Invisible cancers: Seeing, knowing, enacting and proving cancers in Haiti.

In Haiti, pathological confirmation of a cancer diagnosis is often delayed or impossible, imaging is expensive and imperfect, and many tests are unavailable. Physicians frequently struggle to establish cancers at a level of certainty required by "evidence based" standards, delaying definitive diagnosis and rendering some cancers permanently "suspected." I use 22 months of participant observation at the two largest cancer treatment programs in Haiti, as well as throughout Haiti's fragmented healthcare system, to look closely at processes of diagnosis and management of suspected 'cancers' which may never fully come to be. I argue that as global oncology becomes increasingly standardized, local practices are forced into alignment with a global knowledge basis that governs the knowability/unknowability of cancer. Using three case studies drawn from this work, I examine relationships among visibility, power, expertise and the replication of inequity through the governance of knowledge production. Finally, I examine the implications of these processes for cancer care in the global south.

A Narrative Review of Cervical Cancer Screening Utilization Among Haitian Immigrant Women in the U.S.: Health Beliefs, Perceptions, and Societal Barriers and Facilitators.

Haitian immigrant women living in the U.S. have a higher rate of cervical cancer mortality than any other ethnic group, primarily due to lower rates of screening test utilization. Therefore, it is important to understand the issues affecting their pap smear screening behaviors. We conducted a narrative review of articles from PubMed, SCOPUS, Embase, CINAHL/Nursing, and Psych Info. Inclusion criteria: U.S. Haitian immigrant, screening, cervical cancer, health beliefs/perceptions. Exclusion criteria: HPV-vaccine. Primary barriers: (1) lack of knowledge of cervical cancer, HPV, and pap smears; (2) lack of culturally appropriate dissemination of information; and (3) difficulty obtaining the test. Primary facilitators: (1) provider recommendations, (2) Haitian media to disseminate health information, and (3) having health insurance. This review highlights the points for intervention by health professionals and policy makers to address this group's low pap smear utilization.

Incidence of Etiology-specific Hepatocellular Carcinoma: Diverging Trends and Significant Heterogeneity by Race and Ethnicity.

BACKGROUND & AIMS: The main causes of hepatocellular carcinoma (HCC) include chronic hepatitis C and B viral infections (HCV, HBV), nonalcoholic fatty liver disease (NAFLD), and alcohol-related disease (ALD). Etiology-specific HCC incidence rates and temporal trends on a population-basis are needed to improve HCC control and prevention. METHODS: All 14,420 HCC cases from the Florida statewide cancer registry were individually linked to data from the hospital discharge agency and the viral hepatitis department to determine the predominant etiology of each case diagnosed during 2010 to 2018. Age-adjusted incidence rates (AAIRs) were used to assess the intersection between etiology and detailed race-ethnicity. Etiology-specific temporal trends based on diagnosis year were assessed using Joinpoint regression. RESULTS: HCV remains the leading cause of HCC among men, but since 2017 NAFLD-HCC is the leading cause among women. HCV-HCC AAIRs are particularly high among U.S.-born minority men, including Puerto Rican (10.9 per 100,000), African American (8.0 per 100,000), and U.S.-born Mexican American men (7.6 per 100,000). NAFLD is more common among all Hispanics and Filipinos and HBV-HCC among Asian and Haitian black men. HCV-HCC surpasses HBV-HCC in Asian women. ALD-HCC is high among specific Hispanic male groups. Population-based HCV-HCC rates experienced a rapid decline since 2015 (-9.6% annually), whereas ALD-HCC (+6.0%) and NAFLD-HCC (+4.3%) are rising (P < .05). CONCLUSIONS: New direct acting anti-viral drugs have impacted rates of HCV-HCC, offsetting important increases in both ALD- and NAFLD-HCC. Hispanics may be a group of concern because of higher rates for ALD- and NAFLD-HCC. HCC etiology varies remarkably and may warrant specific interventions by detailed race-ethnicity.

Unique Breast Cancer Screening Disparities in a Safety-Net Health System.

