- What are the individual and structural factors that put migrant farm workers in North America at risk of contracting HIV and other sexually transmitted infections?
Key take-home messages
- The instability and mobility of migrant farm workers create unique barriers to accessing health care services including: transportation, cultural, language, and legal barriers. These barriers may prevent the diagnosis and treatment of HIV and sexually transmitted infections (STIs), and encourage their transmission.
- Data on the behaviours of migrant farm workers show: lower rates of condom use; higher rates of use of workers in the sex trade; multiple sex partners; needle-sharing activities, and higher rates of substance use.
- Migrant farm workers may hold misconceptions about safer sex and HIV infection, as well as cultural values, beliefs, and customs that may facilitate HIV acquisition.
- Engagement in higher-risk behaviours may also be a direct response to daily stress of the migrant farming lifestyle, such as separation from family and community, lack of social support, and lack of control over working and living conditions.
The issue and why it’s important
It is estimated that between 25,000 and 30,000 farm workers temporarily migrate to Canada annually – most are employed in Ontario (approximately 17,000).(1) Migrant farm workers are at an increased risk of contracting HIV and other STIs due to the nature of their work, their lifestyle after arrival in Canada, and several other factors including: constant mobility; cultural, geographical, and linguistic barriers; limited education; limited access to health care; psychosocial conditions; low income and poverty; substandard housing; hazardous working conditions; low condom use; discrimination; use of workers in the sex trade; and social isolation.(2-9)
In the US, HIV prevalence rates among migrant farm workers are difficult to obtain as only 20-30% of migrant farm workers report being tested for HIV.(2;4) Research suggests that Mexican migrants may experience behavioural changes upon migration to the US increasing their likelihood of engaging in higher-risk behaviours.(3) Estimates suggest that HIV infection rates are higher among migrant farm workers than the general population – ranging from 3% to 13%.(5;9-11)
In Canada, HIV prevalence is more closely monitored among most migrant populations as the Seasonal Agricultural Workers Program, operated by the Canadian government, screens potential migrants for HIV and a variety of other medical conditions before their arrival. This mandatory HIV testing is required for all ethnic groups except Mexicans as it contradicts Mexican labour laws. The Mexican government and other participating Seasonal Agricultural Workers Program countries, however, use these medical tests as an opportunity to educate applicants about various health issues including HIV.(12;13)
What we found
Despite a thorough search of the academic literature, we were unable to find any systematic reviews or articles discussing the individual or structural factors that put Asian migrant farm workers at risk of contracting HIV and other STIs. We did, however, find a number of articles on Latino and Caribbean migrant farm workers which we have included.
Upon arrival in Canada or the US, many migrant farm workers are exposed to differing levels of acceptance of sexual behaviours and practices than they are used to in their home countries. They also experience less social control and feelings of loneliness and alienation.(6) Migrant farm workers are more likely to engage in higher-risk behaviours due to these feelings in addition to inadequate and overcrowded housing, and social and other forms of isolation.(3;4;6;14)
Studies report that migrant farm workers have higher rates of other STIs, including chlamydia, gonorrhoea, and human papillomavirus (HPV) compared to the general population.(15) Reported rates of STIs vary from 9% to 16%.(2;5;16) This is significant because STIs can increase susceptibility to HIV infection.(2;5;16)
Sex with multiple partners is one of the reasons migrant farm workers are often at higher risk for STIs and HIV infection. Studies from both the US and Canada note that migrant farm workers report high rates of using the services of workers in the sex trade,(2;4;5;8;16) often without condoms.(5) Migrant farm workers may also exchange sex for money and/or drugs, and may receive more for engaging in unprotected sex.(14;17;18) One study in California found that nearly 40% of male migrant farm workers had paid for sex, with only 30% using condoms during these encounters.(6)
Many studies in the US (2;4-6;8;10;16-19) and one in Canada (15) have reported low or inconsistent use of condoms among migrant farm workers. A study in California found that the majority of migrant farm workers reported not using any protection during intercourse, often because they reported being in a relationship and because they or their partner “didn’t like it.”(16) Another study in West Texas found that only 30% of participants had used condoms during vaginal or anal sex.(19) One explanation for this was the high cost and difficulties experienced in accessing condoms.(4)
