JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(3), 161-169 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Cultural Impact of Health-Care Access: Challenges for Improving the Health of African Americans Kathleen Russell,
RN,MSN
Ball State University
Nancy Jewell, MPA Indiana State Department of Health
Disparities in health status of African Americans continue to exist. These disparities of poor health, in part, are attributed to decreased access to healthcare services. However, culture plays a key role in health-care utilization patterns among African Americans. The purpose of this article is to examine cultural factors that affect health-care practices among African Americans and to identify specific community health nursing interventions that integrate these factors into health-care plans for African-American families and communities.
Many barriers to accessible health-care services have been identified for African Americans. The predominate barriers include inability to pay for services, lack of transpartation and child care, decreased understanding of treatment plans, and inability to incorporate prescribed health plans into daily living patterns. Furthermore, the African-American population's cultural beliefs and health practices have a significant impact upon their well-being regardless of their income and educational levels. Consequently, these health beliefs and practices affect utilization of contemporary health-care service delivery systems wen when other barriers have been eliminated. The purpose of this article is to explore avenues for increasing access and utilization of health-care services for African Americans by minimizing sociocultural barriers and integrating nontraditional health beliefs and practices into traditional health-aare settings. An overview of the current health status of African Americans is preseflted, followed by an examination of the impact of their sociocultural beliefs and lifestyle practices on health promotion, disease prevention, and health-care maintenance. Community health nursing interventions that are culturally specific are described and linked within the context of the existing health-care delivery system. Requests for reprints should be sent to Kathleen Russell, RN, MSN,Assistant Professor, Ball State University, School of Nursing, Muncie, IN 47306-0265
162
Russell and Jewel1 CURRENT HEALTH STATUS OF AFRICAN AMERICANS
The health status of African-American families continues to worsen even with the upward mobility of African Americans into mainstream American society and the remarkable advancements in medical technology. Preventable conditions such as cancer and uncontrolled hypertension and diabetes continue to escalate in the Black adult population at much more alarming rates than in the nonminority population. Blacks are approximately 1.3 times as likely to die from cancer than Whites, 1.5 times to die from heart disease, 2 times from stroke, and 2.5 times from complications of diabetes (United States Department of Health and Human Services [USDHHS], 1990). Infant mortality and unintentional and intentional injury deaths are major contributors to excess deaths among Black children and youth. Black infants die at twice the rate of White infants from causes such as low birth weight; Black children die at 1.5 times the rate of White children from unintentional injuries, and Black male adolescents and young adults die at 7 times the rate of their White counterpart from homicide (National Center for Health Statistics, 1991; USDHHS, 1990). Significant differences exist between life expectancies for race and gender with Black men being 64.9 years and White men 72.3 years, and for Black women being 73.4 years and White women 78.9 years (National Center for Health Statistics, 1991). At least 60% of this disparity in decreased life expectancy of African Americans is due to premature deaths from cardiovascular diseases, homicide, malignant neoplasms and infant mortality. The remaining differences in disparity are attributed to a significant proportion of premature deaths from acquired immunodeficiency syndrome (AIDS), drug- and alcohol-related conditions, cerebrovascular diseases, diabetes, and unintentional injuries (National Center for Health Statistics, 1991). The reasons for the health discrepancies among African Americans are multifaceted and complex. A disproportionate number of Blacks lack financial access to the health-care system. According to a report from the U.S.General Accounting Office (1991), Blacks are more than 2.5 times as likely to be uninsured than Whites. lkenty percent of Blacks have no access to primary health-care providers (USDHHS, 1990). Financial health-care access is not the sole determinant of health-care utilization in African Americans. Research shows that when income and education are controlled, health status indicators consistently are poorer for Blacks than for Whites (National Center for Health Statistics, 1991). In the African-American population, culture appears to play a major role in health-care practices and health beliefs. These practices and beliefs can affect an individual's utilization of wellness and illness health-care services (USDHHS, 1985).
