After reading this chapter, the nurse will be able to:
Describe the etiology of the Haitian Creole language.
Explain the tradition of spatial behavior often found among Haitian Americans.
Understand the Haitian family structure and the relevance to assimilation of Haitian Americans into the Western culture.
Describe the relationship of time and social class in Haitian Americans.
Identify the beliefs regarding Voodoo commonly found in the Haitian culture and how they pertain to healing.
Identify diseases that are prominent in Haitian-American people.
The small republic of Haiti in the West Indies has a colorful but tormented history. To provide appropriate care to Haitian-American clients, the nurse needs to have knowledge about the social and political turmoil that Haiti has experienced. In addition, the nurse should be aware of the difficulties that have surrounded migration as Haitians have sought sanctuary from their troubled homeland. It is only through an understanding of Haitian culture and health beliefs that the nurse can adequately meet the needs of Haitian-American clients. In addition to discussing the land of Haiti, the immigration process, and the influence of the six cultural phenomena on nursing care of Haitian-American clients, this chapter explores the struggles that Haitians have experienced in their attempts to assimilate the cultural traits of the dominant culture in North America.
Overview of Haiti
Haiti (République d’Haïti) is situated in the western third of the island of Hispaniola. The other two thirds of the island is occupied by the Dominican Republic. Haiti is in the Caribbean Sea, with Cuba to the northwest, Jamaica to the southwest, and Puerto Rico to the east. Haiti, about the size of Maryland, is two thirds mountainous, and the rest of the country is characterized by great valleys, extensive plateaus, and small plains ( ; ). Columbus discovered the island of Hispaniola on Christmas Eve in 1492, when his flagship, the Santa María, ran aground and was wrecked at Cap Haitien, a historic town on Haiti’s northern coast. As the French took over the island, the native Indians were either exterminated or removed to Mexican gold mines. Black slaves were imported from Africa as the French became owners of flourishing sugarcane plantations. By 1681 there were 2000 slaves in St. Domingue, the French name for Haiti. A little more than 100 years later, there were at least 500,000 African slaves, and some estimate as many as 700,000, compared with 40,000 Whites and 28,000 freemen of color—offspring of masters and slaves ( ). Many slaves were newly imported because many died of overwork, beatings, disease, and undernourishment. The masters were obviously outnumbered, necessitating harsh measures to keep the slaves in line.
Interestingly, the African religions were seen as a source of resistance to the French ( ). Although night ceremonies and dances were often forbidden, they continued and fomented the desire for power and freedom. Legend has it that one night the slaves on half a dozen plantations rose up and burned down their masters’ homes, killing their masters. This revolt spread throughout the country, continuing for some 13 years. In 1802, Napoleon’s troops landed at Cap Haitien, planning to recapture the island from the slaves and use it as a jumping-off place for an invasion of the United States. However, because of yellow fever epidemics, which assisted the Haitians in killing the French soldiers, the Haitians altered the course of world history, and the French admitted defeat. In 1804, Haiti was freed from France and became the second independent nation in the Western Hemisphere and the first independent Black republic in the world. According to , the failure of Napoleonic France to recapture Haiti was one of the main reasons why France liquidated its entire remaining American empire, which was sold by the Louisiana Purchase to the United States. Thus a consequence of the revolution in Haiti was to make the United States a continental world power.
Unfortunately, independence from France did not end the misery for the poor in Haiti. Although they were no longer slaves, the poor soon found that the oppressive French rulers had been almost immediately replaced by equally oppressive new Black rulers, the mulattos. With the advantage of money inherited from their French fathers, the mulattos became educated and wealthy and continued to monopolize Haiti’s resources, with little regard for the social conditions of the poor ( ).
The American occupation, from 1915 to 1934, resulted in reorganization and improvements of the country regarding its road system, telecommunications, health care system, universities, banking system, and so on but did not effect permanent change. This assistance failed to solve the economic and social problems, and when the majority of Americans left in the 1930s, the country once again regressed.
In addition to the attempt at revitalization by the Americans, François Duvalier, who came to power in 1957 and was to become president for life ( ), can be credited with initiating comprehensive programs to alleviate economic and technological problems. Unfortunately, Duvalier, preoccupied with wealth and power and the programs that were initiated, failed to have long-lasting effects, and the country’s money was squandered. In 1963, Duvalier murdered countless enemies and managed to incur the wrath of Haiti’s neighbor, the Dominican Republic, by harboring enemies of its new president. Upon his death in 1971, his son, Jean Claude, succeeded him. A drought from 1975 to 1977 brought famine, and in 1980 Hurricane Allen destroyed most of the rice, bean, and coffee crops. In 1986, following weeks of political unrest, President Jean Claude Duvalier fled Haiti aboard a U.S. Air Force plane. Democracy was attempted, but the country was soon taken over by a military coup ( ). In 1991, the United States joined members of the Organization of American States in a regional embargo aimed at reinstating Haiti’s first democratically elected president, Jean-Bertrand Aristide. The economic blockade led to a sharp downturn in an already poor economy. In July 1991, Aristide and the army signed an accord to return the exiled president to power. When the military leaders failed to resign, the United Nations reimposed an embargo. The embargo had a severe effect on the health of the population because it created difficulties in distributing aid and health care in Haiti. Although food and medicine are exempt from United Nations sanctions, an increase in acquired immunodeficiency syndrome (AIDS), tuberculosis, and malnourishment among children occurred ( ). After Aristide’s return to Haiti in October 1993, he quickly replaced the police force, downsized the military, and purged the officer corps.
On May 14, 2011, Michel Martelly was sworn in as president of Haiti, with the UN Security Council remaining in the country to assist in maintaining peace. The social and political unrest in Haiti has contributed to despoliation of the land. In 1996, it was estimated that only 2% of the country is forested and more than half of the land had been destroyed by erosion ( ). The remaining agricultural land is capable of producing food for only half of the population. Still, Haitian farmers continue to despoil the remaining land by removal of roots and stumps for charcoal manufacture to heat their cooking stoves in order to survive. The lack of farming land in the country has resulted in dependence on food from foreign aid ( ). There are at present efforts in the country by charitable groups to assist the country economically. One example of this is the Mennonite Economic Development Association, which has 20 paid staff who assist Haitians in developing their own small business by giving them small loans for start-up money. This organization has been very effective in helping hardworking Haitians have a chance to be self-supporting ( ). The Mennonite Central Committee has also had workers doing projects, including producing seedlings in 20 community-based tree nurseries ( ).
