Quality of life, stress, occupation status of immigrants: predictors of psychological health condition among the gulf return migrants in India

INTRODUCTION

Millions of people leave their country and migrate for better employment opportunities along with decent payments abroad. However, migrant workers mostly lie at the bottom of the economic hierarchy at the destination place. They work hard and often are employed in precarious or insecure jobs without having an employment contract. Thus, lacking a guaranteed pay cheque and the risk of losing job creates uncertainty for the workers forcing them to accept risk prone job.¹ Research states that the instances of physical and mental health problems are much more frequent among people who have faced adversity at the destination, such as physical and verbal abuse, sexual assault, exploitation, ill-treatment, and labour- rights violation.² Migrants are likely to experience specific challenges with health and related issues due to the nature of being a migrant. Migrants also face problems with access to health care services due to discrimination, language and cultural barriers, low socio-economic status, and uncertain legal position.

The process of migration itself is not necessarily a health risk, but the conditions surrounding the process can increase health vulnerabilities.³ These may include place of destination, duration of stay, working and living situation at the destination, and accessibility and affordability of health care services.⁴ Besides, dietary changes and low exercise, financial constraints, occupational health hazards, and the lack of social network also have a significant impact on migrant’s health.^5,6 Work-related injuries and suicides are relatively common among migrants in GCC countries.⁴ It is also observed that the burden of non-communicable diseases, such as hypertension, cardiovascular diseases, diabetes and cancer, is also increasing among the migrant populations.⁷ However, poor lifestyle and working conditions of the migrants may have an adverse impact on their health status, and trigger their return.⁸ Occasionally, migrants are bound to return home due to ill-health, or chronic illnesses. Migrant workers are found to be among the most vulnerable members of society. They are often engaged in 3-D jobs- dirty, dangerous, and demanding.⁹ They work for more extended hours, and in worse conditions for less salary. Most importantly, these precarious workers may take higher risks on the job, as they have to work without required training or protective equipment, and unsafe working conditions. Mexican Migration Project 2009 revealed that return migrants had good health status in pre-migration stage. After returning, they have a higher prevalence of heart disease, psychiatric disorders, obesity, and smoking than non-migrants.¹⁰ Hypertension, cardiovascular diseases, diabetes, and cancer, are the most common no communicable diseases among migrant populations. Migrants return home with a wide range of health problems. Health impacts are not only restricted to physical health but linked with mental health outcome also. Lu demonstrates that more psychological disorders can be found among rural to urban migrants compared to non-migrants in rural China.¹¹ Loss and lack of social support magnify the mental health consequences of migration.¹² Psychological distress (24.1%) was found among returnees from the Middle East in Ethiopia.¹³ Feelings of distress and worthlessness were common among returnees who had returned as a failure when they could not find suitable jobs after return. Therefore, the main objective of the paper was to examine the occupational status, quality of life at the destination and its impact on psychological health, stress of the gulf return migrants in the Murshidabad district of West Bengal and determine its associated factors.

METHODS

Study area

West Bengal ranked 4^th in terms of granted emigration check required (ECR) (25539) for the Middle East countries. Two districts, namely Gopalganj and Siwan from Bihar, having the highest number of ECR obtained for the emigration to the gulf countries, followed by Murshidabad district in West Bengal. Murshidabad district consists of 5 sub-divisions (Jangipur, Berhampur, Kandi, Lalbagh, Domkal) and 26 blocks. Before starting the survey, a preliminary visit to the study area was made. Three blocks have a long history of gulf emigration such as Beldanga-I, Kandi, and Berhampur were selected for the study.

Methodology

From the selected villages, in discussion with the local people, gulf return household were listed. From this list, the gulf returnee’s household were selected. Information was collected from the households of return migrants and the returnees themselves.

Inclusion and exclusion criteria

Inclusion criteria for selection of the respondents was who had worked in any middle east countries for at least two years and returned to their villages at least one year before the survey were considered. However, we have excluded those people who returned on leave to villages.

330 gulf returnees were interviewed with the help of a structured interview schedule from those selected villages. Data collection was done from June to November 2019 in the Murshidabad district, West Bengal.

