Transnationalism and Hypertension Self-Management Among Haitian Immigrants

543476TCNXXX10.1177/1043659614543476Journal of Transcultural NursingSanon et al. research-article2014 Research Transnationalism and Hypertension Self-Management Among Haitian Immigrants Journal of Transcultural Nursing 1 10 The Author(s) 2014 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: 10.1177/1043659614543476 tcn.sagepub.com Marie-Anne Sanon, PhD, MN, RN 1, Clarence Spigner, MPH, DrPH 2, and Marjorie C. McCullagh, PhD, RN, PHCNS-BC, COHN-S 1 Abstract Purpose: Transnationalism maintenance of transborder activities has important implications for the health status of contemporary immigrants. Yet little is known about how such interconnectivity interacts with health. Design: In this critical ethnography study, 31 Haitian immigrants discussed the influences of transnationalism on their hypertension management. Transcripts of the semistructured individual interviews were analyzed and coded with the assistance of the Atlas.ti 6 software. Findings: Two major themes emerged: social support and financial obligation, both framed within the obligation to send monetary remittances. A duality emerged where social support facilitated hypertension self-management but consequently represented a financial burden. Discussion and implications: The study evidenced that transnationalism, although positively influencing immigrants psychosocial well-being can negatively affect their experience with disease management. Health providers are urged to account for this transnationalism disease management interaction when caring for this immigrant group. Future studies are needed to explore this phenomenon among other immigrant populations. Keywords transnationalism, transmigrant, remittance, immigrant health, hypertension management, Haitian immigrants Background Debates have evolved around transnationalism the maintenance of relationships that transcend the geographical borders across countries to explicate the social and political activities of contemporary immigrants (e.g., Portes & Zhou, 2012) There are disagreements about the definition of transnationalism, its emergence, and its consequences (Dunn, 2010). Nonetheless, it is understood that contemporary immigrants are getting more involved in social and political activities that transcend the geographical borders of their countries of origin and residency (Vertovec, 2009). These activities, hitherto challenging, are now easily facilitated through globalization, technological advancements, and transportation. Transmigrants individuals who sustain multistranded relations and create transnational identities maintain close relationships with friends and family members in their country of origin while getting actively engaged in the matters of their host country (Basch, Schiller, & Blanc, 2013; Levitt & Schiller, 2004). Haitian immigrants are one such immigrant group that tends to create transnational identities (Lundy, 2011; Orozco & Burgess, 2011). Numbering 927,038, Haitian immigrants constitute the second largest Black immigrant group residing in the United States (U.S. Census Bureau, 2014) and have tremendous impact on Haiti s political and economic climate. For example, in 2010, the total remittance flow from Haitians living abroad to Haiti amounted to $1.3 billion (Orozco & Burgess, 2011). Particularly, those living in the United States sent an estimated $842,184,000 in 2010 (Orozco & Burgess, 2011). According to the World Bank (2014), remittance in U.S. dollars represented 50% of Haiti gross domestic product. Clearly, transnationalism is ingrained in many Haitian immigrants lifestyle. Yet the impact of such identity on the Haitian immigrants health and ability to manage their disease remains unexplored. Few researchers have studied the role transnationalism plays in immigrants health and disease management (Gastaldo, Gooden, & Massaquoi, 2005; Greder et al., 2009). For example, Greder et al. explored the relationship between transnationalism and housing and health risk among 78 rural Latino immigrants. They found no relationship between transnationalism and health risks. However, there was noticeable reporting of depression among the participants. Gastaldo et al. (2005) 1 University of Michigan, Ann Arbor, MI, USA 2 University of Washington, Seattle, WA, USA Corresponding Author: Marie-Anne Sanon, Postdoctoral Fellow, School of Nursing, University of Michigan, 400 North Ingalls, Room 3175, Ann Arbor, MI, 48109, USA. Email: sanon@umich.edu

