Strès ak Pwoblèm Pap Janm Fini: Deciphering migration-related stress from the perspectives of Haitian immigrants in Florida

Abstract

Relocating and starting a new life in a foreign country may entail a constellation of new stressors for Haitian immigrants; thus, research that enhances our understanding of how this vulnerable population contextualizes migration-related stress is necessary. The objectives of this study were to: (a) identify what factors are associated with migration-related stress, and (b) describe which and why specific migration-related stressors were most significant from the perspective of those suffering from high migration-related stress post migration via the stress proliferation lens of the stress process model. In this mixed-methods, sequential, explanatory pilot study, first-generation Haitian immigrants (N = 76) were recruited to operationalize migration-related stress, using the Demands of Immigration Scale (DIS). Participants (n = 8), who scored 25 or higher on the DIS, completed an in-depth audio-recorded follow-up interview that consisted of open-ended questions and a stressor-ranking questionnaire. Descriptive statistics, Pearson correlations, multiple linear regression (quantitative), and thematic analysis with a double-coded approach (qualitative) were employed to analyze the data. Female gender, older age, English fluency, and migration after the age of 18 years were associated with higher migration-related stress. However, only gender and English fluency predicted migration-related stress. In interviews, participants ranked five migration-related stressors as most stressful: language barriers, financial strains, loss of social networks, family conflicts, and exposure to discrimination/stigma. A nuanced depiction of migration-related stressors and proliferation mechanisms of migration-related stress may help identify areas where support and preventive efforts should be directed to improve social integration, stress levels, and mental well-being among immigrants.

Keywords

Introduction

A considerable number of Caribbean communities contribute to international migration, which currently involves more than 270 million people (United Nations, 2019). With more than one million immigrants, Haiti has one of the largest Black Caribbean diasporic communities. A large portion of this community resides in the United States (International Organization for Migration, 2017; The World Bank, 2015), with Florida being home to the largest population of Haitian immigrants (Buchanan et al., 2011; Schulz & Batalova, 2017). Despite their considerable contribution to a pluralistic multicultural Floridian society, migration realities remain a major disruptive life event for Haitian migrants, who are plagued by a myriad of psychosocial stressors in the host country (Levitt et al., 2005).

The overwhelming psychosocial and environmental stressors faced by immigrants during the migration and acculturation process are often contextualized as migration-related stress (Torres & Wallace, 2013). Haitian immigrants in the United States experience similar disadvantages and stressors to other immigrant subgroups (e.g., separating from one's family and friends, learning a new language and culture, working and living in unfavorable conditions, discrimination, and many other social, economic and legal problems) (Bekteshi & van Hook, 2015; Concha et al., 2013; Fanfan & Stacciarini, 2020; Nicolas & Smith, 2013). Nevertheless, as a result of their positionality as triple minorities (predominantly Black, immigrant, Creole/non-English speaker), experiences of implicit and explicit immigrant status vilification (e.g., undeserving, illegal, poor, problematic), and unique cultural and historical background (Paik, 2019; Remy, 1996), Haitian immigrants may experience migration-related stress to a greater degree and with more susceptibility compared with other immigrants (e.g., non-Hispanic White, Latino) and non-immigrant populations (e.g., African American) (Huffman et al., 2013; Polanco-Roman & Miranda, 2013; Rogers-Sirin, 2013). This is supported by prior studies showing higher migration-related stress (e.g., discrimination and difficulties being understood culturally and linguistically) among Haitian immigrants compared with other Caribbean and South American immigrants (Kretsedemas, 2003, 2005; Levitt et al., 2005; Mason, 2010; Nicolas et al., 2009; Panikkar et al., 2014; Stepick, 1998).

Haitian immigrants’ experience of migration-related stress is distinct and may reflect factors that occurred before, during, and after migration. Haitians come from the poorest country in the Western Hemisphere, one with strong but troubled political, economic, and historical ties to the United States, as well as a long history of political instability and natural disasters (Linstroth et al., 2009; Nicolas et al., 2010). As a receiving society, the United States has traditionally met Haitian immigrants with hostility, prejudice, mistreatment, and opposition, as well as with fluctuating, discriminatory, and ambivalent migration policies, which have often relegated Haitians to the bottom of the social hierarchy as Blacks and undeserving/unwanted immigrants (Paik, 2019; Remy, 1996; Stepick, 1998). In comparison with other immigrant subgroups (e.g., Cubans), a disproportionate number of Haitian immigrants have been deported, incarcerated, and denied political asylum because the U.S. government classifies Haitians as “economic” and not “political” refugees (Cartright, 2006; Stepick, 1998). Judicial proceedings asserted a strong political asylum claim for Haitians; however, Haitians were often denied the right to due process (see Haitian Refugee Center v. Smith; in Lennox, 1993). Haitians have also faced significant health-related stigma and discrimination (e.g., tuberculosis-related stigma) because tuberculosis is highly endemic in Haiti, and many Haitians were labeled as HIV/AIDS carriers, which uniformly resulted in revoked work permits (Coreil et al., 2010; Santana & Dancy, 2000). These depictions have compounded already existing stereotypes and negative labels (e.g., “boat people,” “voodoo worshipers,” and “illiterates”) and have reinforced their social isolation as triple minorities. Long-term implications of the distinctive stressors that Haitian immigrants encounter (e.g., stigmatization and mistreatment across many contexts) have resulted in feelings of being rejected and self-doubt, negatively impacting self-esteem and interpersonal relationships, and causing intercultural conflict and poor mental health outcomes (Fanfan et al., 2020; Keys et al., 2015; Kretsedemas, 2003, 2005; Panikkar et al., 2014; Santana & Dancy, 2000).

