Abstract
The objective of this research was to explore interview data to understand and characterize the nature of brotherhood in a sample of African American men at two historically Black colleges and universities. The authors used thematic analysis on semistructured interview data, collected by an ethnically diverse research team. Recruitment and interviews were conducted at two historically Black colleges and universities in Texas. Twenty African American men, 18 to 35 years old, were randomly selected from 62 recruited participants. Five categories framed brotherhood and health care utilization: (a) trust lessens individual barriers to action, (b) identity unites men through a process of authentication, (c) generations lead by example, (d) approaching life as a shared learning experience, and (e) social pressure and ridicule uphold collective action. Findings suggest that participants trust a group view, identify with the collective, and respond to social pressure to conform; therefore, brotherhood acts as a support mechanism, and its validation influences individual-level engagement and nonengagement.
Introduction
Does brotherhood, defined by Franklin (1999, 2004) as a community of African American men connected through tacit understanding, common experiences, traditions, and identity, in some way shape behaviors associated with health care utilization among African American men? Recent evidence exploring mental health and help-seeking behaviors among African American men emphasizes a need for more culturally relevant interventions examining their unique social determinants of health to improve health utilization behaviors (Holden, McGregor, Blanks, & Mahaffey, 2012; Lindsey & Marcell, 2012). A literature review of barriers to utilization of primary health care identified masculinity, lack of awareness, racism and mistrust, religion and spirituality (Cheatham, Barksdale, & Rodgers, 2008), as well as fear of morbid diagnosis, and fatalism (Ravenell, Whitaker, & Johnson, 2008). Cheatham et al. (2008) also demonstrated that family, friends, and neighborhoods served as a facilitator whereas religion and spirituality functioned as both a facilitator and barrier to health utilization.
African American men are less likely to seek preventive care services and a greater burden is placed on their overall health as African American men have higher rates of preventable illness than White men of the same age (Ravenell et al., 2008; Rich, 2000). A preponderance of research has described these disparities through a deficit model approach, which pathologizes the behavior of African American men, rather than from a sociocultural approach, which leverages the strengths of African American male relationships and communities (Airhihenbuwa & Liburd, 2006). Evidence reporting on health behaviors identified male gender socialization as an influential factor among African American men (Royster et al., 2006); further, peer-to-peer support at historically Black colleges and universities (HBCUs) has been found to help students overcome personal and academic barriers to accomplish goals (Palmer & Gasman, 2008). This growing evidence outlines the importance of relationships among young African American men, especially as they move closer to adulthood and their value for navigating the life course (Bharmal et al., 2012). Consequently, because of limited culturally competent prevention and intervention strategies focused on African American male relationships and health utilization (Holden et al., 2012), it is not surprising that African American men continue to suffer disproportionate health outcomes (Ravenell et al., 2008).
This article explores and analyzes interview data from 20 African American men at two HBCUs in the southern United States to characterize brotherhood and understand the nature of brotherhood as it relates to wellness and health-seeking behaviors. The aim of this article is to explore the findings and demonstrate how brotherhood may have the potential to mitigate health disparities associated with health care utilization among African American men.
Method
An ethnically diverse research team recruited participants from two HBCUs in Texas. The research team comprised two African American women, two African American men, a Latino man, a White man, and a White woman. We chose HBCUs to conduct this research based on evidence supporting their primary mission to educate Black Americans (Roebuck & Murty, 1993) and their legacy supporting education within the African American community (Lett & Wright, 2003). Further evidence showed that HBCU attendance underscored a unique racial consciousness and a perspective based on unique cultural and racial sensitivities (Museus, 2008).
The African American and Latino members of the research team conducted the 20 face-to-face interviews using a researcher-designed, semistructured interview guide, which had been validated by a panel of content experts. Transcribed interviews were shared with all members of the research team. Independently, the entire research team, and the lead author completed a six-step thematic analysis based on the recommendations of Braun and Clarke (2006). Categories and themes were compared and refined using triangulation and differences resolved through discussion and consensus.
