After reading this chapter, the nurse will be able to:
Identify ways in which the African-American culture influences African-American individuals and their health-seeking behaviors.
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.
Recognize physical and biological variances that exist within and across African-American groups to provide culturally appropriate nursing care.
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.
Develop a sensitivity and an understanding for psychological phenomena that influence the functioning of an African-American when providing nursing care.
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 descriptive 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 45,562,000 African-Americans residing in the United States, representing approximately 14.4% of the American population ( ). 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 ( ). 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) ( ).
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) ( ). In 2014, 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%) ( , ).
In 2012, the median age of African-Americans residing in the United States was 32 years, compared with 35.3 years for the rest of the general population ( ). 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 33.5 years). In 2009, 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 2.5 million in 1990 (up from 2.1 million in 1980). It is interesting to note that in 2009 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 ( ; ). 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 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 ( ).
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 2009, only 12.7% 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 ( ).
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 ( ). 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” ( ). 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 ( ).
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 ( ). 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 ( ; ).
In 1661, the Virginia House of Burgesses formally recognized the institution of African-American slavery ( ; ). 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 ( ).
Even today, the cultural roots of African-Americans are entrenched in the African-American life experience. According to , 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 ( ). In 2013, the life expectancy for African-American men was 71.8 as compared with 76.5 for their White counterparts. Similarly, the life expectancy for African-American women was 78.1 compared with 81.2 for their White counterparts ( ; ).
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 (11.20 per 1000 live births in 2012) compared with White Americans (5.00 per 1000 live births in 2012) ( ). 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 1986 and 2009 continues to shrink ( ). 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 2012, 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 ( ). 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 ( ). 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) ( ).
Communication is 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 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.
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 ( ). 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 ( ; ).
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 ( ; ). 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 ( ). 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.
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 ( ). 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 ( ; ; ). 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 ( ; ).
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” ( ; ).
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.”
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 ( ). Every language also has a set of unconscious assumptions about the world and life. According to , 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 ( ). 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. 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)|
Syphilis/bad blood, pox
Anemia/low blood, tired blood
|Diarrhea/running off, grip|
|Menstruation/red flag, the curse|
|Urinate, urine/pass water, tinkle, peepee|
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 ( ).
According to , 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 , 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 ( ). 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 ( ). 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 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. 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. 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 a documentary of the lives of 75 African-American women, described the heartbreaking tenderness of African-American women and the majestic strength they needed to survive the subjugation and horror of the slavery experience.
In contrast to this view of the destruction of the African-American family during slavery, contends that the African-American family was not disaggregated because of slavery. In fact, 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. 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 ( ). 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 2000, the number of African-American female-headed households was creeping slowly downward. In 2009, such families constituted 44% of African-American families. In addition, between 1950 and 2009, the number of African-American female-headed householders who had never been married quadrupled, from 9% in 1950 to 42.4% in 2012 ( ). 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 , 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 ( ). The annual labor participation rate for African-American males in 2009 dropped slightly from the 1990 and 2000 (65.3%) data to 63.2%, compared with 70.6% in 1980. In 2009, 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 ( ). 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 $36,171, as compared with $45,485 for the rest of the general population ( ). 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) ( ).
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 ( ; ). 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 is a concept that is universal and continuous. All emotional and perceptual experiences are interrelated with the concept of time. 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 ( ). 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) ( ).
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 ( ). 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. 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 ( ).
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 ( ).
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, 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 ( ). 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 ( ). 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. 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 ( ). 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 ( ).
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 ( ). 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 ( ).
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 ( ). 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 ( ). 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 ( ; ).
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 , 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 , 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 ( ). 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 ( ). 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 ( ; ). 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 ( ). 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 ( ).
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 ( ). 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 ( ; ). 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. 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 ( ).
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 ( ; ). 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.
identified distinct types of folk practitioners. 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 ( ). The second type of practitioner is the “spiritualist,” the most prevalent and diverse type of folk practitioner. This individual attempts 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 ( ).
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 ( ). 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 ( ).
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 addition, the practice of witchcraft is not limited to any one particular cultural group. Persons who believe in witchcraft feel that it can be used not only to cure illness or disease but also to cause illness or disease. For example, strokes, dementia, and some gastrointestinal disorders may be perceived by some persons who believe in witchcraft to be the direct result or influence of witchcraft ( ).
The practice of witchcraft is based on the belief that there are some individuals who possess the ability to mobilize the forces of good and evil. These abilities are based on the principles of sympathetic magic, which underlie many of the beliefs of folk medicine practice. The basic premise of sympathetic magic is that everything in the universe is connected. There is a direct connection between the body and the forces of nature. Interpretation and direction of events are accomplished by understanding these connections. Sympathetic magic is categorized into contagious and imitative magic . The basic premise of contagious magic is the perception that physically connected objects can never be separated; therefore, any actions against the parts constitute an action against the whole ( ). Individuals who practice witchcraft may use a piece of clothing or nail clippings from someone to cast an “evil” spell or to protect the individual. The basic premise of imitative magic is that like follows like, or that one will imitate what one desires to achieve. For example, a knife placed under the bed will cut pain; an evil charm put on when the moon is waxing will increase the power of the charm.
A recurring theme in the practice of witchcraft is that of animals being in the body. Lizards, toads, snakes, and spiders are believed to be the most common types of intruders. These animals are dead and pulverized and are generally believed to enter the body by means of food or drink. It is not uncommon for persons who believe in witchcraft to refuse to eat or drink food prepared by someone they believe may have put a hex on them. Individuals who believe that such a spell has been cast on them may present themselves at health care facilities with symptoms described as “reptiles crawling over the body” or “snakes wiggling in their stomach.” Some of these individuals may also share the belief that the physician is powerless to help them once they have been “hexed” ( ).
Perceptions Concerning Folk Medicine and Other Alternative Medical Solutions.
The prevalence of the belief in and the use of folk medicine remedies and other alternative forms of health care is not fully understood ( ). It is impossible to generalize or postulate how widespread the use of folk medicine remedies is among African-Americans. However, evidence does exist that there are some African-Americans in all areas of the United States who believe in and practice folk medicine as well as other alternative forms of health care, such as witchcraft, voodoo, and spiritualism ( ). There is also evidence to support the notion that different levels of folk medicine are practiced ( ). The boundaries of folk healers for some African-Americans may also vary. For example, the “granny” folk healer may possess the skills and knowledge to cure only simple illnesses or ailments. In contrast, a “witch doctor” is believed to possess supernatural powers that allow the “casting out of such things as animal demons” ( ). In addition, African-American folk medicine practitioners may have titles different from those of folk practitioners found in other cultural groups in the United States, such as “conjure doctor,” “underworld man,” “father divine,” “root doctor,” and “root worker” ( ).
Origins of African-American Folk Medicine.
African-American folk medicine practices in the United States can be traced back to regions of West Africa ( ). There are also influences on African-American folk medicine that originated in other countries, such as Haiti, Jamaica, and Trinidad ( ). Because of slavery, there was a blending of various African tribes, particularly in slave cities and states such as New Orleans, Louisiana, and Savannah, Georgia, with other cultural groups such as the French, the Creoles, and the Indians. Various folk medicine practices found among some African-Americans in the North and the South have been handed down from generation to generation. Even today, the consistent use of some form of African-American folk medicine continues, and such continuity indicates that these practices have withstood the test of time and are presumed to be valid, although no empirical data exist that would indicate the validity or reliability of such practices.
Rationale for the Use of African-American Folk Medicine.
Some African-Americans choose to use folk medicine because of tradition, whereas others have made this choice based on previous discriminatory practices and unfair treatments that have existed throughout some regions of the United States. In this regard, the deliveries of health care services were not exempt from Jim Crow laws, which were legally sanctioned until the mid-1960s throughout the South. However, the Northern regions of the United States also were not exempt from such discriminatory practices in regard to health care. This is evident in the passage of the Hill-Burton Act in 1946, which was not abolished until 1966 with the passage of the Federal Medicare Act ( ).
The Hill-Burton Act, also known as the Hospital Construction Survey Act, provided federal grants for hospitals, both private and public, that admittedly did not serve African-Americans. Under this law, hospitals, whether private or public, were allowed to discriminatorily serve populations based on race. In addition, these same hospitals were allowed to continue these discriminatory practices in regard to hiring and staffing patterns. From such practices were born the all–African-American hospitals, which were found not only in the South but also in the North. Inclusions and exclusions for purposes of rendering health care services to those persons in need were left to the proprietors of the hospital. Thus patterns of admission and service to African-Americans varied throughout the country without regard to regional locale. In some northern and western states, admission to and service by some hospitals remained theoretically open to all races on equal terms, whereas in other states the courts upheld the rights of hospital proprietors to segregate as they saw fit.
This discriminatory practice was dramatically emphasized by the deaths of two famous African-Americans: Bessie Smith, in 1937, and Charles Drew, in 1950. Bessie Smith was a legendary blues singer who was critically injured in an automobile accident while traveling from Jackson, Mississippi, to Memphis, Tennessee. White attendants at the scene of the accident surmised correctly that Smith had a severed right arm and therefore needed immediate medical attention. The attendants took Smith to a hospital designated as “all White,” and the administrators at the hospital refused to treat her despite the severity of her injuries. The ambulance attendants were forced to take Smith to Memphis, where she could be treated. On arrival, Smith was in profound shock, having lost a great quantity of blood. It has been said that despite Bessie Smith’s obvious fame and the great admiration shown her by millions of fans, both African-American and White, the fact that she was African-American ultimately caused her death ( ).
