Center of Excellence in Newcomer Health

Spotlight

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Refugee Health Program
651-201-5414
refugeehealth@state.mn.us

Contact Info

Refugee Health Program
651-201-5414
refugeehealth@state.mn.us

Brief Overview for Clinicians Caring for Haitian New Arrivals
Center of Excellence in Newcomer Health

Health care access overseas

A very small percent of Haitian arrivals is accepted as refugees overseas and come through the U.S. Refugee Admissions Program (USRAP). These individuals may have received an overseas medical exam prior to departure. For more information about Panel Physicians and Overseas Medical Exams, refer to the following:

Health care access on the migration path

In addition to this lack of medical exams prior to U.S. entry, Haitians may face further health challenges on the migration path to the U.S. This journey – whether through the Darien Gap or other routes – may present a multitude of challenges, including lack of access to medical care, increased risk of assault, exploitation, trafficking, and exposure to infectious diseases. 

Eligibility and benefits

Please refer to the table below for both Haitian Entrant and immigration status groups that are eligible for receiving Office of Refugee Resettlement (ORR) benefits:

Haitian Entrant Group1/Immigration StatusConditions for Eligibility
Asylee2

Asylum status is a form of protection available to people who must initially apply as an asylum-seeker. This includes individuals that:

  • Meet the definition of refugee*
  • Are already in the U.S.
    OR
  • Are seeking admission at a port of entry
Haitian Entrant3

A citizen or national of Haiti who: 

  • Entered the U.S. as a parolee, OR
  • Is in removal proceedings and does not have a final, order of removal, OR
  • Has an application for asylum pending, and does not have a final, order of removal.
Refugee4Refugee status may be granted overseas to people who prove that they have been persecuted or fear they will be persecuted on account of race, religion, nationality, and/or membership in a particular social group or political opinion. This status is granted prior to the individual entering the U.S.

ORR benefits** for all entrant groups/immigration statuses include access to:

  • Domestic Medical Exam
  • Cash assistance
  • Medical assistance
  • Employment preparation and job placement
  • English language training 
  • May be eligible for federal benefits (e.g., cash assistance through Supplement Security Income (SSI) or Temporary Assistance for Needy Families (TANF), health insurance through Medicaid, and food assistance through Supplemental Nutrition Assistance Program (SNAP))5

The U.S. President determines countries of origin and number of refugees annually permitted into the U.S. Read more about who qualifies for these benefits here: 

*As defined by UNHCR: Refugees are people who have fled their countries to escape conflict, violence, or persecution and have sought safety in another country. View this MN COE webinar training to learn more about refugee health and the process by which refugees arrive to the U.S.: Part 1 Intro to Refugee Health (YouTube).
**To determine benefit and service eligibility, contact your State Refugee Coordinator at ORR: Key State Contacts.


Best practices and cultural considerations

Haiti has two official languages – French, due to colonization by France, and Haitian Creole, a language developed over time that is a mix of French and multiple African languages.6 Many Haitians arrivals are multilingual and might speak Haitian Creole, English, French, Spanish, and/or Portuguese, depending on their level of education attained and migration route. Though they may have varying levels of fluency in other languages, Haitian Creole should be prioritized for interpreter services, if it is their preferred language. The distinction between Haitian Creole and French language speakers is essential to acknowledge and at times may be a highly sensitive topic; those with French fluency tend to be of higher socioeconomic status compared to those who are not fluent in French.7,8,9

While Haitians highly value education, leaders of the education system have struggled with maintaining quality and accessibility, in part due to the increased insecurity, shortage of qualified teachers and resources. This has resulted in limited access to education and an adult literacy rate of 62%.10

Haitian culture 

Haitians have a rich culture and society, including a strong sense of community, hospitality, and respect for family and elders.11 Haitian society is more collectivistic rather than individualistic. It is common to see Haitian families in multigenerational households, which can provide support and positively impact physical and emotional well-being.12,13,14 Due to Haiti’s history of colonial oppression and slavery, Haitian culture has also been influenced by African, European, and Latin American traditions.15