Several authors also noted the use of illegal drugs among some migrant farm workers.(4;5) Both Canadian (15) and US studies (2;3;6;8;10;18;19) explain that the sharing of needles, for injections of vitamins, antibiotics, pain killers and steroids is primarily due to the cultural custom of self- medicating.(3;5) Alcohol and drug use is also common in this population, especially among men.(2;5-7) In one study in South Florida, 17% had used cocaine and 23% had used marijuana at some point in their lives.(2) This is relevant as increased use of alcohol and drugs has been shown to increase the likelihood of unprotected sex with multiple partners.(18)
Latino migrant farm workers come from a culture that emphasizes collectivist values, therefore the perception of lacking a support system has a substantial impact on this population.(20) Migrant farm workers are separated from their family and friends when moving overseas. Once they have migrated, they are physically isolated from nearby towns.(20) Separation from one’s social group may lead to loneliness, stress, anxiety, depression, boredom, and feelings of being misunderstood.(5;13;21) In turn, these can lead to increases in unprotected sex with multiple sex partners, same-sex partners, and alcohol and drug use.(9;13;19-22) It may also lead to relationship problems, domestic violence and psychiatric illness.(7) Other sources of psychological distress include lack of control over working and living environments, and workplace tension with supervisors and coworkers.(3;4;14;15)
Migrants usually come from a culture with different values, beliefs and customs. When arriving in Canada or the US, they enter a society more open and permissive with regards to sexual behaviours and drug use. This can increase the frequency in which migrant farm workers engage in these behaviours. They also tend to adopt new sexual practices (anal sex, same-gender partners).(3) Members of this community also tend to have fewer negotiation skills, and feelings of discomfort when discussing sex and sexuality. Migrant farm workers may also experience shame and embarrassment around the purchasing of condoms, using condoms, or requesting condoms to be used by their partners, thus increasing unsafe sex practices.(3;5;9)
Another cultural factor that affects condom use is the traditional beliefs surrounding it. Due to traditional gender roles, women often feel a sense of impurity and/or shame and therefore rarely discuss methods of protection with their partners.(13;16;18;23) There is also a belief among women that only promiscuous women wear condoms and this prevents them from wearing them with their husbands.(18;23) The risky behaviours of male sex partners may increase migrant women’s vulnerability to contracting HIV and other STIs.(5) For example, males are more likely to have multiple sex partners, and their girlfriends/wives often accept this with little discussion about sexuality and protection, putting them at an increased risk for HIV infection or to acquire STIs.(8-10;19)
Migrant farm workers’ knowledge about HIV is also often misguided. A study conducted in New York reported that about one third of participants believed HIV was no longer a problem in the US and that HIV testing was not necessary if one appeared healthy, and nearly 15% believed HIV was curable.(5) Although migrant farm workers understand the major modes of HIV transmission,(8;9) more than one quarter believed that the virus could be transmitted through coughing, kissing, eating from the same plate of a person infected with HIV, mosquito bites,(2;3;8) public bathrooms, that AIDS is solely a problem for homosexuals and drug addicts, that the test for HIV causes AIDS, and that one could determine by physical appearance if someone was infected.(5;23) Another study from South Florida found that 22% of participants had never heard of HIV even though 70% believed they knew a lot about HIV transmission.(2)
Migrant farm workers migrating to Canada through the Seasonal Agricultural Workers Program are usually educated on a variety of health issues including HIV. Jamaican and Mexican health officials use the health exams applicants must complete prior to acceptance into the Program as an opportunity to provide sexual health information. Applicants to the Program are normally given a talk and pamphlets on basic health issues. These health issues include HIV/AIDS, cancer, substance use, diabetes, condom use and basic hygiene.(14) Even with this information, cultural biases against using condoms still exist and many migrant farm workers report condoms being too expensive and difficult to obtain.(14)
Generally, migrant farm workers have poor knowledge about safer sex practices. (19). Even when there is some knowledge about STIs and safer sex, migrant farm workers may not have access and/or may not be able to afford condoms, and may feel embarrassed to receive condoms from their employers when access is provided.(13) Migrant farm workers’ low knowledge about HIV and safer sex practices may also be a significant factor in determining their engagement in higher-risk behaviours.