Recruitment
The research team recruited all participants in the fall of 2009 using recruitment tables with music, posters, and snacks. Recruitment posters were placed in student centers and used to attract potential participants to the tables. Potential participants were asked to enroll by providing their names, e-mail addresses, and contact information. The research team e-mailed potential participants providing additional information about the purpose of the study and eligibility requirements, which were: self-identify as African American, be 18 to 35 years old, and not have a physician-diagnosed chronic illness. The research team recruited enough students to allow for the selection of 20 African American males (18-35 years old).
The research coordinator, the second author, contacted participants by phone to confirm their interest in participating in the study. On receiving verbal confirmation, the selected study participants were contacted by e-mail and asked to select between one of two interview dates and indicate their preferences for an interview location.
Data Collection
All research received approval by the Human Subjects Review Boards from Indiana University, Texas A&M University, Prairie View A&M University, and Texas Southern University. All participants provided written and verbal consent to record interviews. Participants were assigned a code number to maintain confidentiality and anonymity. These data were kept in a locked office on a password-protected hard drive owned by the research team.
The faculty mentor, the third author, trained members of the research team to conduct the interviews. Each interview session had the interviewer follow a similar protocol: (a) read and discuss the consent form with each participant, (b) ask the participant to sign the consent form, (c) request the participant to complete the demographic profile, and (d) perform the face-to-face semistructured interview. Participants were provided a $25 gift card and offered a copy of the study findings.
Instrumentation
The two-part instrument, developed by the lead author and the faculty mentor, included a 17-question demographic profile (Table 1) and a 54-question semistructured interview guide. The semistructured interview guide derived from a study in 2005, initially developed for a focus group of African American men. The guide was revised by focus groups (n = 4) and pilot tested in 2007 with face-to-face interviews with five African American men. Further revisions were recommended to address clarity, wording, and accuracy in response to formative research and participant recommendations.
Categorical Description of Demographic Variables.
n = 19.
The semistructured interview guide was framed on six domains: the brotherhood, beyond personal relationships, help seeking, experiences with the health system, patient/provider communication, and participation in research. The brotherhood questions were adapted from the Indiana Network Mental Health Study (network batteries) recently published by Perry and Pescosolido (2012) and summary network measures developed by Pescosolido, Wright, Alegría, and Vera (1998).
Content validity had been established using a panel of health experts identified through the faculty mentor. The panel comprised four African American males, distinguished as minority health/health disparities scholars, and primarily focused on issues specific to African American men.
A second panel of experts comprising (n = 4) 18- to 35-year-old African American men enrolled at HBCUs was planned to pilot the instrument for content or face validity, more relevant wording, and comprehension of items (Mokkink et al., 2010).
Data Analysis
Independently, the lead author and the entire research team completed a preliminary analysis, using a six-step multiphase thematic analysis design (Braun & Clarke, 2006, pp. 87-94). Overall themes and relevant characteristics were extracted during the analysis to be shared and assessed according to the principles of indefinite triangulation, a process used to interpret and understand data more accurately (Rizzo, Corsaro, & Bates, 1992, p. 107). Although the analyses were independently conducted, the process of indefinite triangulation enhanced communication between the lead author and the research team to ensure validation of specific findings. Any inconsistencies in category and theme development were resolved through discussion and consensus.
Results
The research team selected 10 men from each HBCU, out of a total of 62 recruited participants, for a total sample of 20 African American men (Table 1).
Interviews lasted approximately 35 to 45 minutes. A second panel of experts, composed of (n = 4) 18- to 35-year-old African American men enrolled at HBCUs, which had been proposed in the methodology to pilot the instrument for content validity, did not occur because of time limitations and unforeseen travel complications with the first author.
Out of 20 completed interviews, we focused on six research domains. The following categories and themes (Table 2) emerged from the interviews.
Categories and Related Themes Framing Brotherhood and Health Care Utilization.
For the purposes of this article, we will concentrate only on data from domains, which addressed the themes of trust, identity, brotherhood, strength in numbers, and help seeking.
Trust Lessens Individual Barriers to Action
When asked what the word “brother” meant to them, responses highlighted the importance of trust. The responses appear consistent and reflective of the following: “Somebody you can trust . . .” (Participant 9) as well as a “friend [you’ve known] from knee high, so you’re like brothers . . .” (Participant 17). Although the concept of trust provided responses indicating long-lasting relationships, still another construction of trust emerged to reveal a bond, “something you share with those you’ve been through stuff with,” said Participant 4.
