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GUIAS DE USUARIO / CONSEJOS ÚTILES SAM Ayuda: Encuentre la guía completa del usuario de SAM, las guías de inicio rápido, las sugerencias útiles y los webinars en la pestaña HELP. Este módulo está dedicado a la memoria del difunto Dr. Wilbur Watson y sus numerosas y valiosas contribuciones al campo de la sociología médica, especialmente en lo que se refiere a la etnogeriatria y la comunidad afroamericana. Gran parte de su trabajo está contenido en este módulo como narrativa y referencias. Sharon Gordon, PhD. VA Tennessee Valley GRECC, Departamento de Asuntos de Veteranos Margaret Hargreaves, PhD. Unidad de Nutrición y el Centro de Educación Geriátrica del Consorcio Meharry, Meharry Medical College Janet Lieto, DO. Centro de Envejecimiento, Universidad de Medicina y Odontología de Nueva Jersey - Escuela de Medicina Osteopática Vyjeyanthi S. Periyakoil, MBBS, MD. Palo Alto Veterans Administration Sistema de Salud y Stanford Geriatric Education Center, Universidad de Stanford, Elyse A. Perweiler, RN, MPP. Centro para el Envejecimiento y el Centro de Educación Geriátrica de Nueva Jersey, Universidad de Medicina y Odontología de Nueva Jersey - Escuela de Medicina Osteopática Veronica J. Scott, MD, MPH. Módulo Comité Presidente VA Tennessee Valley GRECC, Departamento de Asuntos de Veteranos Wilbur Watson, PhD (fallecido), Morehouse Medical College y Meharry Consortium Geriatric Educación Centro, Meharry Medical College Mary P. Williams, EdD, PA-C. Georgia HBCU Centro de Gerontología Multidisciplinaria, Morehouse Medical College Gwen Yeo, PhD. Centro de Educación Geriátrica de Stanford, Universidad de Stanford Motisola Zulu, BA. Instituto de Investigación en el Colegio Médico de Morehouse CONTENIDO ATENCIÓN SANITARIA Y SALUD DE LOS ANCIANOS AFRICANOS Este módulo presenta una visión general de la información disponible sobre las condiciones de salud entre ancianos afroamericanos o negros en los Estados Unidos con énfasis en las influencias históricas en su salud y atención médica. Puesto que no hay datos separados disponibles para los ancianos negros que han emigrado de otros países, el foco está en aquellos que nacieron en los EE. UU. El módulo está diseñado para ser utilizado en conjunto con el Core Curriculum in Ethnogeriatrics. Después de completar este módulo, los estudiantes deben ser capaces de: 1) Describir el estado y el cuidado de los negros mayores durante el período anterior a la guerra de los Estados Unidos. 2) Describir las mejoras en los indicadores de salud, tales como el aumento de la longevidad de los ancianos de 1850 a 2000. 3) Describir los diferentes supuestos que ayudan a informar las concepciones de salud y enfermedad. 4) Describir las formas ocultas y espirituales de la enfermedad. 7) Discutir los efectos del sesgo cultural en los diagnósticos erróneos y los errores en la planificación del tratamiento para los pacientes. 8) Recomendar un enfoque culturalmente apropiado para el cuidado al final de la vida de ancianos afroamericanos. En este módulo los términos negro y afroamericano se utilizan indistintamente. I. Introducción y Visión General A. Crecimiento y Distribución de la Población La población afroamericana de hoy en día está compuesta por individuos de herencia étnica y cultural mixta. La trata de esclavos resultó en una diáspora de África Occidental y Central a muchas partes del mundo, incluyendo las Indias Occidentales, América del Sur, Centroamérica y Estados Unidos. A través de los siglos en todas estas partes del mundo, el africano se ha mezclado con otros grupos étnicos locales. En América este entremezclado ha estado en gran parte con los indios americanos y americanos europeos. Ha habido un crecimiento continuo en la población total de los negros en los Estados Unidos desde 1790. En 1790, el año del primer censo de los Estados Unidos, la población negra numerada alrededor de 757.000. En 1890, había crecido a 7,5 millones de personas, casi diez veces la población en 1790. En 1993, los negros constituían el grupo étnico minoritario más grande de los Estados Unidos. Por ejemplo, en 1970 había 22 millones de negros en los Estados Unidos, de los cuales aproximadamente 1,5 millones o 7 tenían 65 años de edad o más. Desde 1970 ha habido un crecimiento considerable en la población de los negros de 65 años y más. El crecimiento de la proporción de negros de 65 años o más desde 1970, en comparación con la tasa de crecimiento de los negros menores de 18 años y los de 18 a 64 años, muestra una tasa considerablemente más rápida para los mayores que para los más jóvenes. Este patrón se explica en parte por una disminución de la tasa de fecundidad entre los negros que comenzó a finales de 1960. Dada la expectativa de 1) una disminución continua de la tasa de fecundidad, 2) una mejora adicional de la atención de salud y 3) una mayor esperanza de vida de los negros, se prevé que este patrón de crecimiento en el número de personas de 65 años o más continuará (Watson, 1982). En 1990, la población de negros en los Estados Unidos sumaba más de 30 millones de personas. En el censo de 2000, al responder a las preguntas sobre el año 2000, se calcula que 2,8 millones de personas de raza negra tenían 65 años o más, lo que representaba 8.1 de todos los residentes de los EE. Se espera que aumente a casi 10 millones de personas mayores de 65 años en 2050, lo que se espera sea 12 de la población total de estadounidenses mayores (census. gov). No se dispone de datos sobre los subgrupos de ancianos haitianos o de procedencia africana o de otros países del Caribe. Junto con el crecimiento de la población de los negros, ha habido cambios notables en su distribución geográfica en los Estados Unidos. En 1890, año del primer censo en el que se dispuso de datos sobre la distribución urbano-rural de los negros, 80 de todos los negros vivían en el sur rural de los Estados Unidos. En 1970, sin embargo, los patrones de 1890 fueron invertidos: alrededor de 81 de los negros se habían concentrado en las zonas urbanas. Sin embargo, en 1990 aproximadamente 51 de todos los negros aún vivían en el sur de los Estados Unidos. 1. Heterogeneidad. Los estadounidenses mayores que se identifican como negros o afroamericanos son extremadamente variados en casi cualquier dimensión que se pueda nombrar. Aunque muchos son de bajos ingresos, segmentos muy grandes y en crecimiento están en las categorías de ingresos medios y altos. Algunos son profesionales jubilados, y muchos otros tienen hijos con carreras profesionales. Las afiliaciones religiosas incluyen protestantes, católicos, musulmanes y ninguno. Muchos todavía viven en el sur rural, pero más están en áreas urbanas en el norte y el oeste. Los niveles educativos varían desde casi ningún año de escolaridad a aquellos con doctorados. Mientras que muchos en sus años 70 y 80 dependen de la atención de los niños, nietos, o muchos otros están criando a sus nietos o bisnietos. Es importante que los clínicos reconozcan la amplia gama de características que pueden estar representadas en pacientes negros más viejos, de manera que cada paciente pueda ser tratado como un individuo. 2. Arreglos de Vivienda. Entre los ancianos que vivían en la comunidad, los hombres afroamericanos tenían más probabilidades de vivir solos (aproximadamente 24) y menos probabilidades de vivir con un cónyuge (aproximadamente 52) que los hombres de cualquiera de las otras cuatro poblaciones raciales / étnicas más antiguas. Las mujeres afroamericanas mayores viven solas en el mismo porcentaje que la mayoría de las mujeres (un poco más de 40), pero tienen menos probabilidades de vivir con su cónyuge (24). Menos de 10 hombres y mujeres viven con no familiares, pero la tasa es ligeramente mayor que entre otros grupos (Administración sobre el Envejecimiento, 2000). Históricamente, los afroamericanos han residido en hogares de ancianos a la mitad de la tasa de ancianos blancos (Yeo, 1993). Una evidencia más reciente muestra un aumento en el uso de hogares de ancianos, de modo que, excepto para las mujeres mayores de 85 años, un mayor porcentaje de hombres y mujeres de raza negra mayores de 65 años están en asilos de ancianos (Kramerow, Lentzer, Rooks, Weeks, Saydah, . (Ver la Figura 1 en la sección VI.) 3. Educación. La Administración sobre el Envejecimiento (2000) informó que en 1998, 44 de los negros no hispanos de 65 años y más se habían graduado de la escuela secundaria y 7 tenían un título de licenciatura o más. 4. Pobreza. En 1997, 29 de las mujeres afroamericanas mayores y 22 de los hombres mayores estaban en la pobreza. Esto es un poco más que los hispanos mayores y más de dos veces la tasa de estadounidenses blancos mayores (Kramerow et al., 1999). El porcentaje aumenta con la edad y para los que están viudos o viven solos. II. Patrones de riesgo para la salud Muchas tasas de morbilidad y mortalidad son más altas entre los ancianos afroamericanos que en la población general. Debido a la disminución de los niveles educativos y la disminución de los recursos personales, la conciencia de los problemas de salud, el conocimiento de las causas y los factores de riesgo, y la capacidad para acceder a la atención médica puede disminuir considerablemente. A. Expectativa de vida La expectativa de vida al nacer ha sido históricamente más corta para los afroamericanos que los demás estadounidenses, pero las diferencias desaparecen o se revierten a las edades más antiguas, creando las tendencias históricas del crossover y las posibles razones para ello. Discutido en la Sección III bajo Historia de la Salud. A partir de 1997, las mujeres negras en los Estados Unidos tenían una esperanza de vida al nacer de 74,7 años, y los hombres negros 67,2 años. A la edad de 85 años, la esperanza de vida de las mujeres negras es de 6,7 años y 5,7 para los hombres negros (Kramerow et al., 1999). Las tasas de mortalidad de todas las causas para los ancianos 65-74 y 75-84 son más altas entre los ancianos negros que cualquier otro grupo racial y étnico, pero para aquellos de 85 años o más, las tasas son más altas entre los blancos y la segunda mayor entre los negros. Sin embargo, al informar estos datos, los autores advierten que se debe tener cuidado en las comparaciones debido a las preguntas sobre la exactitud de la notificación (Kramerow et al., 1999). Las principales causas de muerte entre los afroamericanos de 65 años o más son: Las tres causas principales de muerte son las mismas para los estadounidenses mayores de origen blanco, asiático / isleño del Pacífico e hispanos. La diabetes es una causa más común de muerte entre los ancianos negros que en otros grupos raciales y étnicos, con excepción de los indios americanos, donde es la tercera causa más común (Sahyoun, Lentzner, Hoyert, Robinson, 2001). Ver Tabla 2 para las tasas de mortalidad por enfermedad. La discusión de la mortalidad entre las minorías se centra frecuentemente en el concepto definido como la diferencia entre el número de muertes realmente observadas en la población minoritaria y el número de muertes que habría ocurrido en ese grupo si las poblaciones minoritarias y no minoritarias tuvieran la misma edad - y las tasas de mortalidad por sexo. La cardiopatía coronaria y el accidente cerebrovascular representan 24 de la mortalidad excesiva entre los hombres negros y 41 entre las mujeres negras (Richardson, 1996). La tasa de mortalidad de todos los cánceres es 30 más alta para los afroamericanos que para los blancos. La mayoría de las causas de muerte han disminuido entre los ancianos negros, pero hay algunas excepciones. El cáncer de pulmón y las muertes por otras enfermedades pulmonares como la bronquitis y el enfisema han seguido aumentando entre los ancianos de raza negra. También ha habido un aumento dramático en la mortalidad por hipertensión (presumiblemente debido a un accidente cerebrovascular) desde 1980 entre los hombres negros mayores, mientras que disminuyó entre los hombres blancos más viejos. Las tasas de mortalidad por hipertensión también han aumentado entre las mujeres negras mayores (Sahyoun et al., 2001). Todas las poblaciones étnicas son propensas desproporcionadamente a algunas condiciones en lugar de otras en comparación con otros grupos étnicos. Las causas de esto son múltiples e incluyen etnicidad, cultura, educación, ingresos y barreras encontradas al acceder a la atención médica. Las diferencias culturales con respecto a la dieta y el ejercicio pueden combinar para predisponer a individuos a algunas de estas condiciones. La hipertensión, la enfermedad de las arterias coronarias y el accidente cerebrovascular se han reconocido durante décadas como riesgos mayores para los ancianos afroamericanos . En la década de 1980, 37 de los hombres negros y 64 de las mujeres de 65 años y más se informó que tienen hipertensión. Existe una relación inversa entre la situación socioeconómica y la presión arterial, de modo que los que están en la pobreza tienen un mayor riesgo. Hay alguna evidencia de que el estrés de (que lo hace debido a un determinismo absoluto contra probabilidades abrumadoras) puede ser un factor que contribuye a la hipertensión para los negros de bajos ingresos con poca educación (Richardson, 1996). 