Implementation of hospital-based sickle cell newborn screening and follow-up programs in Haiti.

ABSTRACT: One in 120 children are born with sickle cell disease (SCD) in Haiti. However, health care challenges include isolated newborn screening (NBS) activities and lack of transcranial Doppler (TCD) ultrasound to assess stroke risk. The implementation activities of the Comparative Study of Children in Haiti and Miami with Sickle Cell Disease involved both NBS and TCD ultrasound implementations at 4 Haitian clinical sites. We hypothesized that hospital-based newborn SCD screening and follow-up programs would be feasible at Haiti. A traditional NBS laboratory method with dried blood samples was performed at 3 Port-au-Prince sites, and the traditional method plus point-of-care (POC) testing was used at the 2 northern sites. The rate of clinical follow-up for newborns with SCD as the outcome for the NBS intervention was compared with that of the NBS method. The NBS programs identified SCD in 0.77% of 8224 newborns over a 24-month period. In the rural hospital assigned to the combination screening, 56% of newborns identified with POC testing returned for follow-up, compared with 0% when POC was not available (P = .044). Newborns who tested positive for SCD and children aged <6 years with SCD at the clinical sites were eligible for study follow-up. Accrual was successful: 165 participants (mean age, 42 months; 53% males; 93% hemoglobin SS) were recruited and received oral penicillin. TCD ultrasound screening was hampered by poor internet connections and trained staff leaving Haiti, with only 1 active site conducting screening. Despite challenges, the implementation of NBS and sickle cell programs in Haiti is feasible. We are in the process of understanding how to mitigate implementation limitations.

Haitian and Haitian American experiences of racism and socioethnic discrimination in Miami-Dade county: At-risk and court-involved youth.

We examine how juvenile justice-involved youth of Haitian descent in Miami-Dade County cope with structural racism and its impact on their mental health. Drawing on longitudinal ethnography, psychosocial assessment data, and a family-based clinical intervention funded by the National Institute on Drug Abuse, this article explores youth narratives of discrimination prior to and during the COVID-19 pandemic. We use critical race theory and theory of practice to understand youths' perceptions as racialized bodies and stigmatized selves, highlighting the experiences and perspectives of a particular black immigrant group, ethnic beings caught up in the everyday practices of racialization, sociocultural marginalization, and racism. We frame these experiences as a variation of the complex continuum of structural racism and racial domination in the US. These experiences have caused anger, fear, anxiety, chronic anticipatory distress, and hopelessness among youth of Haitian descent. We conclude with some recommendations for therapeutic support that encourages youth to process their experiences, promotes their development of a positive self-concept, and provides them with mind-body techniques to attenuate the physical impacts of discriminatory events. The clinical trial registration number for this study intervention is NCT03876171.

Sexual Violence Prevalence and Related Pregnancy Among Girls and Young Women: A Multicountry Analysis.

This study aims to quantify the prevalence of forced sex, pressured sex, and related pregnancy among adolescent girls and young women in five low- and middle-income countries. Nationally representative, cross-sectional household surveys were conducted in Haiti, Malawi, Nigeria, Zambia, and Uganda among girls and young women aged 13 to 24 years. A stratified three-stage cluster sample design was used. Respondents were interviewed to assess prevalence of sexual violence, pregnancy related to the first or most recent experience of forced or pressured sex, relationship to perpetrator, mean age at sexual debut, mean age at pregnancy related to forced or pressured sex, and prevalence of forced/coerced sexual debut. Frequencies, weighted percentages, and weighted means are presented. The lifetime prevalence of forced or pressured sex ranged from 10.4% to 18.0%. Among these adolescent girls and young women, the percentage who experienced pregnancy related to their first or most recent experience of forced or pressured sex ranged from 13.2% to 36.6%. In three countries, the most common perpetrator associated with the first pregnancy related to forced or pressured sex was a current or previous intimate partner. Mean age at pregnancy related to forced or pressured sex was similar to mean age at sexual debut in all countries. Preventing sexual violence against girls and young women will prevent a significant proportion of adverse effects on health, including unintended pregnancy. Implementation of strategies to prevent and respond to sexual violence against adolescent girls and young women is urgently needed.

