health belief system of African-Americans: Essential information for today’s practicing nurses, The
Fields, Sheldon D
This article explores the health beliefs of African-American people and the potential impact of these beliefs on their health. A general overview of some health beliefs of this population is presented with clinical examples. The readers are challenged to think about how they approach this particular client population. Understanding the concerns and historic treatment of this population may serve to make nurses more culturally sensitive and culturally competent in their clinical practice.
KEY WORDS: African-American, Cultural Competence, Cultural Sensitivity, Health Beliefs.
African-Americans are the largest minority group in the United States constituting 12% of the population (US Department of Health, 2000). Most African-Americans have their roots in Africa and are descendants of the estimated 4-24 million slaves that were brought over during the slave trade from 1619-1860. Most of these slaves were from the West Coast of Africa (Walker, 1996; Branch & Paxton, 1976). This is the historical foundation of African-American people in this country and it needs to be appreciated for its potential and continued influences on the community it still has today. Currently the population of African-Americans living in this country has been contributed to by the migration of people from other African countries, and the Caribbean Islands.
Over 100 racial strains encompass the gene pool of African-Americans making identification of who is exactly considered African-American very diverse. Historically identified by a number of terms (Negro, Colored, Black) over the decades, African-Americans are a diverse group and one needs to be aware that intra-ethnic differences do exist among the group. The current politically correct term to use to refer to anyone who has roots in any of the African countries is African-American. This term is also preferable to the younger members (those 30 and younger) of this group. However older members (those 60 and older) may still prefer to be called Negro or Colored and middle-aged members (those 30 to 60) may prefer to be called Black.
It is acceptable to ask African-American patients what ethnic term they personally prefer (Goddard, 1990). Other factors that also contribute to the notion of intraethnic variations are the different religious beliefs, education levels, socioeconomic status, occupation and geographic locations found within the group (CampinhaBacote, 1998).
Traditional Definitions of Health and Illness
Traditional definitions of health stem from the African beliefs about life and the nature of being. Life has been viewed as a process and the nature of a person in terms of energy forces (Walker, 1996). All things living and dead have an effect on each other. People are believed to possess the power to influence their health and the health of others. The mind, body and spirit are not separate and if you possess good health you are in harmony with nature. Illness has been characterized as natural and unnatural, influenced by harmony or disharmony with God and nature (Clarke-Tasker, 1993). Illness is considered to be a state of disharmony. Natural illnesses are seen as occurring from natural causes (cold air, rain, heat, impurities in the air and food) whereas unnatural illnesses are attributed to demons and evil spirits (CampinhaBacote, 1992).
The goal of treatment for unnatural illness is to remove the evil spirits from the body. Traditional healers who were usually women were consulted. These women possessed knowledge regarding the use of herbs and roots as well as mystical voodoo like powers. Some AfricanAmericans who believe that they have been hexed will often seek out a voodoo type healer in addition to or instead of a licensed medical provider (Leininger, 1995).
Disability is viewed in the same context as illness. In the African-American culture illness and disability whether resulting from natural or unnatural causes is seen to exist only when it interferes with ones ability to be productive. Despite the mass media image of AfricanAmericans being lazy they actually possess a strong work ethic and illness in this cultural context is acknowledged to exist when the person can no longer work. Disability is acknowledged to exist after not being able to work for a certain amount of time. The following clinical scenario involving a middle aged African-American man illustrates the connection between the ability to work and the beliefs of illness and disability held by this cultural group.
Clinical Scenario A
Mr. Brown is a 52 year old African-American male with a history of hypertension for ten years. He has refused to take his prescribed medication or to change his diet, insisting that he “feels fine”. Last week Mr. Brown who is employed as a bus driver started to complain of visual changes (blurred vision, circles) and chest pain. These symptoms continued to worsen until today when Mr. Brown missed his first day of work in 20 years. At the insistence of his wife he went to see his healthcare provider believing now that his hypertension might need to be treated.