2. Cáncer. Un tipo importante de cáncer que afecta a hombres afroamericanos mayores es el cáncer de próstata, en el que tienen una incidencia excesiva de 60 (Richardson, 1996). Se ha descubierto que los hombres negros no hispanos tienen el doble de riesgo de cáncer de próstata que los hombres hispanos negros (Manton Stallard, 1997). La incidencia de cáncer de mama parece ser aproximadamente la misma o menor para las mujeres afroamericanas que otras mujeres, pero la tasa de supervivencia es menor. Las tasas de supervivencia parecen estar mejorando, pero la etapa en la que se diagnostica el tumor es aún más tarde para las mujeres negras. Los factores asociados con el diagnóstico tardío son: acceso limitado a la atención, atención en clínicas públicas en lugar de clínicas privadas, índice de masa corporal más alto y menores tasas de mamografía. El riesgo de cáncer cervical es mayor entre las mujeres afroamericanas (Manton Stallard, 1997). La incidencia y la mortalidad por cáncer de mieloma múltiple entre los negros son el doble que entre los blancos, y el riesgo aumenta con la edad. (Para una discusión completa de las causas de las diferencias raciales en los cánceres ver Manton y Stallard, 1997). 3. Problemas de visión. La ceguera debido al glaucoma es de seis a ocho veces más prevalente entre los afroamericanos que los blancos, y el glaucoma parece ocurrir a edades más tempranas y ser más agresivo también. La ceguera de las cataratas no operadas es cuatro veces más común en los ancianos de raza negra que en los blancos, aunque la cirugía de cataratas es el procedimiento quirúrgico más común financiado por Medicare (Richardson, 1996). Debido a la alta prevalencia de la diabetes, los ancianos afroamericanos también están en alto riesgo de retinopatía diabética que puede causar visión extremadamente baja y ceguera. 4. Fracturas de cadera. Aunque las hembras negras tienen aproximadamente la mitad del riesgo de fractura de cadera que las mujeres blancas, el riesgo aumenta con la edad, tanto para hombres como para mujeres. Un estudio encontró que a pesar de las estancias hospitalarias más prolongadas, más comorbilidad y menos deambulación al alta, ninguno de los 44 pacientes mayores de la fractura de cadera negra fueron dados de alta a los centros de rehabilitación y sólo unos pocos fueron a cuidados de larga duración (Furstenburg Richardson, 1996). ). Estudios anteriores han encontrado una mayor tasa de demencia vascular entre los negros mayores que entre los blancos (Froelich, Bogardus, Lieberman, 1996). En un gran estudio epidemiológico en el norte de Manhattan, las tasas de demencia se compararon para afroamericanos, hispanos (principalmente dominicanos y algunos puertorriqueños), y los blancos no hispanos. En todas las edades, los hispanos tenían las tasas más altas de demencia, seguido de cerca por los afroamericanos, los cuales eran mucho más altos que las tasas para los blancos. En el grupo de 85 años de edad, 54 de los afroamericanos fueron identificados como con demencia. Sin embargo, además de la edad, se encontró que la educación estaba altamente correlacionada con la demencia. Los autores afirman, (Gurland et al., 1997, p.225). D. Salud auto-evaluada y estado funcional Se ha encontrado que los afroamericanos califican su salud de manera menos positiva que otros ancianos estadounidenses y tienen más discapacidades funcionales. Vea Cuadros 3 4. E. Apoyo Social, Cuidado Familiar y Papel de Iglesia y Religión Vea la cobertura de estos temas en la Sección VI a continuación. Cuadro 3 Porcentaje de personas que declararon buena a excelente salud por edad, sexo, raza y origen hispano, 1994-1996 Fuente: Tendencias en salud y envejecimiento, nchs. gov. III. Dos aspectos importantes para la atención geriátrica eficaz para ancianos afroamericanos son: 1) conocimiento de antecedentes de los acontecimientos históricos que han influido en sus vidas y actitudes hacia la atención de la salud y 2) conocimiento de sus creencias y prácticas de salud . A. Historia de la salud La siguiente sección fue tomada de los escritos del difunto Wilbur Watson publicado en Black Folk Medicine (1984). Existe el acuerdo general de que los ancianos negros han sido tradicionalmente tratados con gran respeto en sus familias. Esta tradición se extiende desde las costumbres conocidas de las civilizaciones presavery en el continente africano a través de las costumbres modernas entre las familias afroamericanas y grupos de parentesco en los Estados Unidos. Griots, o historiadores orales indígenas fueron respetados como depósitos de creencias históricas culturales, leyendas y hechos (Watson, 1983). Su capacidad para recordar y articular sus conocimientos sobre los antiguos reyes, guerras y acontecimientos importantes de la historia de la familia o del clan, a veces de muchos siglos, ha sido especialmente respetada. Incluso en las condiciones recientes de la rápida industrialización de la África Occidental moderna, Arth (1968) ha observado que los Ibo ancianos de África Occidental gozan todavía de gran reverencia en sus comunidades. El taller ancestral, y la creencia de que los ancianos son los más cercanos a sus antepasados, ayuda a contribuir al respeto de los ancianos vivos. Esta costumbre es similar a la de los chinos, que tradicionalmente veneraron a sus mayores, creyendo que estaban a un paso de la unión espiritual con sus antepasados (Watson y Maxwell, 1977). 1. Arriba de la esclavitud (1619-1865). Con el desarraigo y la importación de negros de África Central y Occidental, que comenzó en el siglo XVII (alrededor de 1619) y marcó el comienzo de la esclavitud en los Estados Unidos, las condiciones sociales de vida de los afrodescendientes en América del Norte cambiaron bruscamente . Desde el comienzo de la esclavitud hasta los tiempos modernos, los negros que crecieron en los Estados Unidos tuvieron que soportar una variedad de experiencias psicológicamente, físicamente y socialmente degradantes resultantes de la economía política de las relaciones raciales en los Estados Unidos. Entre los determinantes del tratamiento de los negros ancianos en la historia social de los Estados Unidos, los factores económicos han tenido una influencia significativa. Por ejemplo, los intereses económicos de los propietarios de esclavos durante el período anterior a la esclavitud en América hicieron que la situación de los esclavos discapacitados mayores fuera particularmente tenue. Genovese (1974) hizo la siguiente observación acerca de los determinantes económicos y relacionados con el trabajo de las oportunidades de vida de los esclavos de antes de la Guerra Civil: Los Blancos de Maryland expresaron su indignación por el grado en que los esclavos manumitaban a sus antiguos esclavos para escapar Responsabilidad por ellos. En Baltimore, al igual que en otras ciudades del sur, los residentes enojados protestaron contra la afluencia de negros de los países manumitted que podrían solamente hacer una carga pública, y lucharon para las leyes duras para frenar la práctica. No menos firme un escritor pro esclavista que el Dr. Josiah Mott de Mobile reveló la fragilidad de las preocupaciones paternalistas en su ataque a la práctica de asegurar a los esclavos. Mientras el negro esté sano y valga más que la cantidad asegurada, el egoísmo le llevará al dueño a preservar la vida del esclavo, pero si el esclavo se vuelve insano y hay pocas perspectivas de una recuperación perfecta, los aseguradores no pueden esperar Fair play - el dinero del seguro vale más que un esclavo, y este último se considera más bien a la luz de un caballo super-annuated (Genovese, 1974, p.520). Genovese también informó que algunos poseedores de esclavos urbanos resolvieron el problema de los esclavos viejos y discapacitados enviándoles a vender o pedir dinero para obtener algo de ingresos, así como para mantenerse a sí mismos. En lo que respecta a los cuidadores o dueños blancos, el tratamiento antes de la guerra civil de los negros ancianos discapacitados iba desde la preocupación plena y amable hasta la atención mínima al paternalismo. En el extremo negativo, hubo indiferencia y abuso físico y mental (Fisher, 1969). Manumisión puede o no haber sido una forma excepcional de tratar a los esclavos mayores. Cualquiera que fuera su frecuencia, ciertamente no era la única respuesta a los ancianos ya los discapacitados. Era inquietante encontrar en mis investigaciones de archivo, aunque no es sorprendente después de la reflexión sobre la economía de la esclavitud de los bienes que los esclavistas a menudo trataban de vender o comerciar a sus viejos esclavos discapacitados y adquirir acciones más jóvenes por temor a perder la inversión que habían hecho. Una cuenta informó que la aparición de B. B. Brown, 1847, pp. 42-45, 92-93). Entre los esclavos, según Frederick Douglass, se esperaba que los jóvenes respetaran a los esclavos más viejos, menos se arriesgan severas reprimendas. (Douglass, 1855, págs. 35 - 40). Los vínculos y costumbres de deferencia entre los esclavos, sin duda, funcionaron como fuentes de apoyo social y psicológico para los viejos esclavos discapacitados facilitando su afrontamiento con las duras e inhumanas demandas de la cultura de los esclavistas. Entre los medios por los cuales los esclavos más antiguos apoyaban y cuidaban la salud de los demás era la medicina popular (Smith, 1881, págs. 4-5). El apoyo a los ancianos también fue proporcionado por los esclavos más jóvenes capaces que compartieron sus retornos del trabajo con los discapacitados mayores que eran menos capaces de defenderse por sí mismos (Steward, 1857, pp. 16-17). 