High levels of mild to moderate depression among men who have sex with men and transgender women in Lima, Peru: implications for integrated depression and HIV care.

ABSTRACTDepression disproportionally affects people at risk of acquiring or living with HIV and is associated with worse health outcomes; however, depression care is not routinely integrated with HIV prevention and treatment services. Selection of the best depression intervention(s) for integration depends both on the prevalence and severity of depression among potential users. To inform depression care integration in a community-based setting in Lima, Peru, we retrospectively analyzed routinely collected depression screening data from men who have sex with men and transgender women seeking HIV prevention and care services (N = 185). Depression was screened for using the Patient Health Questionnaire-9. Prevalence of any depression (PHQ-9 ≥ 5) was 42% and was significantly associated with the last sexual partner being "casual" (p = 0.01). Most (81%) depressive symptoms were mild to moderate (≥5 PHQ-9 ≤ 14). Integrating depression care with HIV prevention and treatment services in Peru should begin by implementing interventions targeting mild to moderate depression.

Post-earthquake Self-Reported Depressive Symptoms and Post-Traumatic Stress Disorder and their Correlates among College-Youths in Kathmandu, Nepal.

Exposure to earthquake has previously been associated with adverse mental health outcomes, however, evidence is limited among youth in resource-limited settings. This study explored the association of retrospective extent of exposure on current day depressive symptoms and post-traumatic stress disorder (PTSD) symptoms among 125 youth attending a college in Kathmandu, Nepal. A self-administered survey including socio-demographic variables, scale for earthquake exposure and Nepali language validated standardized scales for depressive and PTSD symptoms was used. Prevalence estimates for depressive symptoms was 43.2% and PTSD symptoms was 19.2%. For each increasing unit of the extent of earthquake exposure, the odds of having depressive symptoms increased by a factor of 1.26 (p = 0.001) and PTSD symptoms increased by a factor of 1.26 (p = 0.002). Being in a complicated romantic relationship increased the odds of both depressive symptoms and PTSD symptoms. Exposure to earthquake is an important factor to consider while assessing depressive and PTSD symptoms among youth earthquake survivors in Kathmandu. It is important that programs or policies aimed at youth mental health concurrently address disaster exposures.

"Give Me Proof": A Covert but Coercive Form of Non-partner Sexual Violence Contributing to Teen Pregnancy in Haiti and Opportunities for Biopsychosocial Intervention.

Adolescent girls in low-resource settings account for over 7.3 million births annually (generally unplanned). Unplanned teen pregnancies are increasing in low-resource settings. As part of a funded Round 20 Grand Challenges Exploration project (Healthy Minds for Adolescent Mothers), we investigated unplanned teen pregnancies in Haiti's Cité Soleil shantytown, teens' biopsychosocial challenges, and desirable interventions. Key stakeholders (N = 23): pregnant teens (13-17-year-olds, n = 8; 18-19-year-olds, n = 8) and health providers (18 or older, n = 7), participated by age group and role in focus groups (FGs). ATLAS.ti facilitated the analysis of transcribed FG audio recordings. Ninety-four percent (n = 15) of teens reported "Banm prèv," translated "Give me proof," as a cause of their unplanned pregnancies. Banm prèv describes when teens are propositioned by men who demand proof of their unpretentiousness or virginity. A subtle, covert, locally unchallenged phenomenon that is supported by damaging gender norms, Banm prèv constitutes an illusionary choice between teens' yielding non-consensual control of their bodies and the tacit alternative of gang rape. Banm prèv underscores teens' difficulty discerning consensual from coerced sex. Associated unplanned pregnancies occasion guilt, shame, stigma, depression, anxiety, and trauma in teens. Cité Soleil teens need contextually relevant, community-supported, age-appropriate interventions that challenge existing norms, build on cultural strengths, and include comprehensive sexuality education, including knowledge of reproductive rights. A traditional, contextually familiar, engaging, and humorous story-telling tradition, i.e., krik-krak, packaged in video format, is a useful framework for interventions to reduce depressive symptoms, stress, and anxiety for Cité Soleil teens experiencing unplanned pregnancies.

Experiences of sexual and gender minorities in an urban enclave of Haiti: despised, beaten, stoned, stabbed, shot and raped.

