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The Influence of African AmericanElders' Belief Systems on HealthInteractionsHelen K. Black PhD aa Behavioral Research Institute , Arcadia University , Glenside ,PennsylvaniaPublished online: 21 Jun 2012.

To cite this article: Helen K. Black PhD (2012) The Influence of African American Elders' BeliefSystems on Health Interactions, Journal of Religion & Spirituality in Social Work: Social Thought, 31:3,226-243, DOI: 10.1080/15426432.2012.679839

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Journal of Religion & Spirituality in Social Work:Social Thought, 31:226–243, 2012

Copyright © Taylor & Francis Group, LLCISSN: 1542-6432 print/1542-6440 onlineDOI: 10.1080/15426432.2012.679839

The Influence of African American Elders’Belief Systems on Health Interactions

HELEN K. BLACK, PhDBehavioral Research Institute, Arcadia University, Glenside, Pennsylvania

This qualitative article explores how African-American elders’cultural and religious belief systems informed elders’ perceptionsof: (a) healthcare encounters, (b) quality of healthcare receivedand, (c) relationships with providers. The descriptive studyinvolved interviews with African American elders (N = 60),60 years of age and older. Open-ended interview questions con-cerned elders’ perceptions of how their age, gender, race, and beliefsystems impacted quality of healthcare interactions. Three interre-lated themes linked elders’ responses: (a) desire for connectedness,(b) sense of marginality, and (c) reliance on God and culturaltraditions. Findings show the value of social workers designingassessments, programs, and interventions that qualitatively exploreAfrican American elders’ beliefs. A qualitative exploration can useelders’ own words to show the significance of their cultural andfaith traditions in all aspects of their lives.

KEYWORDS African American elders, religious/spiritual beliefsystems, cultural traditions, healthcare interactions, social workimplications

An individual’s belief system emerges from the smaller culture of familyand the larger culture of society, and place in time. In the case of African

Received March 21, 2011; accepted January 30, 2012.Research supported by the National Institute on Aging #R01 AG11112, R. L. Rubinstein,

PI, and the National Institute of Mental Health #R24MH74779, L. N. Gitlin, PI and the NationalInstitute on Aging #R01 AG13687, L. N. Gitlin, PI. The author sincerely thanks Karen Morrison,MSW, LSW, for her insightful comments.

Address correspondence to Helen K. Black, PhD, Senior Research Scientist, BehavioralResearch Institute, Arcadia University, 450 South Easton Rd., Glenside, PA 19038. E-mail:blackh@arcadia.edu

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Influence of African American Belief Systems 227

American elders discussed in this article, the larger culture may be both theurban community in which they live as well as their African roots (Carter,1976; Some, 1994). Consonant with their belief system is the importance ofthe individual and the community. Both the soul of a person and the soulof a neighborhood must be grasped; personal spirituality is also a groupspirituality that cannot transcend its context (Asante, 1980; Karenga, 1993).Research shows that the strengths displayed in this population of elders areoften drawn from interdependence, and a sense of relationship with others,both Divine and human. This belief makes the realms between personaland professional interactions, and the sacred and secular worlds, perme-able (Baer, 1993; Ellison, 1993; Gilbert, Harvey, & Belgrave, 2009; Lincoln &Mamiya, 1990; Mattis & Jagers, 2001).

Research studies acknowledging the role of religion and spirituality onAfrican American elders’ health and well-being have burgeoned. Yet fewstudies have explored how religious and spiritual belief systems informedelders: (a) actions, cognitions, and emotions regarding healthcare encoun-ters; (b) perceptions of the quality of healthcare they receive (Mattis &Jagers, 2001); and (c) relationships with providers. For example, researchshows that African American elders view healthcare providers as indif-ferent toward understanding how elders’ beliefs and culture shape theirworldview, including health concerns and treatment preference (Black,Schwartz, Caruso, & Hannum, 2008; Napoles-Springer, Santoy, & Houston,2005).