In Haiti, the population is 52% non-Catholic Christians, 35% Catholic, 11% non-religious, and 2% Vodouist.16 Vodou is a traditional African spiritual religion. Although most Haitians identify as either Catholic or Christian Protestant, elements of Vodou and traditional beliefs, rooted in West African tradition, remain prevalent within Haitian culture. Since many Haitians have both Haitian Vodou and Western views of illness and treatment, clinicians are encouraged to explore the role of religion and/or spirituality with their patients. Oftentimes, traditional medicine is used for disease prevention, whereas Western medicine is used for curative treatment. 17

Per a review article in the American Psychiatric Association, some Haitians “believe illnesses are supernaturally induced” or sent by others, which is referred to as “maladi moun.”18,19 Because of this belief, many Haitians with mental health issues may be more likely to seek out treatment or alternative therapy services from folk practitioners, which may consist of lay providers, including vodou priests (hougan) and vodou priestesses (mambo), herbalists (dokte fey), Catholic priests, and protestant pastors.20 For many Haitians, spirituality and/or vodou enhances their sense of optimism, and a sense of mastering their destiny.21

Health considerations

It is critical to inquire about health-related social needs including literacy, country of origin, migration pathway, current housing arrangement, and occupation to determine needs and barriers to accessing care.

The average life expectancy at birth in Haiti is 64.1 years (64.8 for women, 63.3 for men), compared to 77.2 years in the Americas.22 In 2021, noncommunicable diseases (NCD) made up 54.8% of deaths, with cardiovascular diseases, cancers, and diabetes collectively accounting for 25% of all healthy lives lost.23,24 Studies show that Haitian immigrant populations have an increased risk of:

  • Hypertension and heart attacks
  • Type 2 diabetes
  • Kidney diseases
  • Chronic obstructive pulmonary disease
  • Cervical cancer
  • Human papillomavirus (HPV)25,26

In Haiti, communicable diseases include Chagas, cholera, Dengue fever, hepatitis A and B, HIV/AIDS, leptospirosis, malaria (P. falciparum malaria), multidrug-resistant tuberculosis (MDR-TB), orthohantavirus, parasitic diseases, rabies, typhoid fever, yellow fever, and Zika virus.27,28

Haiti accounts for 38% of new HIV infections in the Caribbean region. However, Haiti’s HIV incidence as new infections per 1000 uninfected population went from 0.87 (0.73-1.1) in 2010 to 0.48 (0.32-0.72) in 2023.30 This decrease in HIV incidence has been largely due to consolidated national and international efforts. Most transmission occurs from heterosexual sex (with higher prevalence rates in major cities), men who have sex with men, female sex workers, and prison populations.31 Of note, the tumultuous migration journey that many Haitians undertake from Latin America to the United States is marked with sexual violence and other forms of violence, thus contributing to increased HIV and STI rates among men, women, and children.32,33,34

In 2021, the tuberculosis (TB) incidence was 159 per 100,000 people living in Haiti, versus 2.5 per 100,000 in the U.S.35,36 All Haitian new arrivals should be considered high risk for and receive screening for tuberculosis, pursuant with CDC: Tuberculosis Refugee Health Domestic Guidance. Approximately 3.5% to 14% of tuberculosis patients in Haiti have a known positive HIV status.37

Haitian newcomers may have experienced a high exposure to stress and trauma, including pre-migration experiences, exposure to natural disasters, sexual and physical violence, harsh migration journeys, pressure to acculturate in the U.S., language barriers, and lack of and change in supportive social networks. Many may underreport or minimize their problems because of stigma and reliance on religion/spirituality, and as such may not have previously received a mental health evaluation or treatment. Haitians need to be screened with a mental health tool validated in Haitian Creole (refer to links below). 