Studies of sexual and gender minorities in Haiti and globally typically involve HIV research and programming with men who have sex with men. We conducted focus groups with individuals in Haiti's Cité Soleil slum whose assigned gender at birth matched neither their gender identity nor contextual heteronormative constructions of gender roles, i.e. transwomen and transmen. The Yogyakarta Principles provided the study framework. Focus group participants offered emic perspectives on overall well-being, identities, biopsychosocial strengths and HIV-protective and risk factors. We found that gender expression that conflicts with contextual norms evoked recurring, humiliating and intentionally injurious sexual assaults against participants, heightening their HIV risk; participants endured beatings, shootings, stabbings, stonings and socio-political violence. Lack of confidentiality and stigma hinder participants' access to scarce HIV resources. Indistinct boundaries between sexuality, gender identity and gender expression merged with traditional gender-based roles to perpetuate sexual violence towards transwomen by cisgender heterosexual men and by transmen towards cisgender heterosexual women. Despite resignation to omnipresent violence, participants showed resilience regarding gender identity. Needed are integrated socio-behavioural and health programmes to challenge existing gender inequities while providing training on human rights and HIV risk reduction for Haitian sexual and gender minorities.

Psychometric properties of a Haitian Kreyòl version of the trauma symptom checklist.

BACKGROUND: In this study, the first to examine psychometrics of a Haitian Kreyòl version of the Trauma Symptom Checklist-40 (TSC-40), we investigated trauma symptoms in survivors of Haiti's 2010 earthquake who reside in Haiti's Cité Soleil slum, a violent neighborhood where non-partner sexual violence (NPSV) is rampant and whose residents are historically underrepresented in research. METHODS: 233 women and 280 men 18 years or older completed the TSC-40. Differential Item Function (DIF) analysis was performed on the TSC-40 responses for women and men. We examined symptom counts by gender, between NPSV victims and non-victims, and by interaction between gender and NPSV experience. RESULTS: We identified a reduced pool of 17-items that exhibited no gender bias. This 17-item index showed acceptable internal consistency reliability (α = 0.87). Employing this index, average symptom counts for women (x¯â€¯= 11.3) did not differ from men (x¯= 11.1). Average symptom counts for NPSV victims was greater (x¯â€¯= 12.5) than for non-victims (x¯= 10.7). The gender by experience of NPSV interaction indicated that women victims had the highest symptom counts (x¯=14.0). LIMITATIONS: We used non-probability sampling, and data were from self-reports collected in a cross-sectional survey. CONCLUSIONS: Observed differences in trauma burden are likely to be misleading if instruments are administered without regard to DIF. We contribute a Haitian Kreyòl Trauma Symptom 17-item index, which offers clinicians/practitioners in Haiti the opportunity to use a valid and reliable measure of enduring trauma symptoms validated in Haiti.

In their Own Words: Resilience among Haitian Survivors of the 2010 Earthquake.

Social sciences literature highlights the importance of resilience in relation to risk and trauma. The 2010 Haitian earthquake compounded trauma for a nation that has endured slavery/despotic leadership, structural violence and poverty. Since 2010, various sources broadly describe Haitian survivors as resilient. We reviewed definitions of resilience published between 1990 and 2013, comparing them with perspectives of earthquake survivors from economically diverse communities in Haiti who, participated in semi-structured interviews (n=38) and in six focus groups (n=63) between 2010-2011. Haitian resilience accords with some definitions from the literature. It also comprises independent, discrete, and isolated contextual resignation and intentional choice to survive and function-when there is no alternative course of action. Understanding Haitian resilience, can inform health/mental health and policy interventions, if these are taken as cultural resources. Intervention efforts should incorporate survivors' input as key informants on what constitute resilience and reconstruction goals for them.

Religious Beliefs, PTSD, Depression and Resilience in Survivors of the 2010 Haiti Earthquake.

BACKGROUND: This study examines relationships between religious beliefs regarding the origin of the 2010 earthquake in Haiti and posttraumatic symptomatology as well as depressive symptoms and resilience among its survivors. METHOD: We used convenient sampling to recruit participants (n=167). They completed six scales, which had been translated into Haitian Creole, including measures such as the Earthquake Experiences Exposure (EEE), the Peritraumatic Distress Inventory (PDI), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the PTSD Checklist (PTSD-CL), the Beck Depression Inventory (BDI) and the Connor-Davidson Resilience Scale (CD- RISC) RESULTS: Among our participants, 51% were male, (mean age=30.5, SD=11.03), 92% (n=155) were believers in some sort of supernatural force and 65% (n=108) endorsed the earthquake as a natural phenomenon. There was significant difference in average scores at peritraumatic distress, PTSD symptoms and Resilience measures between those perceiving a divine origin and/or a punishment through the event and those who did not. Peritraumatic responses were best predictors for PTSD (ß=.366, p<.001) and Depression symptoms (ß=.384, p<.001). Voodoo adherents appeared to be vulnerable to depression, but reported superior resilience factors.

