Cultural and psychological factors inhibiting self-care in African-American men with hypertension
Intended for healthcare professionals
Evidence and practice    

Open Access Cultural and psychological factors inhibiting self-care in African-American men with hypertension

Wilfred Allen Assistant professor, McAuley School of Nursing, University of Detroit Mercy, Detroit, MI, US

Why you should read this article:
  • To understand why hypertension disproportionately affects certain male populations

  • To gain insight into the parallel process model and people’s reactions to messages perceived as threatening

  • To explore the cultural and psychological factors that can inhibit self-care behaviours in men

Hypertension disproportionately affects African-American men compared with their white counterparts and with African-American women. Self-care is key in the effective management of chronic conditions such as hypertension. This article explores the cultural and psychological factors that make African-American men less likely to engage in self-care behaviours. These factors include the way in which gender socialisation can perpetuate traditional views of masculinity, which can translate in an unwillingness to seek support from healthcare professionals.

A crucial psychological factor is whether people’s reactions to health promotion messages tend to be driven by fear control or by danger control. Gaining insight into what influences the health beliefs and behaviours of African-American men can enhance nurses’ education and health promotion interventions, subsequently leading to better outcomes for these patients.

Primary Health Care. doi: 10.7748/phc.2024.e1814

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software


Conflict of interest

None declared

Allen W (2024) Cultural and psychological factors inhibiting self-care in African-American men with hypertension. Primary Health Care. doi: 10.7748/phc.2024.e1814

Open access

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

Published online: 20 March 2024

In the US, the life expectancy of men is 66.7 years for African-Americans and 73.7 years for their white counterparts (Arias et al 2022). Studies have indicated that African-American men tend to develop health conditions at a younger age and experience more severe symptoms and complications than their white counterparts (