CULTURE AND HEALTH-CARE UTILIZATION
The concept of culture has been studied widely. Although several definitions of culture exist, a common theme can be found among these definitions. The commonal-
Cultural Impact of Health-Care Access
163
ity in definitions of culture is that culture is the sum total of a society's custom, habits, beliefs, and values (Kroeber & Cluckhohn, 1983). Beds (1967) defined culture as ideas, feelings, and practices that individuals adopt as members of a system. This system is composed of people, tradition, material objects, and habitually performed activities. According to Murdock (1972), culture is a combination of habitually pqrformed behaviors, intelligence for problem solving, communication through languqge, and the existence of social life or a society. Leininger (1970) defined culture a$ a way of life which directs the actions and thoughts of a group of people. Cultutie has a significant influence on the health practices of people (Leininger, 1978). Differences in health behaviors will vary among people of various cultures. A ftamework has been developed within health services research for analyzing utilization of health-care services (Aday & Anderson, 1974; Anderson & Newman, 1973). Health-care service utilization is directly related to factors within the healthcare delivery system and to the population targeted for services. Utilization of services is characterized by the type of care received, the site of delivered care, the purpose of the health encounter, the number of visits made, and the time period for rendered care. Utilization patterns will vary for preventive, illness-related and maintenancb care. The health-care delivery system is composed of resources and organization componentls that affect utilization. The resource components include labor and capital for heilth care. The organization components are the entry for gaining access to the system and the structure for the delivery of services that are delivered. The service populaltion components that impact utilization are delineated into predisposing, enabling, and need factors. Predisposing factors include demographic, social structural, and attitudinal-belief characteristics. Enabling factors are conditions that make Mealth-care services available to an individual. The need factors are the perceptiorls that the individual has about the necessity to use the health-care delivery system to remedy actual or potential health problems. Aspects of culture are embedded within the framework of the predisposing and need ~QmponentSof the service population. Characteristics of the African-American population and of the health-care delivery system must be considered in order to increase the utilization of health-care services among African Americans.
HEALTH BELIEFS AND PRA(=TICES
Differences in health beliefs and practices can be observed among African Americans in varying age groups, socioeconomic levels, and geographic locales. These differences often result from the degree of the African-American population's assimildtion into the predominate society. However, common cultural threads can be identified among African Americans. These commonalities include religious orientatio4, social support networks, and informal health-care systems. Religion is a central force within the lives of many African Americans. The roots of religiion stem back to traditional African religions in which religion filtered
164
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throughout all aspects of African family and community life, including work, education, recreation, and health (Mbiti, 1989). Rather than dichotomize health into physiological and psychological components as defined within the traditional science oriented framework of health, African Americans characterize health as a continuum evolving around mind, body, and spirit (Spector, 1985). In her study of rural Blacks, Roberson (1985) found religion to be linked with health beliefs. God was seen as protecting the individual's health. Health was believed to be a gift or blessing from God. By being close to God, one was protected from harmful sources such as evil spirits, stress, fate, and sin. Illness was perceived to be alleviated through strong faith in God as a healer and in the power of prayer. A common method of treating health concerns within the African-American family and community is through prayer (Spector, 1985). Gibson (1982) found that Black adults were more likely to use prayer as a means of coping with worries than were White adults. Support systems, which are often utilized by African Americans, have a significant role in the lives of individuals. These support systems include significant others who may or may not be related by blood or marriage. In times of crisis and stress African Americans are more likely to rely on the family network, both nuclear and extended, than on outside traditional health and human service community agencies (McAdoo, 1977). Lassiter (1987) found that the family was a major source of support for African Americans as opposed to friends or religion in times of stress. In a national study of Black middle-aged and older adults, Gibson (1982) found that these adults were more likely to use multiple family members for support with worries than their White counterparts. Findings from this study also showed that as Blacks grew older, their use of this family network increased. Informal health-care systems within the African-American community often are consulted. A national study showed that 87% of Black Americans reported using an informal social network in dealing with a personal health problem (Neighbors, 1985). Baker and Cook (1983) found that in the event of an illness, Black women, from ages 27 to 55, were more likely to consult family members and friends than the professional health-care system. St. Clair and Anderson (1989) found that pregnant inner city women, of whom 78% were Black, received a medium number of 20 health advice messages from up to 19 support individuals (the medium number of advisors were five). The network most frequently included mothers, sisters, and partners followed by friends, neighbors, and extended family members. The health advice received was generally sound although a few of the messages did cause expectant mothers some worry. CULTURAL VALUES: IMPACT ON HEALTH
Predominant cultural values among White American society conflict and differ with those of African origin. White American values espouse individualism, owner-
Cultural Impact of Health-Care Access
165
ship, autonomy, independence, mastery of the environment, youth, planning and efficiency, progress, and the future (Pinderhughes, 1982). In contrast, values of West Africa, from where most African Americans are descended, emphasize affiliation, collectivity, sharing, obedience of authority, spirituality, acceptance of fate, respect for the elderly, and the past (Pinderhughes, 1982). The predominant cultural values thread throughout modern society in daily living experiences, including the curriculum of health professionals and the health-care delivery system. West African values infiltrate the daily lives of African Americans. These values influence how health and illness are viewed within Black families and communities as well as how health is promoted and illnesses are treated by African Americans. The traditional African views of health and illnesses were that health was achieved when one was in harmony with nature, whereas illness occurred when one was in disharmony (Spector, 1985). lladitional treatment of illness for African Ameriaans relied upon herbs, roots, and voodoo (Spector, 1985). Gradually these treatment modalities integrated health practices of American Indians and Whites (Spector, 1985). Healthcare regimes within the current health-care delivery system often fail to fully integrate cultural values of African Americans. Studies have shown that cultural values of Blacks have influenced the degree of adherence they had with healthcare treatment regimes (Berg & Berg, 1989; Gabriel & McAnarney, 1983; Parraga, Weber, Engel, Reeb, & Lerner, 1988; Scupholme, Robertson, & Karnons, 1991).
