Home - Health Association of African Canadians

Reacutesumeacute

Deacuteterminants de la santeacute des femmes noiresdans les communauteacutes rurales et eacuteloigneacutees

Josephine Etowa JulianaWiensWanda Thomas Bernard et Barbara Clow

Les instigatrices du projet On the Margins se sont attacheacutees agrave eacutetudier lrsquoeacutetat desanteacute la prestation des soins et la freacutequentation des services de santeacute au sein dela population des femmes afro-canadiennes vivant dans les reacutegions rurales eteacuteloigneacutees de la Nouvelle-Eacutecosse On a fait appel agrave un modegravele de recherche-action participative et proceacutedeacute agrave la triangulation des meacutethodes de collecte dedonneacutees mdash entrevues groupes de discussion et questionnaires Le codage etlrsquoanalyse des donneacutees ont eacuteteacute effectueacutes au moyen du logiciel de gestion Atlas tiSix thegravemes srsquoen deacutegagent les rocircles multiples des femmes noires les perceptionsen matiegravere de santeacute les expeacuteriences relatives au systegraveme de santeacute les facteurs quiinfluent sur la santeacute les strateacutegies de gestion de la santeacute et les solutions envi-sageacutees Les auteures se concentrent sur lrsquoun de ces thegravemes soit les facteurs quiinfluent sur la santeacute et proposent une analyse de trois sous-thegravemes connexes race et racisme pauvreteacute et chocircmage et accegraves aux soins de santeacute

Mots cleacutes femmes noires deacuteterminants de la santeacute racisme communauteacutes rurales

CJNR 2007Vol 39 No 3 56ndash76

56

07-Etowa et al1 91407 1116 AM Page 56

Determinants ofBlackWomenrsquos Health in

Rural and Remote Communities

Josephine Etowa JulianaWiensWanda Thomas Bernard and Barbara Clow

The On the Margins project investigated health status health-care delivery anduse of health services among African-Canadian women residing in rural andremote regions of the province of Nova ScotiaA participatory action researchapproach provided a framework for the studyTriangulation of data-collectionmethods mdash interviews focus groups and questionnaires mdash formed the basis ofdata generationA total of 237 in-depth one-on-one interviews were conductedand coded verbatim Atlas-ti data-management software was used to facilitatecoding and analysis Six themes emerged from the data Black womenrsquos multipleroles perceptions of health experiences with the health-care system factorsaffecting health strategies for managing health and envisioning solutionsTheauthors focus on 1 of these themes factors affecting Black womenrsquos health anddiscuss 3 subthemes race and racism poverty and unemployment and access tohealth care

Keywords Black women health determinants racism rural communities

Background

Discrepancies in health are intimately associated with differences in socialeconomic cultural and political circumstances (Aday 1993 BacklundSorlie amp Johnson 1996 Bloom 2001 Brown 1995 Chen amp Fou 2002Rogers 1997) Economic inequities in particular have been implicatedin poor health Individuals of lower socio-economic status are at a muchgreater risk of illness and are much less likely to have timely access tohealth and social services than individuals of higher socio-economicstatus (Hay 1994 Lynch 1996 Lynch Kaplan amp Shema 1997 PappasQueen Hadden amp Fisher 1993 Poland Coburn Robertson amp Eakin1998)Yet while researchers have amply demonstrated the effects of suchdeterminants on the health of people in Black communities the vastmajority of health research on Black women men and children origi-nates in the United States and only a small number of needs assessmentsand student theses focus on the health of African Canadians living inthe province of Nova Scotia (Atwell amp Atwell Human ResourceConsultants 2002 Enang 1999 Enang EdmondsAmaratunga amp Atwell


copyMcGill University School of Nursing 57


2001 Lawrence 2000 Sharif Dar amp Amaratunga 2000Thomas Bernard2001)

Current evidence suggests that the barriers to appropriate care andthe health deficits faced by Black women in Canada are similar to thosefaced by African-American women yet more definitive evidence on thecircumstances and experiences of African Canadians is required (Enang2002) In additionAmerican and Canadian research on people of Africandescent tends to focus on urban conditions and experiences (Calvert1997 Dana 2002 Enang 1999 Enang et al 2001 Geronimus 1992Graham RainesAndrews amp Mensah 2001 Schulz et al 2000)Thechallenges of accessing appropriate health services may be greater orsimply different in rural and remote communities and solutions recom-mended for African Americans living in the inner city may have limitedvalue for African Canadians living along the south and west shores ofNova Scotia (Atwell amp Atwell Human Resource Consultants 2002)

Another shortcoming of health research with respect to marginalizedpopulations is the fact that many studies are conducted on rather thanwith communities (Acker Barry amp Esseveld 1991 Maguire 1987 Maysamp Pope 2000 Nielsen 1990) In the absence of genuine partnershipsbetween communities and academic researchers the questions posed byinvestigators the instruments designed to answer those questions and theconclusions reached may not be meaningful for the people being studied(Dickson amp Green 2001 Douglas 1998 Richard amp Jagielski 1999Sullivan Kone Senturia amp Chrisman 2001)These factors not only serveto devalue the experiences and expertise of African Canadians but canlead to misunderstanding or misidentification of the problems facingBlack people and to inappropriate solutions Local Black researcherspoint out that health-care providers often do not understand the needsof Black women while academic researchers tend to impose biomedicaldefinitions of health and care ignoring the ways in which Black womenview and manage their own health and that of their families (Crawley1998 Edmonds 2001 Fraser amp Reddick 1997) African Canadiansconstitute one of the largest visible minorities in the country and havelived throughout Nova Scotia for centuriesYet they remain sociallyeconomically and politically disadvantaged and are underrepresented inhealth-care delivery in health research and in the design and implemen-tation of health policyAs a result there is a critical gap in research-basedknowledge with respect to the health issues of Black Nova Scotians

Objectives and Procedure

The On the Margins project was designed to investigate health statushealth-care delivery and health-services utilization among African

Josephine Etowa JulianaWiensWandaThomas Bernard and Barbara Clow

CJNR 2007Vol 39 No 3 58


Canadians residing in rural and remote regions of Nova Scotia from theperspectives of both community members and academic researchers Itsspecific research objectives were to raise awareness of the issues that affectthe health status of African Canadians living in southwest Nova Scotiato establish collaborative research partnerships with Black communitiesand to build the community capacity needed to eliminate barriers tohealth and appropriate health care

