Background
The immigration process and the marginalization related to truncated social support networks result in challenging psychological adjustments and can cause excess mental health complications in immigrant populations [
1]. Stressful experiences may result in schizophrenia, psychological distress, depression, and anxiety, as well as in post-traumatic stress disorder and suicidal ideation [
2‐
5].
Social science and medical research in the past two decades, particularly that conducted in North America, has extensively examined the health patterns of immigrants, who tend to be healthier than the native-born population at the time of their arrival in the country. This so-called “healthy migrant effect”, an advantage that tends to be lost over time, is probably the consequence of the poor socioeconomic conditions experienced by immigrants in the host country [
6,
7]. In particular, immigrants who experience discrimination or unfair treatment in their host country are more likely to experience a decline in self-reported health status, showing a clear inverse socioeconomic gradient with respect to increasing levels of feelings of sadness, depression, and loneliness [
6].
Migration to other countries may be due to war or poverty but may also be motivated by the aspiration to a better life. A fulfilling job can represent a key element in the process of integration in the host society [
8]; it can help promote economic independence, planning for the future, meeting members of the host society, learning the language of the host country, restoring self-esteem, and encouraging self-reliance [
9]. Work is a relevant dimension of the social gradient in health, being one of psychosocial domains that influence lifetime health conditions [
10].
In the case of immigrant workers, current evidence shows that the work organization and employment conditions they face are dangerous to their health. Indeed, immigrant workers are more likely to accept jobs that native workers are reluctant to perform, the so-called 3Ds (dangerous, dirty, degrading) [
11]. They are over-represented in precarious, informal jobs, often have no kind of protection or social safety net, suffer from stronger internal competition and discrimination, earn poverty wages, and experience more serious abuse and exploitation in the workplace than do natives [
11‐
13].
In the work environment, discrimination usually occurs when the actions of an employer, supervisor, or co-worker deny individuals or groups of people the equality of treatment they may wish [
14]. The workplace provides opportunities for stereotyping, prejudice, and discrimination [
15], in particular if it is systemic race-based discrimination [
16].
The literature reports that exposure to discrimination is widely understood as a social determinant of psychophysical health, as well as a contributing factor to health inequities between social groups [
17‐
19].
Strong associations between perceived racial discrimination and negative mental health outcomes such as depression and anxiety, psychological distress, and a decline in general well-being (e.g., self-esteem, life-satisfaction, quality of life) have been found in different countries and culture s[
17,
20‐
22]. Individuals who report higher levels or more severe forms of discrimination are exposed to a higher risk of poor health than those who experience discrimination less frequently [
12,
23‐
25].
However, despite the consistency of findings investigating the association between perceived racial discrimination and poor health, research has not adequately addressed the mechanisms and processes by which perceived racial/ethnic discrimination might adversely affect health. Mental health status among immigrants can also be affected by some personal experiences, such as perceived loneliness and life satisfaction. Loneliness has also been documented as relevant to perceived social isolation processes and as a strong predictor of other mental health problems as well as of physical health conditions, particularly in this group of often vulnerable individuals [
26].
According to the model proposed by Pascoe & Smart Richman [
27], discriminatory experiences may affect health through three pathways: directly, partially mediated through stress responses to a discriminatory event, or through health risk behaviors that may emerge as possible coping mechanisms when discrimination is experienced.
Due to the social and economic crisis that began in 2008, the scarce resources of the European (and specifically of the Italian) labour market have given rise to concerns among the native population that migrants are taking jobs away from them, thereby increasing competition, discrimination, and inequality in the workplace [
28,
29]. This climate of xenophobia and discrimination has impacted the lives of immigrants since they are the most deprived workers [
11]. A study based on a representative sample of all people residing in Italy found that the mental health status of both Italians and immigrants worsened between 2005 and 2013 (just before and after the global economic crisis), supporting the hypothesis that the worsening of socioeconomic conditions observed during this period could have contributed to mental health decline [
30].
In Italy, the number of resident immigrants has doubled, from 2.4 million people (4.1% of the resident population) in 2005 to 5.3 million (8.7%) in 2019 [
31].
Given this considerable increase, insight into the health status and quality of life of immigrants in Italy has become essential.