2 Journal of Transcultural Nursing reported that Brazilian women depend on their family and friend networks, as well as on goods such as herbs from both their countries of residency and origin, to care for their hypertension. These researchers acknowledged the need for more studies of the impact of transnational activities and the health of immigrants. This article derives from a critical ethnography study that explored hypertension management among a group of Haitian immigrant hotel housekeepers. During the participants interviews, the issue of being transmigrants arose as influencing their ability to manage hypertension. This article discusses this specific finding of the relationship between transnationalism and hypertension management. Providing Context for Transnationalism: Understanding the Haitian Migration Haiti is the poorest country of the Western hemisphere with over 80% of its population living below the poverty line, 54% living in abject poverty, a 52% literacy rate, and a life expectancy of 48 years (The World Bank, 2014). Much has been written about Haiti s captivating history: its colonization in 1492 by Christopher Columbus, its unique independence revolution as the first Black independent republic in 1804 from France, the long dictatorship of President Francois Duvalier Papa Doc (1957-1971), enduring the invasion of U.S. military between 1915 and 1934, and the subsequent U.S. embargo that further crippled the economy (Quinn & Sutton, 2013), followed by a series of short-lived reform governments. In addition, Haiti experienced a series of natural disasters affecting Haitians living in the country and abroad. In 2004, Hurricane Jeanne killed an estimated 3,000 Haitians primarily in Gonaives (The World Bank, 2014). In 2010, a 7.0-magnitude earthquake struck Haiti, killing over 250,000 and leaving more than 300,000 injured. These events reinforced the creation and maintenance of transnational identity of those living abroad as they sustain strong ties and networks and send remittance to help improve the lives of those living in Haiti (Lundy, 2011; Orozco & Burgess, 2011). Crossing Geographical Boundaries: Experiencing New Challenges and Staying Connected. Haitians immigrate to the United States in waves. Those from the first and second waves were evading the country s political chaos during the Duvalier regime (Celeste, 2013). After Jean-Claude Duvalier, son of Francois Duvalier, took power at the age of 19, a third wave of Haitians moved to the United States. The term boat people (as many arrived on the U.S. shores after sailing across the Caribbean to Florida in small fishing boats) was coined to refer to this third wave, which included individuals seeking political asylum and many others who were fleeing poverty (Fouron, 2013). Haitian migration to the United States has continued in smaller waves since then, rising to a peak during the overthrow of President Jean-Bertrand Aristide. The migration experience of Haitian immigrants differs from that of other immigrants. For example, only a small number of Haitian immigrants were allowed to stay in the early 1990s, compared to the 213,802 Mexican immigrants and 77,735 Vietnamese immigrants, all of whom entered the U.S. soil around the same time. Also, they were more likely to be placed in detention camps and deported compared to other immigrant groups (whether they were asylum seekers or economic refugees; Paik, 2010, 2013). At present, more than 70% of Haitian immigrants participate in the U.S. labor force, with the majority (39.9%) found in service occupations followed by representation in management, business, sciences, and arts occupations (24.1%) and construction and maintenance occupations (19.1%). The reported number of Haitian immigrants in the country is believed to be higher than the actual number, because surveys often place Haitian immigrants in the same category as the non-hispanic Black population living in the United States, despite their distinct ethnic and cultural differences (Zéphir, 2004). The Haitian immigrant population has spread throughout the United States, with the majority residing in Florida (specifically Miami-Dade County), New York, and Boston (U.S. Census Bureau, 2014). Staying Connected and Disease Management: Study Purpose. It is evident that many Haitian immigrants lead a transmigrant life. Yet little is known about how this ability to maintain relationships that transcend the geographical borders of their countries of birth and residency influences Haitian immigrants well-being or their ability to promote their health and manage their diseases. This article is an attempt to address this gap by reporting the findings from a study that explored hypertension management among a group of Haitian immigrant hotel housekeepers. During the interviews, the connection between transnationalism and hypertension management became apparent. The participants reiterated the influence that their connection with Haiti and dual-border activities had on the way they managed their hypertension. Thus, the purpose of this article is to describe the impact of transnationalism on hypertension management among Haitian immigrants. Theoretical Framework The transnationalism theoretical framework (TTF) emphasizes the constructed transnational identities of immigrants within their transnational social fields (Smith & Guarnizo, 1998; Zontini, 2014). These transnational identities involve simultaneous relationships that occur between their countries of origin and residency and are used by immigrants to cope with their new environment, build resiliency, and sustain close contact with their homeland. TTF emphasizes the hegemonic relationship that exists between nation-states (i.e., the birth and host countries of the transmigrants) vis-àvis culture and practice (Vertovec, 2009). The sending of remittances (e.g., money) constitutes a major manifestation of this experience of interconnectivity or transnationalism.

