Cultural Tailoring for an Afro-Caribbean Community: A Naturalistic Approach

Abstract

Purpose

The purpose of this study was to discover ways to tailor health care interventions to fit the cultural identity of a minority group of people in order to reduce health disparity.

Design/Analysis

A naturalistic approach was used to interview four self-identified Afro-Caribbean Americans about their experiences of living on the margin. Through content analysis, categories emerged from the transcription revealed embracing, non-entitlement, enduring disrespect, and caring for self.

Conclusion

Afro-Caribbean Americans have strong values, healthy intentions, and appropriate attitude which are critical combinations for successfully tailoring interventions. Implications are discussed.

The significance of culturally tailored interventions reflects an intrinsic principle surrounding health disparities for racial and ethnic groups. Indeed, research has enlightened modern inquiry that health services might need modification in order to gain the response that is crucial in minority and underserved communities. While nursing has made considerable effort to provide culturally sensitive health care (Lowe & Archibald, 2009), there is a woefully inadequate supply of urgently needed and culture-specific programs for diverse populations in the United States (U.S.), particularly for the Afro-Caribbean group.

Florida is the third fastest growing immigrant-receiving state, being second only to California and New York (Camarota, 2007). Most Caribbean immigrants come to South Florida because of a) its proximity to the Caribbean, b) the climatic conditions resemble that of the Caribbean, and c) because of the Caribbean connection that is evident upon arrival. The socio-economic challenges of this region force people to leave “paradise” in pursuit of upward social and educational mobility and a few modest extras for themselves and their children. Many reside in poor and underserved communities (Nurse, 2004); these living arrangements often predispose such persons to health risks such as HIV/AIDS.

Like many other cultural groups, Caribbean population has its unique values that are not present in conventional health care approaches. While the strategies to achieve cultural appropriateness might vary (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2002), Kreuter and Haughton (2006) agree that one way to help reduce health disparity is to incorporate the culture of the specific population in health programs instead of using a one-size-fits-all approach (p. 795). Since the American Nurses Association (ANA) views cultural diversity as priority in its strategic plan (ANA, 2001), and the transcultural movement has been successful in incorporating culture in nursing curricula, licensure, and certification exams, nurses are uniquely positioned to modify or tailor interventions appropriately in order to narrow health disparities. This awareness has provided initial impetus for this preliminary study.

LITERATURE REVIEW

The concept of “cultural tailoring” is quite common among educators. Pasick, D'Onofrio, and Otero-Sabogal (1996) define cultural tailoring as “the development of interventions, training practices and materials to conform to specific characteristics” (p.145). Also, Eyberg (2005) defines cultural tailoring as “changes made in focus or delivery style of essential elements in an established treatment, based on the unique features of the individual case” (p. 199). While a union of “culture” and “tailoring” might be questionable since “tailoring” suggests individual, and “culture” suggests shared, Kreuter et al.(2002) pointed out that individuals within the culture will “have varying levels of the same cultural beliefs” (p. 137). These beliefs, values, and traditions of various ethnic groups are implied in culturally tailored interventions which in turn will more likely enhance participation.

Cardona and colleagues (2009) used a community-based participatory research (CBPR) approach to investigate the relevance for culturally tailored parenting intervention among Latino populations. The CBPR approach promoted a sense of empowerment among parents as they participated in the intervention. The researchers also found that Latino parents desired to participate in interventions when such interventions are culturally relevant and respectful of their culture. For example, they want the curriculum to reflect their parenting styles to include the extended families.

One example of the success of culturally-tailored interventions is a randomized HIV prevention approach in Trinidad and Tobago (T/T) conducted among parents and their adolescents. Baptiste, Kapungo, Miller, Crown, Henry, and Martinez, et al.'s (2009) tailored intervention aimed at strengthening parenting skills that are empirically linked to reducing adolescent HIV exposure and other sexual risks. Participants were either assigned to the T/T Family HIV Workshop intervention group or a general workshop group. As expected, the tailored intervention group showed improved parenting capacities, change of parental attitudes toward persons with AIDS, improved parent-adolescent communication on sex-related topics, and less intense daily parent-adolescents’ hassles.