The relationships discussed among these men seemed to be mediated by a complex interaction between trust and mistrust. Put another way, the interaction between who and what was authentic compared with who and what was disingenuous permeated the responses. Participant 14 reflected, I’ve seen a lot of dishonesty. Disrespect . . . you know what I’m saying . . . everybody has . . . you have the iffy ones . . . you don’t trust ‘em, you can tell the smile didn’t match the handshake.
Participant 17 indicated that trust and understanding of social behaviors related to right and wrong serve as motivation “somebody is always pushing me to do greater in life . . . so I got these brother[s] to keep me motivated . . . if they go hard I go hard.”
Ultimately, brotherhood appeared to influence the lives of these young men in two ways: (a) it provides a means of support; (b) and it also serves as a daily guide. Participant 13 suggested brotherhood was collaborative, “it influences my daily life by helping my closest friends around me . . . if they don’t have nothing I don’t have nothing.” Participant 15 said, when asked about how brotherhood affected his daily life, “it really puts me on the right path . . .,” and Participant 12 said, “it makes me think about those who didn’t’ have what I have . . . make sure that I can contribute as my other brothers did.”
Identity Unites Men Through a Process of Authentication
A theme, which emerged from the responses, reflected a type of learning through observation or shared experience. One response, characteristic of this theme, came from Participant 14 who said, about his relationships with other African-American men, I learn from them. First and foremost it was a bad outcome, but we’re still on going with that relationship. I had a couple good ones and a couple bad ones . . . but it’s not how big my inner circle is or how big the circle is, so I’ve had good ones and bad ones really.
Several men talked about the value of their own personal strength as a kind of indicator or measuring stick against which they see themselves. Participant 1 compared himself to other African American men when he said, “once I began to have my self-pride and my own cultural pride in myself than therefore these little instances they are meaningless to me because I have my own cultural pride. I have my own racial identity within myself.”
The lived experiences of these men seemed to affect identity, how they saw themselves within the larger group of African American men, as well as how they saw themselves within a group of friends. Participant 5, whose experiences were legitimated by others interviewed, talked about how negative interactions with law enforcement reinforced his sense of vulnerability and suspicion of the world around him.
I was in 7th grade playing in front of my house and an officer came like . . . two officers were in the patrol car and they parked at the front of the driveway . . . I was sitting and most people would have ran, but I just sat there and chilled . . . they got out the car and were like . . . you [Johnson]? [I said] no I’m not . . . you fit the profile and he attacked me . . . put my face into the back of the car and put my hands behind my back and I was like excuse me sir what did I do . . . he was like . . . don’t say anything.
Generations Lead by Example
Evidence supported the idea that African American men learned individual skills to navigate relationships and the hardships of life through storytelling, older generations, and small groups. Particularly, these skills could be developed and mentored through negative feedback in the form of “keeping each other on their toes” and “challenging each other” to make better decisions.
Participant 8 talked about how he learned to fight stereotypes from other African American men, “how to carry yourself and how not to carry yourself. Learn everything . . . it means . . . you learn.” Participant 14 responded to a question asking about how other African American men influenced each other saying, it’s about history, what we’ve been through, what we’re going through . . . because I believe . . . this is a quote from [teacher] . . . if you don’t know your descendants are kings then you’re not a king.
Another theme shared among these men was captured in Participant 2’s answer, which talked about a respect and trust for older generations and what they have overcome through resiliency. He said, well my uncles and my fathers, both of them have mentored pretty good. I looked up to my uncle, my mom’s brother, he was like my big brother, he would show me how to talk to girls and play football . . .
What seemed to connect these men to each other and their past was much more valuable than what divided them. Participant 12 talked about how the older generation was much more interconnected, “older African-American men are the wise ones . . . I feel that the younger African American males are posers, I wouldn’t say all of them are, but the majority are posers.” Participant 5 reflected on the past as also being hard, but the present being uniquely hard, I don’t think this one is harder than this one . . . This guy can work his whole career and give everything he’s got on a farm (barn) and this guy’s working on the street it’s just a different time period.