Charles Drew, a surgeon, discovered blood plasma and developed the procedure for blood plasma transfusion. Even today, people throughout the world, regardless of race, benefit from his discovery. However, despite his profoundly important contribution to the medical field, the discovery of blood plasma was of no benefit to Drew when he, like Smith, was involved in an automobile accident and similarly was refused treatment in an “all-White” hospital. Although Drew was responsible for the technique of blood plasma transfusion, it was not used to save his life because he was taken to a hospital that legally had the right to refuse him treatment.
African-American folk medicine therefore took root not only as an offshoot of African cultural heritage but also as a necessity when African-Americans could not gain access to the traditional health care delivery system. Furthermore, some African-Americans turned to African-American folk medicine because they either could not afford the cost of medical assistance or were tired of the insensitive treatment by caregivers in the health care delivery system ( ). Today African-Americans have access to the health care delivery system through legal channels. Some African-Americans still refuse to use the system, however, citing reasons such as past experiences, the escalating cost of health care, and the sometimes insensitive treatment on the part of non-Black caregivers in regard to the physiological and psychosocial differences evidenced among African-Americans.
Some African-Americans have a strong religious orientation, and most African-Americans belong to the Protestant faith. Although folk medicine and folk practices are widely documented in the literature as being common practices for the treatment of illnesses among African-Americans, the most common and frequently cited method of treating illness remains prayer ( ). According to , many of her informants found it impossible to separate religious beliefs from medical ones.
Death and Dying Rituals.
It is important to note that there are variations in customs regarding death and dying rituals among African-Americans depending on country of origin, religious affiliation, geographic region, economic level, and educational background of each family member ( ; ). Many African-American families are composed of large networks, and often it is thought that such large networks tend to be very supportive during times of crises, such as during death and the dying process ( ). Some researchers have suggested that among many African-Americans there are varying ways that emotions are expressed about the death of a loved one ( ). For example, while many people believe that African-Americans are quite expressive at the death of a loved one, this may not always be the case. For example, some African-Americans cry, whereas others remain silent and stoic ( ). It is not unusual to see large gatherings at the time of death and during the burial process ( ). Some African-Americans, and particularly those in the rural South, have maintained the tradition of keeping the body of the deceased in the home the evening before the funeral ( ). This practice is probably what began the ritual of people coming to a home to help where they could. The church services for the deceased certainly depend on the religious affiliation. But regardless of the religious affiliation, it is not uncommon to see church “nurses” help family members view the body and deal with the stress of a funeral ( ). African-Americans view death as a natural part of living, and their strong religious beliefs (which include seeing death as inevitable and a part of God’s will, the sure and certain hope that the deceased is in God’s hand, and the future hope that they will be reunited in heaven after death with the deceased) helped many of them deal effectively with death ( ). Nonetheless, it is essential for the health care professional to remember that many bereaved African-Americans are more likely to seek help to adjust to the death from their clergy than from a health care professional ( ).
Implications for Nursing Care.
Cultural health practices are often considered efficacious, neutral, or dysfunctional ( ). Practices that are considered efficacious are recognized by Western medicine as beneficial to health regardless of whether they are different from scientific practice. Practices the nurse regards as beneficial should be actively encouraged. The nurse should keep in mind that a treatment plan that is congruent with the client’s own beliefs has a better chance of being successful. For example, some African-Americans believe that certain herbs and spices are essential in the treatment of certain disequilibriums in the body. In this case an herbal decoction could be used in place of water and might be just as beneficial for the treatment of specific conditions such as dehydration. Neutral practices (such as putting a knife under the bed to cut pain) are considered to be of no significance one way or the other to the health of an individual. However, psychological benefits may have a profound effect on the perception of pain. Dysfunctional health practices are viewed as harmful from a health point of view. For example, it is considered a dysfunctional health practice in Western medicine to use sugar and over-refined flour excessively. Dysfunctional health practices found among some African-Americans include such practices as using boiled goat’s milk and cabbage juice for stomach infection.
Because some African-Americans tend to equate good health with luck or success, an illness may be viewed as undesirable and equated with bad luck, poverty, domestic turmoil, or even unemployment. As indicated previously, illnesses may be classified as natural or unnatural. Natural illnesses occur because a person is affected by natural forces without adequate protection. The nurse may be able to help the client more readily understand how these natural illnesses, such as colds and flu, can be avoided. Unnatural illnesses, which are believed to be the direct result of evil influences, are much more difficult for the nurse to combat. If the nurse has a client who believes that unnatural illness has resulted from witchcraft or voodoo or is a punishment from God, it may be very difficult to convince the client that a treatment can be implemented that will minimize or eliminate the problem. For example, a client may view breast cancer as a punishment from God. In this instance the client should be encouraged to seek medical treatment because unnecessary delay can have serious consequences. Although the nurse may not subscribe to cultural healing beliefs, it is essential that the nurse recognize their existence and their importance for some African-American clients. It is also important for the nurse to remember that effective nursing care cannot be implemented until the nurse acknowledges certain cultural health beliefs that have an effect on the client’s behavior and recovery.
Among some African-Americans, it is believed that the maintenance of health is strongly associated with the ability to read the signs of nature. Subsumed in this belief is the idea that natural phenomena, such as the phases of the moon, the seasons of the year, and the planetary positions, all either singly or in combination affect the human body and human physiological functioning. Some African-Americans believe that the best days to wean babies, for example, or to have dental or surgical procedures can be found in the Old Farmer’s Almanac ( ). To the nurse, such beliefs may seem peculiar; however, the nurse must acknowledge the existence of such beliefs before culturally appropriate nursing care can be given. The nurse must also recognize that although some of these beliefs may be helpful, others may be neutral, and still others may be extremely dangerous for the client. The nurse must be able to sort beliefs into these three categories and assist the client in recognizing beliefs that may be dangerous.
Some African-Americans believe that cultural healing remedies help a person psychologically in dealing with discomfort. However, when these things fail, they believe a physician should be consulted. These same African-Americans may also believe that the nurse should recognize these cultural beliefs and use remedies based on these beliefs that prove to be helpful to the client ( ). When an African-American client does arrive for professional health care, the nurse might assume that the client has tried all the cultural healing remedies known. While doing the initial assessment, the nurse needs to find out what the client has been using at home to minimize illness symptoms. This initial assessment will assist the nurse in determining whether these home remedies will interact or interfere with orthodox medical approaches. If the client has been using harmless home remedies, such remedies may continue to be used in the client’s treatment. Other harmless remedies might be added to the client care plan at the client’s suggestion ( ).
Religion for some African-Americans has functioned primarily as an escape mechanism from the harsh realities of life. The African-American church functions to promote self-esteem among its membership as well as to act as a curator for maintaining the culture of many African-Americans. Therefore, the nurse cannot overlook the importance of the African-American minister and the African-American church in the recovery of the client. If there is no African-American minister within the hospital facility, the nurse should contact the client’s own minister. It is essential for the nurse to remember that the African-American minister can essentially bridge the gap between the African-American client and other health care workers because the African-American minister understands the rituals, folkways, and difference in the mores of African-Americans ( ).
Until recently, the education of health care practitioners was based on the biopsychosocial characteristics of the dominant White culture. The lack of an in-depth understanding of biological and cultural differences resulted in less than optimum health care for persons who were not members of the dominant culture. When providing care to African-American clients, the nurse must realize that racial differences involve more than skin color and hair texture. African-American people have distinctive genotypes and phenotypes that characterize them as a racial group and as different from other racial groups. Moreover, the nurse must understand that African-Americans also have ethnic and cultural differences that distinguish them from other ethnic and cultural groups. It is essential for nurses and other health care providers to understand these biological variations in order to avoid racial and ethnic disparities in health care.
In 2002, a committee under the auspices of the Institute of Medicine released a seminal report titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care . The committee unequivocally noted that evidence of racial and ethnic disparities in health care is for the most part consistent regardless of the nature of the illness or the types of health care services rendered ( ). While it has been previously noted that socioeconomic status plays a major contributory factor in unequal treatment, particularly where African-Americans are concerned, noted that even if income levels were standardized and if all impediments regarding access to care were eliminated, disparities in health outcomes might still exist. They contend that this argument gives credence to the need to eliminate cultural incompetence among health care providers. Seemingly, nurses would not be exempt from this argument, as they must serve as advocates for culturally competent care for all clients entrusted to their care.
Data from previous epidemiological reports consistently reveal that there is a difference in the mean birth weight of approximately 200 g between African-American infants and White infants, with White infants weighing more. These differences persist even when socioeconomic status, maternal age, parity, and smoking are controlled for ( ). used ultrasound examinations to compare biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length in 5405 African-American and White fetuses. They found no significant difference in the BPD, HC, and AC; however, femurs in African-American fetuses were significantly longer. The birth weights of the infants were also compared, and these data again revealed differences in birth weight between African-American and White infants (3331 versus 3135 g; P < 0.001), with White infants being heavier.
