Canadian Health Network, February 1, 2007


[Rachel's introduction: The health of many Black women is affected in a negative way by factors such as culture, poverty, racism, and increased risk of certain diseases, as well as by their gender -- the very fact that they are women. These are the all-important social determinants of health.]

February is Black History Month in Canada, which is celebrated as African Heritage Month in Nova Scotia. It's a time to celebrate the many achievements and contributions of Black Canadians and learn about their experiences, including those related to their health. And it's a great time to take a closer look at what shapes and affects the health of Black women.

Black Canadian women are a diverse group who come from many different cultures, backgrounds and situations, each with unique experiences that shape their health. The health of many Black women is affected in a negative way by factors such as culture, poverty, racism, and increased risk of certain diseases, as well as by their gender -- the very fact that they are women. Also, some Black women do not have access to culturally competent healthcare -- that is, healthcare that meets their social, cultural and linguistic needs.

Who are Black Canadian women?

Black people have been part of Canadian history since the early 1600's, first as slaves then as free persons. Currently, most Black Canadians live in Ontario (62%) and Quebec (23%), as well as Nova Scotia, Alberta, British Columbia and Manitoba.

According to the 2001 census, there are now over 660,000 Black people in Canada, 346,000 of whom are women.

Black Canadian women are a diverse group from many cultures, backgrounds and situations. Over half (54%) are immigrants, who mostly come from African and Caribbean countries and Bermuda. Forty-three percent are non-immigrants, and the remaining three percent are non- permanent residents, a category which includes refugees.

While most Black women speak at least one of Canada's official languages, about 1% speak neither English nor French.

Gender and culture affect Black women's health

The health and well-being of many Black women is affected by cultural norms and traditional gender roles and expectations. Jeanine* is a Black refugee from Cameroon. She is a woman who does not fit the traditional expectations of her culture. Single and without children, she faces pressures and judgment from her cultural community. This adds extra stress to her life, which can harm her health and may put her at risk for health problems such as headaches, high blood pressure or insomnia. "I'm in my forties now," she says, "I don't have a child, I'm not married, so I'm judged because of that. It's considered a failure in my community. Men don't experience the same issue."

Strong Black Women don't always get the help they need

In many Black communities, women are often expected to be the main support for their families and others. In the Menopause and the Strong Black Woman Project, Dr. Josephine Etowa, Assistant Professor at the Dalhousie School of Nursing, examined the health and well-being of Nova Scotian women of African descent. "There is an ideology of having to be strong and be there for everybody else", says Dr. Etowa, who notes that "these strong Black women often care for others before themselves". The stress and pressure of this responsibility can take a toll on their health.

Many of these women also reported symptoms of depression, which is often stigmatized as are many mental health issues. "It's a topic that people don't want to talk about in the [Black] community", says Dr. Etowa. "It's a taboo, and they don't want to be labeled with mental conditions." Because of this stigma, some women remain isolated and don't get the support they need from health professionals, family or friends.

Poverty linked to poor health

According to the authors of the Canadian Association of Social Workers' report Income of Black Women in Canada, Black women often work in lower-paying jobs (Table 5) and are less likely to be employed (Table 10), despite having education levels that are similar to other Canadian women. They are also more likely to be poor, with over 46% living in poverty, compared to 29% of all Canadian women (Table 8). Because they're more likely to be poor, Black women are also more likely to have poor health.

Poor women have extra healthcare challenges; for example, some live in shelters or on the street and don't have access to regular care. Others, especially single mothers, can't afford to pay for medications or healthcare services. Black women who are new immigrants to Canada face additional financial challenges. For example, newcomers in some provinces have a three-month waiting period before they are eligible for public healthcare insurance, and have to pay for healthcare services while they wait.

Other women, like Jeanine, support families back home, which can take a toll both on their finances and their well-being. "I have to help the people I left behind by sending them money," she says. "So other things I could do to have better health, I put that all aside because I have to send the money back home. Even if I considered that I am in good health, if I know that my family back home is not, it will affect my well-being." If she had the money to do so, Jeanine would socialize more, join a gym and eat better, all of which would help her to have better health.

* Finding culturally competent healthcare can be a challenge for Black women. "

Racism also affects Black women's health

According to Canada's Action Plan Against Racism, approximately 47% of Black women who participated in Statistics Canada's 2002 Ethnic Diversity Survey: portrait of a multicultural society reported experiencing racial discrimination. While little research has been done on the direct impact of racism on health, it's acknowledged as another factor that can seriously affect health. According to the World Health Organization, "overt or implicit discrimination violates one of the fundamental principles of human rights and often lies at the root of poor health status... Discrimination both causes and magnifies poverty and ill-health."