We suggest that this article has implications for social workers as elderadvocates. It explores the in-depth responses of 60 urban, community-dwelling African American elders (age 60 years and over). Questions regardthe significance of cultural, religious and spiritual belief systems on their(a) beliefs about health, well-being, and the healthcare system; and (b)interactions with healthcare providers. Elders were also asked how impor-tant it was for providers to be aware of elders’ beliefs, and how providersmight use that knowledge in treatment. Elders’ responses revealed the “why”behind health attitudes and behaviors, including treatment choices andnoncompliance.

In this article we will first examine the theories that framed our study,present our findings using participants’ quotes, offer a discussion, notestudy limitations, and consider implications from this study for social workpractice.

THEORETICAL FRAMEWORK

We base our research on a theoretical approach to old age that is socialconstructionist in nature (Berger & Luckmann, 1966). This theory reflectshow people create a personal meaning system, and how they understand

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228 H. K. Black

and interpret the experiences of everyday life. Using this approach, wesuggest that cultural, religious, and spiritual belief systems are integral inthe construction of African American elders’ self- and world-view.

The second theoretical approach on which our study is based is the psy-chology of religion. This theory suggests that religious and spiritual beliefsserve as a psychological template on which individuals map life events, andthrough which meaning is found that might ameliorate the suffering thatresults from negative experiences (Black, 2006).

The third theoretical approach is a relational framework that exploresthe role of belief systems in the development and maintenance of socialrelationships in African American life, including patient/provider encounters(Mattis & Jagers, 2001). This framework examines how belief systems affectthe perceptions and outcomes of personal, social, and professional interac-tions, such as the quality of relations with healthcare providers, commitmentto self-care behaviors, and recommendation compliance.

METHODS

Qualitative research is appropriate to our sample and our subject of study.Usual questions in assessments, such as religious denomination, churchattendance, or frequency of prayer cannot reach core beliefs that informattitudes and behaviors, including those around health (Gilbert et al.,2009), or the importance of personal, requited relationships with Godand others (Mattis & Jagers, 2001). Likewise, the rich oral tradition ofAfrican Americans, begun in slavery and continuing today, renders AfricanAmericans’ accounts, narratives, and stories about their experiences prefer-able to one word responses (Black, 2006). Open-ended responses reveal,in a way that surveys and measures cannot, the complex synergism ofProtestant spirituality and African notions of the person linked in AfricanAmerican belief systems (Rabotaeu, 1978). Likewise, it is difficult to mea-sure a belief system’s impact on health decisions; this information can bebetter interpreted and understood through conversational questions andanswers.

Design and Data Collection

This descriptive, exploratory study consisted of qualitative interviews thatexamined African American elders’ experiences with health providers. Theface-to-face single interview took approximately 1 to 2 hr to complete,and included discussions about several topics. Germane to this article, weexplored the influence of belief systems on interactions with healthcare pro-fessionals. The following questions were embedded in a larger interviewschedule. Entire transcripts formed the basis of analysis.

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Influence of African American Belief Systems 229

1. Describe your relationship with your provider(s).2. How do you think your healthcare is affected by age, gender, or race?3. How can providers work more effectively with African American elders?4. Tell me about the major cultural or religious or spiritual principles you

live by.

Responses were tape-recorded, transcribed, and analyzed using content andthematic analysis. That is, responses were analyzed according to the contentof the entire interview and salient themes within each interview and acrossinterviews. We did not use qualitative software.

Participants

Thirty each, African American men and women (N = 60), 60 years of ageand over, and who fit into one of three self-described functional categories:having none, some, or major functional limitations, were recruited from asenior center. The center, which serves African American elders is located inan urban area of a Northeastern city. Other eligibility criteria involved: (a)living in the community—either alone or with others, and (b) willingness toparticipate in an open-ended, qualitative, conversational type of interview.