INTRODUCTION: Breast cancer screening (BCS) disparities leave historically underserved groups more vulnerable to adverse outcomes. This study explores granular associations between BCS and patient sociodemographic factors in a large urban safety-net health system. METHODS: A retrospective review among female patients ages 50-74 within an urban safety-net health system was conducted in 2019. All patients had a primary care visit in the past 2 years. Multiple patient health and sociodemographic characteristics were reviewed, as well as provider gender and specialty. Bivariate analyses and multivariable logistic regression were performed in 2022. RESULTS: The BCS rate among 11,962 women was 69.7%. Over half of patients were non-White (63.6%) and had public insurance (72.3%). Patients with limited English proficiency made up 44.3% of the cohort. Compared to their sociodemographic counterparts, patients with White race, English proficiency, and Medicare insurance had the lowest rates of BCS. Serious mental illness and substance use disorder were associated with lower odds of BCS. In multivariable analysis, when using White race and English speakers as a reference, most other races (Black, Hispanic, and Other) and languages (Spanish, Portuguese, and Other) had significantly higher odds of screening ranging from 8% to 63% higher, except Asian race and Haitian Creole language. Female (versus male) and internal medicine-trained providers were associated with higher screening odds. CONCLUSIONS: Multiple unique variables contribute to BCS disparities, influenced by patient and health system factors. Defining and understanding the interplay of these variables can guide policymaking and identify avenues to improve BCS for vulnerable or traditionally under-resourced populations.

Haitian State Hospital Orthopedic Grand Rounds Series: A Virtual Curriculum to Address Global Surgery Needs.

Background: Orthopedic Relief Services International (ORSI), in partnership with the Foundation for Orthopedic Trauma and the department of Orthopedic Surgery of La Paix University Hospital in Haiti, has developed a year-round Orthopedic Grand Round series. This series is moderated by Haitian faculty, features presentations by American orthopedic surgeons, and is broadcast to major state hospitals in Haiti for residents and attendings. Objective: To introduce clinical concepts and increase knowledge in an area that is medically underserved, especially in the field of orthopedics, through lectures that tailor to the educational needs of Haiti. Methods: Topics for lecture series are requested by Haitian attending orthopedic surgeons and residents in collaboration with American orthopedic surgeons to meet the educational needs of the residents in Haiti. These lectures reflect the case mix typically seen at state hospitals in Haiti and consider the infrastructural capacity of participating centers. Grand rounds are held an average of twice per month for an hour each, encompassing an educational lesson followed by an open forum for questions and case discussion. Feedback is taken from Haitian residents to ensure the sessions are beneficial to their learning. Findings and Conclusions: To date 95 sessions hosted by 32 lecturers have been completed over Zoom between the US and Haiti. The fourth year of the lecture series is currently ongoing with an expansion of topics. In an underserved medical area such as Haiti, programs that educate local surgeons are crucial to continuing the growth and development of the medical community. Programs like this have the potential to contribute to the educational infrastructure of countries in need, regardless of the specialty. The model of this program can be used to produce similar curricula in various specialties and areas around the world.

Tobacco use in Haiti: findings from demographic and health survey.

INTRODUCTION: Although tobacco has harmful effects on the physical and mental health of individuals, its use remains significant, according to the World Health Organization. To understand this phenomenon, studies have been carried out in many countries around the world, while in Haiti where more than 5,000 people die each year due to tobacco use, little is known about the use of this substance. The aim of this study was to examine the prevalence and the factors associated with tobacco use in Haiti. METHODS: We used data from the 2016/17 Haitian Demographic Health Survey. Both descriptive and multivariate analyses were conducted using STATA 16.0 software to assess the prevalence and identify factors associated with tobacco use. Results were reported as adjusted odds ratios with 95% confidence intervals. Statistical significance was declared at p < 0.05. RESULTS: The prevalence of tobacco use was estimated at 9.8% (95% CI: 9.2-10.4) among men and 1.7% (95% CI: 1.5-1.9) among women. Although the prevalence of tobacco use was low among young people, it increased with age. Respondents aged 35 and above, with no formal education, non-Christians, divorced/separated/widowed, from poorest households, rural areas, "Aire Métropolitaine de Port-au-Prince" region, with high media exposure had a higher likelihood of tobacco use. CONCLUSION: The low prevalence of tobacco use among Haitian women and youth represents a public policy opportunity to prevent these vulnerable groups from starting smoking. Adult male smokers should also be targeted by appropriate policy to reduce the different health burdens associated with tobacco, both for the smokers and other people they may expose to passive smoking. Government and health sector stakeholders, along with community leaders, should create and enforce awareness strategies and rules to control advertisements that encourage irresponsible and health-risky consumption behaviors.