It is postulated that birth weight contributes significantly to neonatal mortality among African-American neonates ( ). It is clear that prematurity, which is defined as a birth weight under 2500 g, is twice as common for African-Americans as it is for Whites ( ), and it has been suggested that the definition for prematurity be lowered from 2500 to 2200 g for African-Americans ( ). The gestational period for African-Americans tends to be 9 days shorter than that for Whites, and a slowing down of gestational growth occurs in African-American infants after 35 weeks. Before 35 weeks of gestation, African-American infants are usually larger than White infants ( ; ). The reasons for these differences in birth weights remain vague. Nonetheless, because the death rates for African-American infants are nearly three times the national average, some researchers have suggested that approximately three quarters of the disparity in infant mortality rates are primarily attributable to the larger proportion of babies with low birth weight and the very low birth weights (less than 1500 g) among these vulnerable neonates ( ; ).
Growth and Development
African-American children tend to mature faster than White children. Today African-American children are more mature at birth in both the musculoskeletal and the neurological systems ( ). Neurologically, African-American children tend to be more advanced until about 2 or 3 years of age, and in the musculoskeletal system they tend to be more advanced until puberty ( ). The differences in skeletal maturity are attributed to genetic and environmental factors.
Body size, height, weight, bone length, and body structure of African-Americans and Whites have been extensively studied in the United States. Studies done by revealed that the average height and weight of African-American and White men 18 to 74 years of age are approximately the same; White men tend to be 0.5 cm taller than African-American men. The average height for African-American and White women is the same; however, African-American women are consistently heavier than White women at every age, and between 35 and 64 years of age they are typically an average of 20 lb heavier than their White counterparts.
The body proportions of African-Americans differ from those of Whites, Asians, and American Indians. There are definitive differences in bone length that are obvious on study. African-Americans have shorter trunks than Whites and tend to have longer legs than Whites, Asians, and American Indians. African-American men tend to have wider shoulders and narrower hips than Asians, who tend to have narrow shoulders and wide hips. The long bones of African-Americans are significantly longer and narrower than those of Whites ( ). The bones of African-Americans are also denser. African-American men have the densest bones, followed by African-American women, White men, and finally, White women, who have the lowest bone density of the two races. The greater bone density explains why osteoporosis is rare in African-Americans and why White women have a greater incidence of osteoporosis. Bone curvature also varies among the different races. The femurs of African-Americans are quite straight; in comparison, the femurs of American Indians are anteriorly convex, and those of Whites have intermediate curvature. This characteristic appears to be genetically determined, but weight also seems to be a factor because obese African-Americans and Whites tend to demonstrate more curvature than other individuals do ( ).
The amount and distribution of body fat are two other areas where there are pronounced differences by virtue of race and ethnic group. The racial differences are mostly related to socioeconomic status. Persons from the lower socioeconomic class tend to have more body fat than those from the middle class, and persons from the middle class tend to have more body fat than those from the upper class. There is some evidence indicating that fat distribution may vary according to race. African-American people tend to have smaller skinfold thickness in their arms than Whites have, but the distribution of fat on the trunk is similar for both Whites and African-Americans ( ). Whites have a larger chest volume than African-Americans; hence they have greater vital capacity and forced expiratory volume ( ). African-Americans, on the other hand, have a larger chest volume than American Indians and Asians and thus greater vital capacity and forced expiratory volume than members of these racial groups ( ).
Skin color, or pigmentation, is the most distinguishing physical difference among the various races and is determined by melanin. All people have some melanin, but some racial groups have more melanin than others. The greater the amount of melanin an individual has, the darker the skin pigmentation will be. The skin color of persons who are classified as African-Americans ranges from “white” to very dark brown or perhaps even black. Melanin provides protection from the effects of the sun; however, the risk of sunburn does exist. African-Americans do get sunburned but not as easily as Whites; repeated, prolonged sun exposure is a risk for cancer. Although African-Americans and other individuals with darker skin have a lower incidence of skin cancer, it is imperative that they receive education regarding risk reduction. Teaching should include the risk of prolonged sun exposure and when to use sunscreen ( ).
The skin coloring should be uniform, but areas that are not exposed to the sun may be lighter, such as the buttocks, abdomen, and thorax. The exceptions to this rule for African-American people are the skinfolds in the groin, the genitalia, and the nipples, which tend to be darker than the rest of the body. (An old wives’ tale suggests that to determine the true color of a newborn infant, one should look at the ears, which tend to be darker at birth than the rest of the body.) Except for the areas just mentioned, hypopigmentation and hyperpigmentation (unless it is a birthmark) are abnormal ( ). Pigmentation of the lips, nail beds, palmar surfaces, creases of the hands, and plantar surfaces and creases of the feet may vary, just as skin coloring does. The range of coloring for the lips of African-Americans may vary from pink to plum. The palmar and plantar surfaces may range from light pink to dark pink to a brown, and the creases may range from dark pink to dark brown, depending on the amount of pigmentation ( ). The gums may have areas of hyperpigmentation, and the sclerae may have scattered areas of brown pigmentation that appear to be freckles.
Mongolian spots are a common variance found in African-American infants. They are migratory leftovers of melanocytes that have lingered in the lumbosacral region at a greater than normal depth, which accounts for their dark blue-green appearance. Mongolian spots occur in 90% of African-Americans, 80% of Asians and American Indians, and only 9% of Whites ( ). Normally found on the buttocks, thighs, ankles, and arms, mongolian spots usually disappear in the first year of life and should not be mistaken for a bruise.
Birthmarks appear to be most common in African-American individuals, occurring in 20% of African-Americans, compared with 2% to 3% of Whites, Mexicans, and American Indians. These pigmented marks appear as sharply demarcated macules that vary from light tan to dark brown, depending on the skin color. They may be present anywhere on the body ( ).
Black skin is also more susceptible to an overgrowth of connective tissue in response to injury, or keloid formation. Keloids are raised areas of scar tissue that can result from minor injuries such as skin tears or punctures, from more major injuries such as burn injuries or traumatic lacerations, or from surgical incisions ( ).
Normal, healthy skin should be warm, dry, and elastic. There should be a red glow present in Black skin. Color changes associated with abnormal conditions are rashes, which may be difficult or impossible to detect in the individual who is darkly pigmented. Darkly pigmented lips and nail beds with melanin deposits make nursing assessment even more difficult. When possible, the nurse should become familiar with the client’s normal coloring to establish a baseline value. The skin assessment should be done in a well-lighted room. Sunlight is the best lighting; if artificial lighting is used, it should be nonglaring ( ; ). When assessing the darkly pigmented individual for specific color changes such as pallor, jaundice, or cyanosis, the nurse should inspect the conjunctivae and oral membranes of the buccal mucosa. Jaundice also appears as a yellowish discoloration of the sclerae if they are not pigmented. The mucous membranes of the buccal mucosa and the palmar and plantar surfaces may also be inspected for yellow discoloration.
The nurse may also rely on palpations and the client’s history to detect the presence of bruises in the darkly pigmented client. The nurse should use the dorsal surface of the hand to assess for areas of increased warmth and tenderness. Questioning should include a history of recent trauma. The petechiae cannot be readily visualized on the dark-skinned individual. The nurse should inspect the sclerae for dark blue spots. The client history should include questioning about symptoms of conditions in which petechiae would be present. Palpation and the client history may also be used to detect the presence of a macular rash on the client who is dark skinned ( ).
Some researchers have noted that moderate hyperhomocysteinemia is a putative risk for the development of cardiovascular disease (CVD) ( ). Hyperhomocysteinemia is an independent risk factor for premature arteriosclerotic vascular disease and venous thrombosis ( ). Mutations in the gene, which code for methylenetetrahydrofolate reductase (MTHFR), account for reduced enzyme levels and elevated plasma homocysteine ( ). The heterozygote state results in mild hyperhomocysteinemia, a risk factor for CVD. Homocysteine levels are also influenced by diet ( ). attempted to determine whether the mutation C→T677 in the MTHFR gene or the TC833/844in68 and G→A919 mutations in the CBS gene were associated genetically with myocardial infarctions (MIs) among African-Americans. The analysis of the data suggested that 15% of the cases analyzed demonstrated that these individuals were heterozygous for C→T677 ( MTHFR ) mutation, whereas 1.8% of the subjects were homozygous. Further findings from this study showed that their controls were 15% heterozygous and 2.1% homozygous and suggested that there was no significant association with myocardial infarction among these African-Americans who participated in the study. Yet these researchers noted that, while no association was noted for T→C833 ( CBS ) among the experimental or controls and while there was no significant association between this mutation and MI, the prevalence of the heterozygous state among African-Americans (15%) was higher than that among their White counterparts (12%). These researchers concluded that the racial differences of these genes warranted further investigation.
Tumor Necrosis Factor Alpha.