A literature review on migration-related stress revealed the following stressors: discrimination (Bekteshi et al., 2017; Dawson & Panchanadeswaran, 2010), lack of social support (Concha et al., 2013), language barriers (Belizaire & Fuertes, 2011), socioeconomic status (Bekteshi & van Hook, 2015; Dillon et al., 2013), family conflict (Bostean & Gillespie, 2018; Dillon et al., 2013), fear of deportation (Arbona et al., 2010), dissatisfaction with post-migration experiences (Bekteshi et al., 2017; Nicolas & Smith, 2013), ethnic identity issues (Negy et al., 2009), conflicts with marianismo beliefs/values (Ertl et al., 2019), legal status (Torres & Wallace, 2013), and neighborhood characteristics (Sanchez et al., 2016). However, many of these studies were conducted mostly with Latino immigrants. The ethnic and racial differences in migration-related stress for Haitian immigrants remain poorly understood. In the few cross-sectional studies conducted with Haitian immigrants in the United States, cultural and linguistic changes, dissatisfaction with life in the United States, inadequate coping strategies, loss of family/social networks, and relational anxiety were explored as key migration-related stressors (Belizaire & Fuertes, 2011; Levitt et al., 2005; Nicolas et al., 2009; Nicolas & Smith, 2013).

It is well documented that post-migration stressors experienced by immigrants may significantly impact their physical and mental well-being, as well as social and economic integration (Bekteshi & Kang, 2018; Kirmayer et al., 2011; Linstroth et al., 2009; Torres, 2010). Unanticipated migration-related stressors (e.g., discrimination, anti-immigrant sentiments) accompanied with losses (e.g., sense of belonging, social networks) and the dearth of social, emotional, and economic capital necessary for adequate coping may lead to poor mental health outcomes among Haitian immigrants (Al-Baldawi, 2002; Belizaire & Fuertes, 2011; Fanfan et al., 2020; Fanfan & Stacciarini, 2020). In prior studies with Haitian immigrants, migration-related stressors were associated with depression, post-traumatic stress disorder, and anxiety (Brunnet et al., 2018; Fanfan et al., 2020; Kaiser et al., 2015). Yet current gaps in knowledge about Haitians’ mental health have limited our ability to provide answers about which factors are most stressful post migration, and why these factors are so stressful. We thus aimed to address this gap in the literature by moving beyond a skewed and narrow view of migration-related stress to understand the broader individual, social, and environmental forces that shape Haitians’ migration-related stress in relation to their unique ethnic, racial, social, cultural, and linguistic realities. This study had two aims: (a) to identify what factors are associated with migration-related stress, and (b) to describe which migration-related stressors were most significant (and why) from the perspective of those suffering from high migration-related stress during the post-migration period.

Conceptual model

Pearlin's stress process model recommends examining three domains when studying stress: sources of stress, mediators and/or moderators of stress, and manifestations of stress (Pearlin et al., 1981). This article is primarily concerned with understanding migration as a source of stress, which may result in the formulation of new stressors or the aggravation of existing stressors (Pearlin, 2000). In this context, what Pearlin calls the process of “stress proliferation” may ensue, defined as mechanisms by which primary sources of stress serve as potent antecedents for a series of secondary stressors during the post-migration lifespan. These mechanisms include: (a) interactions with the social environment; (b) anticipatory negative events (e.g., discrimination); (c) aging and life-course shifts (e.g., family, education, work, and social transitions while living in the United States); (d) generational differences and conflicts; (e) lateral proliferation (a contagion effect wherein one experiences stress from a close family's stressful experience); and (f) a spillover effect, wherein secondary stressors arise from primary stressors (Pearlin et al., 1997; Pearlin & Bierman, 2013). For Haitian immigrants, new strains or secondary stressors that emerge during the post-migration period may include exposure to discrimination, language barriers, anti-immigrant or anti-Haitian sentiments, loss of social status, and loss of social networks (Casey, 2013; Nicolas et al., 2009; Stepick, 1998). From these new stressors, additional stressors such as employment difficulties and social isolation may arise. Unique social conditions of the U.S. environment (e.g., living in racialized social systems, navigating multiple minoritized identities, social and linguistic pressures, and minority stress) may be a significant part of the stress proliferation process (Leblanc et al., 2015). Pearlin's stress proliferation phenomenon provides an important structure for understanding the multidimensional nature of sources of stress and serves as a pragmatic focal point for illuminating mechanisms of migration-related stress. This model is well suited to studying the population of Haitian immigrants in the United States, because it draws attention to a series of stressors along the post-migration life-course continuum, while considering the shifting influence of socioeconomic status, societal structures, and situational context.

Methods

Design

This study was a cross-sectional, explanatory, sequential mixed-methods pilot study in which quantitative data was collected first and analyzed (Phase 1), followed by completion of qualitative data collection (Phase 2) (see Figure 1). We used this mixed-methods approach to: (a) contextualize migration-related stress results from the quantitative phase of the study; (b) explore migration-related stress through quantitative and qualitative data, which provides an in-depth understanding of migration-related stress embedded within the unique ethnic and cultural background of Haitian immigrants; and (c) move beyond a one-dimensional view of migration-related stress to better reflect Haitians’ real experienced lives after migration.

Figure 1.

Outline of explanatory sequential mixed-methods approach.

Quantitative phase

Sample

First-generation Haitian adult immigrants (N = 76) were recruited from Florida through three purposive sampling methods (venue-based, snowball, and convenience), which enabled access to a hard-to-reach, mobile population. Participants met the following inclusion criteria for all phases of the study: (a) first-generation Haitian immigrants who spent at least 12 years in Haiti before moving to the United States; (b) English- and/or Creole-speaking; (c) adults 18 years old or older who have lived in the United States for six months or more; and (d) able to read and/or write English or Creole, or able to understand Creole verbally.

