Marc, a Haitian teacher, experienced bilateral below-the-knee amputations and was transported to the U.S. for treatment. As the healthcare provider offers choices about which tasks he would like to address first in the therapy session, the patient remains silent and does not look at the clinician directly. He says, “The doctor knows what is best.” The clinician is dismayed: Why does the patient seem so uninterested and uninvolved in his care decisions?
Mireille, a Haitian immigrant in the U.S., is brought to the women’s wellness center by her niece. She speaks only Creole; her niece explains she has complained of lower abdominal pain and vaginal bleeding for several months. The patient has been using traditional herbal medicine to try to relieve the pain but is reluctant to tell the healthcare provider.
Would you know how to interview, assess and treat these patients while respecting their beliefs?
Even before the devastating earthquake in January 2010, caring for people from Haiti presented health professionals with numerous healthcare-delivery challenges. Cultural, religious and health beliefs affect how people from Haiti seek care for health concerns and interact with healthcare providers. This module highlights unique aspects of Haitian culture and traditions that influence healthcare delivery. Healthcare professionals across disciplines can use this knowledge to deepen their understanding of traditional Haitian culture and improve their ability to provide culturally competent care.
Haitian immigrants make up one of the fastest-growing immigrant communities in the United States. According to the U.S. Census Bureau, 830,000 Haitian immigrants live in the United States.1 The true population, however, is unknown because of the number of undocumented immigrants. Haitian immigrants can be found in almost every state, but they are concentrated in larger cities in Florida, New York, Massachusetts, New Jersey and Connecticut.1
Geographical, cultural and ethnic factors influence the beliefs, values and practices of Haitian culture. Haiti’s climate is tropical, and the terrain is mostly mountainous. Decades of economic, military and political turmoil have resulted in unfavorable living conditions for many Haitians, prompting waves of immigration to the United States. Differences in practices may exist between socioeconomic classes in Haiti, recent Haitian immigrants and those living in the United States for some time.
Haitian beliefs focus on spirituality, care for close and extended family and divine predestination. “Good health” is the absence of visible disease or disability. The limited appreciation for preventive care and screening for silent or insidious diseases may prompt some healthcare providers to form derogatory opinions of the Haitian world view, thus negatively influencing interactions and care delivery. Haitians may interpret caregivers’ lack of awareness of Haitian values as disrespect or disapproval, which may further reduce their willingness to seek care.2
Haitians speak Haitian Creole and French. While most Haitians speak Creole, it’s considered the language of the poor. Speaking French indicates higher social class, and French is typically used to initiate conversations with strangers.3 Suggesting that someone speaks only Creole, even if it is true, can be construed as an insult.4
In Haiti, a wide gap exists between upper and lower classes, and the middle class is small. Education is limited, and 85% of the population is illiterate; however, Haitians place a high value on education to improve social status. Families will even sacrifice food to send their children to school.5
The tone of oral communication typically reflects strong emotion and may be direct, loud and include hand gestures, even if the person speaking isn’t upset.3 Direct eye contact is expected among social equals, but people may avoid eye contact with those of a higher socioeconomic status or in positions of authority. Patients welcome and often expect eye contact during caregiving interactions and view touch as conveying warmth and friendliness. Haitians may touch others for emphasis during conversation.3 Haitians require much less personal space than Americans and stand close to each other while talking.3
Uneducated Haitians may be unwilling to expose their lack of knowledge to Americans, so they may seem timid or not interested in their care. Haitians often communicate health needs using terms that may seem vague. For example, asthma or hyperventilation may be described as “oppression.” Asking a patient, “What do you or your family think you have?” may help in history taking and assessment.6
The time orientation of Haitians is predominately present and past, essentially because day-to-day survival often overshadows thoughts of the distant future, which can’t be controlled. Haitians don’t equate tardiness with rudeness. People often prioritize interventions and interactions based on their impact at the present time and their experiences with such interventions and interactions in the past. A person with a present and past orientation may consider healthcare screenings unnecessary in the absence of an immediate problem.2,3
In Haiti, women usually make healthcare decisions for themselves and their children; however, when there is a husband, he usually will want to make major health decisions, such as about surgery for his wife. After immigration, the responsibility for healthcare decisions may shift between mother, father and elder family members.
