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Social Science & Medicine 57 (2003) 769–774
Psychological distress among Thai migrant workers in Israel Jennifer Griffina, Varda Soskolneb,* b
a 6001 W. Mary Ct. Visalia, CA 93277, USA School of Social Work, Bar-Ilan University, Ramat-Gan, and Hadassah Medical Organization, Jerusalem, Israel
Abstract The purpose of this cross-sectional study was to examine the associations between migration stressors and psychological distress among Thai migrant agricultural workers in Israel, and to examine the direct and indirect contribution of socio-cultural variables to this relationship. Two hundred and twenty-one Thai male workers were interviewed using a structured questionnaire that included demographic variables and occupational exposures to organophosphate pesticides (as control variables), migration stressors, intervening variables (traditional health beliefs, social support, drinking behavior, and utilization of medical services), and a psychological distress scale. In multivariate analysis, migration stressors, the migrants’ traditional health beliefs, quality of current social relationships, drinking behavior, as well as age and occupational exposure were significantly associated with psychological distress. Workers who reported higher migration stressors (perceived the migration to be difficult, and often felt homesick), those with higher levels of traditional health beliefs, those whose social relationships with other Thai co-workers were poor, those who consumed either no alcohol or large amounts of alcohol, and those who reported ‘‘problem drinking’’ had significantly higher levels of psychological distress. A moderating effect of the quality of social relationships with coworkers on the association between homesickness and psychological distress was found. Additionally, migrants aged 28–34 and those who were experiencing eye irritation from chemicals at work had significantly increased levels of distress. The findings demonstrate the focal role of specific migration stressors and the current socio-cultural context on psychological distress of migrant workers. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Thai migrant workers; Stress; Psychological distress; Traditional beliefs; Social support; Israel
1. Introduction Trends in economic globalization and widening disparities between countries have increased migration to many countries, including Israel (Bartram, 1998; Stalker, 1994). While migration may offer economic benefits, physical health problems and psychological distress are often results of the social stress involved in moving from one’s country (Chung & Kagawa-Singer, 1993; Shuval, 1993), reduced security in daily life (Sundquist, 1994), and experiences of alienation and discrimination (Kaplan & Marks, 1990). Using the stress process paradigm (Folkman, 1997; Pearlin, Menaghan, *Corresponding author. Tel.: +972-3-531-7806; fax: +9723-534-7228. E-mail address:
[email protected] (V. Soskolne).
Lieberman, & Mullan, 1981), psychosocial mediators of the migration-health link, such as social support (Flaherty, Kohn, Levav, & Birz, 1988), hardy personalities (Kuo & Tsai, 1986), beliefs and other factors inherent in the sending culture (Alderete, Vega, Kolody, & Aguilar-Gaxiola, 2000) have been examined.
Thai migrant agricultural workers in Israel Thai foreign workers make up 26% of the total agricultural workforce in Israel, with more than 20,000 legally employed workers (Central Bureau of Statistics, 1999). Approximately 14,000 of these workers are employed through the Moshavim Movement, a collective of cooperative agricultural villages called Moshavim. Most agricultural migrants in Israel are male farmers
0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 4 4 7 - 1
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from northeastern Thailand and are known as ThaiIsaan (Cohen, 1999). Migrating to Israel involves profound changes in the Thai migrant workers’ social, environmental, and cultural context. Many workers migrate without their families or existing social networks. Life in Israel limits opportunities for normative behaviors for young Thai men, such as drinking with friends and ‘‘going about’’ (pai tiao) (VanLandingham, Knodel, Saengtienchai, & Pramualratana, 1998). Israeli Moshavim farmers indicated that drinking among Thai workers is moderate, with occasional incidents of problem drinking. Environmental changes in migrating to Israel include occupational exposures to organophosphate pesticides, still commonly used in Moshavim (Richter et al., 1992). Organophosphate pesticide exposures may result in psychological effects such as anxiety, depression, irritability, and restlessness (Mearns, Dunn, & Lees-Haley, 1994). Thai–Isaan beliefs about health incorporate animist and Buddhist elements, including the use of amulets, spirit houses, meditation, and traditional medicines. Of particular significance to migrants is the belief that moving or changing jobs can result in the loss of one or more of an individual’s thirty-two souls that reside in the body. The baci ceremony is used to bind one’s souls in times of change in order to prevent soul loss and subsequent ill health (Westermeyer, 1988). To date, no study has examined social stress, living context, working conditions, and psychological distress of non-Jewish migrant populations in Israel. The purpose of this study was to examine the associations between migration stressors and psychological distress among Thai migrants, and to examine the direct and indirect contribution of intervening variables (traditional health beliefs, social support, health behaviors and utilization of medical services) on this relationship, controlling for sociodemographic variables and occupational exposures.
