Health seeking behaviors of Haitian families for their school aged children
Abstract: Providing culturally sensitive health care to diverse groups would be enhanced by better understanding of their experiences with the health care system and perceptions of health and illness. Haitians comprise an immigrant group that has increased dramatically in the United States over the past three decades. The purposes of this study were to identify the health seeking behaviors of Haitian parents for their school-aged children and the barriers they experienced in obtaining health care services. Sixty-two Haitian parents and guardians were interviewed. Findings highlighted a lack of health insurance coverage, frequent use of private providers, general satisfaction with health care services, and strong parental values regarding preventive health care behaviors. Parents also reported the combined use of traditional remedies and biomedical treatments during their child’s illness episodes. Implications for practice and future research with Haitian parents and children are identified.
Keywords: Haitian Families, School Aged-Children
The influx of immigrants from different cultures into the United States presents challenges for health care professionals to provide culturally sensitive care. Nurses, especially, are increasingly likely to come in contact with clients of diverse ethnic and cultural backgrounds who are seeking health care for their families (Purnell & Paulanka, 2003). Many immigrant families are classified as vulnerable populations since they are more likely to experience adverse health outcomes than white, middle- and upper-class Americans (Flaskerud & Winslow, 1998).
Health beliefs and health-seeking, behaviors have been addressed in a number of studies over the past several decades. Studies which have addressed the health seeking behaviors of specific ethnic and immigrant groups and families, however, have been limited (May, 1992; Weitzel, Hudak, Becker, Waller, & Stuifbergen, 1994; Wen, Goel, & Williams, 1996). Researchers have identified the need to better understand and address facilitators and barriers to obtaining health care for members of underserved and disenfranchised populations (Aten, Siegel, & Roghmann, 1996; Davis, Gergen, & Moore, 1997). This need is particularly great with respect to immigrant parents who seek health care for their dependent children.
Health behaviors are often similar among persons of the same ethnic background or persons who share similar socioeconomic status. Many health behaviors are influenced by culture and learned within the family. Providing preventive health care and sick care are major functions of the family (Friedman & Morgan, 1998). Families differ in their perceptions of what constitutes health as well as in their definitions of illness. These differences translate into a variety of health practices and healthcare seeking behaviors. Families often use formal health care services in addition to informal health care resources to manage illness and promote the health of their members. Use of professional services for health promotion and care during illness is decided by the family based on economic factors as well as cultural, political, religious, and social influences (Bomar, 1996; Purnell & Paulanka, 2003).
Barriers which impede the ability of families to obtain health care for members include a health care system that is not responsive to their unique needs and a problem of access to care if one or more family members are uninsured or unable to pay for services. Many other families with health insurance are still considered underinsured and vulnerable since their coverage does not include preventive health care services.
Research specifically addressing barriers to accessing health care services in vulnerable populations has produced several common themes. Transportation, inadequate funds, inability to identify a provider, rude health care professionals, and waiting time have been identified as being major deterrents to seeking health care for persons in lower socioeconomic groups and other vulnerable populations (Northam, 1996; Strickland & Strickland, 1995).
Immigrant groups have unique experiences but report many of the same barriers to receiving health care as do other vulnerable populations. In addition, members of immigrant groups and ethnic minorities do not routinely, seek primary or secondary preventive health services due to language barriers, lack of cultural awareness and sensitivity by health care providers, structural barriers, and lack of value placed on preventative care (Cortis, 2000; Duncan & Simmons, 1996; Schmalz & Larwa, 1997).
Contrary to studies conducted in the United States, these barriers were not perceived by immigrant groups in one Canadian study (Wen et al., 1996). Only minor differences were found between use of health care services by immigrants and other ethnic/cultural groups. The authors suggested that the Canadian universal health insurance system does not create the inequalities in access to health care experienced in the United States.
Studies on the use of folk, alternative, and professional care services among Amish-Americans and Latino Americans indicated that although all participants used professional health care services, alternative and folk care services were regularly sought by members of both groups (Talavera, Elder, & Velasquez, 1997; Wenger, 1995). As immigrants acculturate, their, health beliefs and practices change to become more like those of the host culture (Talavera et al., 1997). However, the use of cultural health practices and non-professional health care practitioners often continue among various cultural groups following immigration.