COMMUNITY HEALTH NURSING INTERVENTIONS
Cultural values which relate to health and illness practices of African Americans should be incorporated into the health-care delivery system. Values, beliefs, and standards of the racial/ethnic minority client, the health provider, and the healthcare institution must be identified and combined into a plan of care which is appropriate for the client (Louie, 1985). Strategies for providing improved culturally sensitive care include: (a) magnifying the involvement of the African-American commuoity in the needs assessment, program design, service implementation, and the proeess and outcome evaluation of health services delivery; (b) tapping into already established informal and formal community networks for health-care services utilization; and (c) restructuring internal health-care delivery services to be culturally sensitive. Community involvement
Programs that are initiated should include input from representatives of the AfricanAmerican community where services are provided. Evaluation of the health programs is crucial for identifying health outcomes of the service population as well as utiliaation rates. Community representatives should be part of the evaluation team in designing the evaluation plan and discussing the implications the evaluation
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results have for the target population, their families, and the community. Modifications of the program should be possible and determined by process and outcome evaluation results. When evaluating the organization of services for effective utilization by AfricanAmerican clients and families, input from the service population must be sought in developing the evaluation design and content and in planning the data collection procedures within the Black community. Results of the evaluation should be presented to the service population and community representatives. These individuals should be able to negotiate and jointly plan with providers for the restructuring of services to better meet the needs of clients. These service changes in part will be dependent on the standards, resources, and other organizational requirements of the health-care facility and personnel. Modifying the operation of services can enhance utilization of health care by African Americans. When services were restructured in one primary health-care facility in Baltimore, Black families significantly increased their utilization of services for their children as compared to White families who showed no significant changes in utilization (Tangerose Orr, Miller, & James, 1984). The program modifications included decreasing time required for obtaining an appointment, providing a daily 24-hr telephone answering service, increasing privacy of clients within the healthcare facility, and providing consistency of health personnel through the assignment of the same primary care provider and team members to each family. Community Networks
Significant others such as family, friends, and religious associates should be considered in developing plans of care. Joint planning of care by the community health nurse (CHN)should be initiated with the social support network as well as with the client. Social support needs may vary with each client and should be readily assessed. For example, Uzoma and Feldman (1989)found that adherence to diabetic treatment regimes were more likely to occur in inner city Black women than in men when both groups were provided with satisfying support persons. Outreach efforts to African-American communities must include nontraditional methods. Informal communication networks within the community should be identified and utilized as avenues for reaching the potential service population. These networks include formal and informal community leaders as well as frequented geographic locations within or outside the community. For example, providing information to church mothers (respected older women in Black churches) or posting information in barber and beautician shops are methods of increasing the awareness of the community about available health-care services. Informing Black-oriented institutions and organizations about the health program provides opportunities for increasing awareness about health services to African Americans. Such entities include social clubs, fraternities, sororities, Black professional groups, economic and educational development organizations, and civil rights agencies. In addition to sharing program information, the C H N can
Cultural Impact of Health-Care Access
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recruit representatives from these entities to participate in program planning and evaluation activities and in other health-care agency operations that affect the African-American community. The church can be used as a mechanism for increasing health-care utilization. The sacial networks within the church have a positive impact on health promotion, early detection of disease, and health maintenance. Positive responses have been shown with church-based hypertension screening and monitoring programs (Saunders & Kong, 1983) and alcohol rehabilitation programs (Prugh, 1988). CHNs can assist ahurch health workers in developing effective support skills which can be used in hedth maintenance activities for church members. However, the CHN should have an understanding of the spiritual beliefs of church leaders and the congregation, such as acknowledging the importance and role of