Participants and methods Male migrant workers employed in Israel for at least one month were drawn from the 14,000 legal Thai agricultural workers employed through the Moshavim Movement (in mid-2000). In a two-stage sampling process, nine Moshavim were randomly selected by size of the Thai migrant population: six small-to-medium sized Moshavim, and three large Moshavim (100 Thai workers or more). In each of the Moshavim, a convenience sample was used due to time and financial constraints. Thai workers were asked to attend a meeting where they were informed about the study and completed the questionnaire in small groups. While the response rate of those who attended the meetings was high (>99%) overall, between 25% and 87% of the workers were interviewed in any individual
Moshav. The final sample included 221 participants. We believe that there was no major selection bias in participation. Age and the duration of time since migration of the participants were similar to the total population of Thai workers (data from the Moshavim Movement). Some differences may have occurred in the final convenience sample as those who did not attend the meetings were generally working at the time of the interview. The structured questionnaire was translated from English into Thai by a professional translator, was reviewed by a senior researcher in Bangkok, and was back-translated into English by Thai translators in Israel. The questionnaire included: (1) control variables; (2) migration stressors; (3) psychological distress; and (4) intervening beliefs, social and behavioral variables. Control variables: Socio-demographics included age, years of education, marital status, and region in Thailand. Occupational exposures included smelling irritating chemical odors, experiencing eye irritation from chemicals, and experiencing skin or clothing contamination from chemicals. Migration stressors: Variables were designed to assess aspects of migration stress within the specific context of the workers’ lives. Objective measures included: duration of migration, previous migration to other countries, whether the worker migrated to family or friends, and English/Hebrew proficiency. Subjective measures included: the pre-migration perception of migration, pre-migration feelings about migration, and current frequency of homesickness. Psychological distress: A 9-item scale, originally developed to address the major forms of distress (depression and anxiety) in Thai internal migrants was used. The response categories range on a four-point Likert scale (from ‘1’ never, to ‘4’ often), with a dichotomous response to one item (‘1’ no, ‘2’ yes). The developers reported good validity, a single underlying factor and an alpha coefficient of 0.84 (Fuller, Edwards, Sermsri, & Vorakitphokatorn, 1993). In this study, the alpha coefficient was 0.82. Intervening variables: (a) Health beliefs: Based on known traditional health beliefs held by Thai–Isaan (Westermeyer, 1988), a 4-item scale of the importance of traditional health practices was developed for the study: using traditional medicines, having a baci ceremony to prevent soul loss, having a spirit house, and wearing an amulet (Cronbach’s alpha =0.59). (b) Social support and relationships with peers: Perceived support was measured by a 3-item scale (Cronbach’s alpha =0.63) that determined the current frequency of: (1) receiving practical assistance if sick and confined to bed; (2) having friends to ‘‘go around with’’ (pai tiao) and; (3) having a confidante. Adequacy of similar short-form (2–4 item) scales of social support has
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been reported in other studies of psychosocial factors (Karlsson, Sjostrom, & Sullivan, 1995). In addition, perceived quality of relationships with other Thai workers on the Moshav was measured by a single item. (c) Health behaviors: Alcohol consumption was measured by one single factor, volume of weekly drinking, a combination of the frequency and quantity of beer and vodka consumption (Rehm, 1998). A second question investigated if the respondent ever ‘‘feels bad’’ about drinking. (d) Utilization of health services: The number of doctor visits was dichotomized into use vs. non-use since migration. For univariate analyses, Student’s t-test, one-way analyses of variance, and Pearson’s correlation were used to measure associations with psychological distress. A multiple general linear model (GLM) was conducted for the multivariate analysis. Variables significant at po0:25 in the univariate analysis were included, with control variables, migration stressors, and the size of the Thai population in the Moshav being entered first, intervening variables and their interaction terms with migration stressors (to examine modifying effects) entered second. Variables from the first and second steps that remained significant at po0:10 were included simultaneously in the final linear regression, with the significance level set at po0:05:
Results Fifty percent of the migrant workers were between 21 and 30 years old and had low levels of education (70% had 6 or less years). The majority (89.6%) came from northeastern Thailand, were married (81.9%), and had children (76.9%). Many workers reported occupational exposures, with 81.4% smelling irritating chemical odors, 60.7% experiencing eye irritation from chemicals, and 64.5% experiencing clothing/skin contamination from chemicals at work. Most Thai migrants, while having lived in Israel for more than one year (64%), having immigrated to friends (54%) or family (23%), having some ability to speak English or Hebrew (61%), and having previous migration experiences (46%), report expectations of migration difficulties (85%) and felt homesick (74%). As presented in Table 1, Thai migrants tended to hold some traditional beliefs (M ¼ 2:4; SD=0.72), had moderate levels of social support (M ¼ 8:3; SD=2.2) but with some poor relationships with peers (53%), and drank moderately (53.4 had 1–7 drinks per week); 61% had some ability to speak Hebrew or English. Finally, they reported moderate levels of psychological distress (M ¼ 18:8; SD=5.0). The univariate and multiple linear model for the three groups of variables on psychological distress are
Table 1 Intervening variables (N ¼ 2162221)
and
Variables
Percent
Health beliefs Traditional beliefs scale Social support Perceived social support scale Poor quality of peer relationshipsa Health behavior Total alcohol/week None 1–2 drinks 3–7 drinks 8 or more drinks Feel bad about drinkinga Utilization of services Ever utilized medical services in Israela
771
psychological
distress
Mean (SD, range) 2.4 (0.72, 0.5–4.0) 8.3 (2.2, 3.0–12.0)
53.0
19.0 38.0 15.4 27.6 48.9
42.2
Psychological distress 18.8 (4.98, 9.0–31.0) a
Dichotomous variable.
presented in Table 2. The multiple linear model explained 34.4% of the variance in psychological distress. Two migration stressors remained associated with psychological distress. Workers who felt that migration would be difficult or very difficult reported greater psychological distress (approximately 2 scale points higher) compared to those who reported easy migration. Additionally, workers who were homesick frequently were more distressed compared to those who were infrequently homesick. The intervening and control variables associated with greater distress were high levels of traditional beliefs, poor quality of social relationships, drinking behaviors, younger age, and reporting eye irritation from chemicals. Only one interaction, between homesickness and the quality of social relationships, was significant. Among the workers who perceived their social relationships to be very good, there was a clear ordinal association, namely psychological distress was higher when homesickness was frequent. However, the workers who perceived their social relationships to be poor had relatively high levels of psychological distress regardless of the frequency of homesickness.
Discussion and implications The results of this study supported the hypothesis that migration stressors would be associated with higher
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Table 2 Analysis of psychological distress as a function of control variables, migration stressors, and intervening variables Variables
Control Variables Age p26 27–30 31–34 X35 Smell irritating chemical odors Yes No Eye irritation from chemicals Yes No Clothing/skin chemical contamination Yes No Migration Stressors Previous migration experience Yes No Pre-migration perception of migration Very difficult Difficult Easy Feel homesick in the past month Frequently Infrequently Intervening Variables Quality of peer relationships Not so good/Poor Very good Total alcohol per week 8 or more drinks 3–7 drinks 1–2 drinks None Feel bad about drinking Yes No Utilization of Services Yes No Traditional beliefs scale Perceived social support scale Interaction term Homesickb Quality of peer relationships
Univariate analysis
Multivariate analysisa
Mean (SD)
B
95% CI for B
(4.6)c (5.3) (4.7) (4.8)
1.45 3.29 2.88 —
0.08–2.97 1.81–4.76 1.41–4.35 —
174 41
19.4 (4.7)d 16.1 (5.1)
N/I
129 85
20.1 (4.6)d 16.9 (4.9)
2.62 —
135 77
19.7 (4.7)d 17.1 (4.9)
N/I
98 116
19.4 (4.9) 18.3 (5.1)
N/I
89 94 33
19.3 (5.0) 18.8 (4.9) 17.6 (4.9)
118 98
113 103
N
51 53 60 52
18.7 19.6 20.1 16.8
F
7.93d
1.54–3.69 —
22.99d
2.00 2.11 —
0.29–3.72 0.44–3.78 —
3.29b
19.7 (5.0)c 17.6 (4.7)
1.43 —
0.38–2.49 —
7.17c
20.2 (4.8)d 17.3 (4.7)
2.82 —
1.62–4.03 —
21.32d
(4.5)b (4.8) (5.0) (5.2)
1.82 1.86 — 1.47
0.47–3.18 0.17–3.55 — 0.17–2.95
106 110
19.9 (4.5)d 17.1 (5.2)
2.03 —
0.88–3.18 —
91 123
19.6 (4.9)b 18.2 (5.0) Pearson’s Correlation 0.220d 0.014
N/I
50 51 85 29
214 213
20.2 18.7 17.7 20.1
3.36b
12.20d
N/A N/I
7.15c
N/A
4.26c
a
Final multiple linear model (GLM) includes only the variables that remained in the model. R2 =0.39, Adjusted R2 =0.34. po0.05. c po0.01. d po0.001. N/I= Not included in the final model. N/A=not applicable and — represents the reference group. b
levels of psychological distress, and the significant role of cultural and social intervening factors. In the case of Thai migrant workers in Israel, sociocultural and
occupational variables, including traditional beliefs, poor social relationships, drinking behaviors, and occupational exposures, unique to the present migrant
