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  • The article on lateral violence (LV) in nursing and the theory of the nurse as wounded healer (Christie & Jones, 2014) in the March issue really captured the damaging effect of LV on the entire organization and how important early intervention is to eradicate its cycle repetition.

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Race Consciousness and the Health of African Americans

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Rosalyn J. Watts Ed.D, RN, FAAN

Abstract

The historical experience of African Americans in our country has been shaped by the institution of slavery, dehumanization of blacks, segregation, pursuit of civil rights, and racism in contemporary American society. Disparities in health care provide compelling evidence that issues of race or skin color for the descendants of slaves and other ethnic minorities persist in the 21st century. Nurses providing care for African Americans must bridge the racial divide and incorporate culturally relevant content in the health history. As an integral aspect of their professional growth as culturally competent health care providers, they must incorporate the idea of race consciousness which is described as an awareness of the historical journey of the group, knowledge of disparities in health care for the people, and a self appraisal of one’s attitudes and biases toward the group.

Citation: Watts, R., (January 31, 2003). "Race Consciousness and the Health of African Americans". Online Journal of Issues in Nursing. Vol. 8 No. 1, Manuscript 3. Available: www.nursingworld.org//MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No1Jan2003/RaceandHealth.aspx

Key words: institution of slavery, racial inferiority, segregation, disparities in health, racism, race consciousness, cultural competence

Race Consciousness and the Health of African Americans

Bridging the racial divide in health will be a daunting challenge and opportunity for health care providers of the 21st century. Guidelines for cultural health appraisal of African Americans and other minorities consist of knowledge of the historical experiences of the group and current research on health care issues. For the individual patient, culture-related health concerns must be incorporated as key components of the patient’s history (Lavizzo-Mourey & Mackenzie, 1996; Lipson, Dibble, & Minarik, 1996).

This article explores key issues of race consciousness, which for the purposes of this discussion is defined as an appreciation of the complex historical journey of these persons; knowledge of disparities in health which may facilitate or inhibit optimal levels of care for these individuals and their families; and the self appraisal of one’s attitudes, feelings, beliefs, and biases towards African Americans and/or persons of color. More specifically, this article outlines key historical and sociopolitical forces that help to shape the lives of African Americans as a black race. It examines complex issues of health care disparities for these individuals and several other ethnic minority groups. The article also provides strategies for inclusion of race consciousness as an integral aspect of professional growth for culturally competent health professionals.

Historical and Sociopolitical Contexts

Race is an issue for African Americans.


The black experience in America is distinctively different from that of other immigrants or refugees...
The black experience in America is distinctively different from that of other immigrants or refugees specifically in terms of the extended period of the institution of slavery and the issue of skin color as a metaphor for dehumanization of black persons. For almost four centuries (1619-2002) African Americans have struggled through turbulent periods of slavery, segregation, and discrimination (Bennett, 1993). Matters of race, racism, and racial discrimination are rooted in the legacy of slavery and persist throughout contemporary American life.

The Beginning: Institution of Slavery and Dehumanization (1619-1862)

Inequalities about race are best reflected in slave narratives, historical records, and biographies which describe slaves as property rather than persons. Historians frequently reported the characterizations of black slaves as subhuman species with insatiable sexual appetites who lacked intelligence, feelings, and character (D’Emilio & Freedman, 1988). In comparing the plight of women and slaves in colonial America, historian Howard Zinn (1999) pointed out, "the biological uniqueness of women, like skin color and facial characteristics for Negroes, became a basis for treating them as inferiors" (p. 102). Additionally, the passage of harsh laws and early rulings of the U.S. Supreme Court helped to perpetuate the oppression of blacks and reinforce beliefs about black inferiority.

Thus unlike other immigrants or refugees who traveled to this country on a volunteer basis in the 17th, 18th, 19th and 20th centuries, black Americans came to America, chained together as human cargo and crossed the dreaded "middle passage" during the Atlantic Slave Trade (Thomas, 1997). Millions of slaves died of disease, suicide, or murder and were fed to the sharks following the slave ships. Social historian Bennett (1993) pointed out, "they were packed like books on shelves into holds, which in some instances were no higher than eighteen inches" (p. 49). Some historians state that in 1619, the first West Africans, traveling via Dutch frigates, landed in Jamestown, Virginia, and were considered to be indentured servants. Franklin and Moss (2000) reported that state law recognition of slavery began in Virginia in 1661. Thus for two centuries, as a lucrative business, the institution of slavery became the economic backbone of colonial American and the new republic (Franklin & Moss, 2000).