Human T-lymphotropic virus 1/2 infection among immigrants and refugees in Central Brazil, an emerging vulnerable population.

Introduction: Migratory flows play a significant role in the spread of human T-lymphotropic virus 1/2 (HTLV-1/2). In the last decade, a substantial migration of individuals occurred from Haiti and Venezuela to Brazil. However, data on the prevalence of HTLV-1/2 infection among these international migrants in Brazil are scarce. This study describes the prevalence of this infection among immigrants and refugees in Central Brazil. Methods: A cross-sectional study was conducted with 537 international migrants in the State of Goiás, Central Brazil. Participants were interviewed, and blood samples were collected. Serological screening for anti-HTLV-1/2 was performed using an enzyme-linked immunosorbent assay (ELISA; Murex HTLV-I + II, DiaSorin, Dartford, UK), and seropositive samples were submitted for confirmation by a line immunoassay (INNO-LIA HTLV I/II, Fujirebio, Europe N.V., Belgium). Results: The majority of participants were males (54.4%), between 18 and 50 years old (78%; mean age: 29.1 years), self-declared black (55.1%), reported 1 to 12 years of formal education (70.9%), and were either Venezuelans (47.9%) or Haitians (39.7%). Additionally, 50.1% were immigrants, 49% were refugees, and five were Brazilian children (0.9%) born to Haitian immigrant parents. The overall prevalence of anti-HTLV-1/2 was 0.95% (95% CI: 0.31-2.28), with HTLV-1 at 0.19% and HTLV-2 at 0.76%. All seropositive individuals (n = 5) were refugees from Venezuela, resulting in a rate of 2.26% for anti-HTLV-1/2, HTLV-1 (0.45%) and HTLV-2 (1.81%) among Venezuelan refugees. Of the demographic and behavioral characteristics evaluated, unprotected sexual intercourse and having more than one sexual partner (≥2) in the previous 12 months were associated with HTLV-1/2 seropositivity among Venezuelans. Conclusion: This study revealed, despite the low seroprevalence of HTLV-1/2 among international migrants in Central Brazil, evidence of HTLV-1 and HTLV-2 infections in Venezuelan refugees. In addition, their characteristics highlight that specific social and health programs should be implemented for these emergent and socially vulnerable migrant groups.

Intra-racial disaggregation reveals associations between nativity and overall survival in women with endometrial cancer.