2. Salud y longevidad desde mediados del siglo XIX. A pesar de las duras condiciones de vida de la esclavitud, la reconstrucción y el separatismo del siglo XX, los negros mayores en los Estados Unidos han seguido creciendo y viviendo más tiempo. Algunas estimaciones situaron la longevidad promedio de los negros a los 21,4 años de edad en 1850, con la longevidad promedio de los blancos a los 25,5 años. La combinación de un nivel de vida más bajo, una mayor exposición, un trabajo más pesado y una atención médica más pobre dio a los esclavos una mayor tasa de mortalidad que los blancos. El censo de 1850 informó edades promedio de 21,4 para los negros y 25,5 para los blancos en el momento de la muerte. En 1860, el 3,5 por ciento de los esclavos y el 4,4 por ciento de los blancos tenían más de sesenta. La tasa de mortalidad fue del 1,8 por ciento para los esclavos y del 1,2 por ciento para los blancos (Stamp, 1965, p.77). Estas conclusiones no deben aceptarse sin crítica. Los hallazgos se basan en comparaciones de datos agregados recolectados a nivel nacional por la Oficina Estadounidense del Censo, 1850. Los datos de mortalidad a nivel estatal, por ejemplo en Virginia, para el mismo año no mostraron los mismos resultados. Savitt (1978, pág. 201) encontró evidencia de que entre 1853 y 1860 en cuatro condados de Virginia. Esto sugiere que algunos negros mayores vivían más que los blancos mayores, al menos en esos condados. También se informó que hubo más centenarios entre los negros que los blancos en 1850 (Savitt). a. Cuidado de los esclavos más viejos. En lo que respecta a los negros centenarios que pueden haber numerado a los blancos, no se sigue que los negros mayores recibieron mejor atención médica de los esclavistas que los blancos más viejos. Al menos otros tres factores pueden haber estado operativos incluso en 1850: (1) los negros mayores pueden haber sido más resistentes en algunas características fisiológicas que sus homólogos Blancos y pueden haber tendido, como sugiere el fenómeno de cruce, a sobrevivir a los Blancos después de enfrentar con éxito Con los riesgos para la salud que ocurren con tanta frecuencia entre la infancia y la mediana edad. (2) Si bien algunos esclavistas pueden haber prestado atención humanitaria a los esclavos discapacitados mayores, parece más creíble que el cuidado prestado por la mayoría estuviera motivado económicamente. Cuanto más tiempo estuviera vivo y suficientemente bien para trabajar, mayor sería el retorno económico que el esclavista recibía por su inversión. Esta conclusión es consistente con la práctica de algunos esclavistas de manipular las apariencias de los viejos esclavos decrépitos para hacerlos parecer más jóvenes, aumentando así los medios de esclavizadores de auto cuidado de la salud que ayudó a los esclavos jóvenes y viejos a soportar los peligros de la vida cotidiana durante el período antebellum . Como ya hemos sugerido anteriormente, los negros mayores entre los esclavos fueron tratados con deferencia y recibieron atención médica de otros esclavos. Los detalles sobre el tipo y las cualidades de los esclavos de atención de la salud proporcionados unos a otros aún no están claros. Pero es igualmente probable que lo que los esclavos hicieron por sí mismos contribuyeron significativamente a su bienestar y longevidad al igual que el apoyo y las intervenciones de los esclavistas. segundo. Cambios desde 1900. La discusión anterior sugiere que pocos negros ancianos vivieron el tiempo suficiente para disfrutar de la jubilación, donde eso estaba permitido. Mucho menos los negros ancianos vivían tranquilos y cómodamente bajo la esclavitud (Fisher, 1969 Genovese, 1974). En 1900, algunas mejoras habían ocurrido en la longevidad de los negros: en 1900 la expectativa de vida de las mujeres negras fue de 35 años y la de los negros 32,5 años, en comparación con los 51 años y 48 años para las blancas y los machos respectivamente. Un bebé negro nacido 30 años más tarde podría esperar vivir 49,5 años, o dos años más que un bebé negro. Al mismo tiempo, una niña blanca tenía una esperanza de vida 13,2 años mayor que la de un varón blanco, 11,5 años mayor que la de los negros del mismo sexo en 1930. La diferencia en la esperanza de vida de las dos razas no había cambiado en cuanto a A las mujeres en 1940 (Frazier, 1957, página 569). Desde 1940, se han producido mejoras en la esperanza de vida de los negros y los blancos. Si nacieron en 1900 o 1976, las hembras blancas podían esperar vivir más tiempo de todas, seguidas en orden descendente por mujeres negras, varones blancos y varones negros, que tenían la menor esperanza de vida de todos a pesar de estas diferencias. La esperanza de vida media de cada grupo, sin embargo, en 1976 fue mucho mayor que en 1900. Frazier (1957) observó que las enfermedades crónicas eran especialmente importantes para cualquier intento de explicar las diferencias entre las tasas de mortalidad de blancos y negros. Hubo, por ejemplo, ciertos factores de estrés relacionados con la enfermedad que claramente tuvieron un mayor impacto negativo en la salud de los negros que los blancos y ayudaron a explicar la menor longevidad de los negros durante la primera mitad del siglo XX. A mediados de siglo, Frazier observó lo siguiente: Después de los cinco años, las tasas de las enfermedades transmisibles que caracterizan a la infancia son casi las mismas para las dos razas. Por otro lado, las tasas de mortalidad por tuberculosis, gripe, nefritis, neumonía, sífilis, homicidios y pelagra son uniformemente más altas entre los negros que entre los blancos. Tuberculosis, influenza y neumonía. Son responsables de casi tres cuartas partes del exceso de mortalidad entre los negros menores de 25 años. Alrededor del 50 por ciento del exceso de mortalidad entre los negros entre los 10 y los 24 años de edad es atribuible únicamente a la tuberculosis. Aunque en los grupos de edad avanzada la tuberculosis representa una proporción menor de muertes, la influenza y la neumonía son importantes en todas las edades. Para el grupo de 45 a 65 años de edad (en el año 1950), la nefritis y la cardiopatía fueron responsables del 40 por ciento del exceso de mortalidad (Frazier, 1957, p. La tuberculosis y la neumonía también fueron identificadas como causas de las altas tasas de mortalidad entre los negros a finales del siglo XX. Además, los factores socioeconómicos y psicológicos de la ignorancia, la pobreza, la negligencia y la intemperancia se especificaron como factores condicionales importantes que ayudan a explicar las variaciones en la incidencia de la muerte por estas enfermedades. Aunque los negros todavía mueren, en promedio, en edades más tempranas que los blancos, y los hombres antes que las mujeres en ambas razas, muchas de las enfermedades identificadas arriba se han reducido perceptiblemente como causas de la muerte desde 1850. Con la síntesis de la penicilina en 1940 y su La prescripción generalizada para los ricos y pobres, Negro y Blanco, la neumonía se ha puesto bajo control. Junto con otros avances en tecnología médica y medidas de salud pública (como tratamientos de agua y alcantarillado, educación nutricional), se están haciendo mejoras en la calidad de vida general en las sociedades modernas. 1) El Fenómeno de Crossover. Estrechamente relacionado con el tema de la esperanza de vida diferencial, es el fenómeno del cruce. Cabe señalar que tanto las mujeres negras y los hombres que tenían 80 años de edad o más en 1976 tenían una esperanza de vida más larga que sus homólogos blancos de la hembra y del varón. Esto se conoce como el fenómeno de cruce. Su nombre viene de la reversión en la esperanza de vida media que ocurre entre negros y blancos entre 80 y 85 años de edad. Tanto las hembras negras como los machos tienden a tener una esperanza de vida más corta que sus homólogos Blancos hasta los 80-85 años. Luego, por razones que no están del todo claras, hay una reversión en el patrón después de los 80 años de edad. Este fenómeno es desconcertante y, por desgracia, ha habido muy poca investigación dirigida a desarrollar ideas que puedan ayudar a explicar el evento. Cabe destacar algunos hallazgos y hipótesis sugeridas para estudios posteriores. En un estudio de Manton, Poss y Wing (1979), que se centró en los patrones de mortalidad por edad de las cinco principales causas de muerte, hubo marcadas diferencias entre negros y blancos. Por ejemplo, las enfermedades circulatorias (trastornos cerebrovasculares) mostraron una diferencia consistente entre los negros y los blancos desde la edad media hasta los últimos años de vida. Entre los negros entre 50 y 75 años de edad, las enfermedades circulatorias produjeron un aumento más rápido en las tasas de mortalidad. This increase helped to explain the early Black mortality excess when compared to their White counterparts. By age 75-80, however, the excess for Blacks was overshadowed by Whites, who showed a more rapidly increasing rate of death due to circulatory diseases. Manton, Poss and Wing (pp. 297-299) have suggested a number of possible explanations for these apparent race related differences in life expectancy after 80-85 years: Blacks may have a greater susceptibility to hypertensive disease which, if related to physical exertion, social position, or difference in medical care, would probably be most manifest in middle age. The simultaneous action of hypertension and atherosclerosis among Blacks between 50 and 75 years of age may help to explain the high rates of death among Blacks due to circulatory disease in this age range. The greater susceptibility of Whites to atherosclerotic circulatory disease, which is also a disorder of advanced age, may help to explain the crossover phenomenon after 75-80 years of age. Yet there are other points of view on this phenomenon. For example, Siegel (1972, pp. 54-55) suggests that the difference between Blacks and Whites at these higher ages may be explained by reporting errors in the census, especially with reference to the ages of Blacks. Moreover, some of the differences between the rates for Blacks and Whites may be explained by differential occupational, educational, and income factors (Kitagawa Siegel, 1972, p. 55). Clearly, this is an area in which there are more questions than answers at this point in the development of social gerontology as a field of knowledge. Further inquiry is required. For a later set of possible explanations for the Crossover Phenomenon, see Manton and Stallard (1997). B. Historical Experiences of Current Cohort of African American Elders For information on the historical experiences of older African Americans that might influence their attitudes toward health and health care, see the Cohort Experience charts in Appendix B. C. Health Beliefs This section fosters an examination of historical conceptions of health and illness that may influence older Blacks in the U. S. Major portions of this section are based upon the studies of the late W. H. Watson published in Black Folk Medicine (1984). 