ASSIGNMENT:
Research your culture topic assigned to you. Explain
about the health practice, family dynamic, religious beliefs and anything else interesting that may affect health care:
A brief overview of the culture (religion, geography, government, gender roles, family roles, values, traditions)
Which of these are important specifically to you? Why?
What do you consider different about your cultural beliefs and practices compared to those of your research topic?
How can the Licensed Practical Nurse use this information?
African-Americans
Brenda Cherry, Yolanda Powell-Young and Joyce Newman Giger
Transcultural Nursing, 8, 159-207
Open reading mode
Behavioral objectives
After reading this chapter, the nurse will be able to:
1. Identify ways in which the African-American culture influences African-American individuals and their health-seeking behaviors.
2. Recognize the need for an in-depth understanding of variables that are common within and across cultural groups to provide culturally appropriate nursing care when working with African-Americans.
3. Recognize physical and biological variances that exist within and across African-American groups to provide culturally appropriate nursing care.
4. Develop a sensitivity and an understanding for communication differences evidenced within and across African-American groups to avoid stereotyping and to provide culturally appropriate nursing care.
5. Develop a sensitivity and an understanding for psychological phenomena that influence the functioning of an African-American when providing nursing care.
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In a time when people are seeking to become more culturally aware, it is important to note distinctions in terminology regarding cultural groups. This is certainly true of African-Americans. Some African-American individuals and groups are encouraging the use of the term Black Americans, whereas others are encouraging the use of the term African-Americans . The term African-Americans is used to refer to a cultural heritage that is a combination of African and American. On the other hand, the term Black Americans is believed to place more focus on biological racial identity than on cultural heritage. The term African-Americans is used in this book except in instances where its descriiptive characteristic is inappropriate, for example, Black skin, Black race, non-Black, Black English, and Black dialect. We have chosen these terms because they are now commonly used in the literature.
Overview of African-Americans
According to the U.S. Census Bureau, there are approximately 40,695,277 African-Americans residing in the United States, representing approximately 14.4% of the American population ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). Of the number of African-Americans residing in this country, 54.8% live in the South, 18.8% live in the Midwest, 17.6% live in the Northeast, and 8.8% live in the West ( U.S. Department of Commerce, Bureau of Census, American Community Survey, 2017 ). Although African-Americans live throughout the United States, the states with the greatest number of African-Americans are New York (3,362,736), California (2,451,453), Texas (2,898,143), Florida (2,916,174), and Georgia (2,907,944) ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ).
The cities with the most African-Americans are metropolitan New York City (3,362,616), Atlanta (1,707,913) Chicago (1,645,993), Detroit (980,451), Philadelphia (1,241,780), Houston (1,025,775), Memphis (414,928), and Dallas-Fort Worth (961,871) ( U.S. Census Bureau, Bureau of the Census, American Community Survey, 2017 ). In 2017, African-Americans represented more than 50% of the total population in 10 U.S. cities: Gary, Indiana (84.0%), Detroit (82.8%), Birmingham, Alabama (73.5%), Jackson, Mississippi (70.6%), New Orleans (67.3%), Baltimore (64.3%), Atlanta (61.4%), Memphis (61.4%), Washington, DC (60.0%), and Richmond, Virginia (57.2%) ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, Brief on the Black Population, 2017 ).
In 2015, the median age of African-Americans residing in the United States was 33.7 years, compared with 35.3 years for the rest of the general population ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). This is up from 29.2 years of age in 1990 and 30.2 years of age in 2000. African-American men have a lower mean age than African-American women (29.62 versus 33.7 years). In 2015, only 8.4% of African-Americans were 65 years of age or older, compared with 14% of their White counterparts and 13% of the rest of the general population. The number of African-Americans 65 years of age or older was 4,265,476 in 2010 (up from 2.5 million in 2000). It is interesting to note that in 2010 African-American women dominated the older age groups (62% versus 38% for their male counterparts). It is believed that the disproportionately low number of African-American males 65 years of age or older is a result of the higher mortality for African-American males ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ; U.S. Department of Commerce, Bureau of the Census, The Older Population in the United States, 2018 ). Where age is concerned, an interesting phenomenon is thought to occur for African-Americans and is referred to as the mortality crossover (“crossover phenomenon”). This phenomenon is thought to occur in African-Americans, and particularly African-American women at about 85 years of age. Many researchers postulate that the mortality for Blacks at this age is lower than that for Whites for the first time in the lifespan ( LaVist, 2005 ).
In 2010, 84.1% of African-Americans 25 years of age or older held at least a high school diploma, compared with 91.6% of their White counterparts. In 2015, only 12.8% of African-Americans 25 years of age or older held a bachelor’s degree or higher, which is down from 16.4% in 2000, compared with 21% for their White counterparts. Of the African-American males 25 years of age or older, 424,000 had less than a ninth-grade education; 1,178,000 had less than a high school degree with 9 to 12 years of education; 3,923,000 were high school graduates; 2,714,000 held an associate’s degree or had some college; 1,169,000 held a bachelor’s degree; and 610,000 held a graduate or professional degree. In contrast, of the African-American females 25 years of age or older, 544,000 had less than a ninth-grade education; 1,455,000 had less than a high school degree with 9 to 12 years of education; 4,086,000 were high school graduates; 3,906,000 held an associate’s degree or had some college; 1,709,000 held a bachelor’s degree; and 880,000 held graduate or equivalency or a professional degree ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ).