Haitians comprise an immigrant group that has increased dramatically in the United States over the past three decades. The eastern United States has received the largest number of Haitian immigrants. Haitian culture is characterized by strong family values. Children are highly valued, and close ties and associations are typically maintained with members of extended families. These values are exemplified in child-rearing and health care practices. It has been documented that Haitian families value self reliance and seek traditional or formal health care services as a last resort (Bastien, 1995; Libman, Hardt, & Stern, 1991).
To Haitians, good health is seen as the ability to achieve equilibrium, and illness is attributed to an imbalance, particularly between cho (hot) and fret (cold) (Bastien, 1995; Colin & Paperwalla, 1996; 2003). According to Colin and Paperwalla (1996; 2003), illness may have two distinct etiologies which require different types of treatment: natural causes and supernatural causes. Haitians believe that some illnesses are amenable to Western biomedical intervention, whereas others are not. Researchers who have explored the health care beliefs and practices of Haitians have found that traditional health care practices (i.e., folk systems) are blended with Western biomedical health care practices for both preventive health care and sick care (DeSantis, 1993; DeSantis & Thomas, 1990; Holcomb, Parsons, Giger, & Davidhizer, 1996; Kirkpatrick & Cobb, 1990; Martin, Rissmiller, & Beal, 1995).
Acculturation was cited as a possible reason that Haitian immigrants residing in the United States tended to seek concurrence between the medical advice and the family’s judgment regarding the health of their children (DeSantis, 1993). Haitians tend to use a four-step approach to managing symptoms: self-family treatment, cultural treatment, religious treatment, and biomedical treatment (Bastien, 1995). Researchers have also reported the use of this multilevel approach in preventive health care for infants and preschool children (DeSantis & Thomas, 1990). DeSantis (1993) interviewed 76 Haitian adults to obtain their definitions of health and health promoting beliefs. The participants were born or raised in Haiti. The majority were married (96%) and female (54%), and the mean age was 37 years. Most participants reported that their health and the health of their families were the most important things in life. Practices identified by participants as being important in maintaining health included eating well, exercising through hard physical labor, sleeping well, not smoking, and consulting a physician to assess health status.
DeSantis and Thomas (1990) conducted a descriptive study of immigrant Haitian mothers’ preventive health care practices. These researchers found that most participants reported having routine physical examinations by a health care provider. Additional health care practices included religious practices, use of home remedies and over the counter medications, and other cultural practices.
Kirkpatrick and Cobb (1990) interviewed 83 Haitian women to identify mothers’ beliefs about threats to their children’s health. The mean age of the mothers in this descriptive study was 29.2, and 50% of the mothers reported that they were born in Haiti. The major problems identified by mothers were diarrhea, fever, and communicable disease. The use of hot and cold remedies was described by these mothers along with the use of medications.
Research with Haitian families has consistently confirmed a strong value placed on health. Research has also documented reliance of this population on formal health care services in addition to use of folk health care practices and informal health care resources for health promotion and treatment of illness.
Need for the Study
The purposes of this study were to identify the health seeking behaviors of Haitian parents for their school aged children, the barriers they experienced with obtaining desired health care services, and their preventive health care practices and illness care for their children. The provision of culturally sensitive health care for Haitian families and children would be enhanced by a better understanding of parents’ experiences with the health care system and perceptions of health and illness. Understanding of Haitian’s spiritual and ethnomedical beliefs are also needed to provide care that is valued by this unique immigrant group (Miller, 2000).
The ability to provide quality services for any community group begins with assessment of the needs of the community and available resources. By interviewing family members regarding their experiences with the health care system as well as beliefs and practices with respect to their children’s health, it was hoped that a better understanding of the needs of family members in obtaining health care services would be achieved. This information could then be used to guide the development and implementation of health programs and services that are responsive to the needs of this unique population.