Sanon et al. 3 Assumptions Two major underlying assumptions about the context of Haitian immigrants transmigrant life were considered for the application of the TTF in the qualitative study. First, everyday life and experiences of Haitian born immigrants are influenced by the social constructs of race, class, gender, and immigration status. Second, health promotion and disease management practices could be framed within the experience of transnationalism. These beliefs have been supported by research conducted with other immigrant groups. Messias s (2002) study with Brazilian immigrants reported participants using both preemigration and postemigration (i.e., transnational) resources and health practices. Brazilian women often requested remedies and medications from their place of birth to manage their illness in the United States. Critical Ethnography Method Critical ethnography allows the exploration of social processes influencing cultural knowledge (Madison, 2011). Such exploration requires the consideration of socioeconomic and political context within a given society. Critical methodology is informed by the epistemologies from the fields of anthropology, history, philosophy, education, and sociology. This methodology, which has been described as a type of reflection that examines culture, knowledge, an action (Thomas, 1993, p. 2) relies on the value-laden premises of the existence of social constraints and the need to address them with an emancipatory underlying intent. In this study, the critical ethnography methodology and TTF were used to allow the researcher to address practices of Haitian immigrants within consideration for their current socioeconomic, political, and cultural context. The theoretical framework and methodology were both used to underscore how the historical context of migration and the current cross-border connections of Haitian individuals living as immigrants in the United States influence their approach to hypertension management. Thus, throughout the research process (including data collection, analysis, and dissemination), it was understood that there may be social, political, economic, and transborder forces influencing participants definition and management of hypertension. For example, in the demographic questionnaire (see Appendix A), both closed- and open-ended questions were asked to gain a deeper understanding of their experiences with hypertension and hypertension management. Method Setting and Recruitment The Institutional Review Board of the University of Washington, the first author s prior university affiliation, approved all study protocols. This qualitative study, which was guided by critical ethnography methodology, took place in Miami-Dade County, Florida, which houses the highest number of Haitian immigrants. This qualitative study employed purposive sampling (Coyne, 2008; Suri, 2011). Individuals were recruited from local churches, one barbershop, three restaurants, two boutiques, and a local organization that provided translation and employment services to the Haitian population. Flyers were both in English and Haitian- Creole. Haitian immigrants tend to form strong communities for social support in churches and local businesses (Prou, 2005; Zéphir, 2004). The principal investigator had built trust through constant communication and collaboration crucial to the recruitment. Last, the snowball technique was used to further recruit potential participants. This technique enabled the recruiting of participants who otherwise would not have been accessible. Data Collection The interview guide was translated from English to Haitian- Creole and then back to English in order to ensure equivalence of the language (Chen & Boore, 2010). A demographic questionnaire was administered with each study participants. The questionnaire incorporated both closed- and open-ended questions. The open-ended questions allowed for the critical exploration and understanding of participants context and factors of domination and social control (e.g., gender, class, and immigration status) in managing their hypertension. The demographic questionnaire (Appendix A) and a face-to-face semistructured interview (see Appendix B) were conducted between July and September 2010. Participants were given the choice of preferred language: English or Haitian-Creole. The interviewer was fluent in both. All interviews were audio recorded and conducted at locations that were convenient for participants. Each interview session lasted up to 90 minutes. After each interview, each participant received a $20 gift card. Data Analysis Data analysis for this study occurred on two levels. The first level of analysis began immediately after the first interview. The primary investigator listened to the audio-recorded interviews and took notes. Throughout all the other interviews, the primary investigator asked follow-up clarification questions regarding any comments that showed discrepancies in previous participants responses. The second level of data analysis employed LeCompte and Schensul s (2010) approach of qualitative analysis, and the gathered interviews were analyzed through the following steps: (a) all 31 transcripts were read and reread in keeping with the iterative process and to diminish investigator bias; (b) key words, phrases, sentences, and concepts that best expressed reported experiences were identified and highlighted; (c) with the assistance