Recent Developments in Haiti
In the greatest tragedy in modern times impacting the country, Haiti was struck by a massive earthquake on January 12, 2010. The earthquake, striking some 15 miles southwest of Port-au-Prince, measured 7.0 on the Richter scale and was immediately followed by two aftershocks measuring 5.9 and 5.5, respectively ( ; ). Although the exact number of those who died during this earthquake may never be known, it is estimated that 222,570 people lost their lives and more than 1.6 million people were displaced, especially in the densely populated area around Port-au-Prince ( ; ). Subsequently, a significant portion of Haiti’s debt was cancelled as a part of the “Poor Countries” initiative of the International Monetary Fund and the World Bank. Along with this forgiveness, and in light of the massive $1 billion debt owed to so many other creditors and a barely functioning economy and nation, the G7 countries forgave Haiti’s remaining debts to them ( ; ).
Life in Haiti
Today, Haiti is an independent republic with 9,996,732 inhabitants (2014 estimate) ( ; ). Between 90% and 95% of the population are descendants of West African slaves; 5% of the population are mulatto and White, whereas 95% are Black. Fifty-three percent live in rural settings, 37% live in urban settings, and 10% are overseas. Haiti is considered to be the poorest nation in the Western Hemisphere, with a gross domestic product of $13.4 billion (2013 U.S. dollar estimate) and a per capita income of $1300 ( ). However, other estimates of the income for most rural Haitians is probably more realistically set at $3.56 a day, with 80% living below the poverty line. Haiti’s real economic growth rate is 3.4%, with an inflation rate of 5.9% ( ); this slight growth has not dramatically increased the purchasing power of the population. In 2000, the local currency drastically declined in value, dropping from 16 to 22 gourdes per U.S. dollar ( ) and further plummeting to 41.87 in 2009 and to 70 gourdes per U.S. dollar ( ).
More than two thirds of the labor force do not have formal jobs, and there is widespread unemployment and underemployment (2011 estimate) ( ). Of course, this number is a gross underestimation because of the almost nonfunctionality of the economy of Haiti because of the massive earthquake in 2010. It is postulated that the devastation and massive number of those who died or were displaced occurred because of the inadequate reinforcement of the buildings that disintegrated or imploded on the people, making recovery of some bodies nearly impossible ( ; ). So many people lost their lives during the earthquake that many were never properly identified and a great number were buried in mass graves ( ).
Before the earthquake, some 92% of the population lived in small, rural hamlets in small straw shacks without light, water, or windows. In sharp contrast to the destitute living conditions is the pride of the Haitians, their value of self-respect, and their strong work ethic. Although the issues and problems confronting the people of Haiti are similar to those of many other countries, they seem to be more numerous and more intensified. The country is drastically overpopulated, with a density of 890 persons per square mile ( ). In 2013, the annual population growth rate was 1.08%. The life expectancy is 63.18 years overall, 61.77 years for males and 64.60 years for females. The birth rate is 22.8 per 1000, and the death rate is 7.9 per 1000 (not taking into account the 2010 earthquake). Infant mortality is 49.43 per 1000 live births. Haiti has a young population: 34.0% of the population is 0 to 14 years old, and the median age is 22.2 years ( ). Although these numbers have been reported as accurate, caution should nonetheless be exercised when considering their validity given the massive destruction and slow recovery of the infrastructure ( ).
Haiti has numerous unresolved obstacles to public hygiene, including an inadequate water supply for 77% of the rural population and 62% of the urban population. There is inadequate access to sanitation for 64% of the rural population and 59% of the urban population. Some 80% of the population suffers from malnutrition. Health care services are lacking throughout Haiti. A national health service is responsible for the medical care of the population, but only 50% of the population (47% of the rural population) has access to health care. There is one physician for 8800 people and one nurse for 8600 people. This is even more problematic than it appears because most of the physicians are on the government payroll and are disproportionately concentrated in the capital city, Port-au-Prince ( ).
Health care is also provided by private foundations such as the Mellon Foundation, which sponsors the Hôpital Albert Schweitzer in central Haiti. To make health care more available to the people, small medical teams go out from this hospital into the rural areas to provide village-based health services. In this program, rural farmers, both men and women, are trained in primary health skills and provide direct services to clients. Health service delivered to the natives has resulted in a significant decrease in tetanus, which formerly ranked with tuberculosis and malnutrition as one of the three major health problems ( ; ; ; ). However, although this hospital operates as a charity to the local people, it is not without exposure to the unrest in Haiti. For example, administrators are sometimes threatened that their family members will be harmed if they do not hire certain Haitians who come seeking employment ( ). A number of nursing and medical schools in the United States use Haiti for transcultural experiences in a third-world setting ( ). Nurses from the United States and Canada have gone to Haiti to assist with flooding, disaster, and earthquake recovery ( ; ; ; ).
Immigration to the United States
Most of the immigrating Haitians in the early years were upper-class individuals who came to the United States as resident aliens. These upper-class Haitians were able to obtain permanent residence and citizenship with little difficulty and became assimilated into the dominant culture.
In 1980, an explosion of Haitian immigration took place as a result of a short-lived (April–October 1980) change in the U.S. immigration policy. More than 14,000 Haitian refugees landed on the shores of southern Florida in 1980 ( ), which includes the Mariel boatlift from Cuba. The influx of Cuban refugees required that a special status be created by the U.S. State Department, called “Cuban-Haitian entrant, status pending.” Haitian refugees were included in this status to prevent the policy from being discriminatory ( ; ). The “entrant” status described a temporary status and was used rather than granting the new arrivals political asylum. However, this “entrant” status placed the Haitian immigrants in a bureaucratic limbo that cannot lead to citizenship ( ).