1. Background. Individual and social reactions to illnesses among older Blacks have been multifaceted over the decades during and since chattel slavery in the United States. The differences have included variations in (1) categories and definitions of illness, (2) formal and common sense theories about the causes of illness and (3) modes of intervention to return the afflicted person to a state of health. Most of the literature can be divided into studies of traditional medicine and of modern biomedicine. Traditional, in this usage, refers to cross-generational patterns of thought about health and illness, and beliefs about remedies, such as herbs, that are sustained over time by simple observations and myths pertinent to their use value. Common sense theories that attempt to explain how the remedies work may span many centuries, with or without the support of scientific evidence. While modern biomedicine is dated from 1750 A. D. traditional medicine (sometimes called ) is dated in some documents from as early as 1500 B. C. 2. Types of Healers. According to Snow (1974), practitioners of traditional medicine can be classified according to the healing practices they use and how they received the ability to heal. There are three ranks of healers, distinguishable by the sources of their healing powers: (1) those who learned the ability from others (these are the individuals considered to have the least amount of power), (2) older persons who received the gift of healing from God during a religious experience in later life (these are middle rank in power), and (3) those who are born with the gift of healing, the most powerful (Snow). Root and herb doctors are included among the groups who learned to heal from others, and are believed to have the least amount of healing power (Snow, 1974). The services of a root doctor, who is a type of conjurer, are sought either to place a hex on someone (or induce an illness condition) or to ward off evil (de Albuquerque, 1981, p. 51). Root doctors may also be consulted for help in changing a person s luck, especially in interpersonal relationships. Roots are objects that are believed to have magical powers and can take many forms including dolls, colored stones, and red flannel bags as well as roots of plants grown domestically or in the wild (de Albuquerque). The color of the root also helps to determine its effectiveness. Roberts 1976, p. 52). According to Mitchell (1978), faith or spiritual healers are practitioners with the greatest power, and are believed to have received the gift of healing from a god. They regard themselves as vessels through which the divine will is made manifest (Hand, 1980). The laying on of hands, prayers and incantations are the methods most used to treat spiritual illness. Most individuals who acquire the power through learning or an apprenticeship are able to treat natural and/or occult illnesses, but the person who is born with the power or who receives the gift from a god is believed to be able to cure all illnesses. See the discussion below on causes of illness and approaches to intervention. In contrast to modern biomedicine, when diagnosing disorders and selecting treatment plans, practitioners of traditional medicine tend to depend more upon: (1) the patient s trust that the doctor has accurately perceived and properly negotiated with the patient the nature of the disorder and the treatment needed, (2) the patient s faith in the healing powers of the doctor, and (3) the stock of folk remedies available in the cultural knowledge system of the society. Regardless of the approach to treatment of illness, whether by a biomedical or a folk practitioner, health is thought of as a state of individual well being. Although not admitted by all folk medical practitioners, healthiness may be sustained and/or achieved through internal bodily processes, such as homeostatic mechanisms, as well as life style characteristics that include purposeful health behavior. The range of beliefs among traditional medical practitioners, unlike their biomedical counterparts, include the contention that spiritual forces can intervene in human affairs to influence sustaining and/or restoring health of an individual. Purposeful health behavior by an individual is conceived as action taken deliberately to sustain and/or achieve a state of well being. Such behavior may include following a program of exercise, a planned diet or medical regimen either of which (or a combination thereof) may be believed to be associated with healthful outcomes. 3. Causes of Illness and Approaches to Intervention In some traditional African systems of thought, it is believed that when one has good health, one is in harmony with nature. If one is ill, a state of disharmony is said to exist (Watson, 1984). This holistic notion of health, however, is not peculiar to African systems of thought. Among the various systems of traditional medicine, most illnesses can be classified as having a natural, occultist, or spiritual origin (Murdock, l980). a. Types of Illness. A natural illness is a result of a physical cause, such as infection, disease, weather, and other environmental factors. Treatments of natural illnesses emphasize the uses of herbs, barks, teas, and similar natural substances. An occult illness is a result of supernatural forces, such as evil spirits, and their agents, such as conjurers (Simpson, l970 Tallant, l946). Evidence of occult illnesses and concerns about the treatment thereof is equally as prominent in the literature on traditional medicine as are reports of natural illnesses. There are two important distinctions between natural and occult illnesses: (1) Occult illness is a result of supernatural, not physical causes. The conjurer uses his or her powers, as well as fetishes to induce and/or ward off illness in specific individuals. (2) While natural causes primarily induce physical illness, conjuration may affect the physical and psychological as well as the spiritual life of the person (Mitchell, l978). Finally, spiritual illness is a result of a willful violation of sacred beliefs or of sin, such as adultery, theft or murder (Mitchell). Like the occult, spiritual forces can affect all aspects of life, ranging from the physical to the spiritual characteristics of the person (Simpson, 1970 Willer, l97l). The foregoing discussion suggests a close relationship between the presumed cause of an illness and the type of intervention needed to correct the malady. For example, Sea Island Blacks believe that physical disorders, such as respiratory congestion and skin rash, are due to natural causes and can be treated by modern medical doctors, herbalists and other doctors of natural illnesses (Mitchell, l978 Simpson, l970). By contrast, illnesses and accidents that are believed to be caused by occult forces or their agents require the powers of a conjurer to produce and execute the correct treatment. In many small societies, conjurers are believed to have the ability to summon a supernatural force, such as a devil or evil spirit, either to do harm, such as inducing an illness or to expel a disorder. By the use of spells, sacred names, incantations and other magical media, the conjurer is able to summon the expression of supernatural forces. Finally, it is the power of a god acting through a religious healer or medium that is required to diminish spiritual illness or induce a return to health in the character of a person believed to be suffering from spiritual illness. IV. Culturally Appropriate Geriatric Care: Assessment A. Cultural Biases and Misdiagnoses The following section is taken from the writings of Wilbur Watson. In addition to the insights from examining the basic assumptions and concepts that help to shape the perspectives and practices of believers in bio - and traditional medicine, there are also non-rational factors that operate between practitioners and older clients/patients helping to influence practitioner-patient interactions and patient outcomes. Cultural biases about health and illness, and beliefs about which individuals and/or groups are most susceptible to one or another disorder are key among these factors. Clearly, both health care practitioners and patients have cultural backgrounds through which perceptions of each will be filtered. This discussion, however, is focused on the biases of practitioners when observing their patients. Biases are prejudicial points of view focused upon an object represented by selected perceptions framed by a particular sociocultural background, such as racist beliefs about differences between Blacks and Whites in the United States. The influences of biases on decision making are often unintentional, expressed nonconsciously, and as a consequence may be difficult to control in the doctor-patient relationship. For example, it was once believed that high rates of hospitalization for the treatment of selected mental disorders among African Americans was due to an Williams, 1986). It was also believed among some psychiatrists that African Americans, as a group, tended to have low rates of depression because of their historical social and educational oppression. Somehow, being oppressed and deprived functioned as a social psychological shield against depression: Blacks were less vulnerable because they had less to lose (Prange, 1962). Epidemiological and etiological research have subsequently shown that depression and other illnesses are much more complex disorders than that suggested by the foregoing statements and must be carefully studied, including cross-cultural variations in symptoms of disorders before drawing conclusions and formulating treatment plans. Other studies suggest that the failure to accurately diagnose symptoms of depression, manic depression and other disorders among African Americans sometimes results from preconceived notions that Blacks are Williams, 1986). Cultural insensitivity and deeply rooted prejudices, along with a lack of cross-cultural study by professionals focusing on the cultural backgrounds of their clients/patients contributes to risks of misdiagnoses and inappropriate treatment plans, especially but not exclusively in the care of older Blacks with mental disorders. B. Showing Respect Particularly because of the experience of many African American elders who grew up with segregated health care and social service systems in which they faced continual discrimination, it is extremely important to show respect to them in clinical settings in order to put them at ease and establish rapport. This includes at the least, using respectful titles (e. g. Mr. Mrs.) unless they give the clinician and staff permission to do otherwise. The knowledge of the 40-year Tuskegee Experiment, which recruited African American men with syphilis to be a part of a research project in which they were promised but never given treatment, is widely known in the African American community. This memory, in addition to the widespread discrimination most have faced in their lifetimes, are likely to provide reasons for African elders to be more than a little suspicious of health care providers, especially those who suggest any type of experimental treatment or research. Clavon (1986) and others have emphasized the importance of recognizing and respecting patients cultural habits, listening attentively, and encouraging conversation. Providers have also been encouraged to examine their attitudes and stereotypes of elders from different racial and ethnic populations, especially African Americans, in light of the findings implicating referral patterns of providers in the differential utilization of services. (See the discussion in Section V.) C. Use of Assessment Instruments The variation in reports of the prevalence of dementia warrants carefully chosen instruments to assess cognitive and physical status in African American elders( Froehlich et al. 2001) Baker (1996) reports differences in the validity of cognitive measures with African American elders. The Activities of Daily Living scale and the Short Portable Mental Status Questionnaire are two tools that have been specially tested and shown to be reliable and valid with older African Americans (Mouton, 1997). D. Adapting Assessment Techniques to Skin Color Since African American elders have a wide range of skin color, it is very important for nurses and physicians to use appropriate assessments that reflect skin tone changes for conditions such as