The study was based on both qualitative and quantitative techniques. Statistical methods like bivariate and multivariate techniques were used for the analysis in this paper. Binary logistic regression has been used to determine the significant predictors of self-rated psychological health condition among the return migrants. For this purpose, we have used a tool- self-reporting questionnaire (SRQ) to screen the mental disorder in patients contacting primary healthcare settings. It is a self or interviewer-administered measure of ‘psychological distresses. It does not provide any clinical diagnosis but gives a general idea about the prevalence of mental health problems. The SRQ-20 consists of the neurotic items only, which have to be answered in ‘yes’ or ‘no’. SRQ-20 is based on depressive symptoms, anxiety, and psychosomatic complaints and has been found to detect probable cases of common mental disorder with reasonable accuracy. The questions were written in a simple, easy to understand language and cover many important areas of psychopathology. The SRQ-20 items were scored dichotomously (0= no, symptom absent; 1= yes, symptom present) over a 30-day recall period to obtain a maximum score of 20. Item scores were summarized to get a total score. A score below or equal to 11 indicated that no symptoms had arisen in returnees, and the score above 11 signifies returnees have psychological problems. The SRQ-20 has been tested and validated in several developing countries 2. The internal consistency estimate of the SRQ-20 scale was high (Cronbach’s alpha=0.91). For this study, the SRQ-20 items were translated into the local language.

RESULTS

Background characteristics of the Gulf return migrants

Table 1 presents the socio-demographic and economic characteristics of the migrants after the return. Most of the returnees belonged to the young age group 20-40 year (72.5%), while the mean current age of return migrants was 35 years. However, the mean age of returnees at the time of return was 32.4 years. Most of the return migrants were young and mostly belonged to the Muslim religion (92.7%) and were married (82.7%). About 68 per cent of the return migrants stayed separately from their parents after returning to the village, while 32 per cent of returnees lived in a joint family after their return to the village.

Further, a higher proportion (40.4%) of returnees did not complete their primary level of education, while about 34.9 per cent of respondents attained primary level of education, and 20.6 per cent of the respondents had a secondary level of education. Most of the respondents migrated to the Gulf countries only once (87.3%), whereas 12.1 per cent of returnees migrated twice to gulf countries while only 0.6 per cent of respondents migrated thrice. Despite facing many living and working problems, 56.1 per cent desired to migrate again to the gulf countries. About 44.6 percent of return migrants were classified as failure, while 48.5 percent were classified as conservative. The majority of the migrants stated expiry of job contract (52.2 percent) followed by low wages (60 percent) and worst living and working condition at destination (18 percent), harsh behaviour of the employers (12 percentage) were the main causes for their return to villages (Figure 1).

Quality of life of the migrant workers in the gulf countries

Many respondents reported abuses at workplace in the destination. They faced multiple abuses by the mudirs (company supervisor). Verbal abuse was the most reported form of abuse (45.15 percent) while 27 percent returnees reported about physical injury while 12.42 percent returnees faced hazardous injury and 35.76 percent of returnees felt barriers in free movement in destination countries as the right to freedom of movement are restricted for the Indian migrants in the gulf countries (Figure 2). Migrants were allowed to move only with the permission of their employers. Further, in the gulf countries, iqama (identity card which is provided by their employers) is more important. Without iqama, migrants have no freedom of movement and are subject to arrest at any point of time.

“Those who were lucky enough got a promised job and salary, and good company. But the unfortunate one like me got cheated by the agent. My agent assured me that I would get a driver job with 1500 Riyals salary, but when I landed in Dubai, I came to know that my job would be in the agricultural field, and my salary would be 700 Riyals. I had to agree with this job. I was helpless”. (IDI-age-40 years, returned from Saudi Arabia).