The immigration policies changed in October 1980. A maritime interdiction program was initiated to turn back Haitian refugees at sea. Haitians who arrived in the United States were not classified as entrants but as parolees and were subject to deportation. Haitians were kept in detention along with Cubans while their cases were processed in the courts. Unlike other refugees arriving at the time (such as Indochinese refugees), resettlement was not guided by the federal government. The federal government’s refusal to grant asylum deprived the refugees of benefits under the new 1980 Refugee Act. Emergency aid was limited, and most of it had lapsed by 1983 ( ). Lacking either jobs or government assistance, many refugees were compelled to rely on private charity and to invent jobs in a burgeoning “informal” economy in Miami. In 1991, mass migration of Haitians led to 34,000 Haitians being held at the U.S. Naval Base in Guantánamo Bay, Cuba, while their immigration status was determined ( ). Numerous health problems, including active tuberculosis and AIDS, were addressed by the uniformed service medical support personnel ( ; ). In 1993, the Supreme Court of the United States ruled that repatriation was legal and that illegal aliens could be returned to Haiti ( ). Despite this ruling, thousands of Haitians still attempt to enter the United States each year by trying to travel from Haiti to the United States by boat. Some give all their money to private entrepreneurs and board barely seaworthy crafts for a chance to escape to a better life in the United States ( ). Many Haitians do not survive because the conditions at sea are too harsh or the boat is too full to permit safe travel. When weather conditions are too harsh, older Haitians may be thrown into the sea to lighten the load ( ). Still, perilous as the journey is, many Haitians would rather try for the hope of the opportunities of living in the United States. Of those who do arrive, only a fraction (5%) is allowed to stay under the status of political refugees. The United States has steadfastly clung to a policy that makes it difficult for Haitians to meet the requirements for political refugee status. For example, since the immigration act of 1990, mandatory human immunodeficiency virus (HIV) testing with indefinite detention without treatment in HIV-positive detention camps has discriminated Haitians from other immigrants (that is, Cubans, Vietnamese, Chinese) and required that persons with HIV be held rather than “paroled” ( ). In 1998, the Omnibus Budget Bill made changes in the Haitian Refugee Immigration Fairness Act, which allowed amnesty for some Haitian immigrants in the United States ( ).
These waves of immigrants have resulted in four classifications or categories of Haitians in the United States: (1) citizens, (2) residents or legal aliens, (3) entrants, and (4) illegal aliens. Illegal aliens have all the pressures and fears of discovery, which could result in sudden deportation. Entrants, on the other hand, suffer from the uncertainty of whether they will be able to remain and from being unable to make permanent plans or feel entirely settled ( ). Because possibly half of the Haitians in the United States are here illegally, few programs exist to provide assistance. Some Haitians are understandably reluctant to discuss their difficulty, and they attempt to maintain a low profile with government agencies that might return them to Haiti. Another effect of an uncertain status in North America is infrequent use of health care services after immigration. The nurse should be aware that the Haitian immigrant probably will not seek medical treatment until the condition is severe or has become chronic ( ). The nurse should also be aware that hope is related to economic factors, and lack of economic assets results in feelings of hopelessness ( ).
Despite these difficulties and the possibility of deportation, many, primarily poor, Haitians continue to try to enter the United States. Those who do make it to North America are in one of the most at-risk populations now living in the United States. This high risk becomes actualized in several ways; for example, a study by reported unusual cases of death among Haitians residing in Miami and a high prevalence of opportunistic infections. The nurse should expect, when caring for a Haitian, that the client may never have had immunizations. If a client needs a tetanus immunization, it is unlikely that a tetanus booster is appropriate because the client probably has not received the series.
Adaptation of post-1980 Haitians to the dominant culture in the United States and Canada has been especially problematic because the proportion of refugees having a high school or college education and skills in English has declined. With limited education and money, many Haitians arriving in North America have been restricted to occupations such as migrant agricultural work and service industry jobs in restaurants and hotels ( ). Only a few of the more educated Haitians have been able to find work as mechanics and construction workers. Gaining the requirements needed to adjust to the urban, industrialized culture encountered in the United States and Canada is for most Haitians a stressful, overwhelming, and slow process because the people continue to cling to their cultural values and beliefs. noted that although many other refugees are faring moderately well in the United States, Nicaraguans and Haitians tend to be faring poorly. Assimilation to U.S. culture for Haitians has been particularly difficult. When they are compared with other groups, noted that Haitians on the average had a significantly lower economic status in regard to yearly earnings, percentage employed, and percentage never employed and living in poverty. A substantial proportion of Haitians arriving in the United States are children, who often arrive without their parents and are placed with extended family or in foster care ( ). Children who are with families face intergenerational problems. Children often experience a role reversal because they tend to more quickly adopt the language and culture of the United States and then must translate English for their parents. Because most of the asylum cases of Haitians are denied ( ), many Haitians in the United States are considered illegal aliens. Children who are denied asylum but remain in the country illegally have suffered from nonhumanitarian treatment even into their adult years. Whereas other immigrants have been welcomed, the lack of welcome experienced by many Haitians has had a negative effect ( ). Haitians have not consistently received the same treatment as other asylum-seeking refugees. It was not until May 1995 that the Clinton administration reversed the de facto policy that granted virtual blanket asylum to all Cubans ( ).
In 1975, Haitians could be found in 45 of the 50 states ( ). Large settlements of Haitian people are located in the southern and eastern parts of the United States, with 75% to 95% residing in Florida ( ; ). New York City (especially Brooklyn) and Montreal have large, established Haitian communities that have mushroomed during times of revolution and political unrest in Haiti. For example, in 1960 there were reported to be 2584 Haitians living in New York City ( ; ). It was estimated that 34,000 Haitians had arrived in the United States in 1968, and in 1970 it was estimated that 50,000 Haitians were living in New York City alone ( ). According to the U.S. Census Bureau, in 2009, 1,000,000 people of Haitian descent resided in the United States ( ). This census figure may underrepresent the true numbers because of the number of illegal aliens from Haiti and particularly in light of the 2010 earthquake ( ). The Bahamas, which lie between Haiti and Florida, have been inundated with an estimated 60,000 Haitians who have failed in their attempt to cross the sea and instead have been shipwrecked on the vast Bahamian chain of some 700 islands ( ). Haitians report paying as much as $5000 for the privilege of the odyssey, only to land undetected on the tourist-dependent islands hoping to raise the fare to go on to Florida ( ).
