2012) afforded the ability to ask ourselves a series of interpretive questions, beginning with, “Are value, and specifically, pride in performing well, tied to overcoming health risks?” This question intrigues us because it complicates our own occupational research discourse about how workers perceive low-wage work. While we wanted to shed light on workers’ understandings about the complex linkages between work and health, we struggled with what the value of work means to us as occupational and community health researchers. In the occupational health field, there is a tacit understanding that the value of work to immigrant populations underlies much of the research that is conducted. We and our colleagues have generally assumed that the value of work functions primarily to put immigrants in low-wage work at risk. That is, workers may not leave a dangerous job where they accept risk, danger, stress, humiliation, and injury because work is both materially and symbolically meaningful (see construction cleaning worker above). In this article, we explored data that gestures at the possibility that the value of work could function in ways other than solely putting immigrants at risk. We see some evidence that pride in work, and perhaps how pride is engaged when interacting with employers, may be intertwined with self-advocacy in ways that are intriguing and that challenges the dominant notion in the occupational health field that valuing leads to risk acceptance.

As we dove further into these narratives, a fledgling arc emerged that we believe could link aspects of the value of work with how workers navigate and counter the hazards that they face. The building agency theme features narratives about how workers take some measures to change their working conditions. These data were a clear and important feature of both studies. But we again grappled with searching for the mechanisms that enable workers to make the leap from accepting risks while valuing work, to begin to challenge those risks. We then asked, “How do workers begin to change the way in which they view themselves in a working environment that is often exploitative? Where does the sense of agency come from for them to take action to protect themselves?” These questions seek to understand how the value of work might function in efforts to empower workers to speak out against poor conditions.

As the value of work theme emerged unexpectedly in both studies, our research does not reflect a systematic investigation of the ways that the value of work functions in the lives of immigrants. If the value of work, pride, and respect play roles in overcoming risk, we know they are dependent on many factors that are beyond the sole control or responsibility of individual workers for creating safe conditions. Through these data, our hope is to add texture and complexity as “counter-stories” (Solórzano & Yosso, 2002) to the literature about how immigrant Latinx workers navigate low-wage work environments that may even extend to other marginalized worker groups.

Work as a Venue for Improving Health and Well-Being

We see the viable contribution that this exploration of value of work can make to improve workers’ health and well-being. We recognize that pride in performing well, a dimension of value of work, could be a double-edged sword, influencing workers to accept or, more dangerously, substantiate putting themselves at increased risk. However, using a broader SDH lens affords us to see the intersecting influences of immigration and low-wage work since most immigration is labor-based migration (DeGenova, 2002 in Flynn et al., 2015). As providers for their families in the United States and in their home countries, these experiences create the footing that generates the perceptions about the important role that work plays to the health of immigrant Latinx low-wage workers. We discuss previous related research that has paved the path for our perspective.

Prior research has found that low-wage work, despite its conditions, is very meaningful to immigrants (Markova et al., 2015; Montoya, 2016; Rosso et al., 2010). Eggerth and Flynn (2012) found that the theory of work adjustment (TWA) mapped onto aspects of Latino immigrant workers’ meanings of work in their qualitative study. This study also echoes some of the TWA dimensions, particularly around achievement (e.g., feeling purposeful, and able to do the job well), and to a lesser extent, status (e.g., recognition for a job well done). The qualities of fair treatment by the employer/supervisor and respect that are associated with the dimension of safety are closely related to our interpretation of one of the dimensions of pride we described. Consistent with this and other research (Bosmans et al., 2016), workers in our study clearly value other elements about work aside from job security and compensation. Eggerth and Flynn (2012) acknowledge in their discussion that pride could be involved in achieving job satisfaction.

One interpretation of the value of work is that it could facilitate the perspective that immigrants should bear hazardous work because a bad job is better than no job, or one in the United States is better than the conditions that propelled them to leave their home countries. Our study also provides an example of a counterposition to Flynn et al.’s (2015) theme of killing oneself to make a living. Bakker and Demerouti (2017) propose that when job resources of both low and high-status workers are low, for example, lack of social support, lack of appreciation, and low-quality relationship with a supervisor, engaging personal resources that influence perceptions of control over their environment, for example, optimism and self-efficacy, may become very important to minimize job strain and foment motivation. They further propose that motivation is linked to performing well. The participants in our study also expressed an intrinsic desire to perform well. While Bakker and Demerouti’s (2017) overall job demands-resources theory does not include work organization or social policies that structure individual worker experiences, their interpretations of these personal characteristics remain useful.

We posit that value of work, pride in performing well in particular, could play a role in taking on active coping strategies (Eggerth & Flynn, 2012). To complement how they and other researchers have interpreted how to mitigate occupational health disparities, we offer instead some preliminary evidence about how workers might counter reactive coping strategies and how they can be better supported to become active agents of collective change of their working conditions. Drawing on value of work to support the enhancement of personal resources may help with the ability to demand improved job resources for positive workplace change. Importantly, we do not refute worker disengagement; the need to minimize interactions with the environment that causes them harm is shaped by the organization of work that is deeply rooted in structural economic and political influences. We do not promote the optimization of job performance, nor for intervention programs to be limited to mere individual behavioral change but rather, we see this as an opportunity to draw on individual agency and nurture and channel it into collective spaces that help workers connect to one another, and thus generate stronger momentum to demand changes in the workplace.