Many Afro-Caribbeans cleave to myths, and superstitions about health. For many, illness is direct result of sin or caused by supernatural powers through curse or jealousy. People who hold such beliefs often access the health care system after futile attempts at traditional remedies (Jones, 2005). Moss and McDonald (2005) conducted a study among patients with diabetes in the small island of St Vincent. Findings revealed that with lay beliefs about diabetes, beliefs in the treatment efficacy of herbal medicines, and traditional foods, folk medicine was integral to their wellness. Strong religious influence directed diabetes treatment; for example, revelations, dreams, visions, and prayers, offered some symptom relief and treatment satisfaction.

Afro-Caribbean Americans receive health care in a world dominated by mainstream American or African-American ideals, while the framework and beliefs underlying Afro-Caribbean Americans health and healing are different. The challenge is for interventions to incorporate both perspectives in order to provide care and reduce health disparity in this population. In addition to challenges also faced by many American-born citizens, Afro-Caribbean people live on the margin.

Marginal living includes elements of acculturation, meaning that individuals may speak or engage in social relationships with peers of the host culture but return home to cultural traditions and rituals. Choi (2001) defines marginal living as “the pushing/pulling tension between two cultures while forging new relationships in the midst of old and living with simultaneous conflict /promise” (p. 247). Choi claims that a marginalized population often faces clear or hidden prejudices, which have direct implications for healthcare. Blanchard and Lurie (2004) found that patients who feel disrespected, are unlikely to adhere to routine exams and health advice. They also found that large portions of minority groups feel disrespected during treatment and felt that disrespect was due to their minority status. The Afro-Caribbean population has two options for health care: they can duplicate the American approach to health care or continue the traditional folk healing while living in America. The traditional approach is troublesome because “...it is reactive rather than proactive which further undermines the urgent need for preventive care among this population” (Wheeler & Mahoney, 2008, p. 239). This preliminary study was conducted in an effort to understand more about the Afro-Caribbean culture to facilitate tailoring an effective HIV prevention intervention. Members from the community were interviewed because the essence of the inherent values can only be understood when researchers speak to the individuals of the community (Israel, Eng, Schulz, & Parker, 2005) which is a step beyond the literature.

Purpose

The purpose of this study was to discover from interviews, ways to tailor health care interventions to fit the cultural identity of a minority group of people in order to reduce health disparity. The research questions that guided this study were: 1) “What is your story of being Afro-Caribbean? 2) What do you understand by “health” and “wellness?” 3) How can we provide you with culturally sensitive health care?”

Design

In keeping with the design used by Struthers, Eschiti and Patchell (2008), a qualitative approach was used to interview four self-identified Afro-Caribbean Americans who reside in South Florida. The researcher who is Afro-Caribbean is familiar with the phenomenon being studied conducted the sessions. However, through “bracketing,” a process that helps the investigator to put her feelings as Afro-Caribbean aside and objectively listen to the participants’ stories (Polit & Beck, 2006), the researcher was able to disregard biases. The researcher also made field notes (Morse & Field, 1995) which were used for reflection and data analysis.

METHOD

Data Collection

Human subject protection approval was obtained from the University's Institutional Review Board; potential participants were contacted by phone and in person and solicited for participation in a research study to tell their story of being Afro-Caribbean and straddling two cultures. After written consent was obtained from each participant, available times were arranged for interviews: two were done in their homes and two at their churches. The open-ended audio-taped conversation lasted 45- 60 minutes. Conveying information via stories accommodates oral tradition and is a common method in qualitative research (Smith & Liehr, 2008; Jolly, Weiss, & Liehr, 2007). Each participant was encouraged to describe his/her experience of living on the margin. This approach is consistent with the principles of community based participatory research (CBPR) that asks researchers to listen to the community members and “...to know the community in all its complexity... through a new set of lenses ... and make a partnership that reflects the community...” (Israel, et al. p. 34). Clarification and elaboration of experiences were achieved by the use of probes such as, “Is there anything else you can say about that?” No other incentive than a “thank you” was offered for the participants’ time.