Some Americans have been supportive of the plight of Haitians in Haiti and of the treatment of Haitians who have come to America ( ). In 2000, Haitian Americans marched in New York to protest policy brutality against Haitians in New York City and demanded the resignation of New York City Mayor Giuliani. Cases of mistaken identity have resulted in violence against Haitian Americans ( ). Others have protested deportation practices in which the Immigration and Naturalization Service has made Haitian immigrants who have received deportation orders choose between leaving their children in the United States in hopes of giving them the opportunity for a better life or taking the children back to Haiti ( ).
Life in the United States
As of 2013, approximately 59% of all Haitians residing in the United States were foreign-born compared with only 13% of the total U.S. population ( ). This high number of foreign-born Haitians is reflected in the 81.2% of Haitian Americans 5 years of age or older who speak a language other than English at home, compared with only 20% of the general U.S. population. In 2009, among Haitian Americans 25 years of age and older, 18.2% of both males and females held a bachelor’s degree or greater, compared with 28% of all U.S. males and 27% of all U.S. females.
In 2013, compared with the rest of the general population, slightly more Haitian Americans were actively working in the labor force. In fact, in 2013, 70.9% of Haitian Americans 16 years of age or older were in the civilian labor force, compared with only 65% of the total population ( ). Nonetheless, the yearly median per capita income for both Haitian-American women and men was lower than the general U.S. population at $32,650 for men and $28,937 for women (compared with $45,485 for all U.S. males and $35,549 for all U.S. females). Similarly, the median Haitian-American family income was significantly lower at $45,626, compared with $61,082 for the general U.S. population. Despite the number of Haitians employed in the United States in 2013, the percentage of this population who live below the poverty rate is 19.6% compared with 14.3% of the general U.S. population ( ).
Issues related to communication present a variety of problems for Haitians living in the United States or Canada. In Haiti there are two official languages: Haitian Creole (Kreyòl) and French. French is the official national language and is understood and spoken only by the upper or wealthy class. Although Haitian Creole is the language of the rural or poor population, it is also the primary language and is understood and spoken throughout the country ( ; ). Speaking only Haitian Creole, a hybrid of old French vocabulary and African grammar, is perceived as a sign of poverty and a lack of education. Both Haitian Creole and French are often spoken so fast that one word is slurred into another. Because many Haitian immigrants in the United States continue to combine Haitian Creole and French, a dialect undergoing further creolization has been created, and it creates language barriers for some Haitian immigrants because most people in the dominant U.S. society are unfamiliar with it.
Haitians frequently use hand gestures to complement their speech. Hand gesturing and tone of voice become more pronounced during communication. Primarily, hand gesturing is used as an addition to verbalizations. Touch and direct eye contact are also used in both casual and formal conversation. The Haitians’ use of touch in conversation is perceived as friendship and does not violate personal space. Direct eye contact is used to gain the attention and respect of the other person during conversation. The Haitian cultural uses of touch and direct eye contact and the perception of friendship through conversation are much like those used throughout the United States.
Implications for Nursing Care
Language is often an area where problems arise between refugees and health care providers. One reason Haitians have received limited health care in the United States is the failure of many Haitians to speak either of the dominant languages: English or Spanish. Many schools in the United States have extensive bilingual programs for native Spanish speakers but have paid little attention to other non-English speakers. The problem of providing bilingual education for Haitians is complex and begins with a lack of materials for teaching English to Haitian Creole speakers. There are also varying opinions on the best way to teach literacy skills. Some persons believe that Haitians who have immigrated to the United States must be taught literacy in their native language. The view is that if Haitian Creole is used as a teaching tool, it can facilitate acquisition of reading and writing skills in English ( ).
The nurse should promote the Haitian-American client’s interest in gaining English-language skills to facilitate the client’s adjustment to the dominant culture. Although most Haitians are eager to learn English, learning to read and write as an adult is often difficult and time consuming, and support from health care professionals can encourage the Haitian individual to stick with this difficult task. Many Haitians who use French as their primary language have retained it, even though they have made a permanent move to the United States or Canada. Although many in the United States and Canada share the French-speaking Haitian’s view that French is the language of the culturally elite, it should be noted that French-speaking Haitians have as much difficulty learning English as any other non-English speakers do.
If the client does not speak English, the nurse should first determine what language the client does speak. If the nurse does not know Haitian Creole or French, an interpreter may be necessary. When possible, a bilingual family member can help convey to the client and nurse information essential to health care. The nurse may find that Haitian Americans with children are more likely to speak correct English because speaking correct English is a status symbol and parents who know English will usually speak correct English in the home. The nurse caring for a Haitian-American client should be aware that Haitians value a touch or a smile by the nurse as a sign of friendship. Nonverbal communication can assist in bridging gaps between the differences in language because it can facilitate an understanding of client needs.
Haitian Americans who have newly arrived from Haiti may be unfamiliar with modern technology, including use of the telephone since Haiti has only 140,000 main lines, many of which may be down for a month after a rain ( ). Access to the Internet is new in Haiti, with only four local servers and limited satellite links.
Personal space to the Haitian can be defined as a public zone. Haitians as a cultural group are a sharing population. If they possess something that another person could or might benefit from, it will be shared. Another factor that tends to make the culture a public zone is the closeness of the living arrangements or dwellings. As a result, the Haitians are a public-oriented society. Haitians in the United States, for the most part, usually socialize with other immigrants arriving from their own town in Haiti and maintain primary loyalty to family members, many of whom remain in Haiti. Legal immigrants look forward to spending holidays in Haiti and regard the allowed time each year as a focal point. Illegal aliens are more isolated because they cannot maintain family contact. This represents a great change from the lifestyle led in Haiti, where extended family and the closeness of the community are emphasized.