Haitian life centers on the family. For immigrants in the U.S., this includes relatives in Haiti. Most Haitian immigrants provide financial support to family back home. Because of the close ties between family members, family networks can be a source of stress: People often worry about family in Haiti in addition to family who have recently immigrated to the U.S.7 (Level B)
Haitian customs and practices condemn homosexuality; gay and lesbian relationships in Haitian culture are not recognized.2
Insight Into Voodoo
The two main religions in Haiti, often practiced simultaneously, are Catholicism and Voodoo (Voudou, Vodoun). Haitians in the U.S. are active in several mainstream religious groups, including Catholicism and Protestantism, and the church is a source of support, especially for new arrivals. Religious activity often helps Haitians maintain their cultural identity while integrating into the U.S. way of life.8 (Level B)
The Haitian government has recognized Voodoo as a bona fide religion, and a large part of the Haitian population practices Voodoo or is affected by it to some extent. Many devout Christian Haitians, however, denounce Voodoo.9
Voodoo has two types of practitioners: those who practice peaceful worship of the happy loa (rada or white magic) and those who practice voodoo of the angry loa (petro or black magic). Black magic represents only 5% of all Voodoo practice, but outsiders often overemphasize this aspect of the religion and sensationalize it.
Voodoo doesn’t have a central theology or hierarchy of worship. Voodoo includes a belief in one central god, called Bondye or Bon Dieu, who presides over three spirit categories: loas, twins and the dead. The loa (or lwa) are spirits of family members and spirits of all major forces, including reproduction, health and good and evil. Any powerful person or being can ultimately become a loa. The dead include the souls of family members, who can be helpful if remembered and dangerous if ignored.10
Voodoo is a fatalistic religion. The loa interacts with people and provides protection and luck, yet it can also cause bad things to happen. Each practicing family has a loa as its spiritual protector. Disrespecting a loa can bring illness. Drums and dancing are an integral part of Voodoo ceremonies, and animal sacrifices are often offered to pacify the loa.
The twins are believed to be descendants of the one god. They represent the dichotomy of good and evil and male and female. Voodooists believe that if the twins are occasionally remembered in religious ceremonies, life will improve.10
The most important tenet of Voodoo is healing people from sickness, which is thought to be brought on by evil spirits. Voodoo ministers include the houngan (priest) and the mambo (priestess). Their services include healing, presiding over rituals to contact or calm the loa, foretelling the future, reading dreams, casting spells, creating protections and potions, and exacting revenge.9
Zombification (the dead coming back to life) is a part of Voodoo that even Haitians do not understand well. It is thought to be the result of near-death poisoning, subsequent burial and ritualistic exhumation of the living corpse. Zombies are theorized to have been brain damaged by poisoning and thus walk around in a trance.
Traditional, or ethnomedical, Haitian practitioners include herbalists, Voodoo practitioners, midwives, bone setters and injectionists. Herbalists (docte fey) are the most common traditional healers in Haiti. People seek them out for common illnesses, such as colds, fevers and diarrhea, as well as more complex illnesses, such as cancer and AIDS.10
Voodoo practitioners cure supernatural illnesses and diagnose by using cards, shells or trances.10 Treatment usually consists of dancing, incantations, herbal preparations, prayer and calling on the loa.
Some diseases may need to be treated by a Voodoo practitioner only. Seizure and psychiatric disorders are examples of problems that are traditionally thought to require treatment by a houngan or mambo.