4 Journal of Transcultural Nursing of the Atlas.ti Version 6 software, free quotations were assigned to each highlighted segment within the transcripts; (d) codes were attached to the free quotations through either in vivo (directly from the text/paragraph) or open coding (reflecting the paragraph/statement/phrases); (e) themes emerged as the codes were organized, sorted, contrasted, and compared within and between the 31 transcripts. Reliability and Validity A series of approaches that are crucial for data analysis in qualitative research were undertaken to ensure reliability and validity (Creswell, 2012; Thomas & Magilvy, 2011). First, a full record of the research process was kept, which rendered all aspects of the study process transparent. Second, comparison and member checking were used where the primary investigator consulted with participants for clarification and to correct interpretation. During analysis, the responses were compared against the literature and both similar and contradictory responses were noted. Third, the primary investigator (M-AS) and the research colleague (CS) consulted about the 31 transcripts and coding process and, where there was disagreement, engaged in discussion until a consensus was reached. Reflexivity Reflexivity is a major component of critical ethnographic studies. Through reflexivity, the researcher is able to evaluate how his or her personal experiences and interactions with study participants influence the processes of data collection, analysis, interpretation, and representation (Vandenberg & Hall, 2011). The primary investigator in this study considered her historical, social, and political context and position as they influenced her reflections, and the meanings she ascribed to the participants accounts. She remained aware of the inequality in power relationship between the research participants and herself (researcher from an academic institution and a nurse with knowledge of hypertension and hypertension management). For example, the response of Participant (P) 28 about his thoughts on hypertension was I should be asking you. This rerouting of the question suggested that the participant thought of the researcher as an expert in hypertension. Results Demographics Of the 31 Haitian immigrants who participated in the qualitative study; 27 were women. Ages ranged between 46 and 55 years, and 64.6% (n = 20) reported an annual income of $20,000 or less, with half reporting an annual income between $11,000 and $15,000. All 31 participants were born in Haiti and had migrated to the United States within the past 10 years. Their mean length of residency in the United States was 7.5 years (SD = 2.75) with the shortest being 2 years and the longest 10 years. All but 2 reported having resided in Miami-Dade County, Florida since coming to the United States. Nearly half (n = 13) visited Haiti every year. All 31 reported having kept in touch with friends and family in Haiti, and also reported sending monthly remittances to relatives in Haiti in amounts that varied from $50 to $300. Almost half (n = 15) did not provide the specific amount; 18 others did not report the frequency of their remittances. The overall tone of the interviews and the content of the transcripts suggested that remittances had become such an ongoing experience in their daily life that participants sent whatever they could and whenever they could. A common response from across all participants was It depends on what I have and when I have it. Key Themes Two major interrelated themes emerged and represented a conflicting (but not necessarily contradicting) duality regarding the function of remittances and the self-management of hypertension within the framework of transnationalism. These themes were social support, defined by the process of receiving psychological support, and financial burden, defined by the stress resulting from economic sacrifice due to their low-income status, which might have been exacerbated by the obligation of providing remittances. Theme 1: Social Support. Participants generally reported positive feelings regarding the self-management of their hypertension as a result of maintaining contact with family and friends back in Haiti with financial remittance. Participants reported how phone calls to and from friends and family members in Haiti facilitated them in taking their own blood pressure medication. Contact with loved ones reportedly provided to participants an emotional calming and feeling of inner tranquility, which many believe help lower their anxiety and, hence, their blood pressure. The following quote was indicative of this kind of social support and its perceived influence on personal health: Whenever I send money to them, I know that even if they don t have enough to eat for 30 days, at least they will eat for 15 days. I feel happy (P24). Participants discussed their financial responsibility toward family and friends who reside in Haiti. The process of providing remittance allowed them to take care of relatives and friends in Haiti. They felt obligated to keep their hypertension under control for them to sustain their role of providing needed money back home as a function reflective of their transmigrant experience, as indicated in the representative quote: Ah girl, if I were to tell you the amount of money I send to Haiti, I cannot talk about that, girl. I can tell you everything I make

