ABSTRACT
AFRICANA WOMEN’S STUDIES
PRESLEY-CANTRELL, LETITIA B.S. GEORGIA STATE UNIVERSITY, 1985
M.Ed. UNIVERSITY Of GEORGIA, 1987
BRICKS IN OUR BAGS: EXAMINING HYPERTENSION IN
AFRICAN-AMERICAN WOMEN THROUGH AN AFRICAN
CENTERED PERSPECTIVE
Advisor: Professor Josephine Bradley
Dissertation dated May 2006
This study examines the association between women with characteristics of
Africana Womanism and hypertension (high blood pressure).
An analysis was performed using data from the National Survey of Black
Americans to determine the association between women with characteristics of Afficana
Womanism and hypertension. Data analysis consisted of univariate, bivariate, and multivariate analyses. An analysis of the data revealed that characteristics of Africana
Womanism serve as a protective factor for hypertension in African-American women.
The association between women with characteristics of Africana Womanism and
hypertension when adjusting for age indicates that women with characteristics of
Africana Womanism were 0.56 times as likely to have hypertension.
African-American women have one of the highest rates of hypertension in the
United States. The intersection of gender, race, and class has a direct impact on the
health of African-American women. Cultural theoretical frameworks are critical for
understanding the complex interaction of gender, class, and race on the prevalence of
1 hypertension in African-American women and for eliminating the disparity in cardiovascular health outcomes experienced by African-American women as compared to white women.
Adopting a theory such as Africana Womanism provides the necessary framework from which African-American women understand their lived experiences. It allows them the opportunity to operate from a positive cultural framework on a daily basis. Operating from this framework decreases the amount of stress and conflict that arises when African
American women operate from alien constructs such as feminism. Thus, by reducing the amount of stress and conflict, there should be a reduction in diseases—physical and mental. Africana Womanism offers internal resources that provide invaluable coping strategies for African-American women to fight the twin barrels of racism and sexism that they experience in the United States.
2 BRICKS N OUR BAGS: EXAMINING HYPERTENSION IN
AFRICAN-AMERICAN WOMEN THROUGH AN
AFRICAN-CENTERED PERSPECTIVE
A DISSERTATION
SUBMITTED TO THE FACULTY OF CLARK ATLANTA UNIVERSITY
ENPARTIAL FULFILLMENT Of THE REQUWEMENTS FOR
THE DEGREE OF DOCTOR OF HUMANITIES
BY
LETITIA PRESLEY-CANTRELL
DEPARTMENT OF AFRICANA WOMEN’S STUDIES
ATLANTA, GEORGIA
MAY 2006 p ,LM © 2006
LETITIA PRESLEY-CANTRELL
All Rights Reserved CONTENTS
LIST OF FIGURES iii
LIST OF TABLES iv
ABBREVIATIONS v
CHAPTER
1. INTRODUCTION 1
Significance of the Research
Research Questions
Organization of the Dissertation
Definition of Terms
2. LITERATURE REVIEW, CONCEPTUAL FRAMEWORK . . 24
3. METHODOLOGY 47
4. RESULTS 54
5. SUMMARY, RECOMMENDATIONS AND CONCLUSION 62
APPENDICES
1. NSBA Selected Questions 71
2. SAS Data Set Contents $1
3. SAS Frequencies and Cross Tabulations 84
4. SAS Logistic Regression Models 111
BIBLIOGRAPHY 132
11 LIST OF FIGURES
Figure Page
1. Operational Model of Theory 46
111 LIST OF TABLES
Table Page
1. Characteristics of Africana Womanism Compared to Characteristics of Feminism 44
2. List of Variables 53
3. Demographic Characteristics of African-American Women, U.S., 1979-1980 55
4. Demographic and Cardiovascular-Related Characteristics of African-American Women by Hypertension Status, U.S., 1979-1980 56
5. Demographic and Cardiovascular-Related Characteristics of African-American Women by Africana Womanism Characteristics, U.S., 1979-1980 58
6. Crude and Adjusted Odds Ratio for Hypertension in African-American Women by Characteristics of Afficana Womanism, U.S., 1979-1980 61
iv ABBREVIATIONS
AHA American Heart Association
BRFSS Behavioral Risk Factor Surveillance System
CDC Centers for Disease Control and Prevention
CVI) Cardiovascular Disease
HU Housing Unit
ICPSR Inter-university Consortium for Political and Social Research
NCHS National Center for Health Statistics
NHANES National Health and Nutrition Examination Survey
NIH National Institutes of Health
SES Socioeconomic Status
SRC Survey Research Center
SLASP Standard Listing and Screening Procedure
WASP Wide Area Screening Procedure
v CHAPTER ONE
INTRODUCTION
The primary purpose of this research is to examine the association between
African-American women with characteristics of Africana Womanism and hypertension
(high blood pressure). African-American women have one of the highest rates of hypertension in the United States. The intersection of gender, race, and class has a direct impact on the health of African-American women. Cultural theoretical frameworks are critical for understanding the complex interaction of gender, class, and race on the prevalence of hypertension in African-American women and for eliminating the disparity in cardiovascular health outcomes experienced by African-American women as compared to white women.
Historically, women have played multiple roles in their lives, at once they are wives, mothers, sisters, daughters, workers, housekeepers, or friends—each role bearing its own list of obligations and responsibilities. To the African-American woman’s shoulders, add chief breadwinner in far too many households, nurturer to children who must often maneuver through hostile environments, and partners to husbands or significant others who carry tremendous societal weights of their own. Additionally, stack on financial manager of resources that often just are not enough, underemployment, underpaid employee, often workplace pioneer expected to possess an encyclopedic knowledge of all things black, and do not forget to add sexual goddess and down-home cook.
1 2
In Evelyn White’s, The Black Women’sHealth Book, writer Opal Palmer Adisa asks, “Did you ever wonder why so many sisters look so angry? Why we walk like we’ve got bricks in our bags and will slash and curse you at the drop of a hat? It is because..
We are stressed out!” Adisa aptly describes the physical and mental condition of a commanding percentage of modem African-American women. Daily, many labor under the weight of a job, family, relationships, and the twin barrels of racism and sexism.
Stress, says Adisa, “. . . is hemmed into our dresses, pressed into our hair, mixed into our perfume and painted on our fingers. Stress from the deferred dreams, the dreams not voiced; stress from broken promises, the blatant lies; stress from always being at the bottom, from never being thought of as beautiful; stress from being a black woman in white America.”2
The complex interaction of race, class and gender has a direct impact on the health of African-American women residing within the United States. Cardiovascular disease (CVD), hypertension, obesity, and depression are plaguing Afñcan-Arnerican women at alarming rates. Scholars have attempted to provide theories as to why African-
American women suffer disproportionately from these health issues. There is a convincing body of literature that links socioeconomic status (SES), usually measured by income, education, or occupation, to health documenting a tendency for both to be inversely correlated.3 African-Americans, especially women, are overrepresented in
‘Evelyn White, ed., The Black Women’sHealth Book: Speakingfor Ourselves (Washington: Seal Press, 1994), 13.
3Marilyn Winkleby, Helena Kraemer, David Ahn, and Ann Varady, “Ethnic and Socioeconomic Differences in Cardiovascular Disease Risk Factors: findings for Women From the Third National Health and Nutrition Examination Survey, 1988-1994,” Journal of the American MedicalAssociation 280 (1998): 356. women, Thus, lower the die
responsible conducted biological the
to political of
postulated to environmental African-American
Similarly, Epidemiology NursingResearch26
racial chronic
chronic
prematurely
relationship
societal
African-American
SES
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African-Americans, 4Carol 5David 6Rosatind 7Williams,
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Krieger, (2004):
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3 “I 4 health, primarily hypertension. Krieger concluded that the racial disparity in hypertension must take into account the social meaning of race/ethnicity and what role this has on the health of a people.8
As a group, little research has been conducted on women and even fewer studies on African-American women.9 Research to date has been primarily collected on white males. Research subject preference has traditionally been given to white males and was based on the assumption that the experiences of Europeanlwhite men were “normal” and legitimate. It was not until the National Institutes of Health (NIH) Revitalization Act of
1993 that research on women’s health became a part of the research landscape. Before then, the health of minority women went largely unnoticed.
Minorities were limited to studies which measured their health status only to account for racial difference. As a result, the African-American woman’s lived experiences were absent, not voiced or taken into consideration as part of the research agenda. further review suggests that these studies did not include an Africentric perspective, but relied heavily on varying Europeanlwhite perspectives which did not capture the complex nature of the lived experiences of African-American women. This
European perspective or “feminism” was anchored solely on the experiences of white middle-class women.
The African-American woman is said to have a unique place in America. She occupies a place where the social construction of class, race, gender and oppression are represented as interdependent control systems that interact with one another and give rise
8NancyKrieger, “Racial and Gender Discrimination: Risk Factors for High Blood Pressure,” Social Science Medicine 30 (1990): 1273.
Nancy Krieger and Elizabeth Fee, “Man-Made Medicine and Women’sHealth: The Biopolitics of Sex/Gender and Race/Ethnicity,” International Journal of Health Services 24 (1994): 270. 5 to multiple jeopardies.1° These multiple jeopardies are dynamic, allowing for change as the social context within her life changes. Racism, sexism, classism, and oppression are coupled with the struggle for independence, self-reliance and self-definition.’1 ft is within these experiences that a commonality, a struggle, arises for African-American women. This struggle encompasses both a spiritual and a material component and defines what it means to live as an African-American woman. Although this struggle affects every aspect of her life, only a few scholars have attempted to capture its impact.
In order to accurately assess and prescribe health-promoting and sustaining behaviors, a theoretical framework consistent with one’s cultural experiences must be developed. Such is the case with African-American women. Researchers must develop epistemological frameworks that are not anchored in the experiences of middle-class white women, but that are grounded in the lived experiences of African-American women. Africana Womanism captures these experiences. Africana Womanism articulates and interprets the African-American woman’s woridview. It provides an in- depth analysis of the impact of race, class, gender, and oppression in the lives of African-
American women with priority given to race and class issues. Research that is grounded in a womanist theoretical framework is greatly needed to develop interventions that are consistent with African-American women’s ways of learning. This increases the chances for successful interventions which, in turn, will have a positive influence on the health of these women.
10JanetteY. Taylor, “Womanism: A Methodologic Framework for African-American Women,” Advances in Nursing Science 21(1998): 55.
‘1lbid. 6
One of the most immediate public health crises facing African-American women is Coronary Artery or Cardiovascular Disease which affects the heart and blood vessel system. One of the principal risk factors for CVD is hypertension. Hypertension has been documented as being a strong risk factor for fatal as well as nonfatal CVD events.
CVD accounts for more than 38 percent or 950,000 American deaths each year followed by cancer (23 percent) and all other deaths (39 percent).’2 It is estimated that about one- fourth of the population or 70 million Americans suffer from some form of CVD which includes heart disease, stroke, high blood pressure, congestive heart failure, congenital cardiovascular defects, hardening of the arteries, and diseases of the circulatory system.’3
Heart disease and stroke are considered the primary components of CVD. They are respectively the first and third leading causes of death with more than 40 percent of all deaths in the U.S. attributed to them collectively.14
fueled by misperceptions that CVD is a “man’s” disease and not a real problem for women, women are particularly vulnerable when it comes to CVD. Since 1984, women have exceeded men in the number of CVD related deaths.’5 At present, it is estimated that 8 million women are living with CVD.’6 Some doctors, as well as women, do not recognize the early warning signs of a heart attack or stroke thereby decreasing the
‘2AmericanHeart Association, “Heart Disease and Stroke Statistics,” Available from http://americanheart.org/downloadable/heart/1 13638$92$24$Stats%2006%20book.pdf: Internet, 2005.
‘3lbid.
‘5AmericanHeart Association, “Facts About Womenand Heart Disease, “ Available from http://americanheart.org!presenter.jhtml?identifier=2$76: Internet, 2005.
‘6SuzanneHughes and Laura Hayman, “Improving Cardiovascular Health in Women: An Opportunity for Nursing,” Journal of Cardiovascular Nursing 19 (2004): 145. 7 chances for successful outcomes or providing preventive care.17 This is partly due, as mentioned earlier, to the lack of research focusing on women and CVD. Men have been studied 25 times more than women on CVD.’8
The lack of information and inadequate or delayed treatment offers only a partial explanation of why the mortality rate for women is high. As women increase in age, their risk for heart disease and stroke increases. Analysis of hospital discharge data reveals that CVD is the leading disease category in hospital discharges for women.19 One out of four females will have some form of CVD.2° More women will die from heart disease than all of the remaining 14 causes of death combined.2’ Women are $ times more likely to die from heart disease than breast cancer.22 In 2002, approximately 490,000 women died from CVD which represents about 53 percent of CVD related deaths. 23
Approximately 250,000 women die from a heart attack each year. Only 25 percent of men compared to 3$ percent women will die before the first anniversary of
17 American Heart Association, “facts About Womenand Heart Disease, “Available from http://americanheart.org/presenter.jhtml?identifier=2876: Internet, 2005.
18HiltonHudson and Herbert Stem, The Heart of the Matter: TheAfrican-American’s Guide to Heart Disease, Heart Treatments and Heart Weliness (Illinois: Hilton Publishing, 2000), 15.
‘9NationalInstitutes of Health, “Heart Truth,” Available from http://www.nhlbi.nih.gov/health/hearttruth/: Internet, 2005.
20AmericanHeart Association, “Facts About Womenand Heart Disease, “ Available from http://americanheart.org/presenter.ihtml?identifier=2876: Internet, 2005.
21National Institutes of Health, “Heart Truth,” Available from http://www.nhlbi.nih.gov/healthlhearttruth/: Intemet, 2005.
22Hughesand Hayman, 145.
23Centersfor Disease Control and Prevention, “Preventing Heart Disease and Stroke,” Available from http://www.cdc.gov/nccdphp/publications/factsheetslPrevention/cvh.hUn: Internet, 2005. $ their heart attack.24 By their sixth anniversary, 35 percent of women would have had another heart attack, 11 percent a stroke, 6 percent sudden cardiac death, and 46 percent will be disabled from heart failure.25 Women are more prone to have strokes than men and more than 60 percent of stroke deaths can be attributed to women. The death rate for strokes in 2002 was 56.2 with African-American females accounting for 71.8 percent of the total.26 Women typically have higher rates of stroke due to increased life expectancy and age at occurrence.
Although the age adjusted mortality rates for CVD in African-Americans decreased during the period 1990-98, the disparity by race, ethnicity, and socioeconomic status has grown over the last 4 decades.27 African-Americans and Hispanics exhibit higher rates of CVD mortality than other group. Forty percent of adult African-
Americans have CVD and for African-Americans it is the number one killer.
Approximately 290,000 African-Americans die each year from CVD. For African-
American females, the rate of CVD is 44 percent and 41 percent for black males.
African-Americans are twice as likely as whites to have a first-ever stroke.28 African-
Americans have a higher relative risk of stroke death compared to whites. For ages 35-
54, the risk is four times higher, for ages 55-64, three times higher, and for ages 65-74,
24AmericanHeart Association, “Facts About Womenand HeartDisease,” Available from http://americanheart.org/presenter. ihtml?identifler=2876: Internet, 2005.
25NationalInstitutes of Health, “Heart Truth, “Available from http://www.nhlbi.nih.gov/healthlheartlruth/: Internet, 2005.
27SameerSharma and Ann Malarcher, “Racial, Ethnic, and Socioeconomic Disparities in the Clustering of Cardiovascular Disease Risk Factors,” Ethnicity & Disease 14 (2004): 43.
28AmericanHeart Association, “African-Americans and Cardiovascular Disease, “ Available from http://www.americanheart.org/presenter.ihtml?identifier=3000927: Internet, 2005. 9 two times higher.29 Between 1980 and 1999, hospital discharge rate stroke sufferers increased for both African-Americans and whites, but the relative risk of stroke hospitalization was 70 percent greater for African-Americans.30
CVD poses more threat of death for African-American women than any other racial group. Deaths attributed to heart disease are two-thirds higher for African-
American women than white women. In 2002, approximately 56,000 women died from
CVD compared to 49,000 African-American males. During this same year, approximately 9,000 of these deaths were a result of heart attack and 11,000 died due to stroke.31 African-American women are more likely than white women to suffer from the risk factors for CVD.
The American Heart Association (AHA) conducted a study, in 2003, to assess knowledge, awareness, and perception of CVD in women. African-American and
Hispanic women who are at greatest risk of death from CVD were the least knowledgeable about risk factors for the disease of any other racial or ethnic group. Of the 1,000 women surveyed, a mere 13 percent said they considered heart disease their greatest health risk and only 30 percent of African-American women were aware that heart disease is the leading killer of women.32 Only 36 percent of African-American women listed obesity as a risk factor compared to 44 percent of white women. Similarly,
12 percent of African-American women knew that family history of CVD increased their risk compared to 35 percent of white women. Of all respondents, 70 percent did not
291bjd
30Ibid.
31 American Heart Association, “Facts About Women and Heart Disease, “Available from http://americanheart.org/presenter. jhtm1?identifier2$76: Internet, 2005.
321b1d. 10 know their own levels of low-density lipoprotein (LDL), and high-density lipoprotein
(HDL). On a more positive note, 95 percent of the women when asked a true-false question knew that heart disease developed over a period of years and would not be easily detected.
Although knowledge of CVD and its risk factors has increased since the survey was last conducted in 2000, less than half of the respondents, in 2003, thought that they were well-informed about heart disease. Increasing the awareness of heart disease is crucial to curtailing the increasing mortality rate for African-American women. African-
American women and their providers have to become more knowledgeable about the risk, prevention, and care of CVD. The Al-TAand National Institutes of Health (NIH) have both developed awareness campaigns. In 2002, the MH launched the Heart Truth campaign and the AHA’s “Go Red for Women” promoted the red dress as a symbol for heart disease, similar to the breast cancer campaign’s pink ribbon.