Few HIV prevention and treatment interventions and services are designed for migrant farm workers.(4) Furthermore, many migrant farm workers lack knowledge about health services (1;13;15) and are unaware of their rights and benefits.(13;14) Migrant farm workers may feel shame and embarrassment when seeking sexual health services and fear moral judgment for accessing such services.(13) They may also have lower levels of education, literacy (1) and English proficiency, thus making it difficult for them to access these services.
To access health care fully, migrant farm workers must know about a service, be able to afford the service, have the freedom to leave the property to access the service and have appropriate transportation and translation as part of the service.
Cost and Access to Health Care
In the US, lack of health insurance and high costs of health care prevents many migrant farm workers from receiving and accessing health services.(1;4;7;24) As a result, migrant farm workers are less likely to receive an early HIV diagnosis and treatment, increasing the possibility of transmission.(6) In addition, federally funded treatment programs for HIV are often not available to migrant farm workers (10) and few migrant farm workers know about these programs.(13;18)
Upon arriving in Ontario, migrant farm workers enrolled in the Seasonal Agricultural Workers Program are legally entitled to a health card. Many migrant farm workers, however, do not have access to their health cards due to bureaucratic problems and delays.(13) Employers who are charged with ensuring these individuals get their health cards may forget to take workers to collect their cards or may withhold health cards for safe keeping once they have them.(13) Many migrant farm workers do not know how to make claims resulting in 81% of workers having a health card, but only 7% knowing how to claim benefits.(14) Furthermore, when migrant farm workers arrive in medical centres without health cards, healthcare providers assume they have no coverage resulting in only 24% of workers receiving compensation when using health cards due to the health provider’s lack of knowledge in how to process claims, the worker’s lack of a permanent residential address or worker repatriation.(14) These high costs deter already financially taxed migrant farm workers from seeking medical attention. Additionally, many migrant farm workers may not understand they are entitled to free medical care and those who do may not have the ability to communicate this.(13) Medical and social services also hold traditional hours making it difficult for migrant farm workers to access these services. Migrant farm workers also work long hours and often do not seek health care while at work for fear of losing their job or being expelled from the work program.(1;4;7;13;25) This may encourage self-medication.(25)
Migrant farm workers may not seek health care services often due to elevated concerns with employment and housing, once they arrive in the US or Canada.(4) Even when migrants do seek health care, they often cannot get back for follow-up treatment or tests.(13)
Migrant farm workers often work in rural areas far from urban centres where social and health services are usually located. As a result, transportation or rather the lack of it, becomes a barrier to accessing necessary medical services.(1;4;7;13-15;24) Migrant farm workers must rely on employers, which may raise fears of deportation and privacy, or find other modes of transportation such as taxi or bicycling long distances.(13) To combat these transportation issues, some areas establish mobile medical clinics to attend to migrant farm workers. However, some farm owners prohibit health and other service providers from setting up on-site at farms or camps and some farm owners are reluctant to release workers for doctor visits.(13)
Cultural and Knowledge Barriers
Often language and cultural barriers between doctors and patients lead to misunderstandings and mistrust. Health care providers often lack sensitivity to different cultural norms, religions, values, alternative medical beliefs, and languages used by migrant farm workers.(4;15) Medical services often lack interpreters(13;24) and migrant farm workers often rely on non-medical personnel for translation including neighbours and relatives or clerical staff.(4;13) Language and cultural barriers also result in incomplete medical histories, misdiagnoses, unnecessary tests, poor patient education, non-adherence to medicines, and patient dissatisfaction, which in turn leads to underutilization of health services, distrust of Western medicine, and treatment failures.(1;3;4;11;13) Many migrant farm workers complain that Western doctors do not take their health complaints seriously and the patients are poorly treated. Many Spanish-speaking migrant farm workers prefer injecting medication to pills believing injected medications are stronger and superior.(13) These language and cultural barriers lead many migrant farm workers to avoid Western medical care, and encourage them to try and contact someone in their home country to access traditional medicines.(13;25)
