Community health needs assessment and action planning in seven Dominican bateyes

Accepted Manuscript Title: Community Health Needs Assessment and Action Planning in Seven Dominican Bateyes Author: Sarah V. Suiter PII: DOI: Reference:

S0149-7189(16)30101-X http://dx.doi.org/doi:10.1016/j.evalprogplan.2016.10.011 EPP 1377

To appear in: Received date: Revised date: Accepted date:

11-5-2016 26-9-2016 26-10-2016

Please cite this article as: & Suiter, Sarah V., Community Health Needs Assessment and Action Planning in Seven Dominican Bateyes.Evaluation and Program Planning http://dx.doi.org/10.1016/j.evalprogplan.2016.10.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Title: Community Health Needs Assessment and Action Planning in Seven Dominican Bateyes.

Running Head: NEEDS ASSESSMENT AND ACTION PLANNING

Sarah V. Suiter, PhD, MS Assistant Professor of the Practice, Human & Organizational Development Peabody College of Vanderbilt University Peabody #90, 230 Appleton Place Nashville, TN 37203 [email protected]

Highlights for Community Health Needs Assessment and Action Planning in Seven Dominican Bateyes    

Haitian residents of Dominican bateyes experience high rates of poor health and extreme poverty. High rates of poor health are due to a variety of community-based factors including lack of access to clean water and adequate food, as well as political marginalization Residents of Dominican bateyes are interested in community-level change and eager to participate in the process Broad-scale needs assessment and action planning process are one strategy to identify key interventions for addressing these needs

Abstract: Haitians and persons of Haitian descent living in the Dominican Republic are often relegated to living in deeply impoverished communities called bateyes. Despite obvious needs and some NGO presence in the bateyes, little assessment has been done to identify specific needs as understood and experienced by community members themselves. This article describes a community health needs assessment and action planning process developed and implemented by university researchers, NGO staff, and community members to identify needed areas for community-based health intervention in seven Dominican bateyes. Surveys and focus groups were used to collect data about the needs and assets of the bateyes and their residents around the following broad topics: demographics, health, education, financial/economy, legal issues, and transportation/infrastructure. These data were then used to guide an action-planning process that identified clean water, access to food and nutritional diversity, and economic development as primary and immediate needs in the communities. The process, its outcomes, and lessons learned are discussed. (158 words)

Key Words: Dominican Republic, needs assessment, community health planning, social determinants of health, social change

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Background Haitians and persons of Haitian descent living in the Dominican Republic have a long history of marginalization and exploitation, both by their own government and the government of the Dominican Republic (DR) (Gavigan, 1996). Many of them were forced or coerced into the DR for the purposes of harvesting sugar cane and (increasingly) performing other types of labor (Simmons, 2010). Although some Haitian-Dominicans migrate back and forth depending on the season, many have taken up permanent residence in the DR in communities called bateyes. There are an estimated 400 bateyes throughout the DR, and, although they vary in size and nature, almost all are incredibly poor and lack basic infrastructure and social services (Simmons, 2010). Furthermore, many Haitian-Dominicans lack legal documentation such as work visas, citizenship cards, or birth certificates, even if they were born in the DR, and are therefore prevented from leaving the bateyes for fear of imprisonment or deportation (Gavigan, 1996; Simmons, 2010). As a result, the people who occupy the bateyes are often living in very poor conditions with little to no access to health services, economic opportunities or education (Crouse, et al., 2010). The Batey Health Foundation (pseudonym) started working in 7 bateyes in the southcentral region of the Dominican Republic in 2006 with the intention of improving the health of batey residents. Originally, the foundation worked in partnership with a university located in its hometown, sending medical professionals to the bateyes for 1-2 weeks at a time, 3-4 times a year, during which the medical professionals treated everything from dog bites to heart disease. In 2014, the foundation sought to expand its reach and partnerships to another city, and met with faculty at the author’s home institution to discuss possibilities for university doctors to conduct similar trips to those originating in the organization’s hometown. After travelling to the bateyes

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and having several conversations with the foundation about possible approaches, the foundation and the university came to the mutual agreement that a community-based public health approach to improve health in the bateyes would be a more effective and efficient way for doctors and other members of the university to contribute to the health of the people in the bateyes. To begin identifying strategic priorities, the author was invited into the partnership to conduct a needs assessment and action planning process to guide the development of interventions in the bateyes. Despite obvious needs and some NGO presence in the bateyes, very little assessment had been done to identify specific needs as identified by community members themselves. The purpose of this article is to describe the needs assessment process, findings, and how those findings were used to inform the action planning process. Recommendations for action as well as lessons learned are included. The Batey Health Foundation funded the study, and was involved in providing feedback on the data collection instruments and data interpretation, facilitating relationships with community members in the bateys, and participating in action planning. Methodological Orientation This study and the planning processes that followed it were guided by a methodological orientation this is committed to a whole-person and multi-level understanding of health needs and assets, as well as a participatory approach to health assessment, intervention, and development. Whole-person understanding of needs and assets. Although researchers and practitioners often tend to focus on one or two aspects of human existence, true understanding of human health and well-being requires attention to the whole person, and incorporates education as well as health, family relationships as well as economics, spirituality as well as clean water, and so on (Commission on Social Determinants of Health, 2005). Furthermore, these domains (education,