Adapting an evidence-based intervention for HIV to avail access to testing and risk-reduction counseling for female victims of sexual violence in post-earthquake Haiti.

Haiti has the highest prevalence of HIV/AIDS in the Caribbean. Before the 2010 earthquake, Haitian women bore a disproportionate burden of HIV/AIDS, had lower HIV knowledge, less capacity to negotiate for safer sex, and limited access to HIV testing and risk-reduction (RR) counseling. Since 2010, there has been an increase in sexual violence against women, characterized by deliberate vaginal injuries by non-intimate partners, increasing victims' risk of sexually transmitted infections including HIV/AIDS. Needed is an adaptation of evidence-based interventions for HIV that include HIV testing and counseling for this stigmatized population. We reviewed several features of Centers for Disease Control and Prevention's 103 evidence-based interventions for HIV (e.g., measures used, participant risk characteristics, theoretical framework, outcome variables, and evidence tier) in an attempt to seek a feasibly adaptable evidence-based intervention for HIV that could be used for victims of sexual violence (VOSV). RESPECT, one of the reviewed evidence-based HIV interventions, comprises of one-on-one, client-focused HIV prevention/RR counseling, and RAPID HIV testing. Adapting RESPECT can enhance access to testing for Haitian VOSV and can influence their perceptions of HIV risk, and establishment of RR goals for future consensual intimate relations. Adapting and implementing RESPECT can increase uptake of evidence-based HIV interventions among Haitians and positively affect a region with high HIV prevalence and increased rates of sexual violence.

Symptoms of PTSD in a sample of female victims of sexual violence in post-earthquake Haiti.

BACKGROUND: Globally, sexual violence (SV) impacts 25-33% of women, is often perpetrated by intimate partners and occurs even post-disasters. The 2010 Haiti earthquake occasioned a SV epidemic in Cité Soleil, where over 50% of females are reportedly victims of SV via non-intimate partners/strangers (NPSV). Little is known about the psychological effects of SV perpetrated by NPSV; even less in known about the biopsychosocial consequences of NPSV on women in Haiti. Yet, the World Health Organization recently called for research on NPSV, particularly in poor and disaster-affected countries. METHODS: As a first step in categorizing the consequences of NPSV on female victims in Haiti, we conducted 2 focus groups of 16 female residents of Cité Soleil who survived the earthquake and its aftershocks, along with ensuing hurricanes and cholera. RESULTS: Participants reported rapes by strangers who intentionally "crush the uterus." All endorsed criteria for PTSD, including enduring physiological, neurological and psychological symptoms: significant intrusive, avoidance, arousal, cognitive, mood changes, as well as significant distress/impairment in various areas of functioning; and all but one became pregnant from the experience. All denied substance use and other illness that is not associated with the sexual violence. LIMITATIONS: Our study was exploratory, targeting a small sample of women in one specific neighborhood and cannot be generalized to all SV victims in Haiti. CONCLUSIONS: Following earthquakes, there should be vigilance by public health officials and rescue teams for prevention of SV against women. Women who survive SV in Haiti should be provided access to trauma-informed care that addresses biological consequences of the SV, as well as biological, neurological and psychological sequelae.

Language of sexual violence in Haiti: perceptions of victims, community-level workers, and health care providers.

Non-partner sexual violence (NPSV), an important risk factor for HIV, is of global public health significance and understudied. The 2010 earthquake interacted syndemically with structural factors to increase sexual violence and HIV risk for women in Cité Soleil, Haiti. We used an exploratory sequential qualitative design and Grounded Theory to investigate language/terminology for NPSV, victims and perpetrators, and health effects of NPSV on victims, in four focus groups: Health care providers (HCPs) (n=3; n=8), community advocates (n=8), and victims (n=8). Crucial differences exist among stakeholders: HCPs prefer French and possess different explanatory models of illness from victims, who provided more extensive and explicit descriptions (e.g., "strangled like a chicken," "tuyo"/"faucet"/"flooding" for gang rapes). Victims also reported purposeful injury to their external and internal genitalia, signaling STI/HIV risk. Reconciling within-culture differences between victims and HCPs can inform screening, diagnosis, treatment, follow-up and delivery of relevant interventions.

Shelter recovery in urban Haiti after the earthquake: the dual role of social capital.