In addition to raising awareness regarding the prevalence of CVD in women, these campaigns are also directing their efforts towards highlighting the differences in
CVD symptoms in women and disparity of treatment of women once they have a cardiac event. Recent studies have shown that women were more likely to report suffering from non-chest pain symptoms. Women reported having six of the seven symptoms, dyspnea, nausea and vomiting, indigestion, fatigue, sweating, and arm and shoulder pain.33
Dizziness and fainting were the only symptoms more common in males. In another study by AHA, 70 percent of women reported unusual fatigue, shortness of breath, and sleep
33flughesand Hayman, 145. 11 disturbances in the month preceding any cardiac episode.34 Less than 30 percent of the women reported having chest pain or discomfort which is the classic/marquee symptom preceding a cardiac event. Proper identification of the early warning signs in women, leads to timelier effective treatment for women experiencing a cardiac event.
Stroke is the third leading cause of death behind heart disease and all forms of cancer. It is also the leading cause of long-term disability in America. Controllable risk factors for stroke are high blood pressure, tobacco use, diabetes mellitus, artery disease, atrial fibrillation, heart disease, transient ischemic attacks, high blood cholesterol, obesity, alcoholism, and physical inactivity.
Each year approximately 700,000 people have a new or recurrent stroke. Of these, 500,000 are first attacks and 200,000 are recurrent attacks.35 In 2003, the death rates for stroke were 51.9 for white males, 78.8 for black males, 50.5 for white females, and 69.1 for black females. For the same year, females accounted for 61 percent of the stroke deaths. Over a ten year period from1993-2003, the stroke death rate dropped 18.5 percent.36 Although this is a significant decrease, there have been virtually no changes in stroke mortality for ethnic disparities. African-Americans are still at a 1.8 to 1.9 times relative risk for stroke mortality. African-Americans also have almost double the risk of having a first-ever stroke than whites. This increase in relative risk has been attributed to the excess prevalence of stroke risk factors, primarily hypertension and diabetes.
34AmericanHeart Association, “Heart Disease and Stroke Statistics “Available from http://americanheart.org/downloadable/heartIl I363$$928248Stats%2006%2obook.pdf: Internet, 2005.
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Clinical trials have shown that effective treatment of hypertension reduces the risk of coronary heart disease, stroke, congestive heart failure, and mortality.40 Hypertension, more commonly referred to as high blood pressure, is defined as having a systolic pressure of 140 mm Hg, a diastolic pressure of 40 mm Hg or higher, or having both; taking antihypertensive medicine; and being told at least twice by a doctor/health professional that you have high blood pressure. There are two types of hypertension, essential or primary and secondary hypertension. Essential hypertension is hypertension where the specific cause is unknown. Approximately 90-95 percent of hypertension cases are essential.41 Secondary hypertension is hypertension that is a symptom from an identified medical problem. Once the medical problem is resolved, the hypertension usually abates. The exact causes of hypertension are unknown, but factors such as race, age, environmental and lifestyle factors (e.g., salt intake, weight, stress, alcohol, and physical inactivity) are documented as playing a role in who gets hypertension.
Hypertension is a major risk factor for heart disease, kidney failure, stroke and other
39AmericanHeart Association, “Study of Women’sAwareness of and Attitudes Toward Heart Disease and Stroke,” Available from hftp://americanheart.org!presenter.jhtml?identifler=3037207: Internet, 2005.
40ThomasJ. Wang and Ramachandran Vasan, “Epidemiology of Uncontrolled Hypertension in the United States,” Circulation 112 (2005): 1651.
41LarryE. fields, Vicki Burt, Jeffrey Cutler, Jeffrey Hughes, Edward Roccella, and Paul Sorlie, “The Burden of Adult Hypertension in the United States 1999-2000: A Rising Tide,” Hypertension 44 (2004): 398. 14 conditions. People with hypertension may not have any easily identified symptoms.
Thus, hypertension has been dubbed the “Silent Killer.”
Over the last decade, the number of Americans living with hypertension increased
30 percent.42 It is estimated that 65 million Americans over the age of 20 have high blood pressure. Approximately 1 in 3 adults have high blood pressure.43 For more than
50 years there have been effective medical treatments for hypertension, yet most persons do not have their high blood pressure controlled.44 Thirty percent of persons living with hypertension do not even know that they have it; 34 percent control their hypertension with medication; 25 percent take medication but do not have their blood pressure controlled; and 11 percent are not taking any medication.45
In a study conducted by Larry Fields, et al., using the U.S. Census and National
Health and Nutrition Examination Survey (NHANES), those with hypertension in the 18-
34 age group was estimated to be 4.4 million; in the 35-44 age group 8 million; in the 45-
54 age group 12.7-12.8 million; and in the 75 and older group 14.1 million.46 The death rate increased 26.8 percent from 1992-2002 and the actual number of deaths increased
56.6 percent. For the year 2002, the death rate for white males was 14.4, for black males
49.6, for white females 13.7, and for African-American females
42lbid
43Ibid.
44Maleeka Glover, “Racial/Ethnic Disparities in Prevalence, Treatment, and Control of Hypertension---Unites States, 1999-2002,” Morbidity and Mortality WeeklyReport 54 (2005): 7.
45American Heart Association, “Heart Disease and Stroke, “Available from http://americanheartor/downloadable/heart/1 1363$$92$24$Stats%2006%20book.pdf: Internet, 2005.
46fields, Burt, et al., 39$.
47AmericanHeart Association, “African-Americans and Cardiovascular Disease,” Available from http://www.americanheart.org/presenter.jhtml?identifier=3000927: Internet, 2005. percent 28.7
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African-Americans living in the United States have one of highest rates of high blood pressure in the world. When compared to other racial/ethnic groups, African-Americans have the highest prevalence at 38.8 percent.52 The prevalence of high blood pressure is greatest in the southeastern United States. When compared with whites, African-
Americans are more likely to have high blood pressure earlier in life and have higher average blood pressures. African-Americans that have high blood pressure are typically middle-aged or older, less educated, overweight or obese, physically inactive, and have diabetes. African-Americans with the lowest hypertension rates tend to be younger, but are also obese. Seventy-seven percent of African-American women over the age of 20 are overweight, and 49 percent of those persons are obese.53 Young African-American males who do not have regular examinations are more likely not to be on any medication and have uncontrolled hypertension.54
Additionally, non-Hispanic African-American women have higher rates of hypertension than non-Hispanic white or Asian women. For African-American women with hypertension, 20 percent or more of their deaths were due to hypertension.55 forty- five percent of African-American women over the age of 20 have high blood pressure and African-American women have an ambulatory medical care rate 85 percent higher
52American Heart Association, “African-Americans and Cardiovascular Disease, “ Available from http://www.americanheart.org/presenter.jhtml?identifler=3000927: Internet, 2005.
53Ibid.
54Ebid.
55National Institutes of Health, “Heart Truth, “Available from http://www.nhlb i.nih.gov/health/hearttruth/: Internet, 2005. 17 than white women for the treatment of hypertension.6 In addition, lack of information and inadequate health care also play a significant role in the prevalence of hypertension in the African-American population.
As noted earlier, hypertension is one of the most powerful indicators as to whether or not a person will have a cardiac event. Research has shown through controlled trials that effective treatment of hypertension decreases the risk of stroke, coronary heart disease, congestive heart failure, and mortality.57 Yet, only a third of the population effectively manages their hypertension. According to a NHANES study from
1999-2000, roughly 40 million adult Americans do not have controlled hypertension.58
Patient factors that contribute to the rate of uncontrolled hypertension include restricted access to health care, susceptibility to hypertension, non-compliance to therapy, patient knowledge and perception, and resistant hypertension. In addition, physician factors such as lack of knowledge about blood pressure thresholds; overestimation of adherence to and disagreement with guidelines; concern about medication side effects; hesitation to treat asymptomatic condition; and reduced time during office visits also contribute to uncontrolled hypertension.
When factoring race and ethnicity into the equation, other variables such as access to care, susceptibility to hypertension and co-morbidity must be taken into account.
Findings from the 1999-2000, NHANES revealed the lowest rates of control were in
Mexican Americans (17.7 percent), when compared to non-Hispanic whites (33.4
56LoriMosca, “Summary of the American Heart Association’s Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women,” Arteriosclerosis, Thrombosis, and Vascular Biology 24 (2004): 394.
57Wangand Vasan, 1651.
58lbid. 18 percent), and non-Hispanic Blacks (28.1 percent).59 Women compared to men have the
lowest rates of controlled hypertension. For African-Americans, cultural and socio
demographic characteristics may contribute to the differences between racial groups just
as immigrant status and geographic location correlate with uncontrolled hypertension.
Given these figures, this is of great public health and clinical importance.
Theoretical explanations for this disparity range from slavery-based etiology to
adverse sociological environmental factors and psychosocial theory. One psychosocial
theory that provides a cultural framework as part of the explanation for the racial/ethnic
disparity experienced by African-Americans is “John Henryism.” Proposed by Sherman
A. James, the theory of John Henryism, was derived from a fictional character named
John Henry who defeated a mechanical steel drill in a man versus machine “steel-driving
contest.” Legend has it that the contest was close, but John Henry emerged the victor.
Unfortunately, Henry collapsed immediately after the contest and died from complete
physical and mental exhaustion. According to Sherman, “the legend is a critique of
oppressive economic systems as well as a warning to the oppressed that the health costs
of individually-based prolonged struggles with adversity can be quite high. . . it (John
Henryism) is a synonym for prolonged, high-effort coping with difficult psychosocial
environmental stressors.60
Past research has shown that high-effort coping coupled with adversity is usually
followed by strong activation of the sympathetic nervous system. This repeated process
591b1d.
60ShermanA. James, “John Heniyism and the Health of African-Americans,” Culture, Medicine, and Psychiatry 18 (1994): 166. 19 over a period of time can lead to a permanent increase in resting blood pressure.6’ Hence, the John Henryism hypothesis is that the highest risk for hypertension should be among persons with high levels of high-effort coping and low socioeconomic status. Thus, the disparity in hypertension for African-Americans could be a result of the increased exposure to social and economic adversity or the behavioral disposition to confront these situations with high-effort coping.62
In a recent review of studies examining the relationship between blood pressure and John Henryism, one-third supports the John Henryism hypothesis. Of the remaining studies, SES was positively rather than inversely related to blood pressure and John
Henryism contributed to this positive association. There is an interaction between gender and John Henryism. Dressier et al., found that there is a positive association between blood pressure and John Henryism for men and an inverse association between John
Henryism and blood pressure for women.63 One study suggests that high job status is associated with high John Henryism in all women.64 Clark and Adams have suggested that perceived racism and John Henryism interact to predict blood pressure.65
When looking at the total picture of hypertension and cardiovascular health in
African-American women, one can surmise that the risk of developing heart disease or
61Kathleen C Light, Kimberly Brownley, et a!., “Job Status and High-Effort Coping Influence Work Blood Pressure in Women and Blacks,” Hypertension 25 (1995): 554.
62James, 162.
63William Dressier, James Bindon, and Yasmin Neggers, “John Henryism, Gender, and Arterial Blood Pressure in an African-American Community,” Psychosomatic Medicine 60 (1998): 620.
64Light, Browniey, et a!., 554.
65Rodney Clark and Jann Adams, “Moderating Effects of Perceived Racism on John Henryism and Blood Pressure Reactivity in Black female College Students,” TheAnnals of Behavioral Medicine 28 (2003): 126. 20 any of its components poses a great threat. Anne Taylor, M.D., professor of medicine and an American Heart Association volunteer says, “There is a critical need for greater awareness about the risk of heart disease among African-American women. All women need to be conscious of their own personal risk, and the statistics for African-American women are staggering.”66 As mentioned earlier, African-Americans develop more severe hypertension at an earlier age and remain undiagnosed, untreated or inadequately treated for longer periods of time. This puts them at increased risk for complications of hypertension, primarily stroke. According to Edward Cooper, M.D., “Hypertension is the major treatable risk factor for stroke and it is estimated that strict control of high blood pressure could prevent over one-half of strokes in b1acks.’67
Although the quality of healthcare in the U.S. is state-of-the-art, there is a disparity in healthcare delivery services to women and men. After a woman has had her first heart attack, she is less likely than men to receive diagnostic and therapeutic procedures, and cardiac rehabilitation. After arriving at the hospital, women are less likely to receive life-saving medications such as beta-blockers and aspirin. Among racial/ethnic groups, African-American women were least likely of any group to receive both medications.68 For diagnostic procedures such as cardiac catheterization, African-
American women were less likely to be referred for the procedure. According to Ashish
Tha,et al., the disparity in healthcare delivery for African-American women results from
66LoriMosca and Lawrence Appel, “Tracking Women’s Awareness of Heart Disease: an American Heart Association National Study,” Circulation 109 (2004): 573.
67ElijahSaunders, ed., Cardiovascular Disease in Blacks (Philadelphia: F. A. Davis Company, 1991), 145.
68Agency for Healthcare Research and Quality, ‘Health Care for Minority Women,“ Available from http://ahrg.gov/research/minoritv .pdf: Internet, 2005. 21 less aggressive therapy due to physician preference and bias when prescribing medications.69
In addition to the disparity in healthcare delivery services, access to care and insurance further complicates the picture of health for African-American women which has a direct impact on her cardiovascular health. Women are disproportionately affected
by poverty. Women living in poverty compared to high income women reported fair or
poor overall health and limited activity; therefore, it is not surprising to find that African-
American and Hispanic women were more likely to report they were in fair or poor
overall health given the higher percentage of minority women living in poverty.70 These
women are more likely to be uninsured and without a personal physician.
It is well-documented that people who have a principle source of care have better
health outcomes.71 In 1996, 75 percent of white Americans had a principal source of care
compared to 63 percent of African-Americans. Twenty-two percent of employed
African-American women versus 12 percent of employed white women were uninsured.
Those who do not have insurance face even greater barriers to accessing health care. In
1996, 58 percent of African-American women compared to 70 percent of white women
had either public or private insurance.
The intersection of such factors as sex, race, and class has a direct impact on the
health of African-American women. Each of these factors, when examined
independently, has significant implications on the success of interventions to improve
69AshishJha and Paul Varosy, “Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease,” Circulation 108 (2003): 1089.
70tbid.
71Agencyfor Healthcare Research and Quality, “Women Health Care in the United States,” Available from hftp://ahro.gov/gual/nhgrwomen!nhgrwomen.htm: Internet, 2005. 22 cardiovascular health outcomes for African-American women. Traditionally, these variables have been examined using a non-cultural framework of analysis. This research proposes to examine these variables through the lens of Africentric Theory and Africana
Womanism to see if it has any effect on the cardiovascular health of African-American women.
This research addresses the following research questions: 1) What affect does characteristics of Africana Womanism have on the African-American woman’s risk for hypertension?, and 2) If there is a positive correlation, does this suggest that characteristics of Africana Womanism serve as a protective factor for developing hypertension?
This dissertation consists of five chapters. Chapter One provides the purpose and rationale for the study. Chapter Two includes the review of the literature and describes the theoretical framework for the study. The methodology described in Chapter Three provides details of the research design, the outcome measures, and data analysis. Chapter
Four, the results section, will provide the findings from the quantitative analysis and test for significance and a summary. Finally, Chapter Five will discuss the implications for the study, conclusions, and recommendations. Africana
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23 CHAPTER TWO
LITERATURE REVIEW
Deaths due to hypertension are largely preventable. While much research has been conducted on the risk factors for cardiovascular disease, study participants were predominantly white males with few or no studies involving African-American women.
For African-American women, their cardiovascular health has a profound effect on their quality of life. The overall body of knowledge that speaks to African-American female health issues is minimal. There are some studies that examine the health of African-
American women but none that use the Africentric or Africana Womanist theories to analyze health behavior. The recently funded Jackson Heart Study is one example of a study that examines cardiovascular health outcomes for African-Americans.’
furthermore, clinical studies have failed to account properly for the continued growth in mortality rates in Aflican-American women. Rising rates of uncontrolled hypertension (due to patient non-compliance to therapy) coupled with the need for more racial/ethnic gender-based studies for prevention strategies, create a sense of urgency to improve the health of African-American women. The American Heart Association
(AHA) published its first female-specific guidelines for preventive cardiovascular health in 1999 and the first set of evidence-based guidelines was published in 2004. Past research has almost always centered on pharmaceutical or therapeutic modalities for the
1ErrolCrook and Herman Taylor, “Traditional and Non-Traditional Risk factors for Cardiovascular and Renal Disease in African-Americans: A Project of the Jackson Heart Study Investigators,” American Journal of Medical Science 324 (2002): 115.
24 25 treatment of hypertensive women.2 Only recently has emphasis been placed on developing studies that provide an analysis of the psychosocial or sociocultural factors that contribute to hypertension.3 Given the lack of clinical data, examining the health of
African-American women from cultural theoretical frameworks becomes critically important. These cultural frameworks are necessary to analyze the complex interaction of gender, class, and race relationships that are ever present in the lives of African-
American women and which have an impact on their health.
The interaction of race/ethnicity and class greatly influence the manner in which
African-American women acquire knowledge regarding health and how they respond to this knowledge. According to Byllye Avery, founding president of the National Black
Women’s Health Project, “The daily struggles stemming from being an African-
American woman may be one of the biggest barriers to self-care among this population.