Implications for Nursing Care
It is important for the nurse caring for a Haitian-American client to know that data from studies have indicated that Haitians find touch by caregivers to be supportive, comforting, and reassuring ( ; ). In a study of 10 women, Dempsey and Gesse noted that there were diverse views on whether these women preferred to be touched during childbirth and if the preference was for a man or woman to touch them. In the study, two women specified a preference for being touched by a woman, three preferred to be touched by a man, and three did not have a preference. Nine stated that the father should be present. What is implied by this is that Haitian women may be less likely than women from some cultural groups to insist on having female nurses in the delivery room.
Although Haitians and African-Americans share a heritage that extends back to Africa, the two groups do very little social mixing and tend to mistrust each other ( ). It is important for the nurse to understand that just because two clients may be Black does not mean they will share common interests or find each other suitable companions for sharing a hospital room. Some Haitians, like people from some other social groups, are not free of social prejudice. Appreciation of these cultural socioeconomic issues by the nurse will facilitate assignment of staff to care for Haitian clients as well as room assignments of clients.
Because of the large gap in social classes, it is important for the nurse to consider the economic background of Haitian-American clients before placing them in the same area. For example, a poor client and a wealthy client with a Haitian background, although from the same country, may find a room assignment together in a hospital very distasteful.
The Haitian masses are essentially divided into two class structures: the wealthy and the poor. Statistically, 85% of the Haitian population is classified as poor, 10% as middle class, and 5% as wealthy ( ). Class is demonstrated in many interesting ways. Wearing shoes is a requirement by law in the capital city, but many Haitians, especially in the small towns and villages, go barefoot. This is by no means a matter of choice but a mark of social standing. As an illustration of this, a Haitian physician who was enjoying a little recreation in one of the small towns was told that a client was waiting for him nearby. The physician asked if the client had shoes on. What was implied in this question was that if the client had shoes on, the physician would be obliged to go immediately. On the other hand, if the client did not, the client would be in for a wait (Jeanty, personal communication, 1989). Regardless of class, Haitians are a proud and independent people.
Education in Haitian schools differs greatly from that in American schools. Until 1979, French was the only officially recognized language and the language that was required to be used in school. The educational system and schools are strict and authoritarian. Children who are financially able to attend must wear starched uniforms. The Haitian teacher has the right to use corporal punishment on a misbehaving child. Thus the lack of structure and discipline of many American schools meets with disapproval from Haitians. Much of the information given to students in the Haitian schools is memorized; memorization through repetition is the primary source of learning. Haitian children can be heard reciting multiplication tables through rhyme and song throughout the community. Sheer repetition of the same formula, problem after problem written on the blackboard, manages to register the information in the student’s mind. Haitian teachers enunciate clearly when communicating with their students ( ; ).
Rather than attend the public high schools, Haitian Americans prefer to remain out of the mainstream of education and often strive to accelerate the educational process and obtain the credentials they value by seeking a high school equivalency diploma. Haitian Americans view a college education as a form of prestige and status.
The commonality among Haitians in Haiti and Haitians in the United States, whether wealthy or poor, is family. The family structure or system is very different from that of the American system. The practice of common-law marriage is predominant, particularly among the poor. Most legal marriages occur among the wealthy as a result of their economic status. Common-law marriage gives the father of the family much freedom and imposes much of the responsibility of caring for and meeting the needs of the family unit on the mother. The father, perhaps dividing his time between several family units, becomes a powerful but unreliable figure. The concept of a single-parent family, primarily the single mother, is similar to that in the United States but is more prevalent in Haiti. The Haitian mother is commonly left to raise the children without the support system of the father.
The term plaçage may be defined as the union of a man and woman who desire to live together and who fulfill certain obligations and perform certain ceremonies at the home of the woman’s parents, after which a new household is established. These unions are said to endure as long as recognized church marriages and constitute two thirds of all unions in Haiti ( ; ). Haitian women involved in plaçage can be classified into four groups according to their relationship with Haitian men:
Femme caille (common-law): a woman who shares her home with a man in a common-law marriage situation.
Mama petite (“mother of my children”): a woman who is the mother of some of the man’s children but does not share his house. This is similar to some plaçage unions with children, but in this situation the husband continues to live with his first wife while maintaining the second relationship.
Femme plaçage (woman whom a man “goes with” or a friend): a woman who neither lives with nor has had children by a man but who shares his bed intermittently and often maintains a garden, usually furnished by him.
Femme avec (woman who is lived with): a woman with whom the man cohabits for pleasure and without firm economic ties ( ).
The Haitian family is traditionally extended, with each dwelling or residence paralleling a small community. Outside the extended family, godparents play a very important role in the family organization and are generally considered part of the natural family. Rural or poor families tend to be matriarchal and child centered, with parents exercising strong influence and authority over their offspring, even when the children are grown. Haitians view their children as direct reflections of themselves and the family. If children fail to fulfill obligations or meet expectations, they are seen as having failed the family and as having brought disgrace on the parents ( ). Because of the parent–child ties, many Haitian couples separate only temporarily when immigrating. The wife usually immigrates with the younger children, and the husband remains in Haiti with the older children until the entire family can obtain authorization to relocate. One-parent families are quite common among this immigrant group in the United States. Immigrants often lack support of extended families in child rearing ( ).
investigated Haitian mothers and their childrearing practices. They identified the need for psychiatric mental health nurses to assist immigrant Haitian families in handling intergenerational conflict because there are significant differences between the culture of origin and the culture encountered in the United States. Conflicts arise for children between what their parents say and what they see in the culture around them. Adolescent Haitians tend to fit the profile of high school dropouts in that they are often poor and Black and live in households with high levels of stress. Social support for education is necessary if the adolescents are to remain in school ( ).