Participant 14 reflected, “strong African-American men impact me. It just gives me a vision, you know what I’m saying, about what I want to accomplish. The goals that I want to reach.” A sense of needing to “be better” than those who came before was expressed, “not to be what they were but to be better,” by Participant 12. This also points to drive, to do more with what they have.
Approaching Life as a Shared Learning Experience
Social learning emerged as a category of themes among the responses. Several of the interviews reflected how men learned from each other, their approach to life, and the bonds they share. Here Participant 1 talked about being aware and learning from his mistakes:
Cause if you spend your time with a certain group of people. They’re going to impact you more than any other group. I spend most of my time with males . . . so that’s why they impact me . . . so it’s like eventually they’re going to rub off on you. Sometimes in a positive way, sometimes in a negative way, you just got to be smart enough to learn from your mistakes. Like . . . I’m not going to do this anymore you know.
How men influenced each other through behaviors or implicit comprehension seemed to vary. Yet for some a competition seemed to exist; one that pitted African American men against one another in a way that pushed them to do more. When asked how these experiences affected his life, Participant 5 said, they impact me because I want to be the one to break the fit. Of course there’s many people like me, contrary to public belief there are many people just like me trying to do that . . . but it gives me more of a reason.
Despite this competition, there was a need to stay connected to other African American men. It appeared to reflect a shared struggle to achieve or persevere. Participant 16 talked about fitting in with other men, “it’s just that I feel like I gotta be around them, because I got such a good bond with them.”
What separates these particularly African American male experiences from other racial or gender experiences is the connection these men have to each other. Participant 9 talked about his race and how that connected him with other Black men: So I’m telling you now . . . I couldn’t share that with them because they’re not black. . . so if they’re not black I can’t talk to them as if they are black . . . so if any one of them came up to me and said my nigger, I’d be ready to fight . . . because they don’t know what we went through to say that word.
It is this connection, one based on common ground, prayer, and sharing responsibility seemed to resonate most with the men in this study. The following response identified how Participant 14 thought about his responsibility to other African American men, “this goes back to the teachings of Elijah Muhammad. If you see someone with a dirty glass offer them a clean one. And see which one they drink from. You did your part. That’s it.” Participant 6 talked about making “a pact” with a friend to improve their grades through competition, when we were in school we would always try and outdo each other as far as grades . . . and he would be like, I will buy lunch . . . if I get an A . . . we would try and push each other.
What seemed to connect these men were their experiences. This theme emerged time and again and reflected the inherent nature of brotherhood as a social construction forged through hardship and social meaning as described by Participant 4, “nobody experiences the same thing or whatever, but you can still bond over common ground, because as guys, you know how guys are, in general guys understand each other.”
Social Pressure and Ridicule Uphold Collective Action
The interview data identified several categories, which signify how public shaming was used by friends and groups of friends to motivate others to action. Other categories revealed that collective action, going to “get tested” as a group, was much more likely to happen then having an individual conversation around emotions or feelings. The following are examples of how these findings suggest that pressure when applied in the right circumstance serves to motivate reluctant friends to action.
Participant 9 said to a friend, “if you jump off this you going to break your leg,” and “you take the responsibility and get that caste and look stupid.” He explained how he lets his friends learn from their mistakes by standing aside and allowing them to experience their own failure for themselves. This form of ridicule or shaming is one that was also expressed by Participant 5. He described the word “dokie” and how he and his friends used it to indicate something “[was] just wrong . . . wack, lame not good . . . it all derive from fake shoes.” He explains further, if “you trying to skip church because you was home . . . and you went to Jack-in-the-box, man you dokie.”
Participant 16 explained how the use of shaming and language are used to joke, but also to tell something to a friend in a subtle but publically acceptable way. For example, Participant 16 detailed, “we joke around with each other . . . but they know they’re being clued in . . .” This suggested that among friends they understand a certain level of “face saving” that must occur in order for others to really intuit the importance of making better decisions.
Taking this notion of collective action a step further, Participant 5 shared a story where he and his friends “just got into the car and drove, waited in a two hour line to get tested . . . but we all did it.” Participant 16 supported this comment in a later answer saying, “Where I’m from we got like three or four of us together and we used to go to the clinic.” The idea that learning or working together as useful or helpful also supports the notion that ridicule is simply another form of “tough love” as indicated by Participant 1 who said, “I really don’t make decisions for them, I am just there to support them and to help them realize the consequences of their actions.” Where some responded with “tough love” statements, others, such as Participant 14, indicated that this form of support, “that all goes back to brotherhood, that’s what brotherhood is all about. If you see a brother fall you pick him up.”