Juvenile justice-involved Haitian families' experiences of structural racism and socioethnic discrimination.

Objective: This article examines how Haitian families with youth interfacing with the juvenile justice system cope with structural racism and socioethnic discrimination (RSD). Background: Haitian families' experiences of discrimination based on their histories, immigrant status, and positionality illustrates the need for more scientific scrutiny of the experiences of RSD among Black immigrant groups. This National Institute on Drug Abuse (NIDA)-funded study details the narratives of and responses to RSD experienced by Haitian families interfacing with the juvenile justice system. Method: Data are drawn from psychosocial assessment tools, therapeutic sessions, and ethnographic interviews conducted with Haitian families participating in a family-based therapeutic intervention. Using critical race theory, we foreground the voices of those negatively impacted and use Bourdieu's theory of practice to examine the intersectionality of race and ethnicity in this population's experiences of RSD. Results: The different experiences of and responses to RSD among youth and caregivers of Haitian descent are both a variation of the complex continuum of structural racism in the United States and unique to their immigrant experience of marginalization and cultural invalidation by public institutions, community members, and peers. Conclusion: Professionals working with this population must be sensitive to the ways these experiences impact young people's identity development processes, their health, and well-being. Haitian caregivers should be encouraged to protect their children by engaging in racial and socioethnic socialization that validates their RSD experiences. Implications: Understanding the intergenerational experiences of RSD among Black, immigrant groups and encouraging family dialogue and adolescent support will strengthen family cohesion during this period of racial reckoning.

Forced Sexual Initiation and Early Sexual Debut and Associated Risk Factors and Health Problems Among Adolescent Girls and Young Women - Violence Against Children and Youth Surveys, Nine PEPFAR Countries, 2007-2018.

Adolescent girls and young women aged 13-24 years are disproportionately affected by HIV in sub-Saharan Africa (1), resulting from biologic, behavioral, and structural* factors, including violence. Girls in sub-Saharan Africa also experience sexual violence at higher rates than do boys (2), and women who experience intimate partner violence have 1.3-2.0 times the odds of acquiring HIV infection, compared with those who do not (3). Violence Against Children and Youth Survey (VACS) data during 2007-2018 from nine countries funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) were analyzed to estimate prevalence and assess factors associated with early sexual debut and forced sexual initiation.† Among adolescent girls and young women aged 13-24 years who ever had sex, the prevalence of lifetime sexual violence ranged from 12.5% to 49.3%, and forced sexual initiation ranged from 14.7% to 38.9%; early sexual debut among adolescent girls and young women aged 16-24 years ranged from 14.4% to 40.1%. In multiple logistic regression models, forced sexual initiation was associated with being unmarried, violence victimization, risky sexual behaviors, sexually transmitted infections (STIs), and poor mental health. Early sexual debut was associated with lower education, marriage, ever witnessing parental intimate partner violence during childhood, risky sexual behaviors, poor mental health, and less HIV testing. Comprehensive violence and HIV prevention programming is needed to delay sexual debut and protect adolescent girls and young women from forced sex.

Remote delivery of a therapeutic intervention to court-mandated youths of Haitian descent during COVID-19.

The threat generated by the COVID-19 pandemic has triggered sudden institutional changes in an effort to reduce viral spread. Restrictions on group gatherings and in-person engagement have increased the demand for remote service delivery. These restrictions have also affected the delivery of court-mandated interventions. However, much of the literature has focused on populations that voluntarily seek out face-to-face medical care or mental health services, whereas insufficient attention has been paid to telehealth engagement of court-mandated populations. This article draws on data gathered on an NIH/NIDA-funded study intervention implemented with juvenile justice-involved youths of Haitian heritage in Miami-Dade County, Florida, during the COVID-19 public health crisis. We explore the process of obtaining consent, technological access issues, managing privacy, and other challenges associated with remote delivery of family-based therapy to juvenile justice-involved youth. Our aim is to provide some insights for consideration by therapists, healthcare workers, advocates, researchers, and policymakers tasked with finding alternative and safer ways to engage nontraditional populations in health services. The clinical trial registration number is NCT03876171.

The internal brain drain: foreign aid, hiring practices, and international migration.