Interviews were conducted to explore Haitian parents’ health seeking behaviors and illness care for their children and to identify their perceived barriers to accessing health care services. The setting for this study was an elementary school in an urban area of a southeastern state. The elementary school had approximately 1,500 students, 80% of whom were of Haitian descent. A majority of students (89%) qualified for reduced lunch cost status based on family income.
The Interview Guide, The Comprehensive Health Access Research Form, was developed by a multidisciplinary group of researchers representing nursing, psychology, education, and social work at an international university in the southeast region of the United States. Questions were pilot tested prior to initiation of the study. The final guide focused on three topics. The first area addressed health insurance. Parents were asked if they had health insurance for their child and what barriers they had experienced in obtaining and retaining health insurance for their child. The second set of questions addressed where, parents sought preventive health care services and illness care for their child. Parents also were asked what they liked about the health care services they received and if they had any problems or concerns regarding this care. Additionally, parents were asked how often they sought preventive health care services for their child and how often they thought these services should be provided. In the third part of the interview, parents were questioned about their illness care behaviors for their child when he or she was sick. Prior to collecting data, all interviewers were trained in the administration of the Interview Guide.
Following approval of the university Institutional Review Board for the Protection of Human Subjects, parents of children in the first four primary grades who were willing to participate and gave informed consent were interviewed in their homes or in the Full Service School. The Full Service School provides comprehensive health care and social services for elementary school children attending this school. Interviews were conducted by the investigators and graduate students in social work. A Creole speaking graduate student conducted interviews with those family members who spoke only Creole.
Sixty-two Haitian family members with a child in the elementary school participated in this study. Most of the respondents (n = 58, 93.5%) were parents. Two participants were stepparents, one participant was an uncle, and one participant was a grandparent. Of the parents interviewed, 33 were mothers and 25 were fathers. Most of the parents or guardians interviewed (n = 48, 77.4%) were living with a spouse. Five respondents reported living with a partner other than a spouse, and six families had a grandparent or other family member residing in the home. The mean number of persons residing in the homes of the participants was 5.16 (range = 2-9).
Most families had more than one child (range = 1-7), with a mean of 2.88 children per family. Most of the children (n = 54, 87.1%) were born in the United States. Creole was the primary language spoken in 50 (80.6%) homes, and only 10 (16.1%) participants reported that English was the primary language spoken in their home.
Barriers to Obtaining and Retaining Health Insurance
The most frequently cited reason parents gave for not receiving desired preventive health and dental care for their child was the cost of care. A large proportion (n = 26, 41.9%) of the participants reported that their child did not have health care coverage at the time of the study. Ten (16.1%) participants reported that their child never had health care coverage. Of the participants with health insurance, slightly over one half had private health care insurance coverage, and approximately one fifth cited Medicaid as the insurance they currently had for their child. Only 17 (27.4%) of the participants reported that their child currently received health insurance from one parent s employer. A majority (n = 23, 63.9%) of parents whose child had health insurance at the time of the study reported that they were required to pay some part of their child’s health insurance costs.
The most frequently cited barrier to obtaining health care insurance coverage for their school aged child was that the family’s income was too high for government entitlement programs. Another barrier to obtaining health, insurance was difficulty getting to the welfare office due to transportation problems or conflicts with work. Many participants stated that they did not attempt to apply for Medicaid since their child was not a United States citizen or because the family owned a car.
Twenty seven (43.5%) of the participants indicated that persons of Haitian descent often do not apply for tax supported health insurance due to immigration issues, and seven (11.3%) believed that the number of questions on applications was a reason why Haitians failed to apply. Other reasons identified by participants that Haitians do not enroll in entitlement programs included (a) the cost of programs or perceived cost of programs, (b) lack of knowledge and information of application processes, (c) misinformation regarding programs, and (d) cultural mistrust of government in general.
