BRIEF COMMUNICATION COMUNICACIÓN BREVE
Social stressors, social support, and mental health among Haitian migrants in the Dominican Republic
Factores estresantes sociales, apoyo social y salud mental en los migrantes haitianos de la República Dominicana
Bonnie N. KaiserI; Hunter M. KeysII; Jennifer FosterIII; Brandon A. KohrtIV
IDuke Global Health Institute, Duke University, Durham, North Carolina, United States of America. Send correspondence to: Bonnie N. Kaiser, email@example.com
IIAmsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
IIISchool of Nursing, Emory University, Atlanta, Georgia, United States of America
VIDepartment of Psychiatry & Behavioral Sciences and Global Health Institute, Duke University, Durham, North Carolina, United States of America
This mixed-method study explored the social world of Haitian migrants, examining forms of social support and social stress, as well as their relationship to mental health. Among six Haitian migrant communities in the Cibao Valley of the Dominican Republic, a community-based survey (n = 127) was conducted to assess migration experiences, current stressors, mental health, and functioning. In addition, to explore perceptions and experiences of migration, social interactions, and mental health, the study drew upon in-depth interviews and free-listing activities among Haitian migrants, as well as cognitive interviews with select survey participants. Depressive, anxiety, and mental distress survey scores were associated with 1) negative social interactions (including interrogation or deportation, perceived mistreatment by Dominicans, and overcrowding) and 2) lack of social support, including migrating alone. Mental distress scores were higher among women, and being married was associated with higher anxiety scores, potentially reflecting unmet social expectations. In qualitative data, participants emphasized a lack of social support, often referred to as tèt ansanm (literally meaning "heads together" in Haitian Creole or Kreyòl and roughly defined as solidarity or reciprocal social collaboration). The authors of the study propose that the practice of tèt ansanm-also termed konbit, and, in the Dominican Republic, convite-could be used as a means of facilitating positive-contact events among Haitians and Dominicans. These interactions could help counteract social stress and build social capital in settings similar to those of the study.
Key words: Mental health; social capital; social support; migration; Haiti; Dominican Republic; Caribbean region; Americas.
Este estudio de método mixto exploró el mundo social de los migrantes haitianos, mediante el análisis de las formas de apoyo social y el estrés social, así como su relación con la salud mental. Se llevó a cabo una encuesta comunitaria (n = 127) en seis comunidades migratorias haitianas del Valle de Cibao de la República Dominicana para evaluar las experiencias de migración, los factores estresantes actuales, la salud mental y el desempeño. Además, con objeto de explorar las percepciones y las experiencias de migración, las interacciones sociales, y la salud mental, el estudio se basó en entrevistas exhaustivas y actividades de enumeración libre por parte de los migrantes haitianos, así como en entrevistas cognoscitivas dirigidas a algunos participantes seleccionados. Las puntuaciones de la encuesta correspondientes a depresión, ansiedad y aflicción mental se asociaron con 1) las interacciones sociales negativas (incluidos los interrogatorios o la deportación, el tratamiento por parte de los dominicanos percibido como inadecuado, y el hacinamiento) y 2) la falta de apoyo social, incluida la migración en solitario. Las puntuaciones correspondientes a aflicción mental fueron mayores en las mujeres, mientras que la condición de casado se asociaba con puntuaciones mayores de ansiedad, lo que podría reflejar la existencia de expectativas sociales no satisfechas. En cuanto a los datos cualitativos, los participantes recalcaron la falta de apoyo social, a menudo denominado tèt ansanm (que literalmente significa "cabezas juntas" en criollo haitiano o Kreyòl y se define aproximadamente como solidaridad o colaboración social recíproca). Los autores del estudio proponen que la práctica del tèt ansanm (también denominada konbit y, en la República Dominicana, convite) podría usarse como un medio para facilitar los acontecimientos de contacto positivo entre haitianos y dominicanos. Estas interacciones podrían ayudar a contrarrestar el estrés social y promover el capital social en entornos similares a los del estudio.
Palabras clave: Salud mental; capital social; apoyo social; migración; Haití; República Dominicana; Región del Caribe; Américas.
For migrant populations, life in a host community can entail multiple psychosocial stressors, including adjustment to a new culture, changes in identity, and institutional and interpersonal discrimination (1). Post-migration social support can be an important contributor to mental health (2). Strengthening social capital has thus become a focus of public health and policy goals. Social capital refers to social cohesion, support, and/or participation within a group (bonding) and with the broader social structure (bridging).
Social capital has been considered an important buffer against social stress, defined as stress that arises from negative interpersonal relationships (3). These factors collectively represent the "social world," a term used in this report to describe both positive and negative aspects of the social environment.
