The impact of culture on physical activity among African American women

Staggering under the weight of responsibility: The impact of culture on physical activity among African American women

Banks-Wallace, JoAnne

Objective: To examine African American women’s views regarding the significance of physical activity as a tool for decreasing cardiovascular risks secondary to hypertension. Particular attention was given to exploring how the contexts of women’s lives influenced physical activity behavior. Method: Narrative analysis of transcripts from 2 focus groups comprised of twenty-six women, ranging in age from 23 to 72 years old. Results: Women were motivated to increase their physical activity by personal and familial histories of heart disease and related risk factors. However, culture-based values and roles made it difficult for them to readily incorporate additional physical activity into their lives. Conclusions: Physical activity intervention designs must be flexible and accommodate the tremendous familial or communal responsibilities of African American women Group interventions that include spiritual and community building components may be especially effective for promoting physical activity among this population.

KEY WORDS: African American women, Culture, Health Promotion, Hypertension Prevention, Physical Activity Interventions.

It has been well established that routine physical activity (PA) can reduce blood pressure and decrease the risk of developing hypertension (DHHS, 1991; Healthy People 2010, 2000; NHBP, 1993). Achieving optimal blood pressure control is a major health concern for African American women. African American women have the highest prevalence of hypertension among women across all age groups (Burt et al., 1995; Healthy People 2010, 2000). Above the age of 59, African American women have the highest prevalence of hypertension across all race-gender groups (American Heart Association, 1999; He & Whelton, 1997). Physical activity has been defined as “bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive healthy benefits” (NIH Consensus, 1997, pg. 3). Current guidelines recommend that children and adults engage in moderate intensity PA on most, preferably all, days of the week (NHBP, 1993; CDC & ACSM, 1995). However, the majority of Americans are either sedentary or engage in PA on a sporadic basis (Anderssen et al., 1996; Dishman & Buckworth, 1996). Participation in PA is lower among African American women than all other race-gender groups except Mexican American women (Crespo, Keteyian, Heath, & Sempos, 1996; Kushner, Racette, Neil, & Schoeller, 1995). There is an urgent need for effective interventions to promote PA and decrease the negative outcomes secondary to hypertension among African American women (Healthy People 2010, 2000).

Understanding culture-based contextual factors is essential to the development of appropriate interventions (Banks-Wallace, 2000). Culture and daily experiences profoundly influence how people define or experience health, as well as, their choice of health behaviors (Boutain, 1999A; Gilliland et at, 1998; Eyler et al, 1997; Walcott-McQuigg, 1995).

This paper reports on findings from a study that examined African American women’s views regarding the significance of PA as a tool for decreasing cardiovascular risks secondary to hypertension. Particular attention is given to exploring how culture-based values and roles shape the contexts of women’s lives and influence PA behavior. These findings will be used to inform development of an intervention to promote routine PA among sedentary African American women at risk for negative cardiovascular health outcomes.


This study was conducted in a Midwestern city with a population of approximately 76,000. African Americans represented about 11% of the population. The study was grounded in womanist theory. Womanist epistemology centers the everyday experiences of African American women as a prerequisite to addressing philosophical problems related to the concepts of knowledge and truth (Collins, 1998). Banks-Wallace (2000) provides a fuller discussion of womanist theory.


A convenience sample of African American women was recruited through word of mouth, flyers placed around the community, and announcements in church bulletins. An African American woman who was well known and highly respected within the local community assisted in the recruitment process. Participation was open to all self-identified African American women who spoke fluent English and were at least 18 years of age. No one who met these criteria and wished to participate was excluded from the study. Participants received a $25 honorarium at the end of the first focus group. A catered lunch, from a restaurant owned by members of the local African American community, was provided for the second group.

Data Collection

The data for this study were transcribed from the audio-tapes of two 3-hour focus groups. The groups were facilitated by the principal investigator who is an African American woman. The purpose of the study was explained and questioned were answered before written consent was obtained from participants. Women completed a questionnaire at the beginning of each focus group, prior to the discussion. Questions were designed to elicit specific information with respect to (a) cardiovascular health history, (b) minutes spent each day on household related PA, (c) number of days per week where 5 or more minutes were spent on PA not related to work or household chores, and (d) preferred types of physical activity. The second questionnaire also examined factors relevant to the development of an intervention to promote PA_ Women were asked to identify (a) whether they preferred an individual or group intervention, (b) the preferred gender, age, and racial composition of potential group members, and (c) specific activities that would help them increase PA and decrease risk of heart disease. Group discussion was loosely guided by questions that facilitated conversation regarding (a) knowledge about heart disease, (b) personal experiences with heart disease, (c) the role of PA in promoting heart health, (d) barriers to PA, and (e) factors that promote PA. Participants were also encouraged to bring up any other issues they felt were relevant to the discussion.

