A Descriptive Study on Immigrant Workers in the Elderly Care Sector
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- Ortega, A., Carneiro, I.G. & Flyvholm, M. J Immigrant Minority Health (2010) 12: 699. doi:10.1007/s10903-009-9257-4
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The present descriptive study seeks to explore the differences in terms of psychosocial work characteristics and health & well-being indicators among Danes, Western and Non-western immigrants working in the elderly care sector; and to identify differences in the association patterns between these psychosocial work characteristics and health & well-being across these three groups. The study was based on a large-scale survey of the elderly care sector in Denmark with 78% response rate. Results show that Non-western immigrants had more depression symptoms, poorer quality of sleep and more client-related burnout than their Western immigrants and Danish colleagues. All in all, the associations between psychosocial work characteristics and health and well-being were much stronger among Danes than among immigrant workers and particularly weak among Non-western immigrants.
KeywordsImmigrantsElderly carePsychosocial work environmentHealth and well-being
The population aging process in the coming years will impose a series of challenges to many European countries, among them Denmark. A significant decrease in the population in the working ages (16 to 65 years old) is expected for the following years, along with an increase in the population over 65 years old. Immigrant workers are seen as a possible solution for this gap. Denmark, however, has one of the highest unemployment rates among immigrant among OECD-countries [1, 2]. Given the lower labour market participation rate among immigrants in Denmark, changes in the current integration policies in terms of labour market participation, as well as in the educational, economic and social integration policies will be needed in order to bring them into the labour market.
The elderly care sector has been under pressure due to difficulties to recruit and maintain social-health workers. Especially because this particular work sector has a negative stigma among the Danish population in terms of its work environment. In addition the elderly care work is typically associated with low status work, low pays and poor quality of life due to shifts work. Therefore, the recruitment of immigrants in this work sector has been encouraged through specific campaigns and incentives [3–5]. As result, technical education facilities have reported an increase in the number of immigrants attending social health care education: about 40% of the students have another ethnic background than Danish.1 Hence, the increased interests on descriptive studies to explore similarities and/or differences between immigrants integrated to the labour market and Danish workers in terms of socio-demographic characteristics, occupational health and work related issues (e.g., physical & psychosocial work environment).
Descriptive studies on immigrants working in this specific sector can be beneficial for better understanding of this group’s needs and the designing of appropriate policies to address specific work issues related to immigrants and their interaction in the workplace. The empirical evidence available shows significant differences in terms of age and labour participation. For example, Lindhardt and Frøland reported that in 2004 the labour participation rate was lower in all age groups for both Non-western and Western immigrants when compared to Danes . According to the Danish National Board of Industrial Injuries, there are no significant differences in the prevalence and/or incidence of work related accidents between immigrants and Danish workers . Similarly, according to more recent report on the psychosocial work environment in the Danish Elderly care  there are no significant differences between Danes and immigrants working in the Danish Elderly Care in terms of the physical work environment. However, Giver and colleagues found that overall immigrants reported their work environment to be positive, for example immigrant workers reported less quantitative and cognitive demands and more positive leadership qualities. According to the literature reviewed, in Scandinavian countries immigrants’ present comparatively higher prevalence of diabetes and heart and respiratory system diseases [9, 10]. Similarly, research shows that immigrants tend to have worse health than the general host country population [11–13]. Nonetheless, these studies define immigrants in different ways. Most define immigrants as all those non-natives, but other studies look into specific ethnicities or even a single ethnicity, such as Koreans, Mexicans etc. The studies on immigrant tend to use the western and non-western subdivision, as it is a definition introduced by the Bureau of Statistics in Denmark and well-accepted by the overall population.
This paper aims to contribute to the current, but limited knowledge on immigrant workers by presenting a broad view of immigrant workers in Denmark, their work environment and its association with health. In line with the contemporary stress perspectives,  poor or negative psychosocial work environment could give rise to stress response manifested through sleeping difficulties, burnout, depression symptoms and other psychosomatic symptoms (e.g., back pain) [15–17] Thus, the study seeks to explore further (a) the significant mean differences in terms of psychosocial work related factors and health and well-being indicators among Danes, Western and Non-western immigrant and Danish employees in the social and health care sector; and (b) to identify differences and/or similarities in the association patterns between these factors across these three groups.
The data used for this paper is part of a large cohort study investigating the work environment and health in the elderly care. For the purpose of this study, data stemmed from the baseline of “The Work Environment in the Danish Elderly care survey”. This questionnaire was distributed in 2005 to 12744 elderly care workers in 36 Danish municipalities. A total of 9949 people completed and returned the questionnaire comprising a 78.1% overall response rate; 79% response rate for Danes and 69% for immigrants.