Respondents faced multiple problems in living place at their destination country. Majority of the returnees (35%) faced an extreme hot climate at the place of destination. Several problems were reported by the respondents at the place of destination namely unhygienic living conditions (34%), poor toilet facilities (35%), and lack of safe drinking water (34.2%). About 27 percent respondents reported that they faced language problem as they could not get accustomed to the local language and hence had to suffer a lot at the destination. Almost everyone had to share their accommodation with several people (95%). They did not have any scope to cook their meal as cooking was not allowed in many of the camps (25%) for that, returnees had to depend on mess food (Figure 3).

Note- Since there are multiple responses, the percentage is more than 100

“I got office cleaning work with a salary of 700 Riyals at destination place. They provided me one small room at the terrace of the office. It was in a very bad condition and was a nightmare for me. The room was built by tin material. There was no AC, and I had to stay in 38-42^oC. I felt sick because of this unhygienic environment. They never consider us as a human being. Due to my illness, I returned to my village. I will never migrate again. Whatever I can earn, I want to settle in my village”. (IDI-age-29 return migrants, destination country- Saudi Arabia).

Occupation status of the return migrants

Occupation status before their emigration and while in the gulf countries

Table 2 presents a significant variation in the occupations of migrants before their emigration and while in the gulf countries. Before emigration, more than 56 per cent of migrants engaged in agricultural activity. Among them, few managed to secure semiskilled (5.4%) and skilled jobs (21%), but the majority of them got unskilled work (73.6%) abroad. At the same time, 6.4 per cent of them were involved as constructional workers and 7 per cent as a daily wage worker. Around 27 per cent were unemployed before emigration. While in the gulf countries, primarily emigrants were engaged (69%) in unskilled work. Few returnees managed to do semiskilled (9%) and skilled works (22%) at the destination. From this table, it is clear that mostly emigrants were not engaged in skilled works at their origin place before their emigration, and also they considered jobs whatever came to them at the destination. They even accepted menial jobs in the gulf countries.

“I spent Rs 80 thousand for getting a work visa. My agent informed me that I had to work as a cleaner in a hospital. So, from the first day of my migration journey, I knew about my job profile and accepted it. Most of the villagers are engaged in farming, and they earn very less out of it. In Saudi Arabia, you will get a good salary even for some menial job also. It is better to do a cleaning job there (destination) than doing agricultural work in the village. I used to do overtime to get more money to remit a good amount of money to my wife in the village. But if I had stayed in the village, I would never have achieved what I have today. After returning, I worked in a construction site, but I have to migrate again within few years as I want to earn more money”. (IDI-38 years old return migrant from Dubai, engaged in cleaning work at destination)

Occupation status in the pre-migration phase and the post-return period

Significant changes in the occupations of migrants were seen between the pre-migration phase and the post-return period in Table 3. Sizeable proportions were unemployed (27%) before emigration, but this percentage has been reduced to 13.6 per cent after the return.

“I was very happy with my job in Saudi Arabia. I was working as a salesman in a shopping mall there. All the time, I was dressed in a good manner. I completed my higher secondary education from a madrasa in my village. So, with this qualification, I got a very good job there (Saudi Arabia). I was familiar with the Arabic language and would speak it fluently. I earned about 1700 Riyals and used to send money every month to my family. I returned to the village after my contract got expired. Now fifteen months have passed, but still, I am unable to find any suitable jobs. I will not do farming or any day labour work as I am not used to it. Hope I’ll get a good job or a salesman job in my village or nearest town or else I’ll again emigrate. It is challenging to find any suitable job in the village, but in Saudi Arabia, you will get good salaried jobs”. (IDI- return from Saudi Arabia, 30 years old return migrant, unemployed after return).

More than 40 per cent of returnees were engaged in the agricultural field after their return. They had their land to cultivate, but after returning, the percentage of farmworkers decreased to 13 percent. The rate of construction workers (14%) increased after return period than before emigration period (6%). On the other hand, the percentage of daily workers reduced to 3 per cent than before the emigration phase (7%).