Building on empirical material gathered in Haiti, this paper advances a new and innovative understanding of the internal brain drain phenomenon-the poaching of local skilled workers by international organisations (IOs) or international non-governmental organisations (INGOs)- by conceptualising it as an equilibrium. This equilibrium is composed of two sets of tensions: (i) those between the salary conditions in the public sector and those on offer to local personnel working for IOs and INGOs; and (ii) those inherent in the dual salary scale used by IOs and INGOs for local and international staff. These two sets of tensions contribute in their specific ways to international migration, and, as such, the internal brain drain has a bearing on external brain drain dynamics. In addition, the paper addresses the difficult policy choices facing development and humanitarian organisations, since every set of policies that impacts on one side of the equilibrium is bound to affect its other side.

The experience of violence against children in domestic servitude in Haiti: Results from the Violence Against Children Survey, Haiti 2012.

BACKGROUND: There have been estimates that over 150,000 Haitian children are living in servitude. Child domestic servants who perform unpaid labor are referred to as "restavèks." Restavèks are often stigmatized, prohibited from attending school, and isolated from family placing them at higher risk for experiencing violence. In the absence of national data on the experiences of restavèks in Haiti, the study objective was to describe the sociodemographic characteristics of restavèks in Haiti and to assess their experiences of violence in childhood. METHODS: The Violence Against Children Survey was a nationally representative, cross-sectional household survey of 13-24year olds (n=2916) conducted May-June 2012 in Haiti. A stratified three-stage cluster design was used to sample households and camps containing persons displaced by the 2010 earthquake. Respondents were interviewed to assess lifetime prevalence of physical, emotional, and sexual violence occurring before age 18. Chi-squared tests were used to assess the association between having been a restavèk and experiencing violence in childhood. FINDINGS: In this study 17.4% of females and 12.2% of males reported having been restavèks before age 18. Restavèks were more likely to have worked in childhood, have never attended school, and to have come from a household that did not have enough money for food in childhood. Females who had been restavèks in childhood had higher odds of reporting childhood physical (OR 2.04 [1.40-2.97]); emotional (OR 2.41 [1.80-3.23]); and sexual violence (OR 1.86 [95% CI 1.34-2.58]) compared to females who had never been restavèks. Similarly, males who had ever been restavèks in childhood had significantly increased odds of emotional violence (OR 3.06 [1.99-4.70]) and sexual violence (OR 1.85 [1.12-3.07]) compared to males who had never been restavèks, but there was no difference in childhood physical violence. INTERPRETATION: This study demonstrates that child domestic servants in Haiti experience higher rates of childhood violence and have less access to education and financial resources than other Haitian children. These findings highlight the importance of addressing both the lack of human rights law enforcement and the poor economic circumstances that allow the practice of restavèk to continue in Haiti.

The Role of Fear-Related Behaviors in the 2013-2016 West Africa Ebola Virus Disease Outbreak.

The 2013-2016 West Africa Ebola virus disease pandemic was the largest, longest, deadliest, and most geographically expansive outbreak in the 40-year interval since Ebola was first identified. Fear-related behaviors played an important role in shaping the outbreak. Fear-related behaviors are defined as "individual or collective behaviors and actions initiated in response to fear reactions that are triggered by a perceived threat or actual exposure to a potentially traumatizing event. FRBs modify the future risk of harm." This review examines how fear-related behaviors were implicated in (1) accelerating the spread of Ebola, (2) impeding the utilization of life-saving Ebola treatment, (3) curtailing the availability of medical services for treatable conditions, (4) increasing the risks for new-onset psychological distress and psychiatric disorders, and (5) amplifying the downstream cascades of social problems. Fear-related behaviors are identified for each of these outcomes. Particularly notable are behaviors such as treating Ebola patients in home or private clinic settings, the "laying of hands" on Ebola-infected individuals to perform faith-based healing, observing hands-on funeral and burial customs, foregoing available life-saving treatment, and stigmatizing Ebola survivors and health professionals. Future directions include modeling the onset, operation, and perpetuation of fear-related behaviors and devising strategies to redirect behavioral responses to mass threats in a manner that reduces risks and promotes resilience.

