Robert Collins is a 49-year-old African American. He resides in the inner city of Detroit,
Michigan, with his extended family. He has a 43-year-old wife and five children, aged
26, 18, 16, 14, and 10. His wife, his elderly mother, three of his children (aged 16, 14,
and 10), two grandchildren, and his sick sister-in-law represent the household


Mr. Collins completed the 11th grade and maintains employment in a steel
factory. Although he works more than 40 hours a week, his income places him at the
poverty level. He cannot afford to purchase health insurance.
Mr. Collins’s 18-year-old daughter, Chloe, is pregnant for the third time and is a
single parent. Mr. Collins is caring for her other two children. Chloe is going to night
school to complete her high school education.
The Collins family goes to church every Sunday and is actively involved in the
Mrs. Collins was diagnosed with cancer, and she is receiving spiritual healing
from her pastor and church for this illness. Mr. Collins is extremely concerned about his
wife’s health and has increased his tobacco use.
Study Questions
1. Name one occupation-related disease for which Mr. Collins is at risk.
2. Identify one family member who is likely to be caring for the younger
children in the family.
3. Describe three cultural beliefs that Chloe may have regarding her
4. Discuss the role of spirituality in this family.
5. Identify two religious or spiritual practices in which Mrs. Collins may be
6. Because Mrs. Collins has cancer, discuss possible cultural thoughts she
may have regarding death and dying.
7. Identify two diseases common among African American men.
8. Identify the high school dropout rate among African American teens in the
inner city.
9. Name one tobacco-related disease found in the African American
10. Name two dietary health risks for African Americans.
11. Identify five characteristics to consider when assessing the skin of African
American clients.
12. Name two skin conditions common among African Americans.
Mr. and Mrs. Evans are an African American couple who retired from the school
system last year. Both are 65 years of age and reside on 20 acres of land in a large rural
community approximately 5 miles from a Superfund site and 20 miles from two
chemical plants. Their household consists of their two daughters, Anna, aged 40 years,
and Dorothy, aged 42 years; their grandchildren, aged 25, 20, 19, and 18; and their 2-
year-old great-grandson. Anna and Dorothy and their children all attended the
Mr. Evans’s mother and three of his nieces and nephews live next door. Mr.
Evans’s mother has brothers, sisters, other sons and daughters, grandchildren, and
great-grandchildren who live across the road on 10 acres of land. Other immediate and
extended family live on the 80 acres adjacent to Mr. Evans’s mother. All members of
the Evans family own the land on which they live.
Mrs. Evans has siblings and extended family living on 70 acres of land adjacent
to Mr. Evans’s family, who live across the road. Mr. and Mrs. Evans also have family
living in Chicago, Detroit, New York, San Francisco, and Houston. Once a year, the
families come together for a reunion. Every other month, local family members come
together for a social hour. The family believes in strict discipline with lots of love. It is
common to see adult members of the family discipline the younger children, regardless
of who the parents are.
Mr. Evans has hypertension and diabetes. Mrs. Evans has hypertension. Both
are on medication. Their daughter Dorothy is bipolar and is on medication. Within the
last 5 years, Mr. Evans has had several relatives diagnosed with lung cancer and colon
cancer. One of his maternal uncles died last year from lung cancer. Mrs. Evans has
indicated on her driver’s license that she is an organ donor.
Sources of income for Mr. and Mrs. Evans are their pensions from the school
system and Social Security. Dorothy receives SSI because she is unable to work any
longer. Mr. Evans and his brothers must assume responsibility for their mother’s
medical bills and medication. Although she has Medicare parts A and B, many of her
expenses are not covered.
Mr. and Mrs. Evans, all members of their household, and all other extended
family in the community attend a large Baptist church in the city. Several family
members, including Mr. and Mrs. Evans, sing in the choir, are members of the usher
board, teach Bible classes, and do community ministry.
Study Questions
1. Describe the organizational structure of this family and identify strengths and
limitations of this family structure.
2. Describe and give examples of what you believe to be the family’s values about
3. Discuss this family’s views about child rearing.
4. Discuss the role that spirituality plays in this family.
5. Identify two religious or spiritual practices in which members of the Evans
family may engage for treating hypertension, diabetes, and mental illness.
6. Identify and discuss cultural views that Dorothy and her parents may have about
mental illness and medication.
7. To what extent are members of the Evans family at risk for illnesses associated
with environmental hazards?
