Abuse and Mental Health Concerns Among HIV-Infected Haitian Women Living in the United States

Abstract

This study describes the prevalence of abuse and mental health issues among a cohort of HIV-infected Haitian women living in the United States. We present data on 96 women, ages 19–73 years (M = 47.6, SD = 11.1), who were screened for mental health concerns between 2009 and 2012. Results demonstrated that 12.5% of the women reported a history of abuse. However, posttraumatic stress disorder (PTSD) secondary to HIV was reported by approximately 34% of women. Depression and anxiety were also highly reported, with rates of 49% and 43%, respectively. Women who reported a history of abuse were more likely to report anxiety, PTSD, and PTSD related to HIV symptoms than those without. Our findings suggest that Haitian HIV-infected women may underreport abuse and experience significant depression and anxiety. These preliminary results could be used to develop future studies and to design and implement culturally sensitive interventions for this underserved population.

According to the Florida Department of Health, 47,705 Blacks were living with a diagnosis of HIV through 2011, and among them, 15% were Haitian-born (Florida Department of Health, 2011). A study on Haitians in the United States revealed that although the incidence of AIDS cases was decreasing for Haitian men, it was increasing for Haitian women (Marc et al., 2010). Among Haitian women, it was found that 88% had been infected through heterosexual contact and only 9% through injection drug use (Marc et al., 2010). Many factors contributed to this increase, including the inability to negotiate safe sex, limited HIV knowledge, gender inequality in heterosexual relationships, and domestic violence, which also often led to barriers in HIV treatment and affected HIV disclosure (Fuentes, 2008; Koenig & Moore, 2000; Malow et al., 2000; Marc et al., 2010; Ulibarri et al., 2010; Williams et al., 2008).

Domestic violence, defined as a pattern of coercive behavior perpetrated by a spouse or intimate partner to control the other, is often perceived differently depending on cultural factors and beliefs (Fernandez, 2006; Wallach et al., 2010). In Haiti, gender equality was addressed in the legislation in 1987, providing women equal rights to property, education, and governance (Beauzile, 2006). However, it was not until 2005 that domestic violence and violence against women was recognized as an enforceable crime against women (Beauzile, 2006). Despite this new legislation, attitudes in the general population toward gender inequality and domestic violence did not change as quickly as the law was implemented. Although domestic violence is an observable behavior in Haiti, the underreporting of such behaviors continues to pose threats to the health of women living in Haiti (United Nations, 2010).

In a survey conducted by two Haitian women’s organizations, domestic violence was found to affect an estimated 60% of women living in Haiti (Beauzile, 2006). Due to the economic situation in which they live, many Haitian women tolerate abuse by their partners in exchange for financial security for themselves, their children, and their extended families (Beauzile, 2006). In addition, Haitians have a strong family belief system and they consider family as the main foundation of Haitian life (Nicolas et al., 2009), which may have an impact on women’s tolerance toward domestic violence, related to a fear of disrupting family integrity. According to The World’s Women 2010: Trends and Statistics (United Nations, 2010), 11%–29% of women in Haiti justified the hitting or beating of a wife for reasons such as burning the food, arguing, going out without her spouse, neglecting the children, and for refusing to have sex.

The trend of underreporting violence persists when Haitian women migrate to the United States. In addition to the emotional, verbal, physical, and sexual violence commonly perpetrated on women, immigrant women, including Haitian women, deal with fear of legal problems related to immigration status, which hinders help-seeking behaviors, such as medical care (Moynihan et al., 2008). It is often difficult for Haitian women in the United States to report domestic violence as they deal with multiple factors, such as language barriers, low education level, poverty, limited access to care, and immigration issues (Fordyce, 2009).

The intersection of the two epidemics of HIV and domestic violence has been widely recognized since the last World Health Organization (WHO, 2006) meeting due to the significant threats these two epidemics pose to women’s health. It has been found that some women perceive themselves as having limited abilities to protect themselves from HIV due to fears of (a) a partner’s reaction, (b) abandonment by partner and family, (c) rejection from society, (d) loss of economic assistance, (e) accusations of infidelity, and (f) violence (WHO, 2006). These fears are most prominent among minority women, which may explain the increase in heterosexual transmission of HIV to Black women, including Haitian women (Williams et al., 2008). These fears also serve as a barrier for women to obtain appropriate care. To increase access to HIV treatment and prevention services for Haitian women living in the United States, Devieux et al. (2004), suggested that it was imperative to examine the context in which HIV is transmitted, including interpersonal relationships, community, and cultural factors.