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health, relationships, spirituality, economics) interact in ways that are complicated but predictable (or at least, patterned), and understanding those domains and their interactions are essential to laying the groundwork for any lasting improvements in the bateyes (Singer, 2009). Multi-level understanding of health needs and assets. In addition to promoting an approach to community development that envisions people as whole persons, this study operates from an approach of understanding persons as individuals who are embedded in families, communities and political systems that influence and are influenced by those persons’ beliefs, perceptions and behaviors (Prilleltensky, 2012). As a result, understanding persons and their communities requires research that accounts for multiple levels of influence and analysis (Prilleltensky, 2012). Although there are several frameworks in the field of human and community development that seek to guide multi-level analysis, the ecological approach developed by Bronfenbrenner (1979) and expanded by multiple other scholars continues to influence community practitioners from a variety of disciplines, including health promotion (McLeroy, Steckler & Bibeau, 1998). These approaches almost all include intra- and interpersonal factors (knowledge, beliefs, values, selfefficacy, social support, relational health), institutional and community factors (schools, clinics, religious & community organizations), and more macro-level factors such national economies, social structures, and political systems. As much as was possible, the study instruments were designed to reflect possible health-influencing factors at each of these levels. Participatory approach to assessment, intervention & development. This study strove for a participatory process that honored the knowledge and expertise community residents have about their own lives and communities (Israel et al., 1998); celebrated the existing strengths, skills, and resources they possess (Minkler & Wallerstein, 2008); and drew upon the inherent potential for action, development, and activism they bring to the process (Minkler, 2012).

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Study context. All bateyes are located within 120 Km of Santo Domingo, and although some (Aleman, Alta Gracia, Experimental, and Las Pajas) are quite rural, the others (Bienvenido, Hondonado, and Palave) are nestled along the outskirts of Santo Domingo and are therefore quite urban. It was difficult to know exactly how many people were living in each batey, but estimates from an internal 2014 NGO report, combined with estimates given by people living in the communities, put Alta Gracia as the smallest with around 50 households, and Bienvenido, Hondonado, and Palave as the largest with approximately 2000 households each. The presence of amenities other than housing varied by batey as well. In Alta Gracia, for example, there was little other than houses. In the larger bateyes, there were typically a primary school, a community center, a baseball field, a clinic, a few businesses, and a handful of churches. Although the history of the bateyes identifies them as comprising primarily Haitians living in the Dominican Republic, and indeed almost all residents were of Haitian decent, we were somewhat surprised to find that most residents and their families had been living in the bateyes for at least two generations, and nearly all spoke Spanish. This is not to say that this is true of residents of all 400 bateyes (indeed, limited existing data indicate that it is not), or that residents avoided the strong anti-Haitian sentiment from their fellow Dominicans (many narrative reports indicated that they did), but rather – and simply - that the majority of the persons in our study had been living in the Dominican Republic all or most of their lives. Methods Three broad research questions structured this study: 1) what are the primary needs of the people living in the bateyes? 2) what are the primary assets of the people living in the bateyes? and 3) what priorities do the people living in the bateyes have for improving their communities? The study team used surveys and focus groups to collect data about the needs and assets of the

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bateyes and their residents around the following broad topics: demographics, health, education, financial/economy, legal issues, and transportation/infrastructure. The PI and other researchers at the author’s institution designed these instruments collaboratively. The instruments were then reviewed by the Batey Health Foundation and collaborators in the DR, and the instruments were revised based on their feedback. Surveys included both quantitative and qualitative response items, and were developed to have two components: an adult survey and a child survey. No children were interviewed for this study; rather, every female who was interviewed was asked if she had children under the age of 18, and if she responded affirmatively, was asked questions pertaining to up to 4 of her children. Dominican data collectors, several of whom lived in the bateyes where the study was conducted, and all of whom spoke Spanish and some Creole, collected surveys and led focus groups in person. Data collectors read the informed consent document to each study participant and sought consent prior to conducted each interview and focus group. Language barriers were minimal because data collectors and all participants but 4 spoke Spanish comfortably, most as their preferred language. This study received approval from the Vanderbilt University IRB board. Data collection. The author traveled to the Dominican Republic for approximately one week in the fall of 2014 to visit the bateyes and train local interviewers in survey and focus group administration. Training included modules related to research basics, human subjects protections, survey administration, and focus group methods. After the interviewers had been trained on survey and focus group administration, they practiced with one another and received coaching from the author. The interviewers visited one community per day for approximately one week, and were able to obtain approximately 100 adult surveys, 100 child surveys, and 1-2 focus groups per day. (The only exception to this was Alta Gracia. Because Alta Gracia was so small

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and required substantial travel for several of the data collectors assigned to this batey, Alta Gracia was completed in the same day as was Las Pajas. This resulted in fewer than 100 surveys in Alta Gracia, however, given the size of the batey, the 18 households that were surveyed represent approximately 40% of the households in the community.) In some communities, 100 surveys per day were sufficient to interview members from every willing household. In other communities, 100 surveys represented a much smaller percentage of the overall population. In those communities, interviewers were directed to sample for diversity, meaning that the data collectors intentionally sought participants who lived or were congregated in different areas of the bateyes, who lived in different types of houses, and were different in terms of age and sex. At the end of each day, community leaders who had been identified by the Batey Health Foundations’s primary Dominican counterpart were invited to participate in a focus group. The focus group was generally held at one of the churches or community centers in the bateyes. A table outlining the demographic composition of survey participants by batey is as follows: [Insert Table 1 here] Data analysis & reporting. All survey data were entered into and managed in REDCap (Harris et al., 2009), which allows for the safe, secure, and permanent storage of all study data. For the purposes of this paper, only basic, descriptive analyses of quantitative data were used to understand the sample as well as general trends around questions and domains. Qualitative focus group data were analyzed using NVivo qualitative analysis software and a qualitative analysis process that involved reading transcripts and assigning codes related to the three major research questions (needs, assets, recommended approaches) to the transcripts and then exploring the content of coded material to further identify stated needs, assets, and approaches. These data

