Self-Care of African Immigrant Adults with Chronic Illness

Abstract

This cross-sectional study aims to describe the self-care of adult African immigrants in the US with chronic illness and explore the relationship between acculturation and self-care. A total of 88 African immigrants with chronic illness were enrolled. Self-care was measured with the Self Care of Chronic Illness Inventory v3 and the Self-Care Self-Efficacy scale. Scores are standardized 0 to 100 with scores >70 considered adequate. Acculturation was measured using a modified standardized acculturation instrument and predefined acculturation proxies. The self-care scores showed adequate self-care, with the mean scores of 78.6, 77.9, and 75.6 for self-care maintenance, monitoring, and management. Self-care self-efficacy mean score was 81.3. Acculturation was not significantly associated with self-care. Self-care self-efficacy was a strong determinant of self-care maintenance (p < .0001), monitoring (p < .0001), and management (p < .0001). The perception of inadequate income was a significant determinant of poor self-care management (p = .03). Self-care self-efficacy and perceived income adequacy were better determinants of self-care than acculturation.

Keywords

acculturation African immigrants chronic illness self-care self-efficacy

Background

Globalization has resulted in increased emigration of Africans from their home continent to developed countries. As of 2012, over 2 million Africans had immigrated into the US (Gambino et al., 2014). Many of these immigrants have chronic illness (e.g., type 2 diabetes, hypertension) (Commodore-Mensah et al., 2016; O’Connor et al., 2014). Chronic illness is defined as a physical condition that is slow in progression, prolonged, rarely cured, and often associated with functional restrictions requiring ongoing monitoring and long-term medical and/or nursing management (Bernell & Howard, 2016).

Mastering self-care is essential for successful chronic illness management (Riegel, Dickson et al., 2017; Wong et al., 2018). Self-care entails behaviors people perform to maintain health, manage illness, and minimize illness complications (Riegel et al., 2012). Despite differences in the etiology and pathophysiology of common non-communicable chronic illnesses such as diabetes, hypertension, heart disease, and stroke, there are core similarities in self-care across chronic illnesses (Schulman-Green et al., 2012). Anyone with a chronic illness needs to take medication if prescribed, manage what is often a complex treatment regimen, monitor their symptoms, recognize, label, and respond appropriately to symptoms, and consult with the healthcare team (Riegel et al., 2012; Riegel, Jaarsma et al., 2019; Schulman-Green et al., 2012). Self-care, when performed adequately, can significantly minimize symptoms and complications, reduce hospitalizations, and increase quality of life and perceived control over chronic illnesses (Jonkman et al., 2017; Riegel, Moser, et al., 2017).

To our knowledge, no data exist on African Immigrant Black’s Chronic illness self-care because the data of these individuals in the US are aggregated under the category of African American/Black (Commodore-Mensah et al., 2015). This practice of categorizing people based on race or color while disregarding cultural background also limits our ability to assess the influence of cultural factors on chronic illness self-care among African immigrants (Kagawa-Singer et al., 2015). Culture refers to shared norms, values, hidden rules, and ways of thinking that shape a group’s perceptions, judgments, and behaviors, including self-care (Airhihenbuwa, 1995; Al-Bannay et al., 2014). Culture influences how people define illness, monitor, label, and describe symptoms (Arnault, 2018; Henry Osokpo et al., 2021; Osokpo & Riegel, 2021), and their overall patterns of behavior in the context of their illness (Airhihenbuwa et al., 2014; Henry Osokpo et al., 2021; Osokpo & Riegel, 2021). Acculturation is often used as a proxy to examine the influence of culture on health and health behaviors. Acculturation involves modification of culturally accepted behaviors after adopting or borrowing beliefs, values, norms, practices, and customs from a new host culture due to continuous first-hand contact and immersion (Berry, 2008; Schwartz et al., 2010). Among African immigrants in the US, the influence of acculturation on health behaviors (Addo et al., 2019; Dharod et al., 2011) and health outcomes (Commodore-Mensah, Ukonu et al., 2018; Orjiako & So, 2014) is mixed. Individuals may integrate into the host culture to become acculturated or retain their culture to stay non-acculturated (Berry, 2008; Schwartz et al., 2010).

Studies suggest that African immigrants experience chronic illness risk exacerbation when they emigrate to developed countries and adapt to the host culture over time (Agyemang et al., 2009; Commodore-Mensah et al., 2016; Creatore et al., 2010; Mesoudi, 2018; Reuven et al., 2016; Toselli et al., 2019). One reason for this exacerbation is that culturally normative behaviors may be influenced by acculturation (Osei-Kwasi et al., 2020; Osokpo & Riegel, 2021; Sofolahan-Oladeinde et al., 2014; Venters & Gany, 2011). Among African immigrants in the US, acculturation has been found to be associated with a decrease in traditional high-fiber diets, an increase in fast food consumption and high-fat diets, and uptake of smoking behavior among healthy African immigrants (Bennett et al., 2008). However, it is not known if acculturation similarly influences chronic illness self-care.

Like other immigrant groups, African Immigrants face social and systemic conditions that may affect their self-care behaviors including access to health insurance, insurance status, employment status, level of income adequacy, living situation, and immigration status (Hall & Cuellar, 2016; Malmusi et al., 2010; Venters & Gany, 2011). Health insurance and employment status have been reported to influence health outcomes among African immigrants (Ogungbe et al., 2021) but it is unknown if these factors similarly influence chronic illness self-care. It is important to explore the determinants of self-care in this population.

Given the number of African immigrants in the US and the call for tailored intervention to promote optimal self-care (Dorsey & Pickler, 2019; Dorsey et al., 2019; Hickey et al., 2019), more nuanced research on the self-care among African immigrants is needed to allow for the identification of those with chronic illnesses at greater risk for poor self-care to inform the development of culturally concordant behavioral interventions for an at-risk population. Some of the key knowledge gaps in self-care research are the description of self-care in immigrant populations and the influence of acculturation and other social determinants of health factors on self-care (Riegel, Dunbar, et al., 2019). Therefore, the purpose of the study was to describe the self-care behaviors of adult African immigrants in the US living with a chronic illness, assess the relationship between acculturation and self-care and explore potential determinants of self-care. We hypothesized that acculturation would be significantly associated with self-care.

Theoretical Framework

This study was guided by the Theory of Self-Care of Chronic Illness (Riegel et al., 2012, 2019). Compared to other models, this theory is multi-dimensional and allows for the examination of the full scope of self-care (Jaarsma et al., 2020). The overarching concept entails three core processes: self-care maintenance, self-care monitoring, and self-care management. Self-care maintenance includes behaviors used to maintain physiological stability, preserve health, and minimize disease complications (Riegel et al., 2012). Some of the most common maintenance behaviors are adhering to medication regimens, following dietary recommendations, engaging in physical activity, and stopping smoking (Riegel et al., 2012). Self-care monitoring involves vigilant tracking, recognizing, and labeling of symptoms with the goal of taking appropriate actions before a symptom escalates, such as communicating with a health care provider to obtain timely and adequate care (e.g., monitoring blood glucose for diabetes or checking daily weight for heart failure) (Riegel et al., 2012, 2019). Self-care management entails implementing treatment recommendations, either individually or in consultation with a health care provider, when symptoms occur as well as evaluating the effectiveness of these treatments (Riegel et al., 2012). Another key factor that influences self-care is self-care self-efficacy. Self-care efficacy reflects a person’s confidence in the ability to perform and persist in engagement in self-care despite difficulties (Riegel et al., 2012, 2019). Social and cultural factors (e.g., access to care, cultural beliefs) are theorized to influence self-care (Riegel et al., 2012, 2019).

Methods

A cross-sectional descriptive survey was used to study 88 African immigrants with chronic illness. Approval for the study was obtained from the Institutional Review Board (IRB) of the Institutional Review Board (IRB) of the University of Pennsylvania after an expedited review. Verbal and written informed consent were obtained from all participants before the survey was conducted. Enrollment occurred between March and December 2020.