Historical account of African-Americans
From the sixteenth to the nineteenth centuries, more than 10 million Africans were brought to the United States and bonded into slavery ( Smith et al., 2015 ). In the classic work of Ploski & Williams, 1989 it is reported by historical accounts, nearly 600,000 slaves arrived in the United States in the sixteenth century, 2 million in the seventeenth century, 5 million in the eighteenth century, and 3 million in the nineteenth century. Because of these historical accounts, the perception held by most Americans is that African-Americans may be the only cultural and ethnic group who reside in the United States today who did not immigrate to this country voluntarily. Although this perception has merit, in reality, the history of the arrival of Africans in the United States has become somewhat distorted throughout the years. In actuality, many Europeans (meaning those persons of English, German, and Scotch-Irish ancestry) voluntarily immigrated to the American colonies as laborers and became “indentured servants” ( Osborne, 2016 ). Many of these people were paupers or debtors who used indentured servitude to gain a better way of life. The first 20 African-Americans to land at Jamestown in 1619 (preceding the Mayflower ) were accepted into the community as “indentured servants.” Although it is true that these 20 African-Americans did not have freedom of choice in the decision to come to the colonies because they were systematically captured against their will, they nonetheless, over the same course of time as European indentured servants (7 years), enjoyed the same liberties and privileges of the “free working class,” including the right to own property ( Osborne, 2016 ; Bly & Haygood, 2015 ).
Two of the most notable African-Americans who arrived in this country as “indentured servants” were Anthony Johnson, who became a “freeman” as early as 1622, and Richard Johnson. Anthony Johnson prospered so well that by 1651, he was able to acquire five “indentured servants.” Likewise, Richard Johnson, having been given 100 acres of land of his own, acquired two indentured servants by 1654, two of whom were White ( Smith et al., 2015 ). However, it is appropriate to note that both of these men were the exception, not the rule. In fact, a fissure was cracking open, and African-American servitude and White servitude were beginning to be viewed differently. By 1640, African-Americans had ceased to be viewed as servants and were assigned the status of chattel (meaning one who remained a fixed item of personal property for the duration of life). More importantly, in some states, laws began to differentiate between races and the association of “servitude for natural life” with people of African descent ( Von Sivers et al., 2015 ).
In 1661, the Virginia House of Burgesses formally recognized the institution of African-American slavery ( Von Sivers et al., 2015 ). Of the 13 original colonies, only Pennsylvania protested the system of slavery. By 1667, Virginia had written into its statutes that even purifying the African-American soul through baptism could not alter the condition of the African-American regarding bondage or freedom. Thus, color became the real cutting edge that separated the African, now American, from the rest of the colonists ( Von Sivers et al., 2015 ).
Even today, the cultural roots of African-Americans are entrenched in the African-American life experience. According to the classic work of Bloch (1983) , it is the African-American life experience that has established what has become known as the African-American view of the external world. The African-American life experience has shaped the internal attitudes and belief systems of African-Americans, and it continues to influence interactions of African-Americans with persons from other cultural groups.
Some of the health problems noted particularly in African-Americans are believed to be the result of varying genetic pools and hereditary immunity. However, many of these problems have been found to be more closely associated with economic status than with race. Three intervening and reinforcing variables are poverty, discrimination, and social and psychological barriers. These variables are regarded as being so profound in their effect on African-Americans that they tend to keep these individuals from using the health care services that are available. These variables may also explain why morbidity and mortality rates are higher among African-Americans than for the rest of the general population. Although underrepresented in the general population, African-Americans remain overrepresented among the health statistics for life-threatening illness.
The life expectancy for African-Americans, 75.1 years, continues to lag behind that for Whites, which is 78.9 years ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ; Centers for Disease Control and Prevention [CDC], Health United States, 2018 ). In 2015, the life expectancy for African-American men was 72.2 as compared with 76.6 for their White counterparts. Similarly, the life expectancy for African-American women was 78.5 compared with 81.3 for their White counterparts ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ; CDC, Health United States, 2018 ).
While overall the infant mortality rate in the United States declined slightly from 7.2 in 1990 to 5.96 in 2013, African-Americans continue to have a higher infant mortality rate (11.4 per 1000 live births in 2016) compared with White Americans (4.9 per 1000 live births in 2016) ( CDC, Health United States, 2018 ). Although the average life expectancy for African-Americans at birth edged upward to the middle 70s, and it improved ever so slightly for males, it is important to note that the life expectancy for African-American male babies born between 2000 and 2016 continues to shrink ( CDC, Health United States, 2018 ). A portion of the shrinkage is attributable to infant mortality, which is twice as high for African-American babies as for White babies. Yet another portion of the shrinkage is attributable to disparities in health concerns, especially chronic illnesses, which contribute significantly to premature deaths (before 65 years of age) among African-American males. In fact, in 2016, the rate of deaths for African-American males was 55% higher for heart disease, 26% higher for cancer, 180% higher for stroke, and 100% higher for lung disease than for the rest of the general U.S. population ( CDC, Health United States, 2018 ). Perhaps the greatest disparity was the rate of deaths or the potential for life lost for African-American males attributable to homicides, which was 630% higher, compared with White males ( CDC, Health United States, 2018 ). In health status disparities, African-American women do not fare much better than their male counterparts. When the life expectancy of White women is compared with the life expectancy of African-American women, African-American women have a shorter life expectancy (78 years versus 81.3 years) ( National Vital Statistics Report, 2018 ).
Communication
Communication is described as the matrix for thought and relationship between all people regardless of cultural heritage. Verbal and nonverbal communication is learned in cultural settings. Difficulties arise if a person does not communicate in the way or manner prescribed by the culture because the individual cannot conform to social expectations. Communication, therefore, is basic to culturally appropriate nursing care.
Dialect
Dialect refers to the variations within a language. African-Americans speak English; however, there are widespread differences in the way English is spoken between African-Americans and other ethnic and cultural groups. Different linguistic norms evolve among groups of people who are socially or geographically separated. Social stratification alters the nature and frequency of intercommunication among groups. When social separation by factors such as ethnic origin or class is responsible for the origin and perpetuation of a particular dialect, the dialect is referred to as a stratified dialect . When differences in dialect emerge as a result of geographical separation of people, the dialect is called a regional, or geographical, dialect.
Origins of African-American dialect in the United States.
