A QUANTITATIVE ANALYSIS OF THE SYNERGY AMONG SELF-REPORTED FAITH

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A QUANTITATIVE ANALYSIS OF THE SYNERGY AMONG SELF-REPORTED FAITH, HEALTH AND HEALTH CARE PRACTICES OF BLACK BAPTISTS: A CULTURECOLOGY PERSPECTIVE by Crystal LaVonne Warren B.S., Case Western Reserve University, 1993 M.S., Central Michigan University, 1997 Submitted to the Graduate Faculty of Behavioral and Community Health Sciences Graduate School of Public Health in partial fulfillment of the requirements for the degree of Doctor of Public Health University of Pittsburgh 2006 UNIVERSITY OF PITTSBURGH Graduate School of Public Health This dissertation was presented by Crystal LaVonne Warren It was defended on December 4, 2006 and approved by Dissertation Advisor: Stephen Thomas, Ph.D. Professor Behavioral and Community Health Sciences Graduate School of Public Health University of Pittsburgh Edmund Ricci, Ph.D. Professor Behavioral and Community Health Sciences Graduate School of Public Health University of Pittsburgh Wesley Rohrer, Ph.D.

Assistant Professor Health Policy and Management Graduate School of Public Health University of Pittsburgh James Butler, Dr.P.H. Assistant Professor Behavioral and Community Health Sciences Graduate School of Public Health University of Pittsburgh Rueben Warren, D.D.S., Dr.P.H. Associate Director Institute for Faith-Health Leadership The Interdenominational Theological Center Atlanta, Georgia ii Copyright © by Crystal L.

Warren 2006 iii Stephen B. Thomas, Ph.D. A QUANTITATIVE ANALYSIS OF THE SYNERGY AMONG ... more. less.

SELF-REPORTED FAITH, HEALTH AND HEALTH CARE PRACTICES OF BLACK BAPTISTS: A CULTURECOLOGY PERSPECTIVE Crystal LaVonne Warren, Dr.P.H. University of Pittsburgh, 2006 Abstract In the Black community, faith, spirituality and religion appear to influence health and health care decisionmaking. Therefore, the purpose of this research was to investigate the synergy between faith, health and health care practices of Black Baptists using a Model of Authentic Culturecology as the conceptual framework. The public health importance of this study relates to expanding the understanding of factors that influence health and health care decisionmaking. The study objectives are related to communication between pastor and congregants about health and health care issues, prayer and rating of general health status, and belief in God/Jesus as a healer and health care utilization behaviors. A secondary analysis was conducted using a cross-sectional dataset of 1,327 African American men and women who attended the first Joint Black National Baptist Convention held in Nashville, Tennessee from January 24-28, 2005. A series of regression analyses were completed to determine the relationships regarding pastor- congregant communication, and faith and religious influences on health and health care decisionmaking. iv Having been told that you have hypertension or asthma was a significant predictor for talking to a pastor when sick. Males and females differed significantly in talking to their pastor about personal health issues. Men communicated more often than women. Eating vegetables daily was a significant predictor for communicating with a pastor about physician interactions. Participants who pray before and/or after making a medical decision were more likely to report their health status as excellent or good. Additionally, the belief that God/Jesus is a healer was a significant predictor for the last visit to a physician when the respondent 9s sex was considered. It appears that faith positively influenced the respondents 9 perception of health and health care decisionmaking, and their relationship with their pastors is an important factor. More research is needed for further clarification of these synergistic interactions. v TABLE OF CONTENTS PREFACE&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&. X 1.0 INTRODUCTION....................................................................................................... 1 1.1 HYPOTHESES.................................................................................................... 2 1.2 RESEARCH QUESTIONS................................................................................. 3 1.3 DEFINITION OF TERMS ................................................................................. 4 1.4 FOCUS AND SCOPE OF MANUSCRIPT....................................................... 6 2.0 CONCEPTUAL FRAMEWORK.............................................................................. 7 2.1 HEALTH BEHAVIOR AND HEALTH EDUCATION THEORIES............ 7 2.2 DIMENSIONS OF CULTURAL FRAMING................................................. 13 2.3 PRIMARY ASSUMPTIONS OF THE MODEL............................................ 17 2.4 PRINCIPLES OF THE MODEL..................................................................... 20 2.5 METHODOLOGY OF THE MODEL............................................................ 21 2.6 BASIC PROCEDURAL STEPS FOR THE FRAMEWORK....................... 21 2.7 CONCLUSIONS ABOUT THE FRAMEWORK........................................... 23 3.0 REVIEW OF THE LITERATURE ........................................................................ 24 3.1 FAITH, SPRITUALITY AND RELIGION.................................................... 25 3.2 POLYTHEISTIC AND MONOTHEISTIC RELIGIONS ........................... 27 3.3 HEALTH AND HEALTH CARE IN THE U.S.............................................. 31 vi 3.4 HEALTH AND HEALTH CARE DISPARITIES IN THE U.S. .................. 35 3.5 CHARACTERISTICS OF AFRICAN/AFRICAN AMERICAN FAITH.... 43 3.6 CHARACTERISTICS OF BAPTISTS............................................................ 44 3.7 CHARACTERISTICS OF BLACK BAPTISTS............................................ 50 3.8 FAITH-BASED HEALTH INTERVENTIONS............................................. 55 4.0 METHODOLOGY ................................................................................................... 57 4.1 SAMPLE POPULATION................................................................................. 57 4.2 DESCRIPTION OF THE INSTRUMENT ..................................................... 59 4.3 VARIABLES...................................................................................................... 60 4.4 DATA COLLECTION...................................................................................... 62 4.5 DATA ANALYSIS............................................................................................. 63 4.6 LIMITATIONS OF THE STUDY................................................................... 64 5.0 RESULTS.................................................................................................................. 6 5 5.1 RESEARCH QUESTION ONE....................................................................... 67 5.2 RESEARCH QUESTION TWO...................................................................... 69 5.3 RESEARCH QUESTION THREE.................................................................. 72 5.4 RESEARCH QUESTION FOUR&&&&&&&&&&&&&&&&&. 75 5.5 RESEARCH QUESTION FIVE ...................................................................... 77 6.0 DISCUSSION............................................................................................................ 80 7.0 CONCLUSIONS....................................................................................................... 86 APPENDIX A. OFFICIAL PROGRAM................................................................................. 89 BIBLIOGRAPHY................................................................................................................... .... 