8. Susan has decided to become an organ donor. Describe how you think the Evans
family will respond to her decision.
9. Discuss views that African Americans have about advanced directives.
10. Name two dietary health risks for African Americans.
11. Identify five characteristics to consider when assessing the skin of African
12. Describe two taboo views that African Americans may have about pregnancy.
Elmer and Mary Miller, both 35 years old, live with their five children in the main
house on the family farmstead in one of the largest Amish settlements in Indiana.
Aaron and Annie Schlabach, aged 68 and 70, live in the attached grandparents’
cottage. Mary is the youngest of their eight children, and when she married, she and
Elmer moved into the grandparents’ cottage with the intention that Elmer would take
over the farm when Aaron wanted to retire.
Eight years ago, they traded living space. Now, Aaron continues to help with
the farm work, despite increasing pain in his hip, which the doctor advises should be
replaced. Most of Mary’s and Elmer’s siblings live in the area, though not in the same
church district or settlement. Two of Elmer’s brothers and their families recently
moved to Tennessee, where farms are less expensive and where they are helping to
start a new church district.
Mary and Elmer’s fifth child, Melvin, was born 6 weeks prematurely and is 1
month old. Sarah, aged 13, Martin, aged 12, and Wayne, aged 8, attend the Amish
elementary school located 1 mile from their home. Lucille, aged 4, is staying with
Mary’s sister and her family for a week because baby Melvin has been having
respiratory problems and their physician told the family he will need to be hospitalized
if he does not get better within 2 days.
At the doctor’s office, Mary suggested to one nurse, who often talks with Mary
about “Amish ways,” that Menno Martin, an Amish man who “gives treatments,” may
be able to help. He uses “warm hands” to treat people and is especially good with
babies because he can feel what is wrong. The nurse noticed that Mary carefully placed
the baby on a pillow as she prepared to leave.
Elmer and Mary do not carry any health insurance and are concerned about
paying the doctor and hospital bills associated with this complicated pregnancy. In
addition, they have an appointment for Wayne to be seen at Riley Children’s Hospital,
3 hours away at the University Medical Center in Indianapolis, for a recurring cyst
located behind his left ear. Plans are being made for a driver to take Mary, Elmer,
Wayne, Aaron, Annie, and two of Mary’s sisters to Indianapolis for the appointment.
Because it is on the way, they plan to stop in Fort Wayne to see an Amish healer who
gives nutritional advice and does “treatments.” Aaron, Annie, and Elmer have been
there before, and the other women are considering having treatments, too. Many
Amish and non-Amish go there and tell others how much better they feel after the
They know their medical expenses seem minor in comparison to the family
who last week lost their barn in a fire and to the young couple whose 10-year-old child
had brain surgery after a fall from the hayloft. Elmer gave money to help with the
expenses of the child and will go to the barn raising to help rebuild the barn. Mary’s
sisters will help to cook for the barn raising, but Mary will not help this time because
of the need to care for her newborn.
The state health department is concerned about the low immunization rates in
the Amish communities. One community-health nurse, who works in the area where
Elmer and Mary live, has volunteered to talk with Elmer, who is on the Amish school
board. The nurse wants to learn how the health department can work more closely with
the Amish and also learn more about what the people know about immunizations. The
county health commissioner thinks this is a waste of time and that what they need to do
is let the Amish know that they are creating a health hazard by neglecting or refusing
to have their children immunized.
Study Questions
1. Develop three open-ended questions or statements to guide you in your
understanding of Mary and Elmer and what health and caring mean to them and to
the Amish culture.
2. List four or five areas of perinatal care that you would want to discuss with Mary.
3. Why do you think Mary placed the baby on a pillow as she was leaving the doctor’s
4. If you were the nurse to whom Mrs. Miller confided her interest in taking the baby
to the folk healer, what would you do to learn more about their simultaneous use of
folk and professional health services?
5. List three items to discuss with the Millers to prepare them for their consultation at
the medical center.
6. If you were preparing the reference for consultation, what would you mention about
the Millers that would help to promote culturally congruent care at the medical
7. Imagine yourself participating in a meeting with state and local health department
officials and several local physicians and nurses to develop a plan to increase the
immunization rates in the counties with large Amish populations. What would you
suggest as ways to accomplish this goal?