Sanon et al. 5 where it goes is Haiti. Because all my soul is in Haiti. [I have] six children in Haiti. If I were to let hypertension kill me who would take care of them? So I am obligated to take my medications. (P1) As indicated in this quote, the need to stay healthy and to work in order to send money to Haiti was a major drive for participants to maintain their blood pressure under control. Evidence of transnational identity was also pervasive in participants reports of their definition and approach to manage their hypertension. Participants used their social fields, which encompassed their social network and relationships both within the United States and in Haiti, to exchange ideas, practices, and resources relating to hypertension and hypertension management. For example, participants reported receiving cultural-based herbal medicines from friends and family in Haiti to manage their hypertension. Examples of these cultural-based medicines include Lwil Maskriti, an oil made in Haiti and imported to the United States by participants visiting friends and family members. When applied on the forehead and other parts of the body, this oil is believed to lower blood pressure and address other health issues such as fever, and cold. Participants also reported using imported dry herbs (simen kontra) to use as tea to lower their blood pressure. One participant noted, The simen kontra is good for all types of illness. It is not only good for hypertension. It is good for all types of illness. Simen kontra is a big medication. You boil it and you drink it with salt. (P4) Another participant responded, Doctor [name] himself [who lives in Haiti] did an order for me. He told me that what he ordered was good for me. He told me it is good for [hypertension]. He ordered it from the Spanish people in Cuba. The medication is good for [hypertension] and also helps me lose weight. So I always take it. (P19) When the researcher asked the participant if the medication was different from what her medical doctor in the United States prescribed for her, she responded, Yes [it is different]. I do not remember the name. It is a small, pink pill that is really flat. They get it for me from Cuba and the Dominican Republic. There are different sizes. Participant 25 also stated, Well I always keep in contact with [people in Haiti]. They always tell me to make tea. Sometimes, I send for them to buy medication for the [hypertension] in Haiti for me to take. Thus, participants received strong support from friends and family, who coax them to (a) take good care of themselves, (2) stay calm, and (3) use cultural-based herbal medicines. They used their resources both within the United States and in Haiti to manage their hypertension. Theme 2: Financial Obligation. Sustaining the social support with an adequate health status was also a function of the remittance process. The remittance process activated what might be interpreted as a consequence in the self-management of hypertension. Most if not all participants reported having to split their meager income in order to care for themselves and for their relatives and friends in Haiti. Participants ability to send remittances was possible by them working, and often working longer hours, which, in turn, exacerbated or disturbed the peacefulness they felt was needed to keep their hypertension under control. Thus, maintaining cross-border relationship was also negatively affecting participants ability to manage their hypertension. One participant stated, Taking care of the children in Haiti I think it does not make the hypertension well. Because most of the times you do not have the economy even for your own self if you were to get sick while you do not have insurance. If you were to have a problem, an emergency, you do not even have a dollar to take something, to say let me run to Walgreens, let me run to CVS to go get some medication. Most of the time what you need that would be the best; you need to see a doctor to get it. But you need to have the money to go see the doctor. (P18) As seen in the statement above, this participant struggled to purchase blood pressure medications and maintain doctors visits. The money is sent to Haiti to take care of her children in Haiti and thus she is financially challenged to manage her hypertension. Because of the purpose of the study was to focus on a group of Haitian immigrants who were working as hotel housekeepers, their work characteristics (i.e., pay and work environment) also became a context within which to understand the role transnationalism on their health and disease management. For example, participants exchanged culturalbased herbal medicines within the workplace (during their breaks) to manage their hypertension. In addition, over 64% of the participants reported an income of $20,000 or less with half of those participants making between $11,000 and $15,000 dollars per year. As low-wage workers, participants struggled to financially provide for themselves and their loved ones in Haiti. Discussion This article reports on how a group of Haitian immigrants self-managed hypertension within the context of their transnational experience. These findings add to previous research showing that immigrants who live a transmigrant life use their transnational spaces to transcend the geographical borders and care for their well-being and disease management (i.e., the use of herbal medicines; Gastaldo et al., 2005; Messias, 2002). Studies such as that of Nicolas, Desilva, Prater, and Bronkoski (2009) have uncovered empathetic