OBJECTIVE: Prior studies have demonstrated survival differences between Black women with endometrial cancer (EC) born in the US and Caribbean. Our objective was to determine if country of birth influences EC overall survival (OS) in disaggregated subpopulations of Black women. METHODS: Using the Florida Cancer Data System, women with EC diagnosed from 1981 to 2017 were identified. Demographic and clinical information were abstracted. Women who self-identified as Black and born in the US (USB), Jamaica (JBB), or Haiti (HBB) were included. Statistical analyses were performed using chi-square, Cox proportional hazards models, and Kaplan-Meier methods with significance set at p < 0.05. RESULTS: 3817 women met the inclusion criteria. Compared to USB, JBB and HBB had more high-grade histologies, more advanced stage disease, had a greater proportion of uninsured or Medicaid insured, and had a higher proportion of women who received chemotherapy (all p < 0.05). In multivariate analyses, age (HR 1.03 [1.02-1.05]), regional stage (HR 1.52 [1.22-1.89]), distant stage (HR 3.73 [2.84-4.89]), lymphovascular space invasion (HR 1.96 [1.61-2.39]), receipt of surgery (HR 0.47 [0.29-0.75]), and receipt of chemotherapy (HR 0.77 [0.62-0.95]) were independently associated with OS. Compared to USB, Haitian nativity was an independent negative predictor of OS when evaluating all histologies together (HR 1.54 [1.18-2.00]) and for endometrioid EC specifically (HR 1.77 [1.10-2.83]). Among women with serous EC, HBB had markedly worse median OS (18.5 months [13.4-46.5]) relative to USB (29.9 months [26.3-35.9]) and JBB (41.0 months, [34.1-82.6], p = 0.013). CONCLUSION: Country of birth is associated with endometrial cancer survival in Black women, with HBB demonstrating worse outcomes.

Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti.

BACKGROUND: In Haiti, cardiovascular disease is a leading cause of morbidity and mortality, with congenital and rheumatic heart disease comprising a large portion of disease burden. However, domestic disparities in cardiac care access and their impact on clinical outcomes remain poorly understood. We analyzed population-level sociodemographic variables to predict cardiac care outcomes across the 10 Haitian administrative departments. METHODS: This cross-sectional study combined data from a 2016-17 Haitian national survey with aggregate outcomes from the Haiti Cardiac Alliance (HCA) database (n = 1817 patients). Using univariate and multivariable regression analyses, the proportion of HCA patients belonging to each of three clinical categories (active treatment, lost to follow-up, deceased preoperatively) was modeled in relation to six population-level variables selected from national survey data at the level of the administrative department. RESULTS: In univariate analysis, higher department rates of childhood growth retardation were associated with a lower proportion of patients in active care (OR = 0.979 [0.969, 0.989], p = 0.002) and a higher proportion of patients lost to follow-up (OR = 1.016 [1.006, 1.026], p = 0.009). In multivariable analysis, the proportion of department patients in active care was inversely associated with qualified prenatal care (OR = 0.980 [0.971, 0.989], p = 0.005), and child growth retardation (OR = 0.977 [0.972, 0.983]), p = 0.00019). Similar multivariable results were obtained for department rates of loss to follow-up (child growth retardation: OR = 1.018 [1.011, 1.025], p = 0.002; time to nearest healthcare facility in an emergency: OR = 1.004 [1.000, 1.008, p = 0.065) and for preoperative mortality (prenatal care: OR = 0.989 [0.981, 0.997], p = 0.037; economic index: OR = 0.996 [0.995, 0.998], p = 0.007; time to nearest healthcare facility in an emergency: OR = 0.992 [0.988, 0.996], p = 0.0046). CONCLUSIONS: Population-level survey data on multiple variables predicted domestic disparities in HCA clinical outcomes by region. These findings may help to identify underserved areas in Haiti, where increased cardiac care resources are required to improve health equity. This approach to analyzing clinical outcomes through the lens of population-level survey data may inform future health policies and interventions designed to increase cardiac care access in Haiti and other low-income countries.

Strès ak Pwoblèm Pap Janm Fini: Deciphering migration-related stress from the perspectives of Haitian immigrants in Florida.

Relocating and starting a new life in a foreign country may entail a constellation of new stressors for Haitian immigrants; thus, research that enhances our understanding of how this vulnerable population contextualizes migration-related stress is necessary. The objectives of this study were to: (a) identify what factors are associated with migration-related stress, and (b) describe which and why specific migration-related stressors were most significant from the perspective of those suffering from high migration-related stress post migration via the stress proliferation lens of the stress process model. In this mixed-methods, sequential, explanatory pilot study, first-generation Haitian immigrants (N = 76) were recruited to operationalize migration-related stress, using the Demands of Immigration Scale (DIS). Participants (n = 8), who scored 25 or higher on the DIS, completed an in-depth audio-recorded follow-up interview that consisted of open-ended questions and a stressor-ranking questionnaire. Descriptive statistics, Pearson correlations, multiple linear regression (quantitative), and thematic analysis with a double-coded approach (qualitative) were employed to analyze the data. Female gender, older age, English fluency, and migration after the age of 18 years were associated with higher migration-related stress. However, only gender and English fluency predicted migration-related stress. In interviews, participants ranked five migration-related stressors as most stressful: language barriers, financial strains, loss of social networks, family conflicts, and exposure to discrimination/stigma. A nuanced depiction of migration-related stressors and proliferation mechanisms of migration-related stress may help identify areas where support and preventive efforts should be directed to improve social integration, stress levels, and mental well-being among immigrants.