Sample

Purposive and snowballing techniques were employed to recruit participants from religious and community-based organizations serving African immigrants. Between 2013 and 2017, the largest number (over 300,000) of sub-Saharan African immigrants resided in the greater New York City and Washington, DC metropolitan areas, including the New York, New Jersey, and Pennsylvania metro area, so enrollment focused on these areas (Echeverria-Estrada & Batalova, 2019).

The study was adequately powered to assess the primary hypothesis addressing the relationship between self-care and acculturation (n = 84). The power analysis was based on prior literature (Hinkle et al., 2003), in which a clinically relevant Pearson Correlation Coefficient threshold of .3 was found. A consecutive sample of 84 subjects achieved 80% power to detect a Pearson correlation as low as .30 between acculturation and self-care (primary aim) at the .05 significance level (PASS V15.0.03).

The study was not powered to address our exploratory aim. We performed a post-hoc power analysis to identify effect size estimates that can be used for a larger study examining the determinants of self-care in African immigrants with chronic illness in the US. Using multiple regression and the currently known effects of the covariates, a sample size of 88 achieves 80% power to detect an R² of .06545 attributed to acculturation using an F-test with a significance level (alpha) of .05. The variables tested are adjusted for self-care self-efficacy, length of chronic conditions, age, sex, marital status, employment status, perceived income adequacy, immigrant status, educational level, and insurance status, which have a combined R² of .22 by themselves.

Eligibility criteria specified that participants: (1) self-identify as sub-Saharan African immigrants, (2) be ≥35 years of age, (3) have a symptomatic chronic illness diagnosis (e.g., hypertension) confirmed either by self-report or practitioner, and (4) be able to speak and understand English. The age requirement of 35 years was used because disease and the symptoms of chronic health conditions increase in middle-aged (Barnett et al., 2012) and 35 is an accepted cutoff for defining middle aged adults (World Health Organization, 2015). The exclusion criteria were: (1) unwillingness to sign the consent form; (2) not living in the community where self-care is an individual responsibility; and (3) major cognitive impairment that limited the ability to participate.

Procedure

Enrollment Procedures

Administrators and community leaders of religious and community-based organizations serving African immigrants in the northeastern US were contacted in person, via email and phone to inform them about the study. Permission was sought from these community gatekeepers to address their members virtually or in-person during their meetings (e.g., Sunday Worship service) to inform them about the study. An e-version of the study flyer was shared with all those present at these meetings. Some individuals at these meetings also connected the principal investigator with family members and friends who met the eligibility criteria and might be interested. Additionally, nurse navigators at two organizations serving African immigrants identified and directed potential participants to the principal investigator. Potential participants were approached by the primary investigator and provided with a detailed explanation of the study to determine interest in participating.

Screening

Interested individuals were screened for cognitive impairment using he Telephone Interview for Cognitive Status (TICS) (Brandt et al., 1988), an 11-item interview. The TICS can be administered either over the telephone or face-to face. Before the interview, participants were advised to make sure their environment was conducive for testing and they were able to hear the principal investigator at a conversational volume. The individual item scores are summed to obtain the TICS total score, providing a measure of global cognitive functioning. A TICS score ≤20 is considered “Moderately to Severely impaired,” scores 21 to 25 “Mildly Impaired,” scores 26 to 32 “Ambiguous,” and 31 to 41 scores “Nonimpaired” (Brandt et al., 1988). Interested individuals were eligible if the TICS score was >25. The TICS demonstrates excellent sensitivity and specificity to detect cognitive impairment (Brandt et al., 1988).

In screening for symptoms, individuals were asked: “Have you had symptoms due to your chronic illness or treatment for your illness within the last 3 months (chest pain, palpitations, shortness of breath, polyuria, etc.)?” For ability to read and understand English, individuals were asked: “Can you read and understand English” and “Can you write more than your name in English?” A yes response to both questions made the individual eligible to participate in the study.

Data Collection

Once potential participants were enrolled, data collection was done over the phone or in-person at community centers. Of the 150 African immigrants assessed for eligibility, 52 were excluded because they did not meet inclusion criteria. Another 10 were not interested in participating and four withdrew consent before completing surveys.

Eligible and willing individuals were asked to provide sociodemographic data (e.g., age, marital status, level of education, living condition, perceived adequacy of income, and employment status) and then complete self-report measures of self-care, acculturation, and comorbidity. This process took approximately 20 to 40 minutes to complete.

Data on self-care were collected using the Self Care of Chronic Illness Inventory (SC-CII) v3 (Riegel et al., 2018), a 20-item instrument using a 5-point response scale. The SC-CII reflects the Middle Range Theory of Self-Care of Chronic Illness (Riegel et al., 2012, 2019). Raw scores are standardized to a scale of 0 to 100, with higher scores indicating better self-care. A self-care score ≥70 is considered adequate engagement in self-care activities, although lower levels provide some benefits (Riegel, Dickson et al., 2017). The SC-CII has adequate psychometric properties (Riegel et al., 2018). The global reliability index for the self-care maintenance, monitoring, and management scales were 0.67, 0.81, and 0.71 respectively, while content validity was 0.89, 0.88, and 0.96 respectively (Riegel et al., 2018). The SC-CII captures fundamental views of self-care regardless of the cultural background of the person completing the inventory (De Maria et al., 2021). The SC-CII have been translated into numerous languages and found to be useful in both individualistic and collectivist societies where family involvement overrides individual decision making (Herber et al., 2020).

Acculturation was operationalized using two methods. First, a 12-item standardized acculturation instrument (Marin et al., 1987) was modified to assess an individual’s language and media use and ethnic social relations The instrument was originally developed for Hispanics and found to have adequate psychometric properties (alpha coefficient of .92) (Marin et al., 1987). Items were slightly modified for African immigrants. For example, for the question “In general, in what language do you usually think?” the choices ranged from “Only African dialect (e.g., Yoruba) to Only English.” The 12 items are summed and averaging to produce a general acculturation score ranging from 1 to 5, with higher scores indicating higher acculturation. Scores in the middle (i.e., 2.5) indicate biculturalism (Perez, 2015).

Secondly, acculturation was operationalized using predefined acculturation proxies such as duration of residency and age at immigration (Sofolahan-Oladeinde et al., 2014). Duration of residency in the US was determined by subtracting the year of migration from the current year. Participants were asked: “What year did you come to live in the US permanently?” Age at immigration to the US was calculated by subtracting duration of residency in the US from current age.

Comorbidity was measured using the Charlson Comorbidity Index interview format (Charlson et al., 1987; Katz et al., 1996). Total scores range from 0 to 34. Higher scores indicate higher risk of mortality (Charlson et al., 1987).

Determinants

In addition to acculturation, the following variables were explored as possible determinants of self-care: self-care self-efficacy, age in years, length of chronic conditions in months, sex (male/female), marital status (single never married, divorced/separated/widowed, or married), insurance status (with/without health insurance), employment status (employed [full-time or part-time] or unemployed/retired), perceived income adequacy (have enough or more than enough to meet needs, ordo not have enough to meet needs), living situation (lives alone or lives with family/others), immigration status (US citizen/ permanent resident, Refugee status, and Non-immigrant temporary visa holder), and educational level (high school graduate or below and some college or above). We chose these variables as potential determinants of self-care because they are linked to health outcomes in African immigrant populations in the US (Commodore-Mensah, et al., 2016; Commodore-Mensah, Matthie, et al., 2018; Mukaz et al., 2020; Shoup et al., 2020). Additionally, self-care self-efficacy was included because it has been shown previously to explain self-care behavior (Riegel et al., 2012). The Self-care of Self-efficacy scale is a single-domain 10-item self-report measure for self-efficacy related to self-care in persons with chronic illness (Riegel et al., 2012, 2019). Each item is scored using a 5-point response scale. Higher score represents higher level of self-efficacy. Raw scores are standardized to range from 0 to 100. The scale has been validated for use across different cultural groups and nationalities (Yu et al., 2021).