One candidate gene predisposing to type 2 diabetes within the major histocompatibility complex region is tumor necrosis factor alpha (TNFα), a cytokine. In rats, elevated levels of TNFα have been shown to produce “sustained increase in glucose production, utilization, and clearance,” as well as an insulin resistance (IR) state ( ; ; ; ; ; ; ). TNFα expression has also been observed in rodent models of obesity and diabetes. When TNFα was neutralized in obese fa/fa rats, a significant increase in peripheral uptake of glucose in response to insulin was observed. Treatment of adipocytes with TNFα resulted in downregulation of GLUT4 messenger ribonucleic acid. TNFα also interferes with the signaling of insulin and blocks its biological action ( ; ). In humans, abnormal expression of TNFα appears to play a role in obesity-related IR ( ). A polymorphism in the TNFα promoter has been associated with increased levels of basal serum insulin and leptin ( ; ; ). The differences were greater in women than in men. TNFα has been linked to the development of IR among African-Americans and is considered to be one of the precursors to the development of metabolic syndrome (syndrome X).
Metabolic syndrome (syndrome X) is a clustering of abnormalities characterized by the primary defect of compensatory IR, glucose intolerance, dyslipidemia, and centrally distributed obesity ( ). conducted a study to examine the age-related patterns of cardiovascular risk factor clusters relative to the metabolic syndrome (syndrome X) among African-American and White children. The clusters in this study for the metabolic syndrome (syndrome X) included (1) insulin resistance index, (2) body mass index (BMI), (3) triglycerides/high-density lipoprotein (HDL) cholesterol ratio, and (4) mean arterial pressure. Regardless of age, four mediating factors contribute to the development of coronary heart disease (CHD): hyperinsulinemia (syndrome X), hypercholesterolemia, hypertension, and obesity. A sedentary lifestyle, the large percentage of fat consumed per day by African-American children, and the prevalence of obesity all may contribute to the development of metabolic syndrome (syndrome X) even among African-American children ( ; ). In other words, African-American children are not exempt because of their tender years from developing syndrome X and starting the downward spiral toward diabetes and ultimately CHD.
Interestingly, findings from the study by suggest that overall, White children had a higher total of adverse clusters among the four indices measured (9.8; P < 0.01) than their African-American counterparts (7.4; P < 0.01). These follow-up findings to the Bogalusa Heart Study are interesting because prior and recent analyses of these data sets suggest that while predictability of childhood adiposity and insulin resistance syndrome is difficult to determine with certainty in children, the contributions of these adverse clusters can provide convincing evidence for the future development of syndrome X, thereby leading to the development of CHD in adulthood ( ). As African-Americans age, the adverse clusters outrank those of their White counterparts, and this ultimately leads to the development of syndrome X and CHD in adulthood. also examined the contributions of childhood adiposity and insulin as a weighed predictor to adulthood risk of developing metabolic syndrome (syndrome X) among African-American and White children with baseline ages of 8 to 17 years. Using a logistic regression model, these researchers noted that childhood BMI and insulin resistance served as significant predictors of adult clustering for metabolic syndrome (syndrome X). In this study, BMI was the strongest indicator, exhibiting a curvilinear relationship. Further findings from this study also suggest that childhood obesity often is a powerful predictor of the development of metabolic syndrome (syndrome X) later in life. These findings suggest that children, and particularly African-American children, can benefit tremendously from programs that underscore the importance of weight control and increased physical activity ( ). Tumor necrosis factor α has also been linked with human leiomyoma, of which African-American women tend to have a disproportionate prevalence ( ). In fact, were among the first researchers to demonstrate increased cellular levels of TNFα in leiomyoma cells.
Apolipoprotein E (ApoE) is a polymorphic protein involved in the catabolism of chylomicron remnants. Various ApoE phenotypes are related to the development of combined hyperlipidemia and familial combined hyperlipidemia, total and low-density lipoprotein (LDL) cholesterol, and insulin levels and are associated with CHD, stroke, and type 2 diabetes ( ; ; ; ; ). The high frequency of the appearance of ApoE supports this gene as a candidate marker for CHD. It is thought that ApoE participates in the receptor-mediated clearance of blood lipids such as cholesterol, which is considered a major risk factor for CHD ( ). In North America, it has been estimated that the variability of this gene ( ApoE gene locus) accounts for up to 6% of the variation in CHD. The ApoE locus lies on chromosome 19 and has three common alleles ( E 2, E 3, E 4), which are coded for the E isoforms ApoE2, ApoE3, and ApoE4, respectively ( ). While the frequencies of these isoforms vary from race to race, it is thought that ApoE3 shows the highest frequencies (≥49%) and ApoE2 the lowest (≤15%). The frequency by population in North America is generally no higher than 6%. Among African-Americans there tends to be a direct correlation between the frequency of this candidate gene and the development of CHD ( ; ).
C-reactive protein (CRP) is produced by the liver and released in response to inflammation. It is present in the serum within 24 to 48 hours after an inflammatory stimulus. C-reactive protein is a known predictor of increased risk for heart attacks, strokes, and peripheral vascular disease and is used to screen for atherosclerosis in middle-aged and elderly people. High-sensitivity CRP (hs-CRP) has been developed to detect low-grade inflammatory activity within the vascular system. An hs-CRP of <0.7 mg/dL denotes a low risk, 0.7 to 1.1 mg/dL indicates a mild risk, 1.2 to 1.9 mg/dL is a moderate risk, 2.0 to 3.8 mg/dL is high risk, and 3.9 to 15 mg/dL is very high risk. Data from several research studies have indicated that CRP values may vary according to gender and race and in the presence of certain chronic disease states. In a multiethnic population-based study that examined CRP values in over 2500 White and Black subjects, which controlled for traditional cardiovascular risk factors such as BMI, estrogen, and statin use, findings suggested that CRP values above 3 mg were more common in White females (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1–2.5) and Black females (OR 1.7; 95% CI, 1.2–2.6). However, in male subjects, the CRP values were within the normal range. Nonetheless, conclusions from this study suggested that differences in race and gender existed ( ).
examined the relationship between hs-CRP and osteoarthritis in 662 subjects. The applicability of using CRP values in predicting risk for cardiovascular events was also evaluated in this study. The study suggested that hs-CRP values were higher in African-Americans, women who used pain medications, and individuals who had hypertension or chronic obstructive pulmonary disease. These researchers also found a correlation between the CRP values and BMI and waist circumference. But even given these findings, these researchers concluded that the pathogenic significance of hs-CRP elevations in women and African-Americans was unclear and that obesity, ethnicity, and gender confound the use of serum hs-CRP values in predicting CVD risk ( ). Similarly, studied the effects of socioeconomic status and CRP levels. Data for this study were obtained from the fourth wave of the . This survey included an oversampling of older persons, Blacks, and Hispanics who were predominantly Mexican. From the sample of 6946 individuals, demographic data suggested that persons with higher CRP levels were older, Black, or female or were living in poverty. These researchers concluded that the differences in extremely elevated CRP levels (≥10 mg/dL) may be a reflection of high levels of poverty, which affect the ability to acquire adequate medical treatment. Nonetheless, chronic disease along with risky health behaviors that are associated with poverty were also cited as plausible causes for CRP elevations in this group.
Biochemical variations and their effects on health vary according to race. As with other racial variations, biochemical variations are attributed to genetic factors and environmental influences. Lactose intolerance is a well-known condition that is correlated with race: 90% of African Blacks and 75% of African-Americans have lactose intolerance ( ; ; , ). Individuals with lactose intolerance lack the enzyme to convert lactose to glucose and galactose, and as a result, gastrointestinal symptoms of bloating, cramping, and diarrhea occur. The condition is genetically transmitted, although the specific gene has not been identified ( ). There appear to be two periods in life during which symptoms occur: infancy shortly after weaning and the teen years or early 20s. The condition is diagnosed on the basis of signs or symptoms that occur after the ingestion of milk or other products containing lactose. Treatment consists of avoidance of these products, with appropriate substitution of other products. In addition, there are products available on the market that can be taken to help alleviate symptoms associated with this condition. Some people report a degree of success with such products, whereas other people report little benefit from their use. The nursing implications for nurses caring for African-American clients include (1) knowledge of the condition and its prevalence among African-Americans and (2) education of clients with the condition to avoid products containing lactose. The education of these clients should include encouraging them to read labels and make appropriate food substitutions ( ).