Instruments

Quantitative data were collected using a demographic questionnaire, developed by the first author for this study, and the Demands of Immigration Scale (DIS). The demographic questionnaire and DIS were translated from English to Creole using back-translation and forward-translation approaches provided by the Functional Assessment of Chronic Illness Therapy translation guidelines (Eremenco et al., 2005). Translation procedures are described in more detail elsewhere (Fanfan et al., 2020).

The demographic data included age, gender, ethnic identity, marital status, education, employment status, number of children, region of birth, length of time in the United States, age at arrival, English language fluency, health insurance status, documentation status, occupation, income, religion, and 2010 earthquake experiences.

The 23-item DIS uses four-point Likert scales to measure six domains of migration-specific stress (Aroian et al., 1998): (a) language (barriers in communication); (b) loss (emotional attachment to people, places, and experiences in home country and a sense of loss after immigration); (c) not at home (not feeling at home); (d) novelty (difficulties in dealing with new situations and in acquiring new skills); (e) discrimination (not being treated equally or being treated like an outsider); and (f) occupation (disadvantages in the job market). The range of scores is between 0 and 69 (0–23, mild distress; 24–46, moderate distress; 47–69, high distress) (Aroian et al., 1998). In this study, Cronbach's alpha of the English and Creole DIS were .937 and .932, respectively. Cronbach's alpha of the DIS subscales ranged from .771 to .839 in English and from .638 to .831 in Creole.

Procedure

Study approval was obtained from the institutional review boards of University of South Florida and University of Florida. Haitian churches, organizations, restaurants, barbershops, and businesses were approached and provided with bilingual flyers about the study (venue-based sampling). Recruitment occurred at convenient, accessible events held by Haitian organizations or churches (convenience sampling). Referrals were obtained from participants who identified friends and family members who met the inclusion criteria (snowball sampling). All participants received two options for informed consent: signed written consent or consent waiver with verbal assent, which was completed prior to completion of quantitative surveys. Participants selected their preferred language (Creole or English) for consent and surveys. Data were collected by the principal investigator and completed at participants’ preferred locations to ensure comfort, privacy, and confidentiality. When participants completed their questionnaires, they were asked to indicate their willingness to participate in a follow-up, in-depth interview.

Data analysis

Descriptive analyses were completed, including means for continuous variables and percentages, plus frequency distributions for categorical variables (categorical variables were dichotomized for bivariate analyses). Bivariate Pearson's r correlations and multiple linear regression were used to explore the relationships between demographic variables and migration-related stress. Correlations were completed with both the composite scores and the six subscales of migration-related stress to provide richer contextualization. All demographic variables (dichotomous and continuous) associated with the composite DIS that had a p < .10 at the bivariate level were included as covariates in the multiple linear regression. Via the backward stepwise regression process, we removed one variable (with the highest p-value) at a time until a final parsimonious model was achieved.

Characteristics of the sample

Most participants were female (57%), between 20 and 50 years old (67%), migrated to the United States after the age of 18 (55%), and had been living in the United States for more than 10 years (59%). Participants identified themselves as Haitian (75%), Haitian-American (20%), and Black (5%). Most participants preferred to speak Creole all the time (68%), were employed (75%), with approximately 45% reporting a household income below $26,000. Most participants were single (59%), had less than a bachelor's degree (57%), and were American citizens (66%). About 40% of participants were born in Port-au-Prince, the capital of Haiti, and the majority were neither in Haiti during the 2010 earthquake (72%) nor were directly affected by it (64%).

Qualitative phase

For the qualitative interviews, participants met two additional criteria: (a) participated in the quantitative phase of the study, expressed interest in the qualitative phase, and provided follow-up contact information; and (b) obtained a score of 25 or higher (moderate–severe distress) on the DIS. Although 18 participants were eligible to participate in qualitative interviews, only eight completed the in-depth interviews because of the time limit, resources, and lack of funding.

Procedures

A semi-structured qualitative interview guide developed by the principal investigator, encompassing dimensions of migration-related stress found in the literature and Haitian-specific factors, were used. The interviewer was a bilingual and native Creole speaker, but participants expressed a preference for completing the interviews in English (no translations required). Interviews lasted from 30 to 75 min and were audio-recorded. Quantitative and qualitative data were collected in South and West Florida, which encompasses Miami-Dade, Broward, Palm Beach, Lee, and Hillsborough counties, from February 2018 to July 2018.

This interview consisted of two parts: (a) a series of broad data-generating open-ended questions about overall experience of migration-related stress since migrating to the United States, followed by (b) a ranking list with stressors to be organized from most stressful to least stressful and probing questions to ascertain reasons for the stress. Broad data-generating open-ended questions about the overall experience of migration-related stress were completed first, so participants could provide candid responses unrestricted by the ranking. This approach allowed the principal investigator to (a) gauge consistencies between answers provided during the two parts of the interview and (b) narrow the focus of interviews to factors that were most stressful. The ranking list was primarily based on three dimensions of migration-related stressors identified by Caplan (2007): (a) instrumental/environmental stressors (employment status, access to healthcare, language barriers, financial issues, education, neighborhood characteristics); (b) social/interpersonal stressors (family conflict, loss of social networks, intergenerational conflict, loss of social status, changing gender roles); and (c) societal stressors (discrimination/stigma, legal status, historical/political factors. This list of stressors was more comprehensive than the DIS because it encompassed both the six domains of the DIS as well as other factors shown to be stressful in the literature (e.g., family and intergenerational conflict). Once ranking was completed, participants were asked open-ended probing questions about why factors chosen as most stressful were so stressful during the post-migration lifespan.