6 Journal of Transcultural Nursing family stress among Haitian immigrants in their prevision of financial support to family members, but fewer studies have shed light on the influence of transnationalism regarding disease self-management. In the present study, we uncovered baseline evidence that the act of remittance, which can be considered at the core of transnationalism, facilitates social networking and social support by providing an interpersonal calming effect that was perceived to lower the participants blood-pressure. We also detected some indications that the act of remittance could also exacerbate feelings of stress, particularly among our study group, on relatively low-income hotel workers, thereby enhancing their hypertension. In their study of remittance among Brazilian immigrants in the United States and Canada, Goza and Ryabov (2012) observed that family obligations to provide financial support were especially significant within the United States. Heard, Whitfield, Edwards, Bruce, and Beech (2011) studied African Americans who self-reported perceived stress and hypertension and found that having higher levels of social support was felt to lower blood pressure. As with other immigrant populations in a host country, Haitian immigrants rely on strong social support networks within their communities. The vivid existence of little Haiti in Miami, Florida, is an example of this group s needs and their functional behavior toward sustaining a strong social support system (Prou, 2005; Stepick & Swartz, 1998. Transnationalism has been driving the current understanding of the socioeconomic and political context of the beliefs and behaviors of many contemporary immigrants. Transnational identities and transnational connections have considerable economic, sociocultural, and political impact on immigrants, their families, and their communities, in both the birth and the host countries. However, extending this understanding even further to the realm of health status and health provision may address the need for better health in a multicultural society. For instance, a study has noted that transnational identities have aided in the psychological and mental health status of immigrants (Murphy & Mahalingam, 2004). The present study adds that this identity can be a strain on immigrants health status and can influence their behaviors toward disease management. Limitations Only 31 individuals participated in the study. However, generalizability and statistical inference are not the aims of qualitative studies (Creswell, 2012; Thomas & Magilvy, 2011). The focus of the analysis was on the depth and breadth of the participants reports (Thomas & Magilvy, 2011). Validity of qualitative data is dependent not on sample size but on saturation and redundancy (Creswell, 2012), which was reached in this study when no new information was forthcoming. Further studies, with larger and more diverse sample of immigrants with transnational identities, are needed to further explore the phenomenon of transnationalism and its impact on disease management. Another limitation is that only four men participated in this study. Therefore, the study did not fully represent the Haitian immigrant men s perspectives about their experiences with hypertension and hypertension management and how being transmigrants influenced their ability to manage the disease. However, during the recruitment, men did not come forward to show interest in the study. The original study explored hypertension management among hotel housekeepers. This lack of representation was not surprising because women are overrepresented in the housekeeping industry (Wial & Rickert, 2002). More research is needed to explore whether the influence of transnationalism on health and disease management differs for men and women. Implications Clinical Implications. This study has clinical implications for nurses and other health providers caring for Haitian immigrants. Nurses can (a) direct Haitian immigrants to resources where they can have more affordable access to blood pressure medications and services to alleviate their financial burden, (b) encourage interactions with friends and family members to enhance the positive sense of social support and thus positive psychological well-being, (c) discuss with participants the cultural-based herbal medicines they take to manage their hypertension and explore their interaction with the prescribed medications. Research Implications. More research into the social, psychological, and physical perspective is needed to understand the influence of transnationalism on the life experiences of Haitian immigrants and other immigrant group who maintain transborder activities. More specifically, further research is needed to explore the duality phenomenon when it comes to transnationalism and health outcomes. Policy Implications. Much emphasis has been put on the outcomes of financial exchanges between countries. Individual monetary remittances are examples of such exchanges. Policy makers are advised to explore the outcomes of remittance practices on the financial status of immigrants. As this study suggests, transnationalism, which parallels the globalization movement, holds important financial implications and consequently potentially negative health outcomes for immigrants.

Sanon et al. 7 Appendix A Demographic Data Questionnaire Date Participant ID Now I would like to get some more information about your background. I will read each of the following questions to you and check your answer. Please feel free to skip the questions that you do not want to answer. What is your gender? Ki sex ou? Female Male Other How do you think being a (if male say: male; if female say female) influences the management of your participant s term? Antan ke yon------- kijan ou panse sex ou enflyanse jan ou kontrole.? What is your age? Ki laj ou? 18-25 26-35 36-45 46-55 56-65 How do you think being (being: state age influences the management of your participant s term? Kijan ou panse laj --------- an enflyanse jan ou kontrol.? What is your marital status? Eske ou marye? Single Divorced Separated Partnered How do you think being (state marital status) influences the management of your participant s term? Kijan ou panse.. enflyanse jan ou kontrole..? How many people, including yourself, are there in your household? Konbyen moun kap viv avek ou nan kay? 1 2 3 4 5 6-10 11-15 16+ How do you think living with (state the number of people) influences the management of your participant s term? Kijan ou panse viv avek.. enflyanse jan ou kontrole? Is everyone in your household related to you?.. Eske tout moun kap viv avew se fanmi?.. How do you think living with.influences the management of your participant s term? Kijan ou panse genyen nan kay you enflyanse jan ou kontrole..? What is the highest level of education you have completed? Nan ki klas ou rive? 1 st -5 th Grade 6 th -9 th Grade High school College Masters Doctorate

