The week why haitians are killing themselves

Why does it matter? Growing insecurity is also driving instability and increased migrant flows within and outside the country. What should be done? Funnelling aid to vulnerable people hit by recent natural disasters, preferably through local civil society, is the imperative. International backing for prosecuting high-level crimes, police reform and support for a broad-based representative and inclusive interim government stand a better chance than a rush to elections of helping restore stability.

Violence, largely perpetrated by criminal groups funded by powerful business leaders, politicians and drug dealers, had shut down much of the economy. They will need outside help to pull through. It is essential that Haiti accept foreign support to investigate high-profile crimes and set in motion long overdue economic and security reforms. When it was my turn, I cried my eyes out, and when I make you cry, I will make you cry tears of blood," he said. Haitian media outlet Le Nouvelliste on Thursday said that Charles had presented his resignation.

A Haitian police spokesperson did not immediately respond to a request for comment. The White House said on Thursday it would do all it could to help the missionaries. A senior State Department official told reporters that the video was legitimate. Christian Aid Ministries said it was aware of the video but would not comment until the hostage negotiators determined that any such remarks would not jeopardize the well-being of the group.

The Mawozo began as small-time local thieves and rose to become one of Haiti's most feared gangs, controlling a swathe of countryside east of the capital Port-au-Prince, according to security experts. Haitian gangs have steadily expanded their territory in recent years, and have grown more brazen since the July assassination of President Jovenel Moise.

Idioms of distress that reflect psychosocial complaints among lay persons are often interpreted as other biomedical maladies in healthcare settings e. Socio-cultural differences in the understanding of mental distress and suicidal behavior necessitate the study of culturally-specific risk factors and the use of culturally-adapted psychometric screening tools in order to build appropriate prevention and treatment services [ 21 , 23 , 25 , 28 , 34 ].

Yet, the lack of appropriate mental health services and training for health workers may be an even greater challenge than cultural differences for the treatment of mental disorders. There is a dearth of research on suicidal behavior and associated factors in Haiti. Risk factors for suicide documented in other LMICs include: female gender, living in a rural area, young or old age, having low SES, and holding religious beliefs that sanction suicide [ 36 , 37 ].

Also, in India, Taiwan, and China, recent stressful life events, including familial problems and social change [ 38 , 39 ], as well as previous suicide attempts [ 40 , 41 ], have been associated with suicidal behavior.

Other studies in Asia have found that young women carry a disproportionate burden of suicide and that there is a weaker association with mental illness than in high-income countries [ 28 , 42 — 47 ]. Worldwide, there are contrasting findings on the impact of natural disasters, such as earthquakes, on suicide-related behaviors [ 48 — 50 ].

Most research has been conducted in developed countries and suggests that suicide rates decrease following natural disasters [ 48 , 49 ]. However, in one study following Hurricane Katrina in the US, suicidal ideation rates were shown to increase [ 50 ]. In Haiti, access to biomedical healthcare is especially low in rural areas. Approximately half of Haitians lack access to primary healthcare, and in rural areas mental health services are virtually nonexistent [ 52 ]. This study aims to inform the development and scale-up of sustainable mental health and psychosocial services in Haiti.

We conducted a cross-sectional, zone-stratified household survey over six weeks in May-June in the rural Central Plateau of Haiti. Surveys took place in the communal section of La Hoye, with the stratification factor being governmentally-determined zones within the area.

Four of the 17 zones were not included in the sampling frame because they had a low population density and were difficult to safely access during the rainy season.

The majority of the population cannot read or write [ 55 ]. Regarding impact of the earthquake, the Central Plateau sustained little direct damage.

However, many areas of the Central Plateau saw significant increases in population due to internally displaced persons. Additionally, many residents of the Central Plateau had family members killed or directly impacted by the earthquake, and many housed displaced family or friends.

Despite these devastating and far-reaching impacts, participants made it clear that the earthquake represents one among many challenges that impact mental and physical health in the Central Plateau. The communal section of La Hoye was chosen as the research site because of its proximity to a non-governmental organization NGO that was interested in providing mental health services in the future.

The NGO partners with American medical schools and Haitian healthcare personnel to provide year-round medical care in several communal sections in the Central Plateau. While there are three hospitals within a two-hour drive from the research site, the time and resources required to reach these healthcare facilities by foot, horseback, or motorcycle puts them firmly out of reach for the majority of rural Haitians.

Instead, they rely on small clinics, many run by NGOs. At the time of the research, one town in the research setting had a small clinic with one doctor, one nurse, two auxiliary nurses, and one lab technician. Approximately once per week, medical staff conducted mobile clinics, visiting each zone in the communal section once every three months.

During the single day of healthcare provision for the zone, dozens of patients would line up, with several often being turned away at the end of the afternoon when rains began.