97 vii LIST OF TABLES Table 1. Study variables and their corresponding survey questions&&&&&&&&&&&..61 Table 2 . Demographics of survey respondents&&&&&&&&&&&&&&&&&&&..66 Table 3. Factors influencing communication with pastor when sick and personal health conditions&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&...68 Table 4. Frequency distributions for risk behavior variables&&&&&&&&&&&&&&70 Table 5. Factors influencing communication with pastor about personal health conditions&&72 Table 6. Significant differences in the sex of participants and communication with pastor about personal health issues&&&&&&&&&&&&&&&&&&&&&&&&&&&&&73 Table 7. Chi square on frequency of response by gender&&...&&&&&&&&&&&&..74 Table 8. Factors influencing rating of general health status&&...&&&&&&&&&&&..76 Table 9. Frequency distributions for prayer and making a medical decision&&...&&&&&76 Table 10. Factors influencing last visit to a medical doctor&&&&&&&&&&&&&&.78 Table 11. Frequency distributions for last visit a medical doctor&&&&&&&&&&&&79 viii LIST OF FIGURES Figure 1. An alternative view of public health as the health of relationships....&&&&.&&.14 ix PREFACE It is ironic that my research about the influence of faith on health and health care practices of Black Baptists would result in a true test of my faith in myself and others. I asked the Lord to lead my path toward His will; He has and continues to do so. I thank God for His eternal love and grace. This doctoral process was a complex journey, one that I would not have accomplished without others 9 encouragement, guidance, love and/or support 4emotional, spiritual, and financial. To my Committee Members, Dr. Warren, Dr. Thomas, Dr. Ricci, Dr. Rohrer and Dr. Butler, thank you for investing your time and energy in helping me. Dr. Rueben Warren, thank you for taking a chance with me and helping me beat tremendous odds to complete my dissertation and earned my doctorate. You became my navigator when I lost my compass&guiding me down complicated paths and nudging me over massive hurdles. Your gift of mentoring will never be forgotten!!! Dr. Thomas, thank you for being the Dissertation Chair I needed to move me from the rank of ABD to become Dr. Crystal Warren. To Dr. Alema- Mensah, you will forever be my honorary Committee Member. Thank you for helping me decipher the cworld of statistics d. To my parents, your love and support have been immeasurable. To my mother, you have been there for me from the beginning before earning my Doctor of Public Health degree was even a dream 4mine or yours. Thank you for editing the final version of this dissertation. I love you and thank you for believing in me. To my father, thank you for helping me to see the bright side of the darkest situations. You provided the parental support I needed to get me through a very difficult last year of this process. I thank you for always lifting my spirit, I love you. x To my husband, you have endured my moods, complaints and frustrations. Thank you for reading and editing every page of this dissertation. You supported my relentless pursuit of my doctorate, even though it appeared to be an endless process. Thank you for your love and devotion. I love you. To the entire Faith in the City/Institute for Faith-Health Leadership staff at The ITC, thank you all for your support. Rev. Lockett, thank you for providing expert knowledge on the meaning of faith from a theological perspective; it was a critical part of my research. Dr. King, thank you for helping me to understand your Model and for allowing me to use it as the conceptual framework for my research. Dr. Carter, thank you for introducing me to Dr. Rueben Warren. Crystal L. Warren December 2006 xi 1.0 INTRODUCTION The 1985 Report of the Secretary 9s Task Force on Black and Minority Health brought national attention to the fact that 60,000 excess deaths occurred annually because of health disparities among African Americans, compared to non-Hispanic Whites. The term cexcess deaths d expresses the difference between the number of deaths actually observed in a minority group and the number of deaths that would have occurred in that group if they experienced the same death rates for each age and sex in the non-Hispanic White population (DHHS, 1985). Eighty percent (80%) of the excess deaths occurred from six causes 3 heart disease and stroke, cancer, diabetes, cirrhosis, homicide and unintentional injuries, and infant mortality (DHHS, 1985). By 1991, Acquired Immune Deficiency Syndrome (AIDS) was added as the seventh excess death (DHHS, 1985). According to a recent study by Satcher et al. using 2002 data, the black-white mortality gap has increased to more than 83,000 excess deaths. This persistence of health inequalities in the United States has lead to additional research suggesting a need for behavioral and social scientists and others to explore the risk factors that predispose African Americans to disproportionately high mortality rates, morbidity risk factors, and other adverse health conditions. 1 In the Black community, faith, spirituality and religion play an important role in daily living for many people. It is reasonable to suspect that these metaphysical factors may positively influence health and health care decisions for African Americans. Furthermore, research in minority health, suggests linkages between African Americans 9 perceptions on faith, spirituality, and religion, with health and health care (Dessio et al, 2004; Felix et al., 2003; Musgrave, Allen & Allen, 2002; Steffen et al, 2001; Strawbridge et al., 1997, vanOlphen et al., 2003). The purpose of this research is to investigate the synergy between faith, health, and health care practices among African American Congregants attending the Joint National Black Baptist Conference, which took place from January 24-28, 2005 in the Gaylord Opryland Hotel located in Nashville, Tennessee. The public health implications of this study are broad and purport to explore a new research paradigm to improve African American health and health care and hopefully, eliminate the growing health disparity problem. The research will allow for a better understanding of health care patterns of decision-making, health financing, and health outcomes. The overall goal is to develop culturally appropriate strategies to improve the health, health care and the overall well-being of African Americans. 1.1 HYPOTHESES The following five hypotheses were developed for this study: Hypothesis 1: African American male and female participants who have been told by a doctor that they have a chronic health conditions (i.e. hypertension, diabetes, asthma, and/or cancer) are more likely to talk to their pastor when they are sick compared to when they are not. Hypothesis 2: African American male and female participants who communicate with their pastors about personal health issues are more likely to engage in a healthy lifestyle. 2 Hypothesis 3: African American female participants are more likely to communicate with their pastors about personal health issues compared to African American male participants. Hypothesis 4: African American female participants who pray before or after making a medical decision are more likely to rate their general health status as excellent or good. Hypothesis 5: African American female participants who believe that God and/or Jesus is a healer are likely to visit their medical doctor more often than African American male participants who also have the same belief. 1.2 RESEARCH QUESTIONS The following five research questions were investigated in this study: 1. To what extent is there a relationship between personal health conditions of African American male and female participants and their communication with their pastor when they are sick? 2. What is the relationship between risk behaviors (exercising, eating, smoking & drinking) of African American Baptist men and women, and communication with a pastor about personal health issues? 3. To what extent are there sex differences between African American men and women in communication with pastors about personal health issues? 4. To what extent is there a difference between African American male and female participants who pray before or after making a medical decision and their rating of general health status? 