Thus, it is important for researchers to develop culturally competent relevant studies that provide a foundation for intervention development which assist African-American women to incorporate healthy behaviors into their lives.”4 Interventions that are consistent with the ways of learning and lived experiences of African-American women are more likely to be successful in promoting and changing behaviors in these women.
2Lori Mosca, “Summary of the American Heart Association’s Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women,” Arteriosclerosis, Thrombosis, and Vascular Biology 24 (2004): 394.
3William Dressier, James Bindon, and Yasmin Neggers, “John Heniyism, Gender, and Arterial Blood Pressure in an African-American Community,” Psychosomatic Medicine 60 (119): 620.
4JoAnne Banks-Wallace, “Womanist Ways of Knowing: Theoretical Considerations for Research With African-American Women,” Advances in Nursing Science 22 (2000): 33. 26
Also, in an attempt to provide a theory for the lived experiences of African-
American women, author Alice Walker proposed a definition of Womanism that
1) recognizes the uniqueness of the lived experiences of African-American women; 2) gives voice to the similarities and differences between these experiences and those of other ethnic minority women; and 3) addresses the relationship between African-
American women and men. Another theory that incorporates the lived experiences of
African-American women and the manner in which they receive information is Africana
Womanism.
Clenora Hudson-Weems, a Womanist theorist, under the terminology of “Black
Womanism,” began debating the importance of self-naming the African-American woman’s movement. The term “Black Womanism” eventually evolved into “Africana
Womanism.” Afficana Womanism identifies the woman’s ethnic background, establishes her cultural identity and connects her directly to her ancestral land base.
Womanism refers to the rich legacy of African womanhood and more critically “woman” is an extension of “womanism.”
According to Hudson-Weems, “Africana Womanism is neither an outgrowth nor an addendum to feminism. Africana Womanism is not Black feminism, African
Feminism, or (Alice) Walker’s Womanism that some Afticana women have come to embrace.”5 Feminism, she said, emanates from a European middle-class perspective that cannot account for the effects of being both African-American and female in America.
Africana Womanism is a theoretical framework created and designed for all women of African descent. Its foundation lies in African culture and it addresses the
5ClenoraHudson-Weems, Africana Womanism: Reclaiming Ourselves (Michigan: Bedford Pubjishers, Inc., 1998), 15. 27 unique experiences, struggles, needs, and desires of Africana women. It focuses on the dynamics of the conflict between the mainstream feminist, the black feminist, the African
Feminist, and the Africana Womanist. 6
Africana Womanism as a theoretical application is holistic and humanistic in its approach and can be applied to the daily experience of the African-American woman and her larger community. According to Janette Taylor:
we must not exclusively define or compare those experiences (of African- American women) through theories that privileged white middle class women and
men. . . womanist theory is recommended when working with African-American women because a womanist perspective includes participatory witnessing values and validates African-American women in a way that moves against mainstream positivist methodology and traditional ethnographic participatory observation.7
Africana Womanism provides a venue to conduct a psychosocial analysis of why
African-American women are plagued with higher rates of hypertension. Thus, it becomes critically important to understand the factors associated with the escalating rates of hypertension in this population.
Hypertension is a serious public health threat for African-American women.
Hypertension leads to stroke, heart attack, and other coronary diseases. It affects a person’s life and is more prevalent in African-Americans and elderly women. The
Centers for Disease Control and Prevention (CDC) and the Al-IAare the leading sources of information concerning women and cardiovascular health. The AHA reports that heart attack, stroke, and blood vessel diseases are the primary killers of American women.8 Of
6lbid.
7Janette Y. Taylor, “Womanism: A Methodologic framework for African-American Women,” Advances in Nursing Science 21(1998): 53.
American Heart Association, “Facts About Women and Heart Disease “ Available from http://americanheart.org/presenter.jhtml?identifler=2876: Internet, 2005. 28 these, heart disease is the leading cause of death. AHA has developed a list of factors, some of which can be modified, that increase a woman’s risk for heart disease and stroke.
The more risk factors a woman has increases her risk of having a cardiac episode. These factors include high blood pressure, increasing age, gender, heredity, previous episodes, smoking, high blood cholesterol, physical inactivity, obesity, diabetes, hormonal factors, alcohol, and stress.
Both agencies have published findings that show excess mortality rates for
African-American women. The National Center for Health Statistics (NCHS) of the
CDC reports that the ratio of African-American women who die due to heart disease is
1.5 times higher than their white female counterparts.9 Additionally, the death rate for
African-American women is disproportionately higher than all groups including white males, black males, and white females. The AHA finds that African-American women are 70 percent more likely to die due to heart attack than white women.10 Similarly, both report that while the life expectancy for African-American women has increased in the last 10 years, African-American women are more likely to die five years earlier than their white counterparts.
In 2000, the AHA commissioned a study by Yankelovich Partners, Inc. to determine how aware women were concerning their cardiovascular health.’1 The findings revealed that only a small percentage of women believed that heart disease and stroke were threats to women. While most women could identify the classic signs of
9Michelle Casper and Elizabeth Bameff, Womenand Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality, Second Edition, Office for Social Environment and Health Research (West Virginia: West Virginia University, 2000), 22.
10 American Heart Association, “Facts About Womenand Heart Disease,” Available from http://americanheart.org/presenter.jhtml?identifier=2$76: Internet, 2005.
“Ibid. 29 heart attack, 90 percent did not know the less common signs that most women exhibit prior to a heart attack. Only a third of the women surveyed knew the warning signs of stroke and 50 percent knew that women are at greater risk of having a heart attack afier menopause. The study highlighted how little knowledge surrounded this serious health threat to women, especially African-American women.
Lack of knowledge and increasing mortality has the health community seeking answers to the current public health crisis facing African-American women. Although the number and proportion of women who have participated in studies has increased, earlier studies did not include this important subgroup.’2 As a result, there are limited findings to give recommendations to effectively treat minorities, especially women of racial and ethnic minority groups.
It should be that of the limited number of studies on African-American women, most examined racial discrimination and its effects on hypertension. Several studies have linked racial discrimination to elevated blood pressures in African-Americans suggesting a positive relationship between discrimination and blood pressure.13 Sharon Wyatt, et al., found that racist provocation leads to increased cardiovascular reactivity.’4 In a 1990 study, Nancy Krieger found that although racial discrimination was related to high blood pressure for African-American women, gender discrimination was unrelated to high
‘2LoriMosca and Lawrence Appel, “Tracking Women’sAwareness of Heart Disease: an American Heart Association National Study,” Circulation 109 (2004): 573.
t3ShermanJames, “John Henryism and the Health of African-Americans,” Cuttura1 Medical and Psychiatry 18 (1994): 163.
145haronWyatt and David Williams, “Racism and Cardiovascular Disease in African-Americans,” American Journal of Medical Science 325 (2003): 315. 30 blood pressure for white women.15 Similarly, it has been documented that disproportionately high rates of heart disease among older African-American women are associated with chronic stress related to environmental and psychosocial factors.’6
Conceptual Framework
In an attempt to capture the plight of the African-American woman’s struggle, which directly impacts health status, academics have put forth two theories, black feminism and Africana Womanism. Feminism, according to noted feminist scholar bell hooks, for most Americans is synonymous with women’s liberation, a movement that seeks to make women the social equals of men.17 feminism’s history lies with the
Woman’s Suffrage Movement organized by liberal white women seeking to abolish slavery and support equal rights regardless of race, class, or sex. As the organization evolved, white women began to advocate for rights solely for middle-class white women leaving the African-American woman to her own devices.’8 These actions created feelings of hostility and racism that have moved forward through history.’9
The quest for equality for all may have begun to slow with the passage of the
Fifteenth Amendment to the Constitution in 1870. African-American men were granted the right to vote while white women were denied that privilege. African-American men were clearly excited with their voting rights. Any vote for the African-American
15NancyKrieger, “Racial and Gender Discrimination: Risk Factors for High Blood Pressure,” Social Science Medicine 30 (1990): 1273.
16NationalWomen’s Health Resource Center, “Women, Chronic Stress, and Resilience,” (National Women’s Health Repori 2003), 5.
‘7hooks,bell. feminist Theory: from Margin to Center. (Boston: Southend, 1984), 19.
‘8ClenoraHudson-Weems, Africana Womanism: Reclaiming Ourselves (Michigan: Bedford Publishers, Inc., 1998), 21.
‘9Jbid. 31 conmiunity was good for the entire community. However, this jubilation over expanded voting rights was not reciprocated by white women who were clearly disillusioned.20
In 1890, the National American Women Suffrage Association was founded.
Southern white women were encouraged to join. Immediately, the association began to depart from the former ideology of suffragette leader Susan B. Anthony, who advocated equal rights for all, and protest the voting rights of African-American males. Citing the virtues of Anglo-Saxons and white supremacy, Carrie Chapman Catt, a conservative, warned that the vote of the African-American male who was unqualified and biologically inferior, could gain political power within the American system. Catt and her white middle class counterparts lobbied to band with white men to secure votes for “pure” whites, thereby excluding African-Americans and immigrants.2’ Although the white women’s movement began addressing white women’s civil rights and social injustice, it alienated an entire group of women—women of African descent. Thus, feminism from its inception has been based entirely on the priorities, agenda, and experiences of middle class white women.
feminism was conceptualized by white women to address specifically the needs of middle-class white women in their quest for gender equity.22 It is based on the assumption that gender is first and foremost in our patriarchal society. Hudson-Weems,
20Hudson-Weems,Africana Womanism, 20.
21CtenoraHudson-Weems, “Africana Womanism and the Critical Need for Afticana Theory and Thought,” The WesternJournal of Black Studies 21(1997): 79.
22PatriciaHill Collins, Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment, (New York: Routledge, 2000): 4; and hooks, 19. 32 agrees with this position stating “feminism was conceptualized and adopted by white women, reflecting an agenda which was designed to meet their particular needs.”23
Rosalyn Terborg-Penn, in Womenin Africa and the African Diaspora, documented chronologically the historical record of African-American women in the feminist movement. While feminists have included African-American women as the movement progressed through the 20th century, Terborg-Penn detailed the institutionalized discrimination experienced by African-American women. This discrimination, she contends, led African-American women to develop their own organizations that championed issues of race and gender inequality.24
Mae King, a recent scholar and one of the first African-American women to suggest the uniqueness of the African-American woman’s societal position in the struggle for race and gender equality, noted the lack of distinction between the roles of African-
American women and African-American men.25 The cult of true womanhood, a white gender ideology during the 19th and early 20th century characterized by piety, purity, domesticity, and submissiveness, did not include African-American women. Thus, according to this theory, African-American women and white women do not have a common gender identity.26 Chattel slavery subjugated them to the status of objects, subhumans, and animals. African-American women have been forced to assume economic responsibility for the family along with African-American men. Therefore,
23Hudson-Weems, Africana Womanism, 4.
24RosalynTerborg-Penn and Andrea Benton Rushing, eds., Women in Africa and the African Diaspora, (Washington, DC: Howard University Press, 1996), 39.
25 Mae King, “Oppression and Power: The Unique Status of Black Women in the American Political System,” Social Science Quarterly 56 (1975): 124.
26Collins,74. 33 according to King, it seems reasonable to conclude that race, not sex, is the decisive determining factor for the status of African-American women in the United States.27
Race, said King, shaped her role and kept her from the gauze (sic) of “American femininity” for in America race is the foundation for the African-American woman’s oppression and sex only intensifies the first burden, race.2
Thus, to King and her counterparts, feminism is a western construct which has largely gone uncontested. According to Clenora Hudson-Weems, “the mainstream feminist’s assertion is for equal and individual rights for white women in a patriarchy where white men have monopolized power. Her fight against her white male counterpart has to do with her submission of rights and property and her subsequent inferior status in society attributable to years of domination by the males in her life.”29
In direct contrast is the African-American woman who shares a common problem and a joint fate with African-American men. Since the African-American male has never had the institutionalized power to oppress, family pride and solidarity have been embraced by the African-American woman. She does not feel that gender is her primary concern in the patriarchal system. Filomina Chioma Steady, in TheBlack WomanCross-
Culturally, adequately assessed this position. According to Steady:
Several factors set the black woman apart as having a different order of priorities. She is oppressed not simply because of her sex but ostensibly because of her race
and, for the majority, essentially because of their class. . . Black women do not perceive their enemy to be black men, but rather the enemy is considered to be
27Ibid.,117.
281b1d.
29[bid.,80. 34
oppressive forces in the larger society that subjugates black men, women, and children.30
As a result of the African-American woman’s thoughts on gender equality, she and white women do not share the same ideological thoughts on feminism. The historical and present-day realities of these women are not the same, and thus, feminism cannot possibly be applicable to both given the circumstances.
Black feminism emerged in the 1970’s as an offshoot to feminism. Black feminism is defined by sociologist Patricia Hill Collins as “the subordination of black women within the intersecting oppressions of race, class, gender, sexuality and nation...
Its purpose is to resist oppression, both its practices and the ideas that justify it.”31
No mailer which definition one uses, many of today’s scholars find black feminism problematic. Its foundation lay in empowering women and not empowering the race. Bettina Aptheker, a white feminist, does not see feminist priority as a way for the African-American woman to be empowered. In her article, “Africana Womanism and the Critical Need for Africana Theory and Thought,” Hudson-Weems quotes Aptheker as saying:
when we place women at the center of our thinking, we are going about the business of creating an historical and cultural matrix from which some may claim autonomy and independence over their own lives. For women of color, such autonomy cannot be achieved in conditions of racial oppression and cultural genocide. In short, feminist, in the modem sense, means the empowerment of women. For women of color, such an equality and empowerment, cannot take place unless the communities in which they live can successfully establish their own racial and cultural integrity.32
30filomina Chioma Steady, ed., The Black WomanCross-Culturally (Vermont: Schenkman Books, Inc., 1981, 1999), 23.
31CoIlins,22.
32Clenora Hudson-Weems, “Africana Womanism and the Critical Need for Afticana Theory and Thought,” The WesternJournal of Black Studies 21(1997): 79. 35
Thus, the feminist movement itself recognizes its own inability to effectively deal with the class, gender, and race issues facing African-American women.
Hudson-Weems suggests that black feminism is not the appropriate vehicle for
Africana women. Weems states that by and large African-Americans do not support the feminist movement. Africana women do not see their male counterparts as the enemy and there is still a healthy amount of distrust among African-Americans and white organizations. Weems postulates, as historian and scholar Valethia Watkins did, that no black feminists existed prior to around 197O. These scholars contend that the long tradition of black women’s activism and consciousness was not feminist activity.
Activists such as Maria Stewart, Frances Harper, Sojourner Truth, Harriet Tubman, and
Ida B. Wells were not championing the rights of women, but were race defenders.
Hudson-Weems and Watkins agree that the greatest offenders are black feminists who misclassify the works of Anna Cooper, who states that “woman’s cause is man’s cause: (we) rise or sink together, dwarfed or godlike, bond or free,” as early feminist activity.34 Hudson-Weems even suggests that white feminists modeled their movements from these early African-American activists. Hudson-Weems contends that Africana women have adopted a feminist perspective primarily because of the lack of a framework for the individual needs of Africana women.
33ValethiaWatkins, “Womanism and Black feminism: Issues in the Manipulation of African Historiography,” in African WorldHistory Project: The Preliminary Challenge, eds., Jacob H. Carruthers and Leon C. Harris, 245-284, by the Association for the Study of Classical African Civilizations (Los Angeles, 1997), 265.
34DeloresP. Aldridge and Carlene Young, eds., Out of the Revolution: TheDevelopment of Africana Studies (Maryland: Lexington Books, 2000), 205. 36
Feminism, no matter what name appears before it, shares the ideology of its forerunner white feminism. According to scholar Watkins, some black women see
Africana Womanism as a viable alternative to feminism. Watkins identifies five areas that are problematic for black feminists: 1) African women have traditionally rejected feminism; 2) women that have petitioned for inclusion in the movement have been marginalized or ignored; 3) feminist thought is based on the sole experiences of white women and western values; 4) middle class white women dictate the direction of feminist theory; and 5) feminist theory is racist.35
Hudson-Weems agrees in principle with Watkins. She says, “While white feminists today are not necessarily hostile to the most dominant issues that impact more upon the lives of Africana Women, the majority are not sensitive to the magnitude of these concerns. For example, the feminist movement is not free from racism, since many feminists are guilty of it.”36 Scholars believe aforementioned statements substantiate what many African-American women feel regarding the feminist movement.
According to bell hooks, in her celebrated book feminist Theory: from the
Margins to the Center, “(So far), despite our continuing efforts to transform feminist thinking, we reside on the margins of the feminist movement. . . overall, within most feminist circles power continues to be distributed in ways that maintain and perpetuate existing racial hierarchies wherein white women always have greater status and power
35Watkins, 245.
36Kudson-Weems, Africana Womanism, 4. 37 than black women.”37 If Africana women are to move from the margins of feminism, they must begin to write and document their own history.
Clenora Hudson-Weems offered the best alternative for Mricana women.
Africana Womariism rejects the term feminist and offers a platform for action and the theory’s conceptual framework allows the Africana woman to name and define her concerns. Moreover, it allows the Africana woman the opportunity to engage collectively in dialogues concerning womanhood, family, and society and sets agendas for future generations of Africana women.
Hudson-Weems proposed her theory specially to define the ethnicity and cultural identity of Africana women. Africana Womanism gives voice to the Africana woman’s historical struggle. She further theorizes that an Mricana Womanist does not view men as her primary enemy because African-American men have not possessed the power to oppress African-American women as white men have oppressed white women.