Content Analysis

Descriptive statistics was used to analyze the demographic information. Stewart and Shamdasani's, (1990) content analysis technique was used to analyze the interview data. According to the technique, frequency, order, or intensity of occurrence of words, phrases, or sentences, or partial statements derived from participants’ stories can be described systematically using content analysis. The researcher personally transcribed the tapes which also allowed her to become immersed in the data which is a necessary process in qualitative research. The transcribed manuscript was then scrutinized by words or sentences about the phenomenon of interest. The statements were clustered into categories based on similar thoughts or characteristics, and a theme was identified for each cluster.

Findings

Sample

The four participants who were interviewed are Caribbean natives of Antigua, Bahamas, Jamaica, and St. Kitts; they were between the ages 35-45 years. The mean level of acculturation or mean length of time in the US was eight years. The participants were very excited because they felt that had something important to contribute by telling their stories of what it means to be Afro-Caribbean. Their stories are presented primarily in direct quotations addressing the themes that emerged from the data: embracing two cultures, non-entitlement, enduring disrespect, and caring for self.

Embracing Two Cultures

This theme describes the graceful waltz between cultures that Afro-Caribbean Americans create in order to live in America. “Sometimes I feel like I have one foot in the culture that I'm a part of everyday, and one foot in the culture I left behind 10 years ago.” “I learn to live in America. I came here for a bigger good, for myself and my children”;“I am conforming to make society work”, and “I am a Kittitian, but I can act and speak like Americans when necessary”, are some examples of embracing cultures. One participant expressed that she heartily embraced many American ways while remaining her “Caribbean” self: “I am a Jamerican” she laughed. Conversely, participants expressed confusion with embracing the American culture. Participants expressed that often Americans cannot be taken literally: “They will say, ‘see you later’, and I used to say to myself, ‘where am I going to see them later’?” Also, “...they will ask you, ‘how are you?’ but are only prepared to hear ‘I'm fine’... at first I started telling them all my problems only to find out that they really were not interested.” “I learn in an embarrassing way that when someone says, ‘let's go to a restaurant’, to make sure I have money to pay for my food, for you are not someone's guest.”

In daily conversations, “We still speak our dialect here in America, but someone recent from the islands will say that our dialect now includes American idioms.” Participants also verbalized how mind-boggling it is for others to experience our sudden switch in accents, “ ...if I am with my American colleagues and someone from the Caribbean happens to get in the circle, we automatically switch accents midstream.” However, another participant brought to view the harsh criticisms that often pursues from fellow Afro-Caribbeans when one tries to adapt an American accent: “They will ask, ‘yuh turn ‘merican a'ready?” One parent expressed her child's adaptation, “My son switched his accent quickly to American as he spoke to friends; I was surprised... pleased ...and upset ... I just don't want him speaking the broken American English so that he become stigmatized.” A parent reported an interesting observation: “I have seen children playing outside with other Caribbean children, and the dialect is clear; one American child joins, and suddenly everyone's accent changes to American.”

The process to embrace American cuisine occurs at a slower pace, but participants admitted, “I have learned to appreciate American food... but when I go home, I want my island food.” Another participant stated that like Americans, she finds herself eating “five-minute-meals” while moving from one commitment to the next. “We couldn't afford fast food back home...and were ashamed of eating produce from our garden and not having meat in our dinners.” Another spoke of “adding desserts and slowly introducing quick and easy meals”. Refusing to conform /develop a habit of “eating breakfast food” a participant stated, “I will still eat curry goat for breakfast ...no such thing as ‘breakfast food’ in the islands although ‘tea’ is a must for starting the day.” Participants expressed an awareness of the change for worse eating habits: “in the islands we eat starch[y foods]... but now one person eats enough meat that would serve the entire family back home. So we are [now] eating starch and meat.” “Eating healthy is expensive” said one participant, “...I would love to eat organic food, but I cannot afford it.” Another participant agreed, “I try to eat healthy, but it does not always work. I am grateful to be able to provide for my family.”