3 5. To what extent is there a difference between African American male and female participants who believe that God and/or Jesus is a healer and the last time they visited a medical doctor? 1.3 DEFINITION OF TERMS Convention is the organizational unit by which Baptist churches are commonly grouped for purposes of fellowship, to carry on educational and missionary work, and to administer pension plans (Mead & Hill, 2001). Faith is not always religious in its content and context (Fowler, 1981). c&the concept of faith does not require religion d (Warren, Lockett & Zulfiqar, 2002, p. 131). It is a person 9s or groups 9 way of moving into the force field of life (Fowler, 1981). Faith is a way of finding coherence in and giving meaning to the multiple forces and relations that make up people 9s lives. It is a way of seeing one 9s self in relation to others against a background of shared meaning and purpose. The root verb for faith may be translated cto believe, to commit, or to trust d (Hobbs, 1964, p.96). Faith is the most fundamental category in the human quest for relation to transcendence (the existence above and beyond the limits of material experience). (Fowler, 1981) It is a universal feature of human living, recognizably similar everywhere despite the remarkable variety of forms and contents of religious practice and belief. (Fowler, 1981) Faith can also be viewed as a state of being ultimately concerned (Tillich, 1957). That ultimate concern may center in our own ego or its extensions 4work, prestige and recognition, power and influence, and wealth. One 9s ultimate concern may be invested in family, university, nation, or church. 4 Spirituality refers to a basic or inherent quality in all humans that involves a belief in something greater than the self and a faith that positively affirms life (Musgrave et al., 2002). Religion is: (1) a system of symbols which acts to (2) establish powerful, pervasive, and long- lasting moods and motivations in men [and women] by (3) formulating conceptions of a general order of existence and (4) clothing these conceptions with such an aura of factuality that (5) the moods and motivations seem uniquely realistic (Geertz, 1966). Health may be described as a relationship, a synergistic interplay between the physical, social, psychological, and spiritual elements that create the well-being of individuals and/or groups in their physical and social environment (Warren, 1999). Disease can be described, from a biomedical perspective, as an impairment of the normal state of the living animal or plant body or any of its components that interrupts or modifies the performance of the vital functions. It is a response to environmental factors (e.g., climate, malnutrition, industrial hazards), to specific infective agents (e.g., viruses, bacteria, worms), or to a combination of these factors (Pilch, 2000). Illness is the social and personal perception of socially disvalued states including but not necessarily restricted to what modern Western science would identify as disease (Pilch, 2000). Sickness is the misfortune or irregularity in well-being that people recognize. It can be viewed from two perspectives and described by one of two explanatory concepts: disease and illness (Pilch, 2000). 5 1.4 FOCUS AND SCOPE OF MANUSCRIPT This manuscript focuses on how faith provides a critical context for improving the health of African Americans. Specifically, it examines the concept of faith and its influence and interactions in relation to the health and healthcare practices of one group of African Americans. This paper aims to: (1) discuss faith and its similarities and differences from spirituality and religion; (2) review major morbidity and mortality trends among African Americans and the social and behavioral implications; (3) examine health and health care disparities and their social and behavioral implications; and (4) describe the synergy between faith, health, and health care. 6 2.0 CONCEPTUAL FRAMEWORK The conceptual framework for this research is based on the Authentic Culturecology Model developed by Lewis M. King, Ph.D. Dr. King is the Executive Director of the Fanon Research Center, and Professor of Human Development at Drew/UCLA Medical School in Los Angeles, California. The Authentic Culturecology Model is the organized framework used to capture the cultural framing of people of color in relation to health. Culture framing is the idea that the individual 9s health is a relational event that can be best understood as a situationally bound unit of relationships (organic, psychological, family, social, political, and spiritual) in which culture is the unifying unit (King, 2002). A culturally framed event, is then defined in terms of its own reality, system of values and ways of knowing (King and Davis, 1999). Culture is defined as the customs, beliefs, values, knowledge, and skills that guide a people 9s behavior along shared paths (Linton, 1947). Operationally, culture includes the shared values, norms, traditions, customs, arts, history, folklore, and institutions of a group of people (Orlandi, 2000). Culture is foundational in influencing health behavior and learning theories related to health education. 2.1 HEALTH BEHAVIOR AND HEALTH EDUCATION THEORIES Health behavior change is a dominant theme in public health approaches (King, 2002). The body of research in health behavior and health education is recognized increasingly as a way to meet public health objectives and improve the success of public health and medical interventions (Glanz, Lewis, & Rimer, 1997). Theories of health behavior identify the targets for change and the methods for accomplishing these changes (Glanz, Lewis, & Rimer, 1997). Great 7 emphasis is placed on lifestyle changes (King, 2002). However, little has been accomplished in changing the lifestyles of underserved populations particularly when many of the needed health changes are perceived to be beyond their locus of control. Illness prevention studies have relied heavily on models of behavior change (King, 2002). Unfortunately, health outcomes related to these models have been disappointing. For example, the Transtheoretical or cStages of Change d Model (Prochaska & DiClemente, 1983) focuses on cognitive behavior by using stages of changes to integrate processes and principles of change from across major theories of intervention. The Transtheoretical Model considers behavioral change as a process involving progress through a series of five stages 3 Precontemplation, Contemplation, Preparation, Action, Maintenance, and Termination. According to cognitive behavioral theory, change progresses as the individual moves from the precontemplation stage (has no intention to take action within the next six months), to the contemplation stage (intends to take action within the next six months), followed by a preparation stage (intends to take action within the next 30 days and has taken some behavioral steps in this direction), then to the action stage (has changed overt behavior for less than six months), and finally, to the maintenance stage (has changed overt behavior for more than six months). The Health Belief Model (Becker, 1974) has been one of the most widely used conceptual frameworks in health behavior. The Health Belief Model proposes that individuals are most likely to take preventive action when they perceive themselves as susceptible to an adverse health condition. The Health Belief Model asserts that individuals believe that poor health outcome would be more severe for them, and see more benefits to make the change than barriers to making the change. The key concepts and definitions of the health belief model 8 include perceived susceptibility (one 9s opinion of chances of getting a condition), perceived severity (one 9s opinion of how serious a condition and its sequelae are), perceived benefits (one 9s