A large number of participants (n = 28, 45.1%) reported that their child was cut off from Medicaid coverage, and many indicated that they were unaware of the reason for discontinuation. Several parents indicated that they were unaware of the need to renew Medicaid coverage periodically. One mother stated, “I never received a letter from Medicaid saying they closed it. My doctor said it was closed.” Several parents reported that their child lost insurance coverage because they made too much money. One mother with two children ages 7 and 10 stated:
“They cut it off because they thought my child did
not need it anymore. This is so unfair, I work, and
I am not qualified to get benefits because of my income.
But those who do not work get everything
without paying taxes.”
A father of three sons said, “They said my wife and I make too much money. They gave one of my children Medicaid for a while, then the rest of them were denied.” Several parents also discussed concerns related immigration and the amount of information that they needed to disclose to retain coverage. One mother stated, “Welfare dropped him because I would not give them information about my husband.”
Sources of Health and Illness Care
The majority (n = 37, 59.7%) of participants reported that they sought health and illness care for their child from a private physician. Other parents indicated that they took their child to a public health clinic (n = 18, 29%) or a hospital (n = 7, 11.3%) for health and illness care. A majority of participants (n = 56, 90.3%) reported that they were satisfied with the health and illness care that their child received. The most frequently cited reason (n = 37, 59.7%) for satisfaction with services received was that the staff was good and parents trusted them to provide the care needed. This finding did not differ between participants who received care from a private care provider and those who received care from a public health clinic. One father who sought health care from a private physician stated, They know my child and take good care of him.” A mother who received health care services from a public health clinic stated, “They respect people and treat them nice.”
A convenient location (n = 6, 9.7%) and not having a long wait to receive services (n = 12, 19.4%) were other reasons given by participants for satisfaction with health and illness care. Participants who received care from a private physician’s office were more likely to report that the wait was shorter than were participants receiving care from public health care services.
One half of the respondents could not identify anything they disliked about the health and illness care services they obtained. Participants who reported some dissatisfaction with services most often identified frustration with waiting time. One mother of three school-aged children stated, “They used to be good but not any more. It takes a long time waiting. I loose time from my job taking my child to the doctor.” Only six (9.7%) of the participants indicated that a reason for their dissatisfaction was the cost of health care services.
Preventive Health Care Behaviors
To identify preventive health care behaviors, participants were asked what they did to keep their child healthy. Additionally, parents were asked how often they thought their child should receive physical and dental examinations as well as how often their child actually received these examinations. Discrepancies were followed up to determine why their child did not have examinations as frequently as they believed he or she needed.
Only 28 (45.2%) of the participants reported that they gave their child a daily vitamin, but almost all parents (n = 60, 96.8%) believed that eating good food was important for the health of their child. A majority of parents (n = 46, 74.2%) also believed that exercise was important for their child’s health.
All parents believed strongly in the use of professional health services to maintain their child’s health. Forty six (74.2%) of the participants believed that their child needed a complete physical examination at least once a year. This same percentage reported that their child actually received a physical examination at least annually. One mother stated, “He needs to go once a year for a checkup to ensure his health.” A slightly larger percentage, of participants (n = 49,79%) believed that their child needed to visit a dentist at least twice a year; however, only 26 (41.9%) reported that they took their child to a dentist on a semi-annual basis. Cost was the most frequently cited reason participants gave for not taking their child for regular dental care, and the need to take time off work was also a concern for many parents.
Behaviors during Periods of Illness
Most of the parents (n = 43, 69.4%) stated that they thought their child’s health was excellent or very good, and only nine (14.5%) of the participants reported that their child was ill more than twice a year. One fourth (n = 16, 25.8%) of the participants reported that their child had a problem with his/her vision, and four (6.5%) reported that their child had difficulty hearing.
Nine (14.5%) of the parents reported that their child had a behavior problem. These participants reported that their child did not complete their work in school, did not pay attention, or talked too much in class. However, none of these participants indicated that their child had behavior problems at home. These parents believed that it was their responsibility to monitor the behavior of their child. Participants varied in their responses regarding from whom they would go to seek counsel if their child had a behavior problem. The child s teacher (n = 17, 27.4%), primary care provider (n = 10, 16.1%), and family (n = 11, 17.7%) were the most frequently cited sources of assistance; other identified counseling sources were priests, social workers, and counselors.