According to the classic work of Turner, 1948 , accurate and reliable data concerning the different dialects spoken by most African-Americans are unavailable to the public or to educators. The study of pidgin and Creole language has facilitated an intelligent study of Black English and of the notable differences between Black English and Standard English ( Mazzon, 2016 ). Research into the languages of Brazilians of African descent, as well as Haitians, Jamaicans, and the present-day African-American inhabitants off the seacoasts of South Carolina and Georgia, indicates a correlation of structural features of several of the languages spoken in parts of West Africa, as well as a similarity to the English spoken by Whites in the United States ( Hymes, 1971 ; McWhorter, 2017 ; Kelley, 2016 ).
The first Africans brought to the United States as slaves were systematically separated during transportation, and this separation continued after arrival. African slaves may not have been forced to give up their African languages; however, they were thrown into situations in which learning a new language became a priority in establishing a way to communicate with slaves from other countries ( Kelley, 2016 ). As a result, the various African languages combined with the languages of other cultural groups in the New World, such as the Dutch, the French, and the English. This combination of the different African languages with other languages fostered a need for a “common language” for all African-Americans, which ultimately led to the restructuring of grammar of all languages, including English. This process is referred to as “pidginization” and “creolization.” Pidgin English is not a language but a dialect. Pidgin tends to be simple in grammar and limited in vocabulary. Typically, in communities where pidgin is spoken, its use is limited to trade purposes, task-oriented activities, and communication among cultural or ethnic groups ( Mazzon, 2016 ). When a pidgin dialect undergoes internal expansion and extension of use, the results are creolization. It is from a pidgin dialect that a Creole language was born. In the United States, several Creole dialects still exist, particularly in the rural South and in such places as New Orleans, Louisiana; Hattiesburg and Vicksburg, Mississippi; and Mobile, Alabama. Furthermore, the migration of African-Americans from the South saw the development of pidginization and creolization in some northern cities such as New York, Chicago, and Detroit. Evidences of past migration and its effect on dialect and Black English remain obvious even today.
Language usage.
The dialect that is spoken by many African-Americans is sufficiently different from Standard English in pronunciation, grammar, and syntax to be classified as Black English. The use of Standard English versus Black English varies among African-Americans and in some instances may be related to educational level and socioeconomic status, although this is not always the case. The use of Standard English by African-Americans is important in terms of social and economic mobility. However, the use of Black English has served as a unifying factor for African-Americans in maintaining their cultural and ethnic identity. This may explain why many African-Americans continue to speak Black English despite the social, economic, and educational pressures that are often exerted by members of other cultures ( McWhorter, 2017 ). Thus, it is not uncommon for some African-Americans to speak Standard English when serving in a professional capacity or when socializing with Whites and then revert to Black English when interacting in all–African-American settings. Some African-Americans who have not mastered Standard English may feel insecure in certain situations where they are required and expected to use Standard English. When confronted with such situations, they may become very quiet, with the result that they may be labeled hostile or submissive.
Pronunciation of Black English
There is a tendency for users of what is often referred to as “Black dialect” to pronounce certain syllables and consonants somewhat differently. For example, th, as in the, these, or them, may be pronounced as d, as in de , dese, and dem ( McWhorter, 2017 ). In Black English there is also a tendency to drop the final r or g from words; thus, father and mother become fatha and motha . The words laughing, talking , and going are pronounced laughin, talkin , and goin . Speakers of Black English may also place more emphasis on one syllable as opposed to another; for example, brother may be pronounced bro-tha . In addition, the final th of words is pronounced as f in Black English; thus bath, birth, mouth, and with are pronounced baf, birf, mouf, and wif ( McWhorter, 2017 ).
Copula deletion of the verb to be is a common omission in some environments; for example, the speaker of Black English might say, “He walking” or “She at work” in contrast to the Standard English “He is walking” or “She is at work.” Black English speakers may also use the unconjugated form of the verb “to be” where Standard English speakers would use the conjugated form. An example of this would be “He be working” in contrast to the Standard English “He is working.”
In Standard English every verb is in sequence and must be marked as either present or past tense. However, in Black English only past-tense verbs need to be marked. For example, in Black English the s marking the present tense may be omitted: thus “He go” or “She love.” Attempts to correct this can result in phrases such as “goes” and “We loves.” Speakers of Black English may also omit the possessive suffix. For example, in Black English one might say, “Richard dog bit me” or “Mary dress” in contrast to the Standard English “Richard’s dog bit me” or “Mary’s dress” ( McWhorter, 2017 .
Speakers of Black English also have some words that are classified as slang. These words are different from slang words used in other dialects and may or may not convey the same meaning. For instance, African-Americans may use the word chilly or chillin to infer sophistication, whereas a White individual may use the word cool or (formerly) groovy to convey the same meaning. Some African-Americans may use the verb to fix to denote planned actions, for example, “I’m fixin to go home,” whereas the user of Standard English would say, “I’m getting ready to go home.”
The speech of some African-Americans is colorful and dynamic. For these persons, communication also involves body movement (kinesics). Some African-Americans tend to use a wide range of body movement, such as facial gestures, hand and arm movements, expressive stances, handshakes, and hand signals, along with verbal interaction. This repertoire of body movements can also be seen in sports and in dance, which is the highest communicative form of body language.
Some African-Americans use sounds that are not words to add expression to their conversation or to music, such as oo-wee or uh huh, which have analogies in some of the West African languages as expressed in the surviving Gullah dialect (Sea Islands, South Carolina) but not in English.
The term signifying describes an approach wherein one attempts to chide or correct someone indirectly. For example, one might correct someone who is not dressed properly by saying, “You sure are dressed up today.”