Data analysis

Interviews were transcribed verbatim. The principal investigator reviewed the text line-by-line for each transcribed interview to identify meaningful qualitative units for analysis and understand why migration-related stressors were experienced as stressful. Data analysis entailed appraising and synthesizing transcribed interviews through thematic analyses, which were then organized into major themes and sub-themes. We employed a double-coding approach, which included conceptual first-cycle codes and thematic second-cycle codes (Raskind et al., 2019). Once sections of text were identified, they were first allocated deductively to the conceptual codes (a priori themes), based on the three dimensions of migration-related stressors and previous research. During the iterative analysis process, sub-themes emerged (thematic second-cycle codes) that were related to the overarching a priori themes. As data analysis progressed, the soundness, sensitivity, and specificity of the sub-themes were continuously assessed against the data, and sub-themes were modified where necessary. Verbal counting (e.g., some, several) (Chang et al., 2009) was used to illustrate the qualitative themes present in the study to avoid generalizing the experience of participants. To identify migration-related stressors commonly ranked as most stressful, descriptive analyses were completed.

Characteristics of the sample

Of participants who completed in-depth interviews (n = 8), six were women and two were men. Ages ranged from 25–57 years; six participants were born in Port-au-Prince, and two were born in Cap-Haitian. Most participants were 18 or younger when they migrated to the United States (ages ranged from 14 to 20 years) and spoke English often or all the time. All participants were employed, three had associate degrees, four had bachelor's degrees, and one completed some high school. Length of time living in the United States ranged from 6 to 37 years. Six participants were citizens and were not in Haiti during the earthquake. DIS scores from the eight participants who completed interviews signified moderate to severe levels of migration-related stress (mean = 45.38, scores ranged from 31 to 62; SD = 11.87).

Results

Quantitative analyses

Composite score

Haitian immigrants reported moderate levels of migration-related stress with a mean score of 24; scores ranged from 0 to 62 (SD = 15.7). In bivariate analyses, factors significantly associated with higher migration-related stress included female gender, older age, older age at migration, and limited English language fluency. Factors not significantly correlated with migration-related stress included marital status, region of birth, length of time in the United States, health insurance status, citizenship status, and income. In a multiple linear regression, English language fluency (β = –.264, p = .017) and gender (β = –.280, p = .011) were independent predictors of migration-related stress and accounted for 15% of the observed variance (R²= .149, F(2, 73) = 6.403, p = .003).

Subscales

Women recounted significantly more stress related to language barriers, discrimination, and sense of loss. Immigrants who were older reported more language barriers and occupational stress. Migrating after the age of 18 and limited English fluency were each associated with more language barriers, occupational, and novelty stress. Not having a bachelor's degree or higher and having more children were each associated with more language barrier stress. Immigrants who were directly impacted by the 2010 earthquake disclosed higher discrimination stress. Table 1 provides correlation coefficients for the subscales.

Table 1.

Sociodemographic correlates of migration-related stress subscales (N = 76).

Sociodemographic factor	Novelty	Sense of loss	Language barriers	Occupation difficulties	Discrimination	Feeling not a home
English language fluency	−.319**	−.222	−.406**	−.233*	−.080	−.054
Age	.203	.163	.283*	.240*	.042	.062
Education: Bachelor's degree or higher	−.083	.013	−.316**	−.117	.044	.101
Age at migration	.321**	.201	.374**	.318**	.113	.197
No. of children	.096	.217	.352**	.167	.038	.085
Gender	.167	.232*	.384**	.059	.326**	.218
Directly affected by 2010 earthquake	.141	.077	.260*	.120	.274*	.033

Note: Pearson’s r correlation coefficients: *p < .05; **p < .01.

Qualitative

Participants reported experiencing chest pain, stomach aches, ulcers, insomnia, anxiety, increased frequency of panic attacks, depression, and suicidality (thoughts and attempts) during moments of severe stress. Help-seeking behaviors for stress were almost never mentioned except when stress grew severe (mentioned by a single participant). Coping strategies practiced by participants included keeping busy with work or other activities, avoiding certain stressful situations (avoidant coping), and over-indulgence in substances (e.g., alcohol). Positive coping activities included reading/writing, exercising, meditating, doing arts and crafts, and engagement in religious activities, including church and/or spiritual practices. Cultural norms, mistrust, and fear of being a burden to others were described as rationales for not seeking help, professional or otherwise.

Responses from both broad data-generating questions and the ranking list were congruent and described the following as stressful: discrimination, cultural shock/changes, U.S. cultural misconceptions, differences in educational pedagogy and infrastructure, language barriers, financial issues, lack of social support/help, living with strangers and unknown family members, immigration status, and shift in priorities. However, ranking results indicated that the most stressful stressors were language barriers, financial issues, loss of social networks, family conflicts, and discrimination (Table 2 and Figure 2); thus, these factors are the primary focus of the qualitative findings discussed.

Table 2.

Frequency of most stressful migration-related stressors (N = 8).

Stressor	Frequency	%
Most stressful instrumental/ environmental stressors
Language barriers	4	50
Financial strains	3	37.5
Most stressful social/interpersonal stressors
Family conflict	4	50
Loss of social networks	3	37.5
Most stressful societal stressors
Discrimination/stigma	8	100

Figure 2.

Understanding “which” migration-related stressors were most stressful and “why”.