Prior to asking what they usually did for their child when he/she was ill, participants were asked to respond to questions directly related to the child’s last illness episode. The most frequently reported last illness episodes were viral infections such as a cold or the flu. When participants were asked what they did for the child at the time, 42 (67.7%) reported that they took their child to a doctor, clinic or a hospital, and 14 (22.6%) stated they gave home medication. The remainder of the participants stated they did nothing but watch the child.
Regarding specific care provided when their child was ill, parents reported the use of both traditional and nontraditional health care practices. A large proportion (n = 54, 87.1%) of the participants gave their child traditional over the counter medicine when the child was ill. Many parents (n=46, 74.2%) gave their child tea, and 14 (22.5%) of the participants used poultices when their child was ill. Of the 46 parents who gave their child tea, 14 (22.5%) reported that they made the tea themselves. Many of the parents (n = 52, 83.8%) reported regularly using prayer when their child was ill. Fewer parents reported occasional use of purgatives (n = 17, 27.4%), and four (6.5%) of the participants specified that they used honey, juice, or bush leaves to treat their child’s illness.
Over two-fifths (41.9%) of the Haitian parents who were interviewed reported that their child did not have health insurance coverage at the time of the study. This finding was much higher than the national average for children in the United States. The National Center for Health Statistics reported that 11.2% of children under the age of 18 were without health insurance in the first half of 2001, lower than the 13.9% reported in 1997. This same report noted that one in three Hispanic children did not have health insurance coverage, and 18.9% of non-Hispanic black children lacked coverage in the first half of 2001 [Centers for Disease Control (CDC), 2002].
It has been suggested that many immigrants do not apply for tax-supported health insurance due to distrust of the government or immigration fears (Miller, 2000). Additionally, many vulnerable populations are not aware of eligibility requirements for government supported health insurance coverage programs. Many participants in this study were also not aware of eligibility criteria for Medicaid or the potential for their child to receive coverage under KidCare, a state-sponsored Children’s Health Insurance Program available at a reduced rate. If health insurance coverage is a key to healthier children and families, as Department of Health and Human Services Secretary Tommy G. Thompson suggested (CDC, 2002), then the Haitian families in this study were at risk for adverse health outcomes.
Despite difficulties in obtaining and retaining health insurance for their school-aged children, participants were satisfied with the health care that their child received. Concerns regarding the long waiting times to receive services and the cost of health care were the reasons offered by the few participants who were dissatisfied with the health care their children received.
The high percentage of participants who sought health care from a private physician was possibly reflective of the fact that there was a large family practice in the area with several Haitian primary care providers. This medical practice demonstrated a strong commitment to serving families in the area and, as is the case with most minority pediatricians (Brotherton, Stoddard, & Tang, 2000), its patient panel was comprised primarily of minority children on Medicaid or children without health care coverage. Families who utilized this practice setting as their usual source of health care stated that the care was satisfactory, the wait was not a problem, and the staff was attentive. They also commented that the practice was in their community in a convenient location and that they were comfortable because many of the staff were Haitian. Surprisingly, however, even participants who used public health clinics within their community did not report dissatisfaction with the care their child received.
The finding that participants’ used a combination of biomedical health care services and traditional health care practices for preventive health care and illness care was consistent with findings reported by DeSantis and Thomas (1990) as well as findings reported from studies of other immigrant groups in the United States (Talavera et al., 1997; Wenger, 1995). Use of biomedical providers and systems may reflect assimilation of Haitian parents into American culture or represent satisfaction with being able to obtain culturally sensitive, quality health care.
The importance of preventive health care to Haitian families was exemplified by the finding that over three-fourths of the participants reported that their child had annual physical examinations despite the fact that many children did not have health insurance coverage. Although many participants also agreed that children should visit a dentist at least twice a year, actual dental visits were less frequent suggesting that parents were less willing or able to pay for dental care out of pocket. It is noteworthy that subsequent to data collection for this study, lobbying efforts were successful toward inclusion of dental care under the state-sponsored health insurance program for children. However, a lack of dental providers who accept governmental reimbursement continues to serve as a barrier to access to dental care.