According to the classic work of Dillard 1972 , most African-Americans use Black English in a systematic way that can be predictably understood by others; thus, Black English cannot and should not be regarded as substandard or ungrammatical. It is estimated that approximately 80% of African-Americans use Black English at least some of the time
Implications for nursing care
The nurse must develop a sensitivity to communication variances as a prerequisite for accurate nursing assessment and intervention in multicultural situations. In all nursing environments the potential for misunderstanding the client is accentuated when the nurse and the client are from different ethnic groups. Perhaps the most significant and obvious barrier occurs when two persons speak different languages. However, the nurse must be cognizant of the fact that barriers to communication exist even when individuals speak the same language. The nurse may have difficulty explaining things to a client in simple, jargon-free language to facilitate the client’s understanding. The nurse must develop a familiarity with the language of the client because this is the best way to gain insight into the culture. Every language and dialect are special and have unique ways of looking at the world and at experiences ( McWhorter, 2017 ). Every language also has a set of unconscious assumptions about the world and life. According to McWhorter (2017) , people see and hear what the grammatical system of their language makes them sensitive to perceive.
The nurse who works with African-American clients may find that although the language is the same, the perception of what message is being sent and received by the nurse and the client may be different. The important variables that may pose a problem for the nurse is the client’s interpretation of specific verbal and nonverbal messages, such as communication style, eye contact, and use of touch and space ( Taylor et al, 2019 ). Therefore, it is of the highest priority for the nurse who is working with African-Americans, particularly those who speak Black English, to understand as much of the context of the dialect as possible.
The nurse must bear in mind that Black English cannot be viewed as an unacceptable form of English. Thus, it is important for the nurse to avoid labeling and stereotyping the client. The nurse should avoid chiding and correcting the speech of African-Americans because this behavior can result in the client’s becoming quiet, passive, and, in some cases, aggressive or hostile. On the other hand, although the nurse should attempt to use words common to the client’s vocabulary, mimicking the client’s language can be interpreted as dehumanizing. For example, if a nurse were to say dem for them or dese for these, the client may perceive this as ridicule.
When working with persons who speak Black English, the nurse must keep in mind that the client may use slang to convey certain messages. However, slang terms often have different meanings among individuals and especially among cultural groups. For example, an African-American client’s response to questioning about a diagnostic test, “It was a real bad experience,” may actually mean that it was a unique and yet positive experience. The nurse working with this client will need to clarify the exact meaning of the word bad . In Black English the word bad is often used for the exact opposite, in other words, “good.” In another example, an African-American client who states that the medication has been taken “behind the meal” may mean the medication has been taken “after eating.” A nurse may interpret behind to mean “before” rather than “after” because the dictionary definition states that behind means “still to come.” The nurse must be cautious about interpreting particular words each time an African-American uses certain terms.
It is essential that the nurse identify and clarify what is happening psychologically and physiologically to the African-American client. When possible, the nurse should substitute words commonly understood by the African-American client for more sophisticated medical terms. When this is done, the nurse will find that the African-American client is more receptive to instructions and more cooperative. A classic work by Stokes (1977) offers a list of terms commonly used by nurses and equivalent words used by some African-Americans:
Conditions (Medical/Black English) Functions (Medical/Black English)
Diabetes/sugar
Pain/miseries
Syphilis/bad blood, pox
Anemia/low blood, tired blood
Vomiting/throwing up Constipation/locked bowels
Diarrhea/running off, grip
Menstruation/red flag, the curse
Urinate, urine/pass water, tinkle, peepee
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The nurse must remember that some African-Americans place a great deal of importance on nonverbal elements of communication and that the verbal pattern of some African-American clients may differ significantly from that of a non–African-American nurse. It is also important for the nurse to keep in mind that words used by some African-American clients may be the same as those used by the nurse but have different, idiosyncratic meanings. When working with African-American clients, the nurse must also remember that eye contact, nodding, and smiling are not necessarily essential or direct correlates that the African-American client is paying attention ( Sue, 2016 ).
Space
According to the classic work of Hall (1990) , the degree to which people are sensorially involved with each other, along with how they use time, determines not only at what point they feel crowded or have a perception that their personal space is collapsing inwardly but the methods for alleviating crowding as well. For example, Puerto Ricans and African-Americans are reported to have a much higher involvement ratio than other cultural groups such as German Americans or Scandinavian Americans. It is believed that highly involved people, such as African-Americans, require a higher density than less involved people. However, highly involved people may at the same time require more protection or screening from outsiders than people with a lower level of involvement do.
To understand the variable of space, it is essential to understand time and the way it is handled because the variable of time influences the structuring of space. According to the classic work of Hall (1990) , there are two contrasting ways in which people handle time, monochronic and polychronic, and each affects the way in which an individual perceives space. People with low involvement are generally monochronic because such individuals tend to compartmentalize time; for example, they may schedule one thing at a time and tend to become disoriented if they have to deal with too many things at once. On the other hand, polychronic individuals tend to keep several operations going at once, almost like jugglers, and these individuals tend to be very involved with each other.
Implications for nursing care
The nurse who works with Latin Americans, Africans, African-Americans, or Indonesians may feel somewhat uncomfortable because these cultures generally dictate a much closer personal space when personal and social spaces are involved ( Taylor, 2019 ). Because some African-Americans are perceived as polychronic individuals, it is important for the nurse to remember that polychronic individuals tend to collect activities.
When polychronic individuals interact with monochronic individuals, some difficulties may be experienced because of the different ways in which these individuals relate to space and to each other. An example of a difficulty encountered between monochronic and polychronic individuals is when monochronic individuals become upset or angry because of the constant interruptions of polychronic individuals.
Some monochronic individuals believe that there must be order to get things done. On the other hand, polychronic individuals, such as some African-Americans, do not believe that order is necessary to get things done. The nurse who works with African-Americans must keep in mind that to reduce polychronic effects, it is necessary to reduce multiple-activity involvements on the part of the client. The nurse can accomplish this by separating activities with as much screening and scrutiny as necessary ( Hall, 1990 ). One goal of nursing intervention should be to help the client structure activities in a ranked order that will produce maximal benefits for the client.
Social organization
Social organization refers to how a cultural group organizes itself around particular units (such as family, racial or ethnic group, and community or social group). Most African-Americans have been socialized in predominantly African-American environments. Historically, because of legalized segregation, African-Americans were separated or isolated from the mainstream of society. Consequently, African-Americans are the only cultural group in the United States that has not been assimilated into the mainstream society. Even today, African-Americans maintain separate and, in most cases, unequal lifestyles compared with other Americans. Evidence of the failure to assimilate on the part of African-Americans is seen in the existence of predominantly African-American neighborhoods, churches, colleges and universities, and public elementary and high schools.