Flynn et al. (2015) point to the fact that workers that initiated changes in their study had gotten support from worker-centered community-based organizations (WCBOs). While we did not screen for this particular characteristic, we recruited participants through WCBOs and we know that some of them had participated in their activities or services. This further supports the need to enhance community-based workplace health promotion intervention programs. To empower workers to make realistic changes, these programs should address the hazards of low-wage immigrant work, the structural influences that create harmful conditions, but highlight the positive coping strategies that brought them to the United States, and help them forge a life here. Building collective agency through this holistic perspective about the immigrant worker experience could bolster necessary alternative safety nets for these workers.

Some of our own previous research about disaster preparedness among construction day laborers from immigrant Latinx communities provides an analogous outlook on individual and collective efficacy. WCBO leaders reframed the locus of resilience from the individual to the community as a way to take, “collective action to advocate for positive change to improve conditions that existed prior to the disaster, thereby reducing its negative impacts and strengthening how a community responds to a future traumatic event” (Cuervo et al., 2017, p. S163).

Implications for Community-Based Intervention Design and Practice

Other research has shown that for workers the act of being involved in a participatory occupational health and safety intervention helps to build self-efficacy in the workplace (Punnett et al., 2013). Participation in that program has also supported the participation in workplace programs to improve their overall health and well-being contending that for workers, the positive feelings associated with making change at work are translated to making change in other aspects of their lives. As we have argued elsewhere (Baron et al., 2019), we propose that this workplace-based approach can be translated to community-based settings for immigrant workers. To bridge individual self-efficacy with collective action, we created a training module for our CBO partner, MRNY, titled, “Working with Workers: Talking About Workplace Safety and Health,” for community health workers (CHWs) to learn how to start a conversation about workplace exposures and identify hazards, how workplace exposures contribute to disease, health and safety rights of workers, and action planning. A goal is for workers to potentially better address their health-related issues. CHWs are further encouraged to guide their clients to talk with other workers at their workplace to identify opportunities for collective engagement.

Community health practitioners can implement community-based participatory research-based intervention strategies (see, for example, Arcury & Quandt, 2017; Vaughn et al., 2017), which tap into the more encompassing role that low-wage work plays in the health of Latinx immigrants. Other research similarly recommended for programs to draw on the values of immigrants (Greder & Reina, 2019). A general strategy would honor the hazards and stressors as well as the value of work to help directly foment self-efficacy. A possible method could be to scaffold the intervention approach by beginning with the workers’ dynamic experiences, introduce the core of the intervention and relate it to these experiences, and then add actionable steps they can take to protect and promote their health. This proposal extends the idea of drawing on counter-stories to inform strength-based perspectives to mitigating risk (Dill, 2017).

Our findings are in accordance with broader research on the role of empowerment training in promoting health and well-being. Findings from a World Health Organization report (Wallerstein, 2006) on the effectiveness of participatory empowerment strategies in public health projects differentiated between empowerment as an outcome and empowerment as a means to long-term improved health and reduced health disparities. It indicated that, “The most effective empowerment strategies are those that build on and reinforce authentic participation ensuring autonomy in decision-making, sense of community and local bonding, and psychological empowerment of the community members themselves” (p. 5). Results of a youth development program evaluation found a positive association with prosocial changes (Zimmerman et al., 2018). The program operationalized empowerment theory through a curriculum that addressed self-related indicators, including confidence (intrapersonal), critical thinking about community conditions and connections (interpersonal), and participation in a community change project (behavioral).

Limitations

This study has potential limitations. Our research focuses entirely on Latinx immigrants, and other immigrant groups with differing immigrant histories may experience their work environment differently. The occupations we targeted are gendered low-wage occupations that are more reflective of women Latinx immigrants than males. A third of all female immigrant workers are employed in the services sector, compared with only 19% of native born workers and a majority of those immigrant women work as cleaners or personal care workers (U.S. Bureau of Labor Statistics, 2019). Some of the themes we observed, such as performing well, may be tied in part to the nature of caring professions, as has been shown by others (Delp et al., 2010). However, our findings are comparable with some of our previous findings that have focused on more gender and occupationally diverse workers, including our own previously mentioned work regarding Latinx construction laborers (Cuervo et al., 2017). Finally, most of our participants were recruited through WCBOs, potentially influencing how they spoke about workplaces changes.

Future Research

It is essential to further develop a possible intervention approach for immigrant workers’ health and well-being. Systematic inquiry is needed to explore the value of work dimensions for immigrant Latinx low-wage workers, with a particular focus on the role of pride in work as a potential link to building a sense of agency to become empowered to make change. This could include interviews with workers and WCBO staff, and documentation of the discourse about work, health, and immigration that staff and other leaders use as they conduct, for example, classes, services, and leadership-building activities. This evidence could be used to generate a conceptual model with specific concepts that apply to existing or new interventions. Additional research is needed to determine whether our findings and intervention strategy are transferable to other low-wage/status workers that are not immigrants. Finally, future intervention research should test the effectiveness of integrating such a value of work approach.