Volume 15 No. 1-2 Summer/Fall  2014
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            Understanding the complex ways in which migration and health are interconnected is important for thorough examination of the social determinants of health (1). An expanding body of scholarship provides rich insight into the ways in which migration and health operate in the lives of specific types of migrants, with considerable attention on displaced persons and persons who have migrated to and live in Higher Income Countries (HIC) (2). The ways in which migration, health, and equity are interrelated, however, are crucial concerns for Lower and Middle Income Countries (LMIC). If health inequities are to be addressed comprehensively, as a health gradients approach would suggest (3), much more attention is needed on migration dynamics and health within LMIC.
            The Caribbean Migrations: Jamaica Return Migrants Study (CM: JRMS) has as its primary aim the systematic investigation of this timely and important topic. As the first step in the Principal Investigator’s larger programme of research in this area, the JRMS focuses on two sub-populations of interest in Jamaica. The study applies a WHO/PAHO-defined social determinants of health approach (4, 5) to explore whether there was heterogeneity in the mental and physical health outcomes of Jamaican voluntary return migrants (VRM), according to a set of locally appropriate equity stratifiers, and whether and how these prevalence outcomes differed for a comparison sample of Jamaicans with no international migration history (NIMH). A stress-diathesis model was used to specify several variables that may act as risk and resource or vulnerability and protective factors.
            Over the past several decades, great progress has been achieved in advocating for and developing empirical work that justifies the need to focus on the preventable, avoidable, and unfair perpetuation of health inequalities between and within countries (4, 5). However, much remains unknown about inequities within the LMIC. Multiple factors likely contribute to this gap in the social determinants literature. Limited research infrastructure to systematically tackle social determinants, a favoring of medical models of health and illness, and inadequately specified and measured locally specific equity stratifiers, often compound inherent biases in well-intentioned research, policy, and practice agendas that, when exploring inequities and the ways in which these relate to health outcomes, seem to favor HIC in funding and other resource allocation.
            To develop more complete appreciations for health inequities, greater attention must be paid to inequities within LMIC. Close attention to inequities within LMIC requires careful consideration of migration. Intra- and inter-country movements characterize the lived realities of the majority of persons in these contexts.
            Over the past few decades research about the health of immigrants suggests that migration is intricately related to both positive and negative mental and physical health outcomes (6, 11). Much of this research has been devoted to delineating and attempting to explain the complex ways in which migration-specific differential exposures (e.g. more time in the migratory context) and vulnerabilities (e.g. interrupted family roles and relations) may manifest and relate to health outcomes. Such approaches are indeed useful to clarifying the extent of health inequities between countries and within HIC. However, a recentering of the experiences and realities of persons from and in LMIC must also be a part of conversations on health inequities. The JRMS was specifically designed with this need for examination of the heterogeneity in migration and inequities within LMIC in mind.
            Despite the significant role that movement within and outside the Caribbean region plays in the livelihoods and wellbeing of Caribbean persons (12, 13), limited information from Caribbean countries is available that documents the interrelations between migration and health. This makes it difficult to develop coherent public policies and systematic guidelines that may be truly relevant for the populations of interest. Furthermore, in LMIC contexts in which the fixed and firm categories in traditional migration literature (e.g. resident) may not capture the totality of migration experiences (e.g. persons having migrated to and returning from multiple locations), the complexity of interrelations between migration and health must be examined closely.
            Baseline data on Caribbean migrants and their health and well-being are therefore needed to inform and justify policy decisions if the commitment is to evidence-based policy and interventions. For this reason, one important priority within countries such as Jamaica is to ascertain whether health inequities exist and whether and to what extent migrations within and outside Jamaica may contribute to or attenuate such inequities.     


            Return migrants are a key component of many of the interventions and programmes focusing on community renewal across Jamaica and other Caribbean countries. In many of these efforts to enable communities to discover their self-reliant, interdependent, and empowered selves, a crucial part of the conversations is the role of persons who have travelled outside these very communities and have returned, and the reasons why others have not returned.