The Declaration of Independence, signed on July 4, 1776, did not address the plantation system, slavery, or the slave trade. Thus, during the Revolutionary War (1775-1783), the notion that " all men are created equal" did not apply to slaves (or women) (Bennett, 1993). Decades later, French visitor to the country Alexis de Tocqueville predicted that race would be a problem for the young nation. In his 1840 book entitled Democracy in America he stated, "If there are great revolutions, they will be caused by the presence of blacks on American soil. That is to say, it will not be the equality of social conditions but their inequality" (de Tocqueville,1840/2000, p. 638). The dehumanization of blacks in this country was reinforced by the 1857 U.S. Supreme Court decision that the slave Dred Scott was "property and not a person," even though this individual had lived in a free state for a brief period of time (McPherson, 1988).

Emancipation, Segregation, and Discrimination (1863 –1953)

On January 1, 1863, at the midpoint of the Civil War (1861-65), President Abraham Lincoln signed the Emancipation Proclamation. This historical document freed the slaves in the rebellious Confederate states. Thus, as a people, African Americans have spent more time in bondage prior to the War Between the States than in freedom (Franklin & Moss, 2000). During the post-bellum, reconstruction period, passage of "Jim Crow" or segregation laws in the South prevailed, resulting in a fostering of white supremacy and overt discrimination against blacks in America. In 1896, U.S. Supreme Court case "Plessy v Ferguson" upheld the notion of segregation with the ruling of "separate but equal" doctrine. This doctrine of separation of the races dominated all segments of society and American life. Referred to as "America’s version of apartheid" this ruling prevailed until the 1960s (Edley, 1998).

In 1903, African American sociologist W. E. B. DuBois warned in his book The Souls of Black Folk that race would be the problem of the 20th century (DuBois, 1990).


For the first half of the 20th century, the United States continued to be a racially divided and segregated society.
The oppression of black people was best reflected in crimes of lynching, led by white supremacist groups who kidnapped, tortured, and executed African Americans. It is estimated that over a period of fifty years, i.e. between 1880 and 1930, about 3,220 blacks were lynched in America (Myrick-Harris, 2002). Themes of inequality, social injustice, and perceived inherent inferiority of African Americans resonated throughout all aspects of American life. Due to disparities in education, housing, employment, judicial system, transportation, and health care, African Americans were subjugated to a subordinate status of second class citizenship. Bennett (1993) noted that between 1910 and 1930, given the quest for freedom, education and employment, thousands of blacks moved to the northern cities (Chicago, New York, Philadelphia, Detroit, and Pittsburgh) as part of the "Great Migration". This movement continued until the 1960s. For the first half of the 20th century, the United States continued to be a racially divided and segregated society.

Desegregation, Civil Rights, and Racism (1954-present)

During the second half of the 20th century, societal and political unrest escalated due primarily to the Civil Rights crises and America’s involvement in the Viet Nam War. Although some universities admitted blacks, the 1954 decision of the U.S. Supreme Court in the landmark case Brown v the Board of Education outlawed segregated public school throughout the nation. The issue of relentless racial segregation in America helped to trigger the Civil Rights Movement which peaked during the 1960s and spanned almost 17 years. Under the leadership of Dr. Martin Luther King Jr. and others, the non-violent movement consisted of protests such as street demonstrations, marches, and boycotts which resonated throughout the world via the powerful medium of television (Franklin & Moss, 2000). Later on, spontaneous eruptions of racial violence and riots spread throughout the major cities in the country. During the 1960s four major leaders in government and civil rights were assassinated- President John Kennedy, Malcolm X, Dr. Martin Luther King Jr., and Senator Robert Kennedy. Many other American citizens, young, old, black and white were killed in the long struggle for freedom. (Zinn, 1999).

During the presidency of Lyndon Johnson, the comprehensive Civil Rights Act of 1964 was passed to prevent discrimination in areas of public accommodation and employment.