Healing and Healing Practices
As previously stated traditional healers were often women and healing practices and beliefs were passed down from generation to generation. Many AfricanAmericans believe in the ability of others to heal. Traditional healers used herbs and roots and the laying on of hands. Today a similar practice can be seen in how African-Americans continue to rely on home remedies for the treatment of illness. An example of some home remedies include the following: (1) salt pork placed on a rag to treat cuts; (2) hot lemon water and honey for the treatment of colds; (3) hot camphor oil and flannel wrapping for chest congestion; (4) goldenroot herb tea to treat pain and reduce fever; (5) sassafras tea to treat a cold; (5) nine drops of turpentine nine days after intercourse as contraception; (6) garlic placed on the person or in the room to remove the evil spirits that are causing the illness (Walker, 1996).
The wearing of copper or silver bracelets from childhood is believed to protect female children. If removed it is believed that bad things will happen to the child. What is of interest here however is how many AfricanAmericans who practice this believe that if the skin around the bracelet becomes black it is an indication that the person will get ill. Hence it serves as a sort of diagnostic tool (Walker, 1996). Geophagia is another cultural health practice that involves the consuming of non-food items such as clay, red dirt, starch, and ice. Geophagia is especially common among pregnant African-American women. The underlying cause of geophagia is unknown although the practices are thought to occur due to natural cravings (Boyle & Mackey, 1999). The practices however are controversial because they have been shown to lead to dangerous electrolyte deficiencies in some women (Boyle & Mackey, 1999).
The next clinical scenario involving a newborn African-American female illustrates the potential influence of health and healing practices held by African-American parents.
Clinical Scenario B
Imani was born premature at 30 weeks and was immediately taken to the MCU for care. The family requested that they be allowed to perform a traditional newborn religious ceremony in the NICU. The charge nurse immediately refused the request. The family threatened to remove Imani AMA from the hospital. The social worker on call was contacted and after talking to the family arranged for the ceremony to be conducted. The families cultural/religious beliefs dictated that this type of ceremony be held as soon as possible after the birth of a female child. The high light of the ceremony involved placing a copper bracelet on her ankle to ward off evil spirits and to protect her.
The kinship network that was established in the villages of Africa is the major support system utilized by African-American people. The kinship network refers to the practice of extended family and multigenerational homes (Leininger, 1995). This kinship network includes people who are related by blood as well as fictive kin (boyfriends, preachers, and other family friends). Large extended family networks are the norm for most AfricanAmericans. It is not uncommon at all to have children grow up in the same household as their grandparents and around the comer from several aunts, uncles and cousins (Ladner & Gourdine, 1992). What needs to be noted here is the high percentage of female headed households in the African-American community and when the women are unable to handle various situations they usually rely on grandmothers, mothers, aunts, and godmothers to provide assistance (Campinha-Bacote, 1998). This is in keeping with the tradition of the matriarchal line of lineage in many African villages and the fact that in slavery times many fathers were taken away from the family and sold off (Ladner & Gourdine, 1992).
The reliance on healers reflects the deep religious faith of African-American people. Spirituality plays a major role in African-American culture and is often expressed through religious practices/ activities. Some practices/activities include attending church services several days a week for those African-Americans who are Christians; the wearing of veils by Muslim AfricanAmerican woman; and the distributing of religious literature by African-American who are Jehovah Witnesses (Jennings, 1996). The black church has been a cornerstone in the African-American community serving as an organizing place and stabilizing entity. It has been noted that health screening programs may best be initiated through community and church activities where the entire family is usually present (Jennings, 1996).
African-Americans have historically believed that illness may be due to their failure to live according to or to accept “God’s” will. Some African-Americans even believe that illness comes directly from Satan (Roberson, 1985). The most common treatment for illness in those that believe this is prayer. Roberson (1985) stated that spiritual beliefs form a foundation for the health belief systems in African-Americans. For example AfricanAmericans who follow the teachings of Islam avoid eating pork or pork products as set forth in their beliefs. Also the beliefs of African-Americans who are Jehovah Witnesses forbids them from having blood transfusions (Roberson, 1985). The following clinical scenario involving a middle aged African-American women underscores the influence of religion/spirituality in this group.
