It has been suggested that immigration status alone is a social determinant of health (1). Indeed, immigration status impacts all areas of an individual’s life, including access to safe and healthy work environments (2). Occupational health disparities are more prevalent among immigrant populations who are at an increased risk of workplace morbidity and mortality (3). Immigrant populations, especially those without legal status, are more likely to work in physically demanding jobs that are hazardous, such as construction, agriculture, maintenance, and service occupations that have high incidence rates of nonfatal occupational injuries and illnesses (4, 5). Additionally, the workplace fatality rate is nearly 50% higher for Latino workers than their non-Latino counterparts (6).

As immigrant populations in the United States continue to expand, they will likely account for an increasing percentage of those working under high risk labor conditions. In the state of Georgia, one in eight workers is an immigrant, primarily concentrated in sectors with hazardous working conditions (e.g., manufacturing, construction) (7). Similarly, a retrospective review conducted at a high-volume Emergency Department in Atlanta revealed that of 267 non-English-speaking individuals hospitalized for an injury, nearly 25% were hospitalized for a work-related injury; 95% of whom were Spanish speaking (8). The high rate of work-related injuries among immigrant populations is likely multifactorial, including but not limited to language and communication barriers, lack of immigration status, discrimination and structural barriers to labor protections, training, provision, and use of safety equipment (4, 9). Those without legal status are more likely to be subject to predatory and exploitative labor practices due to fears of reports to immigration enforcement (10). Relatedly, immigrant populations make up a larger percentage of labor trafficking survivors, with the agricultural industry being the largest perpetrator, followed by domestic work and construction (11). It is important to note that immigrants are protected under federal laws. Occupational Safety and Health Administration (OSHA) protections apply to all workers, regardless of their legal status (12). Some states have ‘state plans’ that add additional protections to workers but that is note the case for the state in which this study occurred (Georgia) (13). Employers are thus responsible for following federal OSHA standards (12). OSHA has clearly defined worker rights and protections, noting that under OSHA standards, employees have the right to a safe and healthy work environment and protections from retaliation if advocating for this (14). This includes the right to file a complaint against an employer and be protected from relation via ‘whistleblower’ protections. The challenge is that not all of these protections are enforced and state laws protecting immigrant workers vary such that in some states, an individual without legal status may still face risks of ‘discovery’ by immigration enforcement if attempting to pursue a case (4). Accountability, enforcement, and weak penalties have also been cited as challenges at OSHA. The current OSHA budget does not appropriately cover staffing to process and enforce regulations and there are concerns about their actual ability to protect workers from retaliation (15). Despite existing initiatives that attempt to reach immigrant workers, including the development of Spanish-Language Compliance Assistance Resources and dedicated ‘Hispanic Outreach’ tools (training resources, compliance programs, etc.), immigrant workers remain exceptionally vulnerable and experience a disproportionate amount of work related injuries (16–18).

Experiences of safety and injury among Spanish-speaking workers has been studied previously however few studies explore perspectives of hospitalized patients. Prior studies have resulted in important interventions; however, despite the frequency with which patients present to the hospital for work related injuries, hospital-based interventions are lacking (19, 20). Additionally, interventions largely focus solely on injury prevention rather than emphasizing both injury prevention and Know Your Rights (KYR) training. Hospital settings may represent an important and understudied point of intervention for injury prevention and KYR programming. In collaboration with a local community organization, Sur Legal Collaborative (Sur Legal), we designed a study to characterize the contextual factors around work-related injuries requiring hospitalization, as well as knowledge of OSHA and workers rights among Spanish-speaking patients admitted to the hospital for a work related injury.

A total of eight interviews were completed with seven men and one woman. Participants self-identified as Latino or Hispanic and were from Mexico (n = 3), Guatemala (n = 3), Honduras (n = 1) and El Salvador (n = 1). The mean age was 39 with a range of 23–69 years old. The mean number of years living in the U.S. was 14 with a range of 3–30 years. All participants reported Spanish as their preferred language and two reported also speaking an indigenous language. They had worked in their current job for a range of 3 months to 8 years with a mean of 3.3 years. The highest level of education completed varied from 10 years of age (primary school) to 1 year of college with 14 years old being the mean age of highest education completed. Most did not have insurance (n = 6). See Table 1 for Themes and Representative Quotes.

