Dietary adherence among rural African-American elders with hypertension : an ethnographic approach

260 Pages·1994·9.9 MB·English

by  Schoenberg, Nancy Ellen, 1964-

DIETARYADHERENCEAMONGRURALAFRICAN-AMERICANELDERS
WITHHYPERTENSION:ANETHNOGRAPHICAPPROACH
By
NANCYELLENSCHOENBERG
ADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOL
OFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENT
OFTHEREQUIREMENTSFORTHEDEGREEOF
DOCTOROFPHILOSOPHY
UNIVERSITYOFFLORIDA
1994
ACKNOWLEDGMENTS
Iwishtoexpressmydeepestgratitudetoallwhohaveinstructedand
encouragedmeduringthislongjourneytowardintellectualenlightenment.
ChiefamongtheseisDr.LeslieSueLieberman,amentorandfriend,whoset
meonthispathandofferedunfailingenthusiasm,support,andassistance
alongtheway. Seldominlifedoesoneencountersuchunrelenting
commitmenttohelpingpeoplereachtheirgoals. IsimilarlyacknowledgeDr.
R.PaulDuncan'sinvaluableinvolvementinmyacademiccareer. Ihave
benefitedfromoureveryinteraction,fromhissignificantclasstofuture
researchinvolvements. Dr.OttovonMering'sscholarlycommitmentto
boththedisciplineofanthropologyandtomany,manystudentshasenriched
myacademicexperience. IwishtoexpressmyappreciationtoDr.Mickey
Dougherty,whoisarolemodelwithherfinescholarship,unending
encouragementandsupport,andunparalleledorganization. Throughout
mystudies.Dr.ClaudiaProbarthasofferedvaluableinsightsandencouraging
words. Finally,IamgratefultoDr.LindaB.Bc>broffforhergraciousand
generousinvolvementwithmydoctoraldissertation. Allofthesecommittee
membershaveofferedvaluableinsightsandhavebeenunderstandingand
generouswiththeirprecioustime. Ialsowouldliketoacknowledgethe
DepartmentofAnthropology,theCollegeofLiberalArtsandSciences,and
theNationalScienceFoundationfortheirsupport.
Onapersonallevel,Iwishtoacknowledgethecontributionsofall
familyandfriendswho,overtheyears,havecontributedtomygrowthand
11
development. Withouttheinformational,instrumental,and,most
importantly,affectivesupportofmyhusband,Mark,Iwouldnothave
enjoyedthisdoctorate(aswellasmylife)nearlyasmuch. Markhasalso
contributedtomywell-beingbycreatingandsharingintheraisingofour
wonderfuldaughter,Rachel. Whileattimesmyproductivityhassuffered,
thesetwoindividualshavehelpedkeeplifeinperspectiveforme. Ialsowish
toexpressmylifelonggratitudetoourfamilies,particularlyourparents,
grandparents,andsistersandtheirfamilies,whohavebeenunsurpassedin
theirlove,timeandresourcecommitments,andinterestinourlives.
Finally,Iwouldliketoacknowledgetheessentialcontributionsofthe
studysample,withoutwhomthisdissertationwouldnotexist. Ihopethatby
givingthemthelastwordinthiswork,Icanconvincethemofthe
importanceoftheiropinionsandlives.
iii
TABLEOFCONTENTS
page
ACKNOWLEDGMENTS.
...ii-iii
ABSTRACT
vii-ix
CHAPTERS
1 INTRODUCTION
PurposeandApproachoftheStudy
HypertensionEpidemiology ...1
Adherence ...2
Diet ...5
Hypotheses ...7
ResearchDesign ...8
ResearchMethods ..9
Summary 15
19
2 ADHERENCE
,20
STMtheueadsSyutraRteeemsueolfnttAsdohfeArdehnecreeRnecseearch ''7 ..2204
SUSnoudcmeimrosdateramyongdrianpghDiicetDaertyerAmdihnearnetnsceo:fATdhheerCehnaclelengeofModification ..,433168
44
3 DIETARYPATTERNS
AEfatriincgana-sAameCrulitcuarnalDiIensttitution .45
.48
Fat
3ZZZZZZZZ .57
Salt
DietaryChange .63
"Fresh": NotallIt’sCrackedUptoBe ..7730
SpecialDiets
OtherFactorsInfluentialinDietarySelection ..7753
Obesity
Summary .78
85
IV
4 AFRICAN-AMERICANHEALTHBELIEFS 87
TheConceptof"Traditional"HealthBeliefs 87
HypertensionandHighBloodPressure 89
Hyper-Tension
HighBloodPressure
HealthLocusofControl 103
Health"Knowledge"andAdherence IO7
Information Sources HO
Media Hi
SocialContacts H2
TheDebateover"Rationality"andtheCultureofPoverty 115
Summary H8
5 SOCIALSUPPORT HO
Definitions I2i
MeasurementIssues Hi
TheStateofSocialSupportResearch 123
StructuralisticorFormalSupport
IndividualisticorInformalSupport ...125
EvaluationsofIndividualisticandStructuralSocialSupport
Classification H7
AAffrriiccaann--AAmmeerriiccaannSHoocuisalehSoulpdpoSrttructure "!.!.!"!!!ll3325
EvaluationsofSocialSupport 1...139
StudyResults H3
Summary
6 ECONOMICACCESSTOHEALTHRESOURCES 150
BarrierstoAdherence H2
TheConnectionbetweenLowSES,HBP,andbeingAfrican-
American
1^1
AffordabilityofMedicalRecommendations 164
EnablersofMedicalCare I57
StudyStudy'sAccesstoHealthCareProfessionals 176
SAcucmemssartoyCareVersusUtilization !!l."...."l78
IgQ
7 PATIENT-PRACTITIONERRELATIONS 182
HealingSpecialists H3