Rather than utilizing formal biomedical care, people could also purchase medicines and herbal remedies at local markets or draw upon a range of traditional supports, including hougan -s 1 This paper utilizes the standard convention of adding —s to indicate plural Kreyol words, rather than — yo , the plural indicator in Kreyol.

Our survey consisted of demographic information, daily stressors such as water insecurity , traumatic experiences associated with the earthquake such as injury , general trauma such as death of a family member , social support, care seeking behavior, and explanatory models of distress. Assessing household possessions can provide a more objective measure of SES than estimated household income in subsistence economies or when all household members are not included in financial decision making [ 58 , 59 ].

Additional file 1 : Table S1 includes a detailed description of all study variables. The BDI is a self-report measure of depression symptoms assessed over the past two weeks, with 21 questions answered according to a 0 to 3 severity rating, and an overall range from 0 to 63 [ 61 ].

The BDI has been adapted and validated for use in a variety of cultural settings [ 62 — 67 ]. The BDI was adapted using a standardized approach for transcultural translation that evaluates semantic, content, construct, and technical equivalence [ 24 , 26 ].

This process involves five steps: translation by bilingual lay individuals, review by bilingual medical professionals working from the local setting, focus group discussions with lay representative members of the target group, back-translation by a bilingual individual blinded to the original instrument, and pilot testing.

At each of the five stages, all items are individually assessed for comprehensibility, acceptability, and relevance. These assessments are used to make adjustments to the translation at each stage.

In Haiti, the BDI underwent the process described above using six focus groups comprised of lay men and women [ 59 ]. The item was reworded to incorporate a sense of confusion pa fouti ka pran yon desisyon. The adapted BDI was piloted among a sample of 31 lay participants to assess internal reliability. Of note, the items for sleep difficulties and changes in eating appeared to discriminate poorly between individuals scoring higher or lower on the depression scale, as these items were highly endorsed by nearly all respondents.

This phenomenon has been observed in other settings with high levels of gastrointestinal pathology or other physical medical problems, such as rural Nepal [ 25 , 62 , 68 , 69 ]. Similarly, medically ill and geriatric populations may have somatic complaints that elevate BDI scores in the absence of clinical depression [ 63 , 70 ]. While these items were not removed, they suggest that total BDI scores may be inflated relative to Western settings.

Research assistant training consisted of two days of didactic training on survey delivery, sampling, and basic epidemiologic methods, as well as three days of pilot survey data collection to ensure quality delivery of the BDI. On-going feedback and training took place throughout the period of data collection to ensure appropriate survey implementation. Finalized surveys took approximately one hour to complete. Four research assistant days were spent in each of the 13 zones, beginning at a central zone location and proceeding in opposite directions, sampling every house encountered.

A household was defined as a group of people sleeping in the same lakou compound. Individuals self-identifying as household visitors were ineligible. If a person of the preferred age range was not present, the research assistant chose the person closest in age to the preferred age category. Additionally, research assistants alternated recruiting male and female participants.

Surveys were double-entered into Excel [ 71 ] each day, and data entry errors were fixed by crosschecking for consistency using Excel Compare v2. For individuals with missing or no response on BDI questions, we used the individual mean score on completed BDI questions and multiplied this number by A sensitivity analysis showed that using group mean imputation did not meaningfully change associated factors or magnitudes.

We used SAS 9. Multivariable linear and logistic models were built, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively. Variables considered for inclusion into each model were: age, gender, marital status, education, religion, distance to and type of work, distance to and type of drinking water, care seeking behavior, household size, SES, trauma related to earthquake, general trauma, reported household mental illness, number of children, months without enough food, stigma towards mental illness, explanatory models of distress, alcohol use, care and household help, BDI score minus item 9 for logistic model only , and endorsing suicidal ideation for linear model only.

To examine differences between genders, associated factors, and magnitudes, male-only and female-only linear regression models were built in addition to a combined gender model. We a priori chose to analyze BDI scores separately by gender because of differences in risk factors for common mental disorders between men and women observed cross-culturally [ 74 — 78 ]. For logistic regression, due to limited events, only a combined gender model was built and variables were screened prior to backward elimination.

To establish significance of individual predictors, t-tests were used for linear regression, and Wald chi-square tests were used for logistic regression. For significance of group predictors distance to work, education and marital status , chunk F-tests were used for linear regression, whereas likelihood-ratio tests were used for logistic regression. Because the majority of rural Haitians are not literate, verbal consent was used. Regarding management of high risk participants in the study, an American licensed clinical social worker from our research team conducted a follow-up diagnostic interview with anyone responding with a 2 or 3 on the adapted BDI suicidal ideation item to assess level of distress and refer those who endorsed active suicidal ideation.