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were used in concert with the quantitative data to inform major themes related to the ways in which employment, environment, and political power affected health. Once the data collection was complete, the author emailed an overview of the findings and analysis to the Dominican data collectors for feedback. The author then emailed to report to the NGO and all data collectors, and scheduled a follow-up teleconference with them to discuss findings, feedback, and resulting interpretation. This process, called member-checking, represents one strategy used in participatory research to improve quality & accuracy of data interpretation (Bloor, 1997). Although the data represented in this study are not necessarily generalizable to all Dominican bateyes, the data do offer an accurate metric of the issues and characteristics operating seven bateyes involved in the study, and were use to guide decision-making processes related to priorities and approaches for community health & development intervention. Findings Many people living in the bateyes are experiencing extreme poverty, which affects their ability to access the resources needed for health promotion and disease prevention and treatment. Multiple forms of resource deprivation influence health, however, three will be highlighted: unemployment, community environmental factors, and lack of political power. Measuring health. The community residents we surveyed reported health-related difficulties from many different perspectives. The environments in which they lived often contributed to high incidences of illness, resources to support health prevention and promotion were scarce, and access to health care was often challenging for reasons such as financial cost, transportation, and lack of availability of clinic doctors. Adult physical health. Participants were asked to respond to several questions about their health, including a simple, self-rated health question. Self-rated health is a strong predictor of morbidity

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and mortality even after controlling for several other health-related factors (Idler & Benyamini, 1997; Kaplan & Camacho, 1983).

Furthermore, self-rated health outperforms mortality

predictions based on physician data, existing health problems, and presence of risk factors (DeSalvo et al., 2006). Specifically, in a meta-analysis of over 20 studies examining the relationship between self-rated health and mortality risk, DeSalvo and colleagues found that persons who rated their health as “poor” had twice the mortality rate of those who rated their health as “excellent.” Persons who rated their health as “fair” and “good,” had mortality rates of 1.5 times and 1.25 times of those who rated their health as “excellent.” Differences between “excellent” and “very good” ratings were negligible. The table below contains self-rated health of adults in the bateyes. [Insert Table 2 here] Participants were also asked to list their primary health concerns, and reported headaches, stomach problems, flu, fever, asthma, chikungunya, poor nutrition, and anemia. In addition to these, however, adults also listed cancer, liver disease, hypertension, heart problems, and injury and age-related disability. Because the water and sanitation issues in the bateyes led us to believe that gastrointestinal problems might be a chief concern for persons in the bateyes, we specifically asked, “About how many times per month do you have stomach problems (diarrhea, vomiting, discomfort)?” people responded anywhere from “never” to “constantly.” Community averages, however, were as follows: Aleman, 1.35 times/month; Alta Gracia, 1.1 times/month; Bienvenido, 3.36 times/month; Experimental, 2.69 times/month; Hondonado, 2.23 times/month; Las Pajas, 2.03 times/month; Palave, 4.13 times/month. Access to health services. Participants were asked to estimate how long it had been since they last visited a health professional. Although responses ranged from “40 years” to “yesterday,”

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responses were analyzed based on whether or not the participant reported visiting a health professional within the last year. Eighty-eight percent of participants in Aleman, 50% in Alta Gracia, 43% in Bienvenido, 67% in Experimental, 47% in Hondonado, 69% Las Pajas, and 44% in Palave reported visiting a health professional in the past year. When asked what type of health professional they saw, 69% of participants responded they either visited a hospital or health center, both of which are public facilities in the Dominican Republic. Fewer than 10% of respondents in every batey reported visiting a clinic or private doctor (both types of private providers), pharmacy, community health worker, mobile clinic, traditional healer or friend or relative. Percentages of participants who reported visiting a hospital or health center in the past year are as follows (note some participants might have attended both): [Insert Table 3 here] Some communities had health centers in the bateyes and those that did typically reported that as a strength of their communities. Other bateyes did not have health centers, and in those communities, participants named the distance and costs related to traveling to hospitals as an important barriers to acquiring health care. Few people living in the bateyes have access to their own means of transportation, and as a result, most walked, rode a bicycle, or used public transportation when seeking health services outside the bateyes. Transportation to the hospital (when health needs were critical) was an identified need in several of the communities, but focus group participants in Palave in particular noted difficulty in accessing emergency health care services. Focus group participants in Palave stated that although 911 (a new service in their community) had improved things somewhat, the 40-60km trek to the hospital in Los Alcanizos meant that people frequently arrived at the hospital after it was too late to improve their condition.

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Child health. Participants were asked to rate each child’s health according to whether they believed the child’s health was very good, good, fair, or poor. Child health rating has not been studied as thoroughly as general health ratings for adults, but these rating nevertheless serve as a proxy for overall health and well-being for children in the bateyes. Notably, over a quarter of participants in all bateyes rated their children’s health as fair or poor. In the more rural communities, over 40% of participants rated their children’s health as fair or poor. When asked how many times in the past year their child had visited a health professional, participants indicated anywhere between 0 – 20 times. In every community, the majority of children had been seen by a health professional at least once in the past year, but there were still a substantial number of children who had not. Table 4 indicates the percentage of children who had not visited a health professional in the past year by batey. [Insert Table 4 here] It is not clear from the data if people who had not accessed health services in the past year did not do so because of lack of access or lack of perceived need. When participants had taken their child to see a health professional in the past year, they reported a wide variety of reasons for doing so. By far, the most common reasons were asthma and/or difficulty breathing, allergies, congestion, flu, fever, tonsillitis, headaches and dizziness, gastrointestinal issues including diarrhea, pain, and loss of appetite, and skin problems including rashes, fungi and sores. In addition to these conditions, participants also named injuries (broken bones, dog bites), chikungunya, dengue fever, sexual health concerns, and vision and dental needs. In every community some participants indicated that they had taken their child to a medical professional for immunizations and/or a routine check-up, but it appeared that this type of preventative care was available only to those with the resources (a nearby clinic, ability to pay, access to national