Interviewers

All 60 respondents were interviewed by one of four interviewers (threeinterviewers were African American; one was European American. One inter-viewer was male, three interviewers were female; the European Americaninterviewer was female). Interviewers conducted interviews at times andlocations convenient to participants.

Data Analysis

The general approach to data analysis for this project uses standard meth-ods of qualitative research (Mischler, 1986; Silverman, 2001), which are asfollows: After interviews were transcribed, the author and two experiencedcoders analyzed them using a broad data review, which asks the generalquestions, “What is in the data?” and “How is this data relevant to thetopic under study?” The next step is a large or gross-level sorting of eachtranscript, which gives codes to broad themes and topics intraindividually.We also performed a fine-grained analysis, which gives codes for subthemesand patterns within respondents’ entire transcripts. This reiterative methodenabled us to more fully understand respondents’ interpretations of ques-tions asked (Berger & Luckmann, 1966; Flyvbjerg, 2006). Data also consistedof field notes made by interviewers. We note that as ideas, themes, and

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230 H. K. Black

patterns emerged from new transcripts, we back-checked them selectivelyor universally with data from respondents who had already completed aninterview, and who had already been given codes. Each respondent’s com-plete interview informed the broad issues of the interview and the specifictopics of this article.

RESULTS

Findings revealed at least two overarching categories that informed elders’interactions with providers: (a) the significance of cultural, religious, andspiritual beliefs systems; and (b) the relational nature of all interactions.According to elders, a positive encounter with healthcare providers is man-ifested by: (a) elders feeling known and heard by providers, (b) eldersbeing treated as equals in matters concerning their health, (c) providers notattributing elders’ health concerns to “old age,” and (d) providers acknowl-edging faith in God as integral to treatment. Within this framework, weidentified three themes (see Table 1) constituting elders’ desired interactionwith providers: (a) desire for connectedness, (b) sense of marginality, and(c) reliance on God and cultural traditions.

All themes are interrelated and represent patterns that occurred withinand across gender and functional status groups.

Theme 1–Desire for Connectedness

According to elders, connection (or lack of it) with healthcare professionalswas shown in at least three ways: (a) being listened to by provider; (b)having an equal give and take in healthcare discussions, and (c) sharing areal conversation.

LISTENING

For elders, “not being listened to” regarding their symptoms and prefer-ences for treatment provoked mistrust. For example, a 70-year-old widowargued with doctors’ diagnosis of anxiety, convinced that her chest pain was“something more.” Because she was later diagnosed with “heart disease,”she offered this advice:

Listen to us. Maybe some people make up stuff, but if we say we’rehurting, nine times out of ten we are hurting. When they said I had ananxiety attack, I knew it was more. See, I talked with God about it, andHe knew it and I knew it.

A 73-year-old widow had difficulty, at age 65, in getting a diagnosisof fibromyalgia from providers because the disease typically has an earlier

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232 H. K. Black

onset. “I told them how much pain I was in; they didn’t listen. I prayed forsomeone to listen to me. I said, ‘God, I’m at this intersection; I don’t knowthe way to go.’”

A divorced man reported he had reached age 70 “by the grace of God.”For him, “being listened to” did not mean engaging in small talk with his doc-tor. He wanted to participate, as an equal, in a frank discussion concerninghis health.

He will not return my calls. That bugs me, man. I asked, “Doc, you’vebeen seeing me six, seven years now. How’s my health?” He hemmedand hawed. He didn’t care for that question. He’ll sit and talk aboutsports all day long but when you ask him personal questions about yourhealth he gets antsy.

This respondent could not understand, and resented, why his doctor couldnot “hear” a reasonable request to discuss a subject that was vitally importantto him—his health.

GIVE AND TAKE

In the healthcare interaction, elders perceive that an equal give and takeoccurs when providers listen to them. A 75-year-old widow reported theoutcome of a routine check-up.

My doctor talked to me about getting older, and some things I shouldlet go. When I lost my job, he said it was time for me to leave anyway.I said “I don’t mind it (working) too much.”