Analysis

Research Electronic Data Capture (REDCap) (Harris, 2012; Harris et al., 2009) was used for data management. De-identified participant information was entered into REDCap by the principal investigator and exported into SPSS v.25 (IBM Corp., Armonk, NY, USA) for analysis. The level of significance for statistical tests was set at alpha (α) = .05. REDCap was programed to prevent missing data and we had no missing data. Frequencies (percentages) were used to describe categorical variables (e.g., gender). Means and standard deviations were used for continuous variables. Score distributions were assessed using means of boxplot, median, and interquartile range. Linear regression was used to examine the relationship between self-care and acculturation. An exploratory sensitivity analysis with a backward elimination approach was conducted to identify potential determinants of self-care using an alpha threshold of .1. Multivariable regression analysis was used to explore the relationship between self-care and acculturation while adjusting for confounding variables. In a stepwise manner, the most insignificant variables were removed gradually at different steps until a final model was reached. Acculturation was forced into each model because acculturation was hypothesized to influence self-care.

Results

Tables 1 and 2 present the sociodemographic and clinical characteristics of the final sample of was 88 African immigrants. Majority of participants were Nigerian and Liberian US citizens/permanent residents. Ages ranged from 35 to 78 years. They were mostly married and lived with family or others. Most were highly educated, employed, and reported having enough or more than enough income to meet their needs. Diabetes and hypertension were the most common diagnoses. Most respondents carried health insurance. Most of these African immigrants were acculturated.

Table 1.

Sociodemographic and Clinical Characteristics of Participants (N = 88).

Variables	N (%)
Country of birth
Nigeria	50 (56.8)
Liberia	14 (15.9)
Mali	9 (10.2)
Ghana	6 (6.8)
Others (Angola, Cote d’Ivoire, Mauritania, Democratic Republic of Congo, Togo, Sierra Leone)	9 (10.2)
Age category
35–48 years	18 (20.5)
49–64 years	60 (68.2)
65 and above	10 (11.4)
Gender
Female	42 (47.7)
Marital status
Single never married	11 (12.5)
Married	59 (67.0)
Divorced/separated or widowed or other	18 (20.5)
Education
High school graduate or below	13 (14.8)
Some college	18 (20.5)
Bachelor’s degree	33 (37.5)
Master’s degree and above	24 (27.3)
Employment status
Employed (full-time and employed part-time)	61 (69.3)
Unemployed, retired or other	27 (30.7)
Perceived adequacy of income
I have enough or more than enough to meet my needs	53 (60.2)
I do not have enough to meet my needs	35 (39.8)
Living condition
Lives alone	11(12.5)
Lives with family or with others	77 (87.5)
Immigration status
US citizen/ permanent resident	75 (85.2)
Refugee status	5 (5.7)
Non-immigrant temporary visa holder	8 (9.1)
Insurance status
Insured	72 (81.8)
Non-insured	16 (18.2)
Modified acculturation scale
Less acculturated	38 (43.2)
More acculturated	50 (56.8)
Major chronic illness
Diabetes	16 (18.2)
Hypertension	44 (50.0)
Arthritis	7 (8.0)
Heart disease	3 (3.4)
Asthma	2 (2.3)
Others (e.g., thyroid disorders, breast cancer, colon cancer, GERD/IBS, anemia, chronic dermatitis, HIV)	16 (18.2)

Note. GERD = gastroesophageal reflux disease; IBS = irritable bowel syndrome; HIV = human immunodeficiency virus.

Table 2.

Sociodemographic and Clinical Characteristics of Participants (N = 88).

Variables	Mean ± (95% CI)/median (IQR)
Age	54.7 (52.7, 56.7)
Household size	4 (3.5)
Duration of residency in the US (years)	16.9 (14.5, 19.3)
Age at immigration to the US (years)	37.8 (35.2, 40.4)
Length of chronic condition (months)	32.5 (10, 81.5)
Charlson comorbidity score (possible range 0–5)	1 (0.1)
Acculturation (continuous variable)—Modified standardized acculturation scale (possible range 1–5)	3.0 (2.9, 3.1)

Figure 1 illustrates the self-care maintenance, monitoring and management and self-efficacy distributions. Mean self-care of African immigrants across all domains was adequate (Table 3).

Table 3.

Descriptive Statistics and Ranking of Self-Care Behaviors of African Immigrants With Chronic Illness.

Self-care	N	Minimum	Maximum	Mean (95% confidence limits)
Self-care maintenance	88	40.6	100	78.6 (75.9, 81.3)
Self-care monitoring	88	30.0	100	77.9 (73.8, 82.8)
Self-care management	88	40.0	100	75.6 (72.1, 79.1)
Self-care self-efficacy	88	25.0	100	81.3 (77.8, 84.8)
	N	Mean item score	Never, rarely or sometimes %	Frequently or always %
Self-care maintenance
How often or routinely do you do the following?
Eat a special diet?	88	3.31	61.4	38.6
Make sure to get enough sleep?	88	4.05	41.9	58.1
Do physical activity?	88	4.10	33.0	67.0
Take prescribed medicines without missing a dose?	88	4.14	30.7	69.3
Do something to relieve stress?	88	4.15	30.7	69.3
See your healthcare provider for routine health care?	87	4.21	27.6	72.4
Do you avoid tobacco smoke?	88	4.50	12.5	87.5
Try to avoid getting sick?	86	4.73	5.8	94.2
Self-care monitoring
How often do you do the following?
Monitor for medication side-effects?	86	3.69	40.7	59.3
Monitor whether you tire more than usual doing normal activities?	87	3.98	33.3	66.7
Monitor for symptoms?	87	4.20	24.1	75.9
Monitor your condition?	87	4.25	24.1	75.9
Pay attention to changes in how you feel?	87	4.45	18.4	81.6
	N	Mean item score	Not likely or somewhat likely	Likely and very likely
Self-care management
When you have symptoms, how likely are you to use one of these?
Call your healthcare provider for guidance?	88	3.36	42.0	58.0
Change what you eat or drink to make the symptom decrease or go away?	87	3.85	36.8	63.2
Change your activity level?	87	4.11	24.1	75.9
Take a medicine to make the symptom decrease or go away?	88	4.24	21.6	78.4
Tell your healthcare provider about the symptom at the next office visit?	88	4.36	22.7	77.3

The descriptive analysis of the individual items on self-care maintenance scale revealed that the majority of the sample never, rarely, or only sometimes eat a special diet. Most reported trying to avoid getting sick and avoiding tobacco smoke. On the self-care monitoring scale, a sizeable proportion never, rarely, or sometimes monitor for medication side-effects or feeling more tired than usual doing when doing normal activities. On the self-care management scale, a sizeable proportion never, rarely, or sometimes call a provider for symptoms or change what they eat or drink to make symptoms go away (Table 3). None of the three measures of acculturation were associated with self-care maintenance, monitoring, or management, even after adjusting for confounding variables (Table 4). The hypothesis was rejected.

Table 4.

Association Between Acculturation and Self-Care.

	Estimate	t Value	95% Confidence limits	Pr > \|t\|
Self-care maintenance
Modified acculturation scale	1.89	0.76	−3.05, 6.82	.45
Duration of residency	0.04	0.34	−0.20, 0.28	.73
Age at immigration	0.02	0.14	−0.20, 0.24	.89
Self-care monitoring
Modified acculturation scale	4.53	1.20	−2.99, 12.06	.23
Duration of residency	0.11	0.63	−0.25, 0.48	.53
Age at immigration	−0.23	−1.39	−0.57, 0.10	.17
Self-care management
Modified acculturation scale	3.32	1.03	−3.11, 9.74	.31
Duration of residency	0.13	0.84	−0.18, 0.44	.40
Age at immigration	0.01	0.08	−0.29, 0.30	.94

Exploratory Sensitivity Multivariate Analysis

Self-care self-efficacy was an independent determinant of self-care maintenance, monitoring, and management (Table 5) with low self-care self-efficacy associated with low self-care on each scale. Additionally, the perception of income inadequacy was associated with lower self-care management (Table 5). These variables explained 15%, 35%, and 46% of the variance of the self-care maintenance, self-care monitoring, and self-care management respectively (Table 5).