Participants interviewed describe their work as the following: construction (framing the exterior of houses, installing sheetrock), ironing clothes (using a hand iron to iron clothes), landscaping/hardscaping (demolishing existing outdoor structures and building outdoor kitchens and decorative walls), sandblasting (cleaning/smoothing hard surfaces with a dedicated machine), painting (painting both inside and outside surfaces of residential houses/apartments), torchcutting (cutting metal materials with fire using a torch, roofing removing the existing roof and/or siding of residential buildings and replacing with new roof/siding). The mechanisms of injuries were highly variable and reported as the following: the participant working in landscaping/hardscaping noted his foot was run over by a large machine used to transport heavy materials; the participant working in sandblasting noted he was on a ladder pouring sand when he was struck by the material causing him to fall off a 10 foot ladder; the participant working as a torchbearer was attempting to remove aluminum that was stuck in his machine when it exploded because of the heat; the participant working as a painter reported falling from a ladder that became unsteady while he was painting; the participant working in construction noted he was on a ladder replacing sheetrock inside a house when the ladder became unstable and moved, causing him to fall; the participant who irons clothes described a steam burn from ironing; one of the participants working as a roofer describes falling from a room because the rope for his harness ran out while the other participant working as a roofer experienced a similar problem when the rope holding him to his harness slipped out from where it was tied, causing him to fall to the ground.

In this study, Spanish-speaking patients hospitalized for a work related injury acknowledged and essentially normalized the constant risks they face at work. The level of workplace safety procedures varied from strict daily procedures to no precautions and employer engagement in safety was a facilitator for creating a culture of workplace safety. Most participants had limited knowledge of OSHA and their rights as workers, many expressing an interest in wanting to work in safer environments.

Our findings are similar to other studies conducted in community settings in which Spanish-speaking workers acknowledged working in hazardous conditions, often out of necessity (23–25). Similarly, the employer’s commitment to safety was crucial yet the incorporation of safety procedures was highly inconsistent (24, 25). A study by Roelofs et al. explored perceptions of OSHA in more detail, noting that workers had varying opinions about the actual influence of OSHA standards on safety (24). This is important considering existing OSHA policies related to ‘workers rights’ clearly define the rights and protections of employees, requiring employers to maintain a workplace that is free of hazards.¹ Our findings suggest that OSHA regulations are not appropriately followed, leaving immigrant workers particularly vulnerable to injury. One minor theme that was noted in our study and reflected in others is the responsibility workers take for their own safety, recognizing employer limitations and the need and desire to protect themselves (23). Our findings combined with others suggest that employers can play a critical role in creating a culture of safety. However, we recognize that employers have varying levels of interest and incentives to do this and OSHA requirements appear to be poorly enforced.

Immigrant workers experience different layers of structural vulnerabilities, suggesting that perhaps immigration status is itself a risk factor for injury. The extraordinary unsafe occupational conditions Spanish-speaking workers face are not new and occupational disparities are well documented among this population (4–6). National organizations such as the Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH) have called for more research and tailored interventions specific to immigrant workers and several interventions have been documented. For example, a structured safety curriculum and mobile based video in Spanish with dairy workers at their work site, dissemination of safety posters, brochures and videos at the Mexican consulate, and a short educational video intervention in the community (19, 20, 26, 27). Multi-sector and multi-faceted strategies may be a key component in ensuring interventions address all levels, from individual to structural interventions; a true public health approach. To our knowledge, no hospital-based occupational injury prevention interventions for immigrant populations have been described.

Hospitals and health systems are increasingly recognized as having an important role in addressing social determinants of health and upstream factors that influence health (28). Hospital based injury prevention programs have been efficacious at reducing injury and violence at the point of care (29, 30). Implementing hospital based occupational injury prevention programs may be another important tool in addressing workplace injury. As noted at this study site, Spanish-speaking individuals routinely present to our hospital for work related injuries yet no culturally or linguistically tailored injury prevention intervention exists, leaving individuals who can return to work exposed to the same unsafe conditions that caused their injury. In addition to injury prevention strategies, it may be important to incorporate KYR training into a hospital based injury prevention toolkit given that participants had limited knowledge of their rights as workers. While KYR trainings have not been widely integrated in health settings, they are a routinely used strategy by civil liberties organizations (31, 32). This may be an important area for future research as few existing workplace interventions have incorporated KYR information. If individuals are unaware of their rights as workers, it may be difficult for them to advocate for safer work environments.