Instrumental/environmental stressors

Language barriers

Language barrier was ranked as the most stressful instrumental/environmental stressor and a key difference between life in the United States and Haiti. Key language challenges for participants included using the wrong terms to convey the intended message, pronouncing words incorrectly, or an having an accent that affected word clarity, which ultimately led to a fear of speaking to avoid being ridiculed or making a mistake. Being ridiculed or mistreated for speaking English incorrectly or speaking English with a Creole accent often resulted in low self-esteem and in reduced confidence in the ability to learn and speak the language. This theme was depicted in the following description:

When you’re learning a language and then you make a mistake, and somebody starts laughing, it makes you feel like “Gosh, am I that bad,” and you don’t feel motivated to actually try again or at least speak it. (25-year-old female)

Several study participants expressed frustration and anger regarding the inability to make people understand their feelings, thoughts, and point of view in English, which led them to socially isolated themselves. One participant likened his inadequate English proficiency as a disability that needed to be overcome quickly:

I would say for someone who doesn’t speak the language, you’re a disabled person in a way. You’re not physically disabled, but you’re disabled because you cannot do stuff that you want to do. That's why I feel like … I have to learn the language as soon as possible. (27-year-old male)

Echoed by the participant above, several others indicated that when they were less proficient in English, they experienced significant pressure to learn English quickly to properly communicate, make friends, seek employment, succeed in school, or to just simply navigate activities of daily living. English was a means of survival. As one 26-year-old female immigrant explained, “It is hard when you cannot express yourself because language is everything.”

Financial

Financial strain was ranked as the second most stressful instrumental/environmental stressor. Experiences of less stress in Haiti in comparison with the United States reflected the ability to work, fewer bills to pay, and more financial support from family and friends. After moving to the United States, financial burdens became more stressful owing to more bills or financial obligations, inability to maintain the same career or employment previously held in Haiti, and lower wages. Precarious employments were concerning; unstable vocational jobs provided neither job security nor sufficient earning to pay bills and support a family. Adults who migrated to the United States before the age of 18 expressed having fewer financial concerns personally; however, they indirectly suffered from the financial burdens experienced by their parents. As this participant expressed:

My father … he did not really have like a job … he had like a vocational job, which was air welder. And I think about two years when we moved in and he had recently purchased his house, he lost his job. He was doing like other things to make ends meet … but it was not enough to actually support a wife and three other children in the house. You come home and try to find some food to eat and not all the time you’re gonna find food at the house, so that's the reason why I said financial was stressful. It was like more an indirect impact … because I was 16. (27-year-old male)

More education and the ability to earn higher wages slightly reduced stress, but the protective effects of these factors were diminished in the presence of discriminatory practices (e.g., hostile attitudes to language barriers/accent, racial and ethnic discrimination) in the workplace, which also influenced job security. Some participants also expressed that they experienced more financial stability and greater employment opportunities with time. Despite this, their stress did not diminish because of the degree of responsibilities and financial obligations to their families in Haiti and in the United States. This theme reverberated as such:

…[F]inance changed because more money, even though there's like more bills and you spend more, but at least you are able to do certain thing. You are not like rich, but at least the money comes, you are able to have a decent life, a cleaner life and things are like more accessible. Thing is, it is better than living in Haiti, where a lot of time people don’t have job, especially my mom. She was working but I wouldn’t have access to work. The reason why is more difficult, even though my mom was making more money here than in Haiti, was with all the bills that she had to pay and family in Haiti too. You make the money but it's like you didn’t make it because you pretty much make it and you just pay bills with it. (26-year-old female)

Despite financial challenges, some participants indicated feeling a sense of pride, happiness, and diminished guilt when they were able to send remittances (money and/or goods) to relatives in Haiti.

Social/interpersonal stressors

Family conflict

Family conflict was described as the most stressful interpersonal/social stressor. Stress stemming from family dynamics was primarily related to living and interacting with individuals who were considered strangers. Several participants expressed reconnecting with family members they had not seen in a long time or meeting stepsiblings and stepparents for the first time when they moved in to live with them post migration. One participant articulated this as follows:

Family conflict was stressful simply because I was thinking about living with a stranger, my stepdad, and he is very different from my dad because of like how they see life. My dad is more like lay back, chill, cool and everything, and my stepdad is a real typical Haitian with a lot of point of views completely different and narrow, so it becomes an issue. (26-year-old female)

Difference in ideals, values and beliefs often created conflicts and stress. One 27-year-old male participant described running away from the stress related to family issues: “I end up joining the Marine Corps … because I wanted to go away from my parents and I just couldn’t take it. I was not feeling challenged or loved as I wanted to be by my father.”

Conflicts between parents were also observed in the forms of more household disputes or disagreements that affected parents as well as children. A graduate school student described his experience as the following:

When I was living with my aunt and grandma we had … conflicts, but not to the extent of when I came here, where it was like bickering every day between my mom and dad—to the point where they had to separate. Those kinds of things, it's like every day, whether it's about the kids, whether it's about money, whether it's about whatever it is. … And that kinda makes you rethink twice about like maybe I shouldn’t have come to the U.S., maybe I was better off in Haiti. And those kinda make it stressful staying here. (24-year-old male)

Feelings of powerlessness emerged when immigrants had little choice regarding living arrangements if family members sponsored their residence or visa applications or were their only source of support. Nonetheless, family cohesion was a protective factor against migration-related stress. One participant articulated her experience regarding why family cohesion reduced stress:

It's the only way you feel like you are back home for a bit—nostalgia. Nostalgia is real, being here with family resembled a little bit like home, especially if you don’t have the green card to go back and forth. (57-year-old female)

Loss of social networks

Interview participants ranked loss of social networks as the second most stressful social/interpersonal stressor. Loss of social networks included absence of family, friends, and close-knit neighborhoods where everyone knew and interacted with each other. This theme was echoed as follows:

There was a lot of us in the house; sometimes we had like 9 to 10 of them in the house. Like I said, I always lived with a lot of people. We have struggled together, when it's good time too, we enjoy the good time together and all that. But when I got here, it was only me and my little brother, and then my stepdad who was like a stranger to us and my mom who was always working. So, it was just like coming from a happy big house to a very sad life. (26-year-old female)

After migration, many Haitian immigrants lost their social networks via mechanisms (e.g., distance, inability to visit or contact family in Haiti, acculturation, loss of native language as proficiency in English increased) that decreased contact and access to friends and family. This ultimately resulted in losing support systems, sense of belonging, and sense of community. Contact with bigger and more diverse communities and a faster pace of living also increased stress, because this was a stark difference from their typical lifestyle in Haiti. Social media platforms like WhatsApp and Facebook, which could have made contact with family and friends from Haiti less of a challenge, were not accessible to many Haitians who immigrated before the advent of these major social media platforms or widespread use of cell phones or adoption of these platforms (some access issues were due to lack of awareness and/or monetary constraints in the United States and Haiti). Efforts to integrate and network with non-Haitian individuals in the United States were compromised by (a) limited English fluency that impeded dialogue, and limited friendship and relationship development to other Haitians only, (b) the notion that individuals who were not natives of Haiti would not understand their views, values, and beliefs systems, making it hard to establish trust, and (c) social isolation. This was reflected in the following participant's comment:

When I came here, I didn’t have a lot of friend. I still have to like, see who I could click with because a lot of time I cannot be part of the conversation because first of all I don’t understand what they’re talking about. A lot of kids here, they just speaking English. They are not speaking Creole, so you’re lost, you are pretty much lost, so how are you going to have a conversation with them? And the way I see life, too, was not the same as them. (25-year-old female)

Befriending other Haitians was difficult for some of the highly acculturated first- and second-generation Haitian immigrants. Even when connections with friends and family were established in the United States, their support might have been temporary. Several participants described themselves or their parents being asked to leave families’ or friends’ houses. A participant explained their story of homelessness as follows:

Spent a long time in the hospital because of an infection, at least six weeks. No one visited me for more than six weeks. During that hospital stay, I was kicked out of my home, and my stuff were dropped off at a friend house, but they put them outside, and all got damage from rain and had to throw away everything. When I came out of the hospital, I didn’t know where I was going. I spent some time at a friend house, a few weeks under the bridge in Nebraska [Tampa] before I went to my sister's house in Miami. (57-year-old female)

Living in a Haitian enclave, like Little Haiti in Miami, Florida, provided access to a social network characterized by emotional, informational, and instrumental support, thus reducing migration-related stress. Ethnic enclaves also afforded opportunities to gain a sense of belonging and a way to reconnect with the culture, food, music, and Haitian community. However, potential downfalls of living in Little Haiti were also highlighted, which included: (a) reduced motivation to learn English (less pressure to learn the language); and (b) decreased motivation to branch out of community comfort zones, which negatively influenced pursuit of higher education and upward mobility.

Discrimination/stigma

Discrimination/stigma was ranked the most stressful societal stressor. All participants indicated experiencing different forms of discrimination, which included racial discrimination, discrimination concerning their Haitian descent (e.g., anti-Haitianism), cultural stigma from the way Haitians were portrayed in the media, and cultural myths. For instance, one participant stated this about discrimination:

One thing that made my life stressful was discrimination because in Haiti, we do not have discrimination. We do have class issues, like people who have more money are more acceptable and stuff like that. The discrimination is so deep. That's something I never experienced until I got here. (26-year-old female)

In addition to experiencing discrimination for being Black and Haitian, some participants conveyed that increasingly anti-immigrant attitudes played an important role in their stress. A participant expressed this about stigma and anti-immigrant sentiment:

First, you’re already an immigrant, so a lot of people think, “Oh, you’re an immigrant. You’re taking our job, you’re taking our money, you’re taking everything.” Meanwhile, a lot of them don’t understand that immigrants are doing jobs a lot of them wouldn’t do, and immigrant is part of the economy for this country, and a lot of people don’t understand that. They don’t like the fact that you have an accent; they feel that you should not have an accent from somewhere else and be in the country. So being Black on top of it, it doubles your problem. (26-year-old female)

Several participants disclosed that Haitians were viewed as an inferior population among other Black/Black Caribbean population subgroups. A participant described getting bullied and fighting back in high school for being Haitian:

I mean you fight in school in Haiti, just because you’re being turbulent—your friends don’t like my friends, we go fighting. Coming here I’m fighting because I am Haitian. I am not fighting because I don’t like this guy as a person. I am just fighting because “Oh, my God this guy is Haitian.” You inherit every stigma that has been created upon Haitian. (27-year-old male)

Negative views and stereotypes continually and significantly impacted many participants, even forcing some to question their self-worth and value as human beings: “It's because of the way they look at you—less than human; it's like you’re their maid” (57-year-old female). Some participants sometimes wished they did not identify as Haitian, and this also diminished their sense of self-worth: “In Haiti you never had to question your worth as a Black person, but here in the U.S. for the first time, I have encountered those discussions. So those kinds of things make you think about you as a second-class citizen in the U.S.” (24-year-old male).

Discussion

This mixed-methods, sequential pilot study aimed to improve our understanding of migration-related stress among Haitian immigrants and determine which stressors were most impactful in their lives during the U.S. post-migration period. A cluster of stressors (e.g., language barriers, family conflicts, loss of social networks, financial issues, and discrimination/stigma), in addition to situational context (e.g., age at migration) and gender were key explanatory factors for moderate to severe levels of migration-related stress. Moreover, our findings present evidence about proliferation patterns of migration-related stress, highlighting the chain reaction that may occur as secondary stressors develop post migration.