The participants in the survey were all working in elderly care institutions in the 36 municipalities that agreed to participate in the project. The participants were mostly health-care helpers and health-care assistants whose work tasks involved practical and personal care of the elderly in the institutions, whether they were nursing homes, day-care centres or homecare organizations. However, also physiotherapists and nurses working with health related activities took part on the study, as well as people working in other activities related to elderly care (e.g., administrative stuff, and kitchen, cleaning and maintenance personnel). Those who responded to the survey corresponded to 13% of all people working in the elderly care in Denmark in 2004.
The questionnaire comprises questions on the following topics: the position and its activities; work hours; psychosocial work environment, Physical work environment; violence, threats, bullying and sexual harassment; health, well-being, mental health and work burnout; life style; sickness absence; physical capacity; and perception of quality in services. Information regarding work title/position, and organizational unit were obtained direct from administrative records from the municipalities.
We examine the psychosocial work environment, and the health and well-being of Danes and immigrants working in the Danish elderly care sector. Given the fact that we analyze the psycho-social work environment in this specific sector, we only looked at those employees working with clients/patients e.g., nurses, health care assistants and helpers,2 and physiotherapists.3 The information on employees’ position came directly from the municipalities involved. The reasons for excluding the group of administrative, cleaning and cooking positions from the study population (less than 1%) were: (1) The work tasks carried and responsibilities were different between health care workers and those selected out; and (2) those excluded have little contact with clients/patients. Hence, our final population consisted of 7409 people working in elderly care, for whom nationality and citizenship information was available. The response rate for Danes in the survey was 79% whereas for immigrants it was 69% (Western immigrants had a 75.5% response and non-western had a 60% response). Women’s response rate was 79% whereas men’s was 62%. The mean age of those responding was 45 whereas the mean age of non-respondents was 43 years.
In order to distinguish Danes from immigrants, we used the information on citizenship data, place of birth; parent’s citizenship and parent’s place of birth provided by the Central Personal Register to supplement the information obtain from the surveys. According to the Danish Bureau of Statistics definition of Immigrant, a person was defined as Dane, if at least one of the parents is both Danish citizen and born in Denmark. A person was defined as immigrant in all other cases. Children of immigrants born in Denmark were also defined as immigrant given their cultural ties to the parent’s origin .
The three most common groups among westerns immigrants were Polish, German and Norwegians. As for the non-western immigrants, the three most common groups were from Bosnia-Herzegovinian, Turkish and those from the Philippines. Overall the group of immigrants corresponded to the 8.5% of the entire population in Denmark, as per January 2006. Non-westerns corresponded to 70% of immigrants, compared to 30% of western ones. Among those individuals participating in the labour force, immigrants correspond to 7%. They represent 6% of all individuals working in social institutions (elderly-care is a part of this branch .
For the statistical analyses, respondents from Greenland and the Faroe Islands were classified as Danish. The immigrant group was further sub-divided into two groups: Western and Non-Western immigrants. The Western immigrants group consisted of all those who came from Nordic countries, the 25 EU-countries and/or from North America, Australia and New Zealand. The Non-Western consisted of people from all other countries. Our study population is composed of 7101 Danes (91%), 184 Western immigrants (2.3%) and 124 Non-Western immigrants (1.5%). Among immigrants from non-western countries 49% were not in the labour force, compared to 21% of Danes and 36% of Western immigrants .
Psychosocial Work Characteristics
Psychosocial work factors
Influence at work
Possibility of development
Meaning of work
Quality of sleep
Depression symptoms were measured using a modified version of the Major Depression Inventory . This scale consisted of 10 items that measure depression symptoms during the last 2 weeks on a 6 point-Likert scale with a final score range of 0 to 100 for each item. High scores in the scale indicate high depression symptoms. The psychometric property of this scale is presented in Table 1.
Client-related burnout was measured using a subscale of the Copenhagen Burnout Inventory . This subscale consists of six questions that measure prolonged physical and psychological exhaustion among people working with clients (e.g., patients, students, children, inmates, etc.) during the last two weeks. Three of the items had a five point-Likert response scale ranging from “to a very low degree” to “to a very high degree”; and the five-response category for the other three items ranged from “never” to “always” (for detail on the scale refer to Kristensen et al. ). The client-related burnout subscale scored from 0 to 100 points with high scores indicating high levels of burnout. The psychometric property of this scale is presented in Table 1.