The trauma signature of 2016 Hurricane Matthew and the psychosocial impact on Haiti.

Background. Hurricane Matthew was the most powerful tropical cyclone of the 2016 Atlantic Basin season, bringing severe impacts to multiple nations including direct landfalls in Cuba, Haiti, Bahamas, and the United States. However, Haiti experienced the greatest loss of life and population disruption. Methods. An established trauma signature (TSIG) methodology was used to examine the psychological consequences of Hurricane Matthew in relation to the distinguishing features of this event. TSIG analyses described the exposures of Haitian citizens to the unique constellation of hazards associated with this tropical cyclone. A hazard profile, a matrix of psychological stressors, and a "trauma signature" summary for the affected population of Haiti - in terms of exposures to hazard, loss, and change - were created specifically for this natural ecological disaster. Results. Hazard characteristics of this event included: deluging rains that triggered mudslides along steep, deforested terrain; battering hurricane winds (Category 4 winds in the "eye-wall" at landfall) that dismantled the built environment and launched projectile debris; flooding "storm surge" that moved ashore and submerged villages on the Tiburon peninsula; and pummeling wave action that destroyed infrastructure along the coastline. Many coastal residents were left defenseless to face the ravages of the storm. Hurricane Matthew's slow forward progress as it remained over super-heated ocean waters added to the duration and degree of the devastation. Added to the havoc of the storm itself, the risks for infectious disease spread, particularly in relation to ongoing epidemics of cholera and Zika, were exacerbated. Conclusions. Hurricane Matthew was a ferocious tropical cyclone whose meteorological characteristics amplified the system's destructive force during the storm's encounter with Haiti, leading to significant mortality, injury, and psychological trauma.

Haiti and the politics of governance and community responses to Hurricane Matthew.

This article examines disaster preparedness and community responses to Hurricane Matthew in semi-urban and rural towns and villages in Grande-Anse, Haiti. Based on an ethnographic study conducted in the department of Grande-Anse one week after the hurricane made landfall in Haiti, the article focuses on the perspectives of citizens, community-based associations and local authorities in the affected areas. Sixty-three (63) interviews and 8 community meetings (focus groups) were conducted in 11 impacted sites in 8 communes. Results suggest that preexisting conditions in impacted communities, rather than deliberate and coordinated disaster management strategies, shaped levels of preparedness for and response to the disaster. Affected populations relied primarily on family networks and local forms of solidarity to attend to basic needs such as shelter, health and food. The main argument presented is that Haiti, by virtue of its geographic location, lack of resources, institutional fragility and vulnerability, must systematically integrate community-based assets and capacities in its responses to and management of disasters. Further, it is critical for the government, Haitian institutions, and society to apply integrated risk reduction and management and disaster preparedness measures in all aspects of life, if the country is to survive the many disasters to come in a time of climate change. These measures should be embedded in recovery and reconstruction efforts after Hurricane Matthew.

Fear-related behaviors in situations of mass threat.

This Disaster Health Briefing focuses on the work of an expanding team of researchers that is exploring the dynamics of fear-related behaviors in situations of mass threat. Fear-related behaviors are individual or collective behaviors and actions initiated in response to fear reactions that are triggered by a perceived threat or actual exposure to a potentially traumatizing event. Importantly, fear-related behaviors modulate the future risk of harm. Disaster case scenarios are presented to illustrate how fear-related behaviors operate when a potentially traumatic event threatens or endangers the physical and/or psychological health, wellbeing, and integrity of a population. Fear-related behaviors may exacerbate harm, leading to severe and sometimes deadly consequences as exemplified by the Ebola pandemic in West Africa. Alternatively, fear-related behaviors may be channeled in a constructive and life-saving manner to motivate protective behaviors that mitigate or prevent harm, depending upon the nature of the threat scenario that is confronting the population. The interaction between fear-related behaviors and a mass threat is related to the type, magnitude, and consequences of the population encounter with the threat or hazard. The expression of FRBs, ranging from risk exacerbation to risk reduction, is also influenced by such properties of the threat as predictability, familiarity, controllability, preventability, and intentionality.

Psychological consequences of indirect exposure to disaster due to the Haiti earthquake.