8. Discuss two reasons why many Old Order Amish choose not to carry health
9. Name three health problems with genetic links that are prevalent in some Amish
10. How might health-care providers use the Amish values of the three-generational
family and their visiting patterns in promoting health in the Amish community?
11. List three Amish values to consider in prenatal education classes.
12. Develop a nutritional guide for Amish women who are interested in losing weight.
Consider Amish values, daily lifestyle, and food production and preparation
13. List three ways in which Amish express caring.
William Kapp, aged 55 years, and his wife, Gloria, aged 37, have recently moved from an
isolated rural area of northern Appalachia to Denver, Colorado, because of Gloria’s
failing health. Mrs. Kapp has had pulmonary tuberculosis for several years. They decided
to move to New Mexico because they heard that the climate was better for Mrs. Kapp’s
pulmonary condition. For an unknown reason, they stayed in Denver, where William
obtained employment making machine parts.
The Kapp’s oldest daughter, Ruth, aged 20, Ruth’s husband, Roy, aged 24, and
their daughter, Rebecca, aged 17 months, moved with them so Ruth could help care for
her ailing mother. After 2 months, Roy returned to northern Appalachia because he was
unable to find work in Denver. Ruth is 3 months’ pregnant.
Because Mrs. Kapp has been feeling “more poorly” in the last few days, she has
come to the clinic and is accompanied by her husband, William, her daughter Ruth, and
her granddaughter, Rebecca. On admission, Gloria is expectorating greenish sputum,
which her husband estimates to be about a teacupful each day. Gloria is 5 ft 5 in. tall and
weighs 92 pounds. Her temperature is 101.4°F, her pulse is regular at 96 beats per
minute, and her respirations are 30 per minute and labored. Her skin is dry and scaly with
poor turgor.
While the physician is examining Mrs. Kapp, the nurse is taking additional
historical and demographic data from Mr. Kapp and Ruth. The nurse finds that Ruth has
had no prenatal care and that her first child, Rebecca, was delivered at home with the
assistance of a neighbor. Rebecca is pale and suffers from frequent bouts of diarrhea and
colicky symptoms. Mr. Kapp declines to offer information regarding his health status and
states that he takes care of himself.
This is the first time Mrs. Kapp has seen a health-care provider since their
relocation. Mr. Kapp has been treating his wife with a blood tonic he makes from soaking
nails in water; a poultice he makes from turpentine and lard, which he applies to her chest
each morning; and a cough medicine he makes from rock candy, whiskey, and honey,
which he has her take a tablespoon of four times a day. He feels this has been more
beneficial than the prescription medication given to them before they relocated.
The child, Rebecca, has been taking a cup of ginseng tea for her colicky
symptoms each night and a cup of red bark tea each morning for her diarrhea.
Ruth’s only complaint is the “sick headache” she gets three to four times a week.
She takes ginseng tea and Epsom salts for the headache.
Mrs. Kapp is discharged with prescriptions for isoniazid, rifampin, and an
antibiotic and with instructions to return in 1 week for follow-up based on the results of
blood tests, chest radiograph, and sputum cultures. She is also told to return to the clinic
or emergency department if her symptoms worsen before then. The nurse gives Ruth
directions for making appointments with the prenatal clinic for herself and the pediatric
well-child clinic for Rebecca.AFRICAN AMERICAN CASE STUDY Essay.
Study Questions
1. Describe the migration patterns of Appalachians over the last 50 years.
2. Discuss issues related to autonomy in the workforce for Appalachians.
3. Identify high-risk behaviors common in the Appalachian region.
4. Describe barriers to health care for people living in Appalachia.
5. What might the nurse or physician do to encourage Mrs. Kapp to comply
with her prescription regimen?
6. What would your advice be regarding each of the home remedies that Mrs.
Kapp is taking? Would you encourage or discourage her from continuing
7. What might the nurse have done to help ensure that Ruth would make the
appointments for herself and her daughter?
8. What advice would you give Ruth regarding the home remedies that she
and her daughter are currently taking? Would you encourage or discourage
their use?
9. Do you think Mrs. Kapp will return for her appointment next week? Why?
What would you do if she did not return for her appointment?
10. Do you think that Ruth will make and keep appointments for herself and
her daughter?
11. What would you do to encourage Mr. Kapp to consent to a health
12. What additional services could you suggest to assist the Kapp family at
this time?
13. What additional follow-up do you consider essential for the Kapp family?
14. What advice would you give Ruth regarding her daughter’s frequent bouts
of diarrhea?