cyanosis. Skin color changes in decubitus ulcer formation are not readily apparent in dark pigmentation, so that actual skin breakdown often occurs before formation is noted (Richardson, 1996). For a complete listing of the domains of assessment in ethnogeriatrics, see Module IV of the Core Curriculum in Ethnogeriatrics. V. Culturally Appropriate Geriatric Care: Treatment A. Specialized Procedures in Cardiac Care Numerous studies in the late 1980s and 1990s found that African Americans are less likely to undergo cardiac catheterization and coronary-artery bypass graft surgery than their White counterparts. Most studies have controlled for insurance status, but one study found that there were no effects of race among patients with private insurance. Correlates of the racial differences have included: financial or organizational barriers clinical differences and amount of contact the patients have with the health care system or hospitals that offer invasive cardiovascular services (Shulman, et al. 1999). One particularly insightful study compared referral patterns of 720 internists and family physicians in videotaped interviews of scripted Black and White heart disease patients age 55 and 70 played by professional actors. Care was taken to keep all extraneous factors constant in the scripted scenarios, which were identical between the two racial groups. Analysis of race-sex interactions showed that Black women were significantly less likely to be referred for cardiac catheterization than White men (odds ratio, 0.4, 95 confidence interval, 0.2 p 0.004). There were no significant differences for White women or Black men compared to White men (Shulman et al. 1999). The authors state (Shulman et al. pp. 624-625): Our findings suggest that a patient s clinical characterization. Alternatively, these findings may be the result of other factors not included in the information we presented to the physicians. For example, data on bypass surgery and angioplasty suggest that women may have worse outcomes than men, although these effects may be due to difference in other confounding variables rather than to the sex of the patient. Why these clinical effects would influence recommendations for black and not white women is unclear. Our finding that race and sex of that patient influence the recommendations of physicians independently of other factors may suggest bias on the part of physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient s memory regardless of the level of prejudice the physician has. B. End of Life Care Active end of life care planning is not an unfamiliar concept to most African American elders. Providers who have these discussions, however, should remember that elders might be reluctant to participate due to an understandable mistrust in the health care system based on past history of segregation and discrimination toward African Americans. Several studies suggest that African Americans are less likely to complete advance directives such as do-not-resuscitate (DNR) orders or living wills (Caralis, Davis, Wright, . Religious beliefs may also play a role, in that many older African Americans believe that God is ultimately in control, and is the only one who can determine the timing of death. Among both African American patients and physicians, more have been found to favor aggressive life prolonging treatment in the case of terminal illness than among comparison White groups (Caralis, 1993 Hopp Mouton, 2000). Mouton (2000) points out that life support may be equated with life, and that any effort at withholding life-sustaining therapies might be seen as another attempt of genocide by predominantly Caucasian institutions, recalling the history of unethical experiments on African Americans, such as the Tuskegee Syphilis Study. Some will request tube feeding even in the face of terminal illness. Providers, then, should be very sensitive to issues regarding refusal or withdrawal of tube feedings. Some African-American families may request that certain diagnoses or disease prognoses be withheld from the patient to shelter them from disturbing information. Other patients and families favor forthright discussion of all medical issues and treatment plans. Some patients may prefer that their loved ones be the conduits for information. So direct provider-patient communication may be limited by patients desire not to know the full implications of their illness. The loved ones may be a patient , as the result of longstanding relationships, but may not be linked directly by blood ties. These individuals may be serving as the primary care giver or even as the surrogate decision makers and may be sometimes more involved than the directly related family members. Extreme tact and sensitivity are called for when having discussions about advance care planning and end of life issues. Ensure that you have adequate time and that patient s family is present. Since trust is so critical in adequate end-of-life care with African American elders and their families, it is very important for the provider to have built a trusting relationship with the patient and family in the past. In all cases it may be helpful to ask the patient or family their understanding of the illness and treatment options, and use this as the basis for further discussion. Also many of the elders may have strong religious beliefs, and so having a trusted spiritual counselor as part of the team may be helpful for patients. C. Health Promotion See recommended procedures based on risk in Module V of the Core Curriculum in Ethnogeriatrics. VI. Utilization and Access It is important for providers to understand that cultural norms, historical context, the value of family, and religious beliefs are key determinants of social and kinship networks which in turn affect health behavior and outcomes in all elders, including African American elders. Belief systems and tradition impact on health care utilization and provide a basis on which health care providers should deliver culturally sensitive care. Literature has shown that older African Americans are more likely to rate their health as fair or poor than White elders and are less inclined to seek health care early in the course of a disease. African America elders are less likely to practice preventive health behaviors such as obtaining breast or prostate cancer screening. On the other hand, health providers are less likely to offer some of these services to African American elders than they are to their White counterparts. Religion plays a major role in determining the health beliefs and behaviors of African American elders. Quality of life and life satisfaction are enriched by increased frequency of contact with friends and the availability of family help (Adams Jackson, 2000). A. Social and Kinship Networks: Use and Effects on Health Behavior Much of the research on informal networks, church supports, and extended family in the Black community was done in the early to mid 1980s. Intergenerational family support and support from the extended family has been the hallmark of health care in the African American community. Formal and informal supports are used by both Whites and Blacks in need of help. However, Blacks have more active social support networks, with mechanisms in Black families that serve to expand network membership through creation of Mehrotra, 1998). Studies have shown high levels of social interaction and strong emotional bonds between elderly blacks and their extended families, which is facilitated by the presence of an adult child and proximity to immediate family and relatives (Taylor, 1991). 1. Informal Caregiving. Comparisons of informal caregiving by Black and White older adults showed that Blacks were more likely to be caregivers and more likely to assist friends. Blacks have frequent contact with family, relatives, friends and neighbors, although they utilize the members of their network differently for emergency and non-emergency situations (Petchers Milligan, 1987). It has been noted that the probability of caregiving in African Americans increased in those who are married, with substantial amounts of care to others with health problems and disability provided by those older than age 65 (McCann et al. 2000). Receiving formal services was found to have no association with a reduction in use of informal service supports among Blacks. In testing two contradictory hypotheses, Johnson, 1994). In a study of African American caregiving for a relative with Alzheimer s disease, it was shown that caregiving, a traditionally female role, is not only a traditional family value, but an act of love, and that frequently, social supports serve to mediate caregiver burden (Steritt Pokorny, 1998). It has been noted that Black caregivers report less depression than White caregivers and have greater self-efficiency in managing caregiving problems (Haley et al. 1996). Although African Americans have been found to be in potentially more severe caregiving situations than Whites, they had more favorable psychological indicators of stress. While Black and White caregivers differed in coping responses, they did not differ in social supports in caring for someone with Alzheimer s disease (Wallsten, 2000). 2. Long Term Care. African American elders are frequently supported in adhering to their health care regimens by family members, rather than formal support providers. Family members also act as coordinators of care, including transportation, medication management, diet, exercise and monitoring chronic illness (Jennings, 1999). This is further supported by the fact that most African Americans with functional disabilities and health problems remain at home, with supportive care provided by immediate or extended families and informal support networks in the church or community. Past experiences of Black elders have demonstrated that utilization of institutions for the purpose of Andersen, 1998). In 1999, data was released by the National Center for Health Statistics that for the first time showed nursing home utilization by African Americans equal or greater than that by older White Americans in most age and sex categories. (See Figure 1.) In all of the three age groups of older men, and in all but the oldest women, a higher proportion of Black elders resided in nursing homes. Source: Kramerow et al. 1999, p. 86. 