Felicia Blocker presented research on characterizing cholera risk factors for Haitian migrants living in the Dominican Republic. Through focus groups with Haitian migrants and Dominicans, the research found that poverty, lack of access to healthcare and clean water, and discrimination against Haitians increased cholera risk. Recommendations included increasing access to treated water, improving healthcare quality, reducing stigma against Haitians, and developing culturally appropriate health promotion programs to raise risk awareness. Remaining questions focused on how to reduce barriers to care and anti-Haitian prejudice.

1.
Presenter: Felicia Blocker
Chair: Dabney Evans, PhD, MPH
Committee: Monique Hennink, PhD
Date: April 9, 2013
Canal Water and Clorox:
Characterizing Cholera Risk Factors for
Haitian Migrants Living in the
Dominican Republic

2. Agenda
•Background
•Research Question
•Methods
•Limitations
•Results
• Recommendations
•Remaining Questions
•Final Thoughts
•Acknowledgements
•Q & A Session

3. Background
History of Hispaniola
•East colonized by the Spanish (Dominican) in
1492.
•West colonized by the French (Haiti) in 1777.
•French importation of slaves for sugar
production.
•Slave revolt in 1791.
•Haiti declared an independent nation in 1804
•Dominican vs. Haitian cultural dichotomy
provides context for this study.
(Rogozinsky, 2000; Wucker, 1999)

4. What is Cholera?
• Cholera is a diarrheal disease
transmitted through the ingestion
of contaminated human fecal
matter, usually through unwashed
foods.
• John Snow described the disease as
“traveling along the great tracks of
human intercourse; never going
faster than people travel, and
generally, much more slowly. In
extending to a fresh island or
continent, it always appears first at
a sea-port.”
(Snow, 1855)

5. Present Day Hispaniola
Cholera in Hispaniola Haitian Migrants in the D.R
• January 2010 earthquake in Port-
au- Prince, Haiti initiating the
increased migration of Haitians to
the Dominican Republic (D.R)
• First Case of cholera in Haiti was
reported on October 21, 2010.
• First case of cholera in the
Dominican Republic was reported
less than two weeks later on
October 31, 2010.
• Migrants Compose a large part of
the Dominican economy working
mainly in the tourism, construction
and sugar industries.
• Haitian migrants are a vulnerable
population in the D.R,
experiencing poverty, a lack of
access to health care, and
discrimination daily.
• Major outbreaks of cholera have
occurred in mixed Haitian/
Dominican areas.
(Bartlett et al., 2011; CDC, 2010; Dominguez, 2011; Ferguson, 2006; Howard, 2007; Human Rights Watch, 2002; Kushner & Coto, 2011; PIH,
2010; Tappero & Tauxe, 2011; Tavernier, 2008)

6. Research Question
How does the context of poverty, lack of healthcare
access and discrimination contribute to increased risk
of cholera (compared with Dominican nationals)
amongst Haitian migrants in the Dominican Republic?

7. Methods
Métodos
Metòd

8. Study Methods
• Cross- sectional study design.
• Data were collected through focus group discussions
(FGD) with Dominican and Haitian participants.
▫ A total of eight FGDs were conducted over six weeks.
▫ FGDs were moderated in participant’s native language by
trained facilitators.
▫ Participants stratified by gender, nationality and rural or
urban location.

9. Study Population
Participants Number Age range
Urban Groups
Dominican Men
5
21- 48
Dominican Women 7 40-54
Haitian Men 6 26- 34
Haitian Women 6 19- 23
Rural Groups
Dominican Men
7
23- 73
Dominican Women
Haitian Men
Haitian Women
6
6
6
†
18- 33
25-38
Characteristics of Focus Group Discussion Participants
† Indicates missing information
• The study took place in a rural village, and
an urban barrio in the Duarte Province.
• Participants were recruited through the
use of gate keepers in the community.
• Eligible participants identified as either a
Haitian migrant to the Dominican
Republic, or a native Dominican, were
over 18 years of age, a resident of a mixed
community in the Duarte Province, and
able to give informed oral consent to be
in a FGD.

10. Focus Group Discussion Guide
• Introduction to the focus group
• Explaining study purpose and laying ground rules.
• Community mapping activity
• Ex: Where do Haitians Live? Where do you get water from?
• Free listing activity
• Ex: What Can someone do to prevent getting cholera?
• Key questions
• Ex: How has your community changed since cholera came to
the Dominican Republic?
• Closing questions
• Ex: Of all if the issues that we talked about today which is
the most important to you?
• Conclusion

11. Data Preparation• Recording
• Transcribing & Translating
• Pre-Coding
• Parent Codes
• External Coding
• MaxQDA10 Software
• Grounded Theory Approach
▫ Using data to create a model explaining behavior, not external
theories.