For translated depression screening tools:

Practical advice for caring for the mental health needs of Haitian patients:

Many Haitian patients express mental illness somatically. They may use idioms such as tèt (head) and the kè (heart) to explain their emotional, cognitive, or psychological problems.38 Tèt (Head) idioms are used to express forgetfulness, poor concentration, worry, and unusual behavior while the Kè (Heart) idioms may be indicative of emotional and physical distress and dysfunction. Haitian immigrant women in the U.S. may express three distinctive types of depression: pain in the body, relief through God, and fighting an unwinnable battle.39

To build a stronger therapeutic alliance when evaluating a Haitian patient’s mental health issues, consider asking your patients more generally how they are doing, rather than initially using a screening tool. Clinicians should use a trauma informed approach when working with individuals who have experienced multiple traumas and loss. Assistance can be provided by exploring trauma and loss to promote resilience and posttraumatic growth. It is important to understand how to carefully introduce mental/behavioral health services, and to develop culturally sensitive treatment plans that are consistent with the patient’s presenting symptoms and values. Many Haitians are story and goal-oriented individuals and may benefit from strength-based interventions such as Solution-Focused Therapy and Narrative Therapy. Overall, clinicians must be skilled at promoting therapy by educating patients about relevant information, the process of therapy, and its potential benefits because this may be their first mental health visit/experience. Clinicians may compare the role of therapy to that of the extended family in Haiti.

Refer to Haitian Clinical Guidance: Resources for additional mental health resources.

Considering Haitian newcomers are more likely to work in service industries than other immigrant groups and the U.S. population, clinicians should be mindful that they may experience chemical and physical exposures in factories and meat or poultry plants, in addition to agricultural exposures.40 Review the links below to learn more about the potential hazards and service-specific information:

Haitian children are also at risk for infectious diseases, acute and chronic conditions, and mental health concerns. The leading cause of mortality in children under five years in Haiti is lower respiratory tract infections, though there are also concerning rates of malnutrition of varying severity.41,42 Screening for neurodevelopmental conditions (Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, and developmental delays), particularly for children whose education and learning has been interrupted by conflict or migration, should be ascertained, while avoiding diagnostic overshadowing (symptoms attributed to autism may be stress reactions to traumatic or other adverse events).43

Although there have been significant improvements, Haiti has the highest maternal mortality rate in the Western Hemisphere at 350.4 deaths per 100,000 live births in 2020.44 The contributors to high maternal mortality are multifactorial, including poor health infrastructure and access to health care services, and are as important as the underlying medical causes.45,46 The leading causes of maternal mortality in Haiti are hypertension/eclampsia, postpartum hemorrhage, and indirect causes such as malaria, HIV/AIDs and/or cardiac disease. Haitians residing in the U.S. have a documented increased risk for preterm birth, low birth weight, c-sections, preeclampsia and severe maternal morbidity.47,48,49,50 The underlying causes of these disparities are not well established but are likely a combination of sociodemographic factors and uncontrolled pre-existing medical conditions. Additionally, the recently arrived migrants have significant exposure to stress and trauma which is likely to impact pregnancy outcomes.

Considerations for prenatal care practitioners:

  • Pregnant persons are at risk for all of the conditions outlined above, and relevant screenings should therefore be incorporated into the routine prenatal care, if not managed by a primary care provider. 
  • Post-partum depression: The Edinburgh Postnatal Depression Scale (EPDS) is not available in Haitian Creole. Reference the available translated depression screening tools in the mental health dropdown above. 
  • Prenatal laboratory tests: In addition to routine prenatal screening, recent Haitian arrivals should be considered at an increased risk for and screened at the increased cadence for the following conditions, pursuant to the ACOG: Routine Tests During Pregnancy guidance: Tuberculosis (CDC: Tuberculosis in Pregnancy), HIV/AIDS (ACOG: Prenatal and Perinatal Human Immunodeficiency Virus Testing), syphilis, gonorrhea/chlamydia, and lead screening (ACOG: Lead Screening During Pregnancy and Lactation).
  • Immunization status should be assessed and vaccines given at the appropriate perinatal time period. Review the ACOG: Maternal Immunization recommendations for additional guidance.
  • Cervical cancer screening: Cervical cancer is a leading cause of cancer among women in Haiti due to lack of accessible screening. Cervical cancer screening should be performed for all without documented screening results. 