3. Role of Church and Religion. In a study looking at frailty and family and church support among African American elderly, the frail elderly were more likely to use community services and less likely to report feeling close to family. However, it was noted that family contact, feeling the church was important, and receiving church support was the same for both the frail and non-frail, thus emphasizing that one cannot assume that families and churches support the most vulnerable elderly (Bowles et al. 2000). The value of religion, reading religious materials, listening to religious programs, prayer and other forms of non-organized religious participation are part of the fabric in the life and culture of older African Americans. Studies done in the early 1990s indicate that while the church is a significant contributor to feelings of well-being in elderly Blacks, the family network is viewed as more supportive than the church network (Walls Chatters, 1986). The role of church-based programs in enhancing social integration for older African Americans and building a community-based infrastructure of supportive and health-related services cannot be overlooked. In many communities, the church may be the site of: a senior nutrition center or medical day care program blood pressure and other medical screenings provide immunizations outreach programs home care services such as shopping, friendly visiting, meals or a senior citizen subsidized housing facility. By providing direct services, churches therefore act as a supplement to informal family caregiving and are positioned to refer to other community-based service agencies (Fried Mehrotra, 1998). B. Health Promotion When exploring outcomes and quality of care, it is important to note that African Americans tend to emphasize the Landefeld, 2000). African American elders may rely on varied resources to gain medical education and to take care of themselves. This includes traditional health care providers, but because of cultural and religious beliefs they may rely on less traditional providers or input from clergy or other African American folk remedies (Fahie, 1998). C. Barriers to Access Access to health services differs among races and is influenced by income, geography, culture, and type of health care coverage. Based on personal history and experience, many African Americans view receiving health care as a degrading, demeaning or humiliating experience. Some may even fear or resent health clinics, because of the long waits, medical jargon, feelings of racism or segregation, loss of identity, and a feeling of powerlessness and alienation in the system (Spector, 2000). Often poverty, lack of transportation, or non-compliance with previously prescribed therapeutic regimens act as further deterrents for older African Americans to seek health care. One study demonstrated that community-based service use was significantly lower among black diabetic elders (Witucki D. C. Wallace, 1998). Recent studies about access to health care, utilization rates, health status and outcomes have been done for many specific disease categories. In general, poorer health status among African Americans was not found to be influenced by access to health care (Harris, 2001). Numerous studies about access to health care which look at the role of race and income have been done. Studies on limited access to health care by older African Americans due to economic inequalities, discrimination, and life style factors are inconsistent, although health status and insurance have been important predictors of use (Miller et al. 1997). Many elderly African Americans are categorized as for both Medicare and Medicaid. In many instances, these individuals are enrolled in a managed care plan or are served by a community health center. It has been shown that clinics provide better access to dual eligibles than non dual-eligibles and to non-White compared to White dual eligibles (Basu, 2001). Persons with Medicare and private or Medicare and public coverage (Medicaid) are more likely to have a regular source of medical care, although older adults on Medicare and public assistance or Medicare only coverage were twice as likely to have unmet medical needs than those with Medicare and private insurance (Cohen, 1997). Access to health care and health-information seeking behavior are influenced by mobility, literacy, social networks, and community structure. African Americans are more likely to live near high-technology hospitals than Whites, but are not as likely to travel to a high-technology hospital to obtain care (Blustein Weitzman, 1995). D. Recommendations for Increased Utilization of Health Care Services In conclusion, provision of health care to older African Americans must give consideration to culture and tradition, with the acknowledgement that social and kinship networks, community, extended family, and the church are all significant players in the health care and support service system. Identification of unique points of access to health care and supportive services will differ by community, but must be the focus of the contemporary health care provider who is serving African American elders. Community leaders, church elders, and other should be incorporated in Boards and be involved in health care planning for the community. It is only through cultural awareness and sensitivity that improved access to and utilization of health care services, positive health behaviors and successful outcomes will be attained, not only for African American elders, but for all racial and ethnic groups. Visit a local nursing home or personal care home for older Blacks for a pre-arranged question and answer session featuring older Blacks (men and women, preferably) talking about the history of their health and health care. Participant observations through grand rounds and/or case conferences can also be useful ways of developing and reinforcing insights into conceptions of illness and treatment approaches. Invitations to a traditional medicine practitioner to make a class room presentation and/or visit his/her office to discuss his/her conceptions of illness, treatment and health. Observe a case conference of an interdisciplinary team meeting with a focus on an older Black patient. Assigned readings, lecture, and discussion can be augmented with the following assignments: a) downloading the latest data on life expectancy and mortality rates for elders from different ethnic populations from web sites (e. g. Trends in Health and Aging at nchs. gov) and making comparisons, b) interviewing African American elders on the help they give and receive, or other specific topics (see suggestions for organizing interviews in Appendix C of the Core Curriculum in Ethnogeriatrics), c) presenting the results of the interviews in class to compare and discuss similarities and differences, d) group projects that address individual disease risks, such as diabetes, by researching the ethnic specific incidence and prevalence for African Americans, their risks of complications, followed by conducting interviews with African American elders who have the disease, e) a field trip to a historical museum (e. g. Carver Museum in Tuskegee, Alabama) on African American History to see film, pictorial displays and other objects pertinent to the health history of Blacks, f) film and video, such as produced by the National Center on Black Aged, Washington, D. C., g) problem posing discussions Case of Mrs. H. Mrs. H. is an 83-year-old African American woman with Type II Diabetes and severe diabetic retinopathy. She is widowed and lives alone in a small house she bought with income from 45 years of working as a domestic. She is very proud of her home but cannot see well enough to keep it up. She has two surviving children, but both live several hundred miles away, and she doesn t see well enough to walk or take the bus. Her physician recently retired and referred her to a new doctor. She called the senior transport service for a reservation for the day of her appointment and was told they would have to pick her up three hours before her appointment because the day was so busy. When she arrived at the clinic, the receptionist asked her lots of questions and asked Mrs. H. to fill out many pages of forms. Finally after two hours of waiting, the nurse came to the waiting room and called, The doctor seemed rushed and preoccupied. During their conversation he told her about a new research project she was eligible for that would provide a new treatment for her diabetes, low vision assistive devices, and homemaker services. She said she would think about it. When the nurse called two days later to enroll her in the project, Mrs. H. said she didn t want anyone coming to her house. Questions for Discussion: 1. What could have accounted for Mrs. H. s initial experience with her new doctor more satisfactory 3. What kind of assistance might be given to Mrs. H. and how might it be made acceptable Case of Mrs. W. Mrs. W. a 78-year old African American woman, was brought to the emergency room (ER) complaining of severe abdominal pain. Her history revealed intense chronic abdominal pain for ten years that had begun soon after she had back surgery. She had initially seen many doctors for the pain. The physicians had done multiple tests over the years including an upper and lower endoscopy, and a CT scan several years ago (which had been negative at that time). Mrs. W. had been told that she probably had irritable bowel syndrome and was advised about diet and life style changes. A few months ago, Mrs. W. had switched providers again, and this provider had detected an anemia and splenomegaly on exam and did a redirected work up which revealed Acute Myologeous Leukemia (AML). The physician explained that fact briefly to Mrs. W. and scheduled her to be seen by an oncologist. Mrs. W. did not follow up with the oncologist as she felt that the oncologist would be just another new physician that she had to deal with who probably would not be able to help her to feel better. She quite frankly was tired of seeing multiple providers and getting numerous tests and still having to endure the suffering imposed by the pain, which the physicians were not trying to alleviate. The ER doctor reviewed Mrs. W. t explain her abdominal pain. The physicians could not understand why Mrs. W. was clearly refusing to see and accept the evidence that was so clear and obvious for leukemia. una y otra vez. Shortly before Mrs. W. died four weeks after that last diagnosis in the ER, she said, Background: The frustration from the endless search for relief had brought Mrs. W. to the conclusion that the reason doctors would not identify and treat her pain was that during that first surgery some medical error must have occurred. She assumed the error was apparent to every subsequent doctor who examined her. By the time she came to the emergency room and was hospitalized for what was to be her last time, her distrust had blossomed into a conspiracy theory. Questions for Discussion 1. How might knowledge of African American health history and the experiences of Mrs. W. s cohort have helped the health care providers understand her lack of acceptance of the diagnosis 2. What types of interventions might have helped Mrs. W. understand and cope with her situation more realistically 3. If the health care team felt that Mrs. W. was terminally ill, what recommendations would you have for them for talking about end of life care in a culturally appropriate way This case is adapted from an article by LaVera Crawley (2001) featured in the Knight Ritter/Tribune newspapers. Health status information in this module lends itself to objective questions to evaluate student s retention of the information. Essay questions can be used to evaluate their understanding of the sources and limitations of the data. Group projects, individual written and oral reports, short essay exams, and multiple choice tests can also be used in the evaluation of student performance. The cases in the Instructional Strategies Section can be used as take home or essay questions. Some other examples of pre-/post-test questions are given below. To the best of your knowledge describe the health care of older Blacks during the antebellum period of the United States. How did slavers differ in their care of older disabled slaves In what way did slaves care for each other To what extent did health care for older Blacks improve after the Civil War What were the indicators of improvement or the lack thereof Describe twentieth century developments in the health and health care of older Blacks. Write a brief definition of the following terms: Natural illness Occult illness Spiritual illness Describe the problem of misdiagnosis and the nature of cultural bias in medical practices as it applies to elders from African American backgrounds. 