The effects of abuse and/or domestic violence have been well documented in other ethnic groups (Matud, 2005; Nagassar et al., 2010; United Nations, 2010). However, despite the high prevalence of HIV in Black women and the high rates of domestic violence among minority women, little is known about the abuse and mental health issues of HIV-infected Haitian women living in the United States. Research with other minority women has demonstrated an important correlation between domestic violence and mental health symptoms, such as anxiety, depression, and low self-esteem (Matud, 2005; Williams et al., 2008). While few studies have looked at depression in Haitian immigrant women, it has been noted that Haitian women experience distinct mental health challenges intertwined with culturally bound beliefs, values, and norms (Nicolas et al., 2007).

Our descriptive study aimed to increase the understanding of abuse and mental health issues experienced by Haitian HIV-infected women, which might impact quality of life and adherence to treatment. In this study, preliminary data are presented on self-reported rates of abuse and mental health concerns among a group of 96 Haitian women living in the United States who received medical care at an HIV outpatient clinic located in a large metropolitan city. Given the underreporting of abuse within the Haitian culture (Beauzile, 2006), we hypothesized that Haitian women would be more likely to report avoidance behaviors related to abuse or to their medical conditions rather than the abuse itself. Avoidance behavior is embedded in the Haitian culture and is characterized by an external locus of control, that is, a way of viewing the world by attributing experiences and events to a higher power (e.g., God or Loas) or to external forces that are outside of their control (Desrosiers & St. Fleurose, 2002). Because the initial phase of the study was designed to better understand the mental health concerns of Haitian HIV-infected women living in the United States, the data presented in this paper are exploratory.

Method

Our study was a retrospective analysis of data extracted from a clinical registry of a specialty HIV mental health clinic at the University of Miami/Jackson Memorial Hospital (UM/JMH). The Institutional Review Board of the University of Miami Miller School of Medicine approved the study.

Participants

Data were extracted from a clinical registry and de-identified by the database manager prior to entry into the institutional review board-approved registry to protect the confidentiality of participants. For our study, data were included from 96 participants who were infected with HIV, at least 18 years of age, of Haitian ethnicity, and female, who had undergone a brief mental health screen between 2009 and 2012 during an outpatient primary care visit at the Adult HIV Outpatient Clinic at UM/JMH. The UM/JMH Adult HIV outpatient clinic is located in a large metropolitan city and provides comprehensive medical, psychological, social, and case management services to HIV-infected individuals, including Haitian women. The clinic serves more than 3,000 individual patients infected with HIV on a yearly basis. The clinic serves mostly minority patients (estimated 50% African American, 10% Haitian, and 30% Hispanic), and approximately one third of the patients are female. The majority (>85%) relies on some form of federal assistance to cover health care expenses (Medicaid and Ryan White Part A). Mental health services are integrated into the primary care clinic to decrease stigma and improve access to mental health care. A psychologist screens patients for mental health issues at least once a year and makes referrals for comprehensive assessment and treatment as clinically indicated. A Haitian-Creole-speaking psychologist routinely screens Haitian women for mental health problems during primary care visits.

Measures

Demographic variables.

Demographic variables collected during the mental health screenings included age, gender, ethnicity, and language(s) spoken. Date of HIV diagnosis and mode of HIV transmission were also collected.

Clinical variables.

The brief mental health screening instrument used in the clinic was adapted from the PRIME MD PHQ (Primary Care Evaluation of Mental Disorders Patient Health Questionnaire) and contained 9 subscales that screened for anxiety, abuse, posttraumatic stress disorder (PTSD), posttraumatic stress disorder related to the diagnosis of HIV (PTSD-HIV), panic, depression, substance abuse, and psychosis.

1. Depression subscale (9 items). Sample item: Over the last 2 weeks, how often have you been bothered by any of the following problems: feeling down, depressed, or hopeless?