Table 5.

Determinants of Self-Care.

Variable	Estimate	SE	95% Confidence limits		Pr > \|t\|
Determinants of self-care maintenance (R² = .15; F = 7.47)
Modified acculturation scale	0.74	2.33	−3.90	5.37	.75
Self-care self-efficacy	0.29	0.08	0.14	0.45	.0003
Determinants of self-care monitoring (R² = .35; F = 11.18)
Age	−0.33	0.18	−0.70	0.03	.07
Length of chronic condition	0.05	0.02	−0.002	0.10	.06
Modified acculturation scale	3.39	3.25	−3.08	9.86	.30
Self-care self-efficacy	0.64	0.10	0.43	0.85	<.0001
Determinants of self-care management (R² = .46; F = 17.78)
Marital status (married vr single, separated or widowed)	−5.64	2.96	−11.52	0.25	.06
Perceived income adequacy (have enough or more verses do not have enough to meet my needs)	6.35	2.85	0.69	12.02	.03
Modified acculturation scale	0.64	2.48	−4.30	5.58	.80
Self-care self-efficacy	0.61	0.08	0.45	0.77	<.0001

Discussion

To our knowledge, this is the first investigation to describe self-care in African immigrants with chronic illness in the US and the first to examine the relationship between acculturation and self-care in this population. Self-care was adequate overall and acculturation was not associated with self-care. Specific self-care behaviors were poor in this sample, suggesting areas to target for intervention. Self-care self-efficacy and perceived income adequacy may help identify African immigrants most at risk for poor self-care.

There are limited data on the influence of acculturation on African immigrants to the US, but prior reports are mixed as to the influence of acculturation on dietary practices and health screening behaviors (Sofolahan-Oladeinde et al., 2014). This may be due to differences in the conceptualization of acculturation across studies. Investigators have examined duration of residence, English language proficiency, age at immigration, country of origin, social interactions, and percent of life spent in the host country. Even when standardized instruments were used, the instruments differ across studies (Sofolahan-Oladeinde et al., 2014). This variability highlights the fact that acculturation is a complex and multifactorial social concept.

In a few studies it was noted that, with longer duration in the US, African immigrants may transition from a traditional high-fiber diet to fast food consumption and diets high in fats while decreasing their consumption of fruits and vegetables (Dharod et al., 2011; Okafor et al., 2014; Patil et al., 2009). On the contrary, in a different study, acculturation was associated with higher fruit and whole grain intake and decreased trans-fat intake in Nigerian immigrants in the US when compared to indigenous men living in Nigeria (Kumar et al., 2009). Acculturation may also be associated with the uptake of smoking behavior (Bennett et al., 2008; Giuliani et al., 2012). In another study, a longer duration of US residency was reported to be associated with increased likelihood of accessing health services for preventative screenings, although only women were included in the study (Harcourt et al., 2014). Notably, in that study, access to health services was poor in African immigrants with less acculturation, particularly those with low English comprehension (Harcourt et al., 2014).

The African immigrants in our sample were best at self-care maintenance and worst at self-care management. These findings reflect a typical self-care pattern observed in persons with chronic conditions in other minority US populations (Dickson et al., 2013; Luciani et al., 2021). Dickson et al. (2013) reported that Blacks with heart failure did best with self-care maintenance behaviors and worst with self-care management behaviors. In their study, self-care confidence scores were the highest across all domains of self-care. The self-care maintenance behavior that was particularly low in our sample was eating a special diet. This is unsurprising, since several studies have shown that this population tends to adhere to a traditional African diet and preserve culture through food preferences and choices (Cooper Brathwaite & Lemonde, 2016; Henry Osokpo et al., 2021; Turk et al., 2015). African immigrants’ food choices are culturally framed, incorporating family perceptions of the food (Jakub et al., 2018), cultural taste or preference (Jakub et al., 2018), cultural and social implications, and quality of life (Kindarara et al., 2017; Njeru et al., 2016). Culturally, food evokes pleasant memories, provides comfort and provides a connection to their home countries (Jakub et al., 2018). Additionally, food has an integral role in religious celebrations and traditions, providing family bonding, religious fellowship (Jakub et al., 2018), and a strong sense of community. In addition, African diets are thought to be more nutritious than western diet. For these reasons, dietary practices of African immigrants may be more resistant to acculturation than other self-care maintenance behaviors (Akinlua et al., 2017) and may explain the unwillingness to change food choices in response to symptoms.

The African immigrants in our sample endorsed trying to avoid tobacco smoke. This result is consistent with prior studies showing that cigarette smoking is low in this population (Baluja et al., 2003; Commodore-Mensah et al., 2016; Hamilton & Green, 2017; Nyaaba et al., 2019; Sewali et al., 2015) compared to African Americans (Turkson-Ocran et al., 2020). Smoking is considered a cultural taboo in certain African countries (e.g., Nigeria) and is contrary to “faith-based” norms of Christianity, Islam, and African traditional religions (Odusola et al., 2014). African social and cultural norms regarding smoking persist even after migration to countries outside Africa (Nyaaba et al., 2019).

Participants overwhelmingly endorsed trying to avoid getting sick. Meeting family obligations is a source of cultural pride for this population, leading to a strong commitment to provide for their families in the US and back home in Africa. As a result, African immigrants may feel that they cannot afford to get sick and will do everything in their power to avoid it. In one study, African immigrants with hypertension in Europe expressed fears of being unable to meet their social responsibilities to their families; hence will do their best to control their blood pressure (Beune et al., 2006). The current COVID-19 pandemic may have added to the participants’ desire to try to avoid getting sick.

We found that African immigrants monitor their symptoms but may not monitor for medication side-effects or feeling more tired than usual when doing normal activities. Two separate studies reported that, for the most part, African immigrants monitor their illnesses, except for lapses due to forgetfulness (Njeru et al., 2016; Siad et al., 2018). One reason that they may not monitor for medication side effects may be an inability to understand discharge instructions (Henry Osokpo et al., 2021; Omenka et al., 2020) due to language differences during patient-provider interactions, during which providers use technical names and descriptions that are unfamiliar to this population. Omenka and colleagues reported that impatience in educating African immigrants about medication side-effects may also contribute to poor understanding and nonadherence (Omenka et al., 2020; Woodgate et al., 2017).

Almost half of our participants were unlikely or only somewhat likely to call their healthcare provider for guidance when they have symptoms. Some possible explanations for this finding include lack of trust or difficulty navigating the complex US health system, previous unpleasant experiences (e.g. discrimination, provider dismissiveness, stereotyping, condescending, or hostile attitudes) (Njeru et al., 2016; Omenka et al., 2020), financial constraints (Kindarara et al., 2017; Nyaaba et al., 2019) and limited access to culturally-competent providers (Omenka et al., 2020). Another possible explanation for failure to seek guidance may stem from experiences in Africa, where healthcare providers are only contacted when illness is out of control (Omenka et al., 2020). Due to cultural and religious norms based on collectivism, African immigrants may seek guidance from community elders and religious leaders as an initial response to illness symptoms. Perhaps peer-based education about the need to monitor medication side-effects and fatigue would be useful in this population (Baghianimoghadam et al., 2013; Njeru et al., 2016).