prayer in health and illness. With the assistance of the clergy and church lay leaders, these beliefs should be incorporhted into training programs for church health workers. Assilsting African-American communities to engage in health promotion activities can be effectively done through community development action (Braithwaite & Lythcdtt, 1989; Braithwaite, Murphy, Lynthcott, & Blumenthal, 1989) and community planning (Doyle, Smith, & Hosokawa, 1989). The CHN can be advisory to the neighborhood board by providing information about the incidence and severity of health problems within the African-American community and ways to use the health-care delivery system to prevent or ameliorate these problems. Although all areas af community needs in addition to those pertaining to health (e.g., needs related to education, employment, and political activism) should be assessed, the CHN c m provide input into the development of community needs assessment tools and the analysis of data that address the health component. Health providers should recognize that immediate needs and community plans for interventions may not pertain to potential or existing health problems. However, future goals for health that combine culturally sensitive and creative methods for community health promotion activities can be jointly planned between community members and the CHN. Internal Operations CHNs must assess individual's and families's beliefs about potential and existing health problems and subsequent treatments. These assessment data must be integrated into a comprehensive plan of care. For example, a particular herb tea espoused by the family members as effective may be appropriate when given in combination with a prescribed drug. Assessment information should be obtained about uses of informal lay health networks before and throughout the course of illness and during wellness. Health promotion practices should be identified, evaluated for their efficacy, and integrated into wellness plans. For example, by assisting the family in developing time management skills for prayer and spiritual meditation, the CHN may increase the effectiveness of stress reduction programs that prescribe exercise and rest.
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The CHN also should be aware of her/or his own culture and how those cultural beliefs influence the care that is prescribed and rendered. The attitudes and feelings of CHNs and other health-care providers, who are also ethnic persons, are a function of their cultural and professional experiences (Pinderhughes, 1982). The type and quality of an interaction between the health provider and client is influenced by the provider's own values (Scholz, 1990). Ethnocentrism or believing that one's culture is superior to other cultures and the labeling of other cultures as inferior or disadvantaged (Spector, 1985) further deteriorates relationships between the health provider and client. Skepticism about the health-care system by African Americans is reinforced by these negative attitudes and utilization of health services are delayed or avoided. Communication between CHNs and other health-care providers and AfricanAmerican clients should be promoted. Intercultural communication, a process of transmitting and receiving information between two culturally different individuals (McCormack, 1987)' is a necessary component for care of clients. By learning about the culture of African Americans, accepting the differences within the culture, assessing individual health beliefs and practices, and integrating these beliefs and practices into plans of care, intercultural communication with AfricanAmerican clients and families can be enhanced. African-Americans are a unique and diverse group of people. Variations exist in their health beliefs and practices. Although similar experiences are threaded within their lifestyle and cultural makeup such as spirituality, family and social networks, and lay health-care systems, each individual and family should be assessed for their own unique perceptions of their health needs and for cultural factors that influence how health problems will be managed or prevented. The CHN is challenged to evaluate the existing health-care delivery system for its effects on utilization by Blacks and to integrate strategies that are more responsive to the health needs of the African-American family and community.
REFERENCES Aday, L. A., & Anderson, R. (1974). A framework for the study of access to medical care. Health Services Research, 9, 208-220. Anderson, R., & Newman, J. F. (1973). Societal and individual determinants of medical care utilization in the United States. The Milbank Memorial Fund Quarterly, 51, 95-124. Baker, A., & Cook, G. S. (1983). Stress, adaptation and the black individual. Journal of Nursing Education, 22,237-242. Beals, A. R. (1%7). Culture in process. New York: Rinehart & Winston. Berg, J., & Berg, B. L. (1989). Compliance, diet and cultural factors among Black Americans with end-stage renal disease. Journal of National Black Nurses' Associafion, 3, 16-28. Braithwaite, R. L., & Lythcott, N. (1989). Community empowerment as a strategy for health promotion for black and other minority populations. Journal of the American Medical Association, 261, 282-283. Braithwaite, R. L., Murphy, F., Lythcott, N., & Blumenthal, D. S. (1989). Community organization and development for health promotion within an urban black community: A conceptual model. Health Education, 20, 56-60.