Substandard education is a major factor in sustaining disparities in all aspects of life...
Later in 1965, he signed the voting rights bill which suspended the use of literacy tests for black citizens (Bennett, 1993). In the 1970s and 1980s, during the terms of Presidents Carter, Reagan and Bush other political issues dominated the national dialogue, whereas issues of race tended to be marginalized (Zinn, 1999). In 1998 the advisory board to President Clinton’s "Initiative on Race" recommended specific policy suggestions about race. These included the need to "promote harmony among the nation’s racial and ethnic groups" and the "importance of youth to build bridges among races" (Franklin & Moss, 2000, p. 634). Social scientists provide compelling evidence that education is the key that opens the lock to mainstream American life. Substandard education is a major factor in sustaining disparities in all aspects of life, e.g., advanced education, income status, employment opportunities, health status, and overall wealth (Edley, 1996) As described in the report of the Commonwealth Fund, the statistical profile of the minorities shows that blacks and Hispanics are more likely to die younger, live below the poverty line ($16,000 for a family of four), and have less than a high school education (Collins, Hall, & Neuhaus, 1999).

Finally, in a comprehensive review and analysis of social science studies on racial attitudes and relations, Bobo (2001) asserted that at the end of the 20th century, Americans tended to accept principles of equality and integration for minorities. The "old fashioned" type of racial segregation, discrimination, and overt oppression of blacks had been rejected. However, he postulated that a subtle, more modern type of "laissez-faire racism" that reinforced negative stereotypes about African Americans and contributed to the dilemma of racial divisions in our country was continuing. Reviewing the findings of several studies, Bobo (2001) reported that many whites have negative perceptions of blacks who are perceived to be less intelligent, prone to violence, and persons preferring welfare.

In summary, the unique experience of blacks in American has been a long and tortuous journey of slavery, emancipation, segregation, disenfranchisement, desegregation, Civil Rights revolution, and discrimination. In the 19th and 20th centuries, key decisions of the U.S. Supreme Court have been a major judicial force in terms of inhibiting or enhancing the lives of African Americans. Themes of racism have resurfaced in the public debate. The recent controversial comments of Senator Trent Lott appeared to reflect a political leader who was nostalgic about the days of segregation (Goodgame & Tumulty, 2002). With the exception of Native Americans, no other groups have endured institutionalized slavery and pervasive racial discrimination in America. As descendants of slaves, African Americans represent a unique minority group due to the color of their skin, characteristic physical features, and perceptions about the innate inferiority of the black race. During the last decade of the 20th century, contemporary philosopher Cornel West stated, "Race is the most explosive issue in America precisely because it forces us to confront the tragic facts of poverty and paranoia, despair and distrust" (West, 1994, p. 155). The major theme of the perceived inherent inferiority of blacks resonates throughout the history of this country and continues in contemporary America.

Disparities in Health Care

Race is an issue in health care. For generations, knowledge of the dehumanization and exploitation of blacks in matters of health has been transmitted through folklore and historical documentation of experimentation on these individuals. Perceptions of the inherent inferiority of blacks is a persistent theme. The recent report of the Institute of Medicine (IOM) (Smedley, Stith, & Nelson, 2002), as well as other studies, provide compelling evidence about the scope and depth of disparities in health for African Americans and also other ethnic minorities. Clinical studies must continue to explore the extent to which multidimensional factors such as socioeconomic status, cultural beliefs, behavior, and biological variations contribute to the unequal health status of African Americans.

Health Care Separate but "Unequal": Post Bellum Years and Early 20th Century

During the post bellum years and at the beginning of the 20th century, the delivery of health care to blacks and the education of African American professionals reflected societal values and trends in other institutions, i.e., a segregated health care system. Hine (1989) reported that by the end of the 1920s approximately 200 black hospitals and nurse training schools were established to provide health care services for African Americans in the south and the industrialized cities of the north. As noted by Bates (1992), during this period a small percentage of black students were admitted to predominately white, accredited nursing schools throughout the country. In terms of professional organizations, the National Association of Colored Graduate Nurses (NACGN) was established in 1908. After much deliberation the NACGN was dissolved and black nurses had the opportunity to join the American Nurses Association (ANA) in 1950 (Hine, 1989).