opinion of the efficacy of the advised action to reduce risk or seriousness of impact), perceived barriers (one 9s opinion of the tangible and psychological costs of the advised action), cues to action (strategies to activate one 9s creadiness d), and self-efficacy (one 9s confidence in one 9s ability to take action) (Strecher & Rosenstock, 2002). Social Learning Theory (Bandura, 1977) proposes that a person is more likely to take action in a particular way if they know that that action will result in a desirable outcome. The constructs of the Social Learning Theory include the environment, behavioral capability (knowledge and skill to perform a given behavior), expectancies (the values that the person places on a given outcome, incentives), self-control (personal regulation of goal-directed behavior of performance), observational learning (behavioral acquisition that occurs by watching the actions and outcomes of others 9 behavior), reinforcement (response to a person 9s behavior that increase or decrease the likelihood of reoccurrence), self-efficacy (the person 9s confidence in performing a particular behavior), and reciprocal determinism (the dynamic interaction of the person, the behavior, and the environment in which the behavior is performed) (Baranowski, Perry, & Parcel, 2002). The Theory of Reasoned Action (Fishbein & Ajzen, 1975) asserts that the most important determinant of behavior is a person 9s behavioral intention. The direct determinants of individual 9s behavioral intention are his attitude toward performing the behavior and his subjective norm associated with the behavior. Attitude is determined by the individual 9s beliefs about the outcomes or attributes of performing the behavior, weighted by evaluations of those outcomes will result from performing a behavior will have a positive attitude toward that 9 behavior. (Montano, Kasprzyk, & Taplin, 2002). It describes the process and conditions under which health or other behaviors are acquired and modified, focusing on the importance of an individual 9s attitude toward performing an action, as well as the individual 9s perceptions of how a significant other feels about his or her performing that action (King, 2002). King asserts that these preventive approaches are narrowly focused on individual behavior change, but despite this narrow focus, they should not be negated. He continues by emphasizing that these models are excellent exemplars of a culturally consistent cEurocentric d public health approach, but unfortunately, they are applied to public health practice as cuniversal d models. King proposes that these models, which rely quite heavily on cognition or efficacy, underestimate the value and influence of culture. For example, in a study by Barroso et al. (2000), the Health Belief Model was used as a framework for a comparison study between African American women and non-Hispanic White women on their beliefs about breast cancer and their health locus of control. These researchers noted that there was no relation between health beliefs and years of education among African American women, and that cultural influences are more important than years of education. Additionally, Weinrich et al. (1998) used the Health Belief Model as a framework and found that the most significant factor influencing African American male participation in prostate education program was the presence of a previous church member with prostate cancer. In fact, these researchers noted that having heard about prostate cancer and having had previous screening was not a significant predictor of African American men 9s participation in prostate screening. 10 The line of approach, investigating predicators of behavior change among urban minorities, dominated by personal influence paradigms, has necessarily not produced desired public health results for African Americans (Altpeter et al., 1998). Attributing behavior change problems exclusively to the individual not only has biased providers against the poor and urban multi-cultural populations, but also unwittingly has limited providers 9 willingness to make needed changes in health care services (Weinstein et al., 1998). The Social Ecology Model (Bronfonbrenner, 1979) involves intervention at the intrapersonal and interpersonal levels. The interpersonal level includes formal and informal social networks and social support systems, including family, workgroup, and friendship networks. The intrapersonal level involves the individual 9s personal attributes including knowledge, attitude, beliefs, experiences and values. Ecology describes the interrelation between organisms and their environment. Social Ecology refers to the social, institutional, and cultural contexts of people. Existing ecological models are general statements that multiple levels of environmental variables exert widespread influence on a variety of outcomes related to human health and welfare. The existing models argue that multiple levels of variables are believed to be important, describe some of the principles of environmental influence, and indicate behaviors or outcomes likely to be influenced by environments. According to Sallis and Owen (1997), three core assumptions of the Social Ecology Model are: 1. Multiple dimensions of influence on behaviors. Ecological models specify that intrapersonal factors, social and cultural environments, and physical environments can influence health behaviors. 11 2. Multiple levels of environmental influences . Ecological models specify multiple levels of environmental factors that directly influence behavior. The unique contribution of ecological models is the identification of physical environment factors. The healthfulness of a situation and the well-being of individuals are influenced by multiple facets of the physical and social environments. 3. Environments directly influence behaviors . Human environments are multidimensional and complex - Physical versus Social; Objective versus Subjective; and Proximal versus Distal. Ecological models include the proposition that environmental factors from intrapersonal theories, which sometimes hypothesize that selected environmental influences are mediated through psychological processes. An example of an ecological hypothesis is that factors in intrapersonal, social and cultural, and physical environments make unique contributions to the explanation of health behavior in addition to any health effects these environments may produce through interacting with one another. The most basic assumption of the Social Ecology Model is the multidimensional nature of health and influences on health status. Personal attributes play a role. Participants and the environment can and should be studied at varying levels - individual, small groups, organizational level, and population level. People and their environmental transactions are characterized by cycles of mutual influence, known as reciprocal determinism. 12 The social ecological approach to health promotion (Moos, 1976; Stokols, 1992) suggests that interpersonal factors such as social support are conducive to health change. Additionally, social institutions with organizational characteristics (for example, schools and churches) and corporate culture are institutional factors that influence health promotion. Moreover, the relationships among these organizations and the public policies that influence them are the community factors that promote health. The Ecological Model for Health Promotion states that the social and physical environments influence health. However, it does not explain specifically how culture influences health behavior. King argues that there are three dimensions of the cultural proposition that must be considered relative to the health of African Americans. 