Culture-Sensitive Health Care: African American

African Americans are the second largest minority group in the United States, composing about 10 percent of the total U.S. population, a figure projected to rise to almost 14 percent by the year 2050. African Americans have almost as long a history in the United States as the earliest White settlers, and a longer history than many immigrant groups. Because of this lengthy American heritage, it is easy for both African Americans and White Americans to assume that only one factor-skin color-distinguishes them from one another.

In the health care environment, this assumption can have serious consequences. The belief that to ensure appropriate care all the caregiver has to do is ignore skin color and proceed to the usual treatments can sometimes lead to failure, anger, and frustration on the part of both patient and caregiver. This approach ignores the fact that cultural differences may exist and can result in vastly different expectations regarding the nature of quality care and the elements of a pleasant, nurturing caregiver-patient relationship.

In fact, many African Americans reflect cultural roots that include elements of African healing, medicine of the Civil War South, European medical and anatomical folklore, West Indies voodoo religion, fundamentalist Christianity, and other belief systems. While a great deal of the information presented in this section may be unfamiliar to many African American physicians and patients, these beliefs and practices may directly or indirectly influence the health care behavior of numerous African Americans.

African American communities have become very diverse, especially with the recent arrival of people from Haiti, the Caribbean, and Africa. While this section is limited to an overview of beliefs and practices of U.S.-born African Americans, it is important to note that some of the beliefs and practices of these African Americans have been influenced by beliefs that have arrived with recent immigrants. Furthermore, because diverse African American groups frequently interact, many African American immigrants are also influenced by the beliefs described in this section.

1. Don't assume. Many African Americans will be similar in background to the caregiver, and many will be of different backgrounds. Whatever the race of the caregiver, no assumption should be made about the similarity or difference in background between caregiver and patient. With respect to health-related beliefs and practices, an African American patient may be as different from an African American caregiver as from a White, Hispanic, or Asian physician. On the other hand, an African American patient may be quite similar to the caregiver, regardless of the caregiver's race. It is the task of the caregiver to probe and listen carefully to the patient to determine the patient's expectations and beliefs.
2. Ask for causes. When taking the initial history and performing a physical examination, ask patients not only about their symptoms, but also if they know what caused the illness. Patients' answers may reveal whether they subscribe to a folk or magical belief system.
3. Listen without judgment. It is essential during all stages of a consultation that the caregiver listen carefully and sympathetically. Refrain from expressing anything that might be interpreted as judgmental, patronizing, or ridiculing.

African Americans may have a tendency toward certain health concerns because of cultural factors. In fact, life expectancy for African Americans is 67.4 years, compared with 75 years for Whites. Specific concerns include the following.

1. Hypertension morbidity and mortality rates are three to five times higher than for Whites.
2. Diabetes is 33 percent more prevalent than in Whites.
3. African Americans have a higher rate of coronary heart disease than Whites.
4. Cancer, despite an improvement in the mortality rate, remains a major health problem.
5. AIDS affects about three times as many African Americans as non-African Americans.
6. Infant mortality among African Americans is high, with low birth weight and SIDS accounting for a large percentage of deaths.
7. Sickle cell anemia is a genetically inherited disorder found almost exclusively in African Americans. Only 50 percent of children born with sickle cell anemia live to adulthood; others die before age 20, and many who do live suffer chronic and irreversible complications. Parents who are both AS heterozygotes should be informed that there is a 25 percent chance that their children will be born with sickle cell anemia. The disease can be diagnosed during the first trimester of pregnancy by DNA analysis. If the fetus is an SS homozygote, parents and caregivers may wish to discuss the viability of the pregnancy. Because the disorder is so debilitating to children, women who carry the gene for the disease may wish to consider a wide range of contraceptive options, including sterilization; the caregiver should be prepared for such discussions.
8. Lactose intolerance is common in African Americans (as well as Asians, Africans, and Mexican Americans).