Susceptibility to Disease
Susceptibility, or the degree to which an individual is resistant to disease, is determined by genetics and environment. Technological advances in medicine have contributed to improvement in general health and increases in the lifespan of all Americans. Despite these advances, African-Americans, Hispanics, American Indians, and Asian Pacific Islanders continue to have alarming health disparities that ultimately lead to a shorter life expectancy. For African-Americans, death rates from heart disease, cancer, stroke, diabetes, and acquired immunodeficiency syndrome (AIDS) are much higher than those in the general population. Genetics and environmental factors play a major role in many of the 10 leading causes of death for African-Americans. For example, African-Americans experience higher morbidity and mortality rates from CVD, the number one cause of death for all Americans. Major risk factors for CVD are related to both hereditary predisposition and environmental factors such as diet and physical inactivity. African-Americans have a higher mortality for certain cancers, such as breast and colon cancer. In 2013, the Health United States Report, the age-adjusted death rates for cancer of the colon and rectum, prostate, and breast were higher for African-American males and females compared with individuals from other racial and ethnic groups. For White males and females, the mortality rate per 100,000 for all cancers was 208.2 and 150.6, respectively, compared with 264.8 for Black males and 167.1 for females. Similarly for Hispanics, the age-adjusted mortality rate for all ages was 149.4 for males and 99.4 for females ( ). In females, the breast cancer mortality rate for Whites was 21.5 per 100,000 compared with 30.3 per 100,000 for Blacks and 14.4 per 100,000 for Hispanics ( ). Hereditary predisposition and environmental factors such as diet, obesity, and physical inactivity have been identified as major risks for both types of cancers ( ). Risk factors for type 2 diabetes, the fourth leading cause of death in African-Americans, have been linked to heredity and environment. Another major factor that has been associated with increased susceptibility to disease is disparities in health care. Numerous published reports relate disparities in health care and inequities in access and delivery of health care to higher mortality rates in African-Americans. The complex interaction between the environment, economics, and access to health care all interact to pose a tremendous physical and economic burden on society. In addition, the shortage of minority health care providers has been shown to have a significant impact on access to health care, the practice of specific health promotion behaviors, and the decisions to seek preventative care ( ).
Cardiovascular disease is a pandemic problem and continues to be the major cause of death worldwide. The primary cause for the increased prevalence of CVD in developing countries has been attributed to the westernization of native cultures ( ). The World Health Organization (WHO) has identified CVD as the underlying cause of death in 17.3 individuals worldwide, or 30% of total global mortality. The WHO estimates that the number of deaths resulting from CVD will increase to 23.6 million people by the year 2030 ( ; ; ).
Despite significant progress made in the treatment and prevention of CVD, MI, cerebrovascular accident (CVA) or stroke, and other forms of heart disease, CVD continues to be the leading cause of mortality and morbidity in the United States for adults in all demographic groups. Moreover, Americans suffer more than 1.5 million heart attacks and strokes annually ( ). Cardiovascular disease claims more lives in the United States than the next five leading causes of death combined. Heart disease and stroke are the first and fourth leading causes of deaths, respectively, in the United States, accounting for one of every three deaths in the United States ( ). Data from the AHA Heart Disease and Stroke Statistics 2015 Update indicate that over 83.6 million adults in the United States are living with one or more types of CVD or the complications of a stroke. This statistic includes diseases of the heart, stroke, hypertension, heart failure, congenital cardiovascular defects, atherosclerosis, and other circulatory system diseases. Before 72 years of age, the average annual event rate for the first coronary event in men between 35 and 44 years of age is 3 per 1000. With advancing age, this figure rises dramatically to 74 per 1000 ( ). For women, age is the most important risk factor for developing coronary artery disease. According to the AHA, prior to menopause the death rates from CVD are lower than in men. Although overall death rates for women may actually be lower, rates may be perceived as somewhat comparable because of their sheer numbers; however, death tends to occur at a later age ( ; ; , ). Recent data from the American Heart Association Heart Disease and Stroke Statistics 2015; Update and NHANES III also indicate that over the past 3 decades more women have died of CVD than men.
Cardiovascular disease is the number one cause of deaths in African-Americans. In fact, coronary heart disease (CHD) and stroke together account for more than one third of all deaths in African-Americans ( ). It is interesting to note that nearly half of all African-American adults have some form of CVD, which includes heart disease and stroke. According the Fact Sheet, among African-Americans, 44% of men and 49% of women affected have some form of CVD. The percentage of African-Americans with CHD is 10.7%, compared with 6% for non-Hispanic Whites. Further, African-Americans are more likely to die of a myocardial infarction than any other racial or ethnic group ( ). The disparity in death rates between African-Americans and Whites is partly due to hereditary predisposition for hypertension, type 2 diabetes, obesity, and lifestyle choices. Moreover, it has been well documented that African-Americans have more CVD risk factors such as hypertension, type 2 diabetes, and obesity, which places them at an increased risk for heart and cerebral vascular disease. Hypertension is a major independent risk factor for coronary artery disease, stroke, and peripheral arterial disease. The prevalence of hypertension in African-Americans is the highest in the world. In 2012, an estimated 70% of all CVD was attributed to hypertension; therefore, this condition is an extremely important consideration for the African-American in the development of CVD ( ).
Since the 1900s, CVD has been the number one cause of death every year except 1918. Despite this well-known fact, the general public continues to have a misguided perception about the health risk of heart disease ( ; ). Most Americans still fear cancer more than heart disease. According to , women rank breast cancer high on the list of personal health threats when in fact 1 death in 4.6 among women is due to breast cancer compared with 1 death in 3.2 due to CVD ( ). In African-American women, the greatest risk for CVD is the high prevalence of hypertension and type 2 diabetes. Despite advances in management of CVD, African-American women have a higher prevalence of hypertension compared with other ethnic and gender groups ( ). The rate of hypertension in African-American women has reached epidemic proportions, with 46.1% of African-American women affected nationwide compared with 30.1% of White women ( ). African-American women have greater mortality and morbidity from hypertension compared with women from other racial and ethnic groups ( ). In 2010, the mortality rate from stroke was 49.2/100,000 in African-American women compared with 37.2/100,000 in White women ( ; ).
Coronary heart disease was once perceived as a disease that most commonly afflicted men. This perception probably developed because the condition strikes men more often in the middle years of life. This perception had been reinforced by the Framingham study, which was initiated in 1948. In this classic study, the data indicated that, on average, women develop the symptoms of heart disease a decade later than men. Work relative to this study is ongoing, and although earlier data show that the incidence of the disease was disproportionately higher among men than women, current data indicate that CHD is the number one killer of women and is more prevalent in African-American women than in African-American men ( ; ).
An estimated 85.6 million American adults have one or more types of CVD. Of this number, 43.7 million are over the age of 60 ( ). It is estimated that over 2150 Americans die of CVD every day, an average of one death every 40 seconds. The majority of deaths from CVD are due to CHD. Further, 635,000 new myocardial infarctions and approximately 300,000 recurrent myocardial infarctions occur annually. An estimated additional 155,000 silent myocardial infarctions also occur each year ( ). From 2001 to 2011, the overall CVD death rate declined by approximately 30.8%, but African-American men and women continue to show higher rates of death from CVD compared with Whites. According to the , the 2011 preliminary mortality rates from CVD were 229.1 per 100,000. Rates of death from CVD were 271.9 per 100,000 for White males compared with 352.4 per 100,000 for African-American males. In White and African-American females, the CVD mortality rates were 188.1 and 248.6 per 100,000, respectively. Data from this report also show that African-American women and Mexican American women have a higher prevalence of CVD risk factors than White women of comparable socioeconomic backgrounds. In 2011, the overall mortality rate from CHD was 109.2 per 100,000, with disproportionately higher rates for African-American males and females. Among African-American males, the CHD mortality rate was 161.5 per 100,000 compared with 146.5 per 100,000 for White males. Similarly African-American women did not fare much better than their male counterparts, with a disproportionately higher mortality rate (99. 7 per 100,000) compared with their White counterparts (80.1 per 100,000) ( ). According to , African-American women tend to develop CHD much earlier than White women do. Furthermore, the death rate for African-American women under 55 years of age is twice that of White women. Finally, until 75 years of age the mortality from CHD is higher in African-American women than in women of other racial backgrounds ( ).
There are nine easily measurable and potentially modifiable risk factors that account for over 90% of the risk of an initial acute myocardial infarction. The pathophysiological effects of the risk factors are seen in both men and women in different racial and ethnic groups. These nine risk factors are cigarette smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity, physical inactivity, poor daily dietary intake of fruits and vegetables, excessive alcohol consumption, and stress. Hypertension, obesity, and dyslipidemia continue to be the major independent risk factors for CHD and stroke ( ). Hypertension is now identified as one of the components of metabolic syndrome, and it is recognized as a syndrome of vascular and metabolic disorders that occur along a continuum.
As indicated previously, the term metabolic syndrome or dysmetabolic syndrome refers to a cluster of risk factors leading to CVD and type 2 diabetes mellitus. This constellation of disorders have been identified as the underlying cause of end-stage vascular disease and metabolic derangements ( ). Clinical findings associated with a diagnosis of metabolic syndrome include a waist circumference greater than 88 cm in women and greater than 102 cm in men, dyslipidemia (triglycerides >150 mg/dL, HDL cholesterol <40 mg/dL in men and <50 mg/dL in women), blood pressure greater than 130/85 mm Hg, or receiving drug therapy for hypertension, and two elevated fasting glucose values greater than 100 mg/dL. The presence of three or more clinical findings are needed to confirm the diagnosis of metabolic syndrome ( ).
Data from the NHANES collected between 2003 and 2006 indicated that ~34% of adults over the age of 20 met the new criteria for metabolic syndrome. More recent data from the Update show the age-adjusted prevalence was 21.8% of women and 23.69% of men. The age-adjusted prevalence of people with metabolic syndrome was higher in Mexican American men than non-Hispanic Black men (34.76% and 18.9%, respectively). For women, the prevalence was 31.5%, 38.8%, and 40.6%, respectively, for non-Hispanic white, non-Hispanic Black, and Mexican women. For non-Hispanic Black women, the age-adjusted prevalence was 53% higher than for non-Hispanic Black men and 22% higher for Mexican American women than Mexican American men. When compared with their counterparts, 50% of African-American adults had two or three risk factors, compared with less than one third of non-Hispanic Whites and Mexican Americans. Data from both the American Heart Association and the National Heart, Lung, and Blood Institute support the strong correlation between the identified risk factors and CVD morbidity and mortality ( ).