The physician did not hear, or ignored his patient’s desire to keep working.The interaction highlights the doctor’s authoritarian stance with this patientand his lack of give and take in the relationship.

A 74-year-old married man with severe back pain reported that his doc-tor prescribed an anti-inflammatory drug. Afterward, the respondent calledan African American health-talk radio show. The host, who was not a doctor,asked why the physician prescribed medicine for thirty days. The respondentrecalled the conversation:

I never thought to ask that. Then he asked, “Why didn’t he send you toa chiropractor?” I didn’t ask that either. I didn’t know the right questions.I assumed he’s got all the answers. He knows I don’t like medicines;if he can treat it with herbal supplements, he’ll give them. He wantedme to participate in an experiment with healthy African-American men.I decided not to because I asked him to speak at the senior center, andhe didn’t come, so . . .

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Influence of African American Belief Systems 233

This account reveals several complex themes. The respondent feltuneasy about the doctor’s treatment and asked a member of his commu-nity for advice about his back pain. The respondent viewed his doctor asa professional with whom he had an equal relationship. When the doc-tor failed to speak to his senior group, yet had asked him to take part inresearch, the respondent realized they did not have an equal give and take.

A 65-year-old woman described her interaction with physicians whodisregarded her symptoms.

I had a hard time swallowing. I knew something was wrong physically.I was very verbal and they wouldn’t listen. I went to another doctorand another. I was frustrated because I express myself well and no onelistened. I resorted to acting stupid. When I met the surgeon, I acteddepressed. If you’re verbal and communicate, they don’t listen. When Iwent in acting like an old lady, acting like I didn’t know anything, actinghumble, they listened to me.

Because she believed she could not “be herself” and get what she neededfrom the encounter, she assumed a more “appropriate” role with the doctor.She perceived that she and the surgeon had complementary roles in herwell-being. Hers was to “act stupid and humble.” His was to respond to her“act.”

AUTHENTIC CONVERSATION

Tension may exist between elders’ sense of self as continuing to developspiritually in old age, and fixed age, gender, and racial identities con-structed by society, including healthcare systems. This tension mayprompt indirect communication styles in African American elders andaffect their willingness to disclose symptoms to healthcare professionals.(Mills & Edwards, 2002)

A 69-year-old married man articulated how a lack of “real conversation”with his provider, due to time constraints on their interactions, negativelyaffected his health. “I knew something was wrong with me, but with clinicdoctors I was just another folder. I always thought there should be a balance.You go to church; you see a doctor. Both should help heal.”

An 83-year-old divorced woman offered another example:

I had a male doctor and I didn’t particularly like him. Nothing againsthim, but I didn’t feel he understood. When I first found out about mydiabetes, right away he told me what I should and shouldn’t do, and Ilistened but deep down under, I thought, I can’t do that, and I’m notgonna do that, and that’s not for me.

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234 H. K. Black

This respondent resented the physician’s inability to understand that hisdirectives must be situated in the reality of her life. If they were not, shewould be unable or unwilling to carry them out.

Theme 2–Sense of Marginality

African American elders are not a monolith; our 60 respondents are uniquepersons with singular biographies and personal histories. Yet, they sharea generation cohort and a communal past. Elders’ experiences of suffer-ing due to racism produced a “deep and rich” understanding about humannature (Paris, 1995). Self-insight and acute perceptions about others’ motiveswere refined during a long history of social marginality. African Americans’careful scanning of others, particularly Whites, in social and professional sit-uations, is considered crucial for self-preservation (Black, Groce, & Harmon,2011; Mattis & Jagers, 2001). Likewise, a pragmatic African spirituality hon-ors self-protection and the authority of God in all matters, including health(Raboteau, 1978).