Addressing migration-related stress

Migration-related stress poses a significant obstacle for Haitian immigrants. Key non-modifiable contextual factors (e.g., gender, age at migration) played a significant role in the variability of this stress. In this study, Haitian immigrants reported moderate to high migration-related stress scores even though most of the sample had lived in the United States for more than 10 years. This finding contradicts prior evidence, which showed a decrease in migration- and acculturation-related stressors among Haitian (Belizaire & Fuertes, 2011) and Latino (Bostean & Gillespie, 2018) immigrants who had spent more time in the United States. We speculate that increased engagement with and integration within U.S. mainstream culture and communities may, with more time, coincide with higher exposure to social and cultural situations (e.g., discrimination, anti-immigrant sentiments, family/intergenerational conflicts) that increase the likelihood of experiencing migration-related stress (Sanchez et al., 2016). Perhaps the fact that most participants spent a considerable amount of time in Haiti (12 years or more) before migration could also explain higher levels of migration-related stress, which is supported by prior research in this area (Jaggers & MacNeil, 2015). Older age at arrival indicated significant exposure to the Haitian culture as well as long-term implications for migration-related stress and mental well-being (Jaggers & MacNeil, 2015).

Gender disparities in migration-related stress also suggested that women may be more susceptible. Qualitative and quantitative data indicated that Haitian women's increased perception of migration-related stress may stem from a greater sense of loss after migration, higher family responsibilities that delay language and social integration, and increased commitment to a Haitian ethnic identity (e.g., Creole language and Haitian culture). Notably, migration-related symptoms expressed by interview participants support a preponderance for somatization when in distress, particularly among women. Consistent with prior research, the higher stress reported by women may also translate into an increased likelihood of poor mental health outcomes (Fanfan et al., 2020; Jaggers & MacNeil, 2015). Moreover, lack of formal and informal help-seeking behaviors in our findings, while consistent with prior studies among Haitians (Carson et al., 2010; Nicolas et al., 2009), are concerning and denote focal areas for future research exploration.

Language barriers

The convergence of quantitative and qualitative findings points to the importance of language barriers regarding their impact on shaping social, economic, and environmental challenges. Consistent with previous research with Haitian immigrants (Belizaire & Fuertes, 2011) and other immigrant subgroups (e.g., Latino, Asians) (Arbona et al., 2010; Bekteshi & van Hook, 2015; Salas-Wright et al., 2015), an English language barrier was a significant stressor for Haitian immigrants and it varied by fluency, current age, age at migration, education level, 2010 earthquake experiences, and gender. Through the lens of the stress proliferation pathway, we conceptualized that language barriers served as a secondary stressor, which gave rise to many tertiary stressors at the individual and interpersonal levels (e.g., employment, social isolation), providing affirmation of the potential spillover effect of language barrier stress. English language proficiency has been identified as one of the biggest obstacles faced by immigrants as well as one of the most important skills necessary to facilitate social and labor integration, financial stability, educational attainment, and access to information and services (Farkas et al., 2003). As such, linguistic integration pressures, as noted in this study's findings, may enforce acquisition of the dominant English language at a faster pace for Haitian immigrants (Lueck & Wilson, 2011).

Economic and occupational integration

In comparison with Haiti, the United States provided greater economic and employment opportunities. However, per qualitative data, contextual factors that were attributed to financial stress—such as language barriers, lack of education and social support, unrecognized credentials and skills, racial and ethnic discrimination, and urgent financial obligations in the United States and Haiti—hampered immigrants’ ability to achieve economic and occupational integration. As such, Haitian immigrants readily entered available jobs that were often low-skilled and low-paying, especially those who migrated as adults, subjecting them to unfavorable working conditions that were highly stressful (Dustmann, 2000; Kalter & Kogan, 2006). Previous studies with the Latino immigrant population reflect a similar pattern, showing greater migration-related stress in the face of lower socioeconomic status and downward occupational mobility (Matthews & Gallo, 2011). Furthermore, even when plagued with low wages and financial burdens, Haitian immigrants were committed to maintaining their remittance levels, which has been shown to have many positive social impacts on immigrant lives (Orozco & Burgess, 2011).

Interpersonal relationships

Haitian families and social networks become splintered in the move from Haiti to the United States, with some family members and support networks remaining in Haiti and others relocating to disparate parts of the United States. Although family is important for Haitians, a dramatic shift in closed-knit relationships with family and friends, and more contact with unknown family members entailed the loss of both emotional and instrumental support, as well as increased conflict. Consistent with our findings, previous studies with the Latino population found that separation from family, an absence of pre-immigration friends and difficulties visiting family abroad were significant predictors of migration-related stress (Bekteshi & van Hook, 2015; Bekteshi et al., 2017; Concha et al., 2013). Studies have also demonstrated that the quality of family relationships and social networks may be even more critical than merely being in proximity with family and friends (Dillon et al., 2013; Ibañez et al., 2015; Miranda & Matheny, 2000; Sarmiento & Cardemil, 2009). Effective social support may thus only occur with established connections between family that promote cohesion and when family and friends were supportive while in the United States. In addition, Haitian immigrants highlighted that during their formative adolescent years, conflicts between their parents often influenced them, providing evidence of lateral stress proliferation in this population (Nicolas et al., 2009).