Lower income adequacy was associated with lower self-management, probably due to the cost of healthcare, financial constraints (Henry Osokpo et al., 2021; Kindarara et al., 2017; Nyaaba et al., 2019), and family obligations (Afulani et al., 2016). In other populations, being unemployed or having a low-income was associated with poor self-care (Harley et al., 2014; Smed et al., 2018). Immigrants with higher income may find it easier to adhere to healthy dietary practices because they are unable to afford the financial costs of healthy groceries (Laaksonen et al., 2003). However, the influence of income on health behaviors is not straightforward because other socioeconomic conditions impact the health of socially marginalized persons (Baah et al., 2019, 2021; Braveman & Gottlieb, 2014; Havranek et al., 2015; Riegel et al., 2017). This characteristic cannot be modified, but screening for income inadequacy may help to identify patients at risk for poor self-care.

We found that higher self-care self-efficacy was associated with higher self-care. In persons with chronic illness (e.g., diabetes, heart failure), studies suggest self-care efficacy is a strong determinant of self-care: the higher the self-care self-efficacy, the higher the self-care maintenance, monitoring, and management (Ausili et al., 2016; Irani et al., 2019; Koirala et al., 2018; Luciani et al., 2021; Riegel et al., 2010). Self-care self-efficacy affects decision-making about self-care (Buck et al., 2012). Additionally, self-care self-efficacy has been associated with health-promoting self-care behaviors and positive health outcomes (Eller et al., 2018).

Although the above studies suggest that self-care self-efficacy applies across diverse cultures, its relevance to non-Western cultures has been questioned because of its emphasis on control (Eller et al., 2018; Markus & Kitayama, 1991). However, self-efficacy is important both in individualistic and collectivist cultures (Bandura et al., 1999; Eller et al., 2018). Since this is the first study to measure self-care self-efficacy in African immigrants living with chronic illness in countries outside Africa, more studies are needed to confirm the importance of self-care self-efficacy in this population. Additionally, based on our findings, culturally concordant trials of interventions designed to improve self-care among African immigrants with chronic illness should include core elements to increase self-care self-efficacy.

Limitations of the study include the cross-sectional design and the use of a purposive sample, which limits the generalizability of results. However, the chronic illness profile of the participants enrolled is representative of the African immigrant population in the US. We enrolled a bilingual, well-educated sample with adequate perceived income, which may have interfered with our ability to identify a relationship between acculturation and self-care.

Conclusion

Self-care is important for chronic illness management. Although self-care in this sample was adequate for the most part, further investigation of the reasons for the items that were poor in this population would inform culturally concordant interventions to promote self-care. Additionally, our findings about the determinants of self-care provides effect sizes estimates that can be used for a larger study examining the determinants of self-care in African immigrants with chronic illness in the US. In this study, we identified only two significant determinants of self-care and the amount of variance explained by the regression models was low to moderate (between 15% and 46%). This suggests that other variables serving as determinants of self-care in African immigrants with chronic illness are still unknown. Acculturation was not a significant influence on self-care. Acculturation is a complex and multifactorial social concept that may not lend itself to quantitative methods alone. Perhaps qualitative or mixed methods approaches would facilitate our understanding of the influence of acculturation on self-care in this population.

Footnotes

Acknowledgements

Special thanks to the following religious and community-based organizations serving African immigrants for their support in participants’ recruitment: Africa Cultural Alliance of North America, African Family Health Organization, Deeper Life Bible Church, Egbe Omo Yoruba Delaware Valley, Eko Club Delaware Valley, The Episcopal Church of St. Andrew, and St. Monica, just to name a few.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of Pennsylvania Office of Nursing Research, Xi Chapter of Sigma Theta Tau, and Nightingale Awards of Pennsylvania. The content is solely the responsibility of the authors and does not necessarily represent the official views of these organizations. Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number T32NR009356. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iDs

Onome Henry Osokpo

Barbara Riegel

Author Biographies

Onome Henry Osokpo, PhD, MSc, MSN, RN is a Provost Postdoctoral Fellow and a Postdoctoral Research Fellow at the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.

Lisa M. Lewis, PhD, RN, FAAN is Associate Dean for Equity and Inclusion and Associate Professor of Nursing and Africana Studies at the University of Pennsylvania School of Nursing.

Uchechukwu Ikeaba, MS is currently an IT Business Intelligence Analyst University of North Carolina at Chapel Hill

Jesse Chittams, MS is a Senior Biostatistician at the Biostatistics, Evaluation, Consultation, Collaboration, Analysis (BECCA) laboratory at the University of Pennsylvania School of Nursing.

Frances K. Barg, PhD, MEd is Emeritus Professor of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine

Barbara Riegel, PhD, RN, FAHA, FAAN is Edith Clemmer Steinbright Professor of Gerontology at the University of Pennsylvania School of Nursing.

References

Addo

I. Y.

Brener

Asante

A. D.

de Wit

(2019). Determinants of post-migration changes in dietary and physical activity behaviours and implications for health promotion: Evidence from Australian residents of sub-Saharan African ancestry. Health Promotion Journal of Australia, 30(Suppl 1), 62–71.

Afulani

P. A.

Torres

J. M.

Sudhinaraset

Asunka

(2016). Transnational ties and the health of sub-Saharan African migrants: The moderating role of gender and family separation. Social Science & Medicine, 168, 63–71. https://doi.org/10.1016/j.socscimed.2016.09.009

Agyemang

Addo

Bhopal

Aikins Ade

Stronks

(2009). Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: A literature review. Globalization and Health, 5(1), 7.

Airhihenbuwa

C. O.

(1995). Health and culture: Beyond the western paradigm. SAGE.

Airhihenbuwa

C. O.

Ford

C. L.

Iwelunmor

J. I.

(2014). Why culture matters in health interventions: Lessons from HIV/AIDS stigma and NCDs. Health Education & Behavior, 41(1), 78–84.

Akinlua

J. T.

Meakin

Freemantle

(2017). Beliefs about hypertension among Nigerian immigrants to the United Kingdom: A qualitative study. PLoS One, 12(7), e0181909. https://doi.org/10.1371/journal.pone.0181909

Al-Bannay

Jarus

Jongbloed

Yazigi

Dean

(2014). Culture as a variable in health research: Perspectives and caveats. Health Promotion International, 29(3), 549–557.

Arnault

D. S.

(2018). Defining and theorizing about culture: The evolution of the cultural determinants of help-seeking, revised. Nursing Research, 67(2), 161–168. https://doi.org/10.1097/NNR.0000000000000264

Ausili

Rebora

Di Mauro

Riegel

Valsecchi

M. G.

Paturzo

Alvaro

Vellone

(2016). Clinical and socio-demographic determinants of self-care behaviours in patients with heart failure and diabetes mellitus: A multicentre cross-sectional study. International Journal of Nursing Studies, 63, 18–27. https://doi.org/10.1016/j.ijnurstu.2016.08.006

10.

Baah

F. O.

Chittams

Carlson

Sethares

K. A.

Daus

Moser

D. K.

Riegel

(2021). Sociodemographic indictors of social position and self-care maintenance in adults with heart failure. Clinical Nursing Research, 30, 847–854.

11.

Baah

F. O.

Teitelman

A. M.

Riegel

(2019). Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review. Nursing Inquiry, 26(1), e12268.

12.

Baghianimoghadam

M. H.

Shogafard

Sanati

H. R.

Baghianimoghadam

Mazloomy

S. S.

Askarshahi

(2013). Application of the health belief model in promotion of self-care in heart failure patients. Acta Medica Iranica, 51(1), 52–58.

13.

Baluja

K. F.

Park

Myers

(2003). Inclusion of immigrant status in smoking prevalence statistics. American Journal of Public Health, 93(4), 642–646. https://doi.org/10.2105/ajph.93.4.642

14.

Bandura

Freeman

Lightsey

(1999). Self-efficacy: The exercise of control. W H Freeman.

15.