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health insurance, access to transportation) required to make such visits possible. Participants who indicated that their child had received and/or was receiving routine vaccinations ranged from 37% in Alta Gracia to 77% in Experimental, with an average of 59% across all bateyes. When asked about their biggest concerns related to their child’s health, people listed many of the same conditions for which they sought treatment, including gastrointestinal issues, flu, fever, asthma, congestion, headaches, and skin problems. In addition to these concerns, parents also frequently listed nutrition concerns related to the inability to buy or access food for one’s child, pollution and other environmental problems in the community, and fear that one’s child would become ill and the person would not have the money or resources to pay for the cost of treatment or the cost of travel to access treatment. It is also worth mentioning that although we asked specifically for participants’ concerns about their children’s health, several participants responded with other needs or concerns that were more general including transportation, education, clothes, and shoes. That participants in very poor communities reported poor health and difficulty accessing services is not surprising. Documenting the need however, was important to anchor a model of health through which we could explore factors contributing to poor health in batey communities and begin designing preventive interventions. When asked about primary health needs, participants displayed a multi-level and multi-factor understanding of health – in fact, participants identified so many factors that it is difficult to do them all justice. These factors, of course, interact with one another in complex ways that makes community development and health intervention a significant challenge. Awareness of these interactive factors, however, is an essential first step is designing health interventions that account for and address social- and community-level factors that influence health. The qualitative and quantitative data reveal three

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primary sets of relationships that demonstrate these interactions and complexities. These are the interactions among employment & health, environment & health, and political power & health. Employment & Health. “There are no means of work. Employment does not exist. Employment is the main gateway to survive. Employment is what helps with your general bills. And so if we don’t have employment we are doing poorly financially and in that way you can say that we are in great need of help.” (Male, Palave) Income related poverty in the bateyes is remarkably high, with only one batey reporting average monthly income above 50% of the average monthly income for the Dominican Republic as a whole (average monthly income in Bienvenido is 7985 pesos, 56% of the Dominican national average of 14, 279). In Alta Gracia, the poorest batey, the average monthly income (2123 pesos) was only 15% of the Dominican average national average. To provide context for these amounts, the Central Bank of the Dominican Republic recently released a report saying that the average monthly income for Dominicans does not provide enough to live. The Central Bank estimated the monthly expense for a basic “family basket” (a collections of goods and services such as food, water, housing, utilities, transportation, cell phone, etc.) to be RD$26,855.21, but the average worker’s income was just RD$14, 279 (Dominican Today, 2014). Considering the average batey resident’s salary vis-à-vis these figures highlights the financial difficulties many participants have and would have in procuring the most basic resources. The clear source of poverty in all of the bateyes was lack of employment. Almost all people were doing something to generate income, however those activities were frequently unreliable (in the case of casual work), unsafe (in the case of sex work, for example), or severely

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underpaid (in most all cases). Across all bateyes, 40% of people reported that they earned a living doing salaried work; 30% participated in casual labor, 3% owned their own business, 2% farmed their own plot, and 4% were vendors or some type or another. Twenty percent of participants reported no income whatsoever, beyond what was given to them as gifts or donations. Participants reported that the primary barrier to holding a job was that there simply were no jobs available (46%). Another 25% of participants reported that they did not have the skills, education, or materials required to do the jobs available. Less than 1% of all respondents indicated that they were not working by choice. Many participants noted that lack of employment and income made it impossible to even afford the resources required to be healthy, such as clean water, healthy food, and medical care. Notably, in 3 of the bateyes (Alta Gracia, Las Pajas, and Palave), more than 2/3 of the respondents indicated that someone in their household had gone without food due to lack of resources at some point in the past month. Across all bateyes, 19% of respondents reported that members of their households ate one meal/day or fewer on most days during the past month. Focus group participants indicated the belief that little could be done about the conditions of the bateyes until something was done about employment. Environment & Health. In addition to issues with employment, people in the focus groups talked about community-wide issues such as having poor roads, lacking access to water systems, and inconsistent trash pick up. Community members reported being “forgotten” by the government, and indicated that even when the government did collect trash or bring water, it was unpredictable and inconsistent. Echoing the sentiments of participants in almost every focus group, a man in Aleman said, “the third (need) is picking up the trash. They come when they want and when they don’t want to come…they just don’t.” Trash collection is sporadic and