Data Analysis

Major themes were abstracted from the transcripts using a modified version of the procedure developed by the author to interpret stories in an earlier study (BanksWallace, 1998). In the current study, both stories and non-story narratives were analyzed. This technique is akin to what Crabtree and Miller (1999) identify as an editing organizational style. Miller and Crabtree (1992) describe this procedure as a process in which, ‘the interpreter enters the text much like an editor, searching for meaningful segments, cutting, pasting, and rearranging until the reduced summary reveals the interpretive truth in the text’ (pg. 20). The investigator moved continually between the transcripts and audio-tapes during the analysis process. This was done to ensure that meaning carried by the tone of voice, silences, or group responses to the speaker were not lost (Boutain, 1999B). The participants’ full responses are presented whenever possible (Banks-Wallace, 1998). Interjections from other women in the group are included in parenthesis to give the reader a sense of how they responded to the speaker’s comments. Field notes, written at the end of the focus groups, were used to further contextualize the transcripts. Preliminary findings and the transcripts from the first focus group were shared with women during the second focus group. Their comments and suggestions were used to refine the preliminary analysis.


Several themes related to heart disease and the role of PA in promoting heart health were discussed during the focus group. This paper focuses exclusively on the impact that culture-based values and roles had on women’s incorporation of PA into their lifestyle. The overview of sample characteristics which precedes the discussion may help the reader to more fully appreciate how women’s contexts influenced their thoughts regarding PA.

Sample Characteristics

Twenty-six women, ranging in age from 23 to 72 years old participated in the study. Eighty five percent (n= 22) of the women participated in the first group and 46% (n = 12) participated in the second group. Thirty .one percent (n = 8) of the women participated in both focus groups. Forty six percent (n = 12) of the women were between the ages of 23 and 50 and 42% (n = 11) were between 51-72 years of age. Three women did not report their age, but appeared to fall within the above age range. Fifty eight percent (n = 15) of the women were single; 31 % percent (n = 8) were married or in a committed relationship; and 12% (n = 3) were widowed. Sixty two percent (n = 16) of the participants had some formal education beyond high school. Three women had gone to a trade school, one woman had an undergraduate degree, and six women had graduate degrees. Six women had attended college but had not completed a degree.

Women participating in this study were very concerned about improving their cardiovascular health. They had experienced a range of cardiovascular and related health issues. Thirty eight percent (n=10) of the women had experienced or currently experienced shortness of breath; 31% (n =8) had high blood pressure; 12% (n =3) had blood clots; 12% (n = 3) had diabetes. Fifteen % (n = 4) women had experienced either a heart attack (n = 1), stroke (n =1), blocked arteries ( n =1), or kidney failure (n =1). Only 15 % (n = 4) of the women reported that they smoked.

Household chores were the most frequent source of PA for participants. The majority of women spent significant amounts of time engaged in PA related to household chores. Fifty percent of the participants (n = 13) reported they spent more than 40 minutes a day on household related PA, and 69% (n =18) reported spending at least 30 minutes. Only one woman reported spending less than 10 minutes a day on household related PA Fifty eight percent (n = 15) of the women reported they engaged in some PA on a weekly basis that was not related to work or household chores. Thirty five percent (n = 9) women reported that they participated in this PA three or more days a week. Walking and dancing were by far the preferred forms of PA for the women, while lifting weights was a distant third. Seventy three percent (n =19 of the participants) reported that walking was their preferred form of PA, 46% (n = 12) enjoyed dancing, and 12% (n = 3) listed weight lifting as their favorite form of PA.