There are about 2.4 million immigrant workers employed in Italy (10.6% of the total workforce), almost 90% of whom are employed in the economic sectors “Other collective and personal services” (36.6%, including caregivers, domestic workers, babysitters, home care services operators), “Hotels and restaurants” (17.9%), “Agriculture” (17.9%) and “Construction” (17.2%). About 80% of immigrants in Italy, especially those from non-EU countries, work as manual workers. Overall, 86.5% of employed immigrants in Italy have an unskilled job, 26% more than native-born workers (the average of OECD countries is 65% for immigrants, with a 10% gap with natives). Moreover, 46.0% of non-EU workers and 50.8% of EU workers declare a high level of satisfaction, compared to 57.5% of Italian workers [
32]. Immigrants also present higher occupational injury risk than do Italian workers [
33,
34].
Although a previous study found that self-perceived workplace discrimination was more likely among immigrants than among Italians [
35], there are still few data on how discrimination affects the mental health of the immigrant workforce in Southern Europe [
12,
36].
Results
In the sample of 12,408 immigrants, individuals were mainly young (mean age 38.9 years, SD10.2), with an average length of stay in Italy equal to 10.7 years (SD 6.4).
Table
1 summarises the characteristics of the study population by MCS score. At the time of the interview, 83.1% of subjects were employed, while 16.9% had a work history in Italy but had lost their job. Most of the immigrants had a middle/low education level (61.3%) and came from Europe (61.3%). Of all interviewed subjects, 17.3% reported self-perceived discrimination in the workplace in Italy, 16.3% declared they felt lonely, and 44.4% felt low satisfaction with their life. Subjects who reported S-PWD had lower MCS mean scores than those who did not (51.4 vs 53.9), as did those who reported S-PL (50.2 vs 54.1) and those who reported having a low LS (51.6 vs 54.9). We found that a unitary increase of level of life satisfaction and PCS were associated with a 1.308 probability of increase and a 0.026 decrease in the MCS score, respectively.
Table 1
Individual characteristics and Mental Component Summary (MCS). SCIF survey 2011–2012
Categorical variables | n. | % | MCS score (mean ± SD) | p-value |
Self-perceived workplace discrimination | No | 10,262 | 82.7 | (53.9 ± 6.7) | < 0.0001 |
Yes | 2,146 | 17.3 | (51.4 ± 8.4) |
Self-perceived loneliness | No | 10,385 | 83.7 | (54.1 ± 6.5) | < 0.0001 |
Yes | 2,023 | 16.3 | (50.2 ± 9.1) |
Length of stay (years) | <=9 | 6,050 | 48.8 | (53.7 ± 6.8) | 0.04 |
> = 10 | 6,358 | 51.2 | (53.3 ± 7.4) |
Age group (years) | 15–39 | 6,746 | 54.4 | (53.9 ± 6.9) | < 0.0001 |
40–64 | 5,662 | 45.6 | (53.0 ± 7.4) |
Sex | Male | 6,217 | 50.1 | (53.8 ± 6.8) | < 0.0001 |
Female | 6,191 | 49.9 | (53.1 ± 7.4) |
Education level | High | 4,808 | 38.7 | (53.7 ± 7.2) | < 0.0001 |
Middle/Low | 7,600 | 61.3 | (53.3 ± 7.1) |
Employment status | Employed | 10,316 | 83.1 | (53.8 ± 6.7) | < 0.0001 |
Formerly employed | 2,092 | 16.9 | (51.8 ± 8.7) |
Area of origin | Europe | 7,604 | 61.3 | (53.4 ± 7.1) | < 0.0001 |
North Africa | 1,526 | 12.3 | (52.8 ± 7.7) |
Sub-Saharan Africa | 711 | 5.7 | (53.3 ± 7.3) |
Central-western Asia | 873 | 7 | (54.3 ± 6.1) |
East Asia / Pacific | 854 | 6.9 | (54.6 ± 6.2) |
The Americas | 840 | 6.8 | (53.3 ± 7.4) |
Discrete and continuous variables | n. | mean ± SD / median (IRQ) | MCS score (β coefficient) | p-value |
Level of life satisfaction | 1 more score value | 12,408 | 7.6 ± 1.6 / 8 (1) | β = 1.308 | < 0.0001 |
Physical Component Summary (PCS) | 1 more PCS value | 12,408 | 54.7 ± 5.6) / 56 (2) | β = − 0.026 | 0.022 |
Among immigrants who self-reported discrimination, 91.4% declared that the reason was due to being a foreigner, 29.2% to their way of speaking Italian, 15.7% to skin colour, 6.8% to religion; in 12.6% of cases the self-reported discrimination was gender-related (data not shown in table).