2.2 DIMENSIONS OF CULTURAL FRAMING A conceptually different approach to viewing public health is depicted in Figure 1. According to King (2002): cIn this [alternative] view 8public consists of people-I relationship 9 4individuals embedded in family, family rooted in community, community based in society. Health is viewed as quality of relationships that affect biological, psychological, social and spiritual well-being. The validity of epistemological claims depends on this understanding that health 9s essential quality is in relationships. Health is represented in unity as one line, polarized to indicate negative ( 3) or optimum (+) health relationships. However, both of these together do not complete the picture of public health. What is required is the 8ground 9, or context, on which they stand. Context permits the authentic relationship of the public with its existence 4political, cultural, ecological, and economic. This is represented by a single line, again polarized into negative and positive, not as objective sum and substance but as perceptions of the 8public 9 of the context d (pp. 96-7). 13 PUBLIC HEALTH PUBLIC Society Community Family Individual HEALTH - biological - psychic - social - spiritual CONTEXT -political -social -economic -ecological Figure 1. An Alternative View of Public Health as the Health of Relationships (King, 2002) The first leg of the cpublic health stool d is culture (Gergen et al., 1997; Nobles and King, 2000). One dimension of cultural framing attends to the group as cpublic d (King, 2002). In this instance, the public refers to African Americans. There is an assumption in mainstream thinking that African Americans have no legitimate culture (King, 2002). However, African Americans, in anthropological, social, and political contexts, constitute culture (King, 2002). African Americans are a culturally distinct group of people bound by an ideological unity (Butler, 2000).Many cultural and historical factors distinguish African Americans from the rest of American society (Grace, 2000). Wade Nobles has defined three significant time periods that have been used to describe the experiential communality of Africans living in the Western world, 14 particularly in North America: (1) the African experience (prior to 1600), (2) the slavery experience (1600-1865), and contemporary Black America (1865 to the present) (Nobles, 1972). Moreover, slavery is considered the pivotal period and the one to have most profoundly affected the identity of African Americans and the unfolding of their true selfhood as men and women (Butler, 2000). According to Butler (2000), not only were African Americans removed from a strong cultural heritage and required to reestablish a cultural identity during slavery, but they were also denied the essence of their very nature as human beings. W.E.B Dubois (1903) has described the effects of transplantation and adjustment on the personhood of African Americans by characterizing the history of African Americans as a conflict of longing to attain self- conscious manhood, to merge his double self into a better and truer self. More than four centuries separate the descendants of those persons who were dispersed from Africa to North and South America, and yet there remains a oneness, rhythmic unity (Asante & Asante, 1990), a depth of knowing and understanding that has been felt from that time to the present (Butler, 2000). In fact, over time African Americans have developed a set of values, beliefs, meanings and practices 4and by extension, a way of health (King, 2002). Thus, the authentication of public health for African Americans requires an affirmation of the primacy of culture (King, 2002). The second dimension focuses on the culture of public health, itself as health (King, 2002). Modern public health practice has adopted and reflected the culture of modern medicine (King & Nobles, 1996). The medical model is the dominant paradigm of modern medicine. Therefore, the emphasis of modern public health is on the individual cat-risk d, or the identification of biological intrapersonal factors (weak organ systems), or psychological intrapersonal factors (beliefs, cognitions, attitude, intentions, skills) as determinants of health 15 outcomes (King, 2002). Given that the health status of African Americans is influenced not only by the unique pattern of exposure to stressors based on the African Americans 9 social status in the U.S., but also by the way African Americans, given their historical values and meanings (culture), behave in response to stress and life 9s adversities in rapidly changing society (King, 2002). Consequently, the authentication of public health for African Americans aims in large part to move away from the emphasis of improving health outcomes solely through targeting change in the individual 9s personal characteristics and behaviors (King, 2002). The African Americans should be seen as the csubject d of interest not the cobject d, focusing less on the conditions that influence the individual 9s health at the expense of how they perceive or react to those conditions. The third dimension spotlights the environment as context 4political, ecological, economic and spiritual (King, 2002). In other words, the third dimension of culture is context, the web of relationships between the public and social reality (King, 2002). Culture is the mediating construct in the web of relationships (Nobles & King, 2000), and the force that maintains unity and coherence of the web of relationships (King, 2002). In the clash between the culture of public health dominated by cpsychological genetics d and African Americans, if African American person 9s health circumstance is to be adequately understood and addressed, then it must be done from the vantage point of culture (King, 2002). Making explicit the core elements of African American culture and the unifying forces that give depth and dimension to the dynamics and character of this group will aid in differential attempts to design programs on the group 9s behalf (Butler, 2000). 16 According to the Institute of Medicine (1998), the real face of health problems in the U.S. is chronic illness. African Americans suffer disproportionately with chronic diseases such as diabetes, HIV/AIDS, high blood pressure, heart disease and stroke. When treating conditions of cunknown etiology d and particularly the complex life-process disorders that give rise to chronic problems, illness or disease, much broader systemic issues take primacy (King, 2002). It is fundamental that the social position of African Americans be addressed (King, 2002). There are three parameters that govern the cultural orientation of public health practice: ontology, which is the premise of defining the individual, singly, or collectively devoid of context and outside of the hospital setting; axiology, which is the value premise of the absence of disease construct; and epistemology, which is the search for the cause as genetic disease determinants, either biological or psychological (King, 2002). 