Hudson-Weems differentiates feminism from African Womanism by three main characteristics: 1) Africana Womanism is race-centered whereas feminism is female- centered; 2) Africana women prioritize race, class, and gender, whereas the feminist concentrates on gender; and 3) Africana Womanism seeks to empower all women of
African descent.38 Mricana Womanism recognizes the collective struggle of Afficana people. Hudson-Weems identifies 1$ characteristics key to human survival in Mricana
Womanism. They are: self-naming, self-definition, being family-centered, being in concert with the male struggle, becoming a flexible role player, forming a genuine
37hooks,2.
38Hudson-Weems, Africana Wornanism, 22. 3$ sisterhood, being strong, having male compatibility, earning and giving respect, achieving recognition, being complete, making cultural connections, having spirituality, being respectful of elders, being adaptable, having ambitions, and mothering and nurturing. She believes that the true Africana Womanist possesses these qualities to a varying degree which encompass all aspects of her life. These characteristics seek to create a holistic existence and resolve much of the conThctexisting among Africana men, women, and children.39
Hudson-Weems contends that Africana women must not use an alien framework such as feminism to resolve their concerns because the historical realities of
Eurocentrism, oppression, and domination should be articulated from a position that is inclusive of these realities. Race, she says, is of paramount importance in any discussions of Africana women. Human discrimination transcends sex discrimination.
Africana Womanism examines race from an historical perspective. According to
Hudson-Weems, slavery was synonymous with poverty. When examining the origins of
slavery it becomes apparent that”.. . it was an attitude constructed to authorize exploitation by the dominant culture to acquire free or cheap labor-economic exploitation by the dominant culture arguing race inferiority as a justification for slavery.”40
Therefore, Hudson-Weems says racism and classism are inextricable. She notes that while classism gave birth to racism, racism is by far the larger issue. “Consider the experience of a woman who said that from so many feet away, her race was noticed; as she got into closer proximity, her class was detected; but that it was not until she got into
39Ibid.,73.
40DeloresP. Aldridge and La Francis Rodgers-Rose, eds., River of Tears. The Politics of Black Women’sHealth (New Jersey: Traces Publications, 1993), 205. 39 the door that her sex was known.” Thus, the Africana woman must prioritize the obstacles before her and must first fight the battle of racism. She works in concert with the Africana male solidifying their relationship in the struggle against racial oppression.
Africana Womanism recognizes the traditions that have existed within the
African-American community that have survived the penetration of Eurocentric values.
Unlike white women, Africana women have never been considered the property of their men nor have they received or participated in the cult of true womanhood. African-
American women and men have been equal partners in the fight against oppression recognizing that they could not be divided by sex.
Africana Womanism allows the Africana woman and her community to take control of its destiny by writing and giving voice to their lived experiences. African-
Americans must use epistemological frameworks to meet their needs and provide explanations that originate from within a valid cultural context. Africana Womanism is an ideology created for all women of Africana descent. It is a conceivable alternative to all forms of feminism for the Mricana woman in her collective struggle.42
Africana Womanism shares some of its fundamental concepts with Womanist
Theology. Born out of a methodology that validates past lives of Africana slave women,
Womanist Theology seeks to question the social construction of black womanhood in relation to her church, community, family, and larger community. Just like Afticana
Womanism, Womanist Theology embraces:
the crucial connection between African-American women and the plight, survival, and struggle of women of color throughout the world. It utilizes
41Hudson-Weems, Africana Womanism, 41.
421b1d.,31. 40
traditional church doctrines, African-American fiction and poetry, black women leaders of the century, personal narratives, poor and working class black women in holiness churches, and African-American women under slavery to give voice to a history, to declare authority for their community, to learn from previous generations, and improve the quality of life for all.43
Just as Africana Womanists do not align themselves with feminists, Womanist
Theologians also do not align themselves with feminist theologians. Feminist Theology primarily addresses the oppression of white women and did not in its development address race and economics. Although feminist theologians provided great strides into an overwhelmingly male discipline, they did not address the lived experiences of Africana women. Like feminism, feminist Theology does not address issues of all women; therefore it is not universal in its application. In addition, Feminist Theology creates a paradigm in opposition to men.
Thus, in order to establish a “holistic God-talk” with and for African-American women there has to be a presence, a voice, which advocates and stands in solidarity for all the oppressed. Synonymous with Africana Womanism, “Womanist Theologians bring to center the experience and knowledge of those marginalized by a complex layering and overlapping by race, gender, and class experiences of all groups, inclusive of those with privilege and power.”44 A common thread between Womanist Theology and Africana
Womanism is the importance of spirituality. Spirituality is integral to the epistemological development of Africana women. Thus, Womanist Theology is essential in the girding of
Africana Womanism. Africana Womanism provides a relevant framework to overcome
43LindaE. Thomas, “Womanist Theology, Epistemology, and a New Anthropological Paradigm,” Cross Currents48 (1992): 488.
44jacquelynGrant, White Women‘sChrist and Black Women‘sJesus: feminist Christology and Womanist Response (Canada: Scholars Press, 1989), 195. 41 the historical absence of valid theoretical models which speak to the unique status of
African-American women in the United States. Africana Womanism provides a culturally sound theory from an African-American woman’s view.
Africana Womanism is more than just a response to the limitations of feminism for African-American women—it advances the idea that the Africentric woridview is the best theoretical framework to explain African-American woman’s behaviors and thought processes. According to scholar Jerome Frank, “worldview is a highly structured, complex, interacting set of values, expectations, and images of oneself, others, and the world.”45 Worldview differs from person to person due to its cultural and ecological base. The way in which one views the world is of critical importance because of its influence on one’s experiences. Thus, worldview acts as a lens through which our experiences are filtered and has the ability to define our actions as well as reactions to our environment.46 Worldview has the potential to act as resources for stress resistance.
African-Americans living in the United States are confronted daily with two conflicting worldviews. More often than not, African-Americans have assimilated into the dominant culture and adopted the negative beliefs and perceptions about their own culture.
Using Hudson-Weem’s Africana Womanism theory and Joseph Baldwin’s Notes on an Africenfric Theory of Black Personality, the researcher proposes to show how the theory of Africana Womanism, using race as a variable, can be used as an epistemological framework for predicting cardiovascular health outcomes in African-
American women. Hudson-Weems states that Africana Womanism is race-centered and
45Jeromefrank, Persuasion and Healing (New York: Schocken, 1977), 52.
46Markfine, Al Schwebet, and Laura Myers, “The Effects of World View On Adaptation to Single Parenthood Among Middle Class Adult Women,” Journal offamily Stress 6 (1985): 107. 42 prioritizes race before class and gender. Likewise, according to psychologist Joseph
Baldwin,”.. . where an alien cosmology is likely to dominate the reality orientation of black people, socialization processes that nurture and reinforce the active operation of the natural African disposition are likely to be weakened or distorted.”47
Operating from an Africentric worldview would provide a more appropriate and positive framework to assess the lived experiences of African-American women. An
Africentric woridview reflects the values, attitudes, and customs of persons from Africa and those of African descent. Several authors have noted that for African-Americans living in the United States, remnants of an African worldview are present and help them adapt to life in a relatively foreign and hostile environment.
Joseph Baldwin’s theory evolved from some of his earlier work in developing theories on black psychology and is based on several assumptions. first, individuals derive all meaning and significance from their social surroundings. One’s social reality has a direct impact on one’s life experiences. Baldwin proposes that one’s first social definition is race. This definition of race is the basis from which all other social meanings arise. Second, one’s woridview or cosmology is defined from one’s social definition and culture. Baldwin states that “one’s biogenetic definition forms the basis of one’s reality structure, which is reflected in all other basic social commonalities, institutionalized processes, physical artifacts and products, and so forth that define one’s approach to survival.”48 Hence, one’s survival thrust, cosmology and culture, are
47]oseph A Baldwin, “Notes on an Africentric Theory of Black Personality,” in Black Studies Theory, Method and Cultural Perspectives, ed., Talmadge Anderson (Pullman, Washington: Washington State University Press, 1990), 134.
48b1d. 43 representative of the racial group to which they belong. As race changes, survival thrust changes.49
Baldwin compares an African and European cosmology. He says that there is a natural relationship between the two cosmologies. Each has a biogenetic commonality, cosmology, culture, and survival thrust. But each thrust has fundamental differences from the other which he terms as “opposite-incompatible.” The African cosmology embraces “inclusiveness” and is characterized by a “man-nature harmony” that is
“inseparable, interdependent, and total.”5° The European cosmology embraces
“exclusiveness” and is characterized by a “man versus nature” with man mastering and controlling nature through oppression, suppression, and unnatural alteration.5’
Both Baldwin and Hudson-Weems provide an Africentric base from which is drawn basic assumptions regarding African-American women. Baldwin also notes the importance of spirituality in the development of one’s Africentric cosmology. Hudson
Weems provides a socio-historic context from which one can analyze behavior. She places value on culture and collectivism. Hudson-Weems offers an alternative construct that can identify gender roles for African-American women outside of the current feminist paradigm. According to Hudson-Weems, the current feminist paradigm does not adequately identify the role of the Africana woman as she interacts within and outside of her race. Hudson-Weems identifies her theory with Baldwin’s African cosmology and places feminist theory with the European cosmology.
491b1d.,135.
501b1d.
5tIbid. 44
Table 1 provides an overview of the cosmologies/theories, Africana Womanism and feminism. When examining the two cosmologies/theories, Afticana Womanism and feminism, the distinction is clear. Thus, the African-American woman must distinguish between feminism, a cosmology she has been primarily exposed to and assimilated with and Africana Womanism, a theory that can set an agenda for intersectionality of race, class, and gender within the African-American community. Baldwin states that,
“Africentric values play a significant role in a black person’s life. . . and challenges to these cultural values are primary sources of stress.”52 Therefore when examining or attempting to understand African-Americans, it should be done from an African cosmology or African cultural framework.
Table 1. Characteristics of Africana Womanism Compared To Characteristics of feminist Theory European Cosmology — feminist Theory African Cosmology — Afticana Womanism Created for middle class white women Created for women of African descent Outgrowth of women’s self-conscious Shared racial oppression and common history struggles of gender oppression that transcends racial, ethnic, or class groups Prioritizes gender, class Prioritizes race, class, gender female empowennent Race empowerment Spiritualism and circularity Materialism and ordinality Rejects patriarchy In-concert with males Privileges and advantages Struggle Exclusiveness Inclusiveness Values women’s ideas and actions Values women’s ideas and actions Adapted from: Janette Y. Taylor, “Womanism: A Methodologic framework for African-American Women,” Advances in Nursing Science 21 (1998): 55; Clenora Hudson-Weems, Africana Womanism: Reclaiming Ourselves (Michigan: Bedford Publishers, Inc., 1998), 22; and Joseph A Baldwin, “Notes on an Africentric Theory of Black Personality,” in Black Studies Theory, Method, and Cultural Perspectives, ed., Talmadge Anderson (Pullman, Washington: Washington State University Press, 1990), 134 45
As demonstrated in figure 1, the researcher offers an operational model that indicates that African-American women who ascribe to the tenants of Africana
Womanism are less likely to be hypertensive. The hypothesis is: Afficana Womanism serves as a buffer thereby decreasing the stress from the daily assaults of racism, sexism, and classism experienced by African-American women. Women who ascribe to the tenants of feminism are not protected from these assaults pulling them at increased risk for hypertension. The researcher proposes a hypothesis that may advance the knowledge and understanding of cardiovascular health in African-American women: Africana
Womanism serves as a protective factor against hypertension among African-American women (see figure 1).
The operational model of theory is a creative way of incorporating Africana
Womanism as presented by Hudson-Weems and Baldwin’s Theory of Black Personality.
In addition, the operational model of theory offers a different way of examining the impact of and distinction of hypertension as possibly experienced by women of African descent and women who adhere to feminism.
This study will estimate the odds ratio of hypertension among women with characteristics of Africana Womanism as compared to women without characteristics of
Africana Womanism. 46
AfricanaWomanism Baldwin’sPersonalityTheory
AfricanCosmology - Womanism European Cosmology - Feminism *_ Decreased rates [increasearates
figure 1. Operational Model of Theory CHAPTER THREE
METHODOLOGY
The purpose of this research is to examine the association between women with characteristics of Africana Womanism and hypertension. National data on African-
Americans has typically been collected using surveys in the general population.
However, the use of such surveys only includes concepts, measures, and methods developed to study white Americans. In order to begin to examine this researcher’s hypothesis, a study that has been formed by an awareness and appreciation for the unique cultural experience of African-Americans is needed. The first data set that takes into consideration the cultural experience of African-Americans was the National Survey of
Black Americans (NSBA) developed by James Jackson, who is a senior research scientist and Program Director of the Institute for Social Research at the University of Michigan.
The NSBA, a pioneering cross-sectional epidemiologic study, was initiated in
1977 to examine major social, economic, and psychological aspects of black American life.’ The NSBA, a 13 year study conducted in four waves, 1979-80, 1987-88, 198$-$9, and 1992, was conducted by University of Michigan, Survey Research Center, Inter- university Consortium for Political and Social Research (ICPSR) and was funded by the
National Institute of Mental Health. The NSBA was chosen even though it was initiated in 1977 and completed in 1999, for the following reasons: 1) It allows for an
‘James S. Jackson and Gerald Gui-in, National Survey of Black Americans, Waves 1-4, 1979- 1980, 1987-1988, 1988-1989, 1992 [Computer file], Conducted by University of Michigan, Survey Research Center, ICPSR version Ann Arbor, MI: Inter-university Consortium for Political and Social Research [producer and distributor], 1997.
47 48 epidemiologic study that provides, even in 2006, available data on a sufficient number of
African-American women, 2) It affords an opportunity to address the health challenges of women of African descent from a humanist perspective as well as an epidemiological one, and 3) It allows for the utilization of Baldwin’s concept of an African cosmology providing a sense of identity, self-naming, a more meaningful way of examining oneself within the social construct of race, and it lends itself to the development of an Afrientric personality for blacks. The Afrocentric personality, along with Hudson-Weems concept of Womanism, set the stage for an investigation of the relationship between the two theories and women’s perception of the impact of race on the delivery of health services.
It is a national probability household survey of individuals 18 years and older.
The sample survey was based on the 1970 census which provided a national picture of where African-Americans were living. Seventy-six primary geographical areas were chosen to ensure that the survey research center ($RC) had African-American households with the minimum size requirements. The overall probability of being selected to participate in this study was one in 2,300 people. Roughly 58% of the sample came from the 1970 $RC national sample.2 The sample was self-weighting with each African-
American household in the United States having an equal chance of being selected to participate in the study.
The Standard Listing and Screening Procedure (SLASP) and the Wide Area
Screening Procedure (WASP) were the two methods used to locate African-American housing units (HUs). The SLASP was developed by the SRC and the WASP developed
2lbid. 49 by the principal investigators of the study. The SLASP method was used in mixed and primarily African-American areas. The SLASP, in addition to listing all households in the desired area, identified a subgroup of households to identify the race of the remaining households. Furthermore, the SLASP interviewers were told exactly which HUs to make contact with by the SRC.
The WASP was used to screen areas suspected of having little or no African-
American HUs. WASP interviewers relied on their own assessment to determine the number and concentration of African-American HUs in the area. The WASP interviews did not list households like the SLASP. They only asked a referring RU about African-
Americans in the area. Only those identified as African-American were listed. For low density African-American areas, this procedure minimized the screening cost and was very effective in locating the African-American HUs. One person from the sample households, 1$ or older, that identified themselves as African-American, and a citizen of the United States, was randomly chosen using the Kish procedure from the list of eligible participants to take part in the study.3
The instrument was developed with the assistance of social scientists, students, and a national advisory panel of African-American scholars. Demographic variables on the survey instrument included education, marital status, income, employment status, occupation, and political behavior and affiliation. Other variables were neighborhood community integration, services, crime and community contact, the role of religion and the church, physical and mental health, self-esteem, life satisfaction, employment, the effects of chronic employment, the effects of race on the job, interaction with family and friends, racial attitudes, race identity, group stereotypes, and race ideology. The
3lbid. 50 instrument took approximately two and half hours to administer. Study participants were interviewed face to face by an all African-American male and female staff with professional training. Over a seven month period, from 1979-80, 2,107 adults were surveyed. The analysis was restricted to female respondents (n1 310).
With an average of 3-4 call backs per household, and a range of 1-22 calls per household to complete interviews resulted in a 67% response rate. The sample was fairly representative of the 1980 census. There was a disparity between women and men, and young men and women were slightly underrepresented and older women were overrepresented.4 The disparity between women and men was attributed to the higher proportion of female-headed households.
The data were analyzed using the SAS statistical software.3 The dependent variable for this study was hypertension. Hypertension was assessed by the following question: “I am going to read a list of health problems. After each one, please tell me whether a doctor has told you that you have that problem.. . hypertension or high blood pressure (see Appendix 1, Page 73, Question Cl 0).6 Additionally, circulation and stroke were ascertained using this same question and format. Two women were excluded because of missing responses on hypertension.
The predictor variable was women with characteristics of Africana Womanism.
Characteristics of Africana Womanism were assessed by the following question: “Is it more important for Black women to fight for the rights of all Black people or to fight for
4lbid.
5A11analyses were completed using SAS V9.1 (Cary, NC: SAS Institute).
6James S. Jackson and Gerald Gurin, National Survey of Black Americans, Waves 1-4, 1979- 1980, 1987-1988, 1988-1989, 1992 [Computer fileJ, Conducted by University of Michigan, Survey Research Center, ICPSR version Ann Arbor, MI: Inter-university Consortium for Political and Social Research [producer and distributorJ, 1997. 51 the rights of all women or both equally important (see Appendix 1, Page 74, Question
G34)?”7 Respondents answering “fight for the rights of all Black women” and “both equally important” were classified as having characteristics of Africana Womanism.