Historical review of slavery and discrimination
Patterns of discrimination have existed in the United States since the inception of slavery. With the inception of slavery came the foundations of attitudes and beliefs that were and continue to be the pillars that support the institution of racism. Racism, discriminatory practices, and segregation combined have produced insularity or separatist feelings and attitudes on the part of some African-Americans. As a result, African-Americans are often accused of having more separate and more insular patterns of communication, which have restricted some African-Americans from participating in the wider White society. Thus, some African-Americans prefer to maintain themselves within their own group. Accordingly, this insularity has promoted the retention of culturally seeded beliefs that differ from the beliefs held by the dominant culture. Lim (2015) noted that every cultural group has unique beliefs that influence their attitudes regarding health. These beliefs tend to determine the types of behavior and health care practices that a particular cultural group views as appropriate or inappropriate. In other words, the attitudes and beliefs regarding health and illness vary in the United States between African-Americans and Whites and even among African-Americans themselves.
Attitudes, beliefs, values, and morals are the basic structural units of any culture. Culture is an outward manifestation of a way of life; it is dynamic, fluid, and ever evolving. The family is the basic social unit of most cultures and is the means by which culture is passed down from one generation to the next. The inception of slavery in the United States precipitated the beginning of the destruction of the transplanted African culture. In Africa, Africans had been accustomed to a strictly regulated family life with rigidly enforced moral codes. A classic work of Jones, 1998 , explains that the family unit was close knit, well organized, connected with kin and community, and highly functional for the economic, social, psychological, and spiritual well-being of the people. The family was the center of African civilization.
The destruction of the African family began with the capture of slaves for transplantation to the New World, which began in 1619. As slaves were captured, the young, healthy men, women, and children were forcibly removed from their families and tribes. This separation continued as these slaves journeyed to the New World because they were placed on ships without regard for family unity, tribe, or kinship. On the arrival of the slaves in the United States, this systematic separation of individuals from families persisted.
The cruelest form of emasculation of the Black Africans, now Americans, was the breeding of slaves for sale. Infants and children were taken from their mothers and sold as chattel. Marriage between slaves was not legally sanctioned and generally left to the discretion of the owners. Some slave owners assigned mates when slaves reached breeding age. Others would not permit their slaves to marry a slave from another plantation. Most slave owners sold husbands, wives, and children without consideration for family ties. The children who were produced of the slave union belonged to the slave owner, not to the parents. The African-American family in the United States during slavery lacked autonomy because the family members were someone else’s property. The parents were unable to provide security or protection for their children. Husbands were unable to protect their wives. In the classic work of Angelou (1989) the heartbreaking tenderness of African-American women and the majestic strength they needed to survive the subjugation and horror of the slavery experience is highlighted.
In contrast to this view of the destruction of the African-American family during slavery, it is argued that the African-American family was not disaggregated because of slavery. In fact, the classic work of Gutman (1976) presents compelling evidence to suggest not only that some African-American families remained intact during slavery but also that many slave marriages were officially documented, as were the names of their offspring. Gutman (1976) cautions, however, that no more misleading inference could be drawn from these data than to argue that the data alone show that slaves lived in stable families.
Changing roles of the African-American family
Under the system of slavery in the United States, the role of the African-American man as husband and father was obliterated. The African-American man was not the head of the household, nor was he the provider or the protector of his family. Instead, he was someone else’s property. Under the system of slavery, the African-American man remained powerless to defend his wife and children from harm, particularly when they were beaten or sexually assaulted by the White overseer or owner or by any other White person. The African-American male slave was often referred to as “boy” until he reached a certain age, at which point he became “uncle.” The only crucial function for the African-American man within the African-American family was siring children.
In the United States under the system of slavery, the African-American woman became the dominant force in the family. She was forced to work side-by-side with her male counterpart during the day and had the additional responsibility of caring for family members at night. The African-American woman was forced to bear children for sale and to care for other children, including those of the slave owner. Some African-American women during slavery were also forced to satisfy the sexual desires of any White man, and any children born out of this union were considered slaves. If the African-American woman had a husband, he was merely her sexual companion and was referred to as her “boy” by the slave owner and by White society in general. The inception of slavery, the division of the African family and subsequently the African-American family, and the subordinate role of the African-American man played a significant part in the establishment of the female-dominated African-American household that exists even today in the United States.
Even after slavery was abolished in the United States, the destructive forces against the African-American family persisted. Today, the residual effects of slavery are still evident in some parts of the country. After slavery was abolished and during the emancipation period and the years that followed, the African-American man was either denied jobs or given tasks that were demeaning and dehumanizing. From the time of the abolition of slavery until the mid-1960s, African-Americans in some parts of the country were attacked, lynched, and murdered. Sexual attacks on African-American women also continued. Such actions further served to drive some African-American men away from their families. Thus, there was further weakening of the family and subsequently of the African-American male role ( Greenbaum, 2015 ). Despite the discriminatory practices and the continued hostile attacks against African-Americans, some African-American families nevertheless were able to establish themselves. As these African-American families were increasingly able to develop a secure economic status, they began to establish schools, churches, and other social organizations.