Hypertension is an independent risk factor for coronary artery disease. It is also associated with an increased risk for developing stroke, heart failure, renal insufficiency, and peripheral vascular disease ( Update). Further, hypertension is a major independent risk factor for CVD morbidity and mortality. In the United States, hypertension remains poorly controlled despite major advances in pharmacological therapies, and as a result health care providers need heightened awareness of achieving tight blood pressure control to reduce morbidity and mortality from CVD ( ; ). Approximately 69% of individuals with a first myocardial infarction, 77% with a first stroke, and 74% with heart failure have blood pressure greater than 140/90 mm Hg ( ). The prevalence of hypertension among African-Americans and Whites in the southeastern United States is higher, and mortality due to myocardial infarction and stroke is greater than in any other region in the country ( ). According to the AHA (Heart Disease and Stroke Statistics 2015 Update), African-Americans have the poorest rate of hypertension control; as a result, the age-adjusted mortality rate from hypertension increased by 36.4%. In 2011, the death rates per 100,000 population from hypertension were 114.5 for White males, 212.8 for Black males, 92 for White females, and 157.9 for Black females ( ; ; ). Of the four leading causes of death in African-Americans, hypertension can be associated with at least three of the four disease states: CHD is the leading cause of death in African-Americans, CVA is listed as third, and diabetes is listed as the fourth ( ). Ventricular hypertrophy, arteriosclerosis, and atherosclerosis occur as a direct result of pathological changes that are exacerbated as a result of sustained blood pressure elevation. Left ventricular hypertrophy causes myocardial ischemia, dysrhythmias, and heart failure ( ). Arteriosclerosis and atherosclerosis lead to CHD and CVAs. Individuals with diabetes have a higher risk of CHD and hypertension, and diabetes can accelerate pathophysiological vascular changes, thereby exacerbating both conditions ( ).
Approximately 47.1% of all deaths in hypertensive Black males and 35.1% of all deaths in hypertensive Black females can be directly attributed to elevated blood pressure ( ). The earlier onset of hypertension, along with a greater percentage of individuals with stage 3 disease, is associated with an 80% higher mortality for stroke and a 50% increase in the prevalence of heart disease. Further, hypertensive African-Americans experience increased rates of end-stage renal failure. When compared with Whites, Black Americans have a 1.3 times higher incidence of nonfatal stroke, a 1.8 times higher incidence of fatal stroke, a 1.5 times higher incidence of fatal heart disease, and 4.2 times higher incidence of end-stage renal failure ( ). The prevalence of hypertension in Black women is more than three times that of White males and females. Compared with White females, Black females have an 81% higher rate of ambulatory medical visits for hypertension ( ).
Serum Cholesterol Levels.
Elevated serum lipid levels, another major risk factor, is associated with increased risk for CVD. Elevated total cholesterol levels greater than 240 mg/dL have been shown to be an accurate predictor of CVD morbidity and mortality. The mean level of LDL cholesterol for American adults age 20 and older is 115.8 mg/dL. Levels of 130 mg/dL to 159 mg/dL are considered borderline high. Levels of 160 mg/dL to 189 mg/dL are classified as high, and levels above 190 mg/dL are very high ( ). Among non-Hispanic Whites, the mean cholesterol levels were 113.8 mg/dL for men and 116.8 mg/dL for women. In non-Hispanic Blacks, the mean cholesterol for males was 113.4 mg/dL and 115.5 mg/dL for women. According to data from the AHA’s Heart Disease and Stroke Statistics 2015 Update, in individuals age 20 and older, total cholesterol was lower in Black American females and males compared with their White counterparts. For total serum cholesterol levels greater than 200 mg/dL, the prevalence was 38.6% for Black males and 40.7% for Black females as compared with 40.5% and 45.8%, respectively, for their White counterparts ( ). The prevalence of total cholesterol levels of 240 mg/dL or higher was 10.8% for Black males and 11.7% for Black females compared with 12.3% and 15.6% for White males and females, respectively ( ). Although total serum cholesterol levels tend to be lower in Black adult males and females than in their White counterparts, some data indicate that Black Americans have higher rates of CVD because of a greater prevalence of comorbid conditions such as diabetes, obesity, and hypertension ( ). For example, in data available from 2000 to 2010, the age-adjusted values in individuals age 20 and older suggest that the prevalence of total serum cholesterol levels greater than 240 mg/dL is higher among White males and females (11.4% and 15.4%, respectively) than among their Black male and female counterparts (10.2% and 10.3%) ( ).
It is interesting to note that high-density lipoprotein cholesterol (HDL) is considered cardioprotective. Higher HDL cholesterol levels are associated with greater protection against CVD. In adults, HDL cholesterol levels less than 40 mg/dL are a known risk factor for CVD. Men and women who have low HDL cholesterol and high total cholesterol levels have the highest risk for myocardial infarction. The mean level of HDL cholesterol in American adults age 20 and older is 52.9 mg/dL ( ). Data from the AHA’s Heart Disease and Stroke Statistics 2015 Update indicated that mean HDL cholesterol levels for non-Hispanic whites was 47.7 mg/dL for males and 58.5 mg/dL for White females compared with 51.9 mg/dL for Black males, 57.4 mg/dL for Black females, 45.4 mg/dL for Hispanic American males, and 54.3 mg/dL for Mexican Hispanic females.
Although the proportion of women with cholesterol levels above 240 mg/dL has steadily declined, the number of women age 20 and older with elevated serum cholesterol levels remains alarmingly high. In fact, data from NHANES 2007–2010 estimate that 31.9 million adults have total serum cholesterol values greater than 240 mg/dL. Among the number of women with high serum cholesterol levels, 15.3% were White, 10.3% were Black, and 13.7% were Mexican American ( ). For African-American women, these numbers become more disconcerting because elevated LDL cholesterol, very low-density lipoprotein cholesterol, and triglyceride levels are positively associated with diabetes and obesity, and African-American women tend to have higher rates of diabetes and obesity. In Blacks, these conditions may negate estrogen’s protective mechanism against CHD ( ; ).
Tobacco use is the leading cause of preventable death and the underlying cause of approximately 5 million premature deaths per year worldwide and just under 500,000 deaths in the United States. Smoking is a powerful risk factor contributing to the development of CVD. Smoking has been linked to 35% of deaths from CVD ( ). Persons who smoke have a 25% higher risk of developing CHD than nonsmokers, and they have a higher incidence of sudden cardiac death. The risk for stroke and MI is two to four times higher in cigarette smokers than in nonsmokers. From 2005 to 2009, an estimated 443,100 Americans died each year of smoking-related illnesses; 35.3% of the deaths were due to CVD ( ). Data from the Heart Disease and Stroke Statistics 2015 Update illuminate the fact that even though the total number of individuals who smoke has dropped, smoking continues to be a prevalent problem among adolescents in high school. In 2013, 16.4% of male students and 15% of female students in grades 9 through 12 reported current tobacco use; 14.7% of males and 2.9% of females reported current smokeless tobacco use. Data from the AHA’s Heart Disease and Stroke Statistics 2015 Update revealed that more White male and female students reported current cigarette smoking (19.1% and 18.1%, respectively) than Black male and female students (10.5% and 6.2%, respectively). Further, data in this report revealed that White youths 18 to 24 years of age from families with lower educational attainment had substantially higher rates of smoking than African-American and Mexican American youths with similar educational attainment. Data from the AHA Heart Disease and Stroke Statistics 2015 Update indicated that in 2012, approximately 69.7 million Americans over the age of 12 were using some type of tobacco product. By race/ethnicity, the age-adjusted estimates for tobacco users 18 years and older was 31.2% for Whites, 27.7% for Blacks, 44.9% for American Indians and Alaska Natives, 28.5% for Native Hawaiians and other Pacific Islanders, 22.9% for Hispanics or Latinos, and 13.6% for Asians. American Indian/Native Alaskans have higher rates of smoking (37.7%) than Black males (24.8%), and American Indian/Native Alaskan females have higher rates of smoking (36%) than Black females (15.5%). For all cigarette smokers, there is a 1.5- to 3-fold increase in risk for myocardial infarction. However, in young women who smoke cigarettes, the risk may be increased as much as tenfold to 25% ( ). In the adult population, although other racial groups have higher smoking prevalence than do African-Americans, the potential effect of smoking appears to produce more devastating consequences among young premenopausal African-American women, including lowering HDL2-C, an associated risk for CVD and myocardial infarction ( ).