Migration in the Americas is an important process that drives much economic activity. There are nearly 60 million international migrants in the Western Hemisphere (4). While most Latin American countries are net emigration centers, there is increasing "south-to-south" movement among Latin American states (4). A case in point is the Caribbean island shared by Haiti and the Dominican Republic. There, migration has profoundly shaped the development of both countries. Haitian migrants are overwhelmingly undocumented and often live in communities without basic services. A legacy of anti-Haitian discrimination (antihaitianismo) has contributed to their status as a nearly invisible population. For example, in response to the cholera outbreak, Dominican authorities undertook a campaign of forced expulsions of Haitian migrants (5), while more recent legislation effectively stripped en-tire generations of Haitian-descended Dominicans of their right to citizenship (6). Unsurprisingly, mental health needs of Haitian migrants remain largely unexplored and underserved (7).
THE SOCIAL WORLD OF HAITIAN MIGRANTS
To address this knowledge and service gap, a field study was completed in the Cibao Valley from March-April 2011 (7). Using ethnographic and epidemiologic methods, this study found a positive association between perceived discrimination and symptoms of mental illness. Haitian migrants often described harmful social interactions with Dominicans and fellow migrants using the term imilyasyon (humiliation). At the same time, they expressed the desire for increased social cooperation with their Dominican neighbors. Across multiple forms of data collection, themes of social capital and social stress arose-findings that demand greater scrutiny.
This report draws upon data from the field study to explore the impact of the social world on mental health of Haitian migrants in the Dominican Republic. Of particular interest are the context and content of social interactions and how they may serve as either sources of support or stress. The report concludes that there is a need to explore potential avenues to promote social capital to enhance mental health. The goal of the report is to shed more light on the mental health of this population with the practical application of informing mental health interventions and policies in the region (8).
The original field project was supported by a research partnership among Emory University (Atlanta, Georgia, United States); Universidad Autonoma de Santo Domingo (San Francisco de Macorís, Dominican Republic); and Hospital San Vicente de Paúl (San Francisco de Macorís) to conduct a mixed-methods study of mental health and migration experiences. Six predominantly migrant communities were identified through in-country discussions with research partners and community members. The communities were located throughout Duarte Province, which has a total population of 310 000. One community was in the urban core of a large city, and the remaining five were in rural settings. Rural communities in Duarte Province tend to be more mixed, with Haitian migrants, including Haitian-descended persons, living alongside Dominicans. This contrasts with communities found in other parts of the country known as bateyes-communities almost exclusively composed of Haitian agricultural workers and their families. Traditionally, bateyes were constructed at the behest of large Dominican ingenios (sugar companies) (9).
Quantitative data were collected through a community-based, cross-sectional survey that assessed mental health using culturally adapted instruments-the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI)-plus two locally developed instruments: the Kreyòl Distress Idioms (KDI) scale and the Kreyòl Function Assessment (KFA) (10). The adapted BDI and BAI underwent a rigorous process of cross-cultural adaptation in Haiti to ensure that the adapted instruments achieved semantic, technical, content, criterion, and conceptual equivalence. The KDI drew on ethnographically identified idioms of distress, locally salient ways of experiencing and expressing cognitive, emotional, and somatic suffering. The KFA was developed based on a free-listing activity among a convenience sample of Haitian migrants (21 men and 23 women). This activity asked participants to identify the necessary tasks for caring for one's self, family, and community. The most commonly cited tasks were used to develop separate male and female function assessments, which ask participants to report difficulty completing each task (7).
A household-level census in each of the six communities facilitated random sampling, which used probability of selection proportional to size of the community for the cross-sectional survey (n = 127). Multivariable linear regression models were constructed using backward selection of significant (α < 0.05) predictors for the BDI, BAI, KDI, and KFA scores, accounting for clustering effects at the community level.
Qualitative data used for this report included audio-recorded in-depth interviews with Haitian migrants (n = 21), free-list data collected during development of the KFA, and cognitive interviews. Table 1 provides an overview of study participant characteristics (with additional details provided in (7)). In-depth interviews drew on a purposive sample of Haitian migrants and focused on migration experiences, perceptions and experiences of discrimination, clinical experiences, treatment-seeking behavior, and causes and symptoms of mental distress. Interviews were transcribed verbatim into Kreyòl (Haitian Creole) by Haitian research assistants and translated into English by bilingual speakers. Transcripts were read closely for instances of social interactions.
The study was approved by the Emory University Institutional Review Board and the Ethics Committee of Hospital San Vicente de Paúl. All participants gave verbal informed consent. No identifying information was recorded with quantitative data, and audio transcripts were de-identified. Three multilingual (Kreyòl- Spanish-French), Haitian-born, locally hired research assistants collected data from the Haitian participants. The second author (HMK), an American proficient in Kreyòl, French, and Spanish, coordinated the study.