Dr. Carol Amaratunga, Women's Health Research Chair at the University of Ottawa's Institute of Population Health, is a co-investigator with Dr. Wanda Thomas Bernard's team on the ongoing Racism, Violence and Health Project and researcher on other projects looking at the health of Black women and men. She sees a direct link between women's experiences of racism in a healthcare setting -- like being stereotyped, talked down to or neglected by their healthcare provider because they are Black -- and their future use of the system. "It really results in people delaying access to healthcare when they're ill, so that by the time they access treatment, in many cases their illness is quite advanced."

Higher rates of certain diseases and conditions

In 2001, Dr. Etowa completed a research project that looked at existing data on the health status of Black women in Nova Scotia. She found little Canadian information on the issue, mainly because health data collected in Canada doesn't often include information about a person's race or ethnicity. However, research from other countries like the United States indicates that Black women experience certain conditions and diseases, like fibroids, lupus and diabetes, more often than other women.

Dr. Etowa believes that to best prevent and treat illness in Black women, a more complete picture of their health status and the issues that affect their health is needed. "We don't know if we have the same issues [as women in the United States]," she says. "We need medical and quantitative research to tell us the incidence of disease among Black women. Ultimately, this is not [just] a Black issue; it's a healthcare system issue."

In some regions of Canada, data are being collected on ethnicity and rates of HIV/AIDS. These data indicate that women from countries in the Caribbean and sub-Saharan Africa experience higher rates of HIV and AIDS compared to other Canadian women (see page 96).

Culturally competent healthcare not always easy to find

Access to culturally competent healthcare that meets social, linguistic and cultural needs can also affect a person's health. Finding this kind of healthcare can be a challenge for Black women.

Lack of access to culturally competent healthcare is a theme that has come up in the ongoing project On the Margins: Understanding and Improving Black Women's Health in Rural and Remote Nova Scotia Communities. According to Dr. Etowa, " [Black women] don't see people who look like them or who understand their issues." For many, this creates a barrier to accessing healthcare.

Culturally competent healthcare means:

Providing health care to patients with diverse values, beliefs and behaviors, and tailoring delivery to meet their social, cultural and linguistic needs

Having an understanding of the communities being served, and the cultural influences on individual health beliefs and behaviors

Developing strategies to identify and address cultural barriers to accessing healthcare.

Adapted from: A Cultural Competence Guide for Primary Healthcare Professionals in Nova Scotia

Developing solutions that work

Targeted prevention initiatives

In response to emerging information on the higher rates of HIV and AIDS among African and Caribbean women, groups in Ontario have developed prevention initiatives aimed specifically at Black communities. For example, the Keep it alive campaign, developed by and for African and Caribbean people, raises awareness about HIV/AIDS among Black communities in Ontario, and Healthy Options for Women provides information to help Black pregnant women make decisions about HIV testing and/or treatment.

Integrating culturally competent care

Women's Health in Women's Hands (WHIWH) is a community health centre in Toronto that serves primarily Black women and women of colour. It is a unique example of a service that provides culturally competent healthcare.

The staff, who are mostly Black women and other women of colour, offer a range of holistic services in multiple languages. They also look at ways to address social issues. "We try to change the system through advocacy and lobbying the external environment to increase their access to care," says Ms. Notisha Massaquoi, the Executive Director. The soon-to-be-completed Collaborative Process to Achieve Access to Primary Health Care for Black Women and Women of Colour is an example of the collaborative research the centre undertakes. The project is investigating barriers Black women face when accessing healthcare, and possible solutions to reduce those barriers.

According to Dr. Sandra Romain, WHIWH physician, there is a growing need for more services for Black women. While opening more centres like WHIWH would be a good start, this may not be possible in some areas of the country. Dr. Romain says there is also a need for cultural competency training for all healthcare providers.

A number of resources on developing cultural competence are already available, such as A Cultural Competence Guide for Primary Healthcare Professionals in Nova Scotia. Also, some professional healthcare associations have adopted policies to encourage their members to develop and maintain cultural competence. For example, the Community Health Nurses Association of Canada Standards of Practice state that community health nurses working in Canada are expected to assess and understand "individual and community capacities including norms, values, beliefs, knowledge, resources and power structure", and provide "culturally sensitive care in diverse communities and settings."

Involving Black women in program development

"Women are experts on their own lives and their own healthcare", says Ms. Massaquoi. "It's important to include them at every level of healthcare, not just in providing services, but in the decision-making as well. We need to let women design the programs in the mainstream, have proper consultation and involve them in program development." For example, in the Healthy Balance Research Program, which looked at how caregiving affects women's health and well-being, women of African descent were involved in various aspects of the program including writing questionnaires and holding focus groups.

As Dr. Amaratunga puts it, the greatest value of working with Black women as they take charge of their health is that the process "recognizes the voice and power in the [Black] community". And as we take time during Black History Month to reflect on the past achievements of Black Canadians, we can also take inspiration from the strength of Black women who are working together to create a healthier future.

*Name changed to protect privacy

This article was prepared by at Women's College Hospital, the Canadian Health Network Women Affiliate.