AGE, GENDER, RACE

The varying nature of participants’ answers speaks to how identity fac-tors, such as age, gender, race, and SES, intersect. This intersection revealscomplicated causal pathways to elders’ perception of bias in healthcareprofessionals. For example, a 60-year-old retiree reported satisfaction withproviders, but resented that her ailments are considered normative “for [her]age.” A 65-year-old woman agreed. “I don’t like that term: because of yourage.” Both respondents believed that healthcare institutions reflect society’sageist views. Both knew they had “real” illnesses that should be diagnosedand treated.

A 70-year-old widow argued that intuitive knowledge of her bodybegan a “nightmare” for her. When she went to emergency, hospital per-sonnel refused to confirm her suspicion—she was suffering from heartdisease. Her symptoms were “shortness of breath and pains around [her]heart.”

You know why they weren’t giving me an EKG? Because I’m a woman, Iwas living by myself, I’m a senior. Oh, she’s a lonely old woman. FinallyI said, “God I don’t know what to do. Please let somebody listen to me.”

The test she demanded showed clogged arteries, and “fluid around [her]heart.” She was in intensive care for three days and was put on heartmedication. This incident provoked a significant depression and alsoproved to her “the power of prayer. God answered my prayer for someoneto finally hear me.”

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Influence of African American Belief Systems 235

An 88-year-old widow is convinced that age is the identity factor thatmost influences her interactions with healthcare workers.

Older people tend to be poor and don’t hear well. And doctors becomeimpatient with them. It’s not just color; they treat their own the same way.I never encountered any discrimination except age. They can’t believeanybody would live that long.

A 65-year-old woman faced similar experiences.

I take questions to my doctor and it’s always, “As you get older . . .”I figure, screw you. I’ll read things. My sister’s a nurse and my son’sa pharmacist; I have people to communicate with. I talk to God. Whywaste time with them [doctors]?

A 73-year-old woman repeated her doctor’s diagnosis aboutmenopause.

He [doctor] said, “You need to see a psychiatrist.” I said to myself, some-thing’s wrong here. Then I found out. I seen on television where lots ofdoctors didn’t know what women go through with menopause. I prayedabout it and sure enough, God sent me to someone else. And I foundout there wasn’t nothing wrong with me, I’m just having hot flashes andnervousness.

Some respondents believed that age was a critical factor in diagnosisand treatment. An 80-year-old married man, when asked if age affected thehealthcare he receives, remarked:

He [doctor] said to me, my heart condition is because of my age. And Ithank the Lord he considered that. They should take into considerationage and race.

A 78-year-old divorced woman thinks stereotyping older women ofColor does not affect the care she receives, but it influences her interactionswith some providers.

People don’t realize they [providers] stereotype people of age, people ofcolor. The most recent was the nurse who is as nice as can be, but thefact she is amazed at my jewelry told me a lot about what she expected.The first time we met she said, “I’m looking at the colors you haveon.” She had never seen a little old lady of color so coordinated. AndI’m saying, I don’t believe this. She hasn’t been exposed to other thanAfrican-American persons of lesser means.

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The intersection of age, gender, and race shaped this respondent’ssense of self, and served as the lens through which she viewed the nurse’scomments.

INDIVIDUALITY

Past and present experiences of racism often become a template forhow elderly African Americans perceive they are viewed by the dom-inant society, and thus how they approach interactions with others.A 69-year-old married man reported that he drew primarily on “God toface the challenges of aging.” One reason is that he believes that thequality of healthcare is determined by the domino effect of racism. Heexplained:

[I’d receive better quality of healthcare] if I had a better job and maybe if Iweren’t the color I am. And made more money, and had more education.Then I could afford more. It’s just one thing falls into step.

When asked if a specific incident had triggered this remark, he said, “I can’trecall now, but probably.” This participant perceived that White society seeshim as an anonymous “Black male” with all the negative attributes thatattends this stereotype, rather than a unique person for whom racism haddetermined every option open to him, and limited the choices he madethroughout life.