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status of the workers, were found to be significantly associated with their psychological health. Thai migrant workers in Israel reported psychological distress levels similar to those of a Bangkok sample of internal Thai migrants (mean=18.4775.86, Fuller, 2000). This may indicate that rural–urban migration in Thailand, or migration to other countries entails comparable consequences for psychological distress despite the differences in culture and location. Two migration stressors significantly associated with psychological distress in the multivariate analysis relate to different aspects. While the one stressor, premigration perception of the ease of migration could have been subject to retrospective recall bias, homesickness was a concurrent stressor that was experienced by 74% of the men. This rate is more than double the rate (32%) of homesickness while overseas reported by Thai migrant workers after returning to their homes, highlighting the problematic use of retrospective reporting of stress (Jirojwong, Chutangkorn, & Leelakraiwan, 2000). The significant association of homesickness and psychological distress is consistent with previous evidence of its extensive negative effects (VanTilburg, Vingerhoets, & VanHeck, 1996). Intervening variables in the stress and health model, namely the current context of the migrant’s beliefs, social support, and behavior, were all related to distress. The finding that maintaining traditional beliefs is related to greater distress contradicts previous research in other migrants (Alderete et al., 2000; Escobar, Gara, & Compton, 1998; Palinkas & Pickwell, 1995). The different nature of migration in these studies, being permanent or temporary, may partially explain this contradiction. The significant association of coworker support with psychological distress, and its interaction with homesickness, reaffirms the protective, buffering role of social support among individuals in general (Berkman, Glass, Brissette, & Seeman, 2000) and migrants in particular (Chung & Kagawa-Singer, 1993; Rousseau, Drapeau, & Corin, 1997). These associations with distress highlight the importance of measuring variables proximate to the individual’s life, rather than general perceptions of available support. The J-shaped association of drinking behaviors with psychological distress (heavy drinkers and non-drinkers had higher psychological distress scores than did light to moderate users of alcohol) has been previously described among Latino migrant populations (Goldberg, Soleas, & Levesque, 1999). Yet, not only the volume of drinking but also the self-image of the drinkers, as measured by feeling bad about drinking, was significantly associated with psychological distress. The only sociodemographic variable associated with psychological distress was age, with migrants having a monotonic increase in psychological distress until the
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age of 35 and older, in which there was a dramatic drop in the level of psychological distress. Similar findings have been reported in Asian migrant populations (Abbott, Wong, Williams, Au, & Young, 2000; Fuller, 2000), contradicting the consensus in the migrant literature which has generally placed adolescents and the elderly at the highest levels of risk (Chung & Kagawa-Singer, 1993; Sundquist, 1994). A more thorough investigation of this association in East and Southeast Asian migrant populations is required. Additionally, this study demonstrates that the specific occupational hazard of Thai agricultural workers’ exposure to pesticides must be considered as a contributing factor to psychological distress, similar to the proven associations between anti-cholinesterase pesticides and depression (Bazylewicz-Walczak, Majczakowa, & Szymczak, 1999; Parron, Hernandez, Pla, & Villanueva, 1996). Although the cross-sectional nature of this study limits any comment on causality, it demonstrates the focal role of the specific migration context on psychological distress. Even though some potential differences may exist between the participants and non-participants, the consistency of the findings with theoretical predictions and research findings in other migrant samples is an indication of their generalizability. To date, this research provides the most comprehensive study of factors associated with psychological distress among Thai labor migrants in Israel, and provides a needed baseline for futures studies and for interventions that target their social, cultural, and occupational context.
Acknowledgements We would like to thank the Thai migrant workers for their participation in the study. Thank you to Dr. Vipan Prachuabmoh and Ms. Mayuree Nokyoungthong from Chulalongkorn University in Bangkok for translating the questionnaire. Special thanks to the Moshavim Movement, the manpower companies, and the local Israeli coordinators and farmers for their excellent cooperation in reaching the Thai workers, and to the Thai coordinators in the Moshavim who assisted in the interviews.
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