Discussion
Main Findings
The results of this project strongly suggest that brotherhood acts as a support mechanism for African American men facing tough decisions: they trust the group view, identify with the collective, respect generational views and shared learning, and respond to social pressure to conform—all of which serve to validate their behaviors according to the wider African American male community. A possible caveat might be that these men are vulnerable to groupthink, internalized prejudices, uniformed views, and reactionary opinions, which may obfuscate the benefits of making positive choices from those motivated by normative pressure to conform.
The social value of trust, in this case developed through storytelling among generations, friends, and acquaintances, has taught these men to judge friendships and other relationships through a lens of experience. It is unmistakably clear from these interviews that peer evaluation and assessment by the brotherhood authenticates individual identity, much more than individually leveled evaluations, which seem to hold much less value. Consequently, receiving validation from the brotherhood acts to influence individual-level engagement or nonengagement—more so than for other groups.
As these men sought to understand their place, their identity, in an ever changing social environment, they learned about themselves through a process of observation that included keeping a mental record of their successes and failures. Consequently, these interviews suggest that individual identities are framed in the context of African American men’s experiences.
Participants reflected on the lives of other African American men as examples of what can be accomplished. These findings clearly identify the importance of shared experiences within and between generations as a social mechanism for establishing trust among these men. The interviews illustrated how social pressure and the public ridicule of friends serves to educate and advocate for better choices. Going to the clinic to get tested as a group was an example of this type of collective action through social influence. If African American men can work together using the strengths of brotherhood to overcome barriers to health utilization, it seems much more likely that individual African American men may choose to seek care when their closest friends do the same.
Strengths and Limitations
Following steps to reduce the level of bias in development, data collection, and analysis strengthened the design of this study. The previously piloted interview study and the use of expert review panel each helped strengthen the content and ecological validity of the instrument. The use of an ethnic minority team to conduct interviews and an independent analysis of data brought rich diversity of experience and culture to the data and the interaction with participants. Generalized training of interviewers prior to conducting interviews had reduced potential researcher bias.
The design of the study included making concerted efforts to pay attention to the sensitivity of information being collected in the interviews. The research team also took tremendous care to work with African American recruiters at the campuses to ensure that all information was seen as legitimate and supported by the schools themselves.
Setting this study within two HBCUs reflected the intention of the lead author to investigate the attitudes, knowledge, and beliefs associated with a distinct culture, socioeconomic, and historical background; accordingly, this choice also recognized how few studies involved college-aged African American men by focusing on this particular population within HBCUs. Findings suggested that participants reported positively on their interview experience as long as it did not exploit or report on men attending HBCUs in a negative way.
As a qualitative study, there were limits on generalizability. Although the study had limited broad applicability, several key findings suggested that a more targeted community-focused approach might be useful. The proposed pilot testing step, using lay experts from the two HBCUs, did not occur and limited the face validity of the instrument. The interviews were completed by more than one person, which demonstrated some concern related to reliability. However, as a qualitative study, one not concerned with generalizability, the use of multiple interviewers added a richness to the data otherwise unseen with the use of only one interviewer.
Another limitation is that the sample was limited to African American males who attended HBCUs. Their choice of attending an HBCU may express an underlying cultural centricity that makes them more relaxed with minority researchers in general. The samples were not chosen to be a descriptive of the general demographics of the United States but rather to reflect on a small sector of college-aged African American men who attend HBCUs.
Broader Research Context
The findings of this study add new relevance to the value of relationships and the power of trust garnered among African American men. Rich (2000) argues “[c]oncerned African-American men have the ability and power to affect the health of their communities by influencing their peers to alter unhealthy behaviors and seek regular medical care, while also teaching them to advocate for their health needs” (p. 158).
The men in this sample indicate how they develop trust with each other through their experiences as African American men, which is consistent with how other research suggests that the consistent flow of information across social interactions begins to shape and define trust and shape behavior (Hannerz, 1969; Luft, 1969). Brotherhood, as shown by these findings, consists of a system of beliefs, values, and social constructs and is consistent with health determinant research on African American male social development (Franklin, 2004).