Of surveys completed, were conducted during research assistant training to ensure proper delivery of psychometric screening tools, leaving eligible for final analysis. The 43 individuals with missing BDI data did not have significantly different age or gender distributions compared to the sample as a whole.

Basic demographics showed our sample to be The mean score on the imputed BDI was Of the participants, 6. For the combined, male-only, and female-only linear models, each final model revealed no significant lack of fit or multicollinearity and achieved R-squared values of 0. Older age was associated with increased BDI scores for both genders.

Each year increase in age was associated with an increase of 1. Women, on average, scored 2. In the combined gender model, traveling over one hour to a doctor was associated with scoring 2. However, distance to formal healthcare services was not significantly associated with BDI scores in male-only or female-only models. Compared to those who do not work, traveling over one hour to work was associated with a Compared to those who are single, being divorced was associated with a 7.

Among men only, responding that the last time they were sick they went to the hospital was a protective factor, associated with scoring 5. Each three-month increment that men stated they did not have enough food for their family was associated with scoring 2. Stating that disasters are the primary cause of stress, sad heart, or sadness was associated with men scoring 7.

For women only, each additional item possessed on the SES scale was associated with scoring 1. Reporting that someone in their house suffers from stress, sad heart, or sadness, that a family member died in the earthquake, or that spirits can cause stress, sad heart, or sadness was associated with scoring 4. Compared to those with no formal education, having more than a primary school education was associated with scoring 7. Score on the BDI minus item 9 was the factor most strongly associated with suicidal ideation.

For each ten point increase on the BDI, the odds of endorsing suicidal ideation increased 2. Individuals who use alcohol were 3. Individuals who reported ever having gone to a Vodou priest were 3. Last, individuals reporting that they did not have someone to care for them if sick were 5. Factors significantly associated with depression symptom burden were: age, female gender, SES, recent life stressors such as life-threatening illness or death in the family, daily life stressors such as lack of food or traveling long distances to work, explanatory models of distress, endorsing current suicidal ideation, marital status, and education level.

The observed associations of depression symptom burden with age, female gender, distance from healthcare, and exposure to stressful life events, including disaster-related stressors, are consistent with literature in other LMICs and post-disaster settings [ 79 — 81 ].

Additionally, the associations of depressive symptomatology with SES and psychological symptoms of household members are consistent with previous findings among medically-ill samples in Haiti [ 29 , 30 ].

Social exclusion might explain the 7. Furthermore, the rarity of divorce in Haiti may also contribute to its stigma and subsequent social alienation. Factors related to healthcare were also associated with depression symptom burden; traveling more than one hour to see a doctor and suffering from a major illness were both associated with higher BDI scores. Explanatory models, i. Among women, the belief that spirits cause sadness was associated with higher BDI scores.

Among men, the belief that disasters cause sadness was associated with higher BDI scores. In some literature, holding an external locus of control, characterized by a belief that factors outside the self primarily drive wellbeing, is associated with greater psychiatric distress [ 85 — 88 ].

In our sample, the nature and cause of the observed gender difference is unclear. In recent priority setting regarding major mental health research questions in humanitarian settings, such as natural disasters, the top rated issue was the identification of major stressors for populations in complex emergencies [ 89 ].

Although the study area did not directly experience damage from the earthquake, significant associations were found between depression and earthquake-related variables. Among women, having a relative die in the earthquake was associated with greater symptoms of depression. Thus, for men, structural and economic consequences of the earthquake were associated with symptoms of depression, whereas for women, emotional consequences may have been more significant.

Taken together, these findings suggest that psychosocial and other mental health responses to disasters may be shortsighted if only focused on areas directly affected. Additionally, interventions to reduce mental distress associated with disasters should consider unique needs based on gender. Two surprising findings were the associations of education among women and employment among both genders with depression symptomatology.

Women with more than a primary-level education scored 7. This may be due to the socioeconomic context of the rural, agriculturally-focused study region from which educated individuals are more likely to migrate to urban areas to escape low-paying agricultural or household work.

The expectation may be that educated women will leave the region to gain employment in Port-au-Prince or abroad. Accordingly, women who are educated but do not leave may be seen as failing to reach their potential, and these women may suffer dissonance between the model of life learned about through education and their current circumstances.

In Afghanistan, education, hope, and aspirations have negative associations with mental health in some groups, and this has been described as a disconnect between what is expected and what is possible in that environment [ 90 ]. A similar disconnect between aspirations and reality may help explain the association between employment and poorer depression outcomes for both genders.

Those employed in rural Haiti may primarily be unskilled laborers traveling away from home for low-paying employment. In-depth qualitative research is required to further elucidate these associations in Haiti.