2.3 PRIMARY ASSUMPTIONS OF THE MODEL According to King and Nobles (1996, 1997), there are four primary assumptions of an Authentic Culturecology Model. The first assumption is that public health is a cultural phenomenon. The basis for all phenomena is relationship, or a person nested in a triadic set of relationships, known as a web of relationships, which consists of the person, his/her community and his/her environment (Haslam, 1994). Culture can be defined as the sum of relationships (unit or web of relationships) of any phenomenon; culture is the defining substance of all human action (Carruthers, 1995; Hilliard, 1976). Culture is a functional, internally consistent beliefs, attitudes, values, expectations and norms/patterns of conduct (King, 2002). In the person dimension, culture directs his/her level of autonomous capacity for self-organization as well as 17 that of self-restoration (King, 2002). In the community dimension, culture directs the level of social and economic support and the balance in relation to ecology and faith (King, 2002). The second assumption is that bonds are the dimensions internal to culture. A bond is a historical-cognitive emotional structure (connection) that has clear functions in everyday functioning of a unit of relationships (King, 2002). The web of relationships reflects bonds to personal, conventional, social and spiritual order (King, 2002). If culture represents the structure of a system in unity, then bonds represent or are forms of cglue d that maintain the ties or attachments, and therefore the function or dysfunction of the web of relationships (King, 2002). The ties that bind African American together define their essential nature as a historically and culturally distinct group, and these ties provide the ccultural key d for interpreting, understanding, and making meaningful a description of African American life in American society (Butler, 2000). Cultural framing prompts the articulation of the organic set of bonds as the defining reality at any given moment for any given relation (King, 2002). The third assumption is that there are four primary bonds (Fiske, 1993). According to King (2002), these bonds can be conceptualized as follows: " Affinity bonds. The need for collective belonging, or solidarity, and intimacy based on memory. These bonds grow from the memory of childhood (feeding, comfort, protection) and are based on the need for security and trust. " Obligation bonds. The drive to establish rules according to status markers such as deeds (good or bad), age, skill, knowledge, class, social position, race. These bonds are based on the meaning of power, order and control, and grow from the spirit nature of relationships and the need for accountability, duty, responsibility, and moral commitment. 18 " Assurance bonds. Bonds based on the organization on common sets of values of exchange, such as vocation, production, money, goods, materials, or intellectual work. The emphasis is on good return on investment or time. Social transaction is based on costs and benefits. Assurance bonds are based on the search or need for competence, mastery, and autonomy. " Harmony bonds. These are the bonds governed by the search for fairness and rhythm. They are the ties organizing the construction and interpretation of relationships in strictly impartial terms. As an example of this is the search for equity (Nobles & King, 1997). These focus on reciprocity, fairness as primary values. Such bonds are based on the motivation for justice, fairness and balance. Every relationship can be defined by these bonds (King, 2002). Bonds are present or absent (King, 2002). When they are present, they are either strong or weak, health-enhancing or health-compromising (King, 2002). Bonds characterize the nature of the event (King, 2002). The fourth and final assumption is that the essence of an event/phenomenon is not the phenomenon itself, but in its web of relationships (King, 2002). This implies that the unit of analysis in the examination of any public health occurrence must be the web of health relationships in that event (King, 2002). Fundamental to understanding the event as a relationship is the nature of the bonds in the culturally framed web (King, 2002). Bonds constitute the essence (King, 2002). cIt is within the framework the person 9s (family 9s, community 9s) bond to a larger reality that factors (psychological, social, ecological, spiritual) central in setting the stage for modifying bonds and therefore conditions for behavior change 4 occur d (King, 2002, p.103). 19 2.4 PRINCIPLES OF THE MODEL According to King (2002), there are three principles of the Authentic Culturecology Model. The first principle is that the presence of strong health-enhancing bonds in all four bonding domains is necessary to optimum health and the prevention of illness (King, 2002). For the person, the stronger health-enhancing the bonds, the stronger the formation of a collective self-identity as a part of community. Therefore, it is less likely that the person will engage in relationships that involve risk factors for a host of negative health outcomes. The second principle is that the same statement is true and can be applied to the family and the community/society (King, 2002). The third principle is that the presence of health- compromising bonds, or the absence or weakness of autonomous bonds (to personal, spiritual and conventional social order), predict a greater likelihood of the person engaging in risk factors for a host of negative outcomes for him/herself, community or society (King, 2002). King and Nobles argue that African American health relations are significantly compromised by a society that has historically negated [Maafa] (Ani, 1994) African American bonds to society (conventional social order). What allows the African American to survive is the positive [Maafa] (Ani, 1994) remnants of historical bonds to cultural history (spiritual connections) (King, 2002). 20 2.5 METHODOLOGY OF THE MODEL The methodology of the Authentic Culturecology Model focuses on the web of relationships as the unit of analysis and the subject for exploration with culture as the unifying link (King, 2002). The model suggests that the first step of design of intervention always begins with careful work in identifying or locating the smallest web of relationship or cultural event of the whole person in whole contexts (King, 2002). The second step is cultural framing, which requires both cultural sensitivity and competence (King, 2002). The frame consists of the representation of the types, strength and valence of bonds present in the web of relationships (King, 2002). The central methodology for the discovery of bonds with cultural framing is the use of narrative (King & Fluker, 1998). The third step is the participation of the subject in change, recognizing that what is to be changed are the nature of bonds within the web-of- relations, which maintain outcomes that are health compromising (King, 2002). 2.6 BASIC PROCEDURAL STEPS FOR THE FRAMEWORK The first task is always to undertake a critical study of the nature and epidemiology of the basic units of relationships that produce high-risk behaviors and the converse, of relationships that preserve health and well-being (King, 2002). The critical search for the relationship must be consistent with seeing the relationship in the context (political, ecological, economic, and social) of the larger web of relationships (King, 2002). 21 The second intervention task begins with selecting and specifying the set of relationships, the relationship of primary focus (as subject) that produces the behavior leading to the outcome (as object) (King, 2002). Careful research must be undertaken to identify and define this basic unit of study, intervention, or discourse (King, 2002). Having specified the key relationship of interest, the task then becomes the thorough exploration in this dominant attributable of interest, the bonds that maintain both health indicators and the relative risk indicators (King, 2002). The third task is one strategic goal setting (King, 2002). The public health approach always must seek to formulate goals and strategic direction for intervention in conjunction with the other relationship (national and community policies, and priorities for prevention and health promotion) in which the primary relations are embedded (King, 2002). This unit must be embedded in the community (King, 2002). The strategic direction should guide the development of goals for health promotion, health protection, prevention services, or clinical intervention (King, 2002). The fourth task is to develop a culturecological intervention program appropriate to and in conjunction with, the subject population (King, 2002). This development is the cultural framing that should guide the intervention to include timing (primary, secondary, tertiary prevention; level personal relations, family relations, community relations, etc.) and desired outcomes (King, 2002). The desired outcome usually falls into one of three categories: changing the existing relational complex, establishing a new relational context, or both (King, 2002). 