Stigma surrounding homosexuality and HIV may also result in fewer migrant farm workers seeking medical care, testing, and HIV education. Migrant farm workers may fear that testing for or educating oneself about HIV signals to the community that they are infected with HIV or homosexual (18) which may result in discrimination and isolation from the migrant community network. Fear of positive STI test results leads to avoidance of testing, as migrants fear repatriation and exclusion from future work programs.(13)
In the US, half of all migrant farm workers are without valid immigration documents and many of these individuals face racism, discrimination and hostility from the communities in which they work.(4) This lack of legal status makes migrant farm workers vulnerable to deportation and may make them leery of government institutions including health care settings.(18) As a result, preventive care is rarely sought by migrant farm workers, instead medical attention is viewed as compulsory only when the health problem interferes with work or requires emergency care.(17)
In Canada, a migrant farm worker’s ability to work is directly related to physical health. Migrant farm workers are screened for a variety of health conditions prior to being enrolled in the Seasonal Agricultural Workers Program. As a result, migrant farm workers, fearing repatriation or loss of future Canadian employment, may be hesitant or unwilling to report injuries or illnesses. Similarly, migrants may be hesitant in applying for workers’ compensation or following through on treatment plans which may require work modification or work absences.(1;4;13-15;18;26) Instead, migrant farm workers rely on self-treatment through the use of herbal remedies, and over-the-counter medications, many of which are used by them to “treat” HIV symptoms.(18)
In Canada, the Seasonal Agricultural Workers Program provides certain social security protections including minimum wage, pension plans, vacation pay, workers compensation, and basic health care. Employer abuses, however, are well-documented.(14) It is the employers who are required to provide housing, meals, and registration of workers into provincial health care and worker compensation programs.(13;14) Workers become dependent on employers for enrollment into and explanation of these social programs. This reliance on employers for health care becomes further problematic when workers must rely on employers for transportation to medical institutions and translation of health information.(13;14;24) Aside from privacy concerns, when employers act as translators, migrant farm workers may fear being repatriated if they report being sick or injured, as migrants can and are repatriated at any time with no formal appeal.(1;13;15) This vulnerability makes accessing rights and entitlements difficult especially with no formal avenue available to complain about abuses.(15)
What we did
We searched Medline, Embase, PsychInfo and Social Work Abstracts, using a combination of text terms HIV AND (migrant farm OR agricultur* worker*). We also conducted Google searches using word combinations (migrant Asian farm workers HIV) and (migrant farm workers HIV). In addition, we reviewed references in all relevant studies found. All searches were limited to articles published since 2000 in English.
Factors that may impact local applicability
While the original request was specific to sexual health for Asian migrant farm workers in North America, there were no articles in this geographic location specific to this ethnic group. Therefore all articles included in this review involve individuals from the Caribbean, Mexico, or other Latin American countries. As a result, these findings may not be generalizable to individuals from ethnic groups not listed above.
- Pysklywec M, McLaughlin J, Tew M, Haines T. Doctors within borders: Meeting the health care needs of migrant farm workers in Canada. Canadian Medical Association Journal 2011;183(9):1039-43.
- Fernandez MI, Collazo JB, Hernan-dez N, Bowen GS, Varga LM, Vila CK et al. Predictors of HIV risk among Hispanic farm workers in South Florida: Women are at higher risk than men. AIDS and Behavior 2004;8(2):165-74.
- Magis-Rodriguez C, Lemp G, Her-nandez MT, Sanchez MA, Estrada F, Bravo-Garcia E. Going North: Mexican migrants and their vulner-ability to HIV. Journal of Acquired Immune Deficiency Syndromes 2009;51 Suppl 1:S21-S25.
- Augustave, W., Devore, R., Morel, W., and Troia, T. Migrant and sea-sonal farmworkers: Health care access and HIV/AIDS in this popu-lation. New York State Department of Health, AIDS Institute; 2007.
- National Center for Farmworker Health, Inc. HIV/AIDS Farmworker Factsheet. National Center for Farmworker Health, Inc.; 2011.
- Sanchez MA, Lemp GF, Magis-Rodriguez C, Bravo-Garcia E, Carter S, Ruiz JD. The epidemiology of HIV among Mexican migrants and re-cent immigrants in California and Mexico. Journal of Acquired Im-mune Deficiency Syndromes 2004;37 Suppl 4:S204-S214.