The noticeable feature about the activity status among the gulf returnees was self–employment. Before emigration, only 7 per cent of them were engaged in self-employed works. Returnees invest their money in small enterprises. It resulted in a sizeable increase in self-employment (20 per cent) among the returnees. A few returnees, who were earlier unemployed, also started their own business. To maintain a good lifestyle, they run their small business (grocery shops, betel stall, chicken firm, packaged water supply, etc.). The low level of literacy among returnees acts as a hindrance to get a better-skilled job in origin. But, no one among the returnee was a prominent entrepreneur nor had a sufficient amount of money to start a small industrial unit where they could also employ others.

“I had Kapil visa. I spent around 1 lakh on my emigration. It was mentioned that I was appointed as a driver in Kapil’s house on my visa. So, I was very happy to migrate with this job. But after reaching there (destination), I came to know that I had to paint 12 flats of my Kapil (employers). Being a graduate student, I did not agree to do so. I used to work for 20 hours there and felt very useless. After I returned home, I got admission to a computer course. Now I am working in a computer centre. Now, I feel more comfortable and satisfied with my job.” (IDI- 29 years old returnee, working at computer centre after return).

Occupational mobility between the pre-emigration and post-return period

In this study, we have categorized the occupational status of the gulf return migrants in three groups, i.e. upward, downward and no occupational movement. Table 4 shows that about 35 per cent of returnees got upward movement in their occupation after their return. While most (46%) had no change in occupation, about 19 per cent of the returnees had downward occupational mobility after their return.

Psychological health status of the gulf return migrants

Table 5 presents the psychological health condition among the return migrants in Murshidabad district. The most frequent symptom of psychological health problem as reported by the respondent was repeated headache followed by low food appetite, irregular sleep pattern, getting tired too easily, and easily anxious. On an average, 93% of the respondents reported of repeated headache, 92% reported of low food appetite, 87% stated of irregular sleep pattern. A large number of respondents complained of getting tired too early (84%), easily getting anxious (72%), and always feeling exhausted (72%). About 60% of the respondents reported loss of satisfactions and feeling of valueless. More than half of the respondents stated of losing interest in life (55%). About one-third of the respondents stated that they lack proper thinking ability (36%), while few developed the feeling of committing suicide (15%). High prevalence of psychological health issues among the gulf returnees was observed in this study (60%) (Table 6).

Table 7 presents the results from the binary logistic regression for self-reported psychological health condition of the return migrants in the Murshidabad district of West Bengal. SRQ (self-reported psychological health) has been taken as a dependent variable, coded as 0 ‘having no psychological problems’ and 1 ‘having psychological problems among returnees after the return’.

***p<0.01, **p<0.05, *p<0.10; ®- Reference category

Factors such as age at the time of return, downward occupational mobility after return, typology of returnees, feeling sick in the destination country, duration of stay in destination countries, and reasons for return were found to be significant predictors of psychological health status of the gulf returnees. Returnees aged 40-50 were 2.68 times more likely to have psychological health problems (95% CI: 1.17, 6.14) than those in 18-28 aged groups. In the case of the typology of return migrants, failures were 6.76 times more likely (95% CI: 1.92, 50.01) to have psychological health problems than those who returned as innovators. Returnees, who had fallen sick at the place of destination were 2.9 times (95% CI: 1.60, 5.32) more likely to have psychological health problems compared to those who had not fallen sick. Those who migrated to Kuwait were 10 times (95% CI: 1.91.109.35) more likely to have psychological health issues than those who migrated to Saudi Arabia. Returnees who stayed for 6-9 years in the destination were 2.7 times (95% CI: 1.94, 7.99) more likely to have psychological health problems than those who have stayed less than five years in destinations. Returnees those who faced downward occupational mobility after return faced 1.15 times (95% CI: 0.55,2.34) more psychological health problem than those who have faced upward occupational mobility after return. Similarly, returnees who stated ‘prefer to work at origin’ as their reasons for return were 0.73 times less likely to have psychological health problems than returnees who said that ‘expire of contract’ was their main reasons for return.

“I was upset, felt very low, and went through a stage of depression after returning to my village. I did not feel like speaking to my children also. I was facing a double burden, as I was having health issues as well as not getting suitable work in the village. It was a big loss for me as I returned home like an unsuccessful returnee.” (IDI- 37 years old return migrant, returned as failure).

