Essential, yet precarious, mistreated, sick and medicalized: a sequential explanatory mixed-methods study on homecare aides in Spain

Background Homecare aides (HCAs) are professional non-family caregivers, who support dependent individuals to live at home with dignity; yet, in Spain, they remain understudied and vulnerable, often facing precarious working conditions. We aimed to characterize HCAs’ employment, living conditions, health, and exposure to workplace violence and harassment, considering migrant background as a key axis of inequality. Methods We conducted a sequential explanatory mixed-methods study. Quantitative data came from an online respondent-driven sampling survey of n=324 HCAs across Spain, with stratified analyses by migrant background. Qualitative data were obtained through three focus groups and analyzed using qualitative content analysis. Findings were triangulated during interpretation. Results The findings suggest that precariousness extends beyond the workplace, affecting everyday life, social relationships, and health. Quantitative results showed poorer health, higher exposure to workplace violence, and greater drug use among migrant HCAs. While the qualitative data did not fully account for these differences, they offered insight into possible underlying mechanisms, such as physically demanding work and lack of resources. Qualitative findings also confirmed greater exposure to different forms of violence and sexual harassment among migrant HCAs, while revealing broader gendered patterns of violence affecting the occupation as a whole. Conclusions A vicious circle of poverty, poor health, and workplace violence/discrimination emerges, described by HCAs as being “poor and enslaved”. Migration background influences inequalities, but widespread structural precariousness tends to homogenize experiences, while gender dynamics further shape vulnerability. Urgent intersectional policies are needed to ensure decent work and protect HCAs’ health 6and rights.