Characteristics of the African-American family
In the United States, there are basically two types of family structures: the male-headed (patriarchal) family structure and the female-headed (matriarchal) family structure. In 2017, the number of African-American female-headed households was creeping slowly downward. In 2010, such families constituted 27.9% of African-American families. In addition, between 1950 and 2017, the number of African-American female-headed householders who had never been married quadrupled, from 9% in 1950 to 49.9% in 2015 ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). The fact that approximately half of the African-American families in the United States are female-headed is attributable in part to factors related to and carried over from slavery. For example, the African-American family has not been able to overcome deficits related to education and income. According to the U.S. Department of Commerce, Bureau of the Census, American Community Survey (2017) , the average income for African-American men, compared with men in other cultural groups with similar skills and educational levels, is significantly lower. African-American males, in particular, have not made significant strides in gaining entry into the workforce since the 1980 census ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). The annual labor participation rate for African-American males in 2010 dropped slightly from the 1990 and 2000 (65.3%) data to 63.2%, compared with 70.6% in 1980. In 2010, 65.5% of African-American men and 63.2% of African-American women participated in the workforce, compared with 74.3% of White men and 60.3% of White women ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). Overall, African-Americans are less likely to participate in the workforce than other racial and ethnic groups. Whereas the median household income (which takes into account all sources of income, including full- and part-time jobs and interest income, for a household) for the nation was $45,320, it was only $39,879 for African-Americans; in comparison, for their White counterparts the median income was $65,000. The median earnings figure for African-Americans for males (which takes into account only full-time work status) was only $38,344, as compared with $45,485 for the rest of the general population ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ). In addition, the median earnings figure for African-American females ($31,546) was disproportionately lower than that of the rest of the general population ($35,299) ( U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2017 ).
Implications for nursing care
Even today, the African-American family is often oriented around women; in other words, it is matrifocal. This has implications for the nurse because within the African-American family structure, the wife or mother is often charged with the responsibility for protecting the health of the family members. The African-American woman is expected to assist each family member in maintaining good health and in determining treatment if a family member is ill. This responsibility has both positive and negative effects because African-American clients often enter the health care delivery system at the advice of the matriarch of the family. The nurse must recognize the importance of the African-American woman in disseminating information and in assisting the client in making decisions. Although the African-American family may be matrifocal, it is nevertheless essential to include the African-American man in the decision-making process.
Some African-American families are composed of large networks and tend to be very supportive during times of crisis and illness. Large network groups can have both positive and negative effects on wellness, illness, and recovery behaviors ( Boyd, 2018 ; Lim, 2015 ). Jackson, Neighbors, and Gurin (1986) in their classic work found that network size was positively related to distress: the more informal helpers there were, the higher the distress score on the instrument used in the survey. One conclusion of the study is that network size is not a good measure of perceived social support. According to the findings from the study, the more serious the problem, the more people within the network are consulted for help. But a greater number of people consulted does not necessarily reduce the severity of the problem; rather, an individual with an acute illness may spend so much time seeking assistance within the network that necessary and timely treatment is delayed. The nurse should include all the members of the network in planning and implementing health care because some members of the network may provide advice or care that could be detrimental to the client. For example, an African-American client who is admitted with an electrolyte imbalance and is brought laxatives from home by a relative may have additional electrolyte problems when the laxatives are taken without consulting members of the health care team. In this case the nurse must emphasize the importance of the nurse’s role in providing health care. Once the family develops a feeling of trust, the nurse is more likely to be consulted should perceived health needs arise, for example, when the client needs a laxative.
Time
Time is a concept that is universal and continuous. All emotional and perceptual experiences are interrelated with the concept of time. Hall, 1989 states in his classic work that the perception of time is individual and determined by cultural experience In the United States, time has become the most important organizing principle of the dominant culture ( Hall, 1989 ). The majority of individuals of the dominant culture are time conscious and very future oriented; they make it a common practice to “plan ahead” and “save for a rainy day.” Time has become very important and comparable to money in the American society. Doing things efficiently and faster has become the American way.
It is impossible to characterize African-Americans and their perceptions of time as one way or the other because African-Americans, just as individuals from other cultural groups, vary according to social and cultural factors. Some African-Americans who have become assimilated into the dominant culture are very time conscious and take pride in punctuality. These individuals are likely to be future oriented and believe that saving and planning are important. They are likely to be well educated and to hold professional positions, although this is not always the case, because some African-Americans who are not well educated and do not hold professional jobs still value time and have hopes for the future (and are likely to encourage their children to seek higher education and to save for the future) ( Dayar-Berenson, 2014 ).
On the other hand, some African-Americans react to the present situation and are not future oriented; it is their belief that planning for the future is hopeless because of their previous experiences and encounters with racism and discrimination. They believe that their future will be the same as their present and their past ( Dayar-Berenson, 2014 ). These individuals are likely to be jobless or have low-paying jobs. Educational levels may vary from junior high school to college degrees among persons who share this belief. Such individuals are unlikely to value time; thus, they do not value the concept of punctuality and may not keep appointments or arrive much later than the scheduled time. It is the belief of some African-Americans that time is flexible and that events will begin when they arrive. This belief has been translated down through the years to imply an acceptable lateness among some African-Americans of 30 minutes to 1 hour. According to the classic work of Mbiti, 1990 , this perception of time can be traced back to West Africa, where the concept of time was elastic and encompassed events that had already taken place as well as those that would occur immediately
Finally, some African-Americans have a future-oriented concept of time because of their strong religious beliefs. These individuals may be from all socioeconomic and educational levels. It is their belief that life on Earth, with all its pain and suffering, is bearable because there will be happiness and lack of pain after death. African-Americans who hold this belief plan their funerals and even purchase their grave plots long before their deaths ( Smith, 1976 ).
Implications for nursing care
Because some African-Americans perceive time as flexible and elastic, it is essential for the nurse to include the client and family in the planning and implementation of nursing care. When planning nursing care with the client and family, the nurse should emphasize events that have flexibility where time is concerned, such as morning care and bathing. On the other hand, the nurse must also emphasize events that have no flexibility where time is concerned and where delay in doing something, such as taking time-release medications or medications for certain conditions, would have serious implications for the client’s well-being. For example, a client with high blood pressure must be made to understand that the medication must be taken as and when prescribed, not as and when desired. A medication missed today cannot be made up by taking double the amount tomorrow. As another example, a client with type 1 diabetes cannot delay the time between meals.