- Hansen E, Donohoe M. Health issues of migrant and seasonal farmworkers. Journal of Health Care for the Poor and Underserved 2003;14(2):153-64.
- Organista KC, Organista PB. Mi-grant laborers and AIDS in the United States: a review of the litera-ture. AIDS Education and Preven-tion 1997;9(1):83-93.
- Organista KC, Organista PB, Bola JR, Garcia de Alba JE, Castillo Mo-ran MA. Predictors of condom use in Mexican migrant laborers. Ameri-can Journal of Community Psychol-ogy 2000;28(2):245-65.
- Fitzgerald K, Chakraborty J, Shah T, Khuder S, Duggan J. HIV/AIDS knowledge among female migrant farm workers in the Midwest. Jour-nal of Immigrant Health 2003;5(1):29-36.
- Villarejo D. The health of U.S. hired farm workers. Annual Review of Public Health 2003;24:175-93.
- Gadon M, Chierici RM, Rios P. Afro-American migrant farmworkers: A culture in isolation. AIDS Care 2001;13(6):789-801.
- McLaughlin J. Trouble in our fields: Health and human rights among Mexican and Caribbean migrant farm workers in Canada University of Toronto; 2009.
- Barnes N. Is health a labour, citi-zenship or human right? Mexican seasonal agricultural workers in Leamington, Canada. Global Public Health 2013;[Epub ahead of print].
- McLaughlin, J. Migration and health: Implications for develop-ment. A case study of Mexican and Jamaican migrants in Canada’s seasonal agricultural workers pro-gram. Ottawa, Canada: FOCAL; 2009.
- Brammeier M, Chow JM, Samuel MC, Organista K, Miller J, Bolan G. Sexually transmitted diseases and risk behaviors among California farmworkers: Results from a popu-lation-based survey. The Journal of Rural Health 2008;24(3):279-84.
- Apostolopoulos Y, Sonmez S, Kronenfeld J, Castillo E, McLendon L, Smith D. STI/HIV risks for Mexi-can migrant laborers: Exploratory ethnographies. Journal of Immi-grant & Minority Health 2006;8(3):291-302.
- Persichino J, Ibarra L. HIV and Latino migrant workers in the USA. Ethnic and Racial Studies 2012;35(1):120-34.
- Varela-Ramirez A, Mejia A, Garcia D, Bader J, Aguilera RJ. HIV infec-tion and risk behavior of Hispanic farm workers at the west Texas-Mexico border. Ethnicity & Disease 2005;15(4 Suppl 5):S5-S6.
- Kim-Godwin YS, Bechtel GA. Stress among migrant and seasonal farm-workers in rural southeast North Carolina. The Journal of Rural Health 2004;20(3):271-8.
- Hovey JD, Booker V, Seligman LD. Using theatrical presentations as a means of disseminating knowledge of HIV/AIDS risk factors to migrant farmworkers: An evaluation of the effectiveness of the Informate program. Journal of Immigrant & Minority Health 2007;9(2):147-56.
- Weine SM, Kashuba AB. Labor migration and HIV risk: a systemat-ic review of the literature. AIDS and Behavior 2012;16(6):1605-21.
- Organista PB, Organista KC, Soloff PR. Exploring AIDS-related knowledge, attitudes, and behav-iors of female Mexican migrant workers. Health & Social Work 1998;23(2):96-103.
- Schmalzried HD, Fallon LF, Jr. Re-ducing barriers associated with delivering health care services to migratory agricultural workers. Rural and Remote Health 2012;12:2088.
- Horton S, Stewart A. Reasons for self-medication and perceptions of risk among Mexican migrant farm workers. Journal of Immigrant & Minority Health 2012;14(4):664-72.
- Edmunds K, Berman H, Basok T, Ford-Gilboe M, Forchuk C. The health of women temporary agricul-tural workers in Canada: A critical review of the literature. The Canadi-an Journal of Nursing Research 2011;43(4):68-91.
Rapid Response Service. Migrant Farm Workers and Sexual Health. Toronto, ON: Ontario HIV Treatment Network; July, 2013.
Joanna Kapusta, Laura Schöffel, David Gogolishvili, and Jason Globerman.