Exposure to environmental smoke is also known to increase the risk for developing CVD and respiratory diseases. An estimated 33,951 nonsmokers die from CHD each year as a result of exposure to secondhand smoke. Data indicated that approximately 60% of children between 3 and 11 years of age are exposed to secondhand smoke ( ). Levels of cotinine, a biomarker indicating secondhand smoke exposure, declined from 52.5% in 1999 to 2000 to 40.1% in 2007 to 2008 for individuals in all age groups. From 2007 through 2008, levels in children ages 3 to 11 declined from 60.5% to 53.6% and from 55.4% to 46.5% in children and adolescents ages 12 to 19. In individuals ages 20 years and older levels dropped from 52.5% to 40.1%. During this same period, cotinine levels were higher in African-Americans (55.9%) compared with Whites (40.1%) and Mexican Americans (25.8%). Data continue to show that Blacks have higher levels of cotinine than non-Hispanic Whites, even though the percentage of exposure to environmental smoke is slightly higher. One plausible explanation for the differences is that Blacks may metabolize nicotine at a slower rate, leading to increased serum levels of cotinine. Another reason for higher levels in Black children is that they may actually experience greater exposure to environmental smoke ( ). The revealed that smoking rates were substantially higher in families with lower educational attainment. In the same report, data showed that smoking rates were highest among persons living below the poverty level. It is well documented that the percentage of African-Americans who live in poverty is higher than that for other racial and ethnic backgrounds. This may explain why poor African-American women have higher rates of smoking than their White counterparts.
Diabetes is defined as a heterogeneous group of chronic metabolic disorders caused by defects in insulin secretion or insulin action. The physical manifestations of diabetes are impaired glucose tolerance, hyperglycemia, and IR ( ; ; ). In type 1 diabetes, which accounts for 1% to 5% of cases, there is an absolute deficiency of insulin secretion. In type 2 diabetes, which accounts for 90% to 95% of cases, the cause is a combination of resistance to insulin action and inadequate compensatory insulin secretory response ( ; ). Hypertension is present in 20% to 60% of persons with diabetes. Hypertension often is an initial presenting symptom of IR and metabolic syndrome and may be a hallmark for the onset of type 2 diabetes. Diabetes is now a global epidemic with an estimated 366 million individuals affected by the disorder ( ). According to data from the Global Diabetes Plan, this number is expected to increase to 552 million within the next 20 years. In the United States, an estimated 29.1 million adults have a known diagnosis of diabetes, 8.1 million have undiagnosed diabetes, and 80.8 million have prediabetes ( ). From 2005 to 2012, the number of adults with diabetes increased from 20.6 million to 29.1 million ( ). In 2012, 1.7 million new cases were diagnosed, and the number of persons with diabetes is expected to continue to rise over the next decade ( ). The prevalence of diabetes varies according to race and gender, increases with age, and at all ages is highest among African-Americans ( ). In 2010, diabetes was recorded as the seventh leading cause of death in the United States. More recent data rank diabetes as the fourth leading cause of death ( ) for African-Americans ( ). In 2011, diabetes was the cause of death for approximately 73,831 people, and it was identified as the contributing cause of death for another 239,189 individuals ( ; ). The prevalence of type 2 diabetes is higher in African-Americans than in Whites, and the age-adjusted overall mortality is 2.2 times higher for African-Americans. African-American, American Indian, and Hispanic women experience the highest diabetes mortality rates ( ; ). In 2009, the overall age-adjusted rate of death from diabetes for African-American males and females was 44.9% and 35.8%, respectively, compared with 24.3% and 16.2%, respectively, for their White counterparts ( ). African-Americans with diabetes have a higher risk for coronary artery disease, stroke, and other major complications of diabetes (such as end-stage renal disease, limb amputations, and blindness) than their White counterparts ( ).
Obesity and sedentary lifestyle.
Obesity is another health condition that remains a pandemic problem. According to the WHO, worldwide obesity has increased by 27.5%. From 1980 to 2013, the number of people who are obese has increased from 857 million to 2.1 billion ( ). According to Ng et al., the United States has seen the greatest increase in adult obesity, with one third of the population meeting the definition. In 2010, the WHO estimated that by 2015 the number of overweight people in the world would reach 2.3 billion and of this number, over 700 million would be obese. If current rates of obesity and overweight in individuals continue to grow, this number will surpass predictions. In the United States, slightly more than 300,000 deaths per year can be directly attributed to obesity, and the condition has been cited as second only to cigarette smoking as a major modifiable risk factor for all causes of death. It is a well-documented fact that obesity and inactivity are significant risk factors for CVD and diabetes ( ; ). Obesity leads to changes in systemic circulation resulting in increased platelet aggregation, increased activity of the sympathetic nervous system and the renin-angiotensin-aldosterone system, as well as endothelial dysfunction ( ; ). Central adiposity, one of the components of metabolic syndrome, is associated with an increase in glucose abnormalities, hypertension, and atherosclerosis. Abdominal obesity is an independent risk factor for ischemic stroke in all racial and ethnic groups ( ). Overweight in children is defined as a value at or above the 95th percentile of the gender-specific BMI for age growth charts. Obesity among adults is defined as a BMI of 30 kg/m 2 or greater. Approximately 69% of Americans are overweight or obese, including 82% of African-American women over 40 years of age ( ). Data from the NHANES III suggested that 23 million American children and adolescents 2 to 19 years of age are overweight and that 74.1 million American adults are obese. This change represents a significant increase in the prevalence of overweight children and adolescents and obesity among adults. Data from NHANES III revealed that obesity is more prevalent among certain racial and ethnic groups and that gender and age are contributing factors. This same study showed that rates of obesity were higher in African-American women (58%) compared with 33% for White women, 43% for Hispanic women, and 5.8% for Asian women. There is a direct link between obesity and the development of CVD, dyslipidemia, type 2 diabetes, sleep apnea, and numerous forms of cancers ( ; ).
Results from NHANES III revealed a positive correlation between obesity and hypertension in African-Americans. Persons who are overweight or obese have an increased risk of developing hypertension, type 2 diabetes, CHD, stroke, and sleep disorders ( ). There is a higher prevalence of obesity in women with lower incomes, and African-American women are more likely to be in a lower income bracket than White women ( ; ). This fact is also supported by recent data from the . This report showed that 82% of non-Hispanic Black females and 69% of non-Hispanic Black males are overweight, compared with 73% of White males and 61% of White females. Non-Hispanic Black females also have the highest rate of obesity (58%) compared with non-Hispanic Black males (38%), non-Hispanic White males (34%), and non-Hispanic White females (33%) ( ; ). Factors contributing to obesity include excessive dietary intake of calories and fatty foods and physical inactivity ( ; ; ). Persons with lower incomes and less education typically have poorer dietary habits and are not as physically active as those who have high incomes and are better educated ( ; ; ). African-Americans and Hispanics in general have lower incomes and are more likely to live in poverty than Whites ( ). In fact, 11,000,000 African-Americans live below the poverty index. If being overweight is a common problem in the general U.S. population, it is said to be at epidemic proportions in children in this country ( ).
Childhood obesity continues to increase steadily and rapidly among African-American children ( ; ). Some researchers conclude that childhood obesity often serves as a primary marker for high-risk dietary and physical inactivity practices ( ). Childhood obesity can also contribute to the development of metabolic syndrome, leading to early onset of CVD and type 2 diabetes.
Strokes are the fourth leading cause of death in the United States. In African-Americans, it remains the third leading cause of death, and the rate of death from stroke is almost twice as high as for Whites because of a greater prevalence of comorbid conditions, along with an increased severity and a more rapid progression of disease processes. Cardiovascular disease, hypertension, and diabetes, the major risk factors for strokes, are seen in disproportionate numbers of African-Americans. Of the four leading causes of death in African-Americans, hypertension can be associated with at least three of the four disease states: CHD, the leading cause of death among African-Americans; CVAs, listed as third; and diabetes, listed as fourth. Coronary heart disease and CVAs can occur or are exacerbated as a result of hypertension. Individuals with diabetes have a higher risk of CHD and hypertension, and both conditions are exacerbated by diabetes ( ).
Sudden Cardiac Deaths.
Significant differences have been noted in the incidence of sudden cardiac arrest among African-Americans. A 2015 report from the AHA indicated that the rate of sudden cardiac death was much higher for young African-Americans than for Whites. Not only are African-Americans more likely to experience sudden cardiac arrest, but they are also more likely to succumb to the arrest ( ). In fact, among African-Americans in all age groups, both men and women have higher rates of cardiac arrests than their White counterparts have. The survival rate for African-Americans, compared with Whites, was remarkably different (0.8% vs. 2.6%). The difference in survival rate can be attributed to the fact that the mortality rate for African-Americans with coronary artery disease, left ventricular hypertrophy, heart failure, and cardiomyopathy is higher than that for Whites ( ). Data from a New York City study of out-of-hospital cardiac arrests show that the age-adjusted incidence for cardiac arrest per 10,000 adults was higher in Blacks at 10.1 compared to 5.8 for Whites. In 2006, a Duke University study by Berger on age, sex, and racial disparities in heart hospital transfer patterns revealed that older, female, and minority patients rushed to community hospitals with acute MIs were less likely to be transferred to larger hospitals offering procedures to restore artery patency.
