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Cultural competence with african american patients with audio lecutre
- 1. Janice K. Warrington, MSNEd, RN, SD/CLTC
Notas del editor
- This module will be about African American patients. African Americans have cultural beliefs that differ from EuroAmericans and it is important to understand theses differences in order to provide culturally sensitive care.
- African Americans are one of the largest ethnic groups in our country. They came to America as slaves and it is believed that between 10 and 12 million Africans were imported to the New World between 1650 and 1850 (Everyculture.com, 2008) There are over 37 million people who identify their race as African American according to the U.S. Census Bureau in the census done in 2006. This number is expected to increase to over 40 million by the year 2010. There are many terms used to identify African Americans-for example: ”Negro”, “colored”, “Black American”, “Afro-Americans”, and “people of color”. Typically the choice of term is related to age and what term was used during specific periods of time. African Americans are largely descendants of slaves who were brought to this country in the years between 1619 and 1860. There is little record of numbers of slaves brought into the country but estimates are that somewhere between 3.5 and 24 million slaves brought from Africa . Most of the people brought to America were settled in the south. Today, over 50% of African Americans live in the south. About 20% live in the North/Northeast , 20%in the Midwest and about 9% live in the west. There are high concentrations of African Americans found in metropolitan areas (U.S. Census, 2009)
- Before 1954, the opportunities for African Americans in education were compromised by segregation and inferior facilities. According to Blum et al in “The National Experience: A History of the United States”, almost one third of blacks were illiterate in 1910. In 1954, a landmark decision by the Supreme Court in Brown v. Board of Education of Topeka, ruled against segregation in public schools. James B. Conant wrote an article in 1961 about the issues of African Americans in segregated schools. He states “that the American slum problem is largely a Negro problem, and that it cannot be remedied without this fact in mind. As a result of decades of patent discrimination, the Negro in our cities rarely expects job opportunities commensurate with his abilities: hence, there is little desire in the Negro slum to progress academically, since the white establishment will not recognize any such progress.” (Conant, 1961) His statement has proved out in inadequate job opportunities and poor wages resulting in poverty form my African American families. This has lead to poorly educated individuals, high drop out rates from high school and high rates of drug and alcohol abuse. Despite these challenges, African Americans place a high value on education. It is through education that they see a light at the end of the tunnel and a way out of the desperate situation some of them find themselves in. It is not uncommon to see siblings assist one another financially to get a college education. In some families as one child gets a degree, he helps the next one and so on until all have completed school. Women are much more likely to achieve a higher degree and secure better positions in the workforce. As a result of educational disparities African Americans continue to be underrepresented in managerial positions and professional positions.
- English is the dominant language of African Americans, however there is a way of speaking among some referred to as African American English or ebonics. Their speech is very highly contextual which means that they use few words, more gestures. They often speak loudly and tend to be misunderstood as angry as a result. African Americans tend to be demonstrative-using facial expressions and body language to communicate. They tend to be “touchy feely” with people with whom they are close. Direct eye contact can be taken as aggression, especially by the elderly and those of lower socioeconomic status, depending on the situation and the conversation. African Americans tend to be more present oriented. They prefer to be greeted formally by their title and surname because the family name is highly respected and connotes pride in their family heritage. Until you are specifically invited to do otherwise, address African Americans by their last name and appropriate title. Many African Americans tend to mistrust health care practitioners and express their feelings only to those who are close to them. “Don’t air your dirty laundry in public” is representative of this perspective.
- It is not uncommon to find a patriarchal system in African American families but most are matriarchal. The head of the household could be a single mother, grandmother or aunt. These types of families are accepted among African Americans without judgment or stigma. When a mother is unable to provide emotional or physical support for her children, it is not uncommon for other family members or church family to step in and help. A growing number of grandparents are raising their grandchildren-almost 44 percent of African American children are living with grandparents and about 66 percent of these children have grandparents who are primary caregivers (Purnell, 2008). Gender roles vary greatly depending on ethnicity, socieconomic class, rural vs. urban location and education. Families generally extend beyond the typical nuclear family structure. African Americans value self reliance and education for their children. They stress respect, obedience and good behavior in their children and believe that firm discipline is necessary for protection of their children from danger outside the home. Elders of the family and in the community are respected for their wisdom and insight. The role of the grandmother is one of the most central roles in the African American family. Healthcare practitioners need to recognize the importance of the female role within the family. Understanding the role of the extended family is essential to providing care and ensuring compliance with treatment plans. Social status is important to African Americans. Some occupations automatically are held at higher esteem than others-doctors, lawyers and clergy.