Those answering “fight for the rights of all women” were classified as feminist. Thirty- eight women were excluded because of missing responses on characteristics of Africana
Womanism.
Covariates examined included age, education, personal income, marital status, circulation problem, and stroke. Age was a derived variable that was calculated by birth year and the date the interview was completed. Education was derived from a summary variable that ascertained the highest grade the respondent completed (see Appendix 1,
Page 75, Question H14). Two categories were created for education, 1) no high school diploma or graduate equivalency diploma, and 2) high school diploma and higher education. Thirty women were excluded because of missing responses on education.
Personal income was ascertained by the following question: “What was your own personal income in 1978 (see Appendix 1, Page 76, Question H2$)?”8 Responses were categorized into three levels, $0 - $4,999, $5,000 - $9,999 and $10,000 - $30,000. One hundred and twenty-two women were excluded because of missing responses on personal income. Marital status was assessed by the following question: “Are you married, divorced, separated, widowed, never married, or if respondent volunteers common law marriage (see Appendix 1, Page 77, Question El 8)?” Employment status was assessed by the following questions: “Now I would like to talk with you about work—are you
7lbid.
8Ibid.
9lbid. 52 working now for pay, laid off, or not working at all for pay?,” and “Do you have only one job, or do you have more than one job (see Appendix 1, Page 78, Question D1)?”°
Number of children was assessed by the following question: “Do you have any children
(see Appendix 1, Page 79, Question E3 1)?” Because all the participants were African-
American, race and ethnicity were not examined as variables.
To prepare the data for analysis, libraries were created to label variable values in the SAS output (see Table 2, Appendix 2). Data analysis consisted of univariate, bivariate, and multivariate analyses. The univariate analysis consisted of frequency distributions for age. Cross tabulations were computed for the demographic or health related variables by the independent (characteristics of Africana Womanism) and the dependent (hypertension) variables. Chi-square tests were computed to determine whether associations were statistically significant. Multivariate logistic regression was used to obtain the crude and adjusted odds of hypertension. A series of models were run to examine various combinations of these covariates that were determined to be significant in the cross tabulations. The final model consisted of the covariates age, education, and employment status. Confidence intervals of 95% were computed to assess significance of these estimates.
t0Ibid.
111b1d Table 2. List of Variables
Variable Value Meaning Dependent Hypertension 1 Have hypertension 0 No hypertension Independent Education 1 Have high school diploma or GED 2 No high school diploma or GED
Marital Status 1 Married 0 Not married
Personal Income 1 $0 - $4,999 2 $5,000 - $9,999 3 $10,000-$30,000
Employment Status 1 Working now 2 Laid off 3 Not working for pay at all
Stroke — Told by Doctor 1 Had stroke 5 Did not have stroke
Have circulation problem 1 Have circulation problem 5 Does not have circulation problem
Respondent’s Age Derived variable by birth year
Respondent’s Sex 1 Male 2 Female Predictor Black women fight for Blacks/Women 1 Fight for black rights! Both equally Important = Womanism 0 Fight for women’s rights = Feminism
Source: James S. Jackson and Gerald Gurin, National Survey of Black Americans, Waves 1-4, 1979, 19$O, 1987-1988, 1988-1989, 1992 [Computer file], Conducted by University of Michigan, Survey Research Center, ICPSR version Ann Arbor, MI: Inter-university Consortium for Political and Social Research [producer and distributor], 1997. CHAPTER FOUR
RESULTS
Of the 1310 African-American women responding to the survey, only data from
111$ were analyzed. One hundred ninety-two African-American women were excluded who had missing data on the outcome (hypertension, n=2), the etiologic factor (Africana
Womanism characteristics, n=38), or any of the covariates of interest (education, 11=30 and income, n122). The age of the respondents ranged from 1$ to 101 years (M = 42.3,
SD = 17.4) (see Table 3). Most of the women were married (35%) or never married
(22%). Seventy-seven percent (77%) of the respondents had children and the majority of the women had a high school diploma with some college (60%). Over half of the women were in the lowest income category (less than $5,000 per year) and more than a third of the women lived in a large city (36%) (see Appendix 1, Page 80, Question H3).
Table 4 shows the demographic and cardiovascular-related characteristics of the study population by hypertension status. Thirty-five percent of the women (n=392) in the sample were hypertensive. Women with hypertension were slightly older (M=52,
SD=16.2) than women without hypertension (M=37, SD=16.0) (p<0.000l) and were more likely to have less than a high school education (57%) compared with non hypertensive women (31%) (p<0.0001). A higher percentage of hypertensive women were in the lowest income category (less than $5,000 per year) (62%) compared to non
54 55
Table 3. Demographic Characteristics of African-American Women, U.S., 1979-1980
Characteristic n=111$
Mean Age 42 yrs. (17.4 Sd) Education < High School 40% > High School 60% Income 0-4,999 54% 5,000 — 9,999 27% >10,000 19% Marital Status Married 35% Divorced 13% Separated 12% Widowed 17% Never Married 22% Common Law 1% Employment Status Working 52% Laid Off 3% Not Working for Pay at Mi 44% Have Children Yes 77% Child(ren) Deceased 1% No 21% Residential Area Rural or Country Area 28% Small Town 18% Small City 13% Suburb of a City 4% Large City 36% Unknown 1% 56
Table 4. Demographic and Cardiovascular-Related Characteristics of African-American Women by Hypertension Status, U.S., 1979-1980
Hypertension No Hypertension Chi Characteristic (n=392) (n=726) Square
Mean Age 52 yrs. (16.2 sd) 37 yrs. (16.0 sd) <0.0001 Education in both groups were married, differences in marital status were not statistically significant. A higher percentage of hypertensive women were unemployed (61%) compared with non-hypertensive women (41%) (p<.O.0001). Eighty-one percent of the hypertensive women compared to 94% (p told by a physician that they had no problems with blood circulation or “hardening of the arteries.” When asked if they had ever been told by a physician that they had a stroke, 4% of hypertensive women reported that they had a stroke compared with 1 percent of the non-hypertensive women (p<0.0009). In summary, age, education, income, employment status, circulatory problems, and stroke were significantly different in hypertensive and non-hypertensive African-American women. In other words, these variables were risk factors for hypertension (see Appendix 3). Table 5 shows the demographic and cardiovascular-related characteristics of women by the predictor variable women with Afticana Womanism characteristics. Ninety-one percent (n 1014) of the respondents identified themselves as having Africana Womanism characteristics. Women identifying themselves as having Africana Womanism characteristics were slightly younger (M= 42, SD = 17.1) than women identified as feminist (M = 50, SD = 18.8) (p some college (61%) compared with feminist women (50%) (p=0.O316). Women with Africana Womanism characteristics were less likely to be in the lowest income category (53%) compared to feminist women (62%). Approximately one-third of the women in both groups reported being married. A smaller percentage of women with Africana Womanism characteristics were unemployed (43%) compared to the percentage of 58 Table 5. Demographic and Cardiovascular-Related Characteristics of African-American Women by Africana Womanism Characteristics, U.S., 1979-1980 Africana Womanism Characteristics Womanism & Both* Feminism Chi Characteristic (n 1014) (n=104) Square Mean Age 42 yrs. (17.1 sd) 50 yrs. (18.8 sd) <0.0001 Education However, a lower percentage of women with Africana Womanism characteristics were told by a physician that they had hypertension (33%) compared to feminist women (54%) (p Stepwise logistic regression models were used to examine the crude and adjusted odds of hypertension. Variables from our descriptive analysis that were determined to be a risk factor for hypertension and were associated with Africana Womanism characteristics were considered as confounders and were adjusted for in the logistic regression models. The crude analysis revealed that compared to feminist, women with Africana Womanism characteristics were 0.43 (95% CI = 0.28 - 0.64) times as likely to have hypertension (see Table 6). When the model was adjusted by age only, we found that age attenuated the model and compared to feminist, women with Afñcana Womanism characteristics were 0.56 (95% CI = 0.36 - 0.87) times as likely to have hypertension. When the model was adjusted for education only, women with Mricana Womanism characteristics were 0.45 (95% CI = 0.30 - 0.69) times as likely to have hypertension. When the model was adjusted for employment status only, women with 60 Africana Womanism characteristics were 0.45 (95% CI = 0.29 - 0.68) times as likely to have hypertension. When the model was adjusted by age and education, women with Africana Womanism characteristics were 0.56 (95% CI = 0.36 - 0.87) times as likely to have hypertension compared to feminist. When the model was adjusted by age and employment status, women with Africana Womanism characteristics were 0.57 (95% CI = 0.36 - 0.89) times as likely to have hypertension compared to feminist. When adjusting for age, education, and employment status women with Afticana Womanism characteristics were 0.57 (95% CI 0.36 - 0.89) times as likely to have hypertension. Adjusting for education and employment status in addition to age in the model slightly attenuated odds ratio estimate and widened the confidence intervals for Africana Womanism compared to models only adjusted for age. Thus, the best model to predict the odds for hypertension is the model adjusted for age (see Appendix 4). Table 6. Crude Crude Education Model Unadjusted Age Employment Age, Age, Age, by and Education Employment Education, Characteristics Adjusted Adjusted Model Status Employment for: Odds Status of Africana Ratio for Status Womanism, Hypertension Odds OR OR (95% (95% 0.43 0.56 0.45 0.45 0.56 0.57 0.57 of Womanism U.S., Hypertension in (0.28-0.64) (0.36-0.87) (0.30-0.69) (0.29-0.68) (0.36-0.87) (0.36-0.89) (0.36-0.89) CI) CI) African-American 1979-1980 for Women 61 CHAPTER FIVE SUMMARY, RECOMMEN1JATIONS AND CONCLUSIONS The purpose of this research was to examine the association between women with characteristics of Africana Womanism and hypertension among a national representative sample of African-American women. An analysis of the data reveals that characteristics of Africana Womanism serve as a protective factor for hypertension in African-American women. The association between women with characteristics of Afficana Womanism and hypertension when adjusting for age indicates that women with characteristics of Africana Womanism were 0.56 times as likely to have hypertension. Summary A review of the literature suggests that there are no previous studies that examine the relationship between characteristics of Africana Womanism and hypertension. The closest one can come to a similar study is one conducted by Clyde Wilcox. Using data from the National Survey of Black Americans (NSBA), 1979-92, Wilcox explored the levels of determinants of feminism among black women.’ In his study, over 2,000 surveys were administered to black families. Respondents were asked whether it was important for black women to work for racial equality, for gender equality, or whether both were equally important. Wilcox’s findings suggest that black women who identified the social and political system to be the source of black disadvantage were more likely to 1ClydeWilcox, “Black Women and feminism,” Women& Politics 10 (1990): 65. 62 63 exhibit feminist consciousness. Wilcox concludes that “black consciousness is expected to promote gender consciousness among black women. . . but some elements of black consciousness lead to a preference for an exclusively black feminist movement for black women.”2 He concludes that black feminists who were more likely to take part in an exclusive black movement were younger, better educated, had high levels of black identification, and were more likely to favor combating racism over sexism. Additionally, Wilcox’s research supports the idea that African-American women have higher levels of racial consciousness than feminist consciousness. According to Wilcox, racial discrimination is a greater problem for African-American women and African-American women have less in common with their white counterparts. Racial oppression coupled with sex discrimination subjugates African-American women to white females as well as white males. He further argues that “a fully-developed racial consciousness may leave little room for a feminist consciousness, with the former having a much higher prioñty.”3 Wilcox offers much needed information regarding the attitudes of African- American women. His findings that the respondents were more likely to favor combating racism over sexism suggest that these women are probably not true feminists. These findings align themselves with the Africana Womanist perspective where race, not gender, is the priority for the Africana woman. Relevant research has been conducted on racism and its effects on hypertension. These studies incorporate variables on stress and coping strategies and have focused on 2Ibjd 3Clyde Wilcox, “Racial and Gender Consciousness Among African-American Women: Sources and Consequences,” Women & Politics 17 (1997): 77. 64 episodes of discriminatory treatment or perceived racism in relationship to blood pressure. These studies have not determined if the perception of racism or the response to discriminatory treatment predicts the response to blood pressure. Two studies conducted by Krieger found that those who do not challenge perceived unfair discriminatory treatment were more likely to have elevated blood pressure than those who experienced racism but challenged it.4 Similar findings have been recorded for African-American men but not African-American women.5 There is a small body of research that examines perceived racism within a stress and coping framework. Researchers using stress and coping models have shown racism and sexism to be stressors and identified coping strategies as a way to decrease their harmful effects.6 Past research findings led Rodney Clark to assert that coping is an important approach to minimizing the damaging health consequences of racism and sexism.7 A qualitative study by Kumea Shorter-Goodwin identified coping strategies used by African-Americans to manage stress. The findings reveal that African-American women use 1) three ongoing internal coping strategies: resting on faith—relying on prayer and spirituality; standing on shoulders—drawing strength from African-American ancestors; and valuing oneself—sustaining a positive self-image; 2) one ongoing external 4Nancy Krieger and Sidney Stephen, “Racial Discrimination and Skin Color in the CARDIA Study: Implications for Public Health Research,” American Journal of Public Health 8$ (1998): 1308; and Nancy Krieger, “Racial and Gender Discrimination: Risk Factors for High Blood Pressure,” Social Science Medicine 30 (1990): 1273. 5Rosalind M Peters, “Racism and Hypertension Among African Americans,” WesternJournal of Nursing Research 26 (2004): 612. 6Rodney Clark and Jann Adams, “Moderating Effects of Perceived Racism on John Henryism and Blood Pressure Reactivity in Black Female College Students,” TheAnnals of Behavioral Medicine 2$ (2003): 126; Kumea Shorter-Gooden, “Multiple Resistance Strategies: How African American Women Cope WithRacism and Sexis,“Journal of Black Psychology 30 (August 2003): 406. 