During the 1920s and 1930s the premise of white superiority prevailed. Bates (1992) noted that a number of scientists from different disciplines published theoretical formulations to support their observations that "blacks as a race were physically, intellectually, culturally and morally inferior to whites" (p. 302). Historian Vanessa Gamble (1997) documented that prior to the Tuskegee study, mistrust of the biomedical community was inextricably connected to episodes of medical exploitation during the 19th and early 20th century. For example, slaves were used to test treatment of heatstroke and techniques for repair of vaginal fistula in the black female (without anesthesia). For generations oral history reports of the plundering of graves for dissection and kidnapping of persons by "night riders" for experimentation contributed to the folklore.

It is the Tuskegee story that continues to reverberate through the black community. In 1932 the United States Public Health Service launched the Tuskegee syphilis study which examined the untreated syphilis in the male Negro for forty years (Kampmeier, 1972). During the study 399 "subjects" thought they were being treated for their infection or "bad blood" but were intentionally not treated. Historian Susan Reverby (1999) describes the study as an exemplar of, "medical arrogance, unethical behavior and racism in research" (p.3). Although many blacks did not know the details of the Tuskegee clinical trial, many have heard the story that "something terrible" happened to African Americans during that study. It may be speculated that fear of exploitation and distrust of the public health system contribute to the reluctance of African Americans to participate in clinical trials for new drugs. For example, Svensson (1989) explored the representation of American blacks in 50 recently published studies for new drugs which were published in the journal Clinical Pharmacology and Therapeutics from 1984-1986. The results showed a showed that only 20% of the studies provided data on the description of the subjects. Svensson concluded that a lack of representation of African Americans in clinical trials for new drugs did not provide sufficient data regarding the safety of these pharmacological agents or future drug utilization with ethnic populations. The researcher recommended the need to determine race-specific responses to drug therapy and increased participation of minorities in clinical studies. Attitudes and beliefs about clinical trials were not addressed.

Health Care Disparities in Contemporary America

Evidence of racial and ethnic disparities in health care are found throughout the spectrum of health care, i.e., health access, utilization, and health care insurance. Language and health-related cultural variables serve as major barriers for access to health care for racial and ethnic minorities (Lavizzo-Mourey & Mackenzie, 1996). For example, a report of the Commonwealth fund (Collins, Hughs, Doty, Ives, Edwards, & Tenney, 2002) examined the quality of care for minority Americans. Conducted by the Princeton Survey Research Associates, the telephone survey of 6,722 white and ethnic minorities (Africans Americans, Hispanics, and Asian Americans) focused on several aspects of health care. The final sample consisted of a 72% response rate in which 25- minute interviews were conducted in English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese. The results showed inequality in health care in four major categories. These included: patient–physician communication, cultural competence in health care services, quality of clinical care, and access to care. More specifically, in comparison to white counterparts, the minority groups were less likely to consider themselves to be in excellent or very good health and have insurance. With regard to provider communication, the various racial and ethnic groups were less likely to: be able to communicate with the physician, follow the doctor’s advice due to cost constraints, have confidence in their physician, be treated with respect, feel that the provider understood them, inform their physician of the use of alternative therapies, report satisfaction with care, receive clinical services essential for monitoring chronic diseases, and have a regular doctor. These results provide substantial evidence that society must address cultural and financial barriers to health care for racial and ethnic minorities.

The comprehensive report of The Institute of Medicine (IOM) (Smedley et al., 2002) clearly documented the pervasiveness of racial and ethnic disparities in health care. This report was commissioned by Congress. The fifteen-member committee reviewed the literature, commissioned papers, and gathered information with the use of workshops, focus groups, and round table discussions. Two major findings were (p.17):

  1. Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.
  2. Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.

Finally, within the context of the clinical encounter the IOM report (Smedley et. al., 2002) suggested that major provider-client issues centered on health care provider prejudices, limited time frame with no time for processing information during the visit, and mistrust and refusal on the part of patients.

In another study, vanRyn and Burke (2000) explored both race and socioeconomic status on physicians’ perceptions of patients. Survey data of 618 patient encounters showed that white physicians reported less favorably about African Americans. In contrast to white patients, black patients were perceived as more likely be noncompliant and less intelligent with a tendency towards substance abuse. Likewise, doctors perceived persons of lower socioeconomic status to be less intelligent persons with negative personality characteristics (vanRyn & Burke, 2000). A major study of 720 physician participants examined the effect of race and sex on doctors’ recommendations for cardiac catheterization. Using patient simulations of videotaped actors, the results showed that white physicians were less likely to recommend black women for cardiac catheterization (Schulman et al., 1999).