Leona Sperry, aged 74 years, lost her husband, a preacher, to emphysema 2 months
ago. Since that time, she has been living alone on a limited income from her husband’s
Social Security. Mrs. Sperry states that she has lived in the same West Virginia
community all of her life, just like her parents and grandparents. She is known in the
community as Miss Leona and is respected for her knowledge of folk medicine and
“deliverin’ babies,” which she has done as long as she can remember, just like her
mother and grandmother. All but one of her nine children live within 50 miles. Miss
Leona does her own cooking, bakes biscuits and bread twice a week, and makes large
pots of meat stew so she does not have to cook every day. A farmer neighbor supplies
her with milk, eggs, and meat in trade for using the land from her small farm to pasture
his cattle. Even though she only went to the third grade, she enjoys reading stories in
the Reader’s Digest, which she keeps on her bedside table. She also enjoys talking on
the telephone with her children and sister, who lives about 5 miles away. Miss Leona
lives on top of a hill and has to cross a footbridge to get to her home. Her driveway
ends at the footbridge, requiring her to carry her groceries up a steep incline with many
steps. Sometimes, a neighbor or the postman delivers her groceries when her children
are unable to bring them to her.
Miss Leona’s granddaughter, a nurse who lives out of the area, called the
Visiting Nurse Association and requested that someone see her grandmother. Miss
Leona tells the visiting nurse that she has had arthritis in her hands, hips, and knees for
many years. She has also suffered from “low blood” all her life. Now, she has other
health problems as well, and some chest congestion, which is not responding to her
usual treatment. Her most recent health concern, she says, is “heart problems,” which
her physician, Dr. Adi, tells her is from her high-fat diet. However, Miss Leona
believes her heart problems were brought on by her husband’s death, because she did
not have them until after he died. Her physician also gave her a jar of salve to put on a
leg wound caused by an insect bite, which became infected when she scratched it in
her sleep.
On her last visit to her physician a month ago, he referred her to a heart
specialist at a medical center 50 miles from her home. He also wanted her to make an
appointment with an arthritis specialist. So far, she has not made an appointment with
either specialist because she does not know when one of her children will be available
to take her to the medical center. Besides, she says, her children have their own
families and jobs, and she does not like to bother them with her problems. In addition,
she tells you that she is looking forward to her 16-year-old granddaughter, who is 3
months’ pregnant, coming to live with her in a couple of months. After all, she misses
being a midwife.
She admits not using the salve given to her by Dr. Adi because he told her to
apply the salve according to the instructions on the jar. She has been drinking the brine
from her home-canned pickles for her “low blood,” drinking ginseng tea for her
arthritis, and applying a poultice made from bacon grease on the leg wound. She tells
you that she does not want to return to Dr. Adi because she cannot understand him, he
does not listen to her, and he did not help her when she last saw him. She explains that
she is a good “Christianwoman,” has lived right all her life, and does not interfere with
her neighbors’ lives. She rarely misses Sunday church services because all her
neighbors go to the same Baptist church and she “allus” has plenty of volunteers to
carry (take) her to the church.AFRICAN AMERICAN CASE STUDY Essay.
Study Questions
1. Why do the members of her community call Mrs. Sperry by the name Miss Leona?
2. What can the nurse do to assist Miss Leona to decrease the barriers to needed health
3. What might Dr. Adi do to ensure a more-trusting relationship with Miss Leona?
4. What historical precedence is there for distrust of “outsiders” in Appalachia?
5. What evidence do you see of the “ethic of neutrality” in this case study?
6. What is the difference between a minister and a preacher, as practiced by Baptists in
7. What do Appalachians mean by the term “low blood”? What are some folk
treatments for this condition?
8. What advice would you give Miss Leona about her folk remedies?
9. What might you do to encourage Miss Leona to make appointments with the
specialists recommended by Dr. Adi?
10. How might you help Miss Leona eat a more-nutritious diet?
11. What strategies might you encourage for Miss Leona to cope with her “heart
problems” that began after her husband died?
12. What kind of prenatal advice would you give the granddaughter when she comes to
live with Miss Leona?