Similarly, a married woman who commented that she “got to theage of 73 by the grace of God and prayer,” said that she believed Whiteproviders must “work harder” to view African-American patients/clients asindividuals.

At one time, white doctors didn’t want to get too close to you. I’ve beento some where they wouldn’t touch me. Someone that’s supposed to helpyou, they acting like this? But we can see the difference, we’ve been todoctors who would come in and get down with us, ask us questions.What about this, that? Just take the time. Sit down and talk. Find out ifthere’s abuse in the family.

Her comments reveal her personal experiences, which included wish-ing that a doctor had questioned her, many years ago, about her “fallsand bruises and fatigue.” Yet, along with the encounters she described,this respondent said she also had positive experiences with providers.Her response highlights the complex expectations of elders’ in healthcareinteractions, and shaped some paradoxical responses.

When asked how providers could work more effectively with elderlyAfrican Americans, a 73-year-old married man responded:

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Influence of African American Belief Systems 237

It depends, because there’s a difference how you relate to black doctors.Other doctors should have an idea of the patient’s living situation. Theyshould know your age and something about you, your personality, yourlifestyle. They should see you as a person; not just a member of a racialgroup. If they have ideas blacks aren’t as healthy, or don’t exercise, orhave menial jobs, we can tell.

Our African American respondents realized that, in most instances,White providers would be treating them. Their hope was that the providerwould not see them solely as a “member of a racial group” with stereo-typed habits and preferences, but as intelligent agents willing to work withproviders to bring about positive health outcomes.

Yet, when an 83-year-old woman was asked whether her ethnicity orrace affects the healthcare she receives, she replied:

Yes. Many doctors have no knowledge of African Americans. They havetheir minds set that we don’t understand or don’t want to. You know,negative thoughts towards African Americans. I think many struggle, butdeep down it’s there. The way they act when they approach you. Likeone said, “Oh, you don’t have any marks, I know you’re not a drug user.”I said, “You got that right.”

This woman perceived that healthcare professionals judge a collec-tive African American identity as “fixed,” that is, certain characteristics arecommon to African Americans, despite age or gender.

Conversely, an 88-year-old widow reported: “Services I received up tonow had nothing to do with race, has never entered into conversations ortreatment I received.”

An 81-year-old married man concurred. “I never been to a black doctor,but I ain’t seen no discrimination at all.”

Despite this, elders approached healthcare interactions with wariness.That is, racial stereotyping remained the always-anticipated, silent premisein each encounter.

When asked how age, ethnicity, or gender affects the healthcare hereceives, an 80-year-old married man remarked:

It has a bearing because your ethnicity has characteristics others don’t,like high blood pressure. I get good medical care based on personalneeds as opposed to general needs. They have to know your culture,eating habits, heredity, what do you believe? They need to recognizethat age doesn’t mean you’re not thinking clearly and you’re not awareof the importance of your health.

Although this respondent believed that ethnicity “does and should”matter in healthcare interactions, he also highlighted that healthcare

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professionals “shouldn’t assume that because someone is old, or minority,or prays, that he’s not willing to do things that preserves their health.”

When asked how healthcare professionals could treat African Americanelders more effectively, an 80-year-old married man answered:

They should get involved in the person’s lifestyle. Each group has typesof food they eat. But then they could be Afro-American and raised by aCaucasian. Look deep into the person. What is their social life like; whatis your sex life like? What’s your religion? So they shouldn’t assume; theyshould inquire.

Respondents urged healthcare professionals to probe the backgroundof their clients, and warned against stereotyping due to age, ethnicity, orgender. Respondents also reminded providers that ultimately God resolvestheir health problems, and that God directs the hands of doctors to discoverthe cause of their pain or illness.

Elders’ responses portray their healthcare interactions as events ofuncertainty. They are poised to have their suspicions—they are not beingheard, they are considered less than a whole person, the interaction is not arelationship between equals—confirmed. Despite this, they also recognized,and appreciated, when healthcare providers focused on “personal, ratherthan general needs.”