1. Skin assessment of African Americans is best done in indirect sunlight.
2. Pallor may be identified among African Americans by an absence of underlying red tones. Brown skin tends to appear yellow-brown and black skin tends to appear ashen.
3. Erythema can be detected only by palpitation. The skin is warm, tight, and edematous in the inflamed area. Deeper tissues are hard.
4. Cyanosis may best be observed in facial skin, the earlobes, the nail beds, and around the mouth. Pressure applied to the nail beds or earlobes can be used to determine normal or slow return of color.
5. Jaundice can be seen in a generalized yellowing of the sclera. Because the normal yellow pigmentation found in dark-skinned individuals tends to be concentrated in the inner and outer canthi of the eyes and in the stool, blood tests may be needed to confirm the presence of jaundice.

The beliefs described below are prevalent in some, but not all, African American populations. While these beliefs may be unfamiliar to many African American physicians and patients, they may influence the health care behavior of a substantial number of patients. For this reason, the caregiver should be familiar with them. According to Snow (1974), the elements of African American folk medicine form "a coherent medical system and not a ragtag collection of isolated superstitions." To those who follow these beliefs, the system "makes just as much sense . . . as the principles of orthodox medicine do to the graduate of an accredited medical school."

1. There is a direct connection between the human body and the forces of nature. Thus, dates, zodiacal signs, and numbers affect everyday behaviors and activities and should be taken into account in making decisions about health care and many other aspects of life.
2. The Farmer's Almanac is used by many African Americans and Whites in the South as a guide for interpreting the effects of the phases of the moon, the position of the planets, and the seasons of the year on natural phenomena. If the Almanac is a reliable guide to planting, harvesting, and animal care, it is equally useful in determining the best dates to have a tooth filled (during the moon's decrease) or pulled (during its increase); the time to wean a baby; and the amount of self-medication to take, and when to take it, for a particular illness.
   Because patients who use the Almanac or other source of zodiacal signs to manage their health will probably not disclose this information to caregivers for fear of being ridiculed, caregivers must listen carefully for patient comments that indicate such beliefs and then ask indirectly about them.
3. Numbers may be either lucky or unlucky. The numbers 3 and 9 are especially powerful, and they are used frequently in deciding on the dosage for home remedies (e.g., taking 3 tablespoons 3 times a day for 9 days) and magical rituals (e.g., identifying 9 signs, saying a chant 9 times, praying for 9 days). While these rituals and remedies are being performed, the person is considered especially vulnerable to illnesses caused by "cold" (see below), and may avoid bathing because water conducts cold into the body.
4. Events, including illnesses, are attributed to phenomena that are either "natural" or "unnatural." Natural events are the result of phenomena, operating according to God's plan, that maintain the balance or harmony of nature. Unnatural events are the result of phenomena, wrought by the devil, that upset or unbalance the harmony of nature. All negative events (including illnesses), whether they are natural or unnatural, can be rectified if their correct cause can be determined and means can be found to reestablish harmony with nature. Natural events can be rectified by natural instruments and means, but unnatural events can be rectified only by supernatural approaches.
   Good health, although considered a matter of good fortune, results when one takes good care of oneself and makes sure that the body, mind, and soul remain in harmony with nature. Illness occurs when this balance is disturbed and is cured when harmony is restored. Because of the conviction that any illness can be cured if only the correct cause and appropriate cure are found, patients may not accept any diagnosis of a terminal disease or a chronic illness, but may instead continue to search for a different doctor, a new medicine, another treatment-including, perhaps, a folk or faith healer.
   Patients who are told that they must take a particular medicine for life (e.g., for hypertension or diabetes) may be noncompliant because they are afraid that the true cause of the illness has not been found and the medicine is only a cover-up for the physician's not knowing how to cure them. They may also fear that too much medication for one illness may tip the balance in the opposite direction (for example, a patient taking medicine for high blood pressure too long may begin to suffer from low blood pressure).