Barnett

Mercer

S. W.

Norbury

Watt

Wyke

Guthrie

(2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet, 380(9836), 37–43.

16.

Bennett

G. G.

Wolin

K. Y.

Okechukwu

C. A.

Arthur

C. M.

Askew

Sorensen

Emmons

K. M.

(2008). Nativity and cigarette smoking among lower income blacks: Results from the healthy directions study. Journal of Immigrant and Minority Health, 10(4), 305–311.

17.

Bernell

Howard

S. W.

(2016). Use your words carefully: What is a chronic disease? Frontiers in Public Health, 4, 159.

18.

Berry

J. W.

(2008). Globalisation and acculturation. International Journal of Intercultural Relations, 32(4), 328–336.

19.

Beune

E. J.

Haafkens

J. A.

Schuster

J. S.

Bindels

P. J.

(2006). ‘Under pressure’: How Ghanaian, African-Surinamese and Dutch patients explain hypertension. Journal of Human Hypertension, 20(12), 946–955. https://doi.org/10.1038/sj.jhh.1002094

20.

Brandt

Spencer

Folstein

(1988). The telephone interview for cognitive status. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 1(2), 111–117.

21.

Braveman

Gottlieb

(2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(1_suppl2), 19–31.

22.

Buck

H. G.

Lee

C. S.

Moser

D. K.

Albert

N. M.

Lennie

Bentley

Riegel

(2012). Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure. Journal of Cardiovascular Nursing, 27(1), 8–15.

23.

Charlson

M. E.

Pompei

Ales

K. L.

MacKenzie

C. R.

(1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40(5), 373–383.

24.

Commodore-Mensah

Hill

Allen

Cooper

L. A.

Blumenthal

Agyemang

Himmelfarb

C. D.

(2016). Sex differences in cardiovascular disease risk of Ghanaian- and Nigerian-born west African immigrants in the United States: The Afro-Cardiac study. Journal of the American Heart Association, 5(2), 1–13. https://doi.org/10.1161/JAHA.115.002385

25.

Commodore-Mensah

Himmelfarb

C. D.

Agyemang

Sumner

A. E.

(2015). Cardiometabolic health in African immigrants to the United States: A call to re-examine research on African-descent populations. Ethnicity & Disease, 25(3), 373–380. https://doi.org/10.18865/ed.25.3.373

26.

Commodore-Mensah

Matthie

Wells

B Dunbar

Himmelfarb

C. D.

Cooper

L. A.

Chandler

R. D.

(2018). African Americans, African immigrants, and Afro-Caribbeans differ in social determinants of hypertension and diabetes: Evidence from the national health interview survey. Journal of Racial and Ethnic Health Disparities, 5(5), 995–1002.

27.

Commodore-Mensah

Ukonu

Cooper

L. A.

Agyemang

Himmelfarb

C. D.

(2018). The association between acculturation and cardiovascular disease risk in Ghanaian and Nigerian-born African immigrants in the United States: The Afro-Cardiac study. Journal of Immigrant and Minority Health, 20(5), 1137–1146. https://doi.org/10.1007/s10903-017-0644-y

28.

Cooper Brathwaite

Lemonde

. (2016). Health beliefs and practices of African immigrants in Canada. Clinical Nursing Research, 25(6), 626–645.

29.

Creatore

M. I.

Moineddin

Booth

Manuel

D. H.

DesMeules

McDermott

Glazier

R. H.

(2010). Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. Canadian Medical Association Journal, 182(8), 781–789. https://doi.org/10.1503/cmaj.091551

30.

De Maria

Matarese

Strömberg

Ausili

Vellone

Jaarsma

Osokpo

O. H.

Daus

M. M.

Riegel

Barbaranelli

. (2021). Cross-cultural assessment of the self-care of chronic illness inventory: A psychometric evaluation. International Journal of Nursing Studies, 116, 103422.

31.

Dharod

J. M.

Croom

Sady

C. G.

Morrell

(2011). Dietary intake, food security, and acculturation among Somali refugees in the United States: Results of a pilot study. Journal of Immigrant & Refugee Studies, 9(1), 82–97.

32.

Dickson

V. V.

McCarthy

M. M.

Howe

Schipper

Katz

S. M.

(2013). Sociocultural influences on heart failure self-care among an ethnic minority black population. Journal of Cardiovascular Nursing, 28(2), 111–118. https://doi.org/10.1097/JCN.0b013e31823db328

33.

Dorsey

S. G.

Griffioen

M. A.

Renn

C. L.

Cashion

A. K.

Colloca

Jackson-Cook

C. K.

Gill

Henderson

Kim

Joseph

P. V.

Saligan

Starkweather

A. R.

Lyon

(2019). Working together to advance symptom science in the precision era. Nursing Research, 68(2), 86–90. https://doi.org/10.1097/NNR.0000000000000339

34.

Dorsey

S. G.

Pickler

R. H.

(2019). Precision science in nursing research. Nursing Research, 68(2), 85. https://doi.org/10.1097/NNR.0000000000000333

35.

Echeverria-Estrada

Batalova

(2019). Sub-Saharan African immigrants in the United States. Migration Policy Institute.

36.

Eller

L. S.

Lev

E. L.

Yuan

Watkins

A. V.

(2018). Describing self-care self-efficacy: Definition, measurement, outcomes, and implications. International Journal of Nursing Knowledge, 29(1), 38–48.

37.

Gambino

C. P.

Trevelyan

E. N.

Fitzwater

J. T.

(2014). Foreign-born population from Africa, 2008–2012. US Department of Commerce, Economic and Statistics Administration, US Census.

38.

Giuliani

K. K.

Mire

Leinberger-Jabari

Ehrlich

L. C.

Stigler

M. H.

Pryce

D. J.

DuBois

D. K.

(2012). Cigarettes and the Somali diaspora: Tobacco use among Somali adults in Minnesota. American Journal of Preventive Medicine, 43(5 Suppl 3), S205–S213.

39.

Hall

Cuellar

N. G.

(2016). Immigrant health in the United States: A trajectory toward change. Journal of Transcultural Nursing, 27(6), 611–626. https://doi.org/10.1177/1043659616672534

40.

Hamilton

Green

T. L.

(2017). Intergenerational differences in smoking among west Indian, Haitian, Latin American, and African blacks in the United States. SSM - Population Health, 3, 305–317. https://doi.org/10.1016/j.ssmph.2017.01.007

41.

Harcourt

Ghebre

R. G.

Whembolua

G. L.

Zhang

Warfa Osman

Okuyemi

K. S

. (2014). Factors associated with breast and cervical cancer screening behavior among African immigrant women in Minnesota. Journal of Immigrant and Minority Health, 16(3), 450–456.

42.

Harley

A. E.

Yang

Stoddard

A. M.

Adamkiewicz

Walker

Tucker-Seeley

R. D.

Allen

J. D.

Sorensen

(2014). Patterns and predictors of health behaviors among racially/ ethnically diverse residents of low-income housing developments. American Journal of Health Promotion, 29(1), 59–67.

43.

Harris

P. A.

(2012). Research electronic data capture (REDCap) – planning, collecting and managing data for clinical and translational research. BMC Bioinformatics, 13(Suppl 12), A15.

44.

Harris

P. A.

Taylor

Thielke

Payne

Gonzalez

Conde

J. G.

(2009). Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.

45.

Havranek

E. P.

Mujahid

M. S.

Barr

D. A.

Blair

I. V.

Cohen

M. S.

Cruz-Flores

Davey-Smith

Dennison-Himmelfarb

C. R.

Lauer

M. S.

Lockwood

D. W.

Rosal

Yancy

C. W.

; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. (2015). Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American heart association. Circulation, 132(9), 873–898. https://doi.org/10.1161/CIR.0000000000000228

46.

Henry Osokpo

James

Riegel

. (2021). Maintaining cultural identity: A systematic mixed studies review of cultural influences on the self-care of African immigrants living with non-communicable disease. Journal of Advanced Nursing, 77, 3600–3617.