8 Journal of Transcultural Nursing How do you think education influences the management of your participant s term? Kijan ou panse edikasyon enflyanse jan ou kontrole..? What is your household s total annual income for the most recent calendar year? Konbyen kobo u fe shak ane? <$10,000 $11,000-$15,000 $16,000-$20,000 $21,000-$30,000 $31,000-$40,000 $41,000-$50,000 $50,000+ How do you think your income influences the management of your participant s term? Kijan ou panse kob wap fe chak ane enflyanse jan ou kontrole? When did you come to the United States?---------------------- Kile ou vini o zeta zini?--------------------------------- How do you think living in the United States since (state number of years) influences the management of your participant s term? Kijan ou panse la lavi o zeta zini enflyanse jan ou kontrole? When did you move to live in Miami-Dade County? ------------------------- Kile ou vini viv nan miyami? --------------------------------- How do you think living in the Miami-Dade County since (state number of years) influences the management of your participant s term? Kijan ou panse la lavi nan dade county enflyanse jan ou kontrole? How long have you been working as a hotel housekeeper?. Konbyen tan wap travay nan fe menaj nan otel?. How do you think working as hotel housekeeper for (state number of years) influences the management of your participant s term? Kijan ou panse job fe menaj sa enflyanse jan ou kontrole..? How many rooms do you clean a day? -Konbyen shanm ou netwaye shak jou? 3-5 6-10 11-15 16-18 18+ How do you think this responsibility of cleaning State the number rooms a day influences your management of your participant s term Kijan ou panse responsabilite pou ou netwaye State the number shanm shak jou enflyanse jan ou kontrole participant s term How often do you go back to Haiti? Shak ki le ou tounen an ayiti? Every 6 months Every year Every 2 years Every 3 years Every 4 years Every 5 years Every 6 years Every 7-10 years Every 10-15 years

Sanon et al. 9 How do you think going to Haiti every State the number influences your management of your participant s term Kijan ou panse ala ayiti shak.enfliyanse jan ou kontrole? Do you send money to friends and/or family members in Haiti? Eske ou kon voye lajan bay zanmi w ou byen fanmiw an ayiti? Yes No (If no, skip to the end) How do you think going to Haiti every State the number influences your management of your participant s term How often do you send money to friends and/or family members in Haiti?--------------- Shak ki le ou voye lajan bay zanmi ou byen fanmiw an ayiti? How do you think going to Haiti every State the number influences your management of your participant s term How much monthly would you say you send to Haiti every month?----------------- Konbyen kob ou voye shak mwa an ayiti? How do you think going to Haiti every State the number influences your management of your participant s term Appendix B Examples of Questions Asked During the Interviews You are participating in this study because your doctor told you that you have hypertension or high blood pressure. What do you think you have? What does that mean to you? Tell me about your [participant s term] What do you think causes your [participant s term?] What do you do to care for your [participant s term?] What do you think about the medications that your health care provider gave you? What other things do you take in addition to the medications your health provider gave you? How do you think being an immigrant influences the way you manage your [participant s term?] What roles do your relationships with your friends and family in Haiti and in the United States play in your management of your [participant s term?] 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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided by the Psi-Chapter-at-Large of Sigma Theta Tau, The International Nursing Honor Society, and the Hester McLaws Nursing Scholarship from the University of Washington. References Basch, L., Schiller, N. G., & Blanc, C. S. (2013). Nations unbound: Transnational projects, postcolonial predicaments, and deterritorialized nation-states. New York, NY: Routledge. Celeste, M. (2013). Framing Haitians and Cubans in The New York Times: Enduring imprints of political history. Journal of Haitian Studies, 19, 66-94. Chen, H.-Y., & Boore, J. (2010). Translation and back-translation in qualitative nursing research: Methodological review. Journal of Clinical Nursing, 19, 234-239. Coyne, I. T. (2008). Sampling in qualitative research. Purposeful and theoretical sampling: Merging or clear boundaries? Journal of Advanced Nursing, 26, 623-630. Creswell, J. W. (2012). Qualitative research design: An interactive approach (Applied social research methods; 2nd ed.). Thousand Oaks, CA: Sage. Dunn, K. (2010). Embodied transnationalism: Bodies in transnational spaces. Population, Space and Place, 16, 1-9. Fouron, G. E. (2013). Race, blood, disease and citizienship: The making of the Haitian-Americans and the Haitian immigrants into the others during the 1980s-1990s AIDS crisis. Identities, 20, 705-719.

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