7Clark and Adams, 126. 65 coping strategy—leaning on shoulders, or relying on social support; or 3) three specific coping strategies (role flexing—altering their outward behavior or presentation; avoiding—diminishing contact with certain people and situations; and standing up and fighting back—directly challenging the source of the problem).8 While Shorter-Gooden did not look at the effectiveness of each strategy, she attempted to provide a foundation for the examination of coping strategies for African-American women when dealing with the impact of the dualities of racism and sexism. Anita Jackson and Susan Sears reviewed the importance of an Africentric woridview in the description of coping strategies. Jackson and Sears point to seven reasons that an Africentric worldview is more appropriate to evaluate the lives of African-American women: 1) an Africentric worldview provides knowledge and understanding about Mricana people; 2) an Africentric worldview provides a positive framework of analysis for the behaviors of African-American women; 3) research findings substantiate a relationship between Africentric woridview and effective psychological functioning; 4) because of its spiritual and material reality it is more applicable to stress reduction; 5) an Africentric worldview fosters the development of intrinsic self-worth; 6) an Africentric worldview fosters a harmonious, cooperative, and communal orientation; and 7) Africentric woridview is inclusive of experiential, past- present time orientation. Several studies have been conducted that found behaviors in African-American mirror an Africentric woridview. Mark Fine and Laura Myers found that African 8Kumea Shorter-Gooden, “Multiple Resistance Strategies: How African American Women Cope With Racism and Sexism,” Journal of Black Psychology 30 (2003): 406. 66 Americans were more likely to be optimistic, holistic and spiritual.9 Jackson and Sears note that African-Americans were more conmuinafly oriented and possessed intrinsic self-worth when compared with European Americans.’° These findings by Clark, Shorter-Goodwin, Jackson and Sears, and fine and Myers reassert the previous review of literature findings from Hudson-Weems and Baldwin adding further credence to the researchers findings that Africana Womanism serves as a protective factor for hypertension in African-American women. Limitations of the Study Several limitations exist for this study. First, the NSBA was conducted in 1979- 80, thus the associations observed over two decades ago may be different than what may be observed in a different cohort of African-American women. However, estimates from this study may be conservative given the educational and career advancements made since the original study was conducted in 1979-80. Second, hypertension status was determined by self-reporting of the study participants. According to NHANES, 1976-80, 51% of the people who had hypertension were aware that they had it.” Given that the NBSA was a self-reporting study also conducted during this time period, there may be additional participants that were unaware of their hypertension status. The NSBA was one of the first data sets to provide more detailed information than the routinely collected data that was used to examine the lives of African 9MarkFine, Al Schwebel, and Laura Myers, “The Effects of World View On Adaptation to Single Parenthood Among Middle Class Adult Women,” Journal of family Stress 6 (1985): 107. ‘°AnitaJackson and Susan Sears, “Implications of an Africentric Worldview in Reducing Stress for African American Women,” Journal of Counseling & Development 71(1992): 184. Vickie Burt, Jeffrey Cutler, Milticent Higgins, et al., “Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in the Adult U.S. Population: Data from the Health Examination Surveys, 1960 to 1991,” Hypertension 26 (1995): 60. 67 Americans. The NSBA was strictly a quantitative survey and did not specifically measure all of the Africana Womanism characteristics. Therefore, the results from this study should be viewed as preliminary evidence for the hypothesis. Recommendations Based on the research findings, the following recommendations are asserted: 1) The researcher feels the study should be replicated to determine whether subsequent findings are consistent with this studies finding, 2) Research from studies reported in this research, as well as the researcher’s findings and proposed operational model of theory, should be utilized by behavioral scientist and health practitioners to design interventions reflective of the culture of African-American women, and 3) Characteristics of Hudson Weems Africana Womanism and Baldwin’s Theory of Black Personality should be expanded on and included in future studies involving women of African descent with health challenges such as hypertension. Conclusion Africana Womanism provides a framework to examine the health effects of racism and sexism, appropriate coping strategies and protective factors for health. It has been embraced in nursing literature as a developing methodology for use with African- American health issues.12 According to JoAnne Banks-Wallace, “Interventions that are consistent with African-American women’s ways of knowing are more likely to be successful in promoting behavior change amongst this population. furthermore, research ‘2JanetteY Taylor, “Womanism: A Methodological Framework for African American Women,” Advances in Nursing Science 21(1998): 53. 6$ designs grounded in culturally consistent epistemiological frameworks, may offer opportunities to integrate healing and scholarly inquiry consciously.”3 Health education and promotion are based on behavioral theory. Public health programs use a variety of theories to diagnose, explain and predict health behaviors. In turn, these theories are used to design effective prevention programs to prevent and/or address diseases. African-American cultural scholars across multiple disciplines have consistently challenged the application of traditional models based on white culture for recommending treatment and/or health promotion behavior change strategies targeted at health promotion and disease prevention among Mrican-Americans.’4 Adopting a theory such as Africana Womanism provides the necessary framework from which African-American women understand their position from a culturally accurate standpoint. It allows them to operate from a positive cultural framework on a daily basis that encompasses all aspects of their lives. Africana Womanism encompasses the Africentric worldview which provides for a communal orientation. Operating from this framework decreases the amount of stress and conflict that arises when African- American women operate from alien constructs such as feminism. Thus, by reducing the amount of stress and conflict, there should be a reduction in diseases—physical and mental. Africana Womanism offers internal resources that provide invaluable coping strategies for Africana women to fight the twin barrels of racism and sexism that Africana women experience in the United States. 13JoAnneBanks-Wallace, “Womanist Ways of Knowing: Theoretical Considerations for Research With African American Women,” Advances in Nursing Science 22 (2000): 34. ‘4CollinsAirhihenbuwa, Health and Culture: Beyond the Western Paradigm (California: Sage Publications, 1995), 92. 69 After analyzing data supplied by 1,118 African-American women, in the NSBA survey, the findings were as follows: 1) Age, education, income, employment status, circulatory problems, and stroke were significantly different in hypertensive and non- hypertensive women; 2) There were no statistically significant differences between women with characteristics of Africana Womanism and feminist women with regard to income, marital status, employment status, circulatory problems or stroke. However, age, education, and hypertension were significantly associated with Africana Womanism characteristics. These findings, along with the stepwise logistic regression analysis, support the hypothesis that Africana Womanism serves as a protective factor against developing hypertension. Women with characteristics of Mñcana Womanism were .56 times as likely as women with characteristics of feminism to have hypertension. The cardiovascular health of African-American women has become an immediate public health threat. To effectively deal with this crisis, will require the design of interventions that are culturally appropriate for this group. Academicians and public health leaders must reshape, reconceptualize, and rethink research that is relevant to the groups being studied. An analysis that is not inclusive of Africentric principles, such as Africana Womanism and the Theory of Black Personality, will almost always lead to incorrect conclusions. To improve the health of African-American women, research must not be based on theories devised for white middle class men and women, but instead must use theories that provide an analysis of the Africana woman’s realities and true lived experiences. In spite of the date of the database and the earlier mentioned limitations, this research is beneficial in that it promotes the notion that theory can be tested. An updated 70 national survey on African-Americans can now be more inclusive of data that will permit researchers to address very specifically Africana women’s health disparities within a socio-cultural, political, and economic framework. A review of the literature in both hypertension and Womanist theory does not suggest that there has been such a groundbreaking effort to link the two fields. This approach to the study of testing theory within the humanities and the sciences is both innovative and challenging. Africana Womanism represents the humanistic component of the study and by its very nature demands consideration as a viable option and means of linking disciplines. Thus, it promotes the very idea of interdisciplinarity. Hence, the strongest case for this dissertation is the recognition that the innovative work done by Joseph Baldwin in writing and testing theory has value for a discipline outside of sociology. In many ways, the work demonstrates that sociology, the humanities, and the sciences can be linked in the study of women of African descent engaging the intersectionality of race, class, and gender. This approach invokes a vision to look at the world of Africana women through a multiple set of lenses—sociology, health, science, and humanities. This approach is both creative and groundbreaking. APPENDIX 1 NSBA SELECTED QUESTIONS 71 72 Project 491722 March—August 1979 SURVEY RESEARCH CENTER Institute for Social Research The University of Michigan Ann Arbor, Michigan 48106 space) . Primary Area 3. Your Interview No.______1. Interviewer’s Label 4. Date 5. Length of Interview______(minutes) NATIONALSURVEY OF BLACKAMERICANS A STUDY OF BLACK AMERICAN LIFE ______ 73 13 dO. I am going to read a list of health problems. After each one, please tell me whether a doctor has told you that you have that problem. Cli. How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all? A GREAT ONLYA NOT DEAL LITTLE AT ALL (1) (2) (3) a. ofarthritis or rheumatism b. ulce r c. can er L NO []—__—__) d. hypertension or high blood pressure” e. Lidiabetes or “sugar” f. a liver problem or “liver trouble” I Nol a kdney problem or ‘kidney trouble” q [oI h. sroke I5.;oI ;. a nervous condition [5. a blood circulation problem or “hardenin of the arteries” [s.Noj k. sickle cell anemia [5.N07 TURT P.14, CiDi 033. G32. 033. 036. What G33a. group and women Do sex Do 1. Is people 1. yuuc you it make discrimination? AS BLACK FIGHT BLACK do more to in Should A or tngczt-hsr think or 1• you ti. j1,ancea demand 1. it GRoJ this RIGHTQj FOR PEOPLE does to impottent _] on think WO1UC M)NG ONLY sex fight Black country? her it with their in * discrimination TOGETHER is depend own? ThtSELVES life for women Do 11 for the rights the 2. 2. you depend best women? more Black organize WOMEN’S FIGHT WHAT DOES rights think or way on women more that is K what FOR I Black of for a among RIGHTS] on all every real to Black you f what women 2. 2. fight women themselves I do problem Black WCE women WORK ALL happens yourself? should for [3. or 13. L WOMEJ woman WITh IT are for the to ON_OWN_[p.- only, BOTh IMPORTANT BOTH to work handle both rights Black CO should Black EQUALLY TO or together equally problems anti 034 work of people work CO Whit-s all lfl hard. important? as as Black 034 of a a 101 74 ______ 75 106 H14. How many grades of school did you finish? GRADESOF SCHOOL COLLEGE H14a. Did you get a high school graduation diploma H14b. What college did pass a high school equivalency test? you attend? Ii. s] I I H14c. Do you have a college degree? Li.TESt GO TO 1114e Hl4d. What degree is that? 1 Hl4e. Have you had any other schooling? 1. YES1 TUR1 TO p.107 Hl4f. What kind? 1128. (HARD H29. 1130. LI LI Q LI LI El LI R What household? How If it CARD C. D. A H. G. F. H. B. only almost many was LJ TURN 25) $1,000 $3,000 $2,000 $4, $5,000 1. $6,000 $ooo $001— your one ALMOST people 000 TO 91 as We person P. own — 999 well - — — — — don’t 114, 3,999 1,999 2,999 4,999 in 5,999 6,999 I personal EJ your as brought need 1131 now, household 2. their income El BARELY GETBJ barely in money, names, in inc1uding.umrse1f, net LI 1978? would by, LI LI just LI LI LI LI LI LI LI 7. H. i,. N. 0. J. P. K. I. Q. E or OTHER you the $10,000 $12,000 $15, $20,000 what? $25,000 $30,000 $7,000 $8,000 $9,000 say number. (SPECIFY: 000 I that — — — — — — OR - give 7,999 8,999 9,999 14,999 11,999 19,999 24,999 29,999 your ______MORE EI money household to [l support would [oRMOREj your make 113 76 _____MONTHS______YEARS _____MONTHS ______MONTHS 77 68 E16. When you visit people, are you more likely to visit friends or to visit relatives? FRIENDS 2. RELATIVES [ 617. When you think of the people you can count on in life, are they mostly your relatives or your friends? 1. RELATIVES 2. FRIENDS 1 [ J 618. Are you married, divorced, separated, widowed or have you never been married? l.MARRIED [2.DIV0RcED [SEPAEATED ‘ VOLUNTEERS: 11 1 i MARRIED COMMONLAW I 1 I I LR11IE 4r E18a. How ElOc. Do you have a main romantic involvement at this ElBg. How long long have time? have the two of you been i I you been together married? 1. YEj 5. NO I - YEARS YEARS 4’ E18d. How long have MONTHS the 61Sf. Would you like — two of you been to have a roman- together? tic involvement at this tine? TURN TO P.69, ElSb. How E19 1.YES fore you were married El8e. Do you live with 4 this person? TURNTO P.70, E2l 1.YEj I L] S(ETDfES TURN TO TURNTO P.69, 620 Dl. Now off, Dia. 015. Dlc. I or would U Do U your How [;. not INTERVIEWER you 2. 1. long like working YEs7 job? R R expect OR 6 LAID LAID have to MONTHS LESS at talk CHECKPOINT OFF OFF to you all SECTION return with MORE 6 been for -—-TURN TURN MONTHS you 5. 0: pay? laid THAN to 1 P.22,02 TO P. NOl about your EMPbOYNENT 40,050 P.40, off TO TO job? work from 050 -- STATUS are you working now for pay, laid 21 78 ______ 79 73 (HARDII CARD 15) E30. For the next two statements please tell me if you strongly agree, agree, disagree, or strongly disagree. a. Both men and women should share equally in childcare and housework. 1. STRONGLY 2 • AGREE] 3. DISAGREE] 4. STRONGLY f I AGREE DISAGREE C b. Both men and women should have jobs to support the family. 1. STRONGLY 2. AGREE 3. DISAGREE f4. STRONGLY AGREE L DISAGREE E31. Do you have any children? YES j (5. NOj 4 1 E31a. Howwould your life be different E31d How would your life be differ if you did not have children? ent if you had children? E31b. How many children have been born to you, not counting stillbirths? E31c. How many of these children are still living? 