Familial and Communal Responsibility

Physical activity behavior was greatly influenced by culture-based values and roles related to self-care and care of others (Eyler et al., 1997; Masse, et al., 1998; Walcott-McQuigg, 1995). Women participating in this study felt a tremendous responsibility for their families and communities. Most had been raised to put family and community first. Almost every woman put the needs of others over their personal needs, and this led to a lack of time for self. This world view is shaped by a cultural reverence of the “Strong Black Woman” and a spirituality that emphasizes collective empowerment (Collins, 1990).

The assumption of a personal relationship with “The Spirit,” and the evaluation of individual well-being in the context of communal health are defining features of African/ American based spirituality (Dancy & WynnDancy, 1994; Haight, 1998; Stewart, 1997; WadeGayles, 1995). Women who were above the age of 50 talked extensively about God as the spiritual core of their lives. These women were passionate about demonstrating the love of God through their interactions with others. Many noted that they derived great pleasure from helping others. One of the eldest participants said,

… I do enjoy going and helping. I do a lot of going and helping others because that’s what its all about is helping each other and I really do a lot of that. I’m always trying to find time to help someone else. You’re supposed to look out for someone else before you look out for yourself..

Few of the younger women voiced this same spiritual foundation for their commitment. However, the majority of women across all age groups believed that the survival of their families and the larger community was dependent on their willingness to shoulder a heavy load.

The majority of women were staggering under the responsibilities associated with being a Strong Black Woman (Banks-Wallace & Parks, in press; Collins, 1998). For most women, being strong meant taking care of others before tending to self. Women noted that they had learned from their mothers and other women how to be strong. A 50 year old woman stated,

A friend of mine told me that Black women take care of everybody else [several women say “amen” to this] and so we manage to get the kids to school, to their play. We manage to get mom and dad where they need to go. We manage to get everybody where they need to go and they get to do what they need to do and we never prioritize ourselves in. We are always at the bottom. And I find even with my children gone, I put tutoring. I put other things ahead of my health. I’m kinda old enough to know better.

Many women felt guilty for needing some rest, noting that their mothers’ had put up with much more than themselves. As a woman explained,

At the same time, it comes from our mothers. Because they tolerated and they put up with a lot [they sure did]. You know, and at the same time, you know, we know that they were strong. And I guess that somewhere along the line we are still strong to a point, but our mothers were some strong Black women [that’s right]. We know they were. Because they put up with a lot more than we ever dreamed of today.

Physical problems limited women’s participation in PA but did not negate their familial or communal responsibilities. Difficulty breathing, pain, fatigue, and limited mobility were the factors that most often kept women from participating in PA. Some women felt that physical limitations could lead to depression, which in turn further limited PA. Many women were exhausted after honoring work, family, and communal obligations. They simply did not have energy left over for additional PA One woman commented,

Yes, I feel that exercise is important and I used to exercise a lot more often, but I developed some health problems. By the time I do things, get in and out of the car, and help take different people places, I don’t have enough energy to exercise. But, if I exercise, I don’t have the energy to take them where they are need to go (laughter) [yes]. And that bothers me because I do exercise. I enjoy being able to walk around the block, now I can’t, I kind of feel like if I tell them I don’t have time, I feel bad because I say it. Sometimes I say it in not such a nice way then I feel bad. Because I think well, 6 a.m. in the morning, the first thing I’m going to do is do my exercise. But invariably somebody will need me first thing in the morning and then I can’t…

Impact of Changing Communal Values on Workload

Inadequate social support limited the amount of time women had for themselves. A lack of family and friends to support one through life’s trials was repeatedly given as the number one barrier to making positive health changes. Inadequate support resulted in women not having appropriate child care, caring for multiple generations at once, being constantly bombarded with still more requests for assistance, and without exercise partners. Furthermore, a lack of social support left many women feeling all alone with their problems. The women were surprised to learn that so many other women shared similar circumstances. Women noted that family and community support were part of their childhood. They felt that this support had kept African Americans more healthy despite harsh environmental or social realities. A woman stated,

I think that goes back to part of the problem. I keep going back to history, our forefathers, our mothers had more to deal with than we have. But, yet they weren’t dying from heart problems like we are. I think it had to do with how they handled it. Their perspective of things and also again that strong family unit and that sense of community was there to pick you up when you fell…I think it has corroded over the years just like everywhere else and we are seeing the results of that… I think it goes back to, you know, we are dying because we don’t have the support we should have. It’s not just exercise, although that’s important, but I think you know breaking your heart also effects when you die [yes].

