Université de Picardie Jules Verne, Département de Psychologie, France ; 2 Pontifícia Universidade Católica do Rio Grande do Sul, Programa de Pós-graduação em Psicologia, Escola de ciências da saúde e da vida, Brazil ; 3 Centro Universitário da Serra Gaúcha ; 4 Universidade Federal do Rio Grande do Sul, Instituto de Psicologia, Brazil ; 5 Université de Bourgogne Franche-Comté, Laboratoire de Psychologie, France ; 6 Pontifícia Universidade Católica do Rio Grande do Sul, Programa de Pós-graduação em Psicologia, Escola de ciências da saúde e da vida, Brazil.

INTRODUCTION

migrants usually access Brazil through northern cities in the state of Amazonas, which is bordered by Colombia and the state of Acre, where some regions border Bolivia and others, Peru (Sousa, 2012). Inside Brazil, the main destinations are cities in the south and southeast regions. In 2015, when our studies with this population started, it was estimated 1,575.00 Haitian migrants living in the state of Rio Grande do Sul, the southernmost state in the country (International Organization for Migration, 2015).

Two important events might have encouraged Haitian migrants to choose Brazil as a host country. First of all, Brazil was responsible for coordinating the peace forces of the United Nations (UN) in a mission that aimed to re-establish the country’s security and politics in 2004 (Brazilian Government, 2020). In addition, with the 2010 Haiti earthquake, which devastated the country and resulted in 222,000.00 deaths and 2.3 million homeless people (UN, 2010), the Brazilian government started offering humanitarian visas for 5 years to Haitians, through the Normative Resolution n° 97, from January 12, 2012. In 2014, the requests received by Haitian migrants achieved 16,920.00 requests (Brazilian Government, 2019). Over the last years, the number of requests started to reduce and data concerning 2018 shows an amount of 7030 requests, Haitians representing 10% of the ongoing procedures in the country (Brazilian Government, 2019). The path to arrive in Brazil varies from taking an airplane or going through the Dominican Republic, following to Panama and Equator or Peru, which can be long and dangerous, since some Haitian migrants suffer high levels of prejudice, humiliation, and arrests during their journey (Keys et al., 2015; Kyle & Sarcelli, 2009). These

Reports from previous research indicated that the profile of Haitian migrants established in the State of Rio Grande do Sul consists of adult men, with ages between 19 and 50 years old, with at least primary education and a previous professional qualification (Uebel & Rückert, 2017). The authors also identified communication skills in 3 or 4 different languages. Another study, conducted right after the increase of requests, identified that Haitian migration might have a familiar character, since many immigrants send financial resources to their families in the home country, in order to provide support or to finance the immigration of other family members to Brazil (Silva, 2015). As for labor occupation, data is not specifically clear, but numbers indicate a greater insertion of these migrants into construction and agricultural industries.

Cahier thématique – Haïti : Perceptions et perspectives transculturelles en santé mentale