INTRODUCTION: Few studies have focused on the mental health consequences of indirect exposure to disasters caused by naturally occurring hazards. The present study assessed indirect exposure to the 2010 earthquake in Haiti among Haitian-Americans now living in Miami; these subjects had no direct exposure to the earthquake, but retained their cultural identity, language, and connection to family and friends in Haiti. METHODS: Two months following the earthquake a sample of Haitian-Americans was surveyed inquiring about: (1) their psychological reactions to the quake; (2) types of exposures experienced by their family members and friends in Haiti; and (3) symptom levels of (a) major depression, (b) generalized anxiety disorder, (c) complicated grief, (d) mental health status, and (e) physical health status. RESULTS: Haitian-Americans living in Miami experienced a broad spectrum of indirect exposures to the 2010 earthquake in Haiti. These exposures were strongly associated with psychological distress, trauma-related mental health consequences, and diminished health status. Most notable was the multiplicity of indirect exposures to the on-scene experiences of multiple family members and friends in Haiti. CONCLUSIONS: Consideration should be given to the psychological impact and needs for support among indirectly-exposed populations with strong affiliation to directly-impacted victims.

The "Trauma Signature:" understanding the psychological consequences of the 2010 Haiti earthquake.

The 2010 Haiti earthquake was one of the most catastrophic episodes in history, leaving 5% of the nation's population killed or injured, and 19% internally displaced. The distinctive combination of earthquake hazards and vulnerabilities, extreme loss of life, and paralyzing damage to infrastructure, predicts population-wide psychological distress, debilitating psychopathology, and pervasive traumatic grief. However, mental health was not referenced in the national recovery plan. The limited MHPSS services provided in the first eight months generally lacked coordination and empirical basis.There is a need to customize and coordinate disaster mental health assessments, interventions, and prevention efforts around the novel stressors and consequences of each traumatic event. An analysis of the key features of the 2010 Haiti earthquake was conducted, defining its "Trauma Signature" based on a synthesis of early disaster situation reports to identify the unique assortment of risk factors for post-disaster mental health consequences. This assessment suggests that multiple psychological risk factors were prominent features of the earthquake in Haiti. For rapid-onset disasters, Trauma Signature (TSIG) analysis can be performed during the post-impact/pre-deployment phase to target the MHPSS response in a manner that is evidence-based and tailored to the event-specific exposures and experiences of disaster survivors. Formalization of tools to perform TSIG analysis is needed to enhance the timeliness and accuracy of these assessments and to extend this approach to human-generated disasters and humanitarian crises.

HIV/AIDS Knowledge and Beliefs Among Haitian Adolescents in Miami-Dade County, Florida.

This study examined HIV/AIDS knowledge and beliefs in Haitian adolescents in an HIV epicenter, Miami-Dade Florida. This study examined survey data from 300 Haitian adolescents, aged 13 through 18, from both low-and middle-income neighborhoods. A sub-sample of 80 adolescents was selected for in-depth interviews and continuous observations with their families and networks of friends, which added rich descriptions to the quantitative data. Overall knowledge about HIV/AIDS was high with the majority of adolescents identifying unprotected sex and sharing injection drug needles as HIV transmission routes. Moreover, approximately 75% of the adolescents reported condom use as an effective preventive strategy. However, misconceptions that could reduce adolescents' adoption of HIV preventive strategies were also identified. The adolescents' sources for information about HIV/AIDS as well as implications for prevention interventions are discussed.

Trends in alcohol, drug and cigarette use among Haitian youth in Miami-Dade county, Florida.

The objective of this article is to report on prevalence of drug and cigarette use among a segment of Haitian youth in the United States. The article is an argument in favor of contextualizing knowledge about drug use among young people across socioethnic lines. Because initiation of licit and illicit drugs tends to occur during adolescence, ethnic differentiation is crucial if we are to understand the drug experience among young people in the United States. Immigration, acculturation, and identity processes are critical in refuting the conventional racial categorization commonly used for interpretation of risks and behaviors among youth in the United States. The task of bringing empirical evidence to bear on drug use and drug choices by young people from different contexts will lead to the re-examination of patterns of drug use as well as to creative ways of conceptualizing these patterns.