2. Anxiety subscale (4 items). Sample item: Over the last 4 weeks, how often have you been bothered by any of the following problems: feeling nervous, anxious, on the edge, or worrying a lot about different things?

3. Panic subscale (15 items). Sample item: In the last 4 weeks have you had an anxiety attack – suddenly feeling fear or panic?

4. Abuse subscale (7 items). Sample item: In your lifetime, have you ever been physically or sexually abused (hurt) by your partner, a family member, or anyone else?

5. PTSD subscale (4 items). Sample item: In your lifetime, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you had nightmares about it or thought about it when you did not want to? Describe the traumatic experience.

6. PTSD-HIV subscale (4 items). Sample item: In your life, have you ever had any experience(s) related to HIV that was so frightening, horrible, or upsetting that, in the past month, you had nightmares about it or thought about it when you did not want to? Describe the experience.

7. Substance abuse subscale (4 items). Sample items: You drank alcohol or used drugs even though a doctor told you not to because of your health? and You missed work or school or another activity, because you were drunk or high or were hung over or coming down?

8. Psychosis subscale (3 items). Sample items: Have you ever seen things other people couldn’t see? and Have you ever heard voices that other people couldn’t hear?

Statistical Analysis Methods

Data were entered into the Statistical Package for Social Sciences version 18.0 (SPSS, Chicago, IL). Descriptive statistical analyses were used to examine the distribution of the sample’s demographic, psychosocial, and behavioral variables for the 96 participants. Chi-squared analysis was used for categorical variables to assess associations and between dependent and independent variables.

Results

A total of 96 Haitian HIV-infected women living in the United States were screened for mental health issues at the Adult HIV outpatient clinic at UM/JMH from 2009 to 2012. Participants were between the ages of 19 and 73 (M = 47.6, SD = 11.1) and were all women of Haitian descent. The mode of HIV transmission for this cohort was predominantly heterosexual contact with an intimate partner (71%, n = 68), with only 2% (n = 2) reporting blood exposure as transmission risk, 6% (n = 6) unknown, and 1% (n = 1) other. Transmission risk information was not available for 19% (n = 18) of the women in our sample.

Twelve women (12.5%) reported a history of physical and/or sexual abuse. This included 10 women (10.4%) who reported abuse occurring as adults and 2 women who reported a history of childhood abuse (2%). One woman did not disclose the type of abuse. The majority of these women indicated that the abuse was not occurring at the time of the screening, and it was no longer affecting their lives (n = 10, 10.4%). Similarly, PTSD unrelated to HIV was reported in only 10.4% of cases (n = 10), with avoidance being the most frequent symptom reported (n = 8, 8.3%), followed by arousal (n = 4, 4.2%), and detachment (n = 3, 3.1%). However, PTSD related to HIV (PTSD-HIV) was reported by approximately 34% (n = 33) of the women, with avoidance also being the highest reported symptom (n = 33, 34.4%). About 7% (n = 7) of the women reported being constantly on guard, watchful, easily startled, or having outbursts of anger that were not present prior to the HIV diagnosis. Intrusive recollections of the traumatic event were reported by 6.3% of the women (n = 6), whereas detachment was reported by only 2.1% of the women (n = 2).

In addition, 49% of the Haitian women (n = 47) reported symptoms of depression. The most predominant symptom was “feeling down, depressed, and hopeless” (n = 35, 36.5%), followed by sleep disturbance (n = 30, 31.3%), decreased energy (n = 27, 28%), decreased interest (n = 23, 24%), decreased self-esteem (n = 18, 18.7%), and decreased appetite (n = 17, 17.8%). Minimal suicidality was reported in this cohort, with only 2% (n = 2) reporting suicidal ideation. Anxiety was reported by 42.7% (n = 41) of the women, with “feeling nervous, anxious, on edge or worrying a lot about different things” as the most reported response (n = 40, 41.7%), followed by irritability (n = 7, 7.3%) and muscle tension (n = 6, 6.2%). Panic symptoms were reported by only 2.1% of the Haitian women, and substance abuse was not reported in this cohort (Figure 1).

Figure 1.

Percentage of mental health concerns endorsed by Haitian HIV-infected women (n = 96). Note: PTSD = posttraumatic stress disorder; PTSD-HIV = PTSD related to HIV.