The mental health of immigrants has been widely studied in the last years (Abebe, Lien, & Hjelde, 2012; Alegría et al., 2008; Aragona & Pucci, 2012; Drogendijk, Van Der Velden & Kleber, 2012; Lindert et al., 2009; Mölsä et al., 2014) and an immigrant paradox has been discussed considering findings about immigrants presenting better physical and mental health when compared to the population from the host country (Blair & Schneeberg, 2014; Bostean, 2013; Breslau et al., 2007; Liddell et al., 2013). However, other studies put in question this perspective (Abebe et al., 2012; Sam et al., 2008), proving that the relationship between migration and mental health varies according to the context and to the presence of risk and protective factors (John et al., 2012). Previous studies have pointed to the influence of pre- and post-migratory experiences in immigrant mental health and the experience of traumatic events as being significantly associated with the development of psychopathologies (Brunnet et al., 2018; Kirmayer et al., 2011). Considering the pre-migratory experiences, Haitians have a history of being exposed to poverty, violence, political instability, and natural disasters (World Health Organization/Pan American Health Organization, 2010). During their journey to the host country, they face long distances and experiences of humiliation and prejudice (Keys et al., 2015). When arriving in the host country, Haitians can be confronted with Post-Migration Living Difficulties (PMLD), which include racial discrimination, language and cultural barriers, poor access to healthcare services, and unemployment (Allen et al., 2013; Wooding, 2018). Higher levels of PTSD, depression, and anxiety are associated with these difficulties (Aragona & Pucci, 2012; Brunnet et al., 2018; Carrer et al., 2011). There is also a negative impact on the quality of life (Belizaire & Fuertes, 2011) and it can cause a low demand, by these immigrants, for seeking help in health services (Allen et al., 2015). Another consequence of such PMLD, along with the migration process per se, a psychosocial stress called Migration-related stress can be experienced by these individuals (Torres & Wallace, 2013). This type of stress is significantly associated with mental health suffering, especially depression (Breslau et al., 2011; Nicolas et al., 2009; Park & Rubin, 2012). A study that investigated Migration-related stress specifically with a sample of Haitian migrants in the context of the United States (U.S.) found migration-related stress as having a strong positive correlation with depression and being a strong predictor of depression in this population (Fanfan et al., 2020). Moreover, the authors found the pre-migratory experience of being present during 2010 earthquake as a significant moderator between migration-related stress and depression, proved by the increase in almost three times the scores in the depression scales. Similarly, several international studies investigated the prevalence and risk factors for psychiatric disorders in migrants, however, most of them were carried out in North American or European countries. Regarding Brazil, a literature review of studies published in Brazilian journals between 2003 and 2015 found only 11 papers exploring the health of migrants living in Brazil. Taking into consideration the increasing number of immigrants in Brazil, research is needed for greater knowledge about this population and their mental health needs, thus allowing the development of interventions to promote health and social well-being (Girardi et al., 2016).

In this context, we developed two research projects, which were carried out between 2015 and 2020. The aims of the first project, called “Haitian migration in Rio Grande Sul: Acculturation processes and mental health”, were to investigate: (1) the acculturation orientations of both migrants and host community, (2) the factors associated with the acculturation orientations, (3) the prevalence of anxiety, depression and PTSD symptoms in Haitian migrants and (4) the factors associated to these symptoms. The second research project was an international project comparing the mental health status of migrants living in France and Brazil. A part of the sample in Brazil was composed of Haitian migrants. In the present study, we describe the sociodemographic profile of the Haitian migrants living in Rio Grande do Sul who participated in these two research projects, as well as data regarding their mental health status.

THE PROFILE OF HAITIAN MIGRANTS LIVING IN RIO GRANDE DO SUL In the first research project, we interviewed 66 Haitian migrants, between 51 (77%) men and 15 (22%) women. The average age of the sample was 32.59 (SD = 5.7) years old, and the average of years of education was 10.56 (SD = 4.54). At the time of the interviews, they were living in Brazil for an average of 16.6 months (SD = 12.4), 51.5% (n = 34) were married and 51.5% (n = 34) were employed.   Regarding the second project, from 103 participants, 35 were Haitians. On this data collection, 40% of the participants were women (n = 14) and 60% men (n = 21). Their mean age was similar to the first project, being 32.11 (SD = 6.9). Participants were living in Brazil for an average of 32 months (SD = 20.9), 14 (40%) were employed, and their mean of years of study was 11.9 (SD = 4.07). In this second project, participants were asked to establish, on a 6-point likert scale, if their migration was involuntary (0 points) or voluntary (5 points). Most participants described their migration as voluntary (n = 21, 60%). The mean score on the likert scale was 4.08 points (SD = 1.31).

MENTAL HEALTH : ANXIETY, DEPRESSION, AND PTSD SYMPTOMS The results of the first project are already published elsewhere (Brunnet et al., 2018). In this study, we aimed to investigate the prevalence of PTSD, anxiety, and depression, along with its associated factors. We also investigated the prevalence of traumatic events before and during migration, as well as PMLD. Concerning exposure to potentially traumatic events during the lifetime, events where there is a direct or indirect threat to life, injury, and sexual violence (criteria A for PTSD; APA, 2013), it was observed that the participants had been exposed to an average of 2.17 (SD = 1.6) traumatic events. The most prevalent events were Natural Catastrophes and non-natural death of a family member, which affected, respectively, 40 (60.6%) and 29 (n = 43.9%) participants. As for stressful events before the migration process – which are not included in DSM-5 criteria as events that cause threat to life but are considered as having a significant impact on life– 19 (28.8%)