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Medical Care, 35(12), 1173-1189. Markides, K. S. L. K. George (Eds.), Handbook of aging and the social sciences (4th ed. pp. 153-170). San Diego: Academic McIntosh, B. R. affect. Journals of Gerontology, Series B: Psychologicial Sciences and Social Sciences, 50B, S229-S239. Mendes deLeon, C. F. Gold, D. T. Glass, T. A. Kaplan, L. George, L. K. (2001, May). Disability as a function of social networks and support in elderly African Americans and Whites: The Duke EPESE 1986-1992. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 56B(3), S179-S190. Nelson, M. A. (1993). Race, gender, and the effect of social supports on the use of health services by elderly individuals. International Journal of Aging and Human Development, 37(3), 227-246. Phillips, R. S. Hamel, M. B. Teno, J. M. Bellamy, P. Broste, S. K. Califf, R. M. et al. (1996, July). Race, resource use, and survival in seriously ill hospitalized adults. The SUPPORT Investigators. Journal of General Internal Medicine, 11(7), 387-396. Prohaska, T. R. Peters, K. Warren, J. S. (2000, July-August). Sources of attrition in a church-based exercise program for older African-Americans. American Journal of Health Promotion, 14(6), 380-385, iii. Taylor, R. J. (1985, October). The extended family as a source of support to elderly blacks. Gerontologist, 25(5), 488-495. Usui, W. M. (1984, May). Homogeneity of friendship networks of elderly blacks and whites. Journal of Gerontology, 39(3), 350-356. Walaskay, M. Whitbourne, S. K. Nehrke, M. F. (1983-1984). Construction and validation of an ego integrity status interview. Journal of Aging and Human Development, 18, 61-72. Wallace, P. E. Jr. (1995, July). Characteristics of black Medicaid elderly and their access to postacute care. Journal of the National Medical Association, 87(7), 467-472. Waters, C. M. (1998, December). Actual and ideal professional support for African American family members. Western Journal of Nursing Research, 20(6), 745-764. Weinick, R. M. Zuvekas, S. H. Cohen, J. W. (2000). Racial and ethnic differences in access to and use of health care services, 1977 - 1996. Medical Care Research Review, 57(Suppl. 1), 36-54. Women of color health data book: Adolescents to seniors. (1999). Office of Research on Women s Health, NIH. Bethesda, MD: National Institutes of Health. Antebellum - events belonging to the period prior to the Civil War in the United States. The Crossover phenomenon - The probability that an older Black American will live longer than his or her White counterpart after a given age. Conjure: To summon a devil, spirit, or supernatural force to appear or act by invoking a sacred name or by some spell to call forth or send away by magic arts. Fetish: A Portuguese word meaning charm may also be called a Talisman. A material object, whether natural, as the tooth or claw of an animal, or artificial, as a carving in wood or bone that is believed to possess magical powers or to be endowed with energies or qualities capable of bringing to successful issue the designs of the owner, preserving him from injury, curing disease, etc. The fetish is regarded as the abode, sometimes temporary, of a supernatural spirit or power, and gains its potency from the indwelling of the spirit. Fictive Kin: people that are considered , as the result of longstanding relationships, but may not be linked directly by blood ties Holistic health: individual is in harmony with nature body, mind and spirit are in harmony or balance. Longevity - the average number of years lived by members of a group. Manumission - the act of freeing a slave. Natural illness: a result of a physical cause, such as infection, disease, weather and other environmental factors. Occult illness: results from supernatural forces, such as evil spirits, and their agents, such as conjurers. May affect the physical and psychological well being as well as the spiritual life of the person. Paternalism - protection and control, like that of a minor child by a parent, exercised by the government over the governed employer over employee, or in similar relationships such as slaver over slave, or the United States Bureau of Indian Affairs over Native Americans on reservations. Spiritual illness: a result of willful violation of sacred beliefs or sin, such a adultery, theft, or murder. Can affect all aspects of life. Appendix B AFRICAN AMERICANS SIGNIFICANT DATES AND PERIODS IN RECENT HISTORY PERIODS AND EVENTS Young Adults Middle Aged Brown, J. (1855). Slave life in Georgia: A narrative of the life, sufferings, and escape of John Brown, a fugitive slave, now in England (pp. 26-27, 56-57). Edited by Louis Alexis Chmerovzow. London: Anti-Slavery Society. The author points out that old slaves were mistreated. Brown recalls that an old slave by the name of Mirney, the mother of thirteen children, was stoned by her master because she would not run fast enough for him. Her master even laughed at her after the stone broke her arm. The writer argues that slaves, young and old, were from other slaves over the years. He asserts that younger slaves respected elder slaves. Brown, W. W. (1847). Narrative of William W. Brown, a fugitive slave (pp. 42-45, 92-93). Boston: The Anti-Slavery Office. The author, William Wells Brown, states that one of his jobs was to prepare the old slaves for the slave market. Mr. Brown was ordered to shave the old men s beards and pluck out their gray hairs. If there were too many gray hairs, he colored them Black. After who was a fortune teller. He told slaves and Whites fortunes and was well respected. Craft, W. Craft, E. (1860). Running a thousand miles for freedom, or, the escape of William and Ellen Craft from slavery (pp. 9-10, 12, 22). London: William Tweedle. One of the writers, William Craft, points out that although his old master had the reputation of being a very humane and Christian man, he thought nothing of selling his aged father and mother, at separate times, to different slave owners. He also argues that his aged parents were very religious and devoted to the service of God. The reason his master sold his parents, and other aged slaves, was that This action was typical of many slave owners. Douglass, F. (1855). My bondage and my freedom (pp. 35-40, 45-49, 69-70, 114). New York: Miller, Orton and Mulligan. The writer, Frederick Douglass, states that the mechanics were called Dubois, W. E. B. pp. 97-103). Atlanta, GA: The Atlanta University Press. The editors provided a brief state-by-state description of specialized health care of older Blacks in the United States. It was estimated that nearly 100 it was shown that churches and women s clubs were major supporters of these facilities and, in some instances actually established and maintained through their own resources long-term care facilities for older Blacks. Genovese, E. D. (1974). Roll Jordan roll, the world the slaves made. New York: Basic Books. This study includes detailed descriptions of selected features of the lifestyles, health characteristics and health care of Black Americans, including selected discussions of older Blacks during the antebellum period of the United States. Grandy, M. (1844). Narrative of the life of Moses Grandy, late a slave in the United States of America (pp. 10, 41). Boston: Oliver Johnson. The writer asserts that his mother was blind and very old and was living in a little hut in the woods, Mr. Grandy recalls that some slaves, including old slaves, were treated so badly that they asked God to take them away from that life. Hughes, L. (1897). Thirty years a slave: From bondage to freedom. The institution of slavery as seen on the plantation and in the home of the planter: Autobiography of Louis Hughes (pp. 43-45). Milwaukee: South Side Printing Co. The author states that when a slave woman was too old to do much of anything, she was assigned to be in charge of young babies in the absence of their mothers. He concludes that it was rare that she had anyone to help her. Mr. Hughes suggests that his mistress was very cruel. Lee, A. S. (1987). The elderly in Black belt counties. In W. H. Watson (Ed.), The health of older Blacks: Social and demographic factors related to the health of older Blacks (pp. 81-102). Atlanta, GA: Center on Health and Aging of Atlanta University. This study focuses on social factors, selected demographic, and health characteristics of older persons in the Southeastern U. S. In addition to the historical development of the region of the U. S. referred to as the the analysis examines the relationship between income and health in the Black belt. There is also a focus on population change, largely accounted for by out migration and indicators of health of older Blacks. Smith, J. L. (1881). Autobiography of James L. Smith (pp. 4-5). Norwich, CT: Press of the Bulletin Co. The author, an ex-slave, told how his grandmother cared for him during slavery. He mentions that an old Black doctor gave his parents some medicine and they recovered from their illness. The author suggests that his mistress was cruel to old house slaves, including Jinny, the cook. Mr. Smith also discusses another Black doctor who was also a fortune teller. The fortune teller told Smith that he would escape to freedom, which he did. Steward, A. (1857). Twenty-two years a slave, and forty years a freeman (pp. 16-17, 24-25, 27). Rochester, N. Y: William Allring, Publisher. The author, Austin Steward, states that on his master s plantation in Virginia, it was the usual practice to have one of the old slaves set apart to do the cooking. All field slaves were required to give into the hands of the cook a certain portion of their weekly allowance either in dough or meal, which the cook prepared. He pointed out that his mistress had older servants punished by having them severely whipped by a man, which she never failed to do for every trifling fault. Watson, W. H. Maxwell, R. J. (1977). Human aging and dying: A study in sociocultural gerontology. New York: St. Martins Press. Part I of this book develops detailed descriptions of selected cross-cultural features of health care of older Africans and African Americans. Included are discussions of beliefs about the dying and the dead and their treatment in the process of dying and the significance of older Blacks as repositories of historically important information. Conceptions of Health Arling, G. (1984). Race and subjective economic well-being in old age. Journal of Minority Aging, 9, 49-59. Data from a l979 statewide household survey of 2,l46 older Virginians (aged 60 and older) were analyzed to determine whether race had an effect on subjective economic well-being. The research showed that race had an independent effect older Blacks had lower subjective economic well-being than older Whites, even when economic and social variables were controlled. Black and White respondents who were in better health and had fewer visits to a physician, and White respondents who were married and older, had greater subjective economic well-being. Individuals with higher economic levels, diverse income sources, fewer dependents and higher education had higher levels of subjective economic well-being in regression models for Blacks and Whites. Home ownership was not a significant variable for either race. The study concluded that the combined effects of income, education and other socioeconomic variables were even more significant than race in the association of these variables with subjective