The authors also found that women were 16% less likely to be transferred than men; compared with White patients, African-Americans were 31% and Hispanics were 41% less likely to be transferred. In another Duke University study, researchers found that hypertrophic cardiomyopathy (HCM), a common cause of sudden cardiac death in young competitive athletes, was an important issue for African-Americans ( ) also found a large discrepancy in clinical diagnosis of HCM in African-American compared with White athletes. Of 1986 patients clinically diagnosed with HCM, only 158 (8%) were African-American. Furthermore, among the 286 cardiovascular deaths, most were caused by HCM ( n = 102). Results of this study showed that, of the 102 athletes who died from HCM, 42 were White (41%) and 56 were African-American (55%). These researchers concluded that HCM is under-diagnosed in African-American athletes and that the condition is a common cause of sudden death in this population.
More recent data continue to support the fact that African-American males experience higher mortality from sudden cardiac death than White males. In 2008, conducted the Sudden Cardiac Death in Heart Failure (SCD-HeFT) study to examine survival benefits from implantable cardiac defibrillator (ICD) therapy. In this study, 23% of the subjects were ethnic minorities and 17% were African-Americans. The investigators evaluated two major prespecified subgroups: heart failure cause (ischemic vs. nonischemic) and New York Heart Association class (II vs. III). The authors compared demographic, clinical variables, socioeconomic status, and long-term outcomes with the subject’s race. The results of this study demonstrated that ICD therapy significantly improved survival compared with medical therapy alone in stable, moderately symptomatic heart failure patients with an ejection fraction of 35% or less. Data also supported the fact that African-Americans were younger and had more nonischemic heart failure, lower ejection fractions, worse New York Heart Association functional class, and higher prevalence of a history of nonsustained ventricular tachycardia when compared to Whites. Data also indicated that survival benefits from ICD therapy in SCD-HeFT were not dependent on race and that death rates were equally decreased in both racial groups receiving ICD therapy compared with placebo (hazard ratio, 0.65 in African-Americans and 0.73 in Whites). Although data support the fact that African-Americans are less likely to receive an ICD, in this clinical trial setting, there was no evidence that they were less willing to accept ICD therapy than were Whites.
Other plausible explanations for the differences between the rates and lethality of sudden cardiac arrest for African-Americans and their White counterparts are as follows: (1) inexperience and lack of familiarity with basic cardiopulmonary resuscitation techniques of the persons at the site; (2) response time of the emergency ambulance to the site, particularly in “African-American neighborhoods”; (3) response time of the hospital emergency team to the African-American client in full cardiac arrest ( ; ; ); and (4) inequities in quality of care for clients at risk for ventricular dysrhythmias ( ). The findings from this study, along with more recent data from the AHA, indicate that the incidence of cardiac arrest is significantly higher among African-Americans in every age group, and early intervention and prevention techniques to reduce the chronicity of CHD appear to be plausible mechanisms to prevent cardiac arrest in this population.
AIDS (HIV) Risk.
While CVDs have been heralded as the single leading cause of death across all ethnic and racial groups, little attention has been paid to the growing incidence of deaths from AIDS among African-Americans under 35 years of age. Human immunodeficiency virus (HIV) and AIDS was once thought of as a disease that primarily affected gay single White males. According to data published by the ; ), the severity of the impact of HIV among homosexual and bisexual men of all races and ethnicities has been seriously underscored. Data from this report clearly show that within African-Americans, Hispanics, and Latinos, the disease has had the severest impact on homosexual or bisexual African-American and White males between ages 30 and 40. In 2010, an estimated 10,600 (72%) of new infections occurred among young homosexual and bisexual African-American males and other men who report having sex with other males occurred in African-American men. The greatest number of new infections, 4500 (45%), occurred in African-American gay and bisexual males ages 13 to 24 ( ; ). This number was more than twice the rate among Whites, Hispanics, and Latinos; both groups had slightly less than 2000 new cases. African-American women continue to account for the largest number of new HIV infections (64%) when compared to infection rates for women of other races ( ). In 2010, the incidence of infection for African-American women was 4 times the rate for Latin American women and 20 times the rate for White women. This same report indicated that the common mode of transmission for African-American women was through heterosexual contact compared with White women in whom the common mode of transmission was intravenous drug injection. Although there were fewer new HIV infections among African-American women compared to African-American men (6595 vs. 1776), the CDC Office of Minority Health’s most recent analysis reveals that African-American women are far more affected than women of other races. The HIV incidence rate in African-American women (40 per 100,000) is nearly 20 times higher than that of White women (2 per 100,000) and five times higher than the rate of infection for Hispanic and Latino women (8 per 100,000). In 2011 alone, 23,168 African-Americans were diagnosed with HIV ( ; ; ; ).
In 2010, approximately 47,989 new cases of AIDS were reported in the United States—a much higher figure than the CDC’s previous estimates ( ). According to the Statistics 2012 HIV Surveillance report, from 2008 to 2011, the number of deaths from AIDS remained stable among children under age 13 and in individuals in the age groups 13 to 14, 20 to 24, 55 to 59, and 60 to 64. The death rate decreased among children and adolescents ages 15 to 19, and in adults ages 25 to 29, 30 to 34, 35 to 39, 40 to 44, 45 to 49, and 50 to 54. The death rate increased in adults from ages 65 and older. Further, the estimated death rate for persons with a diagnosis of HIV infection was highest in persons aged 45 to 59. Although infections and deaths have decreased for all other races, African-Americans continue to have the highest rates of new infection and death compared with individuals of races and ethnic backgrounds. Among racial groups, African-Americans had the highest rates (58.3/100,000) compared with Whites (7/100,000) and Hispanic/Latinos (19.5/100,000) ( ; ). With regard to race and ethnicity, the number of individuals living with HIV/AIDS is highest among African-Americans (44%), compared with Whites (33%) and Hispanics/Latinos (20%). Disparities are also seen in the number of persons diagnosed with HIV/AIDS; from 2008 through 2012, the rates of HIV/AIDS cases were 36.4 per 100,000 in African-Americans, 3.5 per 100,000 in Whites, 10.2 per 100,000 in Hispanics/Latinos, 4.9 per 100,000 in American Indians/Alaska Natives, 2.7 per 100,000 in Asians, and 6.2 per 100,000 in Native Hawaiians/other Pacific Islanders ( ). The impact of AIDS is disproportionately affecting minorities and women. In 2011, African-American females accounted for the greatest number of women diagnosed with AIDS (32.2/100,000 compared to White females at 1.4/100,000). In 2012, approximately 50% of all reported new cases of AIDS (27,928) occurred in African-American women. In 2011, African-American women accounted for 25% of new cases of AIDS in women ( ; ). Similarly, in 2011 nearly 80% of all new pediatric AIDS cases reported were among African-Americans ( ).
In 2011, although African-American males represented only 13% of U.S. males by proportion of the population, they disproportionately represented 44% of all reported cases of AIDS ( ). In 2011 alone, 15,958 African-Americans had a confirmed diagnosis of stage 3 HIV/AIDS ( ). Even more astounding is the number of African-American women who had AIDS (70,812) compared with their White counterparts (19,676). In addition, although by proportion of the population African-American women make up only 14% of U.S. females, these individuals disproportionately represent 36.4% of all reported cases of AIDS in women. In fact, overall, African-Americans now represent approximately 50% of all reported cases of AIDS in the United States to date ( ; ). Moreover, African-Americans between 13 and 19 years of age now account for 82% of newly reported AIDS cases in that age group as of 2011 ( ). Most recent data from the indicate that 1 in 16 African-American men and 1 in 32 African-American women will be infected with HIV at some point in their lifetime. In addition, African-Americans between 13 and 24 years of age continue to account for a disproportionate rate of all HIV diagnoses ( ; ).
Men who have sex with men still represent the largest group of individuals with HIV/AIDS in the United States ( ; ). However, since the first reported case in 1981, HIV/AIDS has become a major cause of morbidity and mortality among African-Americans. Ward and Duchin reported in 1998 that for the first time the number of African-Americans with a diagnosis of AIDS was approximately equal to the number of reported cases in Whites. Since 1995, HIV infection has been cited as the leading cause of death in persons 24 to 44 years of age ( ).
A disproportionate number of individuals with AIDS in this age range (22–44) are African-American ( ). According to the Statistics 2012 HIV Surveillance Report ( ), the rate of death from AIDS was greater for African-American males (16.5 per 100,000) than for White males (2.3 per 100,000). African-American females fare even worse (7.5 per 100,000), with a death rate significantly higher than that for White females (0.5 per 100,000) ( ). Statistical data from the State HIV Prevention Report and Statistics 2012 HIV Surveillance Report ( ) support the fact that a greater percentage of African-Americans are infected with HIV and are dying of AIDS compared with other races. According to demographic data from the CDC Health Statistics 2012 HIV Surveillance Report, a total of 635,816 persons regardless of race/ethnicity have died of AIDS as of 2011. The cumulative estimated number of deaths of persons with an AIDS diagnosis in the United States and dependent areas, through 2011, was 659,068. In the 50 states and the District of Columbia, this included 643,254 adults and adolescents and 5175 children under age 13 years at death. Breaking those numbers out by race/ethnicity has become difficult since 2001. However, Table 8-1 depicts deaths from AIDS through 2011 by race/ethnicity and by gender.