5. Humoral theory, based on Aristotelian and early European medical beliefs, is a part of the African American folk medical system. The theory of humors focuses on the regulation of the body by the four humors, or major bodily fluids: blood, phlegm, black bile, and yellow bile. The liver, which produces bile, must be cleaned out every spring. Phlegm or mucus, often referred to as "slime," must be expelled from the body.
6. The four major causes of natural illness are "cold," "dirt," improper diet, and improper conduct. Natural illnesses occur when a person fails to monitor or manipulate the bodily processes correctly. The body is then unprepared to defend itself against the forces of nature.
• "Cold." "Cold" is associated with an increase in the production of mucus, which results in the accumulation of phlegm in the kidneys or diaphragm. "Cold" enters the body when it is most vulnerable, and the elderly and very young are considered to be particularly susceptible. Illnesses that result from "cold" may not show up immediately; for instance, "cold" may enter the bodies of young people who do not take care of themselves and manifest itself only when they are older.
  Women are more susceptible to "cold" than men, especially during menstruation and right after childbirth, when bleeding causes the body to be "open." Because cold and dampness are thought to impede the flow of blood, women are warned not to wash their hair or do anything that may bring on a chill while bleeding. "Cold" can clot the blood, causing it to back up into the body. This may result in headache, stroke, and elevated blood pressure.
• "Dirt." "Dirt," vaguely associated with germs, is believed to circulate in the system via the blood. It may result from failure to bathe, impeded menses, irregular menses, or sexual excesses. Heat, fever, inflammation, and skin eruptions (including a baby's rash, measles, a syphilitic chancre, and skin cancer) are indications that something in the body is trying to come out.
  The idea of expelling "dirt" manifests itself in several ways, including an overconcern with the gastrointestinal tract. Many African Americans use, and overuse, laxatives, beginning in infancy. In the spring, many adults take additional laxatives to clean out the body; the treatment may consist of a nine-day course of sulfur and molasses to purify the body, castor oil to lubricate it, some form of commercial preparation to cleanse the liver, sassafras tea or poke greens to thin the blood (which is thought to thicken in winter), and numerous other cleansing treatments. It is highly important for caregivers to encourage patient disclosure of home remedies because some are quite dangerous. In addition to overusing laxatives, some African Americans have been known to take kerosene, turpentine, moth balls, and carbon tetrachloride as oral self-medications.
  Another aspect of the "dirt" notion is its linkage with menses. Because of the belief that the function of menstruation is to rid the body of "dirty" blood, some African American women carefully monitor their blood flow during menstruation and after childbirth. Failure to bleed (e.g., during pregnancy) or a reduction in bleeding (e.g., due to the use of oral contraceptives) may cause concern that bad blood is being stored in the body and may back up and thicken, possibly causing hemorrhage or death. For this reason, many African Americans are resistant to the use of oral contraceptives.
  Because the mother does not menstruate during pregnancy, the environment inside the womb is considered unclean. Newborns are often given catnip tea to cause the eruption of hives or small red bumps, which are regarded as a way for the child's body to throw off the "filth" of the uterine environment.
  Finally, another "dirt"-related phenomenon is "geophagy," the eating of clay and dirt, a practice brought by slaves from Africa and considered to be particularly beneficial to pregnant women and their unborn children. Eating clay, which is rich in iron, may be both a cause and a result of anemia. With the end of slavery, when many African Americans moved from farming communities to towns and cities, Argo starch was substituted for clay. Many older African Americans who acquired a taste for Argo years ago still eat it today.
• Improper diet. The terms "high blood" and "low blood," which are widely used among African Americans, refer both to the volume of blood and its distribution throughout the system. African Americans often treat these folk illnesses with home remedies and temporary changes in diet.