Some African-Americans are perceived as individuals with present-time orientations. Such persons may have a more flexible adherence to schedules and may believe that immediate concerns are more relevant than future concerns. Because appointment schedules may lack meaning, the nurse must emphasize the importance of adhering to the appointment schedule. If the nurse knows a particular client has a pattern of arriving late, the nurse may advise that client to arrive for scheduled appointments at least half an hour early. For the nurse who works with clients who are focused on the present, it is essential to avoid crisis-oriented nursing and promote preventive nursing ( Sue, 2016 ).
Environmental control
Health care benefits
In the United States the system of health care beliefs and practices is extremely complex and diverse among cultural groups. Variations in health care beliefs and practices cross ethnic and social boundaries. These variations are evidenced even within families. Culture influences individual expectations and perceptions regarding health, illness, disease, and symptoms related to disease. Accordingly, in the classic work of Anderson & Bauwens 1981 , there is support of the fact that culture, cultural beliefs, and cultural values influence how one copes when confronted with illness, disease, or stress.
In the United States, a distinction between “illness” and “disease” has been made by anthropologists and sociologists ( Staples, 1976 ). Illness has been defined as an individual’s perception of being sick, which is not necessarily related to the biomedical definition of disease. Disease has been defined as a condition that deviates from the norm. Thus, illness may exist in the absence of disease and vice versa ( Staples, 1976 ). Norms used to determine a disease condition, by Western standards, have for the most part been taken from studies conducted on White subjects. Thus, when these norms are applied to other cultural groups, such as African-Americans, the norm values may be meaningless and lead to erroneous conclusions. For example, to receive a 2 for color on the Apgar scoring system for newborns, the infant must be completely pink. Another example of a Western norm expectation is that an inverted T wave may be an ominous, pathological finding. However, in the case of African-Americans and particularly African-American men, such a finding should be the expectation, rather than being perceived as ominous and pathological. Also, growth as related to body size and physique is often normed by White Western standards. Thus African-Americans, who mature at an earlier age and typically have larger physiques than those of their White counterparts, may be perceived as being either overweight or oversized when White Western norms are applied.
Health care beliefs and the African-American family
African-Americans in the United States are a highly heterogeneous group; thus, it is impossible to make a collective statement about their health care beliefs and practices. In the classic work of Smith (1976) , it is noted that many health care beliefs that are exhibited by African-Americans in the United States are derived from their African ancestry. For example, in West Africa, where most African-Americans originated, man was perceived as a monistic being, that is, a being from which the body and soul could not be separated ( Smith, 1976 ). Man was also perceived as a holistic individual with many complex dimensions. Religion was interwoven into health care beliefs and practices. (West Africans continue even today to believe that illness is a natural occurrence resulting from disharmony and conflict in some area of the individual’s life.) Because life was centered on the entire family, illness was perceived as a collective event and subsequently a disruption of the entire family system. The traditional West African healers always involved the individual’s entire family in the healing process, even when the disorder was believed to be somatic. Thus, the traditional West African healer-based treatment on the premise of wholeness, the necessity for reincorporation of the client into the family system, and involvement of the entire family system in the care and treatment of the individual ( Treas & Wilkinson, 2014 ).
Perception of illness.
In the United States some African-Americans perceive illness as a natural occurrence resulting from disharmony and conflict in some aspect of an individual’s life. This belief is a cultural value that has been passed down through the generations to African-Americans as a result of West African influences and tends to involve three general areas: (1) environmental hazards, (2) divine punishment, and (3) impaired social relationships ( Snow, 1977 ). An example of an environmental hazard is injuries as the result of being struck by lightning or bitten by a snake. Divine punishment might include illnesses or diseases that the individual attributes to sin. Impaired social relationships may be caused by such factors as a spouse leaving or parents disowning a child ( Snow, 1977 ).
Another belief held by some African-Americans is that everything has an opposite. For every birth, there must be a death; for every marriage, there must be a divorce; for every occurrence of illness, someone must be cured ( Snow, 1978 ). Some African-Americans may not be able to distinguish between physical and mental illness and spiritual problems and as a result may present themselves for treatment with a variety or combination of somatic, psychological, and spiritual complaints ( Smith, 1976 ). For example, a client may present real symptoms of an ulcer but relate the symptoms to past sins or grief over a financial loss. The client desires assistance not only for the somatic disorder but also for the psychological and spiritual complaints.
African-Americans who share mainstream attitudes about pain may respond to pain stoically out of a desire to be a perfect client. This means that they tend not to “bother” the nurse by calling for attention or for pain medication. For such clients the nurse must make it clear that the client has a right to relief from pain. On the other hand, some African-American clients exhibit a different form of stoicism. Hard experience has convinced them that trouble and pain are God’s will. In this case the nurse needs to help the client understand that pain retards healing and is medically undesirable ( Taylor, Lillis, & Lynn, 2015 ; Treas & Wilkinson, 2014 , Taylor et al., 2019 ).
Folk medicine
Complementary alternative medicine, which includes folk medicine, is germane to many cultural and ethnic groups. Individuals from all aspects of society may use folk medicine either alone or with a scientifically based medical system. The importance of folk medicine and the level of practice vary among the different ethnic and cultural groups, depending on education and socioeconomic status. In contrast to the scientifically based health care system in the United States, folk medicine is characterized by a belief in supernatural forces. From this perspective, health and illness are characterized as natural and unnatural.
According to the classic work of Snow (1983) , it matters whether an African-American person comes from a rural background when it is necessary to select health care providers. Some African-Americans who were reared in the rural South may have grown up being treated by folk practitioners and may not have encountered a physician until they reached adulthood. Therefore, these people are more likely to turn to a neighborhood folk practitioner when they become ill. According to Hazzard-Donald (2013) , folk medicine is still used within the African-American community because of the humiliation encountered in the mainstream health care system, lack of money, and lack of trust in health care workers. Today, some African-Americans go to physicians in order to get prescribed medications, not because they believe the physician is superior in knowledge or training.