            Those who have travelled outside Jamaica are perceived as storehouses of information and conveyors of alternative practices. In many cases this is because return migrants often bring along tangible resources (additional wealth or resources, advanced education or training, or connections abroad). Often the government and civil society organizations call upon return migrants and expect that not only will they will participate in community renewal efforts, but that their voices and experiences will be crucial in clarifying emphases for programmes and policies. However, anecdotal reports reported in local media suggest that even if they return to Jamaica with initial intentions to assist and to lead, these intentions quickly dissipate. Return migrants have reported to local newspapers that they are met with discrimination and scorn from the very moment they return to Jamaica. They state that they feel stigmatized and frustrated and experience poor psychosocial adjustment and wellbeing. There is, however, no empirical substantiation for these claims. Nor is there any data on the psychosocial profiles of different types of return migrants in Jamaican communities (e.g. retirees, seasonal workers, students and young professionals). Furthermore, although health and wellbeing are repeatedly noted as important priorities for the country’s development (14), there is very little data on mental health and wellbeing.  
            The JRMS directly addresses these needs in two key ways. First, it gathers data on the prevalence of mental and physical health outcomes, locally specific equity stratifiers, and modifying factors in the relationships between the stratifiers and health outcomes for both return migrants and those with no international migration history. Second, it contributes to research capacity building in the social determinants of health inequities (particularly mental health for which determinants research has been limited) by
training and employing local project and field staff for the project.

            The JRMS received its initial funding from the University of the West Indies’ Office of the Principal’s New Initiative Grant mechanism. Supplemental support has been received from the Society for Community Research and Action. The Ethics Committee at the University Hospital of the West Indies, Mona, Jamaica approved the recruitment, consent, and field procedures.
            While a multistage national probability sample is the gold standard for the generation of this necessary information on migration and health among peoples in the Region of the Americas, inadequate funding often forestalls such efforts. This was the case with the JRMS. However, the sampling design was still able to demonstrate a fit for the purpose (3) of examining health inequities among Jamaican return migrants.
            The study employed a cluster sample design with a combination of stratified multistage random cluster and quota sampling strategies, with stage 1 as the cluster and stage 2 as households. The ultimate sample units (one adult 18 years or older per household, living in the parishes of St. Andrew, Kingston, St. Ann, and Manchester) were selected from a sample of non-overlapping clusters using simple random sampling without replacement.  The four parishes were purposively selected because of their varying proportion of returning residents (the highest, lowest, and middle-range rates in the island). The communities were clusters and the sample frame of communities employed was the Social Development Commission (SDC) listing of communities (15). The sample frame was stratified on the basis of community poverty level, using the Deprivation Quintiles as the indicator. 
            This use of the SDC listing of communities for the generation of the sample frame is a key innovation of the JRMS. Unlike other community-based or national probability samples conducted in Jamaica that use the simple Enumeration Districts as the sampling units, the use of the Deprivation Quintile for the sampling design is a most appropriate fit for the purpose of examining health inequities (3). The Deprivation Quintile indicator assesses poverty using the Unsatisfied Basic Needs Approach (UBNA), which has been coined “public poverty.” It concerns the quality of life of residents and it involves issues related to physical security, the availability of amenities (e.g. water, light, schools, clinics, and physical infrastructure such as roads etc.) and SDC terms this deprivation.  The quintile ranges from 1 (“Least deprived”) to 5 (“Most deprived”).  
            Two communities from each deprivation quintile were randomly selected and a minimum quota was set for each community. Interviewers were instructed to interview only one eligible adult from each household.  In cases in which there was both an eligible VRM and an eligible NIMH person in the household, the interviewers were instructed to interview only the VRM.  Walking in the clockwise direction dictated by maps of the Enumeration Districts of the national statistical agency (STATIN), comprising each of the communities, every eligible person in the cluster was sampled until reaching the quota.
            Participants were classified as being voluntary returned migrants if they had lived abroad (outside of Jamaica) for a period of at least three months or more and had voluntarily returned to Jamaica and resided there at the point of data collection. Participants were classified as having no international migration history if they had either never left Jamaica or had at some point travelled outside of Jamaica but for a period of fewer than three months. These participants could have, however, moved within Jamaica.  
            The JRMS’s approach to training and working with field staff has been geared to research and community capacity building. The original candidate pool for field staff was over 70 persons, many of whom were young adults recently graduated from high school or university and unemployed. Many of these persons resided in the target parishes and communities. The rigorous training to be selected as a field interviewer for this project involved attendance at both a General Interviewing Techniques and a Study Specific Techniques training session. After this, training participants completed in-the-field pilots of participant recruitment and interview administration. These were observed by senior project officers and additional on-the-spot training was provided to the interviewer candidates After this field pilot, 35 interviewers for the project were selected and employed as field interviewers. The training that these persons received therefore contributed to educational interventions and skills-training outside of a classroom, providing them with training as part of the project.