DISCUSSION

The paper discussed the quality of life of immigrants in the gulf countries. Occupational status, stress of migrants in their whole migration process and its impact on psychological health condition of the return migrants in the Murshidabad district of West Bengal. Davies had thrown some light on the literature related to the poor health condition of migrants. He believed that due to low wages, poor housing, unhealthy food, and difficulty accessing health services promote poor health among migrants.⁴ Migrants often return home less healthy than when they left for emigration. Sometimes, migrants are forced to return home due to ill-health, chronic diseases, and they usually prefer to return or die in their place of origin, if their migration journey is not successful. The study showed that a very high percentage of returnees faced mental health problems and severe somatic distress after the return. However, it did not prove that migration was only the main reason. But the whole migration process may significantly impact on returnee’s mental health condition. Our findings are consistent with the previous study that more unemployment rate at the origin, more expectation of family members, and peer pressure after return were the most common factors for the poor mental health problems. A study was conducted among the Ethiopian return migrants from the Middle East country with the SRQ questionnaire’s help. The study showed similar findings that the prevalence of psychological problems among return migrants was very high due to lack of pre-migration preparation, unsafe migration, faced physical, verbal abuses, mistreatment, exploitation.¹⁴ This study revealed among the 89 unemployed emigrants before emigration, around half were unemployed after the return, because firstly, the unemployment situation is more common in origin place. Secondly, the most important reason was the changing attitudes and aspirations of returnees. They considered their previous job as a low-status job and hesitated to do the same job after returning. Many returnees aspire to improve the socio-economic status after the return. They believe that if they do the same job after returning, it would be very shameful. They would be considered as failure returnee to others. This kind of attitude was more common among the young aged returnees. Simultaneously, their educational attainments were not very conducive, and most of them were engaged as unskilled workers aboard. In this situation, many returnees preferred to remain unemployed and wait for better opportunities to secure their position and status after the return, However, the stay of the emigrants in the gulf is very short as their emigration is on a contractual basis. It is challenging for this short duration to adopt new skills and implement those skills after returning to the origin.

The study showed that the majority of return migrants were suffering from depression, anxiety disorder and faced post return stress. The study revealed that almost half of the respondents returned as a failure so after returned they faced peer pressure and huge family expectations to maintain a good lifestyle as there is a myth about return migrants as whoever return from gulf countries, they earn a lot money and lead a good life after return but if someone fails to fulfil the expectation of others then they pointed out as failure returnees. This social pressure impacted their psychological health.

A systematic review based on 33 articles on the gulf return migrants in Nepal explored that returnee had faced multiple occupational health hazards, along with mental health problems.¹⁵ Low awareness and stigma towards mental health illness is the main hindrance to mitigate the situation. A study conducted in Nepal with repatriated migrants from the Middle East countries also indicated similar findings that return migrants in Nepal were affected by depressive disorder.^16-20 Our study revealed that migrants experienced traumatic conditions in terms of exploitation and mistreatment in the workplace. They had to face living and food-related problems, and few were exposed to abuses. A quantitative study done in Bangladesh showed similar results that migrants faced a higher burden of hypertension and mental illness due to the harsh conditions of migration.²¹

CONCLUSION

The study tries to lighten up the psychological health condition of the unskilled and semiskilled gulf return migrants in India. They are at risk of developing mental health problems. Special attention should be paid to this issue as mental health is a neglected domain in health research. Post-return counselling and generating employment opportunities for the returnees is some ways to handle this problem. Mental health services should be implemented for migrants in both origin and destination countries.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Students Research Ethics Committee of the International Institute for Population Sciences, Mumbai, India