47.

Herber

O. R.

Krischel

Whittal

(2020). Ethical aspects of self-care: Comment on riegel et al (2019) self-care research: Where are we now? Where are we going? International Journal of Nursing Studies, 111, 103758. https://doi.org/10.1016/j.ijnurstu.2020.103758

48.

Hickey

K. T.

Bakken

Byrne

M. W.

Bailey

D. C. E.

Demiris

Docherty

S. L.

Dorsey

S. G.

Guthrie

B. J.

Heitkemper

M. M.

Jacelon

C. S.

Kelechi

T. J.

Moore

S. M.

Redeker

N. S.

Renn

C. L.

Resnick

Starkweather

Thompson

Ward

T. M.

McCloskey

D. J.

. . . Grady

P. A.

(2019). Precision health: Advancing symptom and self-management science. Nursing Outlook, 67, 462–475.

49.

Hinkle

D. E.

Wiersma

Jurs

S. G.

(2003). Applied statistics for the behavioral sciences. Houghton Mifflin College Division.

50.

Irani

Moore

S. E.

Hickman

R. L.

Dolansky

M. A.

Josephson

R. A.

Hughes

J. W.

(2019). The contribution of living arrangements, social support, and self-efficacy to self-management behaviors among individuals with heart failure: A path analysis. Journal of Cardiovascular Nursing, 34(4), 319–326. https://doi.org/10.1097/JCN.0000000000000581

51.

Jaarsma

Strömberg

Dunbar

S. B.

Fitzsimons

Lee

Middleton

Vellone

Freedland

K. E.

Riegel

(2020). Self-care research: How to grow the evidence base? International Journal of Nursing Studies, 105, 103555.

52.

Jakub

K. E.

Turk

M. T.

Fapohunda

Zoucha

(2018). Cultural beliefs, perceptions, and practices of young adult offspring of African immigrants regarding healthy eating and activity. Journal of Transcultural Nursing, 29(6), 548–554.

53.

Jonkman

N. H.

Groenwold

R. H. H.

Trappenburg

J. C. A.

Hoes

A. W.

Schuurmans

M. J.

(2017). Complex self-management interventions in chronic disease unravelled: A review of lessons learned from an individual patient data meta-analysis. Journal of Clinical Epidemiology, 83, 48–56. https://doi.org/10.1016/j.jclinepi.2017.01.004

54.

Kagawa-Singer

Dressler

George

Elwood

(2015). The cultural framework for health. National Institutes of Health.

55.

Katz

J. N.

Chang

L. C.

Sangha

Fossel

A. H.

Bates

D. W.

(1996). Can comorbidity be measured by questionnaire rather than medical record review? Medical Care, 34, 73–84.

56.

Kindarara

D. M.

McEwen

M. M.

Crist

J. D.

Loescher

L. J.

(2017). Health-illness transition experiences with type 2 diabetes self-management of sub-Saharan African immigrants in the United States. The Diabetes Educator, 43(5), 506–518. https://doi.org/10.1177/0145721717724725

57.

Koirala

Himmelfarb

C. D.

Budhathoki

Tankumpuan

Asano

Davidson

P. M.

(2018). Factors affecting heart failure self-care: An integrative review. Heart & Lung: The Journal of Acute and Critical Care, 47(6), 539–545. https://doi.org/10.1016/j.hrtlng.2018.09.004

58.

Kumar

N. B.

Akinremi

T. O.

Odedina

F. T.

(2009). Comparing dietary and other lifestyle factors among immigrant Nigerian men living in the US and indigenous men from Nigeria: Potential implications for prostate cancer risk reduction. Journal of Immigrant and Minority Health, 11(5), 391–399. https://doi.org/10.1007/s10903-009-9231-1

59.

Laaksonen

Prättälä

Helasoja

Uutela

Lahelma

(2003). Income and health behaviours. Evidence from monitoring surveys among Finnish adults. Journal of Epidemiology and Community Health, 57(9), 711–717. https://doi.org/10.1136/jech.57.9.711

60.

Luciani

Rossi

Rebora

Stawnychy

Ausili

Riegel

(2021). Clinical and socio-demographic determinants of self-care maintenance, monitoring and management in US adults with type 2 diabetes mellitus. Clinical Nursing Research, 30, 285–292. https://doi.org/10.1177/1054773820916987

61.

Malmusi

Borrell

Benach

(2010). Migration-related health inequalities: Showing the complex interactions between gender, social class and place of origin. Social Science & Medicine, 71(9), 1610–1619.

62.

Marin

Sabogal

Marin

B. V.

Otero-Sabogal

Perez-Stable

E. J.

(1987). Development of a short acculturation scale for hispanics. Hispanic Journal of Behavioral Sciences, 9(2), 183–205.

63.

Markus

H. R.

Kitayama

(1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98(2), 224–253.

64.

Mesoudi

(2018). Migration, acculturation, and the maintenance of between-group cultural variation. PLoS One, 13(10), e0205573.

65.

Mukaz

D. K.

Melby

M. K.

Papas

M. A.

Setiloane

Nmezi

N. A.

Commodore-Mensah

(2020). Diabetes and acculturation in African immigrants to the United States: Analysis of the 2010–2017 national health interview survey (NHIS). Ethnicity and Health. Advance online publication. https://doi.org/10.1080/13557858.2020.1820958

66.

Njeru

J. W.

Formea

C. M.

Osman

Goodson

Hared

Capetillo

G. P.

Nigon

J. A.

Cha

S. S.

Weis

J. A.

Hanza

M. M.

Patten

C. A.

Sia

I. G.

Wieland

M. L.

(2016). Diabetes knowledge, attitudes and behaviors among Somali and Latino immigrants. Journal of Immigrant and Minority Health, 18(6), 1432–1440. https://doi.org/10.1007/s10903-015-0335-5

67.

Nyaaba

G. N.

Agyemang

Masana

De-Graft Aikins

Beune

Larrea-Killinger

Stronks

(2019). Illness representations and coping practices for self-managing hypertension among sub-Saharan Africans: A comparative study among Ghanaian migrants and non-migrant Ghanaians. Patient Education and Counseling, 102(9), 1711–1721. https://doi.org/10.1016/j.pec.2019.04.008

68.

O'Connor

M. Y.

Thoreson

C. K.

Ricks

Courville

A. B.

Thomas

Yao

Katzmarzyk

P. T.

Sumner

A. E

. (2014). Worse cardiometabolic health in African immigrant men than African American men: Reconsideration of the healthy immigrant effect. Metabolic Syndrome and Related Disorders, 12(6), 347–353. https://doi.org/10.1089/met.2014.0026

69.

Odusola

A. O.

Hendriks

Schultsz

Bolarinwa

O. A.

Akande

Osibogun

Agyemang

Ogedegbe

Agbede

Adenusi

Lange

van Weert

Stronks

Haafkens

J. A.

(2014). Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: A qualitative study. BMC Health Services Research, 14, 624. https://doi.org/10.1186/s12913-014-0624-z

70.

Ogungbe

Turkson-Ocran

Nkimbeng

Cudjoe

Miller

H. N.

Baptiste

Commodore-Mensah

(2021). Social determinants of hypertension and diabetes among African immigrants: The African immigrants health study (pp. 1–13). Ethnicity & Health.

71.

Okafor

M. C.

Carter-Pokras

O. D.

Zhan

(2014). Greater dietary acculturation (dietary change) is associated with poorer current self-rated health among African immigrant adults. Journal of Nutrition Education and Behavior, 46(4), 226–235. https://doi.org/10.1016/j.jneb.2013.11.015

72.

Omenka

O. I.

Watson

D. P.

Hendrie

H. C.

(2020). Understanding the healthcare experiences and needs of African immigrants in the United States: A scoping review. BMC Public Health, 20(1), 27–13.