Cahier thématique – Haïti : Perceptions et perspectives transculturelles en santé mentale

participants faced an important lack of food and water, 10 (10.6%) participants reported living in poor conditions, and 9 (13.6%) described stressful work conditions. During their journey to the host country, 13 (19.7%) participants reported experiencing a lack of food and water and 9 (13.6%) had to live in overcrowded temporary shelters. When asked about stressors after migration, concerns about family in the home country was the most frequent, affecting 48 (72.7%) participants, followed by the impossibility of returning home in an emergency (n=40; 60.6%), loneliness and boredom (n=39; 59.1%), living in as overcrowded home (n=29; 43.9%), lack of adequate living conditions (n = 26; 39.4%), unemployment (n = 34; 51.5%), lack of food and water (n = 19; 28.8%) and discrimination (n = 18; 27.3%). In the second project (Brunnet, 2020), the events “Natural Catastrophes” and “non-natural death of a family member” were also highly prevalent: 74.3% (n = 26) of the participants experienced natural disasters and 54.3% (n = 19) have lost a family member. Regarding the stressful events before migration, 28.6% (n = 10) reported lack of food and water and 20% (n = 7) bad work conditions. During the journey to Brazil, 11.4% (n = 4) were unable to have access to food and water and 5.7% (n = 2) stayed in overcrowded shelters. Regarding the post-migratory difficulties, 37.1% (n = 13) reported bad work conditions, 40% (n=14) had difficulties to access food and water, and 37.4% (n = 13) lived in an overcrowded house. The participants also described difficulties related to the migration experience: feelings of loneliness (n = 20; 57.1%), discrimination (n = 11, 31.4%) and worries about family in the home country (n = 32, 91.4%). When evaluating these migrants’ mental health, in the first project, we found a prevalence of 9.1% for PTSD, 10.6% for high depression symptoms, and 13.6% for high anxiety symptoms (Brunnet et al., 2017). By comparing symptoms, some interesting findings were observed, as for the data that participants who were unable to return to their home country in an emergency presented more PTSD symptoms than those who could. In the same way, the ones who suffered discrimination presented more PTSD symptoms than those who did not, along with more depression symptoms. Participants who reported difficulty in adjusting and coping with the new culture and, loneliness and boredom and worries about the family in the home country presented higher symptoms of anxiety and depression (Brunnet et al., 2017). In the second project, the prevalence of PTSD was 14.3%, and of significant symptoms of anxiety and depression, we found 11.4% and 17.1%, respectively (Brunnet, 2020). However, the symptoms of anxiety and depression were not measured with the same scales in both studies. A linear regression model performed in the first project, pointed to difficulties in adjustment and coping with culture, ethnic discrimination and worries about family in the home country as a significant predictor of depression symptoms (p < .001). When executing a Logistic Regression model with depression symptoms as dependent variable, it was found that participants who did not financially support their family had 29% less chances for presenting high levels of depression symptoms (p < .04; Brunnet et al., 2019). For anxiety, difficulties in adjustment and coping with culture and the number of traumatic events faced were identified as significant predictors (p < .001). For PTSD, difficulties related to adjustment

and coping with culture also significantly predicted the symptoms, as well as the impossibility to return home in an emergency, facing ethnic discrimination, and the number of traumatic events (p < .001; Brunnet et al., 2018).