The evil eye (maldyok) is thought to cause GI problems and even death in children. It results from an envious glance and can be treated by an herbalist or a Voodoo practitioner. At other times, people may choose between a Voodoo practitioner and a biomedical practitioner.10
Midwives deliver most infants, especially in rural Haiti, and provide any prenatal care needed. Midwives also supervise the postpartum seclusion period.10
Bone setters (docte zo) traditionally treat musculoskeletal problems with casts, massage, manipulation, poultices and prayer.9
give medicinal or herbal injections. Haitians believe in injections and generally feel better cared for when they receive them.10
The use of traditional healers may affect the acceptance of Western health practices, including vaccinations and cancer screenings.11 (Level B), 12 (Level B)
Pain, Dying and Death
Many Haitians believe in divine predestination: illness, injury and suffering as the will of God or a punishment for sins. Stoicism and the reliance on prayers to reduce suffering are common, especially if a person lacks access to healthcare. Conversely, Haitians who receive Western medical care tend to be very vocal about and intolerant of pain. For patients who cannot communicate pain verbally, such as many patients with terminal illnesses, healthcare providers of various disciplines should be attentive to physical manifestations (such as an elevated pulse and BP, guarding, and vocal noises); question patients often; and offer measures for pain relief. Pain scales designed for patients unable to verbally communicate may be helpful, such as the Pain Assessment Behavioral Scale.13
Death results in a return to the creator in an afterlife. Suicide, assisted suicide and euthanasia are not prevalent; organ donation is permissible if it is a patient’s wish, but it is not typically discussed or promoted. Haitians respect the physician’s judgment with respect to brain death, end-of-life issues and DNR decisions.2,3
When death is near, Haitians prefer to be at home with family nearby for spiritual support. Death affects the entire extended family, and family members have specific responsibilities in case of a death. The oldest family member typically makes arrangements and notifies others. A family member usually gives the last bath, and the body is kept until the entire family gathers. Cremation isn’t considered since the body is necessary for resurrection; however, autopsy is permissible, and some families may request it to avoid zombification by ensuring the deceased is really dead.9 Haitians typically show extreme emotion and express grief openly at the time of death; however, family members’ lack of overt emotional expression may not indicate denial or inappropriate grieving.
Haitian immigrants face the same healthcare barriers as other underserved groups, compounded by immigrant-specific barriers, such as language, documentation status and insurance ineligibility. In Haiti, health insurance is not available to nongovernment workers, and preventive and emergency medical care is often unaffordable. Vaccination coverage in Haiti is far below the 78% global average.14
Traditionally, Haitians tend to seek care from a biomedical practitioner only when they have exhausted all other options and they are very ill or unable to work.2,3 They may use traditional interventions — including herbs, massage, prayers, music, and modifications in diet and exercise — before seeking care from Western healthcare practitioners or in conjunction with such care.
Obtaining an accurate personal or family health history may be difficult — if not impossible — because many people have parents or other close family members who died in Haiti without medical care or a formal diagnosis. Perspectives on health and healthcare interventions may also differ from Western beliefs and choices. For example, Haitians view being overweight as a sign of prosperity and well-being, not as a risk factor for illness.
Because healthcare is expensive and a luxury in Haiti, some Haitians may feel that services offered at clinics or through government programs are inferior because they are free.6 This may complicate caring for Haitian elders, who may have multiple health problems in addition to language and literacy barriers.8 Haitians may also equate “good care” with receiving a prescription, and better yet an injection, potentially encouraging unnecessary prescribing.6
Western concepts of mental illness are not well accepted in Haiti; Haitians often attribute mental illness to supernatural causes. Screening and treatment for depression can be particularly difficult.2
Haitians in the U.S. aren’t subjected to the political violence that ravages their home country; however, they aren’t immune from the stress and concern for family members left behind.
Many Haitian women are culturally desensitized to domestic violence and abuse. Violence against women is common. One study revealed that the stress associated with actual abuse or the potential for domestic violence could result in increased depression for Haitian women living in the U.S. during pregnancy.15 (Level B)
Clinicians should be aware of the reluctance to report domestic abuse and should be sensitive to cues about domestic violence.15
Modesty and privacy are concerns for Haitian patients. Clinicians can respect modesty by asking permission to uncover or touch any body part. Rather than just “barging in,” healthcare providers ideally should knock and ask permission before entering a patient’s room.
Haitians are guided by strict class-based notions of clinical encounters. They hold physicians and members of the healthcare team in high respect and believe they must not disagree with them. Illiterate Haitians have difficulty asking authority figures questions, as this may be interpreted as a challenge to authority.15