73.

Orjiako

O. E. Y.

(2014). The role of acculturative stress factors on mental health and help-seeking behavior of sub-Saharan African immigrants. International Journal of Culture and Mental Health, 7(3), 315–325.

74.

Osei-Kwasi

H. A.

Boateng

Danquah

Holdsworth

Mejean

Terragni

Powell

Schulze

M. B.

Owusu-Dabo

Meeks

Beune

Agyemang

Klipstein-Grobusch

Stronks

Galbete

Nicolaou

(2020). Acculturation and food intake among Ghanaian migrants in Europe: Findings from the RODAM study. Journal of Nutrition Education and Behavior, 52, 114–125. https://doi.org/10.1016/j.jneb.2019.09.004

75.

Osokpo

Riegel

(2021). Cultural factors influencing self-care by persons with cardiovascular disease: An integrative review. International Journal of Nursing Studies, 116, 103383.

76.

Patil

C. L.

Hadley

Nahayo

P. D.

(2009). Unpacking dietary acculturation among new Americans: Results from formative research with African refugees. Journal of Immigrant and Minority Health, 11(5), 342–358. https://doi.org/10.1007/s10903-008-9120-z

77.

Perez

(2015). Acculturation, health literacy, and illness perceptions of hypertension among hispanic adults. Journal of Transcultural Nursing, 26(4), 386–394.

78.

Reuven

Dreiher

Shvartzman

(2016). The prevalence of diabetes, hypertension and obesity among immigrants from east Africa and the former Soviet Union: A retrospective comparative 30-year cohort study. Cardiovascular Diabetology, 15(1), 74.

79.

Riegel

Barbaranelli

Sethares

K. A.

Daus

Moser

D. K.

Miller

J. L.

Haedtke

C. A.

Feinberg

J. L.

Lee

Stromberg

Jaarsma

(2018). Development and initial testing of the self-care of chronic illness inventory. Journal of Advanced Nursing, 74(10), 2465–2476.

80.

Riegel

Dickson

V. V.

Kuhn

Page

Worrall-Carter

(2010). Gender-specific barriers and facilitators to heart failure self-care: A mixed methods study. International Journal of Nursing Studies, 47(7), 888–895.

81.

Riegel

Dickson

V. V.

Lee

(2017). Self-management of illness in adults. In Grady

P. A.

Hinshaw

A. S.

(Eds.), Using nursing research to shape health policy (p. 127). Springer Publishing Company.

82.

Riegel

Dunbar

S. B.

Fitzsimons

Freedland

K. E.

Lee

C. S.

Middleton

Stromberg

Vellone

Webber

D. E.

Jaarsma

(2019). Self-care research: Where are we now? Where are we going? International Journal of Nursing Studies, 116, 103402.

83.

Riegel

Jaarsma

Lee

C. S.

Strömberg

(2019). Integrating symptoms into the middle-range theory of self-care of chronic illness. Advances in Nursing Science, 42(3), 206–215. https://doi.org/10.1097/ANS.0000000000000237

84.

Riegel

Jaarsma

Strömberg

(2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science, 35(3), 194–204. https://doi.org/10.1097/ANS.0b013e318261b1ba

85.

Riegel

Moser

D. K.

Buck

H. G.

Dickson

V. V.

Dunbar

S. B.

Lee

C. S.

Lennie

T. A.

Lindenfeld

Mitchell

J. E.

Treat-Jacobson

D. J.

Webber

D. E.

, & American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Quality of Care and Outcomes Research (2017). Self-care for the prevention and management of cardiovascular disease and stroke: A scientific statement for healthcare professionals from the American Heart Association. Journal of the American Heart Association, 6(9). https://doi.org/10.1161/JAHA.117.006997

86.

Schulman-Green

Jaser

Martin

Alonzo

Grey

McCorkle

Redeker

N. S.

Reynolds

Whittemore

(2012). Processes of self-management in chronic illness. Journal of Nursing Scholarship, 44(2), 136–144.

87.

Schwartz

S. J.

Unger

J. B.

Zamboanga

B. L.

Szapocznik

(2010). Rethinking the concept of acculturation: Implications for theory and research. American Psychologist, 65(4), 237–251.

88.

Sewali

Harcourt

Everson-Rose

S. A.

Leduc

R. E.

Osman

Allen

M. L.

Okuyemi

K. S

. (2015). Prevalence of cardiovascular risk factors across six African immigrant groups in Minnesota. BMC Public Health, 15, 411–417. https://doi.org/10.1186/s12889-015-1740-3

89.

Shoup

E. M.

Hormenu

Osei-Tutu

N. H.

Ishimwe

M. C. S.

Patterson

A. C.

DuBose

C. W.

Wentzel

Horlyck-Romanovsky

M. F.

Sumner

A. E.

(2020). Africans who arrive in the United States before 20 years of age maintain both cardiometabolic health and cultural identity: Insight from the Africans in America study. International Journal of Environmental Research and Public Health, 17(24), 9405.

90.

Siad

F. M.

Fang

X. Y.

Santana

M. J.

Butalia

Hebert

M. A.

Rabi

D. M.

(2018). Understanding the experiences of east African immigrant women with gestational diabetes mellitus. Canadian Journal of Diabetes, 42, 632–638. https://doi.org/10.1016/j.jcjd.2018.01.013

91.

Smed

Tetens

Bøker Lund

Holm

Ljungdalh Nielsen

(2018). The consequences of unemployment on diet composition and purchase behaviour: A longitudinal study from Denmark. Public Health Nutrition, 21(3), 580–592.

92.

Sofolahan-Oladeinde

Iwelunmor

Tshiswaka

D. I.

Conserve

D. F.

(2014). Acculturation and its influence on the health perceptions, health behaviors, and health outcomes of African immigrants in the United States: A review of the literature. Journal of Race & Policy, 10(1), 89–103.

93.

Toselli

Rinaldo

Gualdi-Russo

(2019). Length of residence and obesity risk among North African immigrant women in Italy. Economics and Human Biology, 34, 74–79.

94.

Turk

M. T.

Fapohunda

Zoucha

(2015). Using photovoice to explore Nigerian immigrants’ eating and physical activity in the United States. Journal of Nursing Scholarship, 47(1), 16–24.

95.

Turkson-Ocran

R. N.

Nmezi

N. A.

Botchway

M. O.

Szanton

S. L.

Golden

S. H.

Cooper

L. A.

Commodore-Mensah

(2020). Comparison of cardiovascular disease risk factors among African immigrants and African Americans: An analysis of the 2010 to 2016 national health interview surveys. Journal of the American Heart Association, 9(5), e013220.

96.

Venters

Gany

(2011). African immigrant health. Journal of Immigrant and Minority Health, 13(2), 333–344. https://doi.org/10.1007/s10903-009-9243-x

97.

Wong

K. C.

Wong

F. K. Y.

Yeung

W. F.

Chang

(2018). The effect of complex interventions on supporting self-care among community-dwelling older adults: A systematic review and meta-analysis. Age and Ageing, 47(2), 185–193.

98.

Woodgate

R. L.

Busolo

D. S.

Crockett

Dean

R. A.

Amaladas

M. R.

Plourde

P. J.

(2017). A qualitative study on African immigrant and refugee families’ experiences of accessing primary health care services in Manitoba, Canada: It’s not easy! International Journal for Equity in Health, 16(1), 5. https://doi.org/10.1186/s12939-016-0510-x

99.

World Health Organization. (2015). Health statistics and information systems: Definition of an older or elderly person. Proposed Working Definition of an Older Person in Africa for the MDS Project.

100.

D. S.

De Maria

Barbaranelli

Vellone

Matarese

Ausili

Rejane

R. E.

Osokpo

O. H.

Riegel

(2021). Cross-cultural applicability of the self-care self-efficacy scale in a multi-national study. Journal of Advanced Nursing, 77(2), 681–692.