QUALITY OF LIFE, POSTTRAUMATIC GROWTH, ACCULTURATION, AND MENTAL HEALTH In the first project, we also explored other aspects of the migration experience: acculturation orientations and quality of life (Weber et al., 2019). Regarding the quality of life, participants reported higher scores in the physical and personal relations clusters when compared to the psychological and environment clusters. When comparing to other studies, our participants reported higher scores of quality of life than migrants living in the United States (Belizaire e Fuertes, 2011). In the second project, we also explored, another positive outcome: posttraumatic growth (PTG). According to the posttraumatic growth model, one traumatic event can challenge the individual’s beliefs about the world, other people and themself, resulting in positive transformations. PTG includes improvement in five major areas: interpersonal relationships; personal strengths; discovering new life possibilities; spiritual development; and a greater appreciation for life (Calhoun et al., 2010; Tedeschi et al., 1998). Participants reported a “small to moderate” in total growth and the most important areas of improvement were “personal strengths”, “greater appreciation for life” and “spiritual development”. When evaluating the impact of PMLD in PTG, a negative association between PTG outcomes and access to food and lack of a social support network was found. Moreover, in terms of PTSD diagnosis, it was observed that PTSD and PTG coexisted in the sample, since no differences between PTSD and non-PTSD participants were found. Nonetheless, some pre-migratory traumatic events, as having lived a combat situation and physical abuse, were negatively associated to PTG and severe PTSD symptoms were negatively associated to PTG, especially in the case of the participants that were refugees or asylum seekers (Brunnet et al., in press). Concerning the acculturation orientations, the participants of our first project adopted mainly the integrative orientation (the individual maintains the original ethnic values and good relations with the majority group), followed by the separation orientation (maintains ethnic values, but without favorable relations with the majority group). The less frequent orientation was the anomie (rejection of both culture of origin and of the host country). In our study, the acculturation strategies were influenced by sociodemographic variables as times since migration and being employed (Brunnet et al., 2019; Weber et al., 2019). We also investigated the relationship among acculturation strategies and mental health. The assimilationist acculturation orientation was associated with lower levels of anxiety while the separatist orientation was associated to higher levels of depression (Brunnet et al., 2019). In this study, higher language separation increased the chances of presenting anxiety symptoms in 76%, surprisingly showing the contact with the home culture through language as a possible protective factor for anxiety. The study did not point to acculturation variables as associated to depression symptoms.

Cahier thématique – Haïti : Perceptions et perspectives transculturelles en santé mentale

CONCLUSION In the present study we reviewed and compared the findings of two research projects exploring the mental health of Haitians living in southern Brazil. The participants of both projects described their migration as voluntary, and their main motivation for migration was to provide a better quality of life for their family. During the years of execution of both projects, we noted some changes in the Haitians population living in southern Brazil. In the first project (20152016), the participants were mainly man who have traveled alone, and in the second (2018-2019) the number of women interviewed increased. The changes in the population demography may impact considerably the social and health interventions. Our results showed that some participants face important difficulties in finding an employment and having access to basic needs. Yet, social and migration-related stressors were related to mental health impairment. Other studies conducted in Brazil with Haitian migrants corroborate our findings. In a qualitative study developed by Melo and Romani (2019), participants described unemployment as one of the main difficulties faced in Brazil. They also described discrimination as an important stressor. In a similar vein, another qualitative study explored the psychological impacts of the 2010’s earthquake in Haitians who migrated to Brazil. (Barros and Martins-Borges,2018). As a result, participants reported, feelings of sadness and self-perception of changes as consequences to the exposure to the earthquake. Regarding the post-migration difficulties, the participants revealed financial problems, difficulties of integration with Brazilians and discrimination. Skin color is indeed still a central element in the structuring of inequalities in Brazil. Epidemiological studies showed that black Brazilians have a lower life expectancy, years of schooling and wages than white Brazilians (United Nations, 2018). In the case of Haitian migrants, they seem to live a double discrimination, as a consequence of being foreign and black (Barros & Martins-Borges, 2018). These results show that, to better understand the mental health of Haitians living in Brazil, one must take into account multiple aspects, including not only the individual’s history, but also the history of both host and origin countries, as well as their common history. According to Derivois (2020), the contact of the host society with certain groups of migrants can reactivate collective traumas, for example the colonial or slavery past. This phenomenon can be observed in Brazil, where the 300 years of slavery of the African peoples brought consequences that are still visible in society. Currently, many migrants in Brazil, and in particular those from the Global South, find themselves in situations of modern slavery (Gotardo & Pereira, 2019). The determinants of the consequences of the encounter between migrants, a new context and a new society are therefore multiple: geographic, historical, political, societal and individual. All this complexity must be taken into account during the clinical encounter with this population, in order to fully understand the individual’s mental health and to provide the best intervention. Therefore, multidisciplinary interventions are essential to this population. In the second project, we had the opportunity to observe community health practitioners who worked in a neighborhood where were living several Haitian families. These professionals

