This document summarizes a study on the experiences and perspectives of older Black women in Tucson, Arizona regarding their interactions with the healthcare system. The study found that the women drew on "ethnic notions" and "healthy paranoias" developed over their lifetime based on their own experiences and stories from others. These led to suspicions of bias and expectations of receiving suboptimal care. Interviews revealed perceptions of disrespect through nonverbal cues or language from providers. The women believed their experiences were different than what White women would receive. The conclusion is that neither the patients nor healthcare system are fully aware of how attitudes about race can unintentionally lead to misinterpretations and misunderstandings between providers and patients of different ethnicities. Understanding

1. Family and Community Medicine
ETHNIC NOTIONS & HEALTHY PARANOIAS:
Understanding of the Context of Experience and Interpretations of Healthcare Encounters Among Older Black Women.
Colette Marie Sims, PhD., Family & Community Medicine, The University of Arizona
Ethnic Notions are societal ideas about “race” that are deeply embedded in
the fabric of Black / White consciousness as core indicators of “racial” difference, rather than
ethnocultural differences. These have implications for patient-centered quality care.
Healthy Paranoias reflect the “earned” suspicion and mistrust among older
Black women of both pre/ post civil rights healthcare systems in the U.S., and are used as protective
and hyper-vigilant factors. Thus, have implications for access and utilization of care.
Ethnic notions & healthy paranoias also run on a steady diet
of perceptions, expectations, and beliefs of both healthcare providers and older Black women.
GOAL:
To report the first-hand,
audio-taped, transcribed
narrative data on
experiences with the health
care system collected
from older Black women
residing in Tucson, Arizona
BACKGROUND: In Arizona, African
Americans comprise only 4.1% of the population and
are the smallest racial/ethnic minority group.
In U.S. between-State variation among racial/
ethnic ambulatory patients who reported good
communication with health providers – Arizona was
one of 7 states ranked “worse for communication” by
patients (AHRQ, 2005). Since 1994 African Americans
have ranked worse than average on 53 of 70
(statewide) health status indicators, higher than many
other larger minority groups in this state.
STUDY:
Sample: 50 AA women > 40 years of age ( 2% of age-
eligible population). Data collected from March 2002
- March 2004 with 75% as qualitative (ethnographic)
and 25% as quantitative (demographic, health status,
health behavior.)
ETHNOGRAPHY:
Women shared their experiences when interacting
with doctors, healthcare support staff, diagnostic
technicians and the health care system over their life
course. Interviews covered perceptions, expectations,
beliefs, details of experiences, and perspectives that
had impacted trajectories of health seeking behavior.
Analyses explored their “points of view” on cultural
differences that emerge within predominantly
White healthcare settings, through interethnic
communication, and how shared personal experiences
(or others’ experiences) as a fund of knowledge may
influence ethnic notions, thus supporting healthy
paranoias.
 Many women spoke candidly about how their
experiences within pre/ post civil rights healthcare
encounters have influenced their hyper-vigilance,
mistrust, perceptions and “feelings” that they would
not be treated as optimally as White women would
be in similar healthcare settings.
 The way in which ethnocultural differences
and interethnic communication are framed
and understood are critical elements of patient
centeredness, as these impact the women’s
ability to stay healthy, get better, live with illness
or disability.
These are quality
of care issues.
CONCLUSION:
Health disparities are often created through non-clinical influences, such as cultural differences, individual experiences,
and beliefs about “race”.
 Study participants noted that they had perceived or experienced bias through non-verbal cues such as a lack of eye
contact, a lack or hesitation of physical touch, “facial movements, twitches and lip curls,” or through actual speech
such as the tone or speed of voice, or the type of language used. These experiences left study participants feeling
disrespected by both the providers / support staff.
 Ethnocultural narrative cues to behavior that referenced quality of care, compliance, aggression, disdain or anger within
healthcare encounters were misunderstood within predominately White healthcare settings by older Black women.
 For example, not being offered a referral for further tests, or “the amount of time that it took to be called in for their
exam (especially when they had made an appointment for the exam or health problem weeks ahead of time),” were
factors that were spoken about as supporting their expectations of receiving less than optimal care.
Therefore, it seems reasonable to conclude that:
 Neither older Black women themselves,
 Nor the health care system as a whole
 Nor individual White healthcare personnel
Are fully insulated from attitudes toward race that are prevalent (though often
unacknowledged) in the larger society.
Thus neither may be aware that their ethnic notions & healthy paranoias may lead to misinterpretations and
misunderstandings in establishing respectful partnerships among practitioners, patients and their families.
EXPERIENCES
(OWN OTHERS)
BIAS
Ethnocultural Differences
Funds of Knowledge
BELIEFS
PERCEPTIONS
Non Verbal Cues
Documented Atrocities
Misinterpretations
EXPECTATIONS
I’ve seen it myself, where the healthcare workers tend to treat Black people
differently than Caucasian people. I don’t know if they feel [Blacks] won’t speak
up or if they believed [Blacks] don’t know any better or expect any better…but
they should know that we ALL talk [word of mouth] …and I will tell
Ms. Carla, (2004)
In some ways we
[Black women] have
been burnt so bad as
individuals and [by]
hearing the horror
stories from family
members and friends
that we are just
generally very skeptical
because we believe
that we are not seen
as real people to them…
doctors
Ms. Wiletta, (2003)
I heard the one about
that Black woman who
got the speculum left
in her while the doctor
went to see about
another patient…now
that wouldn’t happen to
a White woman…
it’s a true statement!
Ms. Sheila, (2003)
I think I coerced a doctor
one time, cause I was
Black…I was explaining the
problem with my jaw, I was
sitting on the table, he was
sitting on one of the stools
with wheels…I use my
hands a lot when I talk…
I don’t know if I scared him
or what because he backed
up and hit his head - BAM-
on the wall and then says
“there’s nothing wrong with
you” Now I don’t know what
else could have made him
react like that except that
he thought I was going to
hit him…and so I thought,
Okay…he’s not for me
Ms. Juanita, ( 2003)
This research has been funded by a grant from the National Institutes of Health/National Institute on Aging - F31 AG021329
and partially supported by a grant from the National Center for Complementary and Alternative Medicine - R01 AT003314-03A1-S1.
CONSIDERATIONS VITAL TO THE HEALTH
OF OUR AGING MINORITY POPULTIONS:
(1) Since healthcare personnel are the more powerful actors
within a clinical setting the development of respectful
partnerships between racial/ethnic patients and healthcare
personnel must be part of clinic “best practices” as an
important dimension of quality of care. In order to provide all
patients with the best possible care healthcare providers must
build these coalitions, thus encouraging racial/ethnic patients
to actively participate in healthcare interactions.
(2) Patient-centered approaches must be adopted within design,
implementation and analysis of intervention and promotion
efforts directed toward eliminating disparities in the health and well being among
racial/ethnic minorities. Hence a patient-centered awareness is encouraged among
individuals and communities regarding how their ethnocultural influences may impact
the intensity and the quality of care delivered and received.
(3) Aspects of patient-centered quality of care include values, beliefs, perceptions,
expectations and experiences of both patients and healthcare personnel. If we are to
improve interethnic communication, transform current approaches to health disparities
and support “best practices” as part of the science of inclusion and of eliminating health
disparities.
Understanding these contexts
will be essential asTHEY HAVE
IMPLICATIONS FOR ACCESS, UTILIZATION,
ADHERENCE, COMPLIANCE AND DELIVERY
OF CARE.