With regard to patient-physician relationships, a telephone survey of 1,816 adults (ages 18-65) examined how race/ethnicity and gender were related to physician styles of participatory decision making. The results showed that in contrast to white patients, African-American patients reported less participatory interactions with white physicians. Thus in race-concordant relationships, black patients disclosed that seeing physicians of their own race usually resulted in a greater participatory process (Cooper-Patrick et al., 1999).

In exploring the extent of racial disparities and the quality of care for Medicare managed care patients, Schneider, Zaslavsky, and Epstein (2002) reported that whites were more likely than blacks to receive breast cancer screening, eye examinations for diabetes, beta blocker medications for treatment of myocardial infarction, and follow up after hospitalization for mental illness.

With regard to epidemiological data trends, heart disease, cancer, and stroke are the leading causes of death for all Americans. In comparison to white males, African American men tend to have twice the mortality rates in prostate cancer and disproportionately higher rates of HIV/AIDS infection and homicide. For all cancers, the five year survival rates are lower for black women that for whites. Minorities in both genders are more likely to experience symptoms of depression. (National Vital Statistics Report, 2001).

In summary, during the 19th and first half of the 20th century, the segregated health care system and separate education of health care professionals reflected the attitudes, beliefs, and laws of the majority in a segregated society. For African Americans, mistrust of the American health care system was due to their experience in bondage, folklore, and substantial evidence of exploitation of these individuals during the Tuskegee Syphilis study. In contemporary America, a number of comprehensive studies provide substantial evidence of disparities in health which may be related to racism and/or bias in throughout the spectrum of health care delivery.

Race Consciousness and Culture Competence Development

Over the last several years, private sector and governmental agencies have addressed aspects of diversity and cultural competence as essential components of the mission statement and overall strategic plan of the organization.


With regard to nursing, specific strategies for bridging the provider–patient racial divide have not been sufficiently developed.
The print literature and World Wide Web Internet resources are replete with information on dimensions of cultural competence. With regard to nursing, specific strategies for bridging the provider–patient racial divide have not been sufficiently developed.

Guidelines and Programs for Development of Culture Competence

Recognizing the need to facilitate culture competence in health care, in 1999 the Office of Minority Health, Department of Health and Human Services, designated specific standards to implement Culturally and Linguistically Appropriate Health Care Standards (CLAS). These standards are available at the CLAS website (www.omhrc.gov/clas/). Based on an analytical review of key laws and regulations the CLAS document outlined 14 standards for providers and policy makers to facilitate the process of delivering culturally competent care. Some community-based programs have been successful in launching culturally competent care. For example, Health Services Financing and Managed Care sponsored a national competition to examine the characteristics of programs that provide culturally competent care and reward them for their efforts (Health Resources Services Administration, 2001). The results showed that the best programs in community settings tended to define culture broadly, value the belief system of the client, and appreciate the intricacy of language interpretation and communication.

Additionally, successful programs encouraged learning between providers and the community, facilitated community participation in aspects of programmatic efforts, collaborated with other groups and agencies, instituted cultural competence training for staff, and incorporated cultural competence as an integral aspect of their health care delivery system. Thus, the most successful programs utilized multiple strategies for implementing comprehensive programs.

Strategies for Inclusion of Race Consciousness in Practice

For Caucasian nurses working in acute care settings or outpatient facilities with predominately African American populations, bridging the nurse-patient racial/cultural gap will be a challenge.


...the professional development of culturally competent providers is a lifelong process.
The development of race consciousness must be interwoven as an integral aspect of the process of becoming a culturally competent professional nurse. As noted earlier, for the purposes of this discussion, race consciousness is defined as an appreciation of the complex historical journey of these persons; knowledge of disparities in health which may facilitate or inhibit optimal levels of care for these individuals and their families; and the self appraisal of one’s attitudes, feelings, beliefs, and biases towards African American and/or persons of color. It is anticipated that the professional development of culturally competent providers is a lifelong process in which the individual has the potential capacity to provide culturally appropriate care for African Americans and other minority groups.