Being Afro-Caribbean living in America comes with isolation said one participant. However, “We quickly identified our people, for we can be our true selves” and “even if they are not from Antigua just being Caribbean is enough”. Another identified South Florida as the best place in America for Caribbean people to live because of the Caribbean connection: “...for there is a big mix [of Caribbean people] here in South Florida; it's not so easy to get homesick.”

Participants expressed raising their children very differently from traditional Caribbean ways though still maintaining select Caribbean values. For example, “My children know they are to stay out of adult conversations; I don't cow them, but they know when, how, and if they need to interrupt.” “I say ‘I love you’ to our children, or ‘I'm proud of you’, and ‘have a great day’ which does not happen back home. Most importantly, our children also know that bringing home a ‘C’ [grade] is not acceptable.” Another parent expressed this: “Our children can express their frustrations; we are criticized as having a ‘watered down’ version of Caribbean values....”

On the subject of sex, parents expressed challenges related to discussing it since for many, it is not part of the tradition. Hence, they [parents] were not equipped with the tools to engage their children in such dialogue. “I spoke to my daughter about ‘her monthly stuff’, but I didn't know how to tell her anything else”. One parent said, “My son never got any discussion; I gave him a book [on puberty].” Another parent said that when she attempted to discuss sex with her children, they “comfortingly” informed her of their knowledge of contraception. The same parent spoke of her attempt to encourage abstinence, but her already-informed or experienced, eye-rolling teen's response made her feeble attempt sound like something from the early colonization of America.

Participants also talked briefly on their attitudes towards people with different beliefs and lifestyles other than their own. “I have come to appreciate differences in people. I go back and forth with my attitudes and feelings towards the gay and lesbian community; I know I am making progress with regards to that.”

Non-Entitlement

Part of the story of being Afro-Caribbean included feelings of non-entitlement. Afro-Caribbeans in this study expressed much gratitude for the opportunity to earn part of the American dream. They pointed out that the move to America was voluntary and consequently, no special accommodation was necessary for them. “We left our country to come here. We only wanted the opportunity to earn a living...no one here owes us anything.”

There was clear unease with being misidentified with other islands: only two islands they know, Jamaica and Haiti”, but more so being called African-American did not resonate well with this group, “We are not African-Americans who think that all their short-comings are the result of slavery; all black people experienced slavery. It was everywhere...in fact, we from the islands get a double-whammy being black and foreigners.” Statements such as, “God bless America, for here I can do for myself what I could not do back home” speak to the Afro-Caribbeans’ indebtedness to America.

Enduring Disrespect

All participants in this study experienced disrespect by health care providers and people in general. While in some instances, this lack of respect was considered mild, the participants identified feeling unrecognized and insignificant. For example, they recounted their hospital experiences as invalidating, and described nurses and physicians treating them as if they were outlaws and taking little interest in them as people. Participants had specific comments about the disrespect related to how they [participants] were addressed. “They need to use my last name and address me as Mrs. P. and not by my first name; I could be their mother,” said one participant and “...asking us questions such as, ‘are you sexually active’?” Without establishing a basis for this question, the participants found this to be disrespectful.

Afro-Caribbean people also experienced disrespect related to feeling stereotyped and stigmatized, “...still, I don't think it is because we are Afro-Caribbean but because we are black.” One parent described an experience of going to an electronic store with his school-aged son, and he was escorted by the store clerk to see the more substandard appliances. Another parent painfully articulated being constantly watched when entering a department store, believing that the sales people did not trust to leave him unattended. “This happens all the time. I don't think they even think I am Afro-Caribbean but that I am black.” Another participant reported, “I go the hospital, and they ask me for my Medicaid card. Without a response, I hand them my private insurance card, and I received no apology.”