The project combined qualitative and quantitative research methodsas well as a participatory action research (PAR) approach to explore theintersecting inequities that compromise the health and health care ofAfrican women in Nova Scotia their families and their communitiesBecause each methodology has specific strengths produces specific kindsof information and creates specific relationships among investigators useof a mixed methodology not only produced much needed insight intothe health of African-Canadian women and their families but alsoallowed for tr iangulation of research methodologies and researchperspectives which enhanced the rigour of the research process and thesignificance and validity of the findings (Kirk amp Miller 1986 Mays ampPope 2000)

The PAR approach combined community action and capacity-buildingThree Community Facilitators were hired for the duration ofthe study Each possessed a high degree of motivation and had close tieswith the community and each was trained in the PAR paradigm Blackpeoplersquos health issues focus group facilitation and interview techniquesready to gather information about the needs and experiences of Blackwomen families and communitiesThe Community Facilitators werealso trained in information technology skills and furnished withcomputer equipment and Internet access so that they could gather anddisseminate health information to members of the Black community

A prototype semi-structured interview was developed by the researchteam but the Community Facilitators were instrumental in refining thisguide and other research instrumentsThe prototype interview containeda qualitative portion as well as a quantitative questionnaire to be com-pleted by the participant at the time of the interview Ethical approval toconduct live research was obtained from the Social Sciences andHumanities Human Research Ethics Board at Dalhousie University priorto the start of the project with continuation of approval grantedfollowing subsequent yearly reviews

The Community Facilitators conducted 12 focus groups withwomen in various Black communities for the purpose of refining theresearch instrumentsThey then carried out 237 in-depth one-on-oneinterviews with Black women throughout the southwestern region ofthe province Snowball sampling was used to recruit participants as the

BlackWomenrsquos Health in Rural and Remote Communities

CJNR 2007Vol 39 No 3 59


Community Facilitators built on their contacts with members of theircommunities Purposive sampling was used to ensure that a multiplicityof perspectives and experiences was captured in the interviews and groupconsultations while snowball sampling served to identify exceptional oratypical perspectives (Kidd amp Parshall 2000Mays amp Pope 2000 Patton1999)The interviews were audiotaped they varied in length from 35minutes to more than 2 hours

Data analysis involved the development of codes and the use ofthematic analysis to categorize codes into themesAtlas-ti data-manage-ment software was used to facilitate this processThe entire research teammet regularly to analyze the data In keeping with the principles of thePAR approachwhich involves the creation of genuine partnerships withcommunity members in order to generate research with rather than aboutcommunities the team ensured that the Community Facilitators wereactively engaged in every aspect of the research process including datacoding and analysis

Rigour in the research process was ensured in a number of waysFirstlymultiple sources of data (triangulation) were used including inter-views and focus groups to obtain a comprehensive account of thewomenrsquos experiences Secondly the participation of the CommunityFacilitators in the data-analysis meetings served as a means for them toreview the researchersrsquo interpretations of the stories confirmed theiranalyses and extended the data analysis In addition eight focus groupswere held with community members who participated in the individualinterviews in order to validate our interpretation of their experiences andto extend the data analysis Guba and Lincoln (1989) describe suchmember ldquochecksrdquo as the best technique for establishing credibilityThirdlywe admitted that as researchers we represented the instrument of datageneration and that our research skills and experience could affect thecredibility of the study (Patton 2002) In response we addressed credi-bility from this perspective through ldquopeer debriefingrdquo Peer debriefingwas evident during the data-analysis meetings at which variousresearchers analyzed codes and themes and provided feedback to theresearch associate who led the data analysisThis process ensured consis-tency in the collective interpretation of the data In addition credibilityand reliability of the study were ensured through an audit trail whichdocumented the details of the research process and the techniques andprocesses of data generation and analysis

Findings

The participants identified numerous issues affecting the health of theirfamilies and communitiesThe researchers identified several themes in


CJNR 2007Vol 39 No 3 60


the data including the multiple roles of Black women perceptions ofhealth experiences with the health-care system factors affecting Blackwomenrsquos health strategies for managing health and envisioning solutionsOne of these themes mdash factors affecting Black womenrsquos health mdash is themain focus of this article In exploring this theme we are able to fulfilone of the main objectives of the study namely to become more awareof issues that affect the health status of Black Nova Scotian women andtheir families Key factors in or determinants of Black womenrsquos healththat emerged during data analysis were racism poverty unemploymentaccess to health services and caregiving roles It is important to note thatthese factors are not mutually exclusive Determinants such as access toemployment and access to health services affect many rural populationsyet for these women racism was a key factor intertwined with all of theother issues For the purpose of this discussion racism serves as the lensthrough which we examine all other determinants None of these deter-minants exist separately in the lived experience and we separate themonly for the purpose of ensuring clarity for the readerThese key deter-minants of Black womenrsquos health are presented below under the headingsof Race and Racism Poverty and Unemployment and Access to HealthCare

Race and Racism

In order to proceed with the main focus of this article it is imperativethat we attempt to clarify the concepts of race and racism and their linkwith health given that race is the main factor distinguishing Blackwomen from their white counterparts and racism is the factor that makesrace salient Race was originally viewed as a biological construct definedby onersquos physical characteristics such as skin colour hair texture and facialfeatures (Thompson amp Neville 1999) In the recent past natural scien-tists acknowledged the limitations of such a notion while social scientistshave moved towards defining race as a social construct (Thompson ampNeville)Although the concept of race applies to phenotypical distinc-tiveness of human beings and one cannot deny the variations in physicalcharacteristics of people around the world the use of these humanbiological characteristics for racial significance is a social and historicalprocessWilliams (1999) states

There is no more genetic variation within our existing racial groups thanbetween themMoreover genetics is not static but changes over time ashuman populations interact with their natural and social environmenthellipOur racial groups importantly capture differences in power status andresources (p 175)


CJNR 2007Vol 39 No 3 61


Winant (2000) defines race as ldquoa concept that signifies and symbolizessociopolitical conflicts and interests in reference to different typesof human bodiesrdquo (p 172) Historically racial categorization has its rootsin racism and the construct of racism may enhance our understandingof racial differences in healthWilliams defines racism as ldquoan ideologyof inferiority that is used to justify unequal treatment (discrimination) ofmembers of groups defined as inferior by both individuals and societalinstitutionsrdquo (p 176) He asserts that this ideology of inferiority can leadto negative attitudes towards and beliefs about racial minorities (prejudice)but he argues that racism lies primarily within organized institutionalstructures and not in individual attitudes or behaviours