economic well-being. Blake, J. H. (1984). In W. H. Watson (Ed.), Black folk medicine: The therapeutic significance of faith and trust. New Brunswick, NJ: Transaction Books. In this study, Blake reports on selected findings from his research on attitudes toward modern, versus folk medicine among older Blacks on the Sea Islands off the southeastern coast of South Carolina. Blake focuses, in particular, on the relationships between folk beliefs about living in harmony with nature, islander perspectives on uses of herbal remedies in response to illness, and attitudes of older Sea Islanders toward modern medicine. Blake also shows that folk medicine in the Sea Islands is primarily practiced by older Black women, who tended to be members of the lower economic classes and lived in small kinship-based villages where trust in them was enhanced by their local residence, common culture, and easy access. Chatters, L. M. (1988). Subjective well-being evaluations among older black Americans. Psychology and Aging, 3, 184-190. Data for the study of the relationship between subjective well-being (happiness and social status, personal and economic resources, health) and stress factors in 581 Blacks aged 55 and older were obtained from the 1979-80 National Survey of Black Americans. Included were measures of health disability, health satisfaction, life problem stress, and happiness. Lower happiness ratings were associated with being younger, being widowed or separated from one s spouse, and with high levels of stress and low levels of health satisfaction. Health disability had a negative influence on happiness through its association with higher stress levels and reduced health satisfaction. In addition to the direct effects of age on happiness and being widowed or separated, other social status and resource factors were important in predicting intermediate factors related to health status, satisfaction, and stress. Hunter, K. I. Linn, M. W. Harris, R. (1982). Characteristics of high and low self-esteem in the elderly. International Journal of Aging and Human Development, 14, 117-126. The purpose of this study was to examine behaviors and background characteristics associated with negative attitudes toward the self in an elderly population. Among the questions addressed were whether personal characteristics distinguish between high and low self-esteem groups and whether symptoms of depression and anxiety were greater for low than for high self-esteem groups. Subjects interviewed were 250 men and women aged 65 and older from large housing projects in Miami, Florida. Anglo, Black, and Cuban American elderly were equally represented. Self-esteem was measured by Rosenburg s Self-Esteem Scale, Coopersmith s Self - Esteem Inventory, and Brown s Self-Report Inventory. Health status was measured by self-report and the Rapid Disability Rating Scale. Dependent variables were measured by Rotter s Internal-External Locus of control Scale and Hopkin s Symptom Checklist. Results indicated that self-esteem was highest in Anglos and lowest among Cubans. Blacks reported more negative ratings on health variables than did other groups. High and low self-esteem groups did not differ in age, income, education, or living arrangements. The low self-esteem group reported poorer health, more daily pain, and greater disability at statistically significant levels. Elderly with low self-esteem reported more somatization, anxiety, depression, and external control orientation than those with high esteem. Tables are included. Jackson, J. S. (Ed.) (1988). Black American elderly: Research on physical and psychological health. New York: Springer. The 19 conference papers in this collection discuss the physical and psychosocial health of the Black elderly. Topics include the following: the role of Black universities in research on aging Black populations research on the demographic makeup of Black aging populations, cancer prevention and control, socioeconomic predictors of health in the later years, and the nature of formal and informal social participation basic differences between Black and White older adults in the areas of social participation, nutrition, obesity and diabetes, hypertension, and dementing illnesses the role of social factors in the subjective well-being of older Blacks, family and social supports, health-seeking behavior, health attitudes and health promotion/prevention, work, retirement, and disability methodological issues in survey research, case-control epidemiological research and clinical trials and major themes related to future research on aging Black populations. Johnson, F. Cloyd, C. Wer, J. A. (1982). Life satisfaction of poor urban black aged. Advances in Nursing Science, 4, 27-34. This quantitative-descriptive study was designed to investigate differences between the life satisfaction of urban Black institutionalized and noninstitutionalized aged and to identify probable causative factors. The study was conducted in a low-income high rise apartment building for the aged in several nursing homes in a Midwestern metropolitan city. Participants included 22 institutionalized and 23 non-institutionalized urban Black subjects ranging in aged from 65 to 92. Data were collected using the Mental Status Questionnaire, the Crichton Royal Behavioral Rating Mental Scale, the Life Satisfaction Index-Z Scale, and a Life Satisfaction Interview Schedule. Data were combined for the total sample and examined through stepwise multiple regression to determine what percentage of variability in life satisfaction could be explained by all of the variables examined together. The non-institutionalized Black aged exhibited higher life satisfaction than institutionalized Black aged on the four components measured, resolution and fortitude, zest for life, congruence between described and achieved goals, and mood tone. Perceived health was an important determinant of life satisfaction. Less support was established for education, income, occupation, political activity, personality variables, and religion as indicators for life satisfaction. Variables related to basic survival (living arrangements), support system, and independence emerged as significant correlates. Mitchell, M. F. (1984). Pharmacists in Jamaica: Health care roles in a changing society. In W. H. Watson (Ed.), Black folk medicine: The therapeutic significance of faith and trust (pp. 41-52). New Brunswick, NJ: Transaction Books. Mitchell s study of folk medicine shows the significance of the pharmacist in Jamaica as (1) intermediary between the modern medical doctor and the patient and (2) lay diagnostician, with implications for pharmacist-consumer relationships in other societies as well. In addition to corroborating the significance of faith and trust in the practitioner-patient relationship, Mitchell s study of folk medicine reveals various ways in which therapeutic interaction between the pharmacist and the customer differs from the relationship between the modern medical doctor and the patient. For example, the folk patient has more control over the direction and duration of practitioner-patient interaction than does the patient in the modern doctor-patient relationship, and pharmacists do not challenge nor attempt to counter the customer s use of popular or lay medical concepts in selecting medications. Primm, B. J. (1984). Poverty, folk remedies and drug misuse among the Black elderly. In W. H. Watson (Ed.), Black folk medicine: The therapeutic significance of faith and trust (pp. 67-70). New Brunswick, NJ: Transaction Books. Primm draws attention to lack of public education about uses of folk remedies, over-the-counter drugs, and prescription medicine, and how the misguided use of two or more drugs can have deleterious effects. He begins with a focus on older poor Blacks in the rural South, and expands to focus on all elders, particularly users of folk remedies. Waring, J. L. Kosberg, J. I. (1984). Morale and the differential use among the Black elderly of social welfare services delivered by volunteers. Journal of Gerontological Social Work, 4, 81-94. This study investigated the relationships among morale, certain life conditions, and the use of social welfare services delivered by predominantly young White volunteers to elderly Blacks living in a small Southern town. All 55 aged Blacks (aged 60 to 92) using the Congregate Meals Program in this community were administered a 114-item questionnaire that included a 20-item morale measure and measures of housing and health status, finances, and social involvement. Morale was generally high. Low morale scores were significantly related to sight and hearing difficulties the diagnosis of two or more major health problems beyond sight and hearing lack of stamina and worry about financing possible future medical expenses. The elderly used the Congregate Meals Program for nourishment and for social needs, but its use was not associated with morale. Although the entire sample maintained a high level of social involvement, social involvement was not related to morale. A major concomitant of high morale was the utilization of social services that fostered the elderly s physical and social mobility. It was concluded that service delivery by Whites did not hinder service utilization by these Black elderly. Wallace, G. L. (1993). Neurological impairment among elderly African American nursing home residents. Journal for the Health Care of the Poor and Underserved, 4, 40-50. In this pilot study, 288 elderly African American and 482 White residents of 10 nursing homes in Wayne County, Michigan, were compared for neurological impairment. The frequency of diagnosis of neurological impairment was equivalent for African American and White males, but greater for African American females than for White females. Cerebral vascular accident (CVA or stroke) and nonspecific dementia were the most common neurological diagnoses for all groups. For males but not females, there was a statistically significant difference in the causes of neurological impairment, with more African Americans diagnosed as having CVA, and more Whites diagnosed as having nonspecific dementia. While the incidence of neurological impairment in African Americans exceeded that of Whites, predominantly White nursing homes offered more sophisticated care. This suggests the need to review the means by which comprehensive nursing home care may be expanded in the African American community. Watson, W. H. (1984). Folk medicine and older Blacks in Southern United States. In W. H. Watson (Ed.), Black folk medicine: The therapeutic significance of faith and trust (pp. 53-66). New Brunswick, NJ: Transaction Books. This study proceeds from the assumption that a full understanding of the social and psychological behavior of Afro-Americans, like that of any group, must take into account their social historical and biographical backgrounds. For example, because the social and developmental histories of most of today s older Afro-Americans are traceable to states in the Southeastern region of the country, inquiry should begin with a careful description of the culture and patterns of social change that shaped the historical context of individual and group development in that part of the country. Within this broad context, Watson develops a discussion of the interfaces of folk and modern medicine and the associated (or conflicting) beliefs and values, and patterns of consumption of folk medicine among older Afro-Americans in the southern United States.
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