Table
2 shows the results of the univariate and multivariate linear regression models assessing the association between MCS score, S-PWD, and other factors. The MCS score was inversely associated with the presence of S-PWD (β:-1.737) and of S-PL (β:-2.653), and an unitary increment of PCS score (β:-0.089); it was directly associated with a unitary increment of LS (β:1.122). We also observed a statistically significant association between MCS score and a length of stay in Italy longer than 9 years (β:-0.719), having lost one’s job at the time of the survey (β:-1.502), being a woman (β:-0.726), and being 40–64 years old compared with subjects 15–39 years old (β:-0.618).
Table 2
Factors associated with Mental Component Summary (MCS). Crude and adjusted ß coefficients with 95% confidence intervals (CI). SCIF survey 2011–2012
Self-perceived workplace discrimination | No | 0 | – | – | – | 0 | – | – | – |
Yes | −2.496 | −2.824 | − 2.168 | < 0.0001 | − 1.737 | − 2.051 | −1.423 | < 0.0001 |
Self-perceived loneliness | No | 0 | – | – | – | 0 | – | – | – |
Yes | −3.898 | −4.230 | −3.566 | < 0.0001 | −2.653 | −2.982 | − 2.324 | < 0.0001 |
Level of life satisfaction | 1 more score value | 1.308 | 1.232 | 1.385 | < 0.0001 | 1.122 | 1.045 | 1.198 | < 0.0001 |
Physical Component Summary (PCS) | 1 more PCS score value | −0.026 | − 0.048 | − 0.004 | 0.022 | − 0.089 | − 0.110 | − 0.068 | < 0.0001 |
Length of stay (years) | <=9 | 0 | – | – | – | 0 | – | – | – |
> = 10 | −0.388 | − 0.639 | − 0.138 | 0.002 | − 0.719 | − 0.966 | −0.472 | < 0.0001 |
Age group (years) | 15–39 | 0 | – | – | – | 0 | – | – | – |
40–64 | −0.914 | −1.165 | −0.663 | < 0.0001 | − 0.618 | − 0.864 | −0.371 | < 0.0001 |
Sex | Male | 0 | – | – | – | 0 | – | – | – |
Female | −0.705 | − 0.955 | − 0.455 | < 0.0001 | − 0.726 | −0.975 | − 0.477 | < 0.0001 |
Education level | High | 0 | – | – | – | 0 | – | – | – |
Middle/Low | −0.308 | −0.565 | − 0.051 | 0.019 | 0.225 | −0.022 | 0.471 | 0.074 |
Employment status | Employed | 0 | – | – | – | 0 | – | – | – |
Formerly employed | −1.948 | −2.281 | −1.616 | < 0.0001 | −1.502 | − 1.821 | − 1.184 | < 0.0001 |
Area of origin | Europe | 0 | – | – | – | 0 | – | – | – |
North Africa | −0.597 | −0.988 | − 0.206 | 0.003 | − 0.079 | −0.458 | 0.300 | 0.684 |
Sub-Saharan Africa | −0.136 | −0.682 | 0.410 | 0.625 | 0.611 | 0.094 | 1.129 | 0.021 |
Central-western Asia | 0.902 | 0.404 | 1.400 | < 0.0001 | 0.979 | 0.506 | 1.452 | < 0.0001 |
East Asia / Pacific | 1.158 | 0.656 | 1.661 | < 0.0001 | 1.026 | 0.552 | 1.500 | < 0.0001 |
The Americas | −0.112 | −0.618 | 0.395 | 0.666 | −0.364 | − 0.840 | 0.111 | 0.133 |
Figure
1 summarizes the conceptual path analysis, showing the coefficients, adjusted for confounders, of the direct relationship between exposure factor (S-PWD) and outcome (MCS) and their indirect relationship decomposed into relationships between S-PWD and each mediating factor (S-PL, LS, PCS) and between each mediating factor and MCS. S-PWD was negatively associated with MCS (β
3:-1.780), PCS (β
1.3:-1.107), and LS (β
1.2:-0.463), while it was positively associated with S-PL (β
1.1:0.113). S-PL (β
2.1:-2.627) and PCS (β
2.3:-0.089) were negatively associated with MCS, that was positively associated with LS (β
2.2:1.116).
Table
3 shows the results from the path analysis, which decomposed the total effect of workplace discrimination on MCS into direct and indirect effects (the full path analysis output is shown in Additional file
1). The direct effect of S-PWD on MCS accounted for 71.3% of the total (β:-1.78 out of − 2.49). The proportion of total effect mediated by psychophysical factors was 28.7%, of which 11.9% was attributable to S-PL (indirect effect β
1.1*β
2.1:-0.30), 20.7% to LS (indirect effect β
1.2*β
2.2:-0.52), and 3.9% to PCS (indirect effect β
1.3*β
2.3:0.10).