How does racism affect health Racism and other forms of socialinequality can affect health in many ways by impacting on economicenvironmental psychosocial and iatrogenic conditions (Krieger 2003)For example racism can limit the socio-economic progress of minoritygroups Racial inequalities are created and reinforced via limited accessby minority groups to educational and employment opportunitiesthrough processes such as segregation (Collins ampWilliams 1999) Racialdifference in socio-economic status is well documented in the literatureand health researchers examining the association between race and healthroutinely adjust for this variable (Williams 1999)Thus socio-economicstatus is considered not only a cofounder of racial differences in healthbut ldquopart of the causal pathways by which race affects healthrdquo (Williams1999 p 177)

Participants in this study spoke about their experiences of racism aswell as the extent to which they perceived racism as a health issueaffecting their families and communities Most of the women indicatedthat racism was a significant problem for Black communities and wenton to describe their experiences of everyday racism mdash the racistcomments and attitudes they had endured throughout their lives aschildren in school as adults in the workplace within their families andin their dealings with health and social services and community organi-zations It was clear to the researchers that the participants found itpainful to share their stories

Many of the women made it clear that racism caused significant stresswhich in turn contributed to other issues and conditions such as lowself-esteem

Anybody will tell you that they battle with their self-esteem every day ButI think particularly as a Black woman when you get ready for the dayand you step outside the door you never know what yoursquore going to faceAnd as you walk the streets with your head high people have certain


CJNR 2007Vol 39 No 3 62


preconceived ideas about who you areAnd some of them are good andsome of them arenrsquotAnd I guess I struggle with that every day

The women also made a connection between racism and physical andemotional health

Women and children theyrsquore the ones [who are] shafted I findWomenare up against a lot of obstacleshellipand all these obstacles that they are upagainst have to do with their mental and physical aspectsAnd as far asBlack people go I find that it is very stressful if you want to become or dosomething in this lifetimehellipthis stress it can cause heart problems it cancause high blood pressure it can cause a lot of thingsAnd migraineheadaches

Participants explored the connection between racism and health inthe context of their experiences with health-care providers Somewomen felt that they were treated differently by health professionalsbecause they were Black in outpatient clinics they had to wait longerthan white women who sometimes were seen right away their doctorsdid not believe them stereotyped them did not present information inan understandable way did not spend an adequate amount of time withthem and would not touch them

When a woman walks into an office and she is complaining about paina doctor tends not to take her seriously or to assume that she is hystericalor there is something mentally wrong rather than saying this is a physicalproblemThat is women in general and Black women especially

A number of women shared specific personal experiences of discrim-ination and mistreatment In a particularly poignant moment onewoman recalled giving birth to her first child at the age of 19

I was having [childrsquos name] at the hospitalhellip My regular doctor couldnrsquotcome so they sent another doctor I wasnrsquot really worried because the nursehad everything down patAnyway the cord was tied around [the babyrsquos]neckhellipSo in pops the doctor who I never seen before I just had the babyand he decides hersquos going to dig inside of me Now that is as blunt asI can put itThe nurse looked at me and she said ldquoIf that was me Iwouldnrsquot let him do thatrdquo He was looking for what they call I guess ableeder or something I didnrsquot know but I got from the nurse that thatwasnrsquot the procedureAnd then he asked me what I named the babyI saidldquoI havenrsquot figured it out yet It may be [name]rdquo He saidldquoWellas long as you donrsquot blame it on merdquoAnd I tried to figure it out I thinkhe figured that I was a single mom and didnrsquot know whose child this was


CJNR 2007Vol 39 No 3 63


When the women believed that they had not received or would notreceive proper medical care because of their race they became reluctantto seek advice from health professionals arguing that there was littlepoint in doing so

Why go to the hospital if Irsquom just going to be discriminated againstTherersquos really no sense hellipIf yoursquore stressed out because you havesomething why go to the hospital and be more stressed because people aregoing to be judging youYou might as well just stay home

Poverty and Unemployment

Race as described in the above section is an antecedent and a determi-nant of socio-economic status and racial differences in socio-economicstatus are to some degree a reflection of discriminatory policies andpractices premised on the inferiority of certain racial groups (Williams1999) In support of this notion Krieger (2003) asserts that ldquohealth isharmed not only by heinous crimes against humanity such as slaverylynching and genocide but also by the grinding economic and socialrealities of what Essed (1991) has aptly termedlsquoeveryday racismrsquordquo (p 195)Furthermore Krieger (1987) argues that the poorer health of the Blackpopulation is the result of white privilege established through manyforms of racial discrimination rather than innate inferiorityThesemany forms of racial discrimination include unemployment and under-employment

In the present study 62 of the sample (n = 237) indicated that theiraverage annual personal income was under $15000 and 28 indicatedthat their average annual household income was under $15000 Inaddition 75 of the sample reported having financial problemsWebegan our data collection with some suspicion that poverty was a majorconcern within Black communities but the incorporation of qualitativemethodology allowed us to examine firsthand accounts of how lack ofaccess to economic resources affects the health and the lives of African-Canadian women living in rural areas

When asked whether there were aspects of their lives that made itmore difficult for them to be healthymany women spoke about povertyWhile some women were reluctant to discuss their actual income othersspoke at length about how their financial concerns affected their overallwell-being

My biggest concern is not being able tohellipafford to eat healthy helliplastpayday when I paid my rent and paid $50 on my phone bill $50 on mylight bill I had $20 left So I donrsquot eat healthy So Irsquoll get french fries orhotdogs or somethingAnd if I do treat myselfhelliponce in a while just to get


CJNR 2007Vol 39 No 3 64


out to stop looking at the four walls I canrsquot really do it I pay for it forweeks and weeks I canrsquot even have a social life

Poverty had a striking impact on the health of these Black womenWorrying constantly about how to pay their bills and provide for them-selves and their families caused significant amounts of stress which asidefrom being a concern in itself can lead to numerous health problemsincluding heart attack and chronic headache (Frey 1999)As indicated inthe examples below poverty also affects the health of Black women invery specific ways In discussing their financial concerns many womenexplained that it was difficult or even impossible for them to affordhealthy foods such as fruits and vegetables especially in the wintertimewhen these foods are more expensive