Participants articulated some disrespect when health care providers are often impatient with the Afro-Caribbean accent. “It is frustrating to be misunderstood when you are sick... they make you feel like you're speaking Greek; we speak English! They don't even see that their English is bad while our problem is the accent.” Also, statements reflecting the use of American slang or abbreviations, which when clarification is sought, “they look at you like you are from a cave!” Connotations also caused much cross communication as one participant hilariously recalled, “The nurse asked me if I use a rubber. I thought, ‘don't we all use rubbers at some point? Rubber is something on the tip of your pencil to use when you make a mistake.’ Yes, it means ‘condoms’ back home, but condom is not the first meaning that comes to mind...”

The participants expressed that culturally sensitive care means 1) “Introduce yourself ... before asking me about my sex life;” 2) “respect me... I only sound different;” 3) “use our educated Caribbean people or our church leaders to promote health as much as possible....”

Caring for Self

Each participant was asked, “What is your definition of health and wellness?” For all participants, “being well” meant the ability to take care of oneself. “I believe that you are healthy if you are able to carry out your daily activities. You are sick when you cannot help yourself.” With regards to “self care”, they all concurred, “We are not pill-takers.” They agreed for chronic diseases like diabetes and hypertension, oral medications might be necessary, but “here [in America] everything, you have to take pills; they have you taking it for the rest of your life.” This group of participants believes in health screenings, a perspective they adopted being in America, for the island mentality of doing healthy checks is, “If you are not in pain, what are you going to check? Or “you are better off if you don't know, for they will always find something wrong”, or “people are fine until they go to the doctor. People just need to eat healthy and seek God.” This group also pointed out that some people will receive treatment without any interest of the diagnosis; “if something is wrong with me, just treat me, for I don't want to know.”

DISCUSSION/IMPLICATIONS

For decades there has been an awareness of the need to design interventions that can reduce health disparities. Many health care providers believe that culturally tailored interventions might be more efficacious in reducing risks for diseases (Ryann & Lauver, 2002) including HIV/AIDS. However, interventions to address people from the Caribbean cannot be done in a generic way, so this study was an attempt to isolate some common experiences of Caribbean people who live in America in an effort to identify the culture-specific values needed to tailor an intervention for this group. Saturation was reached once the four people were interviewed and this is consistent with Struthers, Eschiti, and Patchell's (2008) study.

Embracing both cultures as one major finding of this study is not unusual with migrant groups. During this process, a determination can be made about which values to retain and which to release while living in two cultures. In fact, this phenomenon is described in the Orthogonal Model of Acculturation (OMA) (Oetting, & Beauvais, 1990-1991). Costigan and Su (2004) explained of the OMA that operating skillfully in the host culture does not necessitate relinquishing of one's traditions or identity; rather, they can remain intact despite involvement in the culture of the host country. Choi (2001) concurred that individuals do not have to feel pressured into choosing a particular cultural group but can be members of both groups. If this finding is common to Afro-Caribbeans in general, then some Caribbean values need to be included in interventions designed for this group.

One major idiosyncratic feature of the Caribbean is its dialects. Dialects are held dearly because poverty and history of the Caribbean seem buried, and the region has become a fantasy for tourism, “...still indigenous voices survive through the dialects... children of the original slaves negotiated a new sense of language, religion and tradition which reaffirms the African heritage in a Caribbean context” (Saunders, 2005, p.10). Although island dialects are English-based, they represent a history of contact among different people from many ethnic, linguistic, and social backgrounds (Brian, 2005). This history accounts for the challenges villages and towns of the same island experience understanding the dialect. However, one message is clear: ‘yuh turn ‘merican a'ready” is sarcastic and means sudden abandonment of the Caribbean culture. As a result, if this comment is not articulated in a distinct jovial manner and at the appropriate time and environment, the accused individual feels deflated. Hence, among different sectors of Afro-Caribbeans, there is a pride in living in America for decades and still maintain an unchanged West Indian accent. Clearly, there are disagreements about which styles and practices one should adopt as these might have influence on health outcomes. If acquiring an American accent is wounding the Afro-Caribbean culture, a linguistic approach to interventions for this group as described by Cooper, Hill, and Powe (2002) is necessary. Indeed, translated interventions for different cultural groups have been successful.