Quality of sleep scale (COPSOQ)  was used to measure the quality of sleep respondents had in the last two weeks. The scale scored from 0 to 100 points with high scores indicating poor quality of sleep. The psychometric property of this scale is also shown in Table 1.
Musculoskeletal symptoms were measured using one question from the Standardized Nordic Questionnaire . Respondents were asked to indicate whether or not they had felt pain in neck-shoulder area and knee in the past 7 days.
To examine differences between Danes and the two groups of immigrants in terms of gender, age, occupational group, tenure and musculoskeletal symptoms we used Pearson chi-square test (χ2). Analysis of variance was used to explore significant differences between Western immigrants, Non-western immigrants and Danes in terms of depression symptoms, client-related burnout and quality of sleep. Zero order correlations were used to explore the pattern of association between work factors, depression symptoms, client-related burnout and quality of sleep among Danes, Western and Non-western immigrants working in the elderly care sector.
Demographic and other characteristics of the study sample
Danes n (%)
Western immigrants n (%)
Non-western immigrants n (%)
Social and health assistant
Social and health helper
Activity and physiotherapy
Less than a year
Neck and shoulder
Psychosocial work characteristics
Influence at work**
Possibility of development**
Meaning of work*
Health and wellbeing indicators
Quality of sleep**
The mean differences were observed  between Non-western immigrants and Danes and  between Non-western and Western immigrants in terms of depression symptoms, quality of sleep, client-related burnout influence at work and predictability. Also significant mean differences were observed  between non-western immigrants and Danes in terms of Possibility of development; and  between Non-western and Western immigrants in terms of depression symptoms, quality of sleep, client-related burnout, possibility of development, influence at work and predictability. More specifically, Non-western immigrants scored higher on influence at work and predictability, but they scored significantly lower on possibilities for development in comparison to Western immigrants and Danes. On the other hand, Western immigrants scored significantly lower in meaning of work (Table 3). These results indicate that, Non-western immigrants perceived the work environment more positively than their Western immigrant and Danish colleagues, and Western immigrants perceived their job less meaningful than Non-western and Danes.
The analyses of variance also indicate that Non-western immigrants scored significantly higher than their Danish and Western colleagues on depression symptoms, quality of sleep and client-related burnout. This shows that overall, Non-western immigrants have worse heath & well-being than their Danes & Western immigrants counterpart.
Zero order correlation for Danish employees
Quality of sleep
Influence at work
Possibility of development
Meaning of work
Zero order correlation for western immigrant employees
Quality of sleep
Influence at work
Possibility of development
Meaning of work
Zero order correlation for non-western immigrant employees
Quality of sleep
Influence at work
Possibility of development
Meaning of work
The present paper was a descriptive study that aimed to explore the significant means differences in terms of psychosocial work related factors and health and well-being indicators among Danes, Western and Non-western immigrant working in the Danish Elderly care; and to identify differences and/or similarities in the association patterns between these factors across these three groups.
This study has some important methodological strengths, as well as limitations. As strength, we can point to the fact that this study was based on a large-scale survey of the elderly care sector in Denmark with 78% response rate. Nonetheless the mean differences should be interpreted with caution as the large sample size can explain part of the mean differences reported in this study. Furthermore, a considerable proportion of immigrants working in this sector answered the questionnaire (n = 308, 69%); although lower than Danes (7101; 79%), it was possible to perform descriptive statistical analysis with little risk of incurring a type-II error. It could be argued that this difference in response could affect the correlation results of those variables that were on the limit to being significant. However, that would be the case if among many non-respondents there was a much stronger relationship between psychosocial work environment and health and well-being than the respondents. Considering that we have no reason to believe in such extreme deviation of non-respondents to respondents and since our results did not present cases of ‘borderline’ significant variables, we believe in our overall analysis, results and interpretation.
Due to the cross-sectional design of the study we cannot draw any conclusion regarding causality from the results obtained. It can be also argued that the inherent weakness of self-reported measures represents a limitation in this study. However, it is the individual’s appraisal of a situation that determines his/her behaviour and perception . Hence, by ignoring the appraisal components, studies that seek to explore the differences and/or similarities regarding the work environment and health between nationals and non-nationals might miss out on important cognitive and emotional processes .
The results of this study show that in comparison to Danes, immigrants have a different demographic profile. For example, immigrant workers in the elderly care sector are younger; they tend to be employed more often as health-care helpers and have been employed at their current work place for fewer years than Danes. Also, the results reveal that among immigrants there are more male than among Danes working in elderly care. These results are in line with the literature available on immigrants in the Danish labour market [7, 8].