To eat healthy to do things that are good for your body to keep youhealthy it takes moneyAnd if I followed the Canada Food Guide andate the way that Irsquom supposed to eat Irsquod better go get a couple more jobsbecause this one ainrsquot cutting it I just look at fruit onTV because thatrsquosjust ridiculousAnd this winter itrsquos going to be worse I canrsquot afford to buythose extras If Irsquove got meat and potato on my plate I canrsquot be looking atdessert and appetizers and all the rest that go along with it and this andthat No I canrsquot

Although many of the participants were knowledgeable about healthybehaviours they simply did not have the means to incorporate suchbehaviours into their daily lives

Poverty also acts as a determinant of health by restricting access tohealth services and treatment More than half of the 237 participants57 reported that they did not have enough money for medicationSeveral of the women related instances of failing to seek medicalattention for a health concern only because they could not afford totravel to the nearest health centreOne woman with vision problems saidthat she wore $1 eyeglasses purchased from the drugstore because shecould not pay for prescription glasses Many women indicated that theycould not afford dental care

InterviewerDo you go to the dentistParticipantYou canrsquot afford that woman [giggle] I canrsquot afford no dentistInterviewer So you donrsquot goParticipant No unless itrsquos absolutely necessaryhellip

Interviewer If you had the money to go you would goParticipantWell you know yoursquod goYou could be like everybody elseand have your teeth cleaned


CJNR 2007Vol 39 No 3 65


Very few of the women had access to medical insurance and many ofthose who did have coverage were not reimbursed for all of their medicalexpenses

While for some women poor housing was a sensitive aspect ofpoverty others openly identified poor housing as a major concern inrural Black communities Some participants spoke of being unable toafford the repairs necessary to keep their homes up to standard Othersfaced limited housing choices because of financial constraints

Housing is an issue Many people are living inhelliprundown apartmentshomes that have been amalgamated into 20 apartmentsThey should becondemnedhellipand theyrsquore still rented and the Black people take it becausethey can afford itYou know the doors are thinhellipholes in the walls areterrible the floor hasnrsquot been changed Itrsquos [a] health concern Itrsquos unsani-tary But itrsquos cheap mdash they can afford it

Unemployment is another indicator of health status Due to theremote location of some of the communities concerned and the lack ofaccess to resources very little employment is availableWhile somecommunity members have regular full-time or part-time jobs manyothers are employed only seasonally in fish plants or on lobster boatsUnemployment rates are high and the stress of trying to find workweighed heavily on some of the women

I know that Irsquom never going to get ahead and Irsquom never going to find ajob in this town no matter how hard I try Because whatrsquos the point to gowork at [a fast-food restaurant] you know what I mean Irsquoll only bemaking what Irsquom making right now and thatrsquos nothingAnd then on topof that Irsquom going to have to pay for my own babysitter because welfaredoesnrsquot want to help me pay for a sitter

In talking with some of these women about their lack of employ-ment the intersection of race and poverty became apparent Somewomen shared their experiences of being unable to find work because oftheir skin colour

I went to try at some of the motels there because I had cooking experienceand they advertised for a cook but I was told not to bother going becausethey wouldnrsquot hire me because I was BlackWhen I went in to see thelady just the look on her face told me I wasnrsquot going to be hired

For other women the threat of racism made it very difficult to seekemployment


CJNR 2007Vol 39 No 3 66


Sometimes not having a job that stresses me out because I feel like Irsquomable to work and Irsquom smart and I should be mdash I donrsquot want to be onwelfare but itrsquos not easy to get a job around here Being a Black personand like Irsquom not saying every place is racist but in this town and if yoursquoreBlack and like if therersquos a Black person and a white person theyrsquoll givethe job to the white person and it doesnrsquot matter how many qualities orskills that you could offer it doesnrsquot matter

Women drew upon different explanations to account for their difficultyin finding employment citing access and racism as significant issues

Access to Health Care

Issues relating to access to appropriate health services are prominent in theOn the Margins data Black women living in rural and remote areas face anumber of barriers to health-care access all of which affect their healthstatus Some of these barriers concern the accessibility of the servicesthemselves and are common to most rural communities For example anumber of participants spoke about physician shortages and long line-upsin outpatient clinics Many women reported that they did not have afamily doctor they could see on a regular basis In one community ageneral practitioner who had served the area for years had passed awayapproximately 1 year prior to data collectionAs a result many familieswere left without a doctor and still had not found a new family physicianat the time of the interviewsWhen health issues did arise the womenwere forced to go to the outpatient clinic of a rural hospital and wait forhours to be seenThese barriers prevented many rural Black women fromhaving routine checkups Some women even resigned themselves to goingwithout medical care when they required it

My doctor died so I donrsquot have any doctorThe only doctors that arearound here are the ones that arenrsquot taking any on [or theyrsquore] out in thecountry I donrsquot have any transportation so Irsquom not getting there So wedonrsquot go to outpatients of course because therersquos like a 6-hour wait sittingin there Irsquom sick right now and I canrsquot go see a doctor or anythinghellipmyears have been plugged for 2 weeks and I canrsquot get to see a doctor

As this example demonstrates lack of transportation was also a barrier tohealth-care access Many of the communities do not have public trans-portation and women who did not own a vehicle and could not affordtaxis had great difficulty getting to and from appointments Participantsalso spoke about the inadequacy of rural hospitalsThese hospitals offeronly limited services forcing community members to travel several hoursto the city for specialized testing and even for childbirth


CJNR 2007Vol 39 No 3 67


Lack of information is another barrier to health-care accessWhenthe Community Facilitators spoke with women about services availablein their areas many women were not aware of these resources Forwomen without access to the Internet information on available servicesand on specific health conditions is difficult to access In addition there isa general dearth of information on health issues that affect Black peoplespecifically

I donrsquot think the white doctors know enough about the Black womenrsquosanatomy to be in judgement of us of what our bodies are about hellipIrsquovealways felt that way Irsquove always felt that the doctors out there mdash andtheyrsquove all been white in my books mdash and Irsquove never seen any of themgive me the knowledge of a Black womanrsquos anatomy or how a Blackwomanrsquos body functionsWe have diseases in our system in our Blackhistory that white people donrsquot have So that obviously gives us a differentchemistry level right there hellipthatrsquos one thing I donrsquot think anybody hasenough information on

Some women believed that they would not receive culturally relevantinformation even if they did have access to health services

A related barr ier for Black women living in rural and remotecommunities is the lack of culturally sensitive and appropriate servicesWhile the racist attitudes of health-care providers present an obviousbarrier the lack of diversity among health-care personnel also makes itdifficult for some women to access suitable health-care providers