22 King 9s fifth task is to situate the entire enterprise in a research-based context to inform all relationships within and between units, and put in place intervention, implementation and evaluation protocols to include: a. Process research b. Pilot research c. Efficacy trial d. Effectiveness trial e. Data analysis and dissemination 2.7 CONCLUSIONS ABOUT THE FRAMEWORK The Authentic Culturecology Model asserts that the public health approach should move away from its emphasis on individuals, scientific rationalism, and knowledge gained from objects, but rather focus on the study of relationships. The framework promotes a continuous critique to validate the importance of cultural understanding in the promotion of health in African Americans. 23 3.0 REVIEW OF THE LITERATURE Historically, there has been social and medical relationship between faith and health. Faith is a universal human concern (Tillich, 1957). Faith must not be viewed as synonymous with spirituality and religion. Health, as previously described, is a relationship, a synergistic interplay between the physical, social, psychological, and spiritual elements that create the well- being of individuals and/or groups in their physical and social environment (Warren, 1999). cFaith and health interact at the point of relationships. cThere must be a relationship to define one 9s ultimate concerns in life (faith). They both go hand in hand, with relationships between the physical, social, psychological and spiritual dimensions of one 9s being, and relationships between the vertical, horizontal, and the personal dimensions of one 9s faith d (Warren, Lockett & Zulfiqar, 2002, p.143). When these relationships are out of sync and disconnected, invariably ill health and doubt occur (Fowler, 1981). According to Epperly (1997), issues of health and illness are theological and spiritual issues, and how one takes care of themselves 4body, mind, and spirit 4is a matter of faith and unfaith. Health care is the provision of health services. Health care should not be confused with health. 24 3.1 FAITH, SPIRITUALITY, AND RELIGION For the majority of people, the expression of faith is equated with religion (Al-Faruqi, 1974), however cthe concept of faith does not require religion d (Warren, Lockett & Zulfiqar, 2002, p.131). Faith is a person 9s or group 9s way of moving into the force field of life. It is our way of finding coherence in and giving meaning to the multiple forces and relations that make up our lives. It is a way of seeing [oneself] in relation to others against a background of shared meaning and purpose. Faith is the most fundamental category in the human quest for relation to transcendence. (Fowler, 1981) According to Tillich (1957), faith is a state of being ultimately concerned, and that ultimate concern may center in our own ego or its extensions 4work, prestige and recognition, power and influence, wealth. He continues by indicating that one 9s ultimate concern may be invested in family, university, nation, or church. cHuman beings have the capacity of having faith in something while not prescribing to a particular religion. d (Warren, Lockett & Zulfiqar, 2002) In Christian history, the thirteenth century is often identified as the period when religion was a powerful force in the entire society and thoroughly interwoven with other aspects of life 4 work, education, politics, family, and so on (McGuire, 2002). While religion and medicine were virtually inseparable for thousands of years (Te Velde, 1995), the advent of science created a chasm between the two. The term spirituality is a contemporary bridge that renews this relationship. According to Musgrave et al. (2002), cspirituality refers to a basic or inherent quality in all humans that involves a belief in something greater than the self and a faith that positively affirms life and religion refers to religious attendance, practice, or activity d. 25 Reflecting on the ancient word spirit, May (1982) writes, "Spirit implies energy and power." The word spirituality goes further and describes an awareness of relationships with all creation, an appreciation of presence and purpose that includes a sense of meaning (Musgrave, Allen & Allen, 2002). In 1989, Burkhardt published an interesting formal concept analysis of spirituality, in which spirituality or cspiriting d was defined as a process involving the cunfolding of mystery through harmonious interconnectedness that springs from inner strength d. He asserted that spirituality subsumes religiosity or religion, which may provide intellectual, behavioral, and social form to spiritual expression. However, spirituality continues to be used interchangeably with religiosity, particularly across academic disciplines of study (Newlin et al., 2002). Clifford Geertz (1966) defines religion as ca system of symbols which acts to establish powerful, pervasive, and long-lasting moods and motivations in men [and women] by formulating conceptions of a general order of existence and clothing these conceptions with such an aura of factuality that the moods and motivations seem uniquely realistic d. Religion is something that people do together to face urgent problems and to resolve them by appealing to truths that seem self-evident to them (Neusner, 2003). Religion is also defined as an institution consisting of culturally patterned interaction with culturally postulated superhuman beings (Spiro, 1966). All religious institutions include beliefs, patterns of actions, and value systems; the critical feature of religion is that the beliefs, patterns of action, and values referred to by Spiro (1966) as csuperhuman beings d. 26 3.2 POLYTHEISTIC AND MONOTHEISTIC RELIGIONS Even when faith and religion are not used interchangeably, one cannot understand faith without first reviewing the major religious systems in different parts of the globe. (Warren, Lockett & Zulfiqar, 2002). There are numerous religions throughout the world. Religions are categorized as either polytheistic or monotheistic. Polytheistic means to worship many deities (gods), while monotheistic signifies the worship of one deity (God). The four major polytheistic religions are Hinduism, Buddhism, Taoism, and Confucianism. The three monotheistic religions include Judaism, Christianity (Protestants and Catholics combined), and Islam. Based on the size, for the purpose of this chapter, only these seven major polytheistic and monotheistic religions will be explored. Hinduism did not originate from one founder, and is a collection of sacred writings that do not have rules as we know them (Al-Faruqi, 1974). Hindis worship one main deity at one time by choosing specific ones to give special reverence on particular days. For Hindu believers, Brahma is the creator God and is less widely worshipped since his mission is assumed to have been completed in the Creation; Vishnu, the sustaining God, who maintains order in the world and preserves values whenever and wherever they are threatened; and Siva, the God of consummation or destruction, is believed to bring disease and illness. Additionally, some Hindus may worship other gods or goddesses, of which some choose a personal god with whom they develop a relationship and worship. The ultimate concern for the Hindu believer is to reach Brahman, which is the holy word or sacred knowledge constituting holy power in the living moment. Believers seek salvation in a process of journey called samsara, which is a cyclical process of birth, death and rebirth until the believer 9s soul reaches the creator God Brahma. (Noss, 2003; Partridge, 2005; Sharma, 1993) 27 Buddhism is similar to Hinduism in many ways. Buddha is the main figurehead of Buddhism, however he is not the founder of the religion. Buddhists believe that cthe teachings d that Buddha discovered are the way to be human. Thus, moral action will