- According to Dr. Maulana Karenga, one mustunderstand and appreciate the meaning of Kwanzaa to Umoja (oo-MOH-jah): Unity Success starts with Unity. Unity of family, community, nation and race. Kujichagulia (koo-jee-chah-goo-LEE-ah): Self-Determination To be responsible for ourselves. To create your own destiny. Ujima (oo-JEE-mah): Collective work and responsibility To build and maintain your community together. To work together to help one another within your community. Ujamaa (oo-jah-MAH): Collective economics To build, maintain, and support our own stores, establishments, and businesses. Nia (NEE-ah): Purpose To restore African American people to their traditional greatness. To be responsible to Those Who Came Before (our ancestors) and to Those Who Will Follow (our descendants). Kuumba (koo-OOM-bah): Creativity Using creativity and imagination to make your communities better than what you inherited. Imani (ee-MAH-nee): Faith Believing in our people, our families, our educators, our leaders, and the righteousness of the African American struggle.
- African Americans have a long standing history of disadvantage in the workplace. They are underrepresented in the highly skilled and management positions and are overrepresented in low status positions. Many experience the “glass ceiling” effect where they can only gain so much status and access to better positions is blocked. Some African Americans men have issues with taking direction from European/American supervisors. They typically have no trouble expressing themselves to others but those who speak AAE exclusively may be viewed as poorly educated or unintelligent. In addition to this, their non verbal communication style can be misinterpreted as aggressive. Many African Americans suffer with higher levels of stress related to frustration with their job situation and the absence of African American leadership in the workforce.
- African Americans come from a gene pool of over 100 racial strains. This makes skin color variations from very light to very dark. Since health care practitioners are taught to use skin tone variations to assist in diagnosis, and assessment skills are based on assessment of light skinned people, inaccurate assessment of African Americans results in higher incidence of pressure ulcers with their associated morbidity and mortality. To better assess in African Americans: Pallor-absence of underlying red tones Petechia, inflammation-may need to palpate for warmth Cyanosis-oral mucosa Jaundice-sclera, palms and soles of feet African Americans are more prone to skin disorders. Post inflammatory hyperpigmentation-darkening of the skin after trauma Keloid formation-overgrowth of connective tissue associated with trauma and infection Pseudofolliculitis barbae- ”razor bumps”-caused by curly hair growing back into the skin Melasma-Brown spots on face-happens during pregnancy (more common in darker females). Vertiligo-White patches. Also associated with thyroid disorders and diabetes. Birth marks-happen in 20% of births compared to 1 to 3 percent in other groups. They are also, despite many myths, at risk for skin cancer. African Americans are at higher risk for many chronic diseases related to low income, stress, lack of access to preventative care and risky behaviors. Some of these include: cardiovascular disease, hypertension, infant mortality and morbidity, cancer, HIV/AIDS, violence, type 2 diabetes and asthma. African Americans have been subject to research that has demonstrated that they do no respond to drugs the same as European Americans. They : -are less responsive to beta-blockers -are more responsive to monotherapy -are less responsive to mydriatic dilation -have a high frequency for psychosis and low frequency for depression -need higher doses of neuroleptics -have a higher incidence of side effects for psychotropics and tricyclics
- African Americans engage in high risk behaviors and this is borne out in the high incidence of HIV/AIDS and other sexually transmitted diseases, teen pregnancies, violence, smoking, drug use, alcohol abuse, sedentary lifestyle. Leading cause of death among males is homicide. They do not seek healthcare until these practices have created chaos in their lives in some way. Health care often takes a back seat to such things as food, clothes and shelter.