There are several limitations of our study. Interviews were conducted at a single hospital and thus may not be generalizable to other hospitals. Nonetheless, the hospital is the only Level 1 trauma and safety-net hospital, with a diverse patient population. Participants included were those who suffered a severe injury requiring hospitalization and themes may not necessarily reflect the experiences of those with injuries not requiring hospitalization or those who have not suffered an injury; however, the participants discussed previous injuries for which medical care was not sought. Interviews were conducted during the acute and/or subacute phase of the injury and may not capture the long term emotional and physical impacts of the injury. Most patients admitted to the hospital during this time period for work related injuries identified as men and only one woman was included in this study. Over half of immigrant women in the United States participate in the labor force, most commonly working in healthcare, hospitality, and food service. Immigrant women are also exposed to hazardous conditions, often work in informal sectors with woefully inadequate safety procedures or protection, and experience injury types that are different than men (33–35). The experiences of immigrant women are relatively understudied thus it is important that future studies explore the intersectionality of different identities (gender, race, ethnicity, immigration status) to better understand the experiences of all immigrant workers. Additionally, our study focused on traumatic work related injuries and did not explore non-injury related conditions. Previous studies have demonstrated that immigrant workers experience other occupational risks and occupational diseases with infectious diseases and metabolic cardiovascular disease being the most common (36). We did not include injured workers who spoke languages other than Spanish, who may face similar and unique challenges. Future studies should explore the experiences of diverse populations to better develop culturally and linguistically appropriate injury prevention and KYR resources. Finally, interviews were conducted in Spanish, transcribed, and translated into English thereafter. Coding and thematic analysis were performed utilizing English transcripts. As a result, it is possible that some words or concepts did not directly translate into English and therefore may have been unintentionally mistranslated and not incorporated into the analysis. However, this is unlikely as a professional transcription and translation service was used and coders were bilingual.

The role of Immigration as a Social Determinant of Health is important to consider when identifying injury and violence-related public health threats. Often, an individual’s immigration status can dictate their options for and access to employment. The occupations that may be accessible to immigrants are high risk, hazardous jobs, where injuries are common. Indeed, based on our findings, immigrant workers continue to normalize working in hazardous, injury prone conditions feeling that safety is their own personal responsibility, rather than their employers. Participants voiced how important it is for employers to have a culture of safety to protect workers and how that would add to their feeling of safety at the workplace. Yet, injury prevention mechanisms and protections are highly variable. The inconsistent safety training and safety procedures at work places suggest that OSHA and agencies have a bigger role to play in protecting workers. Moreover, it suggests that public health approaches to injury prevention must account for this, recognizing that immigration status alone is a risk factor for injury and thus a threat to public health. The first step when considering a public health approach to injury prevention is to define the problem and then identify risk and protective factors. In this study, we suggest that immigration, an important social determinant of health, may be a risk factor for injury requiring a public health approach to address the problem. Hospital settings are an important location for injury prevention strategies yet few hospital-based injury prevention interventions specific to immigrant populations exist. Future studies are needed to develop and test hospital-based injury prevention strategies that protect workers from injury. As few workers are aware of their rights, interventions that incorporate rights based education, particularly for high-risk jobs, will be an important component to empower and protect workers. Implementing hospital based occupational injury prevention programs may be another important public health tool in addressing workplace injury and requires further research.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Emory Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

AZ: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JC: Conceptualization, Data curation, Formal analysis, Investigation, Software, Writing – review & editing. HM: Formal analysis, Investigation, Software, Writing – review & editing. RC: Conceptualization, Formal analysis, Funding acquisition, Methodology, Resources, Supervision, Writing – review & editing. RS: Conceptualization, Formal analysis, Funding acquisition, Investigation, Resources, Supervision, Writing – review & editing. AS: Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Writing – review & editing. EZ: Conceptualization, Formal analysis, Funding acquisition, Investigation, Resources, Writing – review & editing. SA: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – review & editing.