  "High blood" is associated with overly rich food and reddish foods, such as beets, carrots, grape juice, red wine, red meat, and pork. A diet rich in these foods is believed to send an oversupply of blood to the heart or brain, raising "pressure" and clogging these organs. Symptoms of "high blood" include "falling out" (sudden collapse in which the eyes usually remain open but the person cannot see), headache, dizziness, and spots before the eyes. Natural remedies focus on lowering the blood and thinning it out, opening the pores and sweating it out, and opening the bowels to eliminate pressure. Treatments include foods (many of them white in color), herbal teas, and laxatives. Remedies used in rural southern areas (where "high blood" may also be called "sweet blood") include "bitters," such as bullfrog urine mixed with garlic and onion. In urban areas, astringents such as vinegar, lemon juice, olive or pickle juice, garlic, and Epsom salts are common home remedies.
  "Low blood" is associated with anemia; its symptoms are weakness, lassitude, and fatigue. It is home-treated with iron pills and tonic.
  A negative consequence of these beliefs is the ready confusion of the folk terms "high blood" and "low blood" with the medical conditions of high and low blood pressure. African American patients diagnosed with high or low blood pressure and given a long-term management plan may be reluctant to take medication indefinitely, fearing that too much high blood pressure medication may thin the blood and cause "low blood," and vice versa. Caregivers must take pains to explain carefully high or low blood pressure and the function of the prescribed medication. Patients may need to be reassured that long-term medication is necessary and will not result in the opposite condition.
• Improper conduct. Because religion is an important component in the health/illness beliefs of many African Americans, disorders-especially in children-may be attributed to parents' transgressions and may need to be healed through prayer. For example, deformity, seizure disorders, and retardation in children may be interpreted as divine punishments for the parents' misdeeds. Home remedies and the ministrations of a physician are alike considered powerless in curing someone who has been punished by God. Only repentance through a contact with God, directly or through the intercession of a faith healer, can effect a cure.
7. Unnatural (magical) illnesses are believed to be outside the realm of nature and unreachable by approaches that might be effective for natural illnesses. Successful treatment requires the intervention of a specialist who commands supernatural powers.
   Unnatural illnesses may be caused by "worriation," evil influences, or sorcery. "Worriation" is produced by everyday stresses or concerns about daily problems. Evil influences result from God's withdrawal of protection from a person who has failed to mend his or her ways. Sorcery-or voodoo or rootwork-may "cross up," "fix," or "hex" someone. More often than not, the person responsible for the hex is someone inside the victim's social circle who intends harm because of anger, jealousy, or envy.
   Certain symptoms-nausea, vomiting, diarrhea, abdominal pain, lack of appetite, or loss of weight-may be interpreted as having been caused by sorcery, especially if someone cursed the victim or the victim has a guilty conscience. The means used by the sorcerer may be a magical poison, affecting only the intended victim, that was slipped into the person's food or drink.
   The sudden inability to perform daily tasks or the onset of erratic behavior may be attributed to a hex. A 1972 study conducted at a Miami psychiatric center found that one third of all African American patients being treated for depression believed they were the victims of a hex.
   Patients who believe in sorcery may be very wary of eating anything outside the home or anything that they themselves have not prepared, convinced that the person who cast the spell on them can introduce such creatures as snakes, lizards, spiders, toads, or frogs into the victim's body by hiding their eggs or pulverized remains in food or drink.
   Only a powerful healer with supernatural powers can put on or take off a hex. Other folk healers will be powerless, as will orthodox physicians. It is even believed that the more the victim of an unnatural illness goes to a doctor, the sicker she or he will get. Often a person who believes she or he is hexed will try a biomedical cure first both as a way of confirming the existence of a hex and as a means of "testing" the physician's diagnostic ability and the "power" of her or his medicine.
   Patients will withhold their suspicion of a hex (or even the fact that they believe in hexes) from the caregiver out of fear of ridicule.