Theme 3–Reliance on God and Cultural Traditions

African American cultural and religious traditions have integral roles inelders’ health. When asked how health professionals could treat AfricanAmerican elders more effectively, a 65-year-old woman commented:

They need to know the culture of African Americans and that religionplays a big part so they have to learn to deal with religion. In referenceto the diagnosis, it has to be done in a very delicate way.

A 69-year-old married man reported he is “looking to do alternativemedicine, get off drugs completely. I don’t go to doctors. I go to thenutritionist.”

A 65-year-old divorced woman viewed doctors as “second in command”regarding her health. “We were raised to know everything comes from God.He puts [doctors] in my life to help me. I talk to God first.” When asked ifshe would discuss mental health issues with doctors, she replied:

Take action and face what it is first. Feel the pain because there is pain.You don’t need a pill for everything. There’s not a pill in the world that’sstops you from having pain, so why get hooked on them? A perfect

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Influence of African American Belief Systems 239

example of pain and knowing it’s okay to be depressed is when JesusChrist died.

A 75-year-old married man, when asked how providers could workmore effectively with African American elders, responded: “They have toknow the species they’re dealing with. Culture is important.”

A 70-year-old divorced man concurred.

Interviewee: We’re a different race apart. We have our own wants. We’rebig on home remedies. Asians have theirs, we’ve got ours. I’m not big onpills because the holistic works for us as a people. Most home remediescame from us anyway. If I could find me a good black doctor I would;he might know something about holistic medicine.

Interviewer: Caucasian doctors wouldn’t know that?

Interviewee: Not especially, not especially.

A 78-year-old divorced woman, when asked what advice she wouldgive to healthcare professionals, spoke of the importance of family legacy:

One thing that bothers me is how little physicians know. They don’teven ask. There’s more to a person than meets the eye. They shouldthink of the person as a whole, as part of something. If there’s a criminalin my building shooting, what would I say? Don’t shoot me. I have fourgreat-grandchildren who’ll miss me. I have a connection. If you kill me,you’re destroying my whole family. And if you treat me as a patient, I’ma product of a whole family. With all our improvements in technologymaybe we’ll get back to a time where we really find out about folk.

This respondent compared the disruption of her family through vio-lence to the disruption of her personhood by providers. She is a necessarypart in an integrated totality—with all parts and roles functioning forthe well-being of the whole. Her remark eloquently blends the themesand subthemes regarding patient/provider interaction presented in thisarticle.

DISCUSSION

Our present study identified three interrelated themes that reflect specificneeds of elders in healthcare interactions. We suggest that these themes arerooted in elders’ belief systems; they highlight a holistic view of body, mind,and spirit, and view all human beings as equal in the sight of God. These

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themes were similar across gender and functional status groups; they sharedconsistency throughout and across interviews.

A theme of connectedness revealed elders’ desire to be heard byproviders and to have a “give and take” in discussions about healthand treatment decision-making. Participants reported health interactions inwhich they perceived that: (a) they were not treated as equals (Kagawa-Singer & Blackhall, 2001; Napoles-Springer et al., 2005; Saha, Arbelaez, &Cooper, 2003), (b) their belief systems were irrelevant in treatment discus-sions (Hagihara & Tarumi, 2009), and (c) providers seemed uninterestedin improving interactions by learning about elders’ beliefs and traditions(Goldberg, Hayes, & Huntley, 2004).

A theme of marginality was woven throughout responses to questionsabout health and healthcare. Elders resented being grouped or labeled,viewed solely as bodies in decline, or having symptoms considered a resultof “old age.” They desired to be viewed as a “whole person” rather than bereduced to a particular pain or specific disease (Paris, 1995).