            In addition, from the pool of field interviewers seven were selected and completed additional training as data entry personnel. These persons gained hands-on supervised experience with working with quantitative data using SPSS.
            Community members were employed as community guides, leading interviewers into some of the more remote or inaccessible communities and providing extra assistance and even security in some of the more volatile communities. These practical strategies contribute to greater commitment to the project’s research and dissemination activities.
            The fieldwork in the JRMS utilized paper-and-pencil questionnaires. Data entry and validation are concurrently being completed by two master’s level psychologists who have been working as the project manager and project coordinator. A handbook of the measures and questions used in the instrument and their corresponding variable names in SPSS was developed to assist in the data entry process. Once entered, the data will be cleaned and processed. Imputation of missing data and the creation of scales and other derived variables will be completed at this time. Weights are currently being developed (i.e. unequal probabilities of selection, a post-stratification weight, and a final weight that is their product) and will be utilized to account for the complex survey design. A request for the necessary 2012 census data for the creation of these weights is being processed. Once created, these will be added to the dataset and entered into a codebook.
            Substantively, not every issue of relevance to return migrants can be captured in a mostly close-ended questionnaire the aim of which is to provide quantitative data that can be used as baseline information for future interventions, programmes, and policies. To address this challenge, consultations with a few leaders of return migrants associations throughout Jamaica were conducted, as were reviews of media articles, secondary literature.
            Gathering quantitative baseline data requires using measures psychometrically validated with non-Caribbean samples and this might mean that the constructs being operationalized by the measures are not as valid for the target populations in Jamaica as they might be for other groups on which the measures were normed. To address this potential barrier, before the fieldwork process, the Principal Investigator consulted with community leaders and experts in the topic areas studied to assess the face-validity of some of the measures. In addition, cognitive interviews were conducted by two of the key project management staff and the Principal Investigator. The extensive feedback from 10 persons who met criteria similar to those of the target community members helped hone the questionnaire tool and helped to ensure that questions and additional measures were included that could help in cross-cultural validation.
            As suggested in the description of the sampling design, the omnibus JRMS instrument captures both individual- and community-level measurements. In addition to the Deprivation Quintile, parish, and community data captured, the questionnaire gathered data on mental health and wellbeing outcomes (depressive symptoms, life satisfaction, happiness, exposures to trauma, interpersonal violence, and childhood sexual abuse) and physical health behaviors and conditions.
            Measures and questions used in large-scale community surveys and national probability sample surveys in other country contexts were also employed. Specifically the study used measures to capture two main categories of determinants, namely 1) social conditions (perceived stressors, discrimination, exposure to violence, living conditions), and 2) psychosocial factors (e.g. social network size and location for both local and international relatives, racial identity, personality traits, primary and secondary psychopathy, impulsiveness, resiliency).
            Data were collected to capture the locally specific equity stratifiers such as marital and union status, household composition and dwelling, social class, remittances received and sent, history of caregivers growing up, several questions related to the migration ideation and intention, questions on the racial and ethnic background of family relatives and of the respondent, and detailed internal and external migration histories. Open-ended questions were also asked about the meaning of mental illness and mental health and health service use.
            Few, if any, prior studies in the Caribbean have assessed the social determinants of mental and physical health and wellbeing and even fewer still attend to the complex ways in which migration relates to these phenomena. Thus the JRMS has implications for the study of migration and health inequities regionally and beyond. The range of stress-diathesis variables that are explored in the study will facilitate thorough examination of the ways in which health inequities may be attenuated or exacerbated in the context of migration.
            Because of its careful attention to the complexity of movements in the lives of the respondents, the JRMS captures types of migration not recorded in the traditional migration literature that tends to focus on longer periods of residence in countries. This element of the study can facilitate the development of policies and programmes at the intersection of migration, health, and development that are sensitive to the dynamism and fluidity characteristic of the lives of Jamaicans and other Caribbean persons.
            The JRMS is intended to serve as the pilot for a replication and extension study using Jamaica as a case study to explore health inequities in the context of migration more completely by including samples of involuntary return migrants, foreign nationals living in Jamaica, and the Jamaica diaspora in different parts of the world. The intention is to then replicate and extend this study and use it as the basis for Caribbean-wide longitudinal explorations of migration and health, using the social determinants of health framework. These types of data are essential for the intended programme of research that proposes to use Age-Period-Cohort models (16) to investigate the complex ways in which “…social, political, historical, economic, and environmental factors . . . [can] accumulate across people’s lifetimes and are transferred across generations” (3).

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