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project.

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

Scaling Surgical Resources: A Capacity Analysis of C-arm Machines in Haiti Following the 2021 Earthquake.

BACKGROUND: In 2021, a 7.2 magnitude earthquake struck Haiti resulting in a surge of orthopaedic trauma requiring immediate surgical treatment. Safe and efficient operative management of orthopaedic trauma injuries requires intraoperative fluoroscopy through C-arm machines. The Haitian Health Network (HHN) received a philanthropic donation of three C-arm machines and considered an analytical tool may guide efficacious placement of those machines. The study objective was to develop and apply a clinical needs and hospital readiness measuring tool relevant to C-arm machines, which may guide decision-makers, such as HHN, in response to an emergency situation with a surge in need for orthopaedic treatment. METHODS: An online survey to assess surgical volume and capacity was created and then completed by a senior surgeon or hospital administrator based at hospitals within the HHN. Multiple-choice and free-text answer data were collected and classified into five categories: staff, space, stuff, systems, and surgical capacity. Each hospital received a final score out of 100, calculated by equal weighting of each category. RESULTS: Ten out of twelve hospitals completed the survey. The average weighted score for the staff category was 10.2 (SD 5.12), the space category was 13.1 (SD 4.09), the stuff category was 15.6 (SD 2.56), the systems category was 12.25 (SD 6.50), and the surgical capacity category was 9.5 (SD 6.47). The average final hospital scores ranged from 29.5 to 83.0. CONCLUSION: This analysis tool provided data as to the clinical demand and capabilities of hospitals within the HHN to receive a C-arm machine and reaffirmed the critical need for more C-arms in Haiti. This methodology may be utilised by other health systems to provide data to distribute orthopaedic trauma equipment, which would benefit communities during periods of surge capacity, such as natural disasters.

Exploring engagement in cervical cancer prevention services among Haitian women in Haiti and in the United States: a scoping review.

PROBLEM IDENTIFICATION: Haitian women in Haiti and in the United States experience a disproportionate burden of cervical cancer, however their uptake of cervical cancer prevention services remains concerningly low. LITERATURE SEARCH: A comprehensive search on bibliographic databases coupled with a grey literature search was conducted. A total of 401 studies were identified, with 28 studies retained after following Arksey and O'Malley's Scoping Review Guidelines. DATA EVALUATION/SYNTHESIS: Knowledge levels of HPV and cervical cancer, along with preventative measures was alarmingly low. Traditional health practices, cultural worldviews, and social networks had an influence on the uptake of cervical cancer prevention. Health systems barriers were found to be a prevalent barrier among Haitian women in the U.S. CONCLUSIONS: Future health promotion interventions developed for Haitian women must address personal, cultural, social, and structural factors with an emphasis on modifying knowledge and beliefs to improve engagement in cervical cancer prevention behaviors.

Factors contributing to delays in initiation of front-line cervical cancer therapy: disparities in a diverse south Florida population.