Many women attributed the deterioration in social support experienced in African American communities directly to a loss of traditional morals and spiritual values. Women noted that economic gains were accompanied by an emphasis on material possessions with a greatly diminished focus on God. As a result, personal gain overshadowed building up the larger community. A woman raised in the area lamented,

At one time we did have our village [yes we did]. But urban renewal came in. We got a couch more than we’re used to having, a TV more or car more than we are used to having. Until urban renewal came in, we had Black businesses, we had it all. What that neighbor needed that neighbor had… When urban renewal came in that’s all over. That’s when our village fell apart. Because coming up we know we had our village. It was there [that’s right]. They taught us good morals. They taught us to give. They taught us to share. It was there for us. Our grandmothers and our mothers and our fathers and our grandfathers. It was there. It’s just that with urban renewal we’ve lost our way. We forgot.

Now we’ve got young mothers that are raising children and some of them don’t even send their kids to Sunday School, won’t even bring them, won’t even bring themselves. When urban renewal came in and they tore down our shanties and we got our light switch we can flick on, we didn’t have to kick the toilet stool to close the door, our village fell apart. [We got too cute].

Perceptions about “Personal Time”

Many of the participants noted that finding time for one’s self was a critical prerequisite to deriving benefits from PA. However, deliberately setting aside time for self was incongruent with the normative value system of most of the women participating in this study. During the first focus group, the author asked, “In a 24-hour day, how many minutes of that day do you think would be okay to spend on yourseIf?” This question was followed by a long silence before women began to answer. Four women thought they could maybe take 1-2 hours. The majority of women replied that 30 minutes was probably the maximum time they could take for themselves. One woman expressed the groups’ sentiments in this way, “I”d take half. I wish I could take half.” Women were afraid that if they took more time for themselves, their families would suffer. This was something else they had learned from watching older Black women. As one woman explained,

They’d fall apart because as Black women what we have done is built ourselves to the point that we think if our family did not have us 24 hours a day they would fall apart. In our head is embedded, I don’t care what anybody says, if we are not there, our family is going to fall apart. It was embedded in us it was embedded in our mothers, it was embedded in our grandmothers.

Despite acknowledging they had inadequate social support and little time, women blamed their limited participation in PA on personal deficiencies. They frequently stated that their inability to get it all done was related to procrastination, poor motivation, low self-esteem, lack of organization, or a fear of failure. At the end of the first session, a young woman challenged other participants to rethink these notions.

I came in kind of late and I’ve been sitting here for the past hour and a half and I’m scratching my head because I’ve heard quite a few of you say that you are not exercising because you’re lazy and you’re procrastinators. But I don’t get that concept because you all are doing so much. You are raising children, you are taking care of parents. I heard somebody say that they have two jobs. If you were lazy and procrastinating, you couldn’t do all of that… I think you all need to acknowledge that. So if you want to take time and just not do anything, believe me you have deserved it [yes] and earned it. You’re more than tired women. I wanted to answer your question about what do you think needed to be said, because you all are not lazy. You are not procrastinators [Laughter and group talk].

Implications for the Design of Physical Activity Interventions

Women in this study were knowledgeable about heart disease and the benefits of PA with respect to promoting healthy hearts. The women were motivated to make PA a routine part of their lives because of personal and familial experiences. However, the majority of women were also overwhelmed by daily responsibilities and unsure of how to make the necessary changes to incorporate PA into their lifestyles. Furthermore, as more young people adopted materialistic and individualistic values, women who subscribed to traditional values were left shouldering increasingly greater responsibility for community wellbeing. Thus, women felt that instilling a communal consciousness into children and young adults, and establishment of adequate social support systems were essential components of being able to make sustainable changes in PA behavior.

Treating all people the same was a widely held value among women participating in this study. This made it difficult for most women to openly discuss their preference in relation to the racial-gender composition of a potential group intervention. Women repeatedly said they had no preference or would participate in a group with anyone during the taped portion of the second focus group. On the questionnaires, completed prior to the discussion, “a group level intervention with African American women of various ages” was unanimously selected as the preference of participants. This was out of eight possible choices that varied according to race, gender, and age of potential participants. However, it was only after one of the youngest participants stated that she would prefer a group comprised solely of African American women that other participants nodded in agreement. Later several women came up to the investigator and whispered that they too would like to be in a group with African American women.