Traditionally, Haitian parents have a strong voice in their children’s selection of a mate and in their choice of a career. Haitians tend to be an extremely status-conscious group and desire marriages or careers that enhance the status of the family. For most Haitian immigrants in the United States, home ties to Haiti remain strong. Even though there may be little opportunity for travel back and forth because of cost and the illegal status of many, ties to the motherland and home remain. Letters, packages, and money are sent regularly. Because many Haitians were illiterate, at one time, sending cassettes to relatives in the United States or home to Haiti was a common form of communication (Jeanty, personal communication, 1989).
Some older Haitian immigrants have been found to depend more on the members of their social support network than other Haitian age groups ( ; ). The older immigrants experienced more changes in life events and loss of network members because of age, in addition to problems associated with migration. The older Haitian immigrants also reported that they encountered hostility and stress because of their African heritage and skin color ( ). On the other hand, reported that aides in nursing homes caring for Black clients from three cultural groups were generally positive toward the elderly but negative toward the families of the elderly residents who did not take care of the elderly at home. Findings indicated the need for education for aides related to differences among people in different cultural groups.
Implications for Nursing Care
Cultural factors related to social organization have an important influence on health and health care behavior. Fundamental norms, such as the desirability of having many children and the traditional roles of men and women, affect reproductive behavior. Because the legal status of many is either questionable, as for entrants, or undesirable, as for illegal aliens, Haitians frequently use different names, giving one name at one clinic and another name at another clinic. In addition to causing confusion to health care providers, this practice leads to people “falling through the cracks” because records are not available. Consequently, there is a loss in continuity of care for some Haitian clients. In addition, because of the repeated intake procedures on the same client, health care services may be delayed ( ).
An astute nurse should keep in mind that because the Haitian family is traditionally extended, the opinions and ideas of the family must be incorporated into a culturally sensitive plan of care. It is also important to remember that because Haitian children are taught from infancy to be unquestionably obedient to adult wishes, it is especially important to provide parents with adequate health education if children are to benefit from improved and knowledgeable health care.
The nurse should also be aware that bisexuality may be an occurrence among Haitian men. Even when this information is important, the client may not readily offer it. The nurse may need to elicit this information by asking if the client has ever had sex with another man, rather than using the labels of homosexual or bisexual ( ; ).
Immigrant Haitian mothers have been found to believe that little can be done to avoid childhood illnesses considered medically preventable in the United States ( ). Many Haitian mothers adhere to the beliefs and practices of Haitian folk medicine because they have not been taught or do not believe in preventive health care. This has important implications for the health education of parents and children ( ). found that nurses were considered the best persons to do health teaching. Teaching is valuable when it is understandable, is practical, reinforces parenting abilities, and allows time for questions.
Traditionally, Haitians have not been committed to time or a schedule. It is not considered impolite to arrive late for an appointment. Everyone and anything can wait. , a Haitian business consultant in Florida, describes how present-time orientation, which might include conducting a personal conversation rather than waiting on a customer, can cause Haitian-owned businesses in the United States to fail. On the other hand, some Haitian Americans have learned to compensate for lack of time orientation by manipulating the timing of activities. For example, a wedding invitation will show a starting time of 6 p.m. when the actual starting time is actually 7 or 7:30 p.m. ( ).
The time orientation of Haitian Americans is related to social class. Poor or lower-class Haitian Americans tend to be relatively past- and present-time oriented because they find it necessary to live from day to day, looking for food and trying to sustain a meager living. Because of their economic and educational status, the future for some of these people remains bleak. If a poor Haitian American has little to no chance of getting ahead, it is unlikely that a future-time orientation will be developed.
On the other hand, wealthy Haitian Americans may perceive time from a totally different perspective. For these people, time orientation may be a combination of both present and future orientations. It would appear that as a result of adequate financial resources, upper-class Haitians and Haitian immigrants do make plans for the future. Because wealth may ensure educational attainment, which may translate into status and prestige, it is likely that a well-educated upper-class Haitian may have a future-time orientation.
Implications for Nursing Care
Because Haitians may have different orientations to time, depending on their social status and class, it is important for the nurse to adequately assess each individual client. It is also important for the nurse to remember that personal ethnocentric attitudes toward time may negatively affect planning care for clients. Persons with a present-time orientation may view future-oriented tasks as irrelevant or unimportant to present situations. Thus a present-time orientation may restrain a Haitian from gaining upward mobility because future-time orientation is required in gaining an education and planning to achieve future goals. It is also important to remember that when a Haitian immigrant does not keep an appointment or does not arrive for a clinic appointment on time, it may be a result of both a present-time orientation and economic constraints. It is important for the nurse to assess not only the time variable but also other socioeconomic variables, including the availability of transportation to and from clinic appointments. If a Haitian American is to arrive at clinic appointments on time, it is very important for the nurse to emphasize the importance of adhering to the clinic’s schedule. The nurse should be aware that Haitian Americans frequently stop a treatment regimen as soon as the symptoms appear to be relieved. It is also very likely that the Haitian American will fail to follow through with a treatment regimen or preventive health care because cultural beliefs do not relate personal actions to health status.
Although Haitians and African-Americans share a lineage that extends back to Africans who were seized from their countries and enslaved, some individuals have surmised that these two cultural groups fraternize very little socially and tend to mistrust and be suspicious of each other ( ). It is believed that Haitians place a high value on personal liberty and are therefore resentful of American prejudice and at times indignant and critical of African-Americans, whom they discern as too submissive and accepting of discrimination ( ). At the same time, African-American militancy and violent protest seem to be contrary to the Haitian personality and are generally regarded by Haitians with disapproval ( ).
Traditionally, the upper classes in Haiti have been the lighter-skinned Blacks, whose skin color results from crossbreeding with lighter-skinned people. Light skin traditionally has been regarded as more prestigious than dark skin in Haiti ( ), with the upper-class, lighter-skinned Haitians dealing with the lower-class, darker-skinned persons in an authoritarian manner. Therefore, because of indoctrination regarding the color of the skin and its perceived relationship to social status or class, some Haitians have developed a social prejudice that causes difficulty in the assimilation process in the United States. As a result of social prejudice formed by such variables as color grading and social status, some Haitians living in the United States or Canada continue to have trouble adjusting to other groups and thereby choose to remain in isolated areas, socializing only with other Haitians and family members.