This paper documents the culture-specific understanding of social capital among Haitians and examines its benefits and downsides in post-disaster shelter recovery following the 12 January 2010 earthquake. The case study of shelter recovery processes in three socioeconomically diverse communities (Pétion-Ville, Delmas and Canapé Vert) in Port-au-Prince suggests that social capital plays dual roles in post-disaster shelter recovery of the displaced population in Haiti. On the one hand, it provides enhanced access to shelter-related resources for those with connections. On the other hand, it accentuates pre-existing inequalities or creates new inequalities among displaced Haitians. In some cases, such inequalities lead to tensions between the haves and have-nots and instigate violence among the displaced.

Type and frequency of substances injected in a sample of Haitian immigrant picuristes (informal injectionists) and clients.

In view of health inequities disfavoring Haitians, substances given by Florida Haitian picuristes/informal injectionists were investigated. Semi-structured interviews of 10 picuristes and 25 clients were obtained, transcribed, and analyzed using ATLAS.ti and SPSS. The most commonly injected substances were antibiotics (reported by eight of 10 picuristes, who sometimes compose substances when conventional pharmaceuticals are inaccessible). Haitian picuristes give injections based on clients' reported symptoms, and no clear or consistent protocol appears to exist for diagnosis, insuring injection safety, determining amount, or frequency of substances injected. Findings indicate frequent use and misuse of antibiotics. While not limited to this sample of Haitian immigrants, frequent and unmonitored use of antibiotics may add to health disparities by increasing antibiotic resistance among them and among others with similar health practices. A harm reduction approach for mitigating effects of antibiotic overuse is suggested.

Picuriste/injectionist use among Haitian immigrants in Miami-Dade County, Florida: implications for HIV-related theory.

OBJECTIVES: We explore the risks reported to picuriste (injectionist) use in a non-probability sample of Haitian immigrant residents of Miami-Dade, Florida, using a mixed method approach. Picuristes typically have no formal medical training, and may use non-sterile needles. METHODS: Face to face semi-structured interviews were conducted of picuristes (n = 10) and picuriste users (n = 25). We sought to corroborate the qualitative findings by fielding a survey based on the interviews in a community-based sample of 205 Haitian immigrants. RESULTS: The findings from the interviews indicate picuriste injections do not adhere 100% to established standards for safe injections, and may pose health risks that are similar to those that exist for injection drug users. Yet, of the survey respondents (n = 205), 17.6% reported obtaining picuriste injections. CONCLUSION: Our findings shed light on a normally hidden cultural health behavior, enhancing our understanding of picuriste practice and use among Haitian immigrant residents of Miami-Dade County, Florida. We suggest that medical care must be delivered in a culturally competent, culturally sensitive manner, with open dialogue between physician and patient regarding health beliefs and practices.

Haitian picuristes/injectionists as alternatives to conventional health care providers in South Florida.

Barriers in seeking access to conventional health care services continue to be a problem in the United States, especially among recent racial and ethnic immigrants who tend to be least able to afford adequate health insurance coverage. Ethnic immigrants sometimes seek out traditional healers as unconventional providers of health care services to overcome barriers in accessing the conventional health care delivery system. The purpose of this work is to provide insight into the practices of Picuristes or Haitian "lay injectionists" in their role as alternative, unconventional providers of health care services among Haitian immigrants in South Florida. Based on in-depth interviews with 10 picuristes who were identified through venue and snowball sampling and who volunteered to participate in a larger exploratory study that examined various aspects of picuriste practices, findings revealed benefits and risks of seeking health care services from these traditional practitioners. Among the benefits reported to their services were greater accessibility, affordability, convenience, and cultural compatibility. Risks observed from analysis of picuriste interviews included the lack of formal medical training for picuristes, their nonadherence to established standards for safe injections and their potential to expose clients and the community to contaminated needles, syringes, and other biohazardous waste materials. Insight was also gained into how picuristes learned to practice their trade and to incorporate Haitian cultural beliefs regarding the relationship between clients and healers. Given the continuation of barriers to health care among ethnic immigrants, implications for conventional heath care practice and social policy are also discussed.

Metaphors as contextual evidence for engaging Haitian clients in practice: a case study.

Haitian immigrants remain underserved in the United States (U.S.), despite their large presence and their visibility, which increased after the January 12, 2010 earthquake. Employing cultural-specific practice strategies to engage Haitians in the U.S. who experienced loss in their social networks, requires understanding the context of their ecological culture and consideration of relevant linguistic and cultural elements. Through a case example, we describe the use of metaphors in cultural language as part of a strategy used to engage a Haitian immigrant with symptoms of posttraumatic stress disorder. Outcomes indicate that the use of storytelling and metaphors facilitate disclosure of clients' worldviews, experiences, feelings and hopes in a safe environment while providing them with tools to determine progress. We identify four practice guidelines for intervention strategies with ethnic minority groups who share similar cultural contexts. Metaphors, which are a viable approach to practice, focus on cultural strengths and resiliencies over traditional models of deficit and can enhance access to needed effective services for underserved populations, such as Haitians in the United States.