The women were excited about continuing the work they had begun through the focus groups. Some women made plans to develop PA partnerships. Women felt that participating in this study was an important part of helping the larger community. One woman noted,

Can I say too that I like the fact that we have a Black researcher doing Black research on Black women [yes]. Eventually, hopefully down the road three years from now she will come up with some techniques that’s going to help Black women all over the country [amen]. That will be important to all of US.

The Potential of Spiritual and Cultural-based Group Interventions

Opportunities to share stories and build relationships with other women who embrace similar spiritual and cultural values may be an important strategies for promoting PA among African American women. (BanksWallace, 2000; Banks-Wallace & Parks, in press; BellScott, 1998; Brady, 1999; Wade-Gayles, 1995). Women spoke at length about how wonderful it was to come together to support one another and learn from each other. In particular, women were grateful for the opportunity to (a) talk to other women experiencing similar life situations, (b) spend time with women across a variety of ages, (c) to laugh together, and (d) to work collectively towards improving personal and communal health. These sentiments were reflected in the statement made by the following participant.

Oh, I appreciate this very much. I’ve learned quite a bit. I love to hear all of you talk. I got a whole lot out of it. I think about us being together. We can be some support to each other [yes] because we do need support… But anyway this is great that we can get together and laugh at simple things, you know [it sure is]. Because ifwe don’t have a little humor in life, where would we be [that’s right].. You know, so that’s why I’m saying, you know, we’ve got to get together and stay together and love one another.


The findings from this study indicate that African American women desire to participate in PA as a means of improving their health. However, interventions for promoting PA must take into consideration constraints stemming from cultural-based familial and communal obligations. Assisting women to work through problems and build support related to finding or taking time for themselves is crucial to the successful adoption of PA as a lifestyle. Group interventions that incorporate spiritual and/or cultural values and priorities may be especially attractive to African American women.


American Heart Association (1999). High blood pressure statistics [on line]. /Heart-and_Stroke_A_Z_Guide/hbps.html

Anderssen, N., Jacobs, D., Sidney, S., Bild, D., Sternfeld, B., Slatterly, M., & Hannan, P. (1996). Change and secular trends in physical activity patterns in young adults: A seven-year longitudinal follow-up in the Coronary Artery Risk Development in Young Adults Study (CARDIA). American Journal of Epidemiology, 143 (4), 351 – 62).

Banks-Wallace, J. (1998). Emancipatory potential of storytelling in a group. Image: Journal of Nursing Scholarship, 30 (1), 17 – 21.

Banks-Wallace, J. (2000). Womanist ways of knowing: Theoretical considerations for research with African American women. Advances in Nursing Science, 22 (3): 33-45.

Banks-Wallace, J. (In Press). There is a balm in Gilead: Storytelling as a healing resource for African American women. In, A. Cox and D. Albert (Eds.), Healing

Hearts: Storytelling as a tool for healing communities.

Banks-Wallace, J. & Parks, L. (In Press). So that our souls don’t get damaged: The impact of racism on

maternal practice and thinking. Issues in Mental Health Nursing.

Bell-Scott, P. (1998). Flat-footed truths: Telling Black women’s lives. New York: Henry Holt and Company.

Boutain, D. (1999A). Considerations in the development of knowledge: The case of race, class, and gender in high blood pressure research about African Americans. The Journal of Multicultural Nursing and Health, 5 (3): 23-8.

Boutain, D. (1999B). Critical language and discourse study: Their transformative relevance for critical nursing inquiry. Advances in Nursing Science, 21 (3): 1-8.

Brady, N. (1999). This Mother’s Daughter. Chicago: N. Brady. Burt, V., Whelton, P.; Rocella, E.; Brown, C., Brown, C., Cutler, J., Higgins, M., Horan, M., & Labarthe, D. (1995). Prevalence of hypertension in the US adult population: Results from the Third National Health and Nutrition Examination Survey, 1988 – 1991. Hypertension, 25 (3), 305-313.

Center for Disease Control and Prevention and American College of Sports Medicine (CDC & ACSM, 1995). Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA, 273 (5), 402 – 07.

Collins, P. H. (1990). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. Boston: Unwin Hyman.