Most parents reported that their child’s health was excellent or very good. However, unaddressed vision and hearing problems were identified despite the fact that screenings for these common problems in school-aged children are conducted in schools. Although several parents reported that their child had a behavior problem at school, they denied that the child had any behavior problems at home. Behavior problems in children might have been seen as a reflection on the family, and parents may have been reluctant to report behavior problems not related to school activities. Alternately, behavioral problems may have been manifested less in Haitian homes under strict parental discipline (Colin & Paperwalla, 1996, 2003) than in the less structured and supervised environments of U.S. classrooms.
The use of home remedies and other ethnomedical treatments other than the use of tea was not as prevalent as expected. The use of tea is part of Haitian belief that illness is a disequilibrium between hot and cold factors (Bastien, 1995; Colin & Paperwalla, 1996; 2003). Families may have been reluctant to admit they used folk remedies and other cultural treatment modalities. Consistent with previously reported findings (DeSantis & Thomas, 1990; Kirkpatrick & Cobb, 1990), parents in this study reported that they used folk or traditional practices in addition to rather than instead of biomedical treatments.
Limitations of the Study
Use of a cross-sectional design precludes any understanding of changes in Haitian parents’ health seeking behaviors or practices as a result of assimilation over time. Since interviews were conducted on a face-to-face basis, social desirability bias may have been inherent in parents’ responses. The relatively small number of participants in this study recruited from a single school setting limits generalizability of study findings to other populations and geographical areas.
Implications for Practice and Future Research
The misconceptions of study participants indicate the need for education of parents and guardians about the availability of federal and state health insurance programs for children as well as program eligibility requirements. Families may also need personal assistance with filling out applications and following through with the application process. Advocacy is necessary to demonstrate that assertiveness and persistence are often necessary toward obtaining health insurance coverage. Many more parents may take advantage of governmental health insurance if they were aware that their child was eligible and that their immigration status would not be jeopardized in the process of applying for coverage. Parents also need to be informed about benefit renewal requirements and coverage retention processes.
The high use of and satisfaction with care received at a private practice staffed with Haitian providers highlights the importance of recruiting and retaining ethnic minorities into the health professions and encouraging these providers to return to their communities to practice upon completion of their educational programs. Even if providers are of different backgrounds than the families they serve, respect for individuals along with knowledge and understanding of health and illness beliefs and traditional health care practices help promote the provision of culturally sensitive care. Minimizing wait time and flexible scheduling to accommodate parents’ work schedules and other responsibilities would also help ensure utilization of and satisfaction with care.
Health care providers should capitalize on the values that Haitian parents hold toward their children and preventive health care to encourage them to attend to their children’s dental needs as well as vision and hearing problems. More extensive lobbying campaigns should be directed toward ensuring that common health problems in school-aged children are covered under state and federal insurance programs. Parents should also provided with information on other resources such as private foundations that assist with the cost of these services for their children. Haitian parents, in particular, may need professional guidance and support regarding use of resources and services to address behavioral problems in their school-aged children.
Future research should be conducted to identify the effects of time elapsed since immigration on Haitian parents’ willingness to seek help from government sponsored programs, health seeking behaviors, and health and illness care practices. Exploration of Haitian children s and adolescents experiences with the health care system, perceptions of health and illness, and health related behaviors would also provide valuable information toward developing and implementing culturally appropriate programs and services for this unique immigrant group.
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Shirley Schantz, EdD, ARNP, is Associate Professor and Director, Primary Care Nursing Center, Barry University School of Nursing, 1130 NE 2nd Ave., Miami Shores, FL 33161. She may be emailed at: firstname.lastname@example.org. Sue Ann Charron, PhD, ARNP, is an Associate Professor at Barry University School of Nursing, Miami Shores, FL. Susan L. Folden, PhD, ARNP, Clinical Nurse Specialist, West Palm Beach Veterans Administration Medical Center, Adjunct Faculty, Barry University School of Nursing Miami Shores, FL.
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