With regard to implementation of a program on race in the health care facility, the philosophical commitment of the administrative/leadership group to culture competence and race consciousness must be reflected in the mission statement and the strategic plan of the facility. As a beginning initiative, a pilot project on one of the nursing units may be launched to focus on the African American health concerns. Campinha-Bacote’s model, The Process of Cultural Competence in the Delivery of Health Services, (2002, 2003) provides an excellent conceptual framework for beginning the journey of becoming a culturally competent professional nurse who has integrated the concept of race consciousness as an integral aspect of practice. The assumption of the model notes the heterogeneity within groups and recognizes that cultural competence is an ongoing, evolving process. The five constructs of the model consist of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.

Given the emphasis on African Americans, it should be noted that contemporary black Americans are a heterogeneous group which consists of those born in the United States and refuges or immigrants from Haiti, the Caribbean, South America, and Africa. (Cabral, Freid, Levenson, Amaro, & Zuckerman, 1990). Each group differs in terms of heritage, language, culture and health beliefs and health practices. Guidelines to begin the process of incorporation of race consciousness as a component of cultural competence professional development would consist of:

  1. Conducting a self appraisal of racial and ethnic heritage that includes:
    • Place of birth
    • Length of time in country and history of migration
    • Ethnic affiliation and identity
    • Primary and secondary languages
    • Style of communication
    • Religion
    • Food practices
    • Health beliefs and health practices
    • Customs around transitions, such as births and illnesses (Lipson et al., 1996)
    • Self appraisal of attitudes, feelings, and beliefs towards African Americans and persons of color

  2. Launching a Culture Interest Group with a focus on African American health concerns
    • Assemble a coalition of colleagues to assist you with this initiative
    • Conduct a survey to examine the racial/ethnic diversity within the group
    • Establish a routine time for group sessions
    • Use different strategies to get to know the other person, e.g., conduct a culture health history on a colleague
    • Gather data about problems of race and ethnicity in your setting with use of surveys or questionnaire
    • Design a strategic plan for increasing culture competence of colleagues and staff
    • Launch a lecture series on race and African American health care issues
    • Obtain a list of potential experts to discuss issues of race, disparities in health, and the black experience
    • Build partnerships with families and community leadership
    • Develop a reference library of resources on aspects of race, culture competency, and health disparities of staff
    • Develop a timetable to evaluate the efficacy of your efforts

  3. Participating in continuing education/professional development programs to increase knowledge about minority health issues with specific emphasis on the African American

  4. Developing a philosophy of lifelong learning

In summary, many businesses, educational, and governmental groups have already incorporated diversity and/or cultural competence initiatives in their mission statement and strategic plans. The federal government has formulated definitive standards or the CLAS to address these issues.

Strategies for incorporation of race consciousness as a component of culture competence development include appraisals of racial and ethnic heritage, commitment to the development of a culture interest group in the facility, continuing education, and development of a philosophy of lifelong learning.

Conclusion

This article provides an overview of several key issues related to race consciousness and the health of African Americans. It described first how, for African Americans, the indelible imprint of race and racism is inextricably interwoven in historical and contemporary aspects of American life. Next it presented clinical studies providing compelling evidence of disparities in health and health care which may be related to systemic bias and prejudice throughout health care delivery. Finally, the article recommended ways in which race consciousness can be incorporated into the process of becoming a culturally competent provider.

Author

Rosalyn J. Watts Ed.D, RN, FAAN
e-mail: rwatts@nursing.upenn.edu

Dr. Rosalyn Watts is Professor Emerita of Nursing at the University of Pennsylvania, School of Nursing. As a member of the faculty her teaching and research initiatives focused on graduate study in Critical Care Nursing and course work on Human Sexuality and Health. For a number of years she served as director of the Biennial Black Health Conference at Penn and chairperson of the Diversity Committee. She returned to Penn where she is currently working as Director for Diversity Affairs and is involved in special projects related to faculty development on diversity, student recruitment, and curriculum.

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Cabral, H., Freid, L.E., Levenson, S., Amaro, H., & Zuckerman, B. (1990). Foreign -born and Us-born black women: Differences in health behaviors and birth outcomes. American Journal of Public Health, 80(1), 70-71.

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© 2003 Online Journal of Issues in Nursing
Article published January 31, 2003


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