Table 3
Path coefficients and proportion (*100) of effects of self-perceived workplace discrimination (S-PWD) on mental component summary (MCS) mediated by psychophysical factors. Results from path analysis model. SCIF survey 2011–2012
Direct of S-PWD on MCS | −1.78 | −2.09; −1.47 | 71.3 | 63.4 |
Indirect of S-PWD on MCS | −0.72 | −0.83; − 0.61 | 28.7 | 36.6 |
Indirect of S-PWD mediated by self-perceived loneliness on MCS | −0.30 | −0.36; − 0.24 | 11.9 | 11.9 |
Indirect of S-PWD mediated by level of life satisfaction on MCS | −0.52 | − 0.61; − 0.43 | 20.7 | 20.7 |
Indirect of S-PWD mediated by Physical Component Summary on MCS | 0.10 | 0.07; 0.13 | −3.9 | 3.9 |
Total of S-PWD on MCS | −2.49 | −2.82; − 2.17 | 100 | 100 |
In the path analysis, the likelihood-ratio test was LR = 1523.14 (number of degrees of freedom equal to k = 21), with the p-value (χ2k ≥ LR) < 0.001; this result indicates that the model with all predictors fit significantly better than the model with only the intercept.
Discussion
This study investigated whether self-perceived workplace discrimination has any role in the mental health status of immigrants living and working in Italy, taking into consideration other personal experiences like self-perceived loneliness, level of life satisfaction, and perceived physical health.
We hypothesized that S-PWD may affect MCS directly as well as through the influences of some psychophysical factors, personal experiences (e.g. S-PL and LS), and self-reported physical status. Our results underline and quantify the relationship between S-PWD and mental health outcomes, directly as well as through S-PL, LS, and PCS as mediators.
In our study S-PWD seemed to act on MCS both through a direct relationship, which we estimated as 68.9% of the total effect, and through an indirect relationship mediated by S-PL (11.9%), LS (20.7%), and PCS (3.9%). In particular, we observed a negative effect of S-PWD on MCS when it was mediated by S-PL and LS, while the indirect effect mediated by PCS was positive, as the product of two negative effects (S-PWD on PCS and PCS on MCS).
Our findings appear to support previous research that underlined the relationship between workplace discrimination and mental health in a large, heterogeneous immigrant sample [
17]. It would seem that self-perceived discrimination – whether suffered during a current or past job – can act as a predictor of alterations in self-perceived mental health, as already demonstrated by a number of other studies. In particular, perceived discrimination has been associated with mental health conditions such as anxiety, depression, fear, frustration, helplessness, hopelessness, paranoia, resentment, and low self-esteem [
12,
17,
20,
36,
44,
45].
Psychosocial risk factors, such as anxiety, insecurity, low self-esteem, social isolation, and the lack of control over work and home life increase the risk of poor mental and physical health. The lower people are in the social hierarchy of industrialized countries, the more common these problems become. In the case of immigrant workers self-reporting discrimination, for whom we can hypothesize long-term stress, these individuals become more vulnerable to a wide range of poor health conditions, acting as an accelerator of mental distress [
18,
36,
46,
47].
An explanation of this process can be found in the construction vs. deconstruction of professional and personal life projects of migrants [
48]. In fact, the process of immigration itself constitutes a pool of life projects and expectations of those people who decide to change their life. The status of these projects can thus greatly influence overall life satisfaction. Among migrants, these projects are usually work-oriented, devised and implemented to guarantee economic survival, obtain personal and professional satisfaction, obtain rights connected with having a residence permit, and improve social inclusion by becoming part of the host country [
49,
50].
Discrimination in the workplace can be extremely harmful, especially for immigrant populations, given that work (and its implications) is one of their priority objectives [
17,
25,
51,
52].
Overall, the literature shows that perceived discrimination in the workplace is a significant stressor for all population groups because one’s job represents a strong link with society; it is an important way to feel part of this new world [
12,
47]. Experiences of unfair treatment and daily difficulties for any reason can therefore have an impact on mental and physical health [
12,
23,
25].
The workplace is a social context where discrimination is experienced due to limited access to certain types of jobs, bad relationships between workers and management, or to the characteristics of the job itself [
45]. Not being valued and respected in the workplace, imbalanced job design, and occupational uncertainty may negatively affect mental health, as can interacting with individual personality characteristics, attitudes, and coping [
20].