I would love to see Black doctors I would love to see Black nurseshellipwhen I was in the hospital in [city] and I was going through my cancertreatment there was one Black nurse and there were three white nursesand they were all on [the doctorrsquos] teamAnd the only one that I couldreally relate to or actually have anything in common with was the Blacknurse

Some women reported a fear or mistrust of health professionals ingeneral Others spoke of feeling much more comfortable around BlackprofessionalsThey believed that Black doctors would be able to identifyissues specific to Black people that white doctors might not know aboutwould be better able to understand how Black women feel would knowhow to approach issues with Black people and would be able to identifyissues in the Black community

Discussion

The findings reveal that numerous factors affect the health status of Blackwomen living in rural and remote Nova Scotian communitiesThese


CJNR 2007Vol 39 No 3 68


factors include racism unemployment and poverty and lack of access tohealth careThe many faces of racism have a significant impact onwomenrsquos healthThey include the lack of information specific to thehealth needs of Black people the lack of culturally sensitive health-careproviders in rural and remote communities in the region and the lack ofculturally relevant outreach programs Inappropriate and insensitive caremay also arise from subtler assumptions embedded in the health-caresystem particularly the tendency to embrace the white middle-classmale experience as normative

Racism causes additional stress in the lives of Black women and yearsof accumulated stress due to racism heightens womenrsquos feelings of fatigueWhen their dedication goes unrewarded with job promotion and recog-nition it takes a toll on their health as Black women must continuallystruggle for validation recognition and commendationWorking in anenvironment rife with overt and covert racism and without supportBlack women have little in terms of motivation Several researchers haveargued that the subjective experience of racial discrimination can haveadverse effects on the health of Black people (Evans et al 2005 Karlsenamp Nazroo 2002Williams 1999)Williams points to several Americanstudies that have linked internalized racism to depression distress andchronic physical conditions Socio-economic status is a powerfulindicator of health affecting overall wellness access to health servicesaccess to information and even life expectancy (Hay 1994 Lynch 1996Lynch et al 1997 Pappas et al 1993 Poland et al 1998Williams)Ethnocultural identity along with socio-economic status profoundlyinfluences the quality of care available to Canadians (Courtney 2000)Cultural stereotypes sometimes translate into overt discrimination Forinstance sex-trade workers typically women often find it difficult toaccess services or receive appropriate care when providers assume thatimmoral behaviour is at the root of their ill health (Jackson 2002) Blackpeople are similarly subjected to insensitive or inappropriate care espe-cially when their illnesses are interpreted as the consequence of a predis-position to violence or sexual promiscuity (Blake amp Darling 2000Bolaria amp Bolaria 1994Murrell SmithGill amp Oxley 1996Robb 1998Thomas Bernard 2001 Utsey Ponterotto Reynolds amp Cancelli 2002Van Ryn amp Burke 2000Williams ampWilliams-Morris 2000)

The impact of race racism and poverty has attracted increasingattentionAs with class and gender race and poverty have been stronglycorrelated with poor health (Barbee amp Bauer 1988 Blake amp Darling2000 Bolaria amp Bolaria 1994 Brancati Kao FolsomWatson amp Szklo2000 Dana 2002 Doswell 2000 Fisher CooperWeber amp Liao 1996Graham et al 2001 LeClereRogers amp Peters 1997 Schulz et al 2000Utsey et al 2000) For exampleAfrican Americans experience hyper-


CJNR 2007Vol 39 No 3 69


tension at younger ages than white Americans and are much more proneto dangerous complications such as end-stage renal disease (AmericanHeart Association 2001) Black people living in the United States arealso twice as likely as white Americans to develop adult-onset diabetesand to face serious sequelae of the disease including amputation andblindness (Brancati et al 2000 National Institutes of Health [NIH]1992)Although fewer Black than white women are diagnosed withbreast cancer Black women are more likely to be diagnosed at anadvanced stage and to die from the disease (Miller et al 1996) In thecase of HIVAfrican-American women are approximately three timesmore likely to become infected than African-American men and eighttimes more likely than white Americans (NIH)

Unemployment and poverty cause stress not only because of personaleconomic deprivation but also because of their impact on onersquos identity(Beiser Johnson amp Turner 1993) Unemployment increases the risk ofdepression because work has the function of providing not only anincome but also a purpose to life defining status and identity andenabling individuals to develop and maintain meaningful social relation-ships (Aycan amp Berry 1996 Pernice amp Brooks 1996 PerniceTrlinHenderson amp North 2000)A number of studies have explored the linkbetween unemployment and mental health and have found unemploy-ment to be a predictor of mental disorders (AbbottWongWilliamsAuampYoung 1999 2000 Pernice amp Brooks)There is also evidence of aninverse relationship between social class and premature death people inlower socio-economic classes die earlier than people in higher socio-economic classes (Adler Boyce Chesney Folkman amp Syme 1993Guralnik Land Blazer Fillenbaum amp Branch 1993 Isaacs amp Schroeder2004)

Black women in the region of Nova Scotia chosen for the study facemany of the same health and access challenges that confront anyoneliving in a rural or remote location including lack of hospital serviceslack of transportation and a shortage of doctors and services Howeverthe ability of Black women to achieve and maintain health mdash their ownand that of their loved ones mdash is further compromised by discriminationand a lack of culturally competent care In addition the combination ofracism and poverty limits womenrsquos choices in housing employment andeducation mdash factors that in turn affect their health status Most vulner-able of all are people who experience overlapping disadvantagesincluding poverty and ethnocultural discriminationWomen from visibleminorities routinely experience this double jeopardy and its perniciouseffect on their health (Thomas Bernard 2001)


CJNR 2007Vol 39 No 3 70


Conclusion

Although Black people have lived in these rural and remote NovaScotian communities for centuries they remain socially economicallyand politically marginalized many are unemployed or underemployedand live in poverty most have limited access to appropriate socialeconomic and health services and they are under-represented in health-care delivery in health research and in the design and implementation ofhealth policies Like their urban counterpartsAfrican Nova Scotiansliving in rural and remote regions encounter strong barriers to appro-priate health care but their situation is compounded by their geographiclocation Even when they have the financial and social resources to accesshealth services they are confronted with the challenge of finding cultur-ally competent providers programs and facilities a reasonable distancefrom their homes