80 102 SECTION H: PERSONAL DATA Now, we’d like to ask you a few questions about yourself. In studies like this, we often compare the ideas of men and women, young and old people, and people of different economic backgrounds. Hi. First, what is your date of birth? MONTH DAY YEAR H2. Where were you born? CITY (OR TOWN) COUNTY STATE fOR COUNTRYIF NOTUSA) H3. And where did you mostly live while you were growing up? (IF R MENTIONSMORETHAN ONE PLACE, PROBE FOR PLACE LIVED MOST BETWEENAGES 6-16) CITY (OR TOWN) COUNTY STATE (OR COUNTRYIF NOT USA) H3a. Was that in a rural or country area, a small town, a small city, a suburb of a city or in a large city? [L RURAL OR J 2. SMELL J 3. SMALL 14.SUBU] 15.1RGE 7. OTHER coua I CITY OT A CITY (SPECIFY ro f AREA ] ] CITY 114. What city and state do you think of as your home? OR CITY f TOWN) COUNTY STATE (OR COUNTRYIF NOT USA) APPENDIX 2 $AS DATA SET CONTENTS $1 82 The SAS System The CONTENTS Procedure Data Set Name WORKLETITIA Observations 1118 Member Type DATA Variables 32 Engine V9 Indexes 0 Created Monday, February 27, 2006 11:44:19 AM Observation Length 256 Last Modified Monday, February 27, 2006 11:44:19 AM Deleted Observations 0 Protection Compressed NO Data Set Type Sorted NO Label Data Representation WINDOWS_32 Encoding wiatinl Western (Windows) Engine/Host Dependent Information Data Set Page Size 16384 Number of Data Set Pages 19 First Data Page 1 Max Obs per Page 63 Obs in First Data Page 45 Number of Data Set Repairs 0 File Name F:\SAS Temporary Files\_TD6304\letitia.sas7bdat Release Created 9.0101M3 Host Created WIN ASRV Alphabetic List of Variables and Attributes # Variable Type Len Format Label 1 V82 Nun 8 V82FFFFF. HW SATISFIED W/ HEALTH 2 V89 Num 8 VB9FFFFF. HAVE HIGH BLOOD PRESSURE 3 V97 Nun 8 V97FFFFF. HAVE STROKE 4 ViOl Nun B V1O1FFFF. HAVE CIRCULATION PROBLEM 5 V301 Num 8 V3O1FFFF. EMPLOYMENTSTATUS 6 V306 Nun 8 V3O6FFFF. HAVE ONE OR MOREJOBS 7 V908 Nun 8 V9O8FFFF. MARITAL STATUS 8 V958 Nun 8 V958FFFF. HAVE ANY CHILDREN 9 V962 Nun 8 V962FFFF. # CHILD BORN TO R 10 V1271 Nun 8 V1271FFF. SHD BLK WMNORGZ W/ WHIT 11 V1272 Nun B V1272FFF. BLK WMNFITE 4 BLKS/WOMN 12 V1406 Num 8 V14O6FFF. WHR GREWUP- -CITY/TOWN 13 V1408 Nun 8 VI4O8FFF. WHR GRWUP--RURAL OR WHT 14 V1409 Nun 8 V14O9FFF. HOME--CITY/TOWN 15 V143O Nun 8 V143OFFF. GTTG SCHOOL/TRAING NOW 16 V1432 Nun 8 V1432FFF. WHT TYP SCHOL/TRNG-TYPE1 17 V1433 Nun B V1433FFF. WHT TYP SCHOL/TRNG-TYPE2 18 ‘11434 Num B V1434FFF. # SCHOOL GRADES FINISHD 19 V1435 Num 8 V1435FFF. HI SCHOOL DIPLOMA OR GED 20 V1439 Num 8 V1439FFF. HAVE COLLEGE DEGREE 21 V1444 Num 8 V1444FFF. R’S EDUC SUMMARY 22 V1500 Num 8 V1500FFF. RS PERSONAL INCOME-1978 83 The SAS System The CONTENTS Procedure Alphabetic List of Variables and Attributes # Variable Type Len Format Label 23 V1586 Num 8 V1586FFF. RS SEX 24 V2012 Nun 8 V2O12FFF. RS AGE 31 age Nun 8 29 edu Nun 8 28 enploymentstatus Nun 8 25 hypertension Nun 8 32 inconelevi Nun B 26 married Nun 8 30 no_highschool Nun 8 27 wonanism Nun 8 APPENDIX 3 SAS FREQUENCIES AND CROSS TABULATIONS $4 85 The SAS System The FREQ Procedure RS EDUC SUMMARY Cumulative Cumulative Vi 444 Frequency Percent Frequency Percent (0) 00: No Schooling or less than One .. 8 0.72 8 0.72 (11) 11: 1-6 Grades, No Other Schooling; Grade .. 95 8.50 103 9.21 (12) 12: 1-6 Grades; Grade School and Non-College .. 9 0.81 112 10.02 (21) 21: 7-8 Grades, No Other . . 92 8.23 204 18.25 (22) 22: 7-8 Grades, plus Non-College .. 13 1.16 217 19.41 (31) 31: 9 Grades, No Other .. 48 4.29 265 23.70 (32) 32: 10-11 Grades, No Other Schooling: or .. 115 10.29 380 33.99 (41) 41: 9 Grades, plus Non-College .. 14 1.25 394 35.24 (42) 42: 10-11 Grades, plus Non-College Training; .. 43 3.85 437 39.09 (50) 50: 12 Grades, but No Diploma or .. 7 0.63 444 39.71 (51) 51: 11 Grades or Less, but High School .. 16 1.43 460 41.14 (52) 52: 12 Grades, Completed High School; .. 189 16.91 649 58.05 (60) 60: 12 Grades, but No Diploma or .. 5 0.45 654 58.50 (61) 61: 11 Grades or Less, but High School .. 14 1.25 668 59.75 (62) 62: 12 Grades, Completed High School; . . 154 13.77 822 73.52 (71) 71: Some College (1-3 Years), No Degree (.. 182 16.28 1004 89.80 (72) 72: Some College (1-3 Years), Degree (Other . . 23 2.06 1027 91.86 (81) 81: Bachelors Degree (Except LLB, JD): BS, . . 68 6.08 1095 97.94 (82) 82: Masters Degree: MS, . . 22 1.97 1117 99.91 (83) 83: Doctorate or Professional Degree: PhD, 1 0.09 1118 100.00 RS PERSONAL INCOME-1978 Cumulative Cumulative V1500 Frequency Percent Frequency Percent (1) 01: $000 121 10.82 121 10.82 (2) 02: $001 -999 59 5.28 180 16.10 (3) 03: $1,000-1,999 100 8.94 280 25.04 (4) 04: $2,000-2,999 133 11.90 413 36.94 (5) 05: $3,000-3,999 115 10.29 528 47.23 (6) 06: $4,000-4,999 71 6.35 599 53.58 (7) 07: $5,000-5,999 73 6.53 672 60.11 (8) 08: $6,000-6,999 61 5.46 733 65.56 (9) 09: $7,000-7,999 57 5.10 790 70.66 (10) 10: $8,000-8,999 58 5.19 848 75.85 (11) ii: $9,000-9,999 54 4.83 902 80.68 (12) 12: $1O,000-11,999 65 5.81 967 86.49 (13) 13: $12,000-14,999 64 5.72 1031 92.22 (14) 14: $15,000-19,999 62 5.55 1093 97.76 (15) 15: $20,000-24,999 20 1.79 1113 99.55 (16) 16: $25,000-29,999 4 0.36 1117 99.91 (17) 17: $30,090 or More I 0.09 1118 100.00 86 The SAS System The FREQ Procedure MARITAL STATUS Cumulative Cumulative V908 Frequency Percent Frequency Percent (1) 1: Married 388 34.70 388 34.70 (2) 2: Divorced 149 13.33 537 48.03 (3) 3: Separated 133 11.90 670 59.93 (4) 4: Widowed 194 17.35 864 77.28 (5) 5: Never Married 246 22.00 1110 99.28 (6) 6: R Volunteers: Common Law Marriage 8 0.72 1118 100.00 87 The SAS System The FREG Procedure EMPLOYMENTSTATUS Cumulative Cumulative V301 Frequency Percent Frequency Percent (1) 1: Working Now 585 52.33 585 52.33 (2) 2: Laid off 38 3.40 623 55.72 (3) 3: Not Working for Pay at All 495 44.28 1118 100.00 88 The SAS System The FRED Procedure HAVE ANY CHILDREN Cumulative Cumulative V958 Frequency Percent Frequency Percent (1) 1: Yes 863 77.19 863 77.19 (2) 2: Child(ren) Deceased 15 1.34 878 78.53 (5) 5: No 240 21.47 1118 1OD.00 (9) (4) (3) (8) (2) (5) (1) 4: 9: 8: 3: 2: 5: 1: (9999) Small Small NA Suburb DK Rural Large Town City City or 9999: of Country V1406 a City NA V1408 Area Frequency WHR WHR 38 The Frequency GRW The GREW FREQ 311 408 UP--RURAL 141 198 SAS 48 10 UP- 2 Percent Procedure 3.40 System -CITY/TOWN Percent 36.49 27.82 OR 12.61 17.71 0.89 4.29 0.18 Wi-IT Cumulative Frequency 1118 Cumulative Frequency 1118 1108 1106 698 650 509 311 Cumulative Percent 100.00 Cumulative Percent 100.00 58.14 45.53 62.43 99.11 98.93 27.82 89 90 The SAS System hypertension=O The UNIVARIATE Procedure Variable: V2012 (RS AGE) Moments N 726 Sum Weights 726 Mean 37.3305785 Sum Observations 27102 Std Deviation 16.0095946 Variance 256.307119 Skewness 1.08771376 Kurtosis 0.63120814 Uncorrected SS 1197556 Corrected SS 185822.661 Coeff Variation 42.8860072 Std Error Mean 0.59417178 Basic Statistical Measures Location Variability Mean 37.33058 Std Deviation 16.00959 Median 33.00000 Variance 256.30712 Mode 25.00000 Range 101 .00000 Interquartile Range 21 .00000 Tests for Location: MuO=O Test -Statistic- p Value Students t t 62.82792 Pr > t <.0001 Sign M 362.5 Pr >= 1M1 <.0001 Signed Rank 5 131587.5 Pr >= ISI <.0001 Quantiles (Definition 5) Quantile Estimate 100¾ Max 101 99¾ 82 95¾ 70 90¾ 63 75¾ Q3 46 50% Median 33 25% 01 25 10% 21 5% 19 1% 18 0%Min 0 Value ----Lowest---- 18 18 18 17 0 Variable: The Extreme UNIVARIATE 718 The 488 649 576 633 Obs hypertension=O SAS Observations V2012 System Procedure Value - ---Highest--- (B’S 101 91 88 87 85 AGE) 690 222 Obs 22 54 7 91 NOTE: Skewness Coeff Uncorrected Std Mean N The Median Mean Mode Deviation Variation mode Signed Sign Test Students Location displayed SS 52.00000 51.51276 58.00000 Rank t Tests Variable: Basic Quantiles 31.4417627 The 51.5127551 16.1965182 -0.0599126 5% 5096 99 7596 Quantile 0% 2596 90 95 100 1% 1096 is S M t -Statistic- 1142767 Mm UNIVARIATE Median Q1 03 for the Statistical The hypertension=1 Max 62.97036 Variance Std Range Interquartile 392 38514 Location: smallest Moments SAS V2012 (Definition Deviation 196 System Std Variance Corrected Kurtosis Sum Sum Estimate Procedure Variability Measures (RS Weights Pr Pr Pr Observations of Error 91.0 MuO=0 38.5 52.0 25.0 29.0 63.0 84.0 20.0 73.0 77.0 18.0 >= > > 2 Range 5) AGE) modes p tI Mean SS ISI IMI Value with 262.32720 <.0001 <.0001 <.0001 73.00000 24.50000 16.19652 a 262.327203 102569.936 -0.8348892 0.8180477 count 20193 392 of 13. 92 93 The SAS System hypertensionl The UNIVARIATE Procedure Variable: V2012 (K’S AGE) Extreme Observations ----Lowest------Highest-- Value Obs Value Obs 18 738 83 1051 19 1103 84 911 19 1040 84 1012 20 1110 85 938 20 1093 91 1107 .Mantel-Haenszel Continuity Statistic Chi-Square Contingency Phi Likelihood Cramers Coefficient Statistics V Total Table Cell Two-sided Col Percent Right-sided Left-sided Row Frequency edu Ad]. Ratio Coefficient Table Pot Pct (1,1) Chi-Square Chi-Square Probability Chi-Square for 2 Fishers The of The Pr hypertension Table Frequency Pr 44.63 64.94 74.59 31.27 50.56 Pr 68.73 20.30 FRED edu <= 499 < 726 227 SAS >= P Exact by F of Procedure 0 F System (P) hypertension OF edu 35.06 25.41 43.37 49.44 1 56.63 1 1 1 15.21 (F) 19.86 Test 392 222 170 by 2.781E-16 I 1 .021E-16 I .554E-16 67.1003 67.7782 68.0907 68.1517 hypertension -0.2469 -0.2469 0.2397 1.0000 Value 100.00 59.84 40.16 Total 227 1118 669 449 <.0001 <.0001 <.0001 <.0001 Prob 94 95 The SAS System The FREQ Procedure Table of incomelevi by hypertension incomelevi hypertension Frequency Percent Row Pct Col Pct 0 Total 355 244 599 31.75 21.82 53.58 59.27 40.73 48.90 62.24 2 209 94 303 18.69 8.41 27. 10 68.98 31.02 28.79 23.98 3 162 54 216 14.49 4.83 19.32 75.00 25.00 22.31 13.78 Total 726 392 1118 64.94 35.06 100.00 Statistics for Table of inconelevi by hypertension Statistic OF Value Prob Chi-Square 2 20.2409 <.0001 Likelihood Ratio Chi-Square 2 20.6380 <.0001 Mantel-Haenszel Chi-Square 1 19.9167 <.0001 Phi Coefficient 0.1346 Contingency Coefficient 0.1334 Cramers V 0.1346 Mantel-Haenszel Contingency Continuity Likelihood Statistic Phi Chi-Square Cramers Statistics Coefficient V Total Table Two-sided Cell Col Percent Left-sided Row married Right-sided Frequency Ad]. Ratio Table Coefficient Pct Pct for (1,1) Chi-Square Chi-Square Probability Chi-Square 0 Fishers of The Table Pr married The Pr Frequency 64.94 66.75 23.17 64.33 63.97 41.77 35.67 Pr hypertension FREQ <= 726 259 <= 467 SAS of >= Exact P F 0 Procedure married System F by (P) OF 35.06 33.25 36.03 32.91 67.09 23.52 1 11.54 1 1 1 hypertension (F) Test 392 263 129 by -0.0277 -0.0277 0.8633 0.3577 0.0343 0.1946 0.8591 0.8599 0.8397 0.7422 0.0277 Value hypertension 100.00 34.70 Total 65.30 467 1118 388 730 0.3528 0.3538 0.3540 0.3890 Prob 96 Chi-Square Cramers Mantel-Haenszel Statistic Contingency Likelihood Phi Coefficient Statistics Col ow V301 Row Total Percent Frequency 1 ng (2) (3) (1) for V 2: Pct 3: Pct 1: (EMPLOYMENT Ratio Coefficient Working Table Not Laid Pay for Chi-Square Worki at Chi-Squace off The of Al The Table N V301 STATUS) FREQ SAS hypertension 59.23 38.46 73.50 36.91 73.68 54.14 23.97 64.94 of 2.50 3.86 Procedure by 430 268 System 726 28 V301 hypertension OF 0 2 2 1 by 39.54 26.50 26.32 57.91 45.86 20.30 35.06 13.86 0.89 2.55 227 392 155 45.4725 43.8657 hypertension 45.4694 10 0.2017 0.7977 0.2017 Value 1 100.00 Total 52.33 44.28 3.40 1118 585 495 38 <.0001 <.0001 <.0001 Prob 97 Chi-Square Cramers Mantel-Haenszel Statistic Contingency Likelihood Phi WARNING: Coefficient Statistics Total V Col Row Percent ViOl(HAVE Frequency (9) (1) (5) 33% than Ratio Coefficient 5: 9: Pct Pct 1: Table of 5. No NA Yes for Chi-Square Chi-Square the The Chi-Square CIRCULATION of Table The hypertension cells Viol FREQ 60.91 38.46 68.10 93.80 64.94 6.20 4.03 0.00 0.00 0.00 SAS 681 726 45 of 0 by Procedure have 0 System ViOl may OF hypertension 2 100.00 2 PROBLEM) I 31.90 28.53 81.38 67.54 35.06 18.37 expected 6.44 0.26 0.09 not 319 392 by 72 1 42.2652 38.0875 hypertension 40.4195 be 0.1944 0.1944 0.1909 Value 100.00 a 89.45 Total 10.47 counts 0.09 7000 1118 valid 117 <.0001 <.0001 test. less <.0001 Prob 98 99 The SAS System The FREQ Procedure Table of V97 by hypertension V97fHAVE STROKE) hypertension Frequency Percent Row Pot Col Pct 0 Total (1) 1: Yes 8 17 25 0.72 1.52 2.24 32.00 68.00 1.10 4.34 (5) 5: No 718 374 1092 64.22 33.45 97.67 65.75 34.25 98.90 95.41 (9) 9: NA 0 1 0.00 0.09 0.09 0.00 100.00 0.00 0.26 Total 726 392 1118 64.94 35.06 100.00 Statistics for Table of V97 by hypertension Statistic OF Value Prob Chi-Square 2 14.0813 0.0009 Likelihood Ratio Chi-Square 2 13.6123 0.0011 Mantel-Haenszel Chi-Square 1 9.9060 0.0016 Phi Coefficient 0.1122 Contingency Coefficient 0.1115 Cramer’s V 0.1122 WARNING: 33% of the cells have expected counts less than 5. Chi-Square may not be a valid test. NOTE: Coeff Uncorrected Mean Skewness Std N The Mode Mean Median Deviation mode Variation Sign Signed Students Test Location displayed SS 53.00000 49.50000 49.54808 Rank t Tests Basic Variable: Quantiles 38.0955598 The 49.5480769 0.02649549 18.8756173 5% 50% 95% 25% 75% 99% 0% 10% 90% Quantile 1% 100% is M S t -Statistic- Mm 292019 UNIVARIATE Median 01 03 for-Location: the Statistical The - Max 26.76963 Variance Std Range womanism=O Interquartile 104 smallest Moments SAS 2730 V2012 (Definition Deviation 52 System Std Variance Corrected Sum Kurtosis Sum Estimate Procedure Variability Measures (RS Pr- Weights Pr Error Pr Observations of 49.5 66.0 79.0 87.0 33.0 75.0 84.0 230 MuO=O 20.0 19.0 18.0 >= > 3 >= Range 5) AGE) modes p tI Mean SS IMI Value S with 356.28893 <.0001 <.0001 <.0001 69.00000 33.00000 18.87562 a 36697.7596 356.288928 1.85090656 -1.0706315 count 5153 104 of 4. 100 101 The SAS System womanism=O The UNIVARIATE Procedure Variable: V2012 (RS AGE) Extreme Observations ----Lowest------Highest-- Value Obs Value Cbs 18 21 80 22 19 86 81 4 19 42 82 30 20 78 84 43 20 54 87 33 Coeff Skewness Mean Uncorrected Std N Median Mode Mean Deviation Variation Test Signed Sign Students Location SS 38.00000 41.56016 25.00000 Rank t Tests Basic Variable: Quantiles The 41.1913011 41.5601578 0.63358627 17.1191697 Quantile 5% 99% 0%Min 50% 90% 75% 95% 25% 10% 100% 1% S M t 2048304 -Statistic- UNIVARIATE Median 03 The Statistical 01 for Max 256795.5 77.30605 1014 Variance womanism=1 Std Range Interquartile 506.5 SAS Location: Moments V2012 (Definition Deviation System Sum Std Variance Corrected Kurtosis Sum Estimate Procedure Variability Measures (RS Pr Pr weights Pr Observations Error MuO=0 101 20 22 38 67 >= 54 73 82 > Range >= 27 18 0 5) AGE) p ItI Mean 55 IS IMI Value <.0001 293.06597 <.0001 <.0001 101 27.00000 17.11917 .00000 0.53760552 293.065973 -0.5047096 296875.83 42142 1014 102 Value - - - 18 18 18 17 -Lowest- 0 Variable: The Extreme UNIVARIATE 1021 1110 1002 The 817 931 Obs - - - womanism=1 - SAS Observations V2012 System Procedure Value - ---Highest-- (RS 101 91 91 88 85 AGE) 1072 1079 607 135 Obs 789 103 Mantel-Haenszel Continuity Statistic Chi-Square Cramers Contingency Likelihood Phi Coefficient Statistics V Total ColPct Row Percent edu Table Frequency Two-sided Cell Right-sided Left-sided Adj. Ratio Coefficient Pct Table (1,1) Chi-Squace Chi-Square Probability 2 Chi-Square Fishers The for womanism The Pr of Pr Frequency 50.00 50.00 FREG Pr 11.58 Table 4.65 9.30 7.77 4.65 <= SAS <= edu 104 52 >= 52 Exact P Procedure F 0 System F by (P) of OF womanism 35.51 90.70 60.85 92.23 55.19 39.15 88.42 1 1 1 1 (F) Test edu 1014 617 397 by 1 0.0643 4.1786 0.0211 0.9874 0.0641 4.5381 0.0085 0.0643 4.6149 4.6190 0.0356 womanism Value 100.00 59.84 40.16 Total 1118 52 669 449 0.0409 0.0331 0.0317 0.0316 Prob 104 105 The SAS System The FREQ Procedure Table of incomelevi by womanism incomelevl wonanism Frequency Percent Row Pct Col Pct 0 Total 64 535 599 5.72 47.85 53.58 10.68 89.32 61.54 52.76 2 25 278 303 2.24 24.87 27.10 8.25 91.75 24.04 27.42 3 15 201 216 1.34 17.98 19.32 6.94 93.06 14.42 19.82 Total 104 1014 1118 9.30 90.70 100.00 Statistics for Table of inconelevi by wonanism Statistic OF Value Prob Chi-Square 2 3.1767 0.2043 Likelihood Ratio Chi-Square 2 3.2591 0.1960 Mantel-Haenszel Chi-Square 3.0967 0.0785 Phi Coefficient 0.0533 Contingency Coefficient 0.0532 Cramers V 0.0533 Sample Size = 1118 Phi Mantel-Haenszel Chi-Square Cramers Contingency Continuity Likelihood Statistic Coefficient Statistics V Total Col Table Cell Two-sided Row