Clinical Scenario C
Ms. Williams is a 45 year-old Black female who was recently admitted to a local hospital for a hysterectomy. Her surgery was scheduled for 10 A.M. but when they cane to take her to the OR she refused to go insisting that she could not go until she obtsined the blessing of her minister. The minister was due to come to the hospital that morning at 8 A.M. to bless her but he was late. The surgeon was furious and insisted that Ms. Williams be bought immediately to the OR because he had a schedule to maintain. The nurse on the unit talked to Ms Williams and discovered that she was afraid to go to the OR without the blessing of her minister. Ms Williams believed that she was being punished for defying God earlier in her life when she worked as a prostitute to support her drug addiction. The blessing from her minister was necessary if she was to be forgiven for her past sins and have her surgery go well.
Several sociocultural and social- demographic forces have negatively affected African-Americans and hence have an influence on their health status. For starters, the average life span of the AfricanAmerican is 6.8 years shorter than that of an Anglo-American. The life expectancy for Anglo-Americans at birth is now 76.8 years and 70.0 for African-Americans (US Department of Health and Human Services, 1999).
Access to education was not always equal and until 1953 school systems in this country were segregated. African-Americans continue to fall behind in educational attainment even after the landmark decision of Brown versus the Board of Education of Topeka made segregated schools a thing of the past (Hammack, 1986). Only 38% of African-Americans aged 25-64 have completed high school and the drop out rates in some urban areas for African-American teens has been historically as high as 60% (US Department of Health, 2000; Hammack, 1986). This disparity in educational attainment translated historically into decreased employment opportunities. Goddard (1990) ten years ago noted that AfricanAmericans are over-represented in the working class and typically do not advance to the higher levels of management. Even when African-Americans due progress educationally it has been found that only 47% who are college graduates earn as much as Anglo-Americans who are high school graduates only (US Department of Health, 2000). Michaels (1993) reported that due to being employed in high numbers in the steel and tire industries some African-American men are at an increased risk of developing occupational related cancers.
Half of all African-Americans live in urban areas in large cities such as New York and Chicago. Over crowding in some urban areas has also added to the stress faced by many African-Americans. These areas tend to be surrounded by the symptoms of poverty, high crime, and inadequate housing (Walker, 1996). In fact murder is the leading cause of death among young African-American males (Campinha-Bacote, 1995). These impoverished neighborhoods often lack adequate health care institutions such as hospitals, clinics, and pharmacies.
Lastly, African-Americans have to contend with higher poverty levels. Nearly 30% of African-Americans live at or below the poverty line compared to only 10% of Whites (US Department of Health, 2000). This represents a large number of single African-American women with children. The effect of poverty on ones health and well being is obvious. In this country the poor are more likely to be sick compared to those with higher incomes who live longer and healthier lives (US Department of Health, 2000). Poverty confronts African-Americans with daily problems and forces them to be concerned with the present necessities of life rather than the future. Sometimes obtaining medical care has to wait while money is allocated to food, shelter, and other basic needs (Leininger, 1995).
Medical Problems of the African-American
The leading chronic illnesses that are causes of death for African-Americans are the same as those for Caucasians, but the rates tend to be greater. For example, infant mortality rates for African-Americans are more than double the rate for Caucasians. Heart disease rates are 40% higher, and death rates for all cancers are 30% higher. African-Americans are 33% more likely to develop diabetes. Finally, the death rate from HIV/AIDS is seven times higher among African-Americans than Caucasians (US Department of Health, 2000; McGee, Cooper, Liao, & Durazo-Arivzu, 1996; Howard et al., 1995).
Sickle cell anemia is a genetically inherited trait that is hypothesized to have originally been an African adaptation to survive malaria. In the condition the red blood cells which are normally disc shaped assume a sickle shape, which leads to hemolysis and thrombosis. This ultimately constricts the flow of blood and can cause intense pain (Hwang, 1999). Some people are unknowing carriers of the sickle cell trait. Limited resources make it impossible to screen all African-Americans for this trait and provide them the proper genetic counseling (Hwang, 1999).
African-Americans and the Health Care System
In general there is a mistrust of the health care system by most African-Americans. This mistrust has been fueled by incidences such as the Tuskegee Study in which the public health service from 1932 to1972 conducted a study on hundreds of black men with syphilis. The men were not treated with antibiotics that would have cured the disease and indeed most of them died (Clarke-Tasker, 1993). The scientific and medical communities reacted with shock after the study was exposed, however most African-Americans universally saw the study as a blatant act of genocide perpetrated against Blacks by Whites. As a result many in the African-American community believe that health care professionals simply do not value their lives.