Mrs. Ayesha Said is a 39-year-old Muslim Arab housewife and mother of six who
immigrated to the United States from a rural town in southern Iraq 2 years ago. Her
mother-in-law and her husband, Mr. Ahmed Said, accompanied her to the United
States as participants in a post–Gulf War resettlement program, after they spent some
time in a Saudi Arabian refugee camp. Their relocation was coordinated by a local
international institution that provided an array of services for finding employment,
establishing a household, enrolling the children in public schools, and applying for
federal aid programs.
Mr. Ahmed, who completed the equivalent of high school, works in a local
plastics factory. He speaks some English. He plans to attend an English-language class
held at the factory for its many Iraqi employees. Mrs. Ayesha, who has very little
formal schooling, spends her day cooking and caring for her children and spouse, with
the assistance of her mother-in-law. She leaves their home, a three-bedroom upper flat
in a poor area of the city, only when she accompanies her husband shopping or when
they attend gatherings at the local Islamic center. These events are quite enjoyable
because most of those using the center are also recently arrived Iraqi immigrants. She
also socializes with other Iraqi women by telephone. Except for interactions with the
American personnel at the institute, Mr. Ahmed and Mrs. Ayesha Said remain quite
isolated from American society. They have discussed moving to Detroit because of its
large Arab community.
Four of the Said children attend public elementary schools, participating in the
English as a Second Language (ESL) program. Mr. Ahmed and Mrs. Ayesha are
dismayed by their children’s rapid acculturation. Although Muslims do not practice
holidays such as Halloween, Christmas, Valentine’s Day, and Easter, their children
plead to participate in these school-related activities.
Mrs. Ayesha is being admitted to the surgical unit after a modified radical
mastectomy. According to the physician’s notes, she discovered a “lump that didn’t go
away” about 6 months ago while breast-feeding her youngest child. She delayed
seeking care, hoping that inshallah, the lump would vanish. Access to care was also
limited by Mrs. Ayesha’s preference for a female physician and her family’s financial
constraints—that is, finding a female surgeon willing to treat a patient with limited
financial means. Her past medical history includes measles, dental problems,
headache, and a reproductive history of seven pregnancies. One child, born
prematurely, died soon after birth.
As you enter the room, you see Mrs. Ayesha dozing. Her husband, mother-inlaw, and a family friend, who speaks English and Arabic and acts as the translator, are
at her bedside.
Study Questions
1. Describe Arab Americans with respect to religion, education, occupation, income,
and English-language skills. Compare the Said family with Arab Americans as a
2. Assess the Said family’s risk for experiencing a stressful immigration related to their
isolated lifestyle.
3. Describe the steps you would take to develop rapport with Mrs. Ayesha and her
family during your initial encounter. Include nonverbal behavior and social etiquette
as well as statements or questions that might block communication.
4. Identify interventions that you would employ to accommodate Mrs. Ayesha’s
“shyness” and modesty.
5. You notice that, although Mrs. Ayesha is alert, her husband and sometimes her
mother-in-law reply to your questions. Interpret this behavior within a cultural
6. Although Mrs. Ayesha is normothermic and states her pain is “little,” Mr. Ahmed
insists that his wife be covered with several additional blankets and receive an
injection for pain. When you attempt to reassure him of his wife’s satisfactory
recovery, noting as evidence of her stable condition that you plan to “get her up”
that evening, he demands to see the physician. Interpret his behavior within a
cultural context.
7. Discuss Arab food preferences as well as the dietary restrictions of practicing
Muslims. If you filled out Mrs. Ayesha’s menu, what would you order?
8. When you give Mrs. Ayesha and her family members discharge instructions, what
teaching methods would be most effective? What content regarding recovery from a
mastectomy might most Arab Americans consider “too personal”?
9. Identify typical coping strategies of Arabs. What could you do to facilitate Mrs.
Ayesha’s use of these strategies?
10. Discuss predestination as it influences the Arab American’s responses to death and
11. Discuss Islamic rulings regarding the following health matters: contraception,
abortion, infertility treatment, autopsy, and organ donation and transplant.
12. Describe the Arab American’s culturally based role expectations for nurses and
physicians. In what ways do the role responsibilities of Arab and American nurses
13. What illnesses or conditions are Arab Americans unlikely to disclose because of
Islamic prohibitions or an attached stigma?
14. Compile a health profile (strengths versus challenges) of Arab Americans by
comparing beliefs, values, behaviors, and practices favoring health and those
negatively influencing health.AFRICAN AMERICAN CASE STUDY Essay.

CaseStudies-2_4 (2)

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