Some Haitians view illness and disease as natural or unnatural events. Natural events keep balance between nature and humankind and as such are believed to be designed by God. Natural laws are believed to give life predictability ( ). Unnatural events are believed to upset the balance of nature and at their worst represent forces of evil and the devil. Unnatural events lack predictability because they exist beyond the parameters of nature and are beyond the control of “mere mortals.” This view is in sharp contrast to traditional Western medical beliefs. It is essential that the nurse remember that some Haitians believe illness is a result of witchcraft. People who supposedly possess supernatural power are believed to be able to alter the health status of others ( ).
The practice of Voodoo, the primary religion in Haiti, is prevalent throughout the country. Voodoo is a religious cult practice that dates back to the preslavery days in the West African homeland ( ). Today, the term voodoo is commonly used both as a derogatory term by non-Haitians to describe the illogical and unexplainable and as a catchword of ethnomedical or ethnoreligious beliefs that involve magic and spirit possession ( ).
In the 1600s, slavery was rationalized by the Code Noir, instituted by Louis XIV, by mandatory evangelization on arrival to a French colony ( ). Catholicism was implemented by required religious assemblies. Nevertheless, the outlawed African religious practices were loosely incorporated, as the slaves identified their deities with the saints of the Catholic church. European religious and decorative objects were also incorporated, allowing the slaves to appear nominally Catholic while still preserving the basic structure common to West African religious systems ( ). However, when the sovereignty of the country was not recognized by the Catholic church from 1804 to 1858, the Catholic church forbade priests to enter the country, and all ordained priests were ordered to leave. During this time, Voodoo flourished and became the dominant belief practice. In 1860, partly as a result of the spread of Protestant missions on the islands, a concordat was approved in Rome, a bishop was consecrated in Port-au-Prince, and Catholicism was once again the official religion recognized by the state. Nevertheless, the new priests sent by the church faced an ineradicable folk religion and a people who were able to reconcile living with two parallel albeit often contradictory spiritual belief systems ( ; ; ). The majority of Haitians combine some degree of both Voodoo and Christianity ( ).
Today many Haitians still believe that humanity is surrounded or enveloped by a variety of powerful, dominant spirits and that it is essential to invoke spirits. In the Haitian culture, the invoked spirits are called loas, mystères, or saints. Some Haitians believe that Voodoo spirits manifest and reveal themselves by possessing or “riding” the devoted believer. It is believed that the personality of the loa “mount” may change; he or she may be calm and subdued one minute and then suddenly become violent. Such transformations may be caused primarily by nervous instability under the influence of compelling drum rhythms and mass emotion ( ). Haitians trust and depend on their Voodoo beliefs and also rely on “readers” or “diviners,” who predict the future by reading cards or hands and cure by means of being possessed by the Voodoo spirit. The readers, or diviners, also considered Voodoo priests, are organized into independent cults.
Voodoo priests may be either male ( hungan ) or female ( mambo ) and are categorized into five classes: shaman (Voodoo practitioner), herbalist ( docte fey, literally “leaf doctor”), midwife ( matronn, or fam saj ), bonesetter ( docte zo ), and injectionist ( pikirist ). Healers are often not well defined, and a Haitian may go to a neighbor who has “extra” medicine or a healing practice in hopes of relief. In terms of the number of practitioners and frequency of use, the herbalists constitute the most significant class of healers. Herbalists are the most generalized caregivers, and thus their role characteristics overlap to a certain extent with those of all other healer types ( ). Haitians often use home remedies and herbs for treating illnesses that are suggested by healers or priests. Many Haitians believe that tea made from leaves of the Bible will cure rheumatism. In this case, the Bible serves as protection against black magic, which is believed to cause rheumatism ( ).
Magic powers may be used for purposes other than destroying enemies or healing the sick. The Voodoo sorcerers of Haiti claim to be able to change themselves into animals, to pass through locked doors, and to raise the dead and make them slaves (zombies). Almost everyone who is a native Haitian claims to know someone who has been a genuine zombie. One man requested his family to cut his corpse into two pieces to be buried in separate graves for fear that the local sorcerer, who was his enemy, would bring him to life as a wretched slave. Although the Haitian government has no valid evidence of the existence of zombies, it sanctioned the belief by passing a law against the supposed practice ( ).
In Haiti, Voodoo is sometimes actualized as fetishes, which are shared by groups of native Haitians. For example, a Haitian might have a small bottle containing some reddish liquid and a small mirror backed by cardboard facing the bottle, and all this wrapped in coarse red cloth with yards of black thread. This object is safeguarded in the most remote part of the house, with its location kept secret from visitors. If the Haitian could be induced to talk about this, he might explain that his father, who was a kind of Voodoo priest, captured his soul when he was very young and put it in the bottle. As long as the bottle is preserved, the person will live, but once the bottle is broken, the soul will depart and the man must die. Not only would this fetish be held by this individual but also identical or similar fetishes might be shared by others in the community ( ).
Many Haitian influences regarding Voodoo practices are evident in the mainstream of American society. For example, in some cities and towns in Louisiana, the Haitian influence is extremely prevalent and is perceived or felt by persons from other cultural groups as well. Louisiana is renowned for its Voodoo society, which is a carryover from Haitian slaves who were brought to areas such as New Orleans for various domestic duties. Even today, because of early Haitian influence, Voodoo and mystical thought remain evident regardless of ethnic or cultural background in cities such as New Orleans ( ). Traditionally, some Haitians believed that a spell could be cast with the possession of a lock of the individual’s hair ( ).
Although health care is a significant problem in urban Haiti, it is even more of a problem in rural Haiti, with pregnant and postpartum women being particularly vulnerable ( ). Many Haitians know nothing about prenatal care and do not routinely seek such care. Some may never have seen or been to a physician in their lives. Healers are related to protection, and physicians are related to sickness. Use of a midwife is culturally permissible and is much more likely among Haitian people than among other cultural groups in the United States. When a nurse is interacting with a pregnant Haitian woman or is providing care for a baby, using the phrase “We will help you have a strong baby” will often elicit cooperation. Staff who are willing to help the mother have a “strong baby” (rather than a “healthy baby”) are more likely to be accepted (Jeanty, personal communication, 1989).