Many African-Americans underutilize the health care system instead opting for home remedies and only seek the help of professionals in extreme emergencies. Feeling beneath the white health care provider and being mistreated and/or misdiagnosed are all reasons for the underutilization of the health care system (Walker, 1996; Leininger, 1995). This again is a direct result of the discrimination towards African-Americans in this country.
The number of African-American health care professionals is low which further compounds the issues of mistrust in the African-American community. Only 6.5% of all physicians and 10.4% of registered nurses are AfricanAmerican (Walker, 1996). These numbers are not in proportion to the overall African-American population. The two broad goals of the Healthy People 2010 agenda are 1) to increase the quality and number of years of healthy living, and 2) eliminate health disparities among different segments of the population. If these goals could be achieved as they relate to the African-American population we would for example see a reduction in homicides among African-American men aged 15-34 and subsequent increase of the life span of African-American men.
We would also see a reduction in asthma morbidity among African-Americans and reduced rates of breast and prostate cancer in this population (U.S. Department of Health, 2000). The following clinical scenario involving an elderly African-American woman illustrates the connection between the historic treatment of AfricanAmerican people in this country and healthcare decisions by some older members of this group.
Clinical Scenario D
As a child growing up in the Deep South, Charlotte witnessed the beating of her grandfather by a white supremacist group. He died enroute to another hospital after the closest trauma unit in the town refused to treat him due to their policy of not treating “Negroes”.
Charlotte now 65 has not had a routine physical exam since she was forced to while in college. She has mainly relied on her grandmother’s book of home remedies to treat her minor illnesses. During a recent physical exam for life insurance the Caucasian male doctor recommended that she get a mammogram. She immediately refused and became very angry when the doctor attempted to explain his recommendation. The office RN, a young African-American female noticed how upset she was and asked her what the problem was. Ms. Williams told the nurse the story of how her grandfather died after not being refused treatment at a hospital in the south because he was Black and how after that she never trusted medical people, especially “white ones”. After explaining the high incidence of breast cancer in Black women and the importance of having a mammogram done for early detection, the nurse was able to help her make an informed decision to have one.
The clinical scenarios underscore the importance of good communication with our clients. All to often in our hectic clinical settings decisions are made quickly and most of the time with the best interest of the client in mind. No matter how well intentioned we may be more consideration needs to be given to the issues of cultural beliefs if we are to deliver the best care to our clients. Also efforts to recruit and maintain more African-Americans in the health professions need to be encouraged in order to combat the mistrust issue that many African-Africans still confront. These efforts could only help to achieve the goals set worth for African-American’s in the Healthy People 2010 agenda.
The situations outlined in the clinical scenarios when viewed in the context of the healthcare beliefs of AfricanAmericans can now be interpreted and understood differently. Instead of labeling Mr. Brown as non-compliant with his care and ignoring his healthcare needs he can now be viewed as a man who in fact did not view himself as ill for cultural reasons until he could no longer work.
Imani’s family was not trying to be difficult or not allow her to be treated in the NICU but they were attempting to help her in the only way they felt empowered too. Ms. Williams was afraid that she would not do well without her ministers blessing. She was not attempting to interfere with the surgeon’s schedule. Finally, Charlotte suffered a great trauma that led her to mistrust healthcare professionals. She needed to have her condition explained to her by someone she perceived as more trustworthy, someone who she thought was not out to hurt her or let her die.
Through this exploration of the health belief system of the African-American many issues have been raised. Although we need to avoid stereotyping any group of people the explanations of certain health beliefs and practices of this group as presented can increase the cultural knowledge base of today’s practicing nurses. As nurses we should seek to challenge ourselves to practice our helping, humanistic profession in as great a culturally sensitive and culturally competent manner as possible.
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Sheldon D. Fields, PhD, RN, CS, FNP, Decker School of Nursing, Binghamton University, Binghamton, New York.
Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter/Spring 2001
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