OBJECTIVE: Delay in initiating cervical cancer treatment may impact outcomes. In a cohort of patients initially treated by surgery, chemoradiation, chemotherapy, or in a clinical trial, we aim to define factors contributing to prolonged time to treatment initiation. METHODS: Data from patients initiating treatment for cervical cancer at a single institution was abstracted. Time to treatment initiation was defined as the interval from the date of cancer diagnosis to the date of treatment initiation. Poisson regression model was used for analysis. RESULTS: Of 274 patients studied, the median time to treatment initiation was 60 days (range 0-551). The median times to initiate surgery (54 days, range 3-96) and chemoradiation (58 days, range 4-187) were not significantly different (relative risk (RR) 1.01, 95% CI 0.98 to 1.04, p=0.54). The shortest median initiation time was for chemotherapy (47 days; RR 1.13, 95% CI 1.08 to 1.19, p<0.0001) and the longest was for clinical trial (62 days; RR 1.18, 95% CI 1.12 to 1.24, p<0.0001). Charity care (RR 1.09, 95% CI 1.05 to 1.14, p<0.0001), Medicare or Medicaid (RR 1.10, 95% CI 1.06 to 1.14, p<0.0001), and self-pay (RR 1.38, 95% CI 1.32 to 1.45, p<0.0001) delayed treatment initiation more than private insurance. Hispanic White women (RR 0.69, 95% CI 0.66 to 0.73, p<0.0001) had a shorter treatment initiation time compared with non-Hispanic White patients, while Afro-Caribbean/Afro-Latina women (RR 0.86, 95% CI 0.81 to 0.90, p<0.0001) and African-American patients (RR 1.13, 95% CI 1.07 to 1.19, p<0.0001) had longer initiation times. Spanish speaking patients did not have a prolonged treatment initiation (RR 0.68, 95% CI 0.66 to 0.71, p<0.0001), though Haitian-Creole speaking patients did (RR 1.07, 95% CI 1.01 to 1.13, p<0.002). Diagnosis at an outside institution delayed treatment initiation time (RR 1.24, 95% CI 1.18 to 1.30, p<0.0001) compared with diagnosis at the cancer center. CONCLUSION: Factors associated with prolonged time to treatment initiation include treatment modality, insurance status, language spoken, and institution of diagnosis. By closely examining each of these factors, barriers to treatment can be identified and modified to shorten treatment initiation time.

High prevalence of obesity among women in urban Haiti: Findings from a population-based cohort.

Introduction: Obesity is associated with increased risk of non-communicable diseases and death and is increasing rapidly in low- and middle-income countries, including Haiti. There is limited population-based data on body mass index (BMI) and waist circumference (WC) and associated risk factors in Haiti. This study describes BMI and WC, and factors associated with obesity using a population-based cohort from Port-au-Prince. Methods: Baseline sociodemographic and clinical data were collected from participants in the Haiti CVD Cohort Study between March 2019 and August 2021. Weight was categorized by BMI (kg/m2) with obesity defined as ≥30 kg/m2. Abdominal obesity was defined using WC cutoffs of ≥80 cm for women and ≥94 cm for men based on WHO guidelines. Sociodemographic and behavioral risk factors, including age, sex, educational attainment, income, smoking status, physical activity, fat/oil use, daily fruit/vegetable consumption, and frequency of fried food intake were assessed for their association with obesity using a Poisson multivariable regression. Results: Among 2,966 participants, median age was 41 years (IQR: 28-55) and 57.6% were women. Median BMI was 24.0 kg/m2 (IQR: 20.9-28.1) and 508 (17.1%) participants were obese. Women represented 89.2% of the population with BMI ≥30 kg/m2. A total of 1,167 (68.3%) women had WC ≥80 cm and 144 (11.4%) men had WC ≥94 cm. BMI ≥30 kg/m2 was significantly more prevalent among women than men [PR 5.7; 95% CI: (4.3-7.6)], those 40-49 years compared to 18-29 years [PR 3.3; 95% CI: (2.4-4.6)], and those with income >10 USD per day compared to ≤1 USD [PR 1.3; 95% CI: (1.0-1.6)]. There were no significant associations with other health and behavioral risk factors. Discussion: In Haiti, women have an alarming 6-fold higher obesity prevalence compared to men (26.5 vs. 4.3%) and 89.2% of participants with obesity were women. Abdominal obesity was high, at 44.3%. Haiti faces a paradox of an ongoing national food insecurity crises and a burgeoning obesity epidemic. Individual, social, and environmental drivers of obesity, especially among women, need to be identified.