Lifetime prevalence rates of sexual violence among adolescents and young adults are 29.02% for women and 25.73% for men.51,52 Forms of gender-based violence reported in Haiti include aggravated sexual assault and penetration with foreign objects with the explicit intent of mutilation.53,54 Foreign personnel, such as peacekeepers, have also participated in exploitation of Haitian men and women.55 With the rise in conflict and gender-based violence in Haiti, there is also a growing concern regarding a surge of HIV and other sexually transmitted infections (STIs).55,57,58

Vaccination coverage in Haiti is variable and should be reviewed with patients. As several vaccines are not available in Haiti on the public market, including the HPV vaccine, immunity should be screened if it is affordable to the patient.59,60,61 The most current immunization dashboard can be found at WHO: Immunization Dashboard | Haiti.

For more information on vaccine guidance and catch-up, reference the following resources:


References

  1. Office of Refugee Resettlement (2023). Benefits for Cuban/Haitian Entrants. Retrieved October 31, 2023 at https://www.acf.hhs.gov/orr/fact-sheet/benefits-cuban/haitian-entrants. 
  2. U.S. Citizenship and Immigration Services (2024, February 12). Asylum. Retrieved March 4, 2024 at https://www.uscis.gov/humanitarian/refugees-and-asylum/asylum. 
  3. https://www.acf.hhs.gov/archive/orr/fact-sheet/benefits-cuban/haitian-entrants
  4. U.S. Citizenship and Immigration Services (2023, September 9). Processes for Cubans, Haitians, Nicaraguans, and Venezuelans. Retrieved October 31, 2023 at https://www.uscis.gov/CHNV. 
  5. U.S. Citizenship and Immigration Services (2022, October 26). Refugees. Retrieved January 30, 2024 at https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees. 
  6. https://www.worldatlas.com/articles/what-languages-are-spoken-in-haiti.html
  7. https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0002221
  8. https://foreignpolicy.com/2021/08/03/haiti-language-education-school-french-haitian-creole/
  9. https://www.opendemocracy.net/en/openglobalrights-openpage/haiti-s-linguistic-apartheid-violates-children-s-rights-and-hampers-/
  10. UNICEF (2022, October 10). Increase in violence and resurgence of cholera in Haiti may leave more than 2.4 million children unable to return to school – UNICEF. Retrieved January 24, 2024 at https://www.unicef.org/lac/en/press-releases/increase-in-violence-and-resurgence-cholera-in-haiti-may-leave-more-2.4-million-children-unable-to-return-to-school 
  11. Meleen, Michele (2021, September 21). Haitian Culture: Understanding Family Values and Beliefs. Love to Know. Retrieved February 14, 2024 at https://www.lovetoknow.com/life/relationships/haitian-family-values-religion-superstitions
  12. Generations United (Unknown). Multigenerational households. Retrieved January 29, 2024 at https://www.gu.org/explore-our-topics/multigenerational-households/
  13. Mercier, Coles (Unknown). Family Values and Beliefs in the Haitian Culture – Part 1. Notre Design. Retrieved February 14, 2024 at https://www.notredesigns.com/blog/family-values-and-beliefs-in-the-haitian-culture-part-1. 
  14. University of Minnesota. National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM): RIM Communities. Retrieved January 26. 2023 at https://nrcrim.org/about-us/rim-communities.