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insufficient in communities and municipalities throughout the Dominican Republic, and there is often little coordination of collection times or who is responsible for collection, meaning that the problems in the bateyes were certainly not specific to those communities (JICA, 2006; Cattafesta, 2013). However, there was general consensus (corroborated by national data) that poorer communities such as the bateyes are even more neglected by government waste management efforts and it is not atypical for them to go a considerably long time in between trash collection dates (Cattafesta, 2013). Although we did not collect data specific to roads and trash pickup, concerns regarding water and sewage were corroborated by our survey data, which indicate that people are relying on a number of safe and unsafe sources for water and sewage. This reliance is likely to blame for the vast majority of diarrheal diseases participants indicated when reporting their health symptoms, as well as other vector-borne illnesses such as dengue, malaria, and chikungunya (WHO, 2006). These diseases are bothersome and debilitating for adults, and even more serious for children. Indeed, untreated diarrheal diseases can be fatal for children and is a leading cause of death for children aged 0-5 worldwide (WHO, 2006). As demonstrated in the table below, people living in the bateyes obtain the water they use for their household through a variety of methods. [Insert Table 5 here] These various sources meant that many participants have to travel away from their homes to get water. In Aleman, 67% of people reported traveling to get water; in Alta Gracia, 94%, in Bienvenido, 13%, in Experimental, 11%, in Hondonado, 39%, in Las Pajas, 32%, and in Palave, 36%. Of those people who reported traveling away from their house to get water, there was considerable variance in how frequently people went as well as how far. People reported that

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they spent anywhere from “just a few minutes” to 2 to 3 hours per day going back and forth to get water. Importantly, 70% of all participants reported traveling to get water at least once a day. Every community mentioned water as one of its needs, but how that need came to be was somewhat different in each community. Some communities had never had a reliable water source and thus the awareness of what was possible and necessary to change the water situation was relatively low. In other communities, the problem was less about resources and awareness and more about the community members’ inability to gain the help they needed to create change. In Aleman, one focus group participant described, “In relation to the water, we had 50 or more years that we had a pumping system that would distribute water to the community. But the motor is so old that it deteriorated and got burnt. And we have gotten together our community leaders here and we have addressed the people in charge responsible for this, we have called, but in the end we have not found any help.” (Male, Aleman) Although drinking water sources are often (and rightly) targeted for improvement as a mechanism through which to improve public health, research indicates that sewage and sanitation infrastructure is just as important (Hopenhayn, Nieves & Rodriguez, 2011). Without proper disposal of human excreta, human waste can contaminate drinking sources, and flies can carry feces particles to food, among other hazards (WHO, no date). The following table lists the primary methods through which people in the bateyes dispose of human waste. [Insert Table 6 here] Consensus among many large, international development agencies indicate that “Facilities that are not shared between households, and that hygienically separate human excreta from human contact are considered to be adequate” (WHO, 2006, p.7). In the above table, the

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first three types of facilities are considered “improved” and therefore adequate. By combining the percentages in the remaining columns, the data show that 40% of households in Aleman, 69% in Alta Gracia, 20% in Bienvendo, 63% in Experimental, 29% in Hondonado, 67% in Las Pajas, and 22% in Palave use means of human waste disposal that are unimproved and have the potential to pose a considerable health hazard. Political Power & Health. Academic and NGO literature highlight lack of paperwork demonstrating legal residency and/or citizenship as a primary source of vulnerability for persons in the bateyes (Gavigan, 1996). Lacking proper documents makes people more likely to experience deportation and police harassment, and often prevents people from being able to access services such as public hospitals and some schools. Prior to administering the surveys, we anticipated that due to the sensitive nature of documentation among batey residents, study participants were likely to over-report having documentation, especially cedulas (national ID cards) and birth certificates. Comparisons between our findings and other literature seem to indicate that we were correct, however, community partners felt that survey questions and focus groups about documentation were nevertheless important and would provide useful information. Based on our survey results, 73% of respondents indicated that they had a cedula (national ID card), 60% a birth certificate, 14% a signed labor contract, 11% a voter registration card, 6% a passport, 2% a drivers license, 2% a visa or immigration papers, and less than 1% (only 2 people) indicated that they had a residency permit. Eighty-four percent of the children for whom we have data are reported to have a birth certificate, which is the documentation necessary to obtain a cedula once the child is an adult. There was quite a bit of variability in the rates of children with birth certificates, however: participants indicated that 94% of the children in

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Experimental have birth certificates, whereas in Alta Gracia, only 52% of children were reported to have birth certificates. Although lack of documentation demonstrating status, citizenship, and ownership is a problem throughout Latin American and the Carribean (Hopenhayn, 2011) and most of the literature about documentation for persons living in the bateyes in the Dominican Republic focuses on the vulnerability that results from lacking birth certificates and national ID cards (Gavigan, 1996; Simmons, 2010), the rates above demonstrate other forms of exclusion from full participation in civic and social life. For example, not one participant from either Alta Gracia or Las Pajas indicated that they had a driver’s license or a voter registration card. During the focus group in Hondonado, one of the participants mentioned a common consequence of these types of exclusions from social and political systems. He stated, “Politicians say we don’t count because there aren’t any votes here.” Other survey and focus group participants indicated that it was difficult to get services without papers, and a handful of people listed “obtaining papers,” as their biggest need. Lack of documentation and political power contributed to a variety of health-related problems ranging from service-specific (persons with proper documentation are entitled to the state-sponsored health insurance, SENASA) to more environmental issues like not being able to get the attention or commitment of the government to pick up trash or repair water pumps. Related to food scarcity mentioned earlier, several participants noted that understanding the political climate was essential to understanding at least some of the issues related to healthy food access: at least 4 of the bateyes are located in rural areas, surrounded by fertile land, and many of the people in the bateyes know how to grow food crops. In these cases, people are prevented