In addition, we found that immigrants working in the Danish elderly care sector reported lower possibilities for development, and perceived their jobs less meaningful than their Danish colleagues. Non-western immigrants also report more depression symptoms, poorer quality of sleep and more client-related burnout than their Danish colleagues. Interestingly, it is the group of Western immigrants that perceive more negatively the work environment. These differences in the perception of the psychosocial work environment might be explained by cultural differences. The way, in which employees evaluate or assess, for example, the meaning of their work and the quality of leadership might mirror the employees’ cultural values and, therefore, their working values. Perhaps other factors related to immigrants understanding and interpreting the questions (e.g., language barriers, differences on the semantic meanings) might act as important intervening factors in these associations. Unfortunately, the data currently available does not allow investigating these possible intervening factors among immigrant workers.
The results also indicate that Non-western immigrants have higher mean scores on influence at work and predictability. Interestingly, it is also the group of Non-western immigrants that have no significant associations between influence at work and any of the health and well-being indicators; and predictability is only significantly associated to decrease client-related burnout. According to Peterson, there is a tendency for the majority group to ignore the values and beliefs of the minority groups, which possibly create an “us vs them” mentality . In order to survive in this type of work environment, minority employees would adopt the majority values system (e.g., attitudes, standards, ethical and ideological values), which they might not agree or would not be their normal values outside work. This would generate what Peterson calls ‘value incongruence’, which might be an intervening factor in their perception and/or appraisal of their influence, involvement and predictability at work. Therefore, it is possible that the incongruence in values might also influence the associations between positive work factors and positive health and well-being.
Furthermore, Non-western immigrants might have had a traumatic experience in their transition from their homeland to the host-country, in addition to the occupational and social downgrading, language difficulties, lack of social support that they might have encountered in the host-country. These could also act as intervening factors in the associations between positive psychosocial work characteristics and good health and well-being, hence the lack of significant associations found among the Non-western immigrant group.
Additionally, taken into account that the average year of service in their current work was 3.96 years (3.5) for non-western and 7.93 years (7.01) for western immigrants, it can be assumed that the immigrant population used in this study has been in the country for at least 4 years. In order to qualify as social-health care worker they must have completed a 3 years of language program and at least 1.2 years of technical education (those working as social-health assistant had completed a total of 2 years and 10 month of technical education). Previous study has shown that overtime individuals achieve more resources that help them adapt to the levels of stress in the work place . It can be argued, therefore, that immigrant workers in our population have developed effective coping strategies to deal with everyday occupational stress. Hence, the positive appraisal of their work environment in spite of their poor health.
Another factor to take into consideration is the fact that non-western immigrant women build their identities around being a mother and wife rather than their occupational roles or profession. As result, the fact that these women have succeed in learning a new language, obtaining an education and finding a job clashes with their patriarchal family values and context [10, 27]. In turn this discrepancy between women’s new economical role and traditional gender role attitudes could result in family conflicts and lack of support from family network, which can affect negatively these women’s mental health [28, 29]. So it is possible that work might represent getaway for them, that is, a place free of family conflicts and patriarchal domestic gender expectations.
These results suggest that there are other factors that might mediate or moderate the associations between psychosocial work environment and health & well-being among immigrant workers. However, the quantitative data on immigrants currently available does not allow us to understand the cognitive process behind their appraisal of the psychosocial work characteristics, neither the dynamics of the interrelation between psychosocial work environment, culture and health. Immigrants are a very heterogeneous group, with different cultural dimension (e.g., language, religion, expectations, etc.), which might shape their perception of the work environment and influence the way they might cope with work-related difficulties. Thus, the need for qualitative studies to better understand the how the perception of the psychosocial work characteristics might be associated to the cultural dimensions and value systems among immigrants in Europe.
For further information see: ‘Arbejdsmiljøforhold for SOSU-uddannede indvandrere i Danmark’, by Hanne Giver et al. (report published in Danish) or contact Hanne Giver at email@example.com.
Health-care helpers deliver personal or practical help to clients’ daily needs. Formal education for this group takes around a year and two moths, after which there is an option to continue further education for another year and eight months to become health care assistants. Health-care assistants carry out caring activity and tasks, which could include coordination and educational functions and arranging basic health and nursing tasks.
Physiotherapists treat physical injuries or dysfunction with exercises and other physical treatments of a physical disorder or injuries.