Issues of trust disproportionately affect African Americans, particularly African American men, who, as these findings suggest, respond positively when they have trusting relationships. This finding is consistent with Whetten et al. (2006), who suggest that trust is associated with more appropriate use of clinical visits and emergency room usage, use of antiretroviral medications, and better health outcomes.
There are several bodies of literature that focus on medical mistrust and masculinity in relation to preventive health and African American men. “Masculinity” reflects a shared understanding of what it means to be a man: what one looks like and how one should behave (Edley & Wetherell, 1996). Men’s enactment of masculinity in a health care–seeking context varies according to their race and social location; since, how men display masculinity depends on how much social power they hold (Courtenay, 2000).
Theorists differ over how masculinity affects African American men’s health care use, largely because this group has experienced socioeconomic challenges (e.g., joblessness) to fulfilling traditional male provider role expectations (Bound & Freeman, 1992; Holzer & Offner, 2006) and defines masculinity differently than non-Hispanic White men (Hammond & Mattis, 2005). Consequently, efforts to understand health-seeking behaviors of African American men must be contextual, based on the lived experiences of African American men, and not adopted from research conducted among other ethnic or racial groups.
Some argue that since African American men hold relatively lower social positions, they may delay health care utilization to symbolically exercise masculine dominion over their bodies (Courtenay, 2000; Staples, 2004; Wallace, 1999). Others posit that barriers to traditional male role fulfillment encourage African American men to reject traditional masculinity and adopt patterns of health care use that contradict dominant male-behavioral norms (Abreu, Goodyear, Campos, & Newcomb, 2000; Aronson, Whitehead, & Baber, 2003; Gordon, 1997; Wade & Brittan-Powell, 2001).
Implications
The implications of these results for African American men’s health are salient for providers, researchers, and policy makers. Understanding just how brotherhood influences and affects the lives of African American men presents providers and health care researchers with a tangible mechanism for improving health utilization rates.
For researchers, developing interventions around groups of African American men, be they shared medical appointments or community-based interventions, there are clear benefits from engaging these men as a group rather than as individuals (Hooker, Wilcox, Burroughs, Rheaume, & Courtenay, 2012; Kirsh et al., 2007; Victor, 2009). Taking care to reach out to African American school officials, by investigating this question within HBCU campuses, signals to male students that an interest in this research exists and that their individual experiences are valuable. Consequently, there is strong support for this type of work to be conducted in the future.
For providers, there is a recognized need to apply a more culturally relevant methodology during the clinical encounter. Research in the area of patient–provider racial concordance may provide a helpful basis to build further work in order to bridge cultural differences using a patient-centered framework (Saha et al., 2011).
If policy makers recognize the implications of brotherhood to influence the health-seeking behaviors of African American men, there is an opportunity to change reimbursement for physicians and clinicians who target groups of African American men through health promotion and education interventions. If policy makers link funding streams to group-level care, brotherhood could have wide implications for mental health providers, substance abuse counselors, and community health workers.
Conclusion
Considering how intrinsic the brotherhood is in the lives of these men, it is not unreasonable to think that interventions designed to leverage the strengths of brotherhood for the improvement of health care utilization among African American men have the chance to change the way health promotion and education efforts are targeted to African American men. If we heed the admonishment, which states “the most significant gap in this health disparities research is the failure to identify mechanisms by which these disparities occur” (Smedley, Stith, & Nelson, 2003, p. 75), then we must focus on the distinctly influential nature of brotherhood to shape behavior among African American men. Thus, Franklin’s (2004) statement “that brotherhood, at its best, is a viable gateway to authentic visibility and empowerment” (p. 48) clearly demonstrates its potential to positively affect health care utilization among African American men.
Footnotes
Acknowledgements
The authors would like to thank Professor Glyn Elwyn, Senior Scientist at The Dartmouth Center, for his invaluable contributions, generosity, and expert guidance in the development of this article. We would also like to acknowledge the research team at Texas A&M University who contributed to this project.
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) received no financial support for the research, authorship, and/or publication of this article.