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from farming due partly to lack of resources to get started (seeds, tools, etc.), but also because they cannot access the land that surrounds them. One focus group participant said: “Look, I can say, when it comes to help we are like a “hachipiera” Do you know what a “hachipiera” is? We are like some sort of island surrounded by sugarcane and fields on all sides…we have sugar cane fields surrounding us that belong to the government. If we could have the possibility to farm, we can offer to people to plant there. Grow vegetables, right here we could grow our produce and it would grow beautifully here. And if we just had someone who would help us, in other areas they have done this and have had success.” (Male, Aleman) “Someone to help us,” was a common request in community focus groups as participants seemed to believe that the relationships and efforts in which they had the least power was vis-à-vis the Dominican government. Community members perceived that there were several resources (jobs, land, political power) that could and should be available to them if they only could make claims of the government that ruled them. Action Planning Once data had been analyzed and submitted to the foundation and its Dominican partners in the form of a final report, the author coordinated a day-long retreat at the author’s institution to use the data to guide action planning. People who attended the retreat (either in person or via skype) included 3 members of the foundation, 2 members of a local NGO that works in the Dominican Republic, 3 global health researchers from the author’s university, 4 students, and a Dominican collaborator. Action planning involved five steps, that loosely followed a concept mapping framework (Kane & Trochim, 2007): reviewing the study findings, listing and

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categorizing priorities identified by the data, ranking priorities in terms of importance and feasibility, and planning for next steps and action targets. Reviewing study findings. The retreat began with the author giving a presentation in which she outlined the background, methods, and findings of the study, much like they are presented in this article, and had been distributed in the final report. All retreat participants had the opportunity to ask questions, discuss findings, and suggest aspects of the needs assessment that stood out to them as surprising, alarming, important, or notable in some other way that related to planning future interventions. Identifying & categorizing priorities. After discussing the study findings, each participant was given post-it notes on which s/he could write as many “development priorities” based on the data as s/he was able to come up with. These statements were combined into one group, duplicates removed, and then participants worked together to sort statements in to categories. Collectively, participants generated 44 unique statements that resulted in five categories: collaboration and coordination, human capacity building, education and employment, health, infrastructure, and food and agriculture. Ranking priorities in terms of importance and feasibility. Participants then divided up according to the category with which they felt they had the most knowledge and expertise, and the subgroups worked to rank the statements in their category according to importance and feasibility. The groups then arranged the statements for each category according to statements that were high priority and high feasibility, high priority and low feasibility, low priority and high feasibility, and low priority and low feasibility. (Insert Figure 1 here). Planning for next steps and action targets. Finally, participants used the priorities identified through the action planning process, which grew out of data from the needs assessment to

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identify 2-3 issues the foundation would focus on in the coming year. Those issues included clean water, access to sufficient and healthy food, and economic development. Additionally, the university and the Dominican collaborators recommended to the foundation that regardless of focus and approach, community interventions and development projects should be planned, implemented, and evaluated in partnership with persons living in the bateyes, as these are the people who have the knowledge, investments, and energy to generate change. As one focus group participant said it: For me it’s important to believe in those that are from the batey, not just those that come from the outside. I think that what is important is to believe…like that song they sing in Nicaragua, “when the poor believes in the poor.” For me that is fundamental. To believe that if we can organize ourselves we can do it. (Male, Las Pajas) Once planning for next steps and action targets was complete, participants were given the opportunity to elect an issue with which they aligned or were interested from among the identified targets (water, food, or economic development). These smaller “action teams” independently coordinated their efforts to design interventions and connect with existing organizations that might be possible collaborators in the bateyes. Currently, their work is in progress. Lessons Learned This was a large-scale project that involved many phases and multiple stakeholders. The lessons learned were related to both the methods used for data collection and the process of action planning. Methodologically, the lesson learned deals with creation of the research instruments. Because of funding restrictions, the author was not able to travel to the DR to pilot the surveys. Although the surveys were designed collaboratively with substantial input from

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people who either lived or worked in the bateyes, and generally speaking, the surveys yielded excellent data, there were nevertheless some questions that missed the mark. Most important of these were three questions aimed at assessing resources available to children in the household, specifically those asking if the child slept on a bed or mattress (as opposed to on the floor), if the child had shoes, and if the child had more than one set of clothes. According to the survey, answering “yes,” to each of those questions indicated a basic level of subsistence for the child, however, we found that a “yes,” answer may or may not indicate that. For example, a parent might answer “yes,” that a child sleeps in a bed, but there might also be 5 other people sleeping in the bed at the same time, a known risk factor for spread of infectious diseases. Similarly, a parent might report that both of her children have a pair of shoes, but in reality, there was one pair of shoes that the children shared. Although this scenario likely decreased some of the healthrelated risks of walking outside barefoot, it did not improve other scarcity-related deprivations, for example that each child would need a pair of shoes to attend school. These discrepancies between what was reported in the data and the reality the author and interviewers experienced on the ground led the author to conclude, in retrospect, that community input in survey design is necessary but not sufficient to creating a valid and reliable research instrument. If given the opportunity to do this study again, the author would be more creative in determining a way to pilot test the instrument. In terms of action planning, one of the key lessons learned was that having reliable data and a definitive and agreed-upon process for developing action plans was essential to the success of this initiative. Despite having common interest in the bateyes and deep respect for one another, the foundation, the university researchers, and the people living in the bateyes all came to the partnership with different understandings and beliefs about the causes, effects, and

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mechanisms of poverty, health, and community development, as well as what should be done to address them. These ideological differences had the potential to derail the project had the partners not agreed to trust the data and the process. Although differences will likely continue to emerge, using the process to develop common goals and intervention targets was a crucial first step in forming a successful working relationship.