Bivariate analysis, comparing those who reported history of abuse (n = 12) with those who did not report history of abuse (n = 84), showed that women who reported a history of abuse were more likely to report symptoms of anxiety, PTSD, and PTSD-HIV. Specifically, 75% (n = 9) of women with abuse histories reported symptoms of anxiety, versus only 38% of those without abuse histories (p = .016). Three quarters of women (n = 9) who reported a history of abuse reported symptoms of PTSD-HIV, compared to 29% (n = 24) of those who did not report histories of abuse (p = .002). Similarly, 33% (n = 4) of women with abuse histories reported symptoms of non-HIV PTSD, compared to 7% (n = 6) of the nonabuse cohort (p = .005; see Table 1 for comparison between the two groups). No significant differences were found regarding rates of depression between the two groups (p = .487).

Table 1.

Comparison of Mental Health Concerns Among Haitian HIV-Infected Women who Reported Abuse Versus Did Not Report Abuse (n = 96)

	Number of Women Reporting Abuse (n = 12)	% of Women Reporting Abuse	Number of Women Not Reporting Abuse (n = 84)	% of Women Not Reporting Abuse	p-Value
Anxiety	9	75	32	38	.016
PTSD-HIV	9	75	24	29	.002
PTSD	4	33	6	7	.005

Note: PTSD = posttraumatic stress disorder; PTSD-HIV = PTSD related to HIV.

Discussion

The results of this preliminary study suggest that some HIV-Infected Haitian Women living in the United States tend to underreport abuse and demonstrate avoidance behaviors related to abuse or to HIV. Sociocultural factors, such as strong family values, gender inequality, lenient attitudes toward violence against women, fear of immigration retaliation, minimal formal education, language barriers, and lack of access to care, may have had an impact on the women’s help-seeking behaviors and their willingness to report abuse. As indicated by the United Nations (2010) report, 11%–29% of women in Haiti justified the hitting or beating of a wife for specific reasons. Because Haitian immigrants in the United States tend to maintain their cultural beliefs, despite the fact that they are living in a new environment (Nicolas et al., 2009), it is not surprising that these women underreported abuse, including domestic violence. The marked coexistence between domestic violence and HIV is salient, as it impacts a woman’s ability to negotiate safer sex (Fuentes, 2008; Josephs & Abel, 2009; WHO, 2006). Therefore, one cannot ignore the impact of either on women’s health. Most of the women in our study indicated that they contracted HIV through heterosexual activities with an intimate partner. Gender inequality within the Haitian culture suggests that the increased rate of HIV infection among Haitian women may be related to the inability to advocate for safe sex and the fear of retaliation if they refuse to have unprotected heterosexual sex with an intimate partner (Devieux et al., 2004; Fuentes, 2008; Malow et al., 2000). As indicated by Devieux et al. (2004), health disparities for Haitians infected with HIV will decrease if we take into consideration ecological and cultural factors, while empowering individuals in the community to take ownership of their problems.

Because more than one third of the women reported cognitive and behavioral avoidance as one of the clinical presentations of their PTSD, one can assume that avoidance patterns will compromise their health, as it could contribute to medication and treatment nonadherence. Avoidance behaviors in the Haitian culture have been documented in the literature and demonstrated by a high dependence on a higher power, such as God or voodoo priests, and by a tendency to attribute events to external forces outside of one’s control (Desrosiers & St. Fleurose, 2002; Nicolas et al., 2007). Prevention programs targeting HIV among Haitian women living in the United States should take into consideration cultural factors, such as normative multiple sex partners, the clash between a traditional voodoo belief system and medicine, and the lack of formal education (Hempstone et al., 2004).

It is important to educate Haitian women about accessing health services in a timely manner instead of ignoring their medical care needs until they are acutely ill. Although access to health care may present a challenge for Haitian women due to socio-economic factors, they should be encouraged to access free services provided by health departments and routine check-ups for sexually transmitted diseases offered by Ryan White-funded programs. Due to a high level of illiteracy among Haitian-born women, it would be more effective to provide health care education via Haitian Creole radio programs, which are broadcast across South Florida. The implementation of local health fairs in areas where there are a majority of Haitians would be another avenue to provide education, health screening, and basic health care to Haitian women. Educating Haitian women about the importance of negotiating safe sex and reporting abuse situations within their relationships should also be encouraged.