Discrimination

Discrimination occurred along many dimensions for Haitian immigrants (e.g., language, race, ethnicity, and immigrant identity). Haitians with certain characteristics (e.g., women and individuals directly impacted by the 2010 earthquake) may perceive or report more discrimination. Collectively, Haitian immigrants described living in an environment that devalued their ethnic background and skin color, ridiculed Creole accents, and was antagonistic toward their immigrant identity. These experiences and their day-to-day unpredictability could “get under the skin” of the individual, triggering declines in mental health (Allen et al., 2019). Recent increases in immigration enforcement and deportation, uncertainty about Temporary Protected Status, and existing anti-immigrant rhetoric within the social and political environments of the United States also heightened migration-related stress (Roche et al., 2018). Being targets of discrimination and feeling like second-class citizens are profoundly emotional and stressful experiences likely to be particularly salient predictors of mental illness, making discrimination too important a factor to ignore.

Limitations

Despite the empirical contributions of this study, the findings may not be generalizable to the broader Haitian immigrant population living in the United States because this study was limited to Haitian immigrants who migrated after the age of 12. The validity of the DIS needs to be investigated in greater detail with a larger and heterogeneous group of Haitians, because this was the first study to use the measure with Haitian immigrants. Because in-depth interviews were only completed with participants who experienced high levels of migration-related stress, qualitative findings may only be reflective of Haitian immigrants with much higher levels of stress. The migration-related stressors discussed may be most reflective of immigrants who migrated to the United States as adolescents and spent a considerable of time in the United States, given the sociodemographic profile of the interview participants. Several participants reported on the experience of another person, which contributed to their own stress. Lateral stress proliferation is an important source of the stress mechanism; however, reports of others’ stress experiences also represent a limitation. Future comparative studies are warranted to assess differences in stressors among Haitian immigrants with different levels of migration-related stress and across varying cohorts. Additional concerns included the small sample size, the combining of English and Creole responses into one data set, participant's choice to respond in English (and not Creole) during the qualitative interviews, use of verbal counting, and potential for several biases—social desirability bias and selective bias/memory. Participants may not have fully remembered what occurred, making it difficult to verify self-reported data. Despite these limitations, this study provided preliminary evidence that sheds light on the “what and why” of key migration-related stressors among those most vulnerable within this population.

Recommendations

Migration-related stress has repercussions beyond the individual immigrants concerned in this study. It also impacts families, communities, socioeconomic/cultural integration, institutions, and policies for current and subsequent immigrant generations. As one of the first studies to contextualize migration-related stress and highlight post-migration factors most stressful for Haitian immigrants, our findings significantly contribute to the minority immigrant mental health/well-being literature. A clear message from this study's findings is that key migration-related stressors in Haitian communities are potentially modifiable. Because these stressors manifest at different levels, efforts are needed to prioritize multilayered sustainable efforts that promote social, economic, and psychological integration and to increase help-seeking behaviors.

As researchers and mental healthcare providers embark on initiatives to address global mental health disparities among racially and ethnically diverse immigrants, we need to first consider factors such as language barriers, occupation/financial strains, social networks, family dynamics, and discrimination that may influence integration and mental well-being in the host country. Our findings suggest the need for contextualized English language programs that are affordable and provide integrated education and training to help increase newcomers’ English language competencies (National Immigration Forum, 2016). Haitian immigrants may benefit from community-based and family-orientated interventions promoting social integration and avenues for connecting with other Haitians in their areas (Michael et al., 2008). Institutional/community support and resources that promote family reunification strategies while considering family history, Haitian culture, the realities of living in the United States, and the cultural gap between family members may be necessary (Rousseau et al., 2004). More favorable policy efforts and a positive shift in public and political discourse are also necessary to create upward socioeconomic mobility within Haitian communities, promote acceptance, and reduce stigma and discrimination. Perhaps, the provision of tools and information via formal and informal community efforts/services (e.g., families, private organizations, churches, social media/television) early in the post-migration process should be a priority, particularly for Haitian women who may encounter more integration barriers (Duguay, 2012). Understanding individual and social barriers may also help in the promotion of informed and population-focused strategies to improve help-seeking behaviors, along with helping Haitian immigrants learn effective, adaptive coping strategies (Tran et al., 2014). One thing is for certain: to overcome the notion that “strès ak pwoblèm pap janm fini” (stress and problems will never end), a “one size fits all” approach will not be effective for this culturally diverse and heterogeneous population when developing programs to promote mental well-being post migration.

Footnotes

Acknowledgments

We would like to thank Pam Selby for her contribution to editing several drafts of this manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Dany Fanfan

Dany Fanfan, PhD, MSN, RN, is an assistant professor at the University of Florida College of Nursing. Fueled by passion, philanthropy and the immigrant communities she serves, her research has centered on bridging gaps in scientific knowledge for promoting mental well-being and preventing poor mental and behavioral health outcomes among vulnerable and minority populations. Dr Fanfan engages in mixed-methods research focused on understanding the biobehavioral, cultural, and psychosocial mechanisms linked to mental health/well-being and distress symptoms (e.g., stress, depression) among ethnic-minority immigrants and other underrepresented populations.

Carmen S. Rodriguez, PhD, APRN, ANP-BC, AOCN, is an associate professor at the University of South Florida, College of Nursing. Dr Rodriguez's research focuses on symptom science in cancer, and health disparities in Hispanics and other ethnic populations. Her published works focus on interventions to improve symptom reporting and management of vulnerable populations, technology-enhanced communication interventions, and minority populations’ risk behaviors and disparities.

Jeanne-Marie R. Stacciarini, PhD, RN, FAAN, is an associate professor and Associate Dean for Diversity, Inclusion, and Engagement the University of Florida College of Nursing. Dr Stacciarini's research interests are in the area of mental health promotion and health disparities among minorities living rural areas, including ethnic-minority immigrants, LGBTQ+, and migrant farmworker populations. She uses community-based participatory research, mixed-methods research, and social network analysis to examine social determinants of mental health among minority and underserved populations.

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