Funding: This study was funded in part by a grant from the Pujols Family Foundation Acknowledgement: The author would like to thank Todd Perry, Bernard and Marguerite Okeke, Ansel Sierra Ferriera, Deiby Ramirez, Lorena Carrion, Doug Heimburger, Conor McWade, Erin McCauley, Mary Bayham, Jessica Hinshaw, Amma Bosompem, Elizabeth Spitznagle, Shellese Shemwell, & Gabby Flynn

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References Agencia de Cooperacion Internacional de Japon (JICA) (2006). El studio del plan de manejo integrado de desechos solidos en el Distrito Nacional, Santo Domingo en Guzmán Republica Dominica. Santo Domingo, Dominican Republic. Bloor (1997). Techniques of validation in qualitative research: A critical commentary. In Miller & Dingwall (eds). Context and Method in Qualitative Research, pp. 383-395. Brewer, T., Hasbun, J., Ryan, C., Hawes, S., Martinez, S., Sanchez, J., Butler de Lister, M., Costanzo, J., Lopez, J. & Holmes, K. (1998). Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic. AIDS, 12, 18791887. Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press. Burdine, J.N., Felix, M.R. & Abel, A.L. (2000). The SF-12 as a population health measure: An exploratory examination of potential for application. Health Services Research, 35(4): 885–904. Commission on Social Determinants of Health. (2005). Towards a conceptual framework for analysis and action on the social determinants of health. Geneva, Switzerland: World Health Organization. Cattafesta, C. (2013). Proyecto para la creacion de capacidades y el perfeccionamento en la formulacion de politicos y de la capacidad de negociacion en medio ambiente. Diagnostico Preliminar: Republica Dominicana. Dominican Republic. Crouse, H.L., Macias, C.G., Cruz, A.T., Wilson, K. & Torrey, S. (2010). Utilization of a mobile medical van for delivering pediatric care in the bateys of the Dominican Republic. International Journal of Emergency Medicine, 3, 227-232. DeSalvo, K., Bloser, M., Reynolds, K., He, J. & Muntner, P. (2005). Morbidity prediction with a single general self-rated measure of health. Journal of General Internal Medicine, 21(3), 267275. Dominican Today (July, 2014). Average wage in Domincan Republic ‘not enough to eat.’ Dominican Today, July 1, 2014. Retrieved from: http://www.dominicantoday.com/dr/poverty/2014/7/1/51975/Average-wage-in-DominicanRepublic-not-even-enough-to-eat

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Gavigan, P. (1996). Beyond the bateyes. New York, NY: National Coalition for Haitian Rights. Retrieved 8/7/14 from: http://www.yspaniola.org/linked%20articles/Beyond%20the%20Bateyes.pdf Harris, P., Taylor, R., Thielke, R., Payne, J., Gonzalez, N. & Conde, J. (2009). Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2): 377-81. Hopenhayn, M., Nieves, M. & Rodriguez, J. (2011). The right to an identity: birth registration in Latin America and the Caribbean. Challenges [Internet], 2011 Nov. Retrieved 12/5/14 from: http://www.unicef.org/lac/challenges-13-ECLAC-UNICEF(1).pdf Idler, E. & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21-37. Israel, B.A., Schulz, A., Parker, E. & Becker, A. (1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health,19:173-202. Kaplan, G. & Camacho, T. (1983). Perceived health and mortality: a nine-year follow-up of the human population laboratory cohort. American Journal of Epidemiology, 117, 292–304. Kane, M. & Trochim, W.M. (2007). Concept mapping for planning and evaluation. Thousand Oaks: Sage Publications McIntyre, P., Moon, T. & Author. (In progress). Multidimensional poverty of Haitian immigrants living in Dominican bateyes: a metric for targeting development interventions. McLeroy, K. R., Steckler, A. and Bibeau, D. (Eds.) (1988). The social ecology of health promotion interventions. Health Education Quarterly, 15(4):351-377. Retrieved May 1, 2012, from http://tamhsc.academia.edu/KennethMcLeroy/Papers/81901/An_Ecological_Perspective_on_He alth_Promotion_Programs McWade, C., Moon, T. & Author. (In progress). Food security & dietary diversity within seven Dominican bateyes. Minkler M, Wallerstein N. Community-based participatory research for health: From process to outcomes, 2nd Edition. San Francisco: Jossey-Bass, 2008.

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Minkler M. Community organizing and community building for health and human welfare, 3rd Edition. New Brunswick: Rutgers University Press, 2012. Nelson, G. & Prilleltensky, I. (2010). Community psychology: in pursuit of liberation and wellbeing. 2nd Edition. New York, NY: Palgrave Macmillan. Prilleltensky I. (2012). Wellness as fairness. American Journal of Community Psychology, 49(1):1-21. Simmons, D. (2010). Structural violence and social practice: Haitian agricultural workers, antiHaitianism, and health in the Dominican Republic. Human Organization, 69(1), 10-18. Singer M. (2009). Introduction to syndemics: A critical systems approach to public and community health. San Francisco: Jossey-Bass. Sturgeon, S. (2006). Promoting mental health as an essential aspect of health promotion. Health Promotion International, 21(suppl 1): 36-41. World Health Organization (2006). Core questions on drinking-water and sanitation for household surveys. Retrieved 6/1/14 from: http://www.who.int/water_sanitation_health/monitoring/oms_brochure_core_questionsfinal2460 8.pdf

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Figure 1: Action Planning Statements, Categories, and Results

High Importance/ Low Feasibility

High Importance/ High Feasibility

Collaboration & Coordination

 Coordination on the ground among organizations working in the bateyes  Identify other efforts going on and attempt to partner & compliment  Develop public/private partnerships to improve stock of medications, materials, etc.  Develop partnerships in the DR with DR companies, NGOs & government  Advocacy on behalf of the bateyes vis-à-vis the government (what can we expect the government to do or not do)  Work on getting people papers (Cedulas, Voter Registration, SENASA, etc.)  Access to bank accounts