While people living in rural areas irrespective of cultural backgroundhave been identified as lacking access to appropriate health care Blackwomen face additional barriers such as racism and lack of culturallycompetent care Most of the participants in this study faced higher riskof marginalization because of their triple-jeopardy situation being Blackbeing poor and living in a rural communityAlthough a few studies haveattempted to explicate the determinants of Black womenrsquos health statusin Canada in general and Nova Scotia in particular this is the first toexamine the issue in the context of rural and remote communities thusadding a unique perspective to the growing body of literature in thisarea

Health disparities along racial lines have multiple root causesincluding racism poverty and differential health-care access which areinterwoven in complex waysThe present findings illuminate someaspects of these complex issues including the ways in which racismimpacts on Black womenrsquos healthAn understanding of these issues isvital to efforts aimed at addressing diversity and social inclusion in todayrsquosculturally diverse societyAlthough studies in other jurisdictions haveidentified the health impact of racism poverty and access to health carethe On the Margins project has uncovered the extent to which thesecomplex issues are interwoven to create health problems in the NovaScotia contextThe project has explicated some of the intersectinginequities that affect and compromise the health and health care of Blackwomen families and communities in the region It is important thatresearchers maintain the goal of forming research partnerships withAfrican-Canadian communities in order to fully explicate their health


CJNR 2007Vol 39 No 3 71


issues and improve the health of this population It is also important thatany future research in this area be undertaken with the recognition thatrace interacts with numerous other variables and experiences to deter-mine the health of Canadian Black women and their families

The analysis presented above also explicates the potential areas offuture research including specific conditions (ie hypertension diabetesheart disease) in order to further identify differences and similarities inthe health of African Americans and African Canadians

References

Abbott MWWong SWilliams MAu M ampYoungW (1999) Chinesemigrantsrsquo mental health and adjustment to life in New Zealand Australianand New Zealand Journal of Psychiatry 33(1) 13ndash21

Abbott MWWong SWilliams MAu M ampYoungW (2000) Chinesemigrantsrsquo mental health and adjustment to life in New Zealand and primaryhealth care utilizationDisability and Rehabilitation 22(12) 43ndash56

Acker J Barry K amp Esseveld J (1991) Objectivity and truth Problems indoing feminist research In MM Fonow amp JACook (Eds)Beyond method-ology Feminist scholarship in lived research (pp 133ndash153) Bloomington IndianaUniversity Press

Aday LA (1993)At risk in AmericaThe health and health care needs of vulnerablepopulations in the United States San Francisco Jossey-Bass

Adler N E BoyceWT Chesney MA Folkman S amp Syme S L (1993)Socio-economic inequalities in health No easy solution Journal of theAmerican Medical Association 269 3140ndash3145

American Heart Association (2001)Heart and stroke statistical update RetrievedMarch 20 2001 from wwwamericanheartorgstatisticsstrokehtml

AtwellY amp Atwell Human Resource Consultants (2002) Finding the wayEstablishing a dialogue with rural African Canadian communities in the PrestonsUnpublished manuscript prepared for Population and Public Health BranchAtlantic Regional Office Health Canada

Aycan Z amp Berry JW (1996) Impact of employment-related experiences onimmigrantsrsquo psychological well-being and adaptation to CanadaCanadianJournal of Behavioral Science 28(3) 240ndash251

Backlund E Sorlie P D amp JohnsonN J (1996)The shape of the relationshipbetween income and mortality in the United States Evidence from theNational Longitudinal Mortality Study Annals of Epidemiology 6 12ndash20

Barbee E L amp Bauer JA (1988)Aging and life experiences of low-incomemiddle-aged African-American and Caucasian womenCanadian Journal ofNursing Research 20(4) 5ndash16

Beiser M Johnson P J ampTurner R J (1993) Unemployment underemploy-ment and depressive affect among Southeast Asia refugees PsychologicalMedicine 23 731ndash743

BlakeW M amp Darling CA (2000) Quality of life Perceptions of AfricanAmericans Journal of Black Studies 30 411ndash427


CJNR 2007Vol 39 No 3 72


BloomG (2001) Equity in health in unequal societiesMeeting health needs incontexts of social changeHealth Policy 57 205ndash224

Bolaria B S amp Bolaria R (Eds) (1994)Racial minorities medicine and healthHalifax Fernwood

Brancati F L Kao L FolsomARWatsonR L amp SzkloM (2000) Incidenttype 2 diabetes mellitus in African American and white adultsThe Athero-sclerosis Risk in Community Study Journal of the American Medical Association283(17) 2253ndash2259

Brown P (1995) Race class and environmental healthA review and systemati-zation of the literatureEnvironmental Research 69 15ndash30

CalvertW J (1997) Protective factors within the family and their role infostering resiliency in African American adolescents Journal of CulturalDiversity 4 110ndash117

Chen J amp Fou F (2002) Unmet needs for health careHealth Reports 13 23ndash34

Collins C ampWilliams D R (1999) Segregation and mortalityThe deadlyeffects of racism Sociology Forum 14(3) 493ndash521

Crawley I (1998) Black womenrsquos health research Policy implications HalifaxMaritime Centre of Excellence forWomenrsquos Health

Dana R H (2002) Mental health services for African Americans Aculturalracial perspectiveCultural Diversity and Ethnic Minority Psychology 83ndash18

DicksonG amp GreenK L (2001) Participatory action research Lessons learnedwith Aboriginal grandmothersHealth Care forWomen International 22 471ndash482

DoswellW M (2000) Promotion of sexual health in the American culturalcontext Implications for school age African American girls Journal of theNational Black Nurses Association 11 51ndash57

Douglas J (1998) Developing appropriate research methodologies with Blackand minority ethnic communities Part IReflections on the research processHealth Education Journal 75 329ndash338

Edmonds S (2001)Racism as a determinant of womenrsquos healthToronto NationalNetwork on Environments andWomenrsquos Health

Enang J E (1999) The childbirth experiences of African Nova Scotian womenUnpublished masterrsquos thesis Dalhousie University Halifax

Enang J E (2002) Black womenrsquos health Health research relevant to BlackNova Scotians In CAmaratunga (Ed)Race ethnicity and womenrsquos health (pp43ndash82) HalifaxAtlantic Centre of Excellence forWomenrsquos Health

Enang J E Edmonds SAmaratunga C amp AtwellY (2001) Black womenrsquoshealthA synthesis of health research relevant to Black Nova Scotians HalifaxHealth Association of African Canadians and Maritime Centre of ExcellenceforWomenrsquos Health

Essed P (1991)Understanding everyday racismAn interdisciplinary theory LondonSage