It was not surprising that the groups identified the church and leaders as vehicles to assist with health behavior change. Similar to the Afro-American population, churches play a major role in the Afro-Caribbean community. Churches have the potential to impact public health education and risk behaviors but have been underutilized by researchers (Jemmott, Jemmott, Braverman & Fong. 2005). For Caribbeans, “religious and spiritual beliefs are interwoven with health beliefs, and life and health are controlled by divine will and fate” (Jones, 2005, p. 79) and sickness “a test of one's allegiance to God” (Archibald, 2007, p. 71). In agreement with Jones (2005), an understanding of this religious perspective, effective intervention programs must be implemented in places where Caribbean populations gather and also assess their use of folk remedies. This will facilitate the healing process for Afro-Caribbeans who are using indigenous treatments. In addition, an investigation of the actual or perceived efficacy of traditional remedies is legitimate.

Non-entitlement for American benefits among immigrant populations has not been traced in the literature. This sentiment is beyond simply gratitude to America. Nonetheless, a cognitive dissonance exists between what immigrants and specific groups of America are saying. For while “politicians and anti-immigrant coalition leaders argue that immigrants take jobs away from Americans” (Fujiwara, 2005, p.81), immigrants perceive Americans as lucky enough to live in a country where certain jobs are considered menial, and that Americans can exclude themselves either by choice or qualification from such areas of job market. Such jobs are what many immigrants request and seize to make a life and pave the way for their future generation. Unlike other groups within the host country, who subscribe to the belief that they should get exactly what they want, when they want it (Fisk, 2010), most reasonable Americans would probably agree with this Afro-Caribbean group that no one is entitled to material things that are not earned and not essential to productive life. In fact, Fisk continued that “...entitlement-related attitudes are influencing life in many social institutions...and are even disconcerting in corporate America....” (p.102). If non-entitlement is a strong emotion of Afro-Caribbeans, it might predispose them to vulnerability such as access to available health care resources. Non-entitlement can assist groups to anticipate scarcity rather than to expect excess. Conversely, it is also possible that in time, this Afro-Caribbean attitude of non-entitlement will merge in the American habits and become an expectation. Studies related to non-entitlement among other immigrant groups and other Afro-Caribbean groups are recommended.

Respect is a strong Afro-Caribbean value, and it begins by addressing older individuals with a title “Mr.” or “Ms”. Afro-Caribbeans feel entitled to a identity. Since no literature to support this has been traced, perhaps the title speaks to their experience and prudence that come with age. This respect might be expected reciprocity, for it is, Caribbean value to address professionals by their skilled titles, example “Nurse Brown”. Evidently, inquiry needs to be conducted to explore this concept further.

While it might be ambitious for every nurse to understand the values of all ethnic subgroups in America, nurses need to understand the characteristics that cluster within a given race or ethnic group (Kreuter et at. (2002). Above all, “Society expects nursing to be culturally competent in response to the increasing prevalence of diverse people in the U.S. “(Lowe & Archibald, 2009, p.12).

LIMITATIONS/CONCLUSION

The author acknowledges the limitations of this study. This was a small sample, and differences between islands and subgroups within each island could not be examined. Therefore, the results may not accurately describe Afro-Caribbeans’ experiences as a group. In addition, the design was qualitative, so the findings cannot be generalized. The immigration status of participants was not controlled which could exaggerate the responses. Participants’ general life influences were not considered and could also manipulate the responses. Consequently, these are preliminary findings but hopeful.

Despite the increasing numbers of recent immigrants from the Caribbean, there is limited knowledge of their values and practices. These values and practices cannot be assumed but must be assessed in order to provide cultural competent care. Clearly, Afro-Caribbean Americans have strong values, healthy intentions and the appropriate attitude all of which are critical combinations for successfully tailoring interventions in an effort to reduce health disparities.