Witchcraft, voodoo, and magic are an integral aspect of folk medicine ( McKenzie & Chrisman, 1977 ). Natural events are those that are in harmony with nature and provide individuals who believe in and practice folk medicine with a certain degree of predictability in the events of daily living. Unnatural events, on the other hand, represent disharmony with nature, and so the events of day-to-day living cannot be predicted ( Harley, 2006 ; Hinkle & Cheever, 2018 ). Another aspect of the folk medicine system is a belief in opposing forces—that everything has an opposite. For example, for every birth, there must be a death. Also incorporated into the system of folk medicine is the belief that health is a gift from God, whereas illness is a punishment from God or a retribution for sin and evil ( Harley, 2006 ; Hinkle & Cheever, 2018 ; Vaughn, Jacquez, & Baker, 2009 ). This concept is evidenced by the belief held by some African-Americans that if a child is born with a physical handicap, it is a punishment from God for the past wrongdoings of the parents. In this way, sins of the father and mother are passed on for retribution by the children ( Snow, 1983 ). Such beliefs are not limited to African-Americans but are also found among other cultural groups in the United States; for example, some Mexican Americans believe that illness is a punishment for some sin or misdeed ( Hinkle & Cheever, 2018 ).
Practice of African-American folk medicine.
Some African-Americans in the rural South and in the urban northern ghettos still practice folk medicine based on spirituality, including witchcraft, voodoo, and magic ( Harley, 2006 ; Taylor, 2019 ). Some of these individuals may also use the orthodox medical system. Historically, such cities as New Orleans and Baton Rouge, Louisiana, were very much voodoo oriented, and such beliefs were held not only by African-Americans but also by members of other cultural groups. Even today, the African-American folk medicine system is practiced by the high-ranking voodoo queen in some Louisiana cities. The Louisiana Voodoo Society is a carryover from a combination of Haitian and French cultural influences ( Dayar-Berenson, 2014 ; Lim, 2015 ; Hinkle & Cheever, 2018 ). Voodoo and witchcraft are not restricted to Louisiana and are also practiced in such places as the Georgia sea islands, which are just off the coast of Savannah. Interestingly enough, some of the inhabitants of the Georgia sea islands remain pure-blooded descendants of West African ancestry. Wolfram and Clark (1971) state in their classic work that even today, some people there have refused to intermarry with members of other cultural groups, thus maintaining the tradition of “pure-blooded” lineage. Pure-blooded descendants of West Africans are also found off the coast of South Carolina. A few of these people still speak Gullah (English with an admixture of various African languages) and tend to isolate themselves when possible from the mainstream of society ( Wolfram & Clark, 1971 ).
African-American folk medicine system defined.
In the system of African-American folk medicine, illness is perceived as either a natural or an unnatural occurrence. A natural illness may occur because of exposure to the elements of nature without protection (such as a cold, the flu, or pneumonia). Natural illnesses occur when dangerous elements in the environment enter the body through impurities in food, water, and air. However, the words natural and unnatural are connoted to mean more or less than the dictionary definitions of these words. For example, cancer, which is linked to such environmental hazards as smog, cigarette smoke, toxic waste, and other chemical irritants, is considered a natural illness in a professional medical system. However, those persons who share beliefs in African-American folk medicine might view cancer as an unnatural illness, perceiving it as a punishment from God or a spell cast by an evil person doing the work of the devil ( Harley, 2006 ; Vaughn et al., 2009 , Hinkle & Cheever, 2018 ). Such persons may not readily acknowledge the fact that cancer, for example, may be caused by environmental factors such as cigarette smoking; thus, they may continue smoking even after being diagnosed with cancer. Unnatural illnesses are perceived as either a punishment from God or the work of the devil. This perception is in contrast to the dictionary definition of illness as an unhealthy condition of the body or mind.
Types of folk practitioners.
Distinct types of folk practitioners are identified in the classic work of Jordan (1975) . The first type is the “old lady” or “granny” who acts as a local consultant. This individual is knowledgeable about many different home remedies made from certain spices, herbs, and roots that can be used to treat common illnesses. Another duty of this individual is to give advice and make appropriate referrals to another type of practitioner when an illness or a particular medical condition extends beyond her practice ( Jordan, 1975 ). The second type of practitioner is the “spiritualist,” the most prevalent and diverse type of folk practitioner. This individual attempt to combine rituals, spiritual beliefs, and herbal medicines to effect a cure for certain illnesses or ailments. The third type of practitioner is the voodoo priest or priestess. In some West Indies islands, the voodoo practitioner can be a man, whereas in some rural southern areas of the United States, the voodoo practitioner must be a woman and may inherit this title only by birthright and a perceived special gift ( Snow, 1974 ).
In contrast to the type of voodoo priest or priestess found in some West Indies islands and in some rural or urban southern U.S. areas is the type of voodoo priest or priestess found in some larger urban areas such as Chicago; Queens, especially the neighborhood of Jamaica, in New York City; or Los Angeles. In these cities the voodoo folk practitioner may be either male or female, does not have to inherit the right to practice by virtue of bloodline, and does not have to possess significantly powerful gifts ( Snow, 1974 ). Historically, the voodoo priestess found in cities such as New Orleans must possess certain physical characteristics; that is, she must be African-American, and more specifically she must be of mixed ancestry, either an octoroon (a person of one-eighth Black ancestry) or a quadroon (a person of one-fourth Black ancestry) if her powers are to be superior ( Snow, 1974 ).
Even today, some African-Americans still turn to one of these three types of practitioners when seeking medical advice. Educational level or socioeconomic status does not appear to alter or affect how some African-Americans perceive folk practitioners. Similar views are shared by some members of other cultural groups. In the summer of 1988, newspaper articles throughout the United States carried the story that the First Lady of the United States refused to make any moves or to allow her husband, the president of one of the most powerful countries in the world, to make decisions unless an astrologer was consulted.
Witchcraft: An alternative form of folk medicine.
The practice of witchcraft is widespread and is not limited to the boundaries of the United States. Various degrees of witchcraft are practiced in countries throughout the world. In