  15. https://www.mededportal.org/doi/10.15766/mep_2374-8265.11207 
  16. U.S. Department of State (2023). 2022 Report on International Religious Freedom: Haiti. Retrieved January 19, 2024 at https://www.state.gov/reports/2022-report-on-international-religious-freedom/haiti/. 
  17. Auguste E., A. Rasmussen (2019, October 18). Vodou’s role in Haitian mental health. Global Mental Health Volume 6, e25. Retrieved January 24, 2024 at https://doi.org/10.1017/gmh.2019.23. 
  18. https://psycnet.apa.org/record/2006-22033-017 
  19. Using a multicultural lens to understand illnesses among Haitians living in America. 
  20. Farmer, P. (1992). The birth of the Klinik: A cultural history of Haitian professional psychiatry. Ethnopsychiatry: The cultural construction of professional and folk psychiatries, 251-272. 
  21. https://pubmed.ncbi.nlm.nih.gov/12520887/ 
  22. https://data.who.int/countries/332 
  23. https://data.who.int/countries/332 
  24. https://hia.paho.org/en/countries-22/haiti-country-profile 
  25. Joseph N. P., Clark J.A., Bauchner H., et. al (2012, November). Knowledge, Attitudes, and Beliefs Regarding HPV Vaccinations: Ethnic and Cultural Differences Between African-American and Haitian Immigrant Women. Womens Health Issues 22-6 (2012) e571-e579. https://doi.org/10.1016/j.whi.2012.09.003 
  26. Magny-Normilus C., R. Whittemore (2020, April 22). Haitian Immigrants and Type 2 Diabetes: An Integrative Review. J Immigr Minor Health 22(2): 399-409. Retrieved January 30, 2024 at https://doi.org/10.1007/s10903-019-00914-5 
  27. Centers for Disease Control and Prevention (2023, July 13). Travelers’ Health: Haiti. Retrieved January 31, 2024 at https://wwwnc.cdc.gov/travel/destinations/traveler/none/haiti 
  28. https://wwwnc.cdc.gov/travel/yellowbook/2024/itineraries/haiti#:~:text=falciparum%20malaria%20is%20endemic%20to,cases%20per%20100%2C000%20people%2C%20annually.
  29. https://www.unaids.org/sites/default/files/media_asset/2024-unaids-global-aids-update-caribbean_en.pdf 
  30. https://www.unaids.org/sites/default/files/media_asset/data-book-2024_en.pdf 
  31. https://www.state.gov/wp-content/uploads/2020/04/Haiti-RM-2019.pdf 
  32. https://www.migrationpolicy.org/article/haitians-flee-collapse 
  33. https://www.houstonchronicle.com/projects/2022/haiti-odyssey-texas-migrants/#:~:text=Doctors%20Without%20Borders%2C%20which%20provides,sexual%20violence%20survivors%20were%20Haitian 
  34. https://www.houstonchronicle.com/projects/2022/haiti-odyssey-texas-migrants/#:~:text=Doctors%20Without%20Borders%2C%20which%20provides,sexual%20violence%20survivors%20were%20Haitian
  35. https://www.cdc.gov/global-hiv-tb/php/where-we-work/haiti.html 
  36. https://www.cdc.gov/tb/statistics/default.htm 
  37. https://www.cdc.gov/global-hiv-tb/php/where-we-work/haiti.html?CDC_AAref_Val=https://www.cdc.gov/globalhivtb/where-we-work/haiti/haiti.html 
  38. https://sites.duke.edu/haitilab/files/2014/11/Keys-et-al-2012_SSM_Idioms-of-Distress-in-Haiti.pdf 
  39. https://psychiatryonline.org/doi/10.1176/appi.psychotherapy.2007.61.1.83 
  40. https://www.migrationpolicy.org/article/haitian-immigrants-united-states-2022 