conducted home visits and accompanied these families in different areas, as reproductive and children’s health. The families were also accompanied by a non-governmental organization, in order to have access to basic needs. These interventions were essential to allow these families to access the health and social systems. However, the Haitian population living in Rio Grande do Sul still have low access to mental health services. Even if our results show that most part of the participants didn’t report significant symptoms of depression, anxiety and PTSD, some of them were exposed to important difficulties such as experiencing discrimination, adaptation to the new culture, distance from the family, unemployment, and traumatic events. Therefore, for some individuals, an individual or group psychotherapy may be necessary.

REFERENCES Abebe, D. S., Lien, L., & Hjelde, K. H. (2012). What we know and don’t know about mental health problems among immigrants in Norway. Journal of Immigrant and Minority Health, 16, 60-7. Alegría, M., Canino, G., Shrout, P. E., Woo, M., Duan, N., Vila, D., ... Meng, X.-L. (2008). Prevalence of mental illness in immigrant and non-im- migrant US Latino groups. American Journal of Psychiatry, 165(3), 359–369. https://doi. org/10.1176/appi.ajp.2007.07040704 Allen J. D., Leyva, B., Hilaire, D.M., Reich, A. J., & Martinez, L. S. (2015). Priorities, concerns and unmet needs among Haitians in Boston after the 2010 earthquake. Health Soc Care Community, 24(6), 687-98. Allen, J. D., Mars, D. R., Tom, L., Apollon, G., Hilaire, D., Iralien, G., ... Zamor, R. (2013). Health beliefs, attitudes and service utilization among Haitians. Journal of Health Care for the Poor and Underserved, 24(1), 106–119. https://doi. org/10.1353/hpu.2013.0015 Aragona, M., & Pucci, D. (2012). Post-migration living difficulties as a significant risk factor for PTSD in immigrants: A primary care study. Italian Journal of Public Health, 9, 1–8. Barros, A. F. O., & Martins-Borges, L. (2018). Reconstrução em Movimento: Impactos do Terremoto de 2010 em Imigrantes Haitianos. Psicologia: Ciência e Profissão, 38(1), 157–171. https://doi.org/10.1590/1982-3703003122016 Belizaire, L. S., & Fuertes, J. N. (2011). Attachment, coping, acculturative stress, and quality of life among Haitian immigrants. Journal of Counseling and Development, 89(1), 89–97. https://doi. org/10.1002/j.1556-6678.2011.tb00064.x Bostean, G. (2013). Does Selective Migration Explain the Hispanic Paradox? A Comparative Analysis of Mexicans in the U.S. and Mexico. J Immigrant Minority Health, 15, 624–635. https://doi.org/10.1007/s10903-012-9646-y Blair, A., & Schneeberg, A. (2014). Changes in the “healthy migrant effect” in Canada: Are recent immigrants healthier than they were a decade ago? Journal of Immigrant and Minority Health, 22, 1-7. Breslau, J., Aguilar-Gaxiola, S., Borges, G., Kendler, K. S., Su, M., & Kessler, R. C. (2007). Risk for psychiatric disorder among immigrants and their US-born descendants: Evidence from the National Comorbidity Survey-Replication. The Journal of Nervous and Mental Disease, 195(3), 189–195. https://doi. org/10.1097/01.nmd.0000243779.35541.c6 Breslau, J., Borges, G., Tancredi, D., Saito, N., Kravitz, R., Hinton, L., ... AguilarGaxiola, S. (2011). Migration from Mexico to the United States and subsequent risk for depressive and anxiety disorders: A cross-national study. Archives of General Psychiatry, 68(4), 428–433. https://doi.org/10.1001/archgenpsychiatry.2011.21 Brunnet A. E., Kristensen, C. H., Bolaséll, L. T., Seibt, L. T., Machado, W. L., Derivois, D., (In press). Posttraumatic Growth and Migrations: Results from a Transcultural Study in France and Brazil. Journal of Loss and Trauma. Brunnet. A., Bolaséll, L., Weber, J., & Kristensen, C. (2018) Prevalence and factors associated with PTSD, anxiety and depression symptoms in Haitian