Some pregnant Haitian women who experience an increase in salivation do not believe they should swallow the saliva. Sometimes they carry a “spit” cup with them and are not embarrassed to use it in public ( ). Many dietary precautions are followed by Haitian pregnant women.
Pregnant women are viewed as special and are likely to be treated with more kindness and respect than other women. Chants or sounds of a woman in labor include praying, singing, crying, and moaning in various combinations, which is done to call on their Voodoo protectors ( ).
A study conducted by Scott in 1978 identified the postpartum period as the most crucial and decisive period of childbearing for the Haitian woman. During the postpartum period of 6 to 11 weeks, the Haitian woman follows a cultural regimen of baths, teas, vapor baths (see later in this paragraph), and dressing warmly. This practice is supposed to make the client healthy and clean again after the birth. For the first 3 days, the mother bathes in hot water in which herb leaves have been boiled. She also drinks a decoction made from boiled herb leaves. (Also during the first few days after childbirth, the mother takes “vapor baths” by sitting above a pot of steaming water with leaves in it, especially orange tree leaves, and draping a cloth over her head and shoulders.) For the next 3 consecutive days, the mother takes her second series of baths, which are prepared with leaves in water warmed by the sun. At this point the mother drinks only water warmed by the sun or an infusion made with leaves steeped in water warmed by the sun. The mother takes constant special care to keep her body warm. She stays inside her dwelling for at least 3 days after the birth and keeps the doors and windows closed to keep out the cool air. She wears long sleeves, keeps her head covered, and wears heavy socks and shoes.
After 2 weeks to 1 month, the mother takes another bath. She may take a cold bath or perhaps jump into a cold stream. After this ritual, she may self-induce vomiting to cleanse her inner body. After all of this is completed, she can again resume normal activities and is considered clean ( ).
The Miami Health Ecology Project ( ) reported beliefs about menstruation among Haitians, a majority of whom believed the function of menstruation was to rid the body of “unclean,” “waste,” or “unnecessary” blood. Many Haitians also described menstruation in this manner: “It means you are a woman,” with “woman” meaning that the individual has sexual feelings or needs and is not sterile. The Haitian girl reportedly learns about menstruation at a median age of 10 years. For 85% of the sample, this information was obtained from their mothers or in classes at school.
Rituals Related to Death and Dying
has studied patterns of bereavement among Haitian-American families. Death arrangements are usually taken care of by a male kinsman of the deceased who has had experience with American bureaucracies. Death appears to mobilize the entire extended family, including matrilateral and patrilateral members. Because Haitians frequently believe that illness and death can be of a supernatural as well as natural origin ( ), death is often accompanied by feelings of guilt and anger. The surviving relatives may believe that the death was a result of failure to relate appropriately to the Voodoo spirit. Recurrent dreams of the deceased person, so much a part of grief work, take on a particular meaning to the Haitian. Haitians commonly evaluate illness in terms of symptoms previously experienced by close kin ( ), and grief work frequently includes taking on symptoms of the deceased person’s last illness ( ).
noted that health care professionals should tell the family spokesperson when death is imminent so family members can assemble at the bedside. Family members try to meet the spiritual needs of the dying person by using religious medallions, pictures of saints, or fetishes or talismans for protection or as good luck for a peaceful death and restful afterlife. A kinsman usually makes the arrangements of telling the family and making preburial arrangements, including purchase of a coffin and prayer services before the funeral. Traditional Haitians have 7 days of consecutive prayer to assist the passage of the soul to the next world. This is terminated by a mass that begins the official mourning process.
Implications for Nursing Care
The nurse should be aware that the healing systems associated with Voodoo and Haitian ethnomedicine may be seen by some health care professionals as barriers to health care and even as adversely affecting health care ( ). If Haitian Americans do use conventional means of health care, they tend to use emergency rooms or clinics and to seek health care only when they are quite ill ( ; ). Haitian Americans may also seek relief from their symptoms through a physician and at the same time consult a cultural healer. The client’s having both a faith healer and a physician should not be perceived as incongruent (Jeanty, personal communication, 1989). A client’s fear and anxiety that he or she has been “hexed” may be alleviated or reduced if the therapist combines conventional treatment with the assistance of a cultural healer who is believed to be able to remove the hex or spell. Nurses, as primary health care providers, must formulate and use a treatment plan that displays respect and understanding of the client’s cultural healing system or systems and must accept that a Haitian-American client may use a variety of sources to obtain relief when sick.
It is important for the nurse to understand that for many Haitians, leaves have a special significance. When the client comes into the hospital or the clinic for an examination, leaves may be found in the clothes and on various parts of the body. Leaves are believed to have mystical power, and therefore keeping them close to the body is related to regaining or keeping health (Jeanty, personal communication, 1989). The nurse should be accepting of this practice and avoid being shocked if leaves are found in the luggage or on the body of a client being treated. The nurse should also appreciate that religious medallions, rosary beads, or figures of a saint to whom the Haitian client is devoted may have special significance and be felt to offer protection; they should be left with the client ( ). The nurse should be cautious about forming negative judgments about a client who may have practices with Voodoo origins ( ).
Haitians have grown accustomed to receiving some direction from authority figures in their lives—parents as well as religious and social leaders. The nurse, as an authority figure, will usually find that Haitian Americans respond well to counseling approaches that foster self-help and independence and should consider the need for heightened self-esteem, which is manifested by the pride and willingness to work that is present in most Haitians.
Haitian Americans need to have occupational options expanded for them and need to understand the steps involved in achieving an occupational goal. Because Haitians have not traditionally had the freedom to set goals, the nurse may be of assistance in this process, as well as in problem solving, to achieve the established goals.
A variety of tools have been used to measure Haitians’ beliefs about illness and wellness ( ). used a semistructured interview for three Black cultures, including Haitian.