Evans J Butler L Etowa J Crawley I Rayson D amp Bell D G (2005)Gendered and cultured relations Exploring African Nova Scotiansrsquo percep-


CJNR 2007Vol 39 No 3 73


tions and experiences of breast and prostate cancer Research andTheory forNursing PracticeAn International Journal 19(3) 255ndash271

Fisher S G Cooper RWeber L amp LiaoY (1996) Psychosocial correlates ofchest pain among African-American womenWomen and Health 24(3) 19ndash35

Fraser R amp ReddickT (1997) Building Black womenrsquos capacity on health Finalreport Halifax North End Community Health Centre

Frey R J (1999) Stress In The Gale Encyclopedia of Medicine (Vol 42) DetroitGale

GeronimusAT (1992)The weathering hypothesis and the health of African-American women and infants Evidence and speculations Ethnicity andDisease 2 207ndash221

Graham G J RainesT L Andrews J O amp Mensah GA (2001) Raceethnicity and geography Disparities in heart disease in women of colorJournal ofTranscultural Nursing 12(1) 56ndash67

Guba E amp LincolnY (1989) Fourth generation evaluation Newbury Park CASage

Guralnik J M Land K C Blazer D Fillenbaum C G amp Branch L G(1993) Educational status and life expectancy among older Blacks andwhitesNew England Journal of Medicine 329 110ndash116

HayD I (1994) Social status and health status Does money buy health In B SBolaria amp R Bolaria (Eds) Racial minorities medicine and health (pp 9ndash51)Halifax Fernwood

Isaacs S L amp Schroeder SA (2004) ClassThe ignored determinant of thenationrsquos healthNew England Journal of Medicine 351(11) 1137ndash1142

Jackson L (2002) HIV prevention programmes and female prostitutesTheCanadian context Striking to the heart of the matter In CAmaratunga ampJ Gahagan (Eds) Selected readings on gender and HIV (pp 87ndash104) HalifaxMaritime Centre of Excellence forWomenrsquos Health

Karlsen S amp Nazroo JY (2002)Relation between racial discrimination socialclass and health among ethnic minority groups American Journal of PublicHealth 92(4) 624ndash631

Kidd P S amp ParshallM B (2000) Getting the focus and the group Enhancinganalytical rigor in focus group researchQualitative Health Research 10 293ndash308

Kirk J amp Miller M L (1986) Reliability and validity in qualitative researchLondon Sage

Krieger N (1987) Shades of differenceTheoretical underpinnings of themedical controversy on Black-white differences 1830ndash1870 InternationalJournal of Health Service 17 258ndash279

KriegerN (2003) Does racism harm health Did child abuse exist before 1962On explicit questions critical science and current controversiesAn ecosocialperspectiveAmerican Journal of Public Health 93(2) 194ndash199

Lawrence D (2000)Culturally Diverse Community Capacity Project Final reportDigbyNS Digby County Family Resource Centre

LeClere F B Rogers R G amp Peters K D (1997) Ethnicity and mortality inthe United States Individual and community correlates Social Forces 76


CJNR 2007Vol 39 No 3 74


169ndash198Lynch JW (1996) Social position and healthAnnals of Epidemiology 6 21ndash23Lynch JW Kaplan GA amp Shema S J (1997) Cumulative impact of sustained

economic hardship on physical cognitive psychological and social func-tioning New England Journal of Medicine 337 1889ndash1995

Maguire P (1987)Doing participatory researchA feminist approachAmherst MACenter for International Education

Mays N amp Pope C (2000)Assessing quality in qualitative research BritishMedical Journal 320 50ndash52

Miller BA Kolonel LN Bernstein LYoung J L SwansonDMWest Det al (1996) Racialethnic patterns of cancer in the United States 1988ndash1992NIH Publication 96-4104 BethesdaMDNational Cancer Institute

Murrell N L Smith R Gill G amp Oxley G (1996) Racism and health careaccess A dialogue with childbearing women Health Care for WomenInternational 17 149ndash159

National Institutes of Health (1992)Diabetes in Black America Bethesda MDNational Institute of Diabetes and Digestive and Kidney Diseases

Nielsen J M (1990) Feminist research methods Exemplary readings in the socialsciences BoulderWestview

Pappas G Queen S HaddenW amp Fisher G (1993)The increasing disparityin mortality between socioeconomic groups in the United States 1960 and1986New England Journal of Medicine 329 103ndash109

PattonMQ (1999) Enhancing the quality and credibility of qualitative analysisHealth Services Research 34 1189ndash1208

PattonMQ (2002)Qualitative research and evaluation (3rd ed)Thousand OaksCA Sage

Pernice R amp Brooks J (1996) Refugeesrsquo and immigrantsrsquo mental healthAssociation of demographic and post-migration factors Journal of SocialPsychology 136(4) 511ndash519

Pernice RTrlinA HendersonA amp North N (2000) Employment andmental health of three groups of immigrant to New ZealandNew ZealandJournal of Psychology 29(1) 24ndash29

Poland B Coburn D RobertsonA amp Eakin J (1998)Wealth equity andhealth careA critique of a ldquopopulation healthrdquo perspective on the determi-nants of health Social Science and Medicine 46 785ndash798

Richard J amp JagielskiM (1999) Hearing the voices of the ethnic communityin health and health careA community perspectiveHealth and Cultures14(1) 6ndash9

Robb N (1998) Racism can rear its ugly head at medical school study findsCanadian Medical Association Journal 159(1) 66ndash67

RogersA C (1997)Vulnerability health and health care Journal of AdvancedNursing 26 65ndash72

SchulzA Israel BWilliamsD Parker E BeckerA amp James S (2000) Socialinequalities stressors and self-reported health status among African Americanand white women in the Detroit Metropolitan Area Social Science andMedicine 51(11) 1639ndash1653


CJNR 2007Vol 39 No 3 75


Sharif J R DarAA amp Amaratunga C (2000) Ethnicity income and access tohealth care in the Atlantic regionA synthesis of literature Halifax MaritimeCentre of Excellence forWomenrsquos Health

SullivanM KoneA Senturia KD amp ChrismanN J (2001)Researcher andresearched mdash Community perspectivesToward bridging the gapHealthEducation and Behaviour 28 130ndash149

Thomas BernardW (2001) Including Black women in health and social policy devel-opmentWinning over addictions empowering Black mothers with addictions toovercome triple jeopardyHalifax Maritime Centre of Excellence forWomenrsquosHealth