StudyingPatient/PhysicianRelations 184
TThheeSPtartuicetnutr-ePhaynsdicNiaatnuRreelaotfiPonhsyhsiipc'isanReVilseivtasncetoAdherence ...119805
V
Physicians’Characteristics
TheImportanceofBeingSatisfied
Summary
205
8 CONCLUDINGSUMMARYANDRECOMMENDATIONS 207
SummaryofFindings 207
Recommendations
212
APPENDICES
AB.. SIUNMSMTRAURMYENOTFSINFORMANTINFORMATION ."!.1....""!!Z."221293
REFERENCES
225
BIOGRAPHICALSKETCH oaq
vi
AbstractofDissertationPresentedtotheGraduateSchool
oftheUniversityofFloridainPartialFulfillmentofthe
RequirementsfortheDegreeofDoctorofPhilosophy
DIETARYADHERENCEAMONGRURALAFRICAN-AMERICANELDERS
WITHHYPERTENSION: ANETHNOGRAPHICAPPROACH
By
NancyEllenSchoenberg
December,1994
Chairman: LeslieSueLieberman
MajorDepartment: Anthropology
Thisstudyassessedtheinfluencesofeconomic,socialandcultural
variablesonprescribeddietarybehaviorsinchronichypertension
managementamongforty-oneruralsouthernAfrican-Americansoverage
65. Despitetheoverwhelmingprevalenceofhypertension-relatedmorbidity
andmortalitywithinthisstudy,researcheffortstendtobefragmented,
interventionsinappropriate,andadherencetorecommendationsreportedly
limited.
Adherencewasevaluatedthroughatwenty-fourhourdietaryrecall
andafoodfrequency inventory,physicians’opinionsandweightcharts.
Vll
Outcomeswereplacedonanordinalscaleand,usingstandardtestsof
association,werecorrelatedwithHealthBeliefModel-basedvariablesand
others. Suchvariablesincludesociodemographicfactors,treatmentduration,
healthbeliefsandlocusofcontrol,socialsupport,medicalcareaccessand
patient/practitionerrelations. Instrumentsincludeethnomedicalopen-
endedquestionnaires,theNorbeckandIPRIsocialsupportscales,andtwo
Likertscaleinstrumentsmeasuringhealthlocusofcontroland
patient/practitionerrelations.
Statisticalanalysesandethnographicinterviewsrevealhigheroverall
adherencetodietaryrecommendationsthanreportedinmostresearch.
Nearlytwo-thirdsofthestudysamplemettheirphysicians'guidelinesfor
weightreductionandfatintake; however,fewerthanone-thirdsuccessfully
limitedtheirsodiumintake.
Thedataindicatefewsignificantassociations,probablyduetofactors
associatedwithsmallsamplesize. Ofthesociodemographicvariables,only
educationhasasignificantpositivecorrelationwithadherence. Treatment
durationisinverselyrelatedtothelevelofadherence. Theinfluenceof
healthbeliefsondietarychoicesiscomplexbecausestudymembersmaintain
both"traditional"andbiomedicalhealthorientationsandbehaviors. While
physicians'carewashighlyappraised,therewasnoassociationbetween
dietaryadherencelevelandassessmentofthepractitioneroraccesstohealth
facilities. Similarly,whilestudyparticipantspositivelyevaluatesocial
support,statisticalassociationbetweenadherenceandperceptionofsupport
wasonlyfoundifthefamilymemberorfriendisahealthcareprofessional.
Theauthorconcludesbyissuingsubstantiveandculturallyappropriate
recommendationstoresearchers,policymakers,andhealthcareprofessionals
Vlll
designedtofacilitatetreatmentadherenceandreducetherisksof
hypertension-relatedmorbidityandmortality.
IX
CHAPTER
1
INTRODUCTION
PurposeandApproachoftheStudy
Forcenturies,anthropologistshavebeenengagedinthecollection,
recording,andanalysisofinformationaboutvarioussocietiesandpeoples. In
sodoing,theymaybetestingnewhypothesesorre-testingonestheybelieve
lackvalidityduetoculturalchangeorinadequateresearchdesign.
Alternatively,ethnographersmayseektodeterminetheapplicabilityof
anthropologicalprinciplesorideastoaculturewiththeultimategoalof
achieving"practicalends"forthebettermentofpeople. Increasingly,
contemporarysocialscientistshaverecognizedthenecessityofachieving
suchimprovementsbyundertaking mulitdisciplinaryapproaches,or
studyingtheentire"problem"orissue.Usingabroadrangeof
anthropologicalandothermethods,Ihaveattemptedtoconstructamore
comprehensive"ethnographyofadherence"toanti-hypertensivedietary
recommendations.
Likemoretraditionalethnographies,Ihaveundertakenamultifaceted
investigationofthepossibleconsiderationsinvolvedinhealthdecision-
making. Specifically,Ihavechosentoinvestigate factorsthatinfluence
whetherolderruraldwellingAfrican-Americanlhypertensivesfollowtheir
doctors'recommendationsondietandweightcontrol.
^Throughoutthisdissertation,Ialternatebetweentheterms"African-
American"and"black." Whiletheformerisgenerallyacceptedinthe
scholarlycommunity,participantsinmystudypreferthelatter. Tothem,
"African-American"impliesadirectconnectiontoAfricaevocativeof
1