Collins, P. H. (1998). Fighting words: Black women and the search for justice. Minneapolis: University of Minnesota Press.

Crabtree, B. & Miller, W. (1999). Doing Qualitative Research (2nd,ed.). Thousand Oaks, CA: Sage.

Crespo, C., Keteyian, S., Heath, G., & Sempos, C. (1996). Leisure time physical activity among US adults: Results from the Third National Health and Nutrition Examination Survey. Archives of Internal Medicine, 156 (2), 93 -98.

Dancy, J. & Wynn-Dancy, M. L. (1994). Faith of our Fathers (Mothers) living still: Spirituality as a force for the transmission of family values within the Black community. Activities, Adaptations, and Aging, 19 (2): 87-105.

Department of Health and Human Services Public Health Service (DHHS, 1991). Healthy People 2000: National Health Promotion and Disease Prevention Objectives: Full Report with Commentary (DHHS Publication No. PHS 9150212.Washington, D. C.: U.S. Government Printing Office.

Dishman, IL & Buckworth, J. (1996). Increasing physi cal activity: A quantitative synthesis. Medicine and Science in Sports and Exercise, 28 (6), 706 – 719.

Eyler, A., Brownson, IL, King, A., Brown, D, Donatelle, IL, & Heath, G. (1997). Physical activity and women

in the United States: An overview of health benefits, prevalence, and intervention opportunities. Women and Health, 26 (3), 27 – 49.

Gilliland S.S., Carter, J. S., Perez, G. E., Two Feathers, J., Kenui, C. K. & Mau, M. K. (1998). Recommendations for development and adaptation of culturally competent community health interventions in minority populations with type 2 diabetes mellitus. Diabetes Spectrum, 11 (3): 166-174.

Haight, W. (1998). AGathering the Spirit@ at First Baptist Church: Spirituality as a protective factor in the lives of African American children. Social Work: Journal of the National Association of Social Workers, 43 (3): 213

Healthy People 2010 (2000). [OnLine]. people. He, J., & Whelton, P. (1997). Epidemiology and prevention of hypertension. Medical Clinics of North America, 81 (5), 1077 – 97.

Kushner, R, Racette, S., Neil, K & Schoeller, D. (1995). Measurement of physical activity among black and white obese women. Obesity Research, 3 (2), 261s – 265s.

Masse, L.C., Ainsworth, B., Tortolero, S., Levin, S., Fulton, J. E., Henderson, K A., & Mayo, K (1998). Measuring physical activity in midlife, older, and minority women: Issues from an expert panel. Journal

of Women’s Health, 7 (1): 57 – 67.

Miller, W. & Crabtree, B. (1992). Primary care research: A multimethod typology and qualitative road map. In, B. Crabtree and W. Miller (Eds.), Doing qualitative research: Research methods for primary care, vol. 3 (pp. 3- 28). Newbury Park, CA. Sage.

National High Blood Pressure Education Program Working Group (NHBP, 1993). National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Archives of Internal Medicine, 153 ,186-208.

NIH Consensus Statement (1997). In, A. Leon (Ed.), Physical activity and cardiovascular health: A national consensus (pp.3-13). Champaign, IL: Human Kinetics.

Stewart, C. (1997). Soul survivors: An African American spirituality. Louisville, KY: Westminster Tafoya, T. (1994). Epistemology of Native healing and family psychology. The Family Psychologist, Spring: 28-31.

Wade-Gayle, G. (1995). My soul is a witness: African American women’s spirituality. Boston: Beacon Press.

Walcott-McQuigg, J. A. (1995). The relationship between stress and weight control behavior in African American women. Journal of the National Medical Association, 87 (6), 427 – 432.

JoAnne Banks-Wallace, PhD, RN

Acknowledgement: This study was funded by a minority supplement to Nursing Interventions to Enhance Older Women’s Exercise” (NR04521-SI), National Institute of Nursing Research. The author acknowledges the efforts of Judy Enyart, who recruited the participants for this study and the women who participated.

JoAnne Banks- Wallace, RN, PhD, Assistant Professor, Nursing and Women’s Studies, Sinclair School of Nursing 5324, University of Missouri, Columbia, MO.

Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Fall 2000

Provided by ProQuest Information and Learning Company. All rights Reserved