REFERENCES

1. 1. Moyce SC, Schenker M. Migrant workers and their occupational health and safety. Ann Rev Public Health. 2018;39:351-65.
2. 2. Zeleke W, Minaye A, Kygana G. Mental health and somatic distress among Ethiopian migrant returnees from the Middle East. Int J Ment Health Psychiatr. 2015;1:2.
3. 3. IOM. Standing Committee on Programmes and Finance SCPF/12. Migration and health. IOM’s programmes and perspectives: towards a multi-sectoral approach. Geneva: International Organization for Migration; 2008.
4. 4. Davies AA, Borland RM, Blake C, West HE. The dynamics of health and return migration. PLoS Med. 2011;8(6):e1001046.
5. 5. Hargreaves S, Rustage K, Nellums LB, McAlpine A, Pocock N, Devakumar D, et al. Occupational health outcomes among international migrant workers: a systematic review and meta-analysis. Lancet Glob Health. 2019;7(7):e872-82.
6. 6. Zapata-Villa C, Agudelo-Suárez AA, Cardona-Arango D, Ronda-Pérez E. Health status and experience of the migrant workers returned from Spain to Colombia: A qualitative approach. J Immigr Minor Health. 2018;20(6):1404-14.
7. 7. World Health Organization. Gender disparities in mental health. World Health Organization. Department of Mental Health and Substance Dependence. Geneva, Switzerland; 2004.
8. 8. Petreski M. Does Return Migration Affect Health Outcomes in Macedonia? CEI Working Paper Series 2016-5, Center for Economic Institutions, Institute of Economic Research, Hitotsubashi University. 2016.
9. 9. Quandt SA, Arcury‐Quandt AE, Lawlor EJ, Carrillo L, Marín AJ, Grzywacz JG, et al. 3‐D jobs and health disparities: The health implications of Latino chicken catchers’ working conditions. Am J Indust Med. 2013;56(2):206-15.
10. 10. Ullmann SH, Goldman N, Massey DS. Healthier before they migrate, less healthy when they return? The health of returned migrants in Mexico. Soc Sci Med. 2011;73(3):421-8.
11. 11. Lu Y, Qin L. Healthy migrant and salmon bias hypotheses: a study of health and internal migration in China. Soc Sci Med. 2014;102:41-8.
12. 12. Hunter LM, Simon DH. Might climate change the “healthy migrant” effect? Glob Environ Change. 2017;47:133-42.
13. 13. Wiking E, Johansson SE, Sundquist J. Ethnicity, acculturation, and self-reported health. A population-based study among immigrants from Poland, Turkey, and Iran in Sweden. J Epidemiol Community Health. 2004;58(7):574-82.
14. 14. Tilahun M, Workicho A, Angaw DA. Common mental disorders and its associated factors and mental health care services for Ethiopian labour migrants returned from Middle East countries in Addis Ababa, Ethiopia. BMC Health Serv Res. 2020;20(1):1-3.
15. 15. Paudyal P, Kulasabanathan K, Cassell JA, Memon A, Simkhada P, Wasti SP. Health and well-being issues of Nepalese migrant workers in the Gulf Cooperation Council countries and Malaysia: a systematic review. BMJ Open. 2020;10(10):e038439.
16. 16. Chapagai M, Pant SB, Tulachan P, Dhungana S. Psychiatric morbidity among repatriated Nepalese foreign labor migrants- a hospital-based study. J Inst Med. 2017;41(1).
17. 17. Donato KM, Caron L, Hamilton E. Migration and mental health in Mexico: domestic migrants, return US migrants, and non-migrants. Front Psychiatr. 2020;10:970.
18. 18. Arachchi SH. Violation of migrant women worker’s rights in middle-east. Int J Arts Commerce. 2013;2(2):332-47.
19. 19. Nisrane BL, Ossewaarde R, Need A. The exploitation narratives and coping strategies of Ethiopian women return migrants from the Arabian Gulf. Gender Place Culture. 2020;27(4):568-86.
20. 20. Simkhada P, Van Teijlingen E, Gurung M, Wasti SP. A survey of health problems of Nepalese female migrants workers in the Middle-East and Malaysia. BMC Int Health Hum Rights. 2018;18(1):1-7.
21. 21. Kuhn R, Barham T, Razzaque A, Turner P. Health and well-being of male international migrants and non-migrants in Bangladesh: a cross-sectional follow-up study. PLoS Med. 2020;17(3):e1003081.