married Percent Frequency Right-sided Left-sided Ad). Ratio Coefficient Table Pct Pct (1,1) Chi-Square Chi-Square Probability Chi-Squace for 0 Fishers The Sample of The Pr Table Pr Frequency 39.42 60.58 womanism 10.57 married FREO Pr 3.67 8.63 9.30 5.64 <= 104 SAS <= 41 63 >= Size Exact P of 0 Procedure F System F (P) married OF by = 34.22 31.04 91.37 90.70 89.43 59.66 65.78 1 1 1 1 (F) Test 1014 1118 347 womanism 667 -0.0317 -0.0317 0.9086 0.8783 0.1700 0.0317 1.1255 0.3303 0.0484 by 1.1073 1.1265 Value 100.00 34.70 65.30 Total womanism 1118 63 388 730 0.2927 0.2887 0.2885 0.3405 Prob 106 107 The SAS System The FREQ Procedure Table of V301 by womanism V301 (EMPLOYMENTSTATUS) womanism Frequency Percent Row Pct Col Pct 0 1 Total (1) 1: working N 45 540 585 ow 4.03 48.30 52.33 7.69 92.31 43.27 53.25 (2) 2: Laid off 3 35 38 0.27 3.13 3.40 7.89 92.11 2.88 3.45 (3) 3: Not worki 56 439 495 ng for Pay at Al 5.01 39.27 44.28 1 11.31 88.69 53.85 43.29 Total 104 1014 1118 9.30 90.70 100.00 Statistics for Table of V301 by womanism Statistic OF Value PrQb Chi-Square 2 4.2588 0.1189 Likelihood Ratio Chi-Square 2 4.2268 0.1208 Mantel-Haenszel Chi-Square 1 4.1426 0.0418 Phi Coefficient 0.0617 Contingency Coefficient 0.0616 Cramecs V 0.0617 Sample Size = 1118 Mantel-Haenszel Continuity Cramers Contingency Chi-Squace Statistic Phi Likelihood Coefficient Statistics V Total Col Row Percent V89(HAVE (5) Frequency (1) Two-sided Table Cell Left-sided Right-sided Adj. Ratio Coefficient 5: Pct Pct 1: (l1) Table Chi-Square Chi-Squace No Probability Yes Chi-Square Fishers HIGH The for Pr The Pr Frequency womanism of Pr FREQ Table 46.15’ 53.85 <= 14.29 BLOOD <= 9.30 4.29 6.61 5.01 V89 SAS >= 104 Exact 48 P 56 F Procedure F 0 CP) System by of PRESSURE) DF 1 1 1 1 (F) wonanism Test V89 90.70 66.86 60.64 33.14 93.39 30.05 86.71 1014 678 336 5.360E-05 2.944E-05 1 by .750E-05 17.7527 16.8707 16.9364 17.7686 0.1261 0.1261 0.1251 1.0000 Value womanism 100.00 64.94 35.06 Total 56 1118 726 392 <.0001 <.0001 <.0001 <.0001 Prob 108 109 The SAS System The FREQ Procedure Table of ViOl by womanism V1O1fHAVE CIRCULATION PROBLEM) womanism Frequency Percent Row Pot Col Pot 0 1 Total (1) 1: Yes 13 104 117 1.16 9.30 10.47 11.11 88.89 12.50 10.26 (5) 5: No 91 909 7000 8.14 81.31 89.45 9.10 90.90 87.50 89.64 (9) 9: NA 0 1 0.00 0.09 0.09 0.00 100.00 0.00 0.10 Total 104 1014 1718 9.30 90.70 100.00 Statistics for Table of ViOl by womanism Statistic DF Value Prob Chi-Square 2 0.6048 0.7390 Likelihood Ratio Chi-Square 2 0.6738 0.7140 Mantel-Haenszel Chi-Square 1 0.5455 0.4602 Phi Coefficient 0.0233 Contingency Coefficient 0.0233 Cramers V 0.0233 WARNING: 33% of the cells have expected counts less than 5. Chi-Square may not be a valid test. 110 The SAS System The FREQ Procedure. Table of V97 by womanism V97(HAVE STROKE) womanism Frequency Percent Row Pct Col Pct 0 Total (1) 1: Yes 3 22 25 0.27 1.97 2.24 12.00 88.00 2.88 2.17 (5) 5: No 101 991 7092 9.03 88.64 97.67 9.25 90.75 97.12 97.73 (9) 9: NA 0 1 0.00 0.09 0.09 0.00 100.00 0.00 0.10 Total 104 1014 1118 9.30 90.70 100.00 Statistics for Table of V97 by womanism Statistic OF Value Prob Chi-Square 2 0.3219 0.8513 Likelihood Ratio Chi-Square 2 0.3982 0.8195 Mantel-Naenszel Chi-Square 0.2737 0.6009 Phi Coefficient 0.0170 Contingency Coefficient 0.0170 Cramecs V 0.0170 WARNING: 50% of the cells have expected counts less than 5. Chi-Square may not be a valid test. APPENDIX 4 SAS LOGISTIC REGRESSION MODELS 111 112 The SAS System The LOGISTIC Procedure Model Information Oata Set WORK.LETITIA Response Variable hypertension Number of Response Levels 2 Model binary logit Optimization Technique Fishers scoring Number of Observations Read 1118 Number of Observations Used 1118 Response Profile Ordered Total Value hypertension Frequency 1 1 392 2 0 726 Probability modeled is hypertension=1. Model Convergence Status Convergence criterion (GCONV=1E-8) satisfied. Model Fit Statistics Intercept Intercept and Criterion Only Covariates AIC 1450.555 1435.619 SC 1455.575 1445.658 2 Log L 1448.555 1431.619 Testing Global Null Hypothesis: BETA=O Test Chi-Square OF Pr > ChiSq Likelihood Ratio 16.9364 1 <.0001 Score 17.7686 1 <.0001 Wald 16.9864 1 <.0001 113 The SAS System The LOGISTIC Procedure Analysis of Maximum Likelihood Estimates Standard Wald Parameter OF Estimate Error Chi-Square Pr > ChiSq Intercept I 0.1540 0.1967 0.6130 0.4336 womanism 1 -0.8560 0.2077 16.9864 <.0001 Odds Ratio Estimates Point 95% Wald Effect Estimate Confidence Limits womanism 0.425 0.283 0.638 Association of Predicted Probabilities and Observed Responses Percent Concordant 13.3 Somers 0 0.077 Percent Discordant 5.7 Gamma 0.404 Percent Tied 81.0 Tau-a 0.035 Pairs 284592 c 0.538 Weld Confidence Interval for Adjusted Odds Ratios Effect Unit Estimate 95% Confidence Limits womanism 1.0000 0.425 0.283 0.638 Wald Score Test Likelihood Convergence Optimization Model Number Response Data AIC Testing Probability SC Criterion Number Number -2 Ordered Set Value Ratio Log of Variable Response Model 2 L of of I Global criterion The Model Technique Observations Observations Model modeled Response The LOGISTIC Convergence Chi-Square hypertension Intercept Null Fit 1448.555 151 1455.575 174.8547 178.5770 1450.555 Levels SAS Information .7870 (GCONV=1E-8) Statistics Only Hypothesis: 0 is System 1 Profile Procedure hypertension=1. Used Read Status WORK. 2 Fishers binary hypertension Covariates Intercept OF 1269.978 1291.036 1275.978 Frequency 2 2 2 satisfied. LETITIA BETA=O logit Total and scoring 1118 1118 726 392 Pr > <.0001 <.0001 <.0001 ChiSq 114 womanism age Parameter Intercept womanism Association age Effect Wald Percent Percent Pairs Percent womanism age Effect Confidence OF Analysis 1 1 1 of Concordant Tied Discordant Predicted 1.0000. 1.0000 Estimate Unit -0.5891 -2.2291 0.0487 The of Odds Estimate Interval Maximum 0.555 Point 7.050 The LOGISTIC Probabilities Ratio Estimate 284592 SAS Standard 24.8 74.0 0.555 0.00411 1.050 0.2274 for 0.2929 1.2 Likelihood Estimates Error System Procedure Adjusted Confidence 0.355 1.042 Gamma Tau-a c Somers 95% 95% and Chi-Square Estimates Wald 0.355 1.042 140.4454 Confidence Odds Observed 57.9187 6.7716 0 Limits Wald 0.866 1.058 Ratios 0.499 0.493 0.746 0.225 Responses Limits Pr 0.866 1.058 > 0.0096 <.0001 <.0001 Chisq 115 Wald Test Score Likelihood Convergence Optimization Model Number Response Data Number AIC Probability Testing Criterion SC Number -2 Ordered Set Value Log Ratio of Variable Response Model 2 of of L 1 Global criterion The Model Technique Observations Observations Model modeled Response The LOGISTIC Convergence hypertension Chi-Square Intercept Fit Null 1448.555 Levels 1455.575 1450.555 77.3152 81.7847 81 SAS Information (GCONV=1E-8) .4686 Statistics Only 0 is Hypothesis: 1 System Profile Procedure hypertension=1. Used Read Status WORK. 2 Fishers binary hypertension Covariates Intercept Frequency OF 1367.087 1388.145 1373.087 2 2 satisfied. 2 LETITIA BETA=O logit Total and 1118 1118 scoring 726 392 Pr > <.0001 <.0001 <.0001 ChiSq 116 117 The SAS System The LOGISTIC Procedure Analysis of Maximum Likelihood Estimates Standard Wald Parameter DE Estimate Error Chi-Square Pr > ChiSq Intercept 1 -0.3538 0.2127 2.7668 0.0962 womanism 1 -0.7947 0.2146 13.7126 0.0002 no_highschool 1 1.0370 0.1305 63.1741 <.0001 Odds Ratio Estimates Point 95% Wald Effect Estimate Confidence Limits womanism 0.452 0.297 0.688 nohighschool 2.821 2.184 3.643 Association of Predicted Probabilities and Observed Responses Percent Concordant 44.9 Somers 0 0.286 Percent Discordant 16.3 Gamma 0.467 Percent Tied 38.8 Tau-a 0.130 Pairs 284592 C 0.643 Wald Confidence Interval for Adjusted Odds Ratios Effect Unit Estimate 95% Confidence Limits wonanism 1.0000 0.452 0.297 0.688 no_highschool 1.0000 2.821 2.184 3.643 Vald Score Test Likelihood Convergence Optimization Model Response Number Data AIC SC Testing Criterion Probability Number -2 Number Ordered Set Ratio Value Log of Variable Response Model 2 L of of 1 Global criterion The Model Technique Observations Observations Model modeled Response The LOGISTIC Chi-Square Convergence hypertension Intercept Null Fit 1455.575 1448.555 1450.555 Levels 54.4260 54.2976 51.9449 SAS Information (GCONV=IE-8) Statistics Only Hypothesis: 0 is 1 System Profile Procedure Used hypertension=1. Read Status WORK. Fishers binary 2 hypertension Covariates Intercept DF Frequency 1415.316 1400.258 1394.258 2 2 2 satisfied. LETITIA BETA=O logit Total and scoring 1118 1118 392 726 Pr > <.0001 <.0001 <.0001 ChiSq 118 womanism employmentstatus Parameter Intercept womanism Effect employmentstatus Association womanism employmentstatus Effect Wald Percent Percent Percent Pairs Confidence Analysis of Tied Concordant Discordant OF 1 1 1 Predicted The Estimate of 1.0000 1.0000 Odds -0.8081 -0.2838 Unit 0.7800 Interval Maximum The LOGISTIC Estimate Probabilities Ratio 0.446 2.181 SAS 284592 Point 41.9 39.1 19.0 for Estimate Likelihood System Estimates Standard Procedure 0.1289 0.2116 2.181 0.446 0.2129 Adjusted Error Gamma Somers Tau-a c Confidence 0.294 and 1.695 Estimates 95% Observed Odds 95% Chi-Square D Wald 36.6442 0.294 14.5889 1.695 Confidence 1.7782 Ratios Limits Wald 0.375 0.614 0.228 0.104 0.675 2.806 Responses Pr Limits 2.808 0.675 > <.0001 0.0001 0.1824 ChiSq 119 120 The SAS System The LOGISTIC Procedure Model Information Data Set WORK.LETITIA Response Variable hypertension Number of Response Levels 2 Model binary logit Optimization Technique Fishers scoring Number of Observations Read 1118 Number of Observations Used 1118 Response Profile Ordered Total Value hypertension Frequency 1 1 392 2 0 726 Probability modeled is hypertension=1. Model Convergence Status Convergence criterion (GCONV=1E-8) satisfied. Model Fit Statistics Intercept Intercept and Criterion Only Covariates AIC 1450.555 1262.526 SC 1455.575 1282.603 -2 Log L 1448.555 1254.526 Testing Global Null Hypothesis: BETA=O Test Chi-Square DE Pr > ChiSq Likelihood Ratio 194.0293 3 <.0001 Score 189.2183 3 <.0001 Wald 163.0522 3 <.0001 womanism no_highschool age Parameter Intercept womanism age Effect no_highschool Association Percent Pairs Percent Percent Wald womanism age no_highschool Effect Analysis Confidence of OF Concordant Tied Discordant 1 1 1 1 Predicted 1.0000 1.0000 1.0000 Estimate The of -2.2446 -0.5811 Unit Odds 0.5697 0.0433 Interval Maximum Estimate The LOGISTIC Probabilities Ratio 0.559 Point 1.768 1.044 284592 SAS Estimate 75.0 24.3 0.7 Standard Likelihood for Estimates 0.00429 System 0.559 1.768 1.044 0.1440 0.2277 0.2935 Procedure Error Adjusted Tau-a c Somers Confidence Gamma 0.358 1.333 1.036 and 95 Estimates 95% Chi-Square Observed Odds 101.7161 Wald 0.358 D 1.036 1.333 58.4784 15.6470 Confidence 6.5111 Wald Limits Ratios 0.874 0.507 2.344 0.754 0.231 0.511 1.053 Responses Pr Limits 0.874 2.344 1.053 > <.0001 <.0001 0.0107 <.0001 ChiSq 121 122 The SAS System The LOGISTIC Procedure Model Information Data Set WORK.LETITIA Response Variable hypertension Number of Response Levels 2 Model binary logit Optimization Technique Fishers scoring Number of Observations Read 1118 Number of Observations Used 1118 Response Profile Ordered Total Value hypertension Frequency 1 1 392 2 0 726 Probability modeled is hypertension=1. Model Convergence Status Convergence criterion (GCONVIE-8) satisfied. Model Fit Statistics Intercept Intercept and Criterion Only Covariates AIC 1450.555 1263.447 SC 1455.575 1283.524 -2 Log L 1448.555 1255.447 Testing Global Null Hypothesis; BETA=O Test Chi-Square DF Pr > ChiSq Likelihood Ratio 193.1083 3 <.0001 Score 189.1282 3 <.0001 Wald 160.6155 3 <.0001 womanism employmentstatus age Parameter Intercept womanism age Effect employmentstatus Association womanism age Effect employmentstatus Wald Percent Percent Pairs Percent Analysis Confidence of Tied DF Concordant Discordant 1 1 1 1 Predicted The of Estimate 1.0000 1.0000 1.0000 Odds -2.3856 -0.5693 0.0461 0.5295 Unit Interval Maximum The LOGISTIC Estimate Ratio Probabilities SAS 0.566 Point• 284592 1.698 1.047 75.6 23.8 Likelihood for 0.6 Estimate System Standard Estimates Procedure 0.00417 0.2282 0.1388 0.2973 0.566 1.047 1.698 Adjusted Error Tau-a Gamma Somers c Confidence 0.362 and 1.039 1.294 Estimates 95 Chi-Square Odds Observed 95% D 121.8709 Wald 0.362 64.3892 14.5523 1.039 1.294 6.2244 Confidence Ratios Wald Limits 0.759 0.236 0.522 0.519 0.885 2.229 1.056 Responses Pr Limits 0.885 2.229 1.056 > 0.0001 0.0126 <.0001 <.0001 ChiSq 123 124 The SAS System The LOGISTIC Procedure Model Information Data Set WORK.LETITIA Response Variable hypertension Number of Response Levels 2 Model binary logit Optimization Technique Fishers scoring Number of Observations Read 1118 Number of Observations Used 1118 Response Profile Ordered Total Value hypertension Frequency 1 1 392 2 0 726 Probability modeled is hypertension=1. Model Convergence Status Convergence criterion (GCONV=1E-8) satisfied. Model Fit Statistics Intercept Intercept and Criterion Only Covariates AIC 1450.555 1255.190 SC 1455.575 1280.287 -2 Log L 1448.555 1245.190 Testing Global Null Hypothesis: BETA=O Test Chi-Square DF Pr > ChiSq Likelihood Ratio 203.3654 4 <.0001 Score 198.2742 4 <.0001 Wald 168.2259 4 <.0001 womanism age employmentstatus nohighschool Parameter Intercept womanism age no_highschool Effect employmentstatus Association womanism Effect age employmentstatus no_highschool Wald Pairs Percent Percent Percent Confidence Analysis of Tied Discordant Concordant OF 1 1 1 1 1 Predicted The Estimate of 1.0000 1.0000 1.0000 1.0000 Odds -0.5646 -2.3745 0.4360 0.0420 Unit 0.4758 Interval Maximum The LOGISTIC Estimate Probabilities Ratio Point 0.569 284592 1.547 1.609 SAS 1.043 23.6 76.0 0.4 for Estimate Likelihood Estimates Standard System 0.00432 Procedure 0.1424 0.2287 0.569 0.1476 0.2981 1.043 7.609 1.547 Adjusted Error Tau-a Somers Gamma c Confidence 0.363 and 1.170 1.205 1.034 Estimates 95% 95% Observed Odds Chi-Squace D Wald 0.363 94.5571 63.4324 1.205 1.034 7.170 10.3859 Confidence 9.3753 6.0917 Ratios Wald Limits 0.762 0.239 0.527 0.525 2.044 0.890 2.149 1.052 Responses Pr Limits 0.890 2.149 2.044 1.052 > 0.0022 0.0136 0.0013 <.0007 <.0007 ChiSq 125 126 The SAS System The GLM Procedure Class Level Information Class Levels Values hypertension 2 0 I Number of Observations Read 1118 Number of Observations Used 1118 127 The SAS System The GLM Procedure Dependent Variable: V2012 RS AGE Sum of Source DF Squares Mean Square F Value Pr > F Model 7 51199.6110 51199.6110 198.13 <.0001 Error 1116 288392.5974 258.4163 Corrected Total 1117 339592.2084 R-Square Coeff Var Root MSE V2012 Mean 0.150768 38.00026 16.07533 42.30322 Source DF Type I SS Mean Square F Value Pr > F hypertension 1 51199.61103 51199.61103 198.13 <.0001 Source DF Type III SS Mean Square F Value Pr > F hypertension 1 51199.61103 51199.61103 198.13 <.0001 128 The SAS System The GLM Procedure Least Squares Means HO:LSMeanl= Standard HO:LSMEAN=O LSMean2 hypertension V2012 LSMEAN Error Pr > t Pr > 0 37.3305785 0.5966115 <.0001 <.0001 1 51.5127551 0.8119269 <.0001 129 The SAS System The GLM Procedure Class Level Information Class Levels Values wonanism 2 0 1 Number of Observations Read 1118 Number of Observations Used 1118 130 The SAS System The GLM Procedure Dependent Variable: V2012 RS AGE Sum of Source DF Squares Mean Square F Value Pr > F Model 1 6018.6184 6018.6184 20.14 <.0001 Error 1116 333573.5900 298.9011 Corrected Total 1117 339592.2084 R-Square Coeff Var Root MSE V2012 Mean 0.017723 40.86865 17.28876 42.3cF322 Source OF Type I SS Mean Square F Value Pr > F womanism 1 6018.618418 6018.618418 20.14 <.0001 Source OF Type III SB Mean Square F Value Pr > F womanism 1 6018.618418 6018.618418 20.14 <.0001 131 The SAS System The GLM Procedure Least Squares Means HO:LSMeanl= Standard HO:LSMEAN=O LSMean2 womanisru V2012 LSMEAN Error Pr > Pr > 0 49.5480769 1.6953020 <.0001 <.0001 1 41.5601578 0.5429311 <.0001 ______ BIBLIOGRAPHY Agency for Healthcare Research and Quality. “Health Care for Minority Women.” Available from http://ahrg.gov/researchlminority.pdf: Internet, 2005. 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