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Presenter: Felicia Blocker Chair: Dabney Evans, PhD, MPHCommittee: Monique Hennink, PhDDate: April 9, 2013Canal Water and Clorox:Characterizing Cholera Risk Factors for Haitian Migrants Living in the Dominican Republic
Agenda•Background•Research Question•Methods•Limitations•Results• Recommendations•Remaining Questions•Final Thoughts•Acknowledgements•Q & A Session
BackgroundHistory of Hispaniola•East colonized by the Spanish (Dominican) in1492.•West colonized by the French (Haiti) in 1777.•French importation of slaves for sugarproduction.•Slave revolt in 1791.•Haiti declared an independent nation in 1804•Dominican vs. Haitian cultural dichotomyprovides context for this study.(Rogozinsky, 2000; Wucker, 1999)
What is Cholera?• Cholera is a diarrheal diseasetransmitted through the ingestionof contaminated human fecalmatter, usually through unwashedfoods.• John Snow described the disease as“traveling along the great tracks ofhuman intercourse; never goingfaster than people travel, andgenerally, much more slowly. Inextending to a fresh island orcontinent, it always appears first ata sea-port.”(Snow, 1855)
Present Day HispaniolaCholera in Hispaniola Haitian Migrants in the D.R• January 2010 earthquake in Port-au- Prince, Haiti initiating theincreased migration of Haitians tothe Dominican Republic (D.R)• First Case of cholera in Haiti wasreported on October 21, 2010.• First case of cholera in theDominican Republic was reportedless than two weeks later onOctober 31, 2010.• Migrants Compose a large part ofthe Dominican economy workingmainly in the tourism, constructionand sugar industries.• Haitian migrants are a vulnerablepopulation in the D.R,experiencing poverty, a lack ofaccess to health care, anddiscrimination daily.• Major outbreaks of cholera haveoccurred 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)
Research QuestionHow does the context of poverty, lack of healthcareaccess and discrimination contribute to increased riskof cholera (compared with Dominican nationals)amongst Haitian migrants in the Dominican Republic?
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 bytrained facilitators.▫ Participants stratified by gender, nationality and rural orurban location.
Study PopulationParticipants Number Age rangeUrban GroupsDominican Men 5 21- 48Dominican Women 7 40-54Haitian Men 6 26- 34Haitian Women 6 19- 23Rural GroupsDominican Men 7 23- 73Dominican WomenHaitian MenHaitian Women666†18- 3325-38Characteristics of Focus Group Discussion Participants† Indicates missing information• The study took place in a rural village, andan urban barrio in the Duarte Province.• Participants were recruited through theuse of gate keepers in the community.• Eligible participants identified as either aHaitian migrant to the DominicanRepublic, or a native Dominican, wereover 18 years of age, a resident of a mixedcommunity in the Duarte Province, andable to give informed oral consent to bein a FGD.
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 tothe Dominican Republic?• Closing questions• Ex: Of all if the issues that we talked about today which isthe most important to you?• Conclusion
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 externaltheories.
Codebook ExcerptMHMigrant HaitianExperiences MH1Haitians as DiseaseCarriersDescriptions of Haitians as disease carriers.Disease could be cholera, HIV… Placingblame on Haitians for the emergence ofdiseases in the D.RMH2 Haitian DocumentationDiscussions of Haitian documentation issues-Deportation, illegal immigration, HaitiancensusMH3 Haitian EmploymentDescribes the working conditions of Haitians,how much they get paid, type of work,Wealthy Dominicans need for workingHaitiansMH4 Reasons for Immigration Why do Haitians come to the DR?
Limitations▫ Cross-sectional study design Captures only one point in time Complete data were collected on as many subsections of thepopulation as possible.▫ Language barriers between Spanish and Kreyolspeaking research assistants (R.A.), and the researcher Affects data collection In country collaborators helped explain tasks to R.As andcommunicate R.A questions to the researchers▫ Power dynamics in FGDs Influences data quality During the introduction of the focus group, R.As explainedthat all opinions were welcomed, and equally valid duringthe FGD.
Poverty“The Haitians just want you to take them to work…here towork in the rediodales working with shovels, one day is worthabout 500, 600 pesos [$14-17 USD], one day, but for a Haitianno, the Haitian does it for even 300 pesos [$8.50 USD].”- Rural Dominican Male▫Poverty prevented rural Haitian migrants from being able to access runningwater 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.
Healthcare“In our country some hospitals exist that are extremelyprecarious, you understand, they have very little, um…very fewresources, and they have a low economic level and a low healthbecause they get the poorest people.”- Urban Dominican Male▫The lack of access to quality care was a pervasive theme across allnationalities and geographical locations.▫Provision of quality care was limited to individuals who could affordprivate insurance in private hospitals.▫Public hospitals were free to everyone, but did not have the resourcesto provide quality care. Impacts cholera severity, diagnosis and treatment if anindividual is infected.
Discrimination“I personally have a boss who is an attorney. I used to work withhim. 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 violencewas described in every focus group with Haitian participants. Impact on cholera risk for migrants.▫ Anti-Haitian prejudices increased as Dominicans blamedHaitians for cholera in the Dominican Republic.
Risk Perception“It’s [prevention behaviors] just a suggestion. I sometime seepeople practicing hygiene for themselves to avoid gettingcholera, and I see those people who were practicing it getcholera. 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 behaviorsdon’t affect risk.▫ Rural migrants and urban Haitian men: lack of cholera knowledge. Impacts cholera transmission risk.
Increased Access to Treated WaterShort Term Long TermProviding supplies neededto treat water such asbleach and purifyingtablets for migrants at areduced cost.Incentivizing rural vendersto lower prices of treatedbottled water.
Increased Access to Quality CareShort Term Long TermIncreasing surveillanceefforts, and urgingindividuals to go tohospitals and completemedical testing specificallyfor any cholera-likesymptoms.Raising level of care atpublic hospitals throughincreased funding andpersonnel training.
Reducing Haitian StigmaShort Term Long TermTranslating choleraresearch into communitybased interventions.Providing necessaryeducation to transformwidely held norms thatportray Haitian migrants asdisease carriers.
Risk PerceptionShort Term Long TermIncreasing healthpromotion programsdesigned to raise awarenessabout cholera in bothHaitian and Dominicancommunities in the DuarteProvince.Creating culturallyappropriate educationmaterials for Dominicansand Haitian migrants, andnotifying the public of newcholera cases.
Remaining Questions• How would future studies benefit from considering thecondition of Dominican facilities and the structure of thenational healthcare system, when examining barriers to care?• What are migrants’ reactions to increased discrimination?• What are the most efficacious ways to reduce anti-Haitianprejudices?• Could community-based participatory research be the key in thecreation of culturally appropriate health promotion messages?
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 commonareas
• Thesis Advisor• Dabney Evans, PhD,MPH• Thesis CommitteeMember• 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