12. Codebook Excerpt
MH
Migrant Haitian
Experiences
MH1
Haitians as Disease
Carriers
Descriptions of Haitians as disease carriers.
Disease could be cholera, HIV… Placing
blame on Haitians for the emergence of
diseases in the D.R
MH2 Haitian Documentation
Discussions of Haitian documentation issues-
Deportation, illegal immigration, Haitian
census
MH3 Haitian Employment
Describes the working conditions of Haitians,
how much they get paid, type of work,
Wealthy Dominicans need for working
Haitians
MH4 Reasons for Immigration Why do Haitians come to the DR?

13. Limitations
▫ Cross-sectional study design
 Captures only one point in time
 Complete data were collected on as many subsections of the
population as possible.
▫ Language barriers between Spanish and Kreyol
speaking research assistants (R.A.), and the researcher
 Affects data collection
 In country collaborators helped explain tasks to R.As and
communicate R.A questions to the researchers
▫ Power dynamics in FGDs
 Influences data quality
 During the introduction of the focus group, R.As explained
that all opinions were welcomed, and equally valid during
the FGD.

14. Results
Resultados
Résultats

15. Poverty
“The Haitians just want you to take them to work…here to
work in the rediodales working with shovels, one day is worth
about 500, 600 pesos [$14-17 USD], one day, but for a Haitian
no, the Haitian does it for even 300 pesos [$8.50 USD].”
- Rural Dominican Male
▫Poverty prevented rural Haitian migrants from being able to access running
water in their homes and workplaces.
▫Many migrants did not have the resources to purchase treated bottled water,
or the items needed to treat their water.

16. Healthcare
“In our country some hospitals exist that are extremely
precarious, you understand, they have very little, um…very few
resources, and they have a low economic level and a low health
because they get the poorest people.”
- Urban Dominican Male
▫The lack of access to quality care was a pervasive theme across all
nationalities and geographical locations.
▫Provision of quality care was limited to individuals who could afford
private insurance in private hospitals.
▫Public hospitals were free to everyone, but did not have the resources
to provide quality care.
 Impacts cholera severity, diagnosis and treatment if an
individual is infected.

17. Discrimination
“I personally have a boss who is an attorney. I used to work with
him. When we first met, it used to be that our contact was warm,
but since cholera came, he just shakes hands, no more close contact.
He will give you everything but he just back up.”
- Rural Haitian Male
▫ Discrimination including structural and physical violence
was described in every focus group with Haitian participants.
 Impact on cholera risk for migrants.
▫ Anti-Haitian prejudices increased as Dominicans blamed
Haitians for cholera in the Dominican Republic.

18. Risk Perception
“It’s [prevention behaviors] just a suggestion. I sometime see
people practicing hygiene for themselves to avoid getting
cholera, and I see those people who were practicing it get
cholera. But I, who do not practice hygiene; I do not get it.”
- Urban Haitian Woman
▫ Participants expressed a general lack of risk perception.
▫ Urban Haitian women and Dominicans: prevention behaviors
don’t affect risk.
▫ Rural migrants and urban Haitian men: lack of cholera knowledge.
 Impacts cholera transmission risk.

19. Recommendations
Recomendaciones
Recommandations

20. Increased Access to Treated Water
Short Term Long Term
Providing supplies needed
to treat water such as
bleach and purifying
tablets for migrants at a
reduced cost.
Incentivizing rural venders
to lower prices of treated
bottled water.

21. Increased Access to Quality Care
Short Term Long Term
Increasing surveillance
efforts, and urging
individuals to go to
hospitals and complete
medical testing specifically
for any cholera-like
symptoms.
Raising level of care at
public hospitals through
increased funding and
personnel training.

22. Reducing Haitian Stigma
Short Term Long Term
Translating cholera
research into community
based interventions.
Providing necessary
education to transform
widely held norms that
portray Haitian migrants as
disease carriers.

23. Risk Perception
Short Term Long Term
Increasing health
promotion programs
designed to raise awareness
about cholera in both
Haitian and Dominican
communities in the Duarte
Province.
Creating culturally
appropriate education
materials for Dominicans
and Haitian migrants, and
notifying the public of new
cholera cases.

24. Remaining Questions
• How would future studies benefit from considering the
condition of Dominican facilities and the structure of the
national healthcare system, when examining barriers to care?
• What are migrants’ reactions to increased discrimination?
• What are the most efficacious ways to reduce anti-Haitian
prejudices?
• Could community-based participatory research be the key in the
creation of culturally appropriate health promotion messages?

25. Final Thoughts
• The Greatest needs in the study population:
▫ Access to potable water
 Municipal
 Affordable treated, bottled
▫ Culturally appropriate cholera education
 Messages for Haitians and Dominicans
 Delivered in churches, schools, and neighborhood common
areas

26. Acknowledgements
Reconocimientos
Rekonesans

27. • Thesis Advisor
• Dabney Evans, PhD,
MPH
• Thesis Committee
Member
• Monique Hennink,
PhD
• Research Peers
• Hunter Keys
• Stephanie Leventhal
• Andrea Lund
• Field Advisor
• Rosa Burgos, MA
• Research Assistants
• Study Participants
• Rollins Peers
• Family and Friends

28. Thank you!
¡Muchas
gracias!
Mèsi anpil!

29. Questions?
¿Preguntas?
Kesyons?