Many types of healers are found in African American communities. Some-such as the granny or herb doctor-work in their homes, while others practice in a religious setting. Some work on a one-to-one basis, and others in a group. Some healers claim to heal everything, while others confine themselves to a specific type of illness or problem. Whether they refer to themselves as healers, herb doctors, root doctors or root workers, readers, advisors, spiritualists, or conjurors, all claim that their healing power is a gift from God. They rarely refer to themselves as "Doctor," preferring kinship terms such as Sister, Brother, Mother, Reverend, Prophet, Evangelist, Madam, Princess, King, or Queen. Folk healers may advertise in local, community newspapers, in spite of the fact that they can be arrested for practicing medicine without a license.

Grannies, herbalists, and physicians. Healers are classified according to the origin of their healing power. Those who received their power through learning, such as the granny, herbalist, and medical physician, have the lowest status because of the belief that anyone may learn a healing trade.

Spiritual healers. Higher in status are those who received their gift during a profound religious experience; these are likely to be ministers who heal during regular church services that involve prayer, laying on of hands, and the use of holy oil or holy water with supernatural powers. Spiritual healers are believed to be successful in treating natural illnesses that have not responded to other forms of natural treatment and which may have been caused by sinning.

Supernatural healers. These are the healers of highest status, generally called sorcerers, voodooists, or root doctors. Male voodoo healers are also called houngan or papaloi, while female healers are mambo or mamaloi. The most powerful supernatural healers are those believed to have been selected by God at birth. The seventh child of the same sex, the first child born after twins, and any child born with "the Vail" or caul (amniotic membrane) are likely to have been chosen. These healers are often treated with deference from birth and many have practiced healing since childhood. Reports of the details of voodoo healing rituals are sparse, but one of the most important involves the reading of animal bones. The bones (the source animal appears to be unimportant) are linked to physical attributes or body parts; the patient arranges the bones on the floor and the healer interprets the arrangement.

Identifying patients who may have used folk healing methods. For fear of ridicule, patients who make use of folk healing methods will probably not admit it to the caregiver. When taking the initial history or performing a physical examination, the caregiver should gently probe the patient about the causes of the illness (which may reveal folk beliefs) and any treatments or remedies that have been tried. It is essential to listen closely and to avoid appearing judgmental or skeptical. If the patient admits to taking something that is not harmful, it is best to recommend its continued use. If, on the other hand, the patient reports taking something harmful, it is best to recommend against using it since it may clash with the powerful treatment that the caregiver will provide.

Another indicator of belief in folk medicine is the wearing of charms or amulets. These may include a silver dime (believed to turn black if someone is threatening harm); an amulet of "asafetida," which is rotten flesh resembling a dried-out sponge, around the neck (believed to protect against contagious diseases); and copper or silver wrist bracelets (believed to provide early warning of illness by turning the skin around them black).

Helping "hexed" patients. If careful, sympathetic questioning reveals that the patient believes that he or she is the victim of a hex, the caregiver may take several approaches. One approach is to suggest hypnosis, during which the patient is reinforced in the belief that he or she is strong enough to throw off the hex. Another approach is to enter the patient's belief system by discussing the proposed treatment and suggesting that the patient consider it a more powerful "counter-hex." One physician went so far in the treatment of a patient with seizures as to stage a midnight healing ceremony, complete with candles, for the administration of intravenous medication, which was referred to as the most powerful anti-root medicine known. During the day, this information was reinforced by the nursing staff. The treatment worked; in ten days the patient was discharged from the hospital, feeling like his "old self."

This approach may or may not appear appropriate. The caregiver must use judgment to avoid patronizing or misinforming the patient, but it may be possible to partner with the patient in attacking a hex "on its own terms." In the face of the patient's belief that the physician will be powerless against a hex, an unconventional approach might be justified to convince the patient that modern biomedicine can help. It has now become more common for hospitals and clinics to work with curanderos for Hispanic patients who believe in folk medicine. It may be possible to make similar arrangements with voodoo healers.

Jackson, Jacquelyne Johnson. "Urban Black Americans." Ethnicity and Medical Care. Ed. Allen Harwood. Boston: Harvard University Press, 1981. pp. 37-129.

Murphree, Alice. "A Functional Analysis of Southern Folk Beliefs Concerning Birth." American Journal of Obstetrics and Gynecology, 102(1), 1968, 125-134.

Russell, Kathleen, and Nancy Jewell. "Cultural Impact of Health-Care Access: Challenges for Improving the Health of African Americans." Journal of Community Health Nursing, 9(3), 1992, 161-169.

Snow, Loudell F. "Traditional Health Beliefs and Practices among Lower Class Black Americans." Western Journal of Medicine, 139, 1983, 820-828.

- - -. "Sorcerers, Saints and Charlatans: Black Folk Healers in Urban America." Culture, Medicine and Psychiatry, 2, 1978, 69-106.

- - -. "Folk Medical Beliefs and Their Implications for Care of Patients: A Review Based on Studies among Black Americans." Annals of Internal Medicine, 81, 1974, 82-96.

Spector, Rachel E. Cultural Diversity in Health and Illness. 3rd ed.). New Jersey: Appleton & Lange, 1991.