- Historically, African American social rites revolved around food. Eating food that is identified with slavery has given many a sense of identity. Soul food is a southern tradition that includes things like “chitterlings” (pig intestines fried or boiled with hot peppers, onions and spices. Corn, pork fat and sweet potato pie are typically identified as southern African American foods. African Americans typically like to fry foods and use heavy gravies and sauces. Their diets are high fat, high cholesterol and full of salt. While many enjoy eating greens, they are typically cooked in some kind of salt pork or fatback. Infants are encouraged to begin eating solid foods at an early age-usually before they are two months of age-to help them sleep at night. It is believed that they need “real” food to be healthy. “ Healthy people have healthy appetites”-this belief lends itself to the view that African Americans need to be slightly overweight to be healthy. A common belief is that the blood is an indicator of balance in the body. High blood is believed to be caused by an expansion of the blood volume due to a diet to rich in red meat. The treatment, they believe is to drink vinegar or eat pickles. Low blood is believed to be caused by eating an acidic diet. Treatment is to thicken the blood with red meats and rich foods or drinking “pot liquor”. African American diets are extremely low in calcium. Many are lactose intolerant and do not supplement. They also tend to have low levels of thiamine, riboflavin, Vitamins A and C and iron. No specific food restrictions unless religion related (Seventh Day Adventist, Muslim, Jehovah ’s Witness) ** Muslims do not eat pork and may refuse pork based insulin
- Historically, African American families have been large. Parents depended on children to help support them when they could no longer work. When families began to move to the cities, they found that this could be an issue and they began to use family planning. As with most cultures, the elder women provide advice to the younger about what should or should not be done during pregnancy. One particular belief is PICA. Pica is the eating of nonnutritive substances such as clay or dirt, sand, laundry soap etc. These things cause the woman to be nauseated and supposedly cause an easy birth. Others believe that the pregnant woman should not take pictures because it can cause stillbirth and others believe that the woman should not have her picture taken because it captures the soul.There is also the belief that the pregnant woman should not reach above her head because it causes the cord to wrap around the babies neck. It is also considered bad luck to purchase any clothing before the baby is born. Many believe that riding on a bumpy road, drinking castor oil, eating a heavy meal or smelling pepper will induce labor. Postpartum practices for the infant often include belly bands with coins to prevent the umbilicus from protruding.
- Death rituals can vary depending on religious affiliation. African Americans are very family oriented so it is very important for everyone to be included in the death event. This may mean having large numbers of people at the bedside. African Americans believe that it is important to give their loved ones a “Big send off”. The decision making for this practice can include expensive coffins and what kind of vehicle to carry the coffin. They typically do not believe there is any hurry in burying the deceased-it is not unusual for the service to be 5 – 7 days after the death. This allows time for relatives who live far away to attend the funeral. African Americans believe that the body should be kept intact. It is not uncommon to hear them say “I came into this world with all my body parts and I will leave the world with them”. For this reason they are less likely to consent to organ donation and autopsy. A response that is typical with African Americans upon hearing of the death of a family member is “Falling Out”. This is manifested by a sudden collapse, paralysis and the inability to see or speak. Health care practitioners need to be aware of this condition and recognize that it is not a medical condition that requires treatment rather a cultural response to the news of a death. African Americans are also less likely to have or even know about advance directives. End of life decisions are typically made by the family.
- African Americans religion is an integral part of their lives. They believe in the power of prayer for all situations. They trust that God will take care of them and it is a major coping mechanism for many. The largest African American religious denomination in the country today is the National Baptist Convention of the U.S.A.. Many belong to the Church of God in Christ as well as the Church of Islam and the Roman Catholic Church.
- Many African Americans are suspicious of health care providers and for that reason only seek medical care when it has become absolutely necessary to do so. Some believe that natural illness happens in response to things from which the individual could have protected themselves from and have failed to do so. Unnatural illnesses are those that come to you by spirit or by person. These are illnesses caused by bad spirits. African Americans may use home remedies to maintain their health and may be reluctant to take prescribed medications. For example-they may take hypertension medications on an “as-needed” basis (when they feel bad). They engage in folk medicine (drinking alcohol mixed with fish blood to cure alcoholism-it sure would cure me!) Some barriers to health care for African Americans included low health literacy, lack of access and negative attitudes from health care providers. African Americans have some different cultural responses to illness and it is important to be aware of some of them. For example: Pain is perceived as a sign of illness. If they are not experiencing pain they may not be compliant with meds/treatment plan. High incidence of misdiagnosis contributes to their reluctance to trust health care providers. As with diet there are no cultural preclusions for blood transfusion-only religious. They are less likely to donate organs mostly from fear and lack of education. Many fear that they organs will be taken before they are dead, or that they will not receive appropriate treatment because they are donors.
- Folk practitioners can be grandmothers, respected women or elders in the community, church leaders, root doctors, or voodoo priests and priestesses, who remove hexes. Some individuals may prefer a care provider of the same gender. Folk practitioners are held in high esteem and used by all socioeconomic levels of African Americans. Many African Americans prefer Western healthcare providers who are known to the family or community and it is imperative to establish trust to be effective in return visits.