The significance of African American cultural and religious traditionswas this group’s major theme. They believed that “God comes first” inall aspects of life, including their approach to illness (Black, 1999a), butwere not passive or fatalistic about their symptoms (Twigg, 2004). For them,prayer meant “working with God” toward a good-health outcome (Black1999b); faith served as a framework for understanding the meaning of ill-ness and suffering, and having a relationship with God as well as providers(Black, 2004, 2006). Elders sought providers’ recognition that faith and cul-ture are fundamental to how older African Americans react to symptoms, andhow providers should attend to them (Johnson, Elbert-Avila, & Tulsky, 2005).

LIMITATIONS

One limitation in our study concerns having only one interview session witheach elder. In qualitative research, two or more sessions with a respondentare recommended in order to prompt a relationship between researcherand respondent, which is a goal of qualitative research. Another limitationis that three of the study interviewers were only briefly trained in qual-itative research methodology and interviewing. The necessity of rigoroustraining sessions in the philosophy of the qualitative method, types of qual-itative research, approaches in qualitative methodology, data collection andanalysis, and techniques of interviewing are essential.

Despite these limitations, our data show that elders’ cultural, religious,and spiritual beliefs were overarching in participants’ responses through-out the interview, and were salient in their interpretation of the healthcareencounter.

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Influence of African American Belief Systems 241

Implications for Social Work

Our research points to a specific area of cultural knowledge that might helpsocial workers design assessments, workshops, or intervention programswith African American urban elders:

What comprises our participants’ belief system? The Black Church hasremained significant in the African American community from the time ofslavery until the present. The Church sees the identity factors, such asage, gender, and ethnicity (along with body, mind, and spirit) of AfricanAmerican elders as a congruent whole, but not as a stereotype, and gath-ers the whole person under a sacred umbrella of fostering self-esteem andself-worth (Taylor, Ellison, Chatters, Levin, & Lincoln, 2000).

The Black Church has been a symbolic and virtual center of social andpolitical guidance, and can be designated by health professionals workingwith clergy persons as a source of health information. It is important toremember, however, that the Black Church, especially in urban areas, holdsa crucial though sometimes paradoxical relationship with cultural spirituality.For example, Afrocentric intervention programs in the areas of depres-sion, HIV/AIDS, and substance abuse emerged when traditional Eurocentricpsychological approaches and the Black Church could not address thepsycho-social issues confronting African Americans (Gilbert et al., 2009).Afrocentric programs highlight a spirituality that includes relationships withancestors and succeeding generations, adherence to African principles, suchas Nguzo Saba, (well known as the principles of Kwanzaa), the promotion ofphysical and mental health screenings, focus groups on health problems towhich African Americans are prone, interventions for these health issues,and sessions on African masculinities and African sisterhood (Manning,Cornelius, & Okundaye, 2004). Although an Afrocentric spirituality couldsupplement any traditional belief system, some churches and clergy personsview it as competitive or even inimical to traditional Christian beliefs (Blacket al., 2011).

Based upon our work with this group, we suggest a social work modelthat qualitatively queries elders about their (a) self- and world-view andsense of everyday reality; (b) understanding of the healthcare system andtheir place in it; and (c) cultural traditions and religious beliefs, includinghow the relational and spiritual component of all interactions shape whatthese elders need from interactions with healthcare professionals.

Although work in the past decade has utilized Afrocentric approaches toAIDS, drug use, mental health issues, and physical and mental health dispar-ities in children and younger adults, this has not been the case with elders,especially the old-old. We suggest that researchers and social workers jointlyexplore the complex but underdeveloped areas of: (a) educating providersabout the beliefs and values that underlay elders’ approach to health-care (Wilson, Tilse, & Setterlund, 2009), (b) how African spirituality can

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complement traditional religious and spiritual beliefs of African Americanelders (Manning et al., 2004), and (c) discussing with clergy in the targetedarea how current church programs for the elderly might be aided by teach-ing Afrocentric traditions. Future studies may investigate, on a larger sampleof elders, the impact of an African self-consciousness on elders’ healthcareattitudes, behaviors, decision-making, and interactins.

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