Uterine fibroid: a socially malignant illness in Haiti.

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

[Characterization and Health Risk Assessment of Heavy Metals in PM2.5 in Xiamen Port].

PM2.5 samples at Haitian and Songyu container terminals in Xiamen Port were collected in summer and autumn/winter in 2020 and analyzed for 20 elements to investigate their temporal-spatial distribution features, sources, and health risk. The results showed that the levels of PM2.5 were relatively low and did not show significant spatial and diurnal differences. Ca and Si were the main crustal elements, and Zn and Mn were the main heavy metals in PM2.5. Compared with GB 3095-2012 guidelines, Cr(Ⅵ) was in the range of 27.4-28.6 times above the standard. Under the influence of monsoon and port throughput, the concentrations of some elements in summer were higher than those in autumn/winter. Significant diurnal variations were observed for Cu, Zn, SO2, and NO2 but not for V and Ni. Industrial sources were identified as the primary contributor (55.2%-59.4%), followed by traffic (28.7%-31.3%), ship emissions (7.1%-7.7%), and sea salt plus construction dust (4.8%-5.8%). The results of health risk assessment showed that heavy metals in PM2.5in Xiamen Port had potential carcinogenic risk (ECR>1(10-5) to people living near the port, and Cr(Ⅵ), V, and As together accounted for 97.3%-97.5% of the total risks; however, the non-carcinogenic risk was negligible (HI<1), and the major contributors were V, Mn, Ni, and As (89.6%-91.2%). The relative contributions of each contributor to ECR was in the order of traffic (47.2%-49.4%)>industrial (23.8%-24.2%)>ship emissions (16.9%-20.8%)>sea salt plus construction dust (5.7%-12.1%), and the relative contribution to HI was in the order of traffic (38.7%-42.3%)>industrial (24.5%-28.2%)>ship emissions (24.1%-27.2%)>sea salt plus construction dust (5.4%-9.6%).

Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study.

BACKGROUND: Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care. METHODS: The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months. RESULTS: In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups. CONCLUSIONS: Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators. LAY SUMMARY: In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.

Cromoblastomicosis: primer caso alóctono tratado en Chile / Chromoblastomycosis: first allochthonous case treated in Chile

Resumen La cromoblastomicosis es una infección fúngica de la piel y del tejido subcutáneo, de evolución crónica, causada por hongos dematiáceos que se caracterizan por presentar melanina en su pared celular. La enfermedad se presenta en todo el mundo, principalmente en regiones tropicales y subtropicales. En Chile, solo hay un reporte de caso humano hace más de 30 años. Se presenta el caso de un varón de 46 años, haitiano, residente en Chile, con placas verrucosas en la zona tibial anterior de un año de evolución. El diagnóstico de cromoblastomicosis se confirmó al observar células muriformes en la histopatología y colonias dematiáceas en el cultivo micológico; además, en la miscroscopía directa se observaron conidias compatibles con Fonsecaea spp. Luego de seis meses de tratamiento con antimicóticos sistémicos y crioterapia, se logró la remisión completa de las lesiones.

Abstract Chromoblastomycosis is a fungal infection of the skin and subcutaneous tissue, of chronic evolution, caused by dematiaceous fungi. The disease occurs worldwide, mainly in tropical and subtropical regions, but in regions like Chile there is only one report of a human case more than 30 years ago. We present the case of a 46-year-old Haitian man, resident in Chile, with verrucous plaques in the right anterior tibial area of one year of evolution. The diagnosis of chromoblastomycosis was confirmed when muriform cells and dematiaceous colonies were observed in the histopathological analysis and the direct microscopy, respectively. After six months of treatment with systemic antimycotics and cryotherapy, complete remission of the lesions was achieved.

Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study.

OBJECTIVES: This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN: The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING: A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS: There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS: The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS: CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.