Correlates of picuriste use in a sample of health-seeking Haitian immigrants and adult children of immigrants in Miami-Dade County, Florida.

OBJECTIVES: We explored covariates of the use of picuristes (traditional health workers with no formal medical training who provide intramuscular, subcutaneous, and intravenous injections, typically with nonsterile needles) in the Haitian community of Miami-Dade County, Florida. METHODS: We surveyed a community-based sample of 205 Haitian immigrants and adult children of Haitian immigrants. Through logistic regression analysis, we sought to corroborate the correlates of picuriste use identified in previous qualitative interviews of picuristes and their clients. RESULTS: Picuriste injections had been obtained by 17.6% of our respondents. After control for demographic characteristics, we found that participants who reported that a trusted person recommended a picuriste were 3.9 times as likely as participants without a recommendation to have used a picuriste. Similarly, participants who believed that the benefits associated with picuriste use were worth any resulting problems were 4.5 times as likely as those without this belief to have patronized a picuriste. CONCLUSIONS: A significant minority of our sample patronized picuristes. Our data identified factors associated with picuriste use and shed light on a frequently hidden cultural health behavior.

The relationship among cardiovascular risk factors, diet patterns, alcohol consumption, and ethnicity among women aged 50 years and older.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among women of all races and ethnicities. The risk of developing the disease is greater in postmenopausal women. OBJECTIVE: The purpose of this study was to use cluster analysis to examine diet patterns and to examine the association between diet patterns and the presence of major cardiovascular disease risk factors. DESIGN: Data from the cross-sectional National Health and Nutrition Examination Survey (NHANES) 2001-2002 were used. SUBJECTS/SETTING: Women aged 50 years and older were included (n=1,313). MAIN OUTCOME MEASURES: The following major CVD risk factors were examined: being overweight or obese (body mass index >24.9), having elevated systolic blood pressure (>120 mm Hg), and having low levels of high-density lipoprotein cholesterol (<50 mg/dL [<1.30 mmol/L]). Dietary patterns were derived by cluster analysis using data from a 24-hour dietary recall. STATISTICAL ANALYSES PERFORMED: Odds Ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression to determine the probability of having a risk factor according to diet pattern while accounting for race/ethnicity, physical activity, age, and smoking. RESULTS: Cluster analysis generated six nonoverlapping diet patterns labeled: Pasta and Yellow Vegetables; Sweets; Beef, Starches, Fruits, and Milk; Frozen Meals, Burritos, and Pizza; Meat Dishes; and Soft Drinks and Poultry. The majority of the women were grouped in the Sweets diet pattern. Factors associated with adequate levels of high-density lipoprotein cholesterol included being non-Hispanic African American (OR 0.59, 95% CI 0.44 to 0.81; P<0.0001), alcohol consumption (OR 0.76, 95% CI 0.69 to 0.84; P<0.0001), and being assigned to the Sweets diet pattern (OR 0.27, 95% CI 0.14 to 0.50; P<0.0001) or Meat dishes diet pattern (OR 0.94, 95% CI 0.54 to 1.65; P<0.0075). The Sweets pattern was also associated with having normal systolic blood pressure levels (OR 0.51, 95% CI 0.34 to 0.76; P<0.0001). Individuals grouped in the Beef, Starches, and Milk diet pattern were more likely to have an adequate body mass index (OR 0.42, 95% CI 0.23 to 0.77; P<0.0032). CONCLUSIONS: Significant associations between dietary patterns and major CVD risk factors were observed. Food and nutrition professionals can use this information to assess unhealthful food choices observed in the dietary patterns to guide nutrition recommendations and help reduce the incidence of CVD risk factors. Future research should aim to evaluate dietary intake via complementary methods (ie, dietary patterns and nutrient assessment) to better understand diet-disease relationships.

Cultural adaptations in data collection: field experiences.

We assessed the data collection phase of a study that examines the substance using and other health behaviors of a cohort of 160 dyads of Latino mothers and daughters living in South Florida (N=320), by conducting a focus group with the study's interviewers. The objective of the focus group was to assess the appropriateness of the questionnaire utilized in the Latino Women's Study, and identify potential barriers and challenges that may be encountered when conducting research with Latino women in the United States. The results from this focus provide useful insight into the practice of cultural adaptations in research studies, and illustrate the need for employing culturally-informed interviewers and for devising well-adapted questionnaires in studies with Latino women.