Tèt ansanm ("heads together"): perceptions of social support in migrant communities
Results of the free-list activity that informed the function assessment provided insight into migrants' perceived responsibility toward the community. Responses about caring for one's community were largely focused on social interactions and building solidarity, such as participating in tèt ansanm (literally meaning "heads together" in Kreyòl and roughly defined as reciprocal social collaboration); living in peace; and having meetings. Ways to support the physical community, such as cleaning and hygiene, were secondary. Interestingly, in a previous study in Haiti, activities in support of the physical community, such as planting trees, cleaning, and repairing the road, were more common among participants' responses (9).
The concept of tèt ansanm (also termed konbit, and, in the Dominican Republic, convite) arose frequently not only in the free-lists but also in survey responses and interviews. Tèt ansanm can be used to refer to solidarity as well as a form of collaborative action in which community members assemble to support a neighbor in completing a task requiring many laborers. Rather than expecting payment, participants expect reciprocation when they need equivalent support. As tèt ansanm is considered central to communal life for Haitians, many migrants bemoan its absence in the Dominican Republic. Interview participants pointed to both the transient nature of migration and a general lack of support structure (ankadreman) to explain migrants' lack of ability to realize tèt ansanm. Furthermore, when survey participants indicated that they have difficulty carrying out a task included in the function assessment and were asked to provide reasons, responses often reflected similar themes. Although most reasons for functional difficulty referenced economic problems (65.9%), almost all others were social: mistreatment by Dominicans (16.7%), lack of solidarity (9.5%), and not being in one's own country (4.8%). Thus, nearly 30% of reasons for functional difficulty were related to impaired social relationships. Many responses specifically referenced a need for tèt ansanm. Thus, this key Haitian form of social support appears to be lacking for this migrant population, and its absence is used to communicate a broader lack of solidarity and social support.
Social support, social stress, and mental health outcomes
A lack of social support was associated with worse mental health outcomes in the survey findings (Table 2). Migrating to the Dominican Republic alone was associated with higher depression, anxiety, and mental distress scores. Interestingly, being married was associated with a higher level of anxiety symptoms, and number of people living in the household was associated with increased experience of mental distress. The positive association between anxiety and marriage could be explained by worry for a spouse's safety or the stress of trying to meet family obligations amid difficult conditions. These associations suggest that social stress-such as that brought about by overcrowding and failure to meet role expectations-might play a stronger role in mental health than soial support potentially provided by co-habitants.
Past interrogation or deportation, or knowing another migrant who had had either of those two experiences, was also associated with higher anxiety symptomology. Immigration authorities were said to make arbitrary arrests, leaving some Haitian participants feeling like "little toys." Similarly, perceptions that Dominicans mistreat Haitians were positively associated with depressive symptoms and functional impairment. Finally, Haitian migrant women reported more mental distress and functional impairment than men (7), suggesting important gender implications in potential social support interventions for this population, outlined in more detail below.
Social expectations and social stress. Further evidence that social stress is particularly salient within this migrant population was obtained from qualitative data collected in tandem with survey data. Among the 52 participants indicating particularly severe depressive symptoms (as indicated by scores of 2 or 3 for any of the items listed in Table 3), cognitive interviewing was used to explore reasons for those experiences. While many responses focused on economic hardship (50.0%), a notable proportion of responses (23.1%) attributed depressive symptoms to social interactions or social stress (Table 3). For example, many responses focused on family responsibilities, particularly failure to meet obligations to children. Another common thread was that many depressive symptoms arise due to negative social interactions, generally involving mistreatment by Dominicans, though sometimes including other Haitians. Finally, a lack of support structure or help in the community was reported to leave some feeling a sense of failure or fear. These data suggest that social stress and failure to meet social expectations represent an important mental health burden among Haitian migrants in this study.
In-depth interviews provided a more nuanced understanding of the ways that social expectations contribute to mental distress among migrants. Although communication with family members in Haiti was thought to provide some social support, for many Haitian migrants, familial and other social relationships represented a central cause of distress. Participants spoke of the high expectations held by their family and friends who remain in Haiti, including that migrants will earn sufficient money to support the family through remittances. Sending remittances was commonly practiced, albeit often with difficulty: "Every month, I send money, even if it's not much. I help them. We all help our families. Even those of us that don't make much money, we help our families" (Male rice farm laborer). Nevertheless, many Haitian migrants indicated a profound sense of guilt or failure to live up to expectations, whether due to lack of money to support their family in Haiti, lack of ability to feed or educate their children, or being otherwise unable to fulfill their roles. Participants also reported feeling ashamed for their friends to see how they live.