Thompson C E amp Neville HA (1999) Racism mental health and mentalhealth practiceCounselling Psychologist 27(2) 155ndash223

Utsey S O Ponterotto J G ReynoldsA L amp CancelliAA (2000) Racialdiscrimination coping life satisfaction and self-esteem among AfricanAmericans Journal of Counseling and Development 78(1) 72ndash80

Van RynM amp Burke J (2000)The effect of patient race and socio-economicstatus on physiciansrsquo perceptions of patients Social Science and Medicine 50(6)813ndash828

WilliamsDR (1999)Race socioeconomic status and healthThe added effectsof racism and discriminationAnnals of the NewYork Academy of Sciences 896173ndash188

Williams D R ampWilliams-Morris R (2000) Racism and mental healthTheAfrican American experienceEthnicity and Health 5(34) 243ndash268

Winant H (2000) Race and race theory Annual Review of Sociology 26 169ndash185

Authorsrsquo Note

This project was funded by the Canadian Institutes of Health Researchand by Human Resources and Development Canada

We would like to acknowledge the work of the CommunityFacilitators of the On the Margins project Louise Delisle Gail Jarvis andKaren Johnson

Comments or queries may be directed to Josephine Etowa School ofNursing Dalhousie University Halifax Nova Scotia B3H 3J5 CanadaTelephone 902-494-6534 E-mail JosephineEtowadalca

Josephine Etowa PhD RN is Associate Professor School of Nursing DalhousieUniversity Halifax Nova Scotia Canada JulianaWiens MA is ResearchAssociate Dalhousie UniversityWandaThomas Bernard PhDRSW is Professorand Director School of SocialWork Dalhousie University Barbara Clow PhDis DirectorAtlantic Centre of Excellence forWomenrsquos Health Faculty of HealthProfessions Dalhousie University


CJNR 2007Vol 39 No 3 76


Determinants ofBlackWomenrsquos Health in

Rural and Remote Communities

Josephine Etowa JulianaWiensWanda Thomas Bernard and Barbara Clow

The On the Margins project investigated health status health-care delivery anduse of health services among African-Canadian women residing in rural andremote regions of the province of Nova ScotiaA participatory action researchapproach provided a framework for the studyTriangulation of data-collectionmethods mdash interviews focus groups and questionnaires mdash formed the basis ofdata generationA total of 237 in-depth one-on-one interviews were conductedand coded verbatim Atlas-ti data-management software was used to facilitatecoding and analysis Six themes emerged from the data Black womenrsquos multipleroles perceptions of health experiences with the health-care system factorsaffecting health strategies for managing health and envisioning solutionsTheauthors focus on 1 of these themes factors affecting Black womenrsquos health anddiscuss 3 subthemes race and racism poverty and unemployment and access tohealth care

Keywords Black women health determinants racism rural communities

Background

Discrepancies in health are intimately associated with differences in socialeconomic cultural and political circumstances (Aday 1993 BacklundSorlie amp Johnson 1996 Bloom 2001 Brown 1995 Chen amp Fou 2002Rogers 1997) Economic inequities in particular have been implicatedin poor health Individuals of lower socio-economic status are at a muchgreater risk of illness and are much less likely to have timely access tohealth and social services than individuals of higher socio-economicstatus (Hay 1994 Lynch 1996 Lynch Kaplan amp Shema 1997 PappasQueen Hadden amp Fisher 1993 Poland Coburn Robertson amp Eakin1998)Yet while researchers have amply demonstrated the effects of suchdeterminants on the health of people in Black communities the vastmajority of health research on Black women men and children origi-nates in the United States and only a small number of needs assessmentsand student theses focus on the health of African Canadians living inthe province of Nova Scotia (Atwell amp Atwell Human ResourceConsultants 2002 Enang 1999 Enang EdmondsAmaratunga amp Atwell


copyMcGill University School of Nursing 57








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Findings



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Race and Racism




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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Findings



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Race and Racism




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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Findings



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Race and Racism




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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Findings



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Race and Racism




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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Race and Racism




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07-Etowa et al1 91407 1116 AM 1







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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Discussion



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07-Etowa et al1 91407 1116 AM 0

Conclusion





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References














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Authorsrsquo Note






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Discussion



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Conclusion





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References














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Authorsrsquo Note






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Discussion



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CJNR 2007Vol 39 No 3 70


Conclusion





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References














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Authorsrsquo Note






CJNR 2007Vol 39 No 3 76










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Discussion



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CJNR 2007Vol 39 No 3 69






CJNR 2007Vol 39 No 3 70


Conclusion





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References














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Authorsrsquo Note






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CJNR 2007Vol 39 No 3 66









CJNR 2007Vol 39 No 3 67








Discussion



CJNR 2007Vol 39 No 3 68






CJNR 2007Vol 39 No 3 69






CJNR 2007Vol 39 No 3 70


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















CJNR 2007Vol 39 No 3 75











Authorsrsquo Note






CJNR 2007Vol 39 No 3 76









CJNR 2007Vol 39 No 3 67








Discussion



CJNR 2007Vol 39 No 3 68






CJNR 2007Vol 39 No 3 69






CJNR 2007Vol 39 No 3 70


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















CJNR 2007Vol 39 No 3 75











Authorsrsquo Note






CJNR 2007Vol 39 No 3 76








Discussion



CJNR 2007Vol 39 No 3 68






CJNR 2007Vol 39 No 3 69






CJNR 2007Vol 39 No 3 70


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















CJNR 2007Vol 39 No 3 75











Authorsrsquo Note






CJNR 2007Vol 39 No 3 76






CJNR 2007Vol 39 No 3 69






CJNR 2007Vol 39 No 3 70


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















CJNR 2007Vol 39 No 3 75











Authorsrsquo Note






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CJNR 2007Vol 39 No 3 70


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















CJNR 2007Vol 39 No 3 75











Authorsrsquo Note






CJNR 2007Vol 39 No 3 76


Conclusion





CJNR 2007Vol 39 No 3 71




References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















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Authorsrsquo Note






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References














CJNR 2007Vol 39 No 3 72





















CJNR 2007Vol 39 No 3 73





















CJNR 2007Vol 39 No 3 74





















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Authorsrsquo Note






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CJNR 2007Vol 39 No 3 73





















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CJNR 2007Vol 39 No 3 74





















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Authorsrsquo Note






CJNR 2007Vol 39 No 3 76


Home - Health Association of African Canadians

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Transcript of Home - Health Association of African Canadians