Experiences of perceived discrimination may vary in relation to many contextual factors as well as to other personal and economic resources. Immigrants who experienced discrimination were most likely to report worsening self-reported mental health, with a higher risk of feelings of sadness, depression, and loneliness [
3,
6,
7,
11].
Our findings suggest that the low life satisfaction and perception of loneliness self-reported by immigrants in Italy could have a negative effect on their mental health status. Indeed, our results seem to support the hypothesis that discriminatory experiences may affect mental health through stress responses, which explain part of the effect on MCS of exposure to S-PWD, as suggested by the indirect negative effect of loneliness and low life satisfaction on MCS.
In our study, immigrants in almost all cases reported ethnic/cultural-related factors as the cause of their experience of discrimination in the workplace: being a foreigner, not speaking Italian well, skin colour, religion. It is interesting to underline that, unlike some other European countries, for example France or the United Kingdom, Italy has not experienced immigration from former colonies, with immigrants speaking the same language as in the host country, which means that integration may be even more difficult. In different countries, empirical evidence indicates a negative relationship between perceived ethnic discrimination and life satisfaction or sense of loneliness [
53].
Immigrants face the integration process with an inner sense of inadequacy with regard to the host country and the dominant culture. Losing one’s job or perceiving discrimination could generate a deep sense of self-isolation, perceived social exclusion, and low sense of self-efficacy. Inevitably, this could affect the well-being or mental health status of these persons [
7,
51].
Our findings of worse perceived mental health in people who had been in Italy longer than 10 years was similar to the findings of previous Canadian studies, which showed poorer mental health status among long-term immigrants than among recent immigrants [
54,
55]. It is interesting to note that in a previous study conducted in Italy, psychotic disorders were more frequently diagnosed in immigrants who had had a residence permit for a long time, i.e. those who had been living in the country longer, than in those who had been living in the country for a shorter amount of time [
56].
We also found that having lost one’s job (and therefore being unemployed at the time of the interview) may have negatively affected good mental health status among immigrants. In general, immigrants in a host country have invested considerably in personal projects [
51]. Achieving medium- or long-term personal goals is an important factor in their improved life-satisfaction [
53]. The literature shows that immigrants expect to be recognised as people who contribute to the receiving society in terms of experience and resources as well as in social and cultural wealth. They also expect their rights as citizens to be recognised at least to the degree that they were in their native country [
57]. A collapse of these expectations, such as job loss, could negatively affect their life satisfaction in the host country [
51,
53].
Strengths and limitations
The strength of this study is that it was conducted in a large sample of Italian immigrants, where the first generation still makes up most of the foreign population, which has been strongly affected by the economic crisis and which has been subjected to a concerning increase in xenophobic episodes. Further, because its geographical position makes it the most common port of entry to Europe and thus migration here has very specific and unique characteristics, Italy is the ideal setting to study immigrants in terms of their mental health as well. Moreover, to the best of our knowledge, there have been few studies in Southern Europe that have investigated the implications of perceived discrimination in the workplace [
12,
35,
36,
58].
Our study also extends existing research by examining the independent effects of mental health on other factors strictly related to the perception of one’s life condition. In particular, we considered the potential role of some personal experiences (loneliness, level of life satisfaction) and self-perceived physical health in the association between discrimination and self-perceived mental health.
One possible limitation of this study is that cross-sectional data can make it difficult to discern causality in the association observed. However, theoretical perspectives support the idea that perceived discrimination adversely affects mental health outcomes [
27].
Furthermore, this study relies exclusively on self-reporting, through variables measured by single questions, rather than on validated instruments. However, many of the current studies in this area involve perceptions of discriminatory treatment based on self-reporting of life events and personal experiences rather than on objectively observed discrimination [
27]. Moreover, it has been demonstrated that self-perceived health is a reliable predictor of mortality [
59], reason for which it has frequently been used as an outcome measure in numerous studies on immigrant health [
60].
Another limitation is that we did not have any information about the time frame, the regularity of discrimination experience, whether or not the immigrants had experienced discrimination in other areas of life, or information about income, a factor that leaves immigrants vulnerable to discrimination and is also associated with factors such as life satisfaction and physical health.
Finally, our decision to dichotomize some variables (education level, age, and length of stay) to obtain more robust estimates and to make the interpretation easier, may have produced an information loss about collected data, albeit modest, at least for categorical variables.
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