Human Capacity Building  PFF should hire full-time staff in the DR  Increase training and participation for males in leadership  Connecting with local leaders  Creating opportunities for members of the bateyes to participate in the design & implementation of PFF projects (“skin in the game”)

Education & Employment  Childcare for women while they’re working (creates jobs in the community as well as facilitates availability for employment)  Microfinance  Vocational training

 Identify a team of people in each(*) batey that provides leadership to all PFF projects in that respective batey  Individual attention given to each community so that solutions “fit” the community  Leadership development in each(*) batey

 Increase employment opportunities  Increase in sufficiency of employment  Projects are sustainable (people are empowered to be selfsufficient)  Improved education  Transportation to secondary school

Health

Infrastructure

 Maternal and infant health (basic training in nutrition, etc.)  Exploring medical schools being able to send people to the bateyes for rotations or service  Transportation to health clinics

 Home improvement (concrete floors, etc.)  Provide safe and good quality water in all 7 bateyes

 Outreach to people with special needs  Establish primary care/medical home relationships in each batey  Birth control & family planning (optimal timing and spacing)  Vaccinations

 Improve sanitation in all bateyes

Food & Agriculture  Partner with Medicines for Humanity in their community gardens effort to attempt to get gardens in the bateyes

 Replicate the food/agriculture program in Guatemala  Access to land to grow food

Low(er) Importance/ High Feasibility Low(er) Importance/ Low Feasibility

 Include students in the DR & in the US in efforts on the group for the purposes of education, experience, & additional human resources

 Identify positive deviants (e.g. women in poor households that aren’t food insecure) and see if we can replicate what they’re doing and/or have them teach

 Improvement in access to transportation

2

Table 1: Survey Participant Demographics by Batey Aleman 104

Alta Gracia 18

Bienvenido 123

Experimental 96

Las Pajas 80

Hondonado 123

Palave 108

Age 18-25 26-45 46-65 >65 yrs

21% 42% 29% 8%

28% 50% 17% 5%

43% 43% 10% 4%

23% 38% 30% 9%

19% 47% 23% 11%

30% 38% 25% 7%

24% 51% 25% 1%

Sex Female Male

39% 61%

33% 67%

39% 61%

39% 61%

25% 75%

33% 67%

19% 81%

Housing Material Wood/Tin Cinderblock Other No house

26% 69% 4% 1%

50% 50% 0% 0%

47% 51% 0% 2%

24% 71% 5% 0%

77% 21% 1% 1%

53% 44% 1% 2%

64% 35% 1% 0%

n=

Table 2: Self-rated Health by Batey Aleman Alta Gracia Bienvenido Experimental Hondonado Las Pajas Palave All bateyes

Excellent

Very Good

Good

Fair

Poor

15% 14% 22% 12% 14% 4% 12% 14%

15% 7% 18% 17% 12% 9% 13% 14%

27% 43% 30% 31% 46% 32% 36% 34%

23% 21% 17% 22% 9% 34% 25% 21%

17% 14% 12% 16% 13% 20% 11% 15%

Table 3: Primary Types of Adult Health Service Visits in the Past Year by Batey

Aleman Alta Gracia Bienvenido Experimental Hondonado Las Pajas Palave All bateyes

Hospital

Health Center

30% 44% 49% 50% 37% 45% 39% 42%

32% 33% 15% 18% 29% 31% 30% 27%

Table 4: Percentage of Children Who Had Not Visited a Health Service Professional in the Previous Year by Batey Aleman

Alta Gracia

Bienvenido

Experiemental

Hondonado

Las Pajas

Palave

23%

39%

43%

29%

35%

50%

30%

Table 5: Methods of Obtaining Household Water by Batey

Aleman (n=104) Alta Gracia (n=18) Bienvenido (n=124) Experimental (n=101) Hondonado (n=126) Las Pajas (n=80) Palave (n=109) Total (n=662)

Piped into dwelling

Piped into yard

Public tap

Tubewell/ Borehole with pump

Dug well

Spring

Rainwater

Bottled water

Pond, river or stream

Tanker truck/ Vendor

Other

2% 0% 7% 7% 20% 1% 9% 8%

14% 0% 29% 49% 37% 49% 39% 34%

2% 6% 57% 12% 23% 14% 26% 23%

3% 56% 1% 10% 1% 9% 5% 6%

38% 28% 3% 2% 8% 2% 0% 10%

0% 17% 0% 0% 6% 1% 1% 2%

0% 6% 1% 0% 3% 1% 0% 1%

31% 0% 3% 14% 8% 5% 19% 13%

2% 6% 0% 0% 4% 1% 0% 1%

16% 0% 0% 2% 5% 0% 16% 6%

4% 11% 0% 9% <1% 4% 5% 4%

Table 6: Methods of Human Waste Disposal by Batey

Aleman Alta Gracia Bienvenido Experimental Hondonado Las Pajas Palave Total

Flush to sewage system or septic tank

Pour flush latrine (water seal type)

Improved pit latrine

Traditional pit latrine

Open pit

Bucket

No facilities or bush or field

Other

17% 0% 56% 0% 39% 0% 13% 23%

24% 0% 13% 15% 23% 3% 57% 23%

22% 31% 10% 22% 10% 30% 9% 17%

33% 38% 15% 40% 18% 52% 9% 26%

0% 0% 2% 9% 8% 0% 1% 3%

1% 19% 0% 2% 1% 0% 4% 2%

4% 13% 0% 4% 1% 15% 0% 4%

2% 0% 3% 8% 1% 0% 8% 3%

2