In addition to the burden of trying to meet social expectations, attempts to maintain familial relationships often exacerbated stressors inherent to the migrant experience. Haitian migrants were able to maintain communication through phone calls, but attempts to visit family members placed undocumented Haitians at risk of deportation: "You know we're outside immigration. We don't have papers; we're really not legal. Our heads get loaded (tèt chaje) [we worry]" (Street vendor).
Lack of documentation and fear of deportation-daily stressors that worsen mental health-also disrupt migrants' support systems and strain coping mechanisms. Ultimately, failure to meet social expectations, encounters with the immigration system, and attempts to maintain family relationships only compounded migrants' own feelings of misery (lamizè) due to living apart from their family and support system.
Strengthening social capital for Haitian migrants
This study suggests multiple ways in which the social world of Haitian migrants in the Dominican Republic fails to provide a buffer against mental distress and in fact exacerbates mental ill-health. On one hand, migrants pointed to a general lack of support and particularly the absence of tèt ansanm, an important form of solidarity in Haiti. In addition, the presence of others-including housemates and spouses-seemed to be largely a source of distress in the community-based survey (i.e., social burden rather than social support). Based on this study's qualitative data, this association could be explained through the stress of failing to meet social expectations, which extends to family in Haiti. Finally, life for Haitian migrants is one disproportionately marked by social stress via negative interactions with both Dominicans and fellow migrants.
To counteract social stress and build social capital in this setting, interventions should seek to bond migrants within their social group and bridge them to the larger social matrix of Dominican society. In migrant communities, Haitian "culture brokers"-long-term residents with connections in the area and Spanish- language proficiency-could support newly arrived migrants and educate local Dominican clinicians on important cross-cultural aspects of treating Haitian patients. Local community health workers could be trained to provide mental health services according to a model piloted in Haiti that includes recognition of common mental disorders and basic therapeutic and counseling skills (11). Recognizing that the activities of tèt ansanm are traditionally gender-separated in Haiti, interventions should actively involve both genders to ensure that migrant women, who appear to bear a greater mental illness burden, fully benefit.
A key way forward is through positive-contact events modeled on the convite/konbit. In the Dominican Republic, the convite developed among rural farmers to share tasks, while in Haiti, an identical structure is the konbit, synonymous to tèt ansanm. The common etymological root of this cooperative system reflects the two countries' shared customs and values. Positive-contact events, such as workshops, community meetings, and leisure activities, will likely have greater acceptance by local communities if they are based on this shared history. Furthermore, it may be worthwhile to consider the convite/konbit as appropriate venues for microfinance or health insurance collectives among friends and family. Finally, this strategy would certainly gain greater traction if regional and national governmental and nongovernmental organizations, with budgetary and political capacity, assume a central role in developing and promoting such interventions.
This study had some limitations. First, the quantitative analysis was limited by the 1) small sample size, 2) purposely selected communities, and 3) cross-sectional survey design, which prevented drawing conclusions regarding causality. Second, the qualitative data analysis was conducted in English, potentially losing sight of nuance. Third, female gender was not associated with higher BDI scores in this population, despite a gendered risk with the same Kreyòl BDI among a population in Haiti's Central Plateau (12). This may reflect regional differences in the cultural and linguistic applicability of Kreyòl-adapted items of the BDI (12).
In contrast, the locally developed KDI tool appeared to function well in this Haitian population. Future studies should assess engagement in and perceptions of tèt ansanm in a more rigorous way, such as exploring it as a potentially culturally salient measure of collective efficacy or social capital.
This study explored whether the social world of Haitian migrants in the Dominican Republic represents a source of support or stress. Findings suggest that social stressors and failure to meet social expectations represent causes of mental distress. In addition, tèt ansanm, a key form of social support and solidarity in Haiti, was markedly lacking within this migrant population. The authors suggest that interventions derived from a shared convite/konbit model of social interaction could provide a key means of improving both Haitian-Dominican relations and mental health outcomes by strengthening bonding and bridging social capital.
Acknowledgments. The authors thank the research assistants who collected data for this study, namely Mere Dieuliphene, Willy Altindor, Jean Peter Osirias, and Jhefri Augustin Reyes Reinoso. They also thank Dhaysi Batista Berroa, Rossemary Ausuncion Hierro Burgos, and Ivette Esperanza Hierro Burgos for their time in transcribing Spanish audio files. Bethany Battig, Jean Verneus, and Brian Gross translated Spanish and Kreyòl documents into English. Without the support of Rosa Ypania Burgos Minaya, Rafael Alvarez Castillo, Ambrosio Rosario, and Luis Adolfo Dominguez Garcia, this study would not have been possible.
Conflicts of interest. None.
Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.
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Manuscript received on 30 November 2014.
Revised version accepted for publication on 8 May 2015.