produce karma (the force that moves life forward); human existence is dukka (suffering); all of life is transient; and suffering is caused by attempting to hold on to the things of life that are transient. Moreover, the ultimate concern of the Buddhist is to reach Nirvana. Nirvana is Enlightenment, or the elimination of hatred, greed, and delusion, and the cessation of suffering. (Noss, 2003; Partridge, 2005; Abe, 1993) Confucianism originated in China. It is a religion without a deity, however practice of the faith can include worship of spirits, or eternal human beings, such as the founders and ancestors. The ultimate concern for Confucians is Heaven, which is considered true integrity, at hand and unity with Heaven and Earth. In Confucianism, the way to gain reconciliation with the ultimate concern and to achieve the ultimate destiny is to become a holistic human being in four dimensions: self, community, nature, and Heaven. Moreover, Confucianism teaches that relationships are very important and precedence in relationships is given to status, age and gender. (Noss, 2003; Partridge, 2005; Wei-ming, 1993) Taoism is influenced by Buddhism. It is a polytheistic system which involves the worship of gods, spirits, and ghosts. Taoism began with traditional Chinese ideas and religious practices and embraces almost every ancient Chinese practice, such as offering sacrifices to ancestors, praying for favorable weather, and dispelling evil spirits. The ultimate concern of Taoist is to reach the gods to ensure happiness and prevent disasters. Furthermore, Taoists believe that one transfers the consequences of one 9s own conduct to one 9s children. In other 28 words, there is a transmission of burdens, either merits or demerits, from ancestors. Lastly, Taoists believe in physical immortality. (Noss, 2003; Partridge, 2005; Xiaogan, 1993) Judaism is considered the first of the monotheistic religions (Noss, 2003; Partridge, 2005; Neusner, 1993). According to the great sages, the Hebrew Bible, or the Torah (also known as the Old Testament of the Bible), defines Judaism. There are at least four organized forms of Judaism: Orthodox, Reform, Conservative, and Reconstructionist. Orthodox Judaism believes in the literal way that God gave the Torah, thus keeping the law as God-given. Reform Judaism considers the Torah a statement of eternal principles in historical language and terms, and consequently believes that it can be changed to respond to new conditions. Conservative Judaism affirms the God-given standing of the Torah, but accommodates change. Reconstructionist Judaism views their religion as the historical civilization of the Jews and identifies God in naturalist, rather than supernatural terms, thus moving further away from the Torah as the divinely inspired, authoritative text. (Noss, 2003; Partridge, 2005; Neusner, 1993) To be a Jew can mean a religious affiliation and/or belonging to an ethnic group (Noss, 2003; Partridge, 2005; Neusner, 1993). The ultimate concern of Judaism is to observe the agreement, or covenant, between Israel and God by leading a sanctified life (Noss, 2003; Partridge, 2005; Neusner, 1993). Christianity is reported to have the largest contingency of believers when compared to other religions (Noss, 2003; Partridge, 2005; Neusner, 1993). Christianity sprung from the faith that in its founder, God was made manifest in the flesh as Jesus Christ and dwelt among humankind (Noss, 2003; Cox, 1993). Christians are followers of the principal teachings of Jesus, who in fact, was a practicing religious Jew (Noss, 2003; Cox, 1993). The doctrine of Trinity stands as the basis of Christian thought concerning God (Al-Faruqi, 1974). This doctrine 29 presents the belief that God is one, comprising three entities in the one: God, Jesus Christ, who is considered the embodiment of God on earth, and the Holy Spirit (Al-Faruqi, 1974). The Bible, which consists of both the Old Testament and the New Testament, is the holy book of the Christian religion. There are many denominations included in the Christian religion and their interpretation of the Bible may differ. However, the ultimate concern of Christians is to achieve eternal life in the Kingdom of God (Noss, 2003; Cox, 1993). Islam is the second largest religion in the world (Buchsbaum, 1993). The followers of Islam are called Muslims. Muslim means cone who submits to Allah d or cone who commits himself [or herself] to Islam d (Noss, 2003; Partridge, 2005; Nasr, 1993). The fundamental belief of Islam is the declaration of faith that states: cThere is no God, but Allah, and Muhammad is the messenger of Allah. d (Al-Faruqi. 1982) The one basic scripture of Islamic believers is the Qur 9 n (or Koran), which subscribes the articles of faith, good conduct, and religious duty of Islamic followers. The ultimate concern of Islam is to join Allah in the hereafter (after life) (Noss, 2003; Partridge, 2005; Nasr, 1993). Faith and religion are not synonymous. However, to understand faith one must explore the various religious ideologies. As previously indicated, it is essential to investigate the connection between faith and health if improvements in health are expected. cFaith and health interact at the point of relationships, and there must be a relationship to define one 9s ultimate concerns in life (faith). Holistic health will not be reached until one 9s ultimate concerns are harmonized. d (Warren, Lockett & Zulfiqar, 2002). 30 3.3 HEALTH AND HEALTH CARE IN THE U.S. According to the Health, United States, 2004 report, major changes in the U.S. population were the increasing racial and ethnic diversity of the Nation and the growth of the elderly population. The Hispanic population and the Asian and Pacific Islander population have grown more rapidly than other racial and ethnic groups in recent decades (DHHS, 2004). In 1980 the Hispanic population was reported as 6 percent and the Asian and Pacific Islander population as 2 percent of the total U.S. population (DHHS, 2004). In 2000 the Hispanic population was reported as 13 percent and the Asian and Pacific Islander population as 4 percent of the Nation 9s total population, thus indicating an increase of 50% or higher for both groups in two decades. Moreover, the non-Hispanic White population in the U.S. decreased from 80 percent in 1980 to 70 percent in 2000, and the African American population has increased only slightly from 11.5 percent in 1980 and 12.2 percent in 2000 (DHHS, 2004). One of the goals of Healthy People 2010 is to eliminate health disparities among different segments of the population (DHHS, 2000). Since measures of disease and disability differ greatly by race and ethnicity, the current trends in racial and ethnic composition of the Nation 9s population will have important consequences for the goals of U.S. health policy to eliminate racial and ethnic health disparities by the year 2010 (DHHS, 2004). The growing population will require more health care resources. The United States spends more on health than any other industrialized country, and the annual growth rate for health care expenditures has accelerated since the millennium (DHHS, 2004). Given that information, national health care resources will continue to increase and consume a larger share of the gross domestic product (GDP). Age is another demographic factor that has changed significantly in the past decades. The Health, United States, 2004 report indicated that the population of Americans age 75 years or 31 older doubled during the past four decades from 3 percent in 1950 to 6 percent in 2000. If this population trend continues, it is projected that 12 percent of the U.S. population will be 75 years of age or over by the year 2050 (DHHS, 2004). The aging of the U.S. population has important consequences for the health care system (DHHS, 2004). cAging increases susceptibility to infection in the absence other underlyin

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