Based on direct observations of the clinical team at the Adult HIV outpatient clinic, most women did not report a history of abuse during the initial mental health screen and, in fact, it often took several sessions to disclose incidents of abuse. We therefore suspect that many Haitian women who are victims of abuse may deny abuse during initial assessment. Possible underreporting during the initial screen may be due to sociocultural factors, lack of cultural sensitivity of the assessment tool used, and a general reluctance to disclose sensitive information on an initial encounter. Nevertheless, the fact that a significant difference was found with such a small sample size may signal unique features of women who do report abuse, and warrants further investigation. Similar to studies supporting a correlation between abuse and mental health issues with minority women (Matud, 2005; Williams et al., 2008), our results shed light on the possibility that reported psychiatric symptoms might be connected to a history of physical and/or sexual abuse and may serve as a foundation for future studies with this population.

Our study makes a significant contribution to the literature, as it enhances understanding of an underrepresented population that is experiencing a steadfast increase in HIV rates. However, our study has several limitations. It should be noted that there was a wide age range in our cohort, and it is possible that some age-related differences in perceptions and reporting of domestic violence may have impacted our results. Additionally, the instrument used may not have been culturally sensitive to this population and was not designed to comprehensively assess domestic violence. The low reporting of abuse in our sample may have also been due to the fact that domestic violence was indirectly measured using the abuse scale. The questionnaire asked women if they had been abused, instead of asking specifically about acts that defined abuse, such as: Did your partner ever call you derogative names? Have you been hit by your partner? Have you ever been forced to have sex with your partner when you did not want to? Can you refuse to have sex with your intimate partner? Given that perceptions of violence may be influenced by cultural influences and beliefs, questions that inquire about factual information may lead to better reporting of domestic violence in the Haitian community. Our study also did not take into consideration levels of acculturation, which could have affected a woman’s perception and reporting of domestic violence. In addition, the retrospective nature of the study was limited by the quality of data collected at the time of the clinical encounter.

In conclusion, this study serves to enhance our understanding of mental health issues and abuse of Haitian women infected with HIV who are living in the United States. The results can be used to tailor appropriate mental health services for this underserved population, such as using concrete questions when assessing abuse. It is also imperative to understand that disclosure of abuse may not occur until after several sessions and, therefore, should be addressed during subsequent visits as well. Understanding that avoidance is one of the symptoms experienced by Haitian women will help clinicians tailor interventions to enhance adherence to medication and medical visits.

Providers should also be aware that some Haitian women living in the United States might protect their partners and their families, even if it impacts them negatively. Providers should offer women a safe environment that will promote trust between patient and provider, hopefully leading to disclosure of any abuse (Hodges & Cabanilla, 2011; Klein et al., 2008; Siemieniuk et al., 2010). The cultural sensitivity of health care providers is important in helping women disclose personal information, such as domestic violence and sexual coercion that may impact the woman’s health. Our results could be used as preliminary data for the development of studies to further knowledge about mental health issues in this vulnerable population and its impact on health-related behaviors and outcomes. Future research should also address the need for culturally sensitive measures and norms to identify psychopathology and violence and as well as interventions tailored for HIV-infected Haitian women living in the United States.

Key Considerations.

• Health care providers should inquire about domestic violence during encounters with patients and provide a safe environment where women can express themselves freely.

• It is important for health care providers to screen Haitian HIV-infected women for domestic violence with concrete examples instead of abstract concepts that may have different cultural significance for this group (e.g., Did your partner ever call you derogative names? Did your partner ever hit you? Have you ever been forced to have sex with your partner when you did not want to? What happens if you refuse to have sex with your partner?)

• Culturally appropriate tools to assess mental health problems among Haitian HIV-infected women need to be developed and put into use.

• It is important for health care providers to educate Haitian HIV-infected women about the impact of domestic violence on their health and empower them to negotiate safer sex with their partners.

• To ensure privacy, health care providers should ensure that women be seen without the presence of a partner, as an abuser may attempt to accompany the victim in order to maintain control and prevent disclosure of violence.