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Doyle, E., Smith, C. A., & Hosokawa, M. C. (1989). A process evaluation of a community-based health promotion program for a minority target population. Health Education, 20, 61-64. Gabriel, A., & McAnarney, E. R. (1983). Parenthood in two subcultures: White, middle-class couples and black, low-income adolescents in Rochester, New York. Adolescence, 18, 595-608. Gibson, R. C. (1982). Blacks at middle and late life: Resources and coping. American Academy of Political and Social Science, 464, 79-90. Kroebar, A. L., & Cluckhohn, C. (1%3). Culture: A critical review of concepts and definitions. New York: Vintage. Lassiter, S. M. (1987). Coping as a function of culture and socio-economic status for Afro-Americans and Afro-West Indians. Journal of the New York State Nurses Association, 18, 18-30. Leininqer, M. (1970). Nursing and anthropology: 7bo worlds to blend. New York: Wiley. Leinin$er, M. (1978). lkznscultuml nursing: Concepts, theories and practices. New York: Wiley. Louie, I
Cultural Impact of Health-Care Access: Challenges for Improving the Health of African Americans Kathleen Russell,
RN,MSN
Ball State University
Nancy Jewell, MPA Indiana State Department of Health
Disparities in health status of African Americans continue to exist. These disparities of poor health, in part, are attributed to decreased access to healthcare services. However, culture plays a key role in health-care utilization patterns among African Americans. The purpose of this article is to examine cultural factors that affect health-care practices among African Americans and to identify specific community health nursing interventions that integrate these factors into health-care plans for African-American families and communities.
Many barriers to accessible health-care services have been identified for African Americans. The predominate barriers include inability to pay for services, lack of transpartation and child care, decreased understanding of treatment plans, and inability to incorporate prescribed health plans into daily living patterns. Furthermore, the African-American population's cultural beliefs and health practices have a significant impact upon their well-being regardless of their income and educational levels. Consequently, these health beliefs and practices affect utilization of contemporary health-care service delivery systems wen when other barriers have been eliminated. The purpose of this article is to explore avenues for increasing access and utilization of health-care services for African Americans by minimizing sociocultural barriers and integrating nontraditional health beliefs and practices into traditional health-aare settings. An overview of the current health status of African Americans is preseflted, followed by an examination of the impact of their sociocultural beliefs and lifestyle practices on health promotion, disease prevention, and health-care maintenance. Community health nursing interventions that are culturally specific are described and linked within the context of the existing health-care delivery system. Requests for reprints should be sent to Kathleen Russell, RN, MSN,Assistant Professor, Ball State University, School of Nursing, Muncie, IN 47306-0265
162
Russell and Jewel1 CURRENT HEALTH STATUS OF AFRICAN AMERICANS
The health status of African-American families continues to worsen even with the upward mobility of African Americans into mainstream American society and the remarkable advancements in medical technology. Preventable conditions such as cancer and uncontrolled hypertension and diabetes continue to escalate in the Black adult population at much more alarming rates than in the nonminority population. Blacks are approximately 1.3 times as likely to die from cancer than Whites, 1.5 times to die from heart disease, 2 times from stroke, and 2.5 times from complications of diabetes (United States Department of Health and Human Services [USDHHS], 1990). Infant mortality and unintentional and intentional injury deaths are major contributors to excess deaths among Black children and youth. Black infants die at twice the rate of White infants from causes such as low birth weight; Black children die at 1.5 times the rate of White children from unintentional injuries, and Black male adolescents and young adults die at 7 times the rate of their White counterpart from homicide (National Center for Health Statistics, 1991; USDHHS, 1990). Significant differences exist between life expectancies for race and gender with Black men being 64.9 years and White men 72.3 years, and for Black women being 73.4 years and White women 78.9 years (National Center for Health Statistics, 1991). At least 60% of this disparity in decreased life expectancy of African Americans is due to premature deaths from cardiovascular diseases, homicide, malignant neoplasms and infant mortality. The remaining differences in disparity are attributed to a significant proportion of premature deaths from acquired immunodeficiency syndrome (AIDS), drug- and alcohol-related conditions, cerebrovascular diseases, diabetes, and unintentional injuries (National Center for Health Statistics, 1991). The reasons for the health discrepancies among African Americans are multifaceted and complex. A disproportionate number of Blacks lack financial access to the health-care system. According to a report from the U.S.General Accounting Office (1991), Blacks are more than 2.5 times as likely to be uninsured than Whites. lkenty percent of Blacks have no access to primary health-care providers (USDHHS, 1990). Financial health-care access is not the sole determinant of health-care utilization in African Americans. Research shows that when income and education are controlled, health status indicators consistently are poorer for Blacks than for Whites (National Center for Health Statistics, 1991). In the African-American population, culture appears to play a major role in health-care practices and health beliefs. These practices and beliefs can affect an individual's utilization of wellness and illness health-care services (USDHHS, 1985).
CULTURE AND HEALTH-CARE UTILIZATION
The concept of culture has been studied widely. Although several definitions of culture exist, a common theme can be found among these definitions. The commonal-
Cultural Impact of Health-Care Access
163
ity in definitions of culture is that culture is the sum total of a society's custom, habits, beliefs, and values (Kroeber & Cluckhohn, 1983). Beds (1967) defined culture as ideas, feelings, and practices that individuals adopt as members of a system. This system is composed of people, tradition, material objects, and habitually performed activities. According to Murdock (1972), culture is a combination of habitually pqrformed behaviors, intelligence for problem solving, communication through languqge, and the existence of social life or a society. Leininger (1970) defined culture a$ a way of life which directs the actions and thoughts of a group of people. Cultutie has a significant influence on the health practices of people (Leininger, 1978). Differences in health behaviors will vary among people of various cultures. A ftamework has been developed within health services research for analyzing utilization of health-care services (Aday & Anderson, 1974; Anderson & Newman, 1973). Health-care service utilization is directly related to factors within the healthcare delivery system and to the population targeted for services. Utilization of services is characterized by the type of care received, the site of delivered care, the purpose of the health encounter, the number of visits made, and the time period for rendered care. Utilization patterns will vary for preventive, illness-related and maintenancb care. The health-care delivery system is composed of resources and organization componentls that affect utilization. The resource components include labor and capital for heilth care. The organization components are the entry for gaining access to the system and the structure for the delivery of services that are delivered. The service populaltion components that impact utilization are delineated into predisposing, enabling, and need factors. Predisposing factors include demographic, social structural, and attitudinal-belief characteristics. Enabling factors are conditions that make Mealth-care services available to an individual. The need factors are the perceptiorls that the individual has about the necessity to use the health-care delivery system to remedy actual or potential health problems. Aspects of culture are embedded within the framework of the predisposing and need ~QmponentSof the service population. Characteristics of the African-American population and of the health-care delivery system must be considered in order to increase the utilization of health-care services among African Americans.
HEALTH BELIEFS AND PRA(=TICES
Differences in health beliefs and practices can be observed among African Americans in varying age groups, socioeconomic levels, and geographic locales. These differences often result from the degree of the African-American population's assimildtion into the predominate society. However, common cultural threads can be identified among African Americans. These commonalities include religious orientatio4, social support networks, and informal health-care systems. Religion is a central force within the lives of many African Americans. The roots of religiion stem back to traditional African religions in which religion filtered
164
Russell and Jewel1
throughout all aspects of African family and community life, including work, education, recreation, and health (Mbiti, 1989). Rather than dichotomize health into physiological and psychological components as defined within the traditional science oriented framework of health, African Americans characterize health as a continuum evolving around mind, body, and spirit (Spector, 1985). In her study of rural Blacks, Roberson (1985) found religion to be linked with health beliefs. God was seen as protecting the individual's health. Health was believed to be a gift or blessing from God. By being close to God, one was protected from harmful sources such as evil spirits, stress, fate, and sin. Illness was perceived to be alleviated through strong faith in God as a healer and in the power of prayer. A common method of treating health concerns within the African-American family and community is through prayer (Spector, 1985). Gibson (1982) found that Black adults were more likely to use prayer as a means of coping with worries than were White adults. Support systems, which are often utilized by African Americans, have a significant role in the lives of individuals. These support systems include significant others who may or may not be related by blood or marriage. In times of crisis and stress African Americans are more likely to rely on the family network, both nuclear and extended, than on outside traditional health and human service community agencies (McAdoo, 1977). Lassiter (1987) found that the family was a major source of support for African Americans as opposed to friends or religion in times of stress. In a national study of Black middle-aged and older adults, Gibson (1982) found that these adults were more likely to use multiple family members for support with worries than their White counterparts. Findings from this study also showed that as Blacks grew older, their use of this family network increased. Informal health-care systems within the African-American community often are consulted. A national study showed that 87% of Black Americans reported using an informal social network in dealing with a personal health problem (Neighbors, 1985). Baker and Cook (1983) found that in the event of an illness, Black women, from ages 27 to 55, were more likely to consult family members and friends than the professional health-care system. St. Clair and Anderson (1989) found that pregnant inner city women, of whom 78% were Black, received a medium number of 20 health advice messages from up to 19 support individuals (the medium number of advisors were five). The network most frequently included mothers, sisters, and partners followed by friends, neighbors, and extended family members. The health advice received was generally sound although a few of the messages did cause expectant mothers some worry. CULTURAL VALUES: IMPACT ON HEALTH
Predominant cultural values among White American society conflict and differ with those of African origin. White American values espouse individualism, owner-
Cultural Impact of Health-Care Access
165
ship, autonomy, independence, mastery of the environment, youth, planning and efficiency, progress, and the future (Pinderhughes, 1982). In contrast, values of West Africa, from where most African Americans are descended, emphasize affiliation, collectivity, sharing, obedience of authority, spirituality, acceptance of fate, respect for the elderly, and the past (Pinderhughes, 1982). The predominant cultural values thread throughout modern society in daily living experiences, including the curriculum of health professionals and the health-care delivery system. West African values infiltrate the daily lives of African Americans. These values influence how health and illness are viewed within Black families and communities as well as how health is promoted and illnesses are treated by African Americans. The traditional African views of health and illnesses were that health was achieved when one was in harmony with nature, whereas illness occurred when one was in disharmony (Spector, 1985). lladitional treatment of illness for African Ameriaans relied upon herbs, roots, and voodoo (Spector, 1985). Gradually these treatment modalities integrated health practices of American Indians and Whites (Spector, 1985). Healthcare regimes within the current health-care delivery system often fail to fully integrate cultural values of African Americans. Studies have shown that cultural values of Blacks have influenced the degree of adherence they had with healthcare treatment regimes (Berg & Berg, 1989; Gabriel & McAnarney, 1983; Parraga, Weber, Engel, Reeb, & Lerner, 1988; Scupholme, Robertson, & Karnons, 1991).
COMMUNITY HEALTH NURSING INTERVENTIONS
Cultural values which relate to health and illness practices of African Americans should be incorporated into the health-care delivery system. Values, beliefs, and standards of the racial/ethnic minority client, the health provider, and the healthcare institution must be identified and combined into a plan of care which is appropriate for the client (Louie, 1985). Strategies for providing improved culturally sensitive care include: (a) magnifying the involvement of the African-American commuoity in the needs assessment, program design, service implementation, and the proeess and outcome evaluation of health services delivery; (b) tapping into already established informal and formal community networks for health-care services utilization; and (c) restructuring internal health-care delivery services to be culturally sensitive. Community involvement
Programs that are initiated should include input from representatives of the AfricanAmerican community where services are provided. Evaluation of the health programs is crucial for identifying health outcomes of the service population as well as utiliaation rates. Community representatives should be part of the evaluation team in designing the evaluation plan and discussing the implications the evaluation
166
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results have for the target population, their families, and the community. Modifications of the program should be possible and determined by process and outcome evaluation results. When evaluating the organization of services for effective utilization by AfricanAmerican clients and families, input from the service population must be sought in developing the evaluation design and content and in planning the data collection procedures within the Black community. Results of the evaluation should be presented to the service population and community representatives. These individuals should be able to negotiate and jointly plan with providers for the restructuring of services to better meet the needs of clients. These service changes in part will be dependent on the standards, resources, and other organizational requirements of the health-care facility and personnel. Modifying the operation of services can enhance utilization of health care by African Americans. When services were restructured in one primary health-care facility in Baltimore, Black families significantly increased their utilization of services for their children as compared to White families who showed no significant changes in utilization (Tangerose Orr, Miller, & James, 1984). The program modifications included decreasing time required for obtaining an appointment, providing a daily 24-hr telephone answering service, increasing privacy of clients within the healthcare facility, and providing consistency of health personnel through the assignment of the same primary care provider and team members to each family. Community Networks
Significant others such as family, friends, and religious associates should be considered in developing plans of care. Joint planning of care by the community health nurse (CHN)should be initiated with the social support network as well as with the client. Social support needs may vary with each client and should be readily assessed. For example, Uzoma and Feldman (1989)found that adherence to diabetic treatment regimes were more likely to occur in inner city Black women than in men when both groups were provided with satisfying support persons. Outreach efforts to African-American communities must include nontraditional methods. Informal communication networks within the community should be identified and utilized as avenues for reaching the potential service population. These networks include formal and informal community leaders as well as frequented geographic locations within or outside the community. For example, providing information to church mothers (respected older women in Black churches) or posting information in barber and beautician shops are methods of increasing the awareness of the community about available health-care services. Informing Black-oriented institutions and organizations about the health program provides opportunities for increasing awareness about health services to African Americans. Such entities include social clubs, fraternities, sororities, Black professional groups, economic and educational development organizations, and civil rights agencies. In addition to sharing program information, the C H N can
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recruit representatives from these entities to participate in program planning and evaluation activities and in other health-care agency operations that affect the African-American community. The church can be used as a mechanism for increasing health-care utilization. The sacial networks within the church have a positive impact on health promotion, early detection of disease, and health maintenance. Positive responses have been shown with church-based hypertension screening and monitoring programs (Saunders & Kong, 1983) and alcohol rehabilitation programs (Prugh, 1988). CHNs can assist ahurch health workers in developing effective support skills which can be used in hedth maintenance activities for church members. However, the CHN should have an understanding of the spiritual beliefs of church leaders and the congregation, such as acknowledging the importance and role of prayer in health and illness. With the assistance of the clergy and church lay leaders, these beliefs should be incorporhted into training programs for church health workers. Assilsting African-American communities to engage in health promotion activities can be effectively done through community development action (Braithwaite & Lythcdtt, 1989; Braithwaite, Murphy, Lynthcott, & Blumenthal, 1989) and community planning (Doyle, Smith, & Hosokawa, 1989). The CHN can be advisory to the neighborhood board by providing information about the incidence and severity of health problems within the African-American community and ways to use the health-care delivery system to prevent or ameliorate these problems. Although all areas af community needs in addition to those pertaining to health (e.g., needs related to education, employment, and political activism) should be assessed, the CHN c m provide input into the development of community needs assessment tools and the analysis of data that address the health component. Health providers should recognize that immediate needs and community plans for interventions may not pertain to potential or existing health problems. However, future goals for health that combine culturally sensitive and creative methods for community health promotion activities can be jointly planned between community members and the CHN. Internal Operations CHNs must assess individual's and families's beliefs about potential and existing health problems and subsequent treatments. These assessment data must be integrated into a comprehensive plan of care. For example, a particular herb tea espoused by the family members as effective may be appropriate when given in combination with a prescribed drug. Assessment information should be obtained about uses of informal lay health networks before and throughout the course of illness and during wellness. Health promotion practices should be identified, evaluated for their efficacy, and integrated into wellness plans. For example, by assisting the family in developing time management skills for prayer and spiritual meditation, the CHN may increase the effectiveness of stress reduction programs that prescribe exercise and rest.
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The CHN also should be aware of her/or his own culture and how those cultural beliefs influence the care that is prescribed and rendered. The attitudes and feelings of CHNs and other health-care providers, who are also ethnic persons, are a function of their cultural and professional experiences (Pinderhughes, 1982). The type and quality of an interaction between the health provider and client is influenced by the provider's own values (Scholz, 1990). Ethnocentrism or believing that one's culture is superior to other cultures and the labeling of other cultures as inferior or disadvantaged (Spector, 1985) further deteriorates relationships between the health provider and client. Skepticism about the health-care system by African Americans is reinforced by these negative attitudes and utilization of health services are delayed or avoided. Communication between CHNs and other health-care providers and AfricanAmerican clients should be promoted. Intercultural communication, a process of transmitting and receiving information between two culturally different individuals (McCormack, 1987)' is a necessary component for care of clients. By learning about the culture of African Americans, accepting the differences within the culture, assessing individual health beliefs and practices, and integrating these beliefs and practices into plans of care, intercultural communication with AfricanAmerican clients and families can be enhanced. African-Americans are a unique and diverse group of people. Variations exist in their health beliefs and practices. Although similar experiences are threaded within their lifestyle and cultural makeup such as spirituality, family and social networks, and lay health-care systems, each individual and family should be assessed for their own unique perceptions of their health needs and for cultural factors that influence how health problems will be managed or prevented. The CHN is challenged to evaluate the existing health-care delivery system for its effects on utilization by Blacks and to integrate strategies that are more responsive to the health needs of the African-American family and community.
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Doyle, E., Smith, C. A., & Hosokawa, M. C. (1989). A process evaluation of a community-based health promotion program for a minority target population. Health Education, 20, 61-64. Gabriel, A., & McAnarney, E. R. (1983). Parenthood in two subcultures: White, middle-class couples and black, low-income adolescents in Rochester, New York. Adolescence, 18, 595-608. Gibson, R. C. (1982). Blacks at middle and late life: Resources and coping. American Academy of Political and Social Science, 464, 79-90. Kroebar, A. L., & Cluckhohn, C. (1%3). Culture: A critical review of concepts and definitions. New York: Vintage. Lassiter, S. M. (1987). Coping as a function of culture and socio-economic status for Afro-Americans and Afro-West Indians. Journal of the New York State Nurses Association, 18, 18-30. Leininqer, M. (1970). Nursing and anthropology: 7bo worlds to blend. New York: Wiley. Leinin$er, M. (1978). lkznscultuml nursing: Concepts, theories and practices. New York: Wiley. Louie, I