  41. https://healthcluster.who.int/newsroom/news/item/05-09-2023-haiti-health-cluster-navigating-a-multifaceted-humanitarian-crisis 
  42. https://data.who.int/countries/332 
  43. https://www.ncbi.nlm.nih.gov/books/NBK573608/#:~:text=This%20is%20compounded%20by%20a,leads%20to%20a%20vicious%20circle. 
  44. https://hia.paho.org/en/countries-22/haiti-country-profile
  45. https://everymothercounts.org/grants/haiti-a-deeper-dive/ 
  46. https://www.sciencedirect.com/science/article/abs/pii/S0277953697100181?via%3Dihub 
  47. https://link.springer.com/article/10.1007/s10995-005-0026-2 
  48. https://www.sciencedirect.com/science/article/abs/pii/S152695230900230X?casa_token=hoTN18KRoyIAAAAA:mtUwn26HYvuErwF7GIXafPP5cTuhn0qMekb3oha-mbcUGcMz7u2yAwb8fqKVt49BNIA4VW55wg 
  49. https://www.nyc.gov/assets/doh/downloads/pdf/data/maternal-morbidity-report-08-12.pdf 
  50. https://pmc.ncbi.nlm.nih.gov/articles/PMC9584100/ 
  51. https://www.sciencedirect.com/science/article/pii/S016517812400266X 
  52. https://www.sciencedirect.com/science/article/pii/S014521342200117X?casa_token=_zbF2vZV0T0AAAAA:lItIR59FAuhLbWNv7PeQTEhb4Qbv0HkBm8T-xMSnoFKptwHJxBSXW9oyD_oUrl_mG_rAqlf0rIZz 
  53. Ramos, AA (presenter), Rhode S, Joshi M, PhD, Rahill G - Abstract from APHA 2017 Annual Meeting & Expo, Global Health Oral Session, (Nov. 4-Nov. 8), 2017. Syndemic interaction of structural violence, gender-based violence and risk of sexually transmitted infections, including HIV in a sample of female victims of non-partner sexual violence in post-earthquake Haiti. 
  54. Joshi, M., Rahill, G. J., Lescano, C., & Jean, F. (2014). Language of sexual violence in Haiti: perceptions of victims, community-level workers, and health care providers. Journal of health care for the poor and underserved, 25(4), 1623-1640. 
  55. Bartels, S. A., King, C., & Lee, S. (2021). “When It’sa Girl, They Have a Chance to Have Sex With Them. When It's A Boy… They Have Been Known to Rape Them”: Perceptions of United Nations Peacekeeper-Perpetrated Sexual Exploitation and Abuse Against Women/Girls Versus Men/Boys in Haiti. Frontiers in sociology, 6, 664294. 
  56. https://www.rescue.org/press-release/haitian-women-and-girls-bear-brunt-escalating-violence-warns-irc-during-16-days 
  57. Paultre, A., & Mohor, D. (2023). Haitian Gangs Use Rape As Weapon Of Terror - And There Is Little Support For Survivors - Health Policy Watch. Health Policy Watch. https://healthpolicy-watch.news/haitian-gangs-use-rape-as-weapon-of-control/ 
  58. Cénat, J. M., Amédée, L. M., Dalexis, R. D., Mukunzi, J., Clorméus, L., Guerrier, M., & Hébert, M. (2024). Sexual Victimization and Sexually Transmitted Infections Among a Nationally Representative Sample of Adolescents and Young Adults in Haiti. Archives of Sexual Behavior, 1, 1–15. https://doi.org/10.1007/S10508-024-02923-4/TABLES/5 
  59. https://www.unicef.org/haiti/en/stories/haiti-path-progress-childrens-vaccination 
  60. World Health Organization (2022). Immunization Dashboard Data: Haiti. Retrieved October 21, 2024 at https://immunizationdata.who.int/dashboard/regions/region-of-the-americas
  61. John Hopkins University of Medicine (2023). World Countries: Haiti Coronavirus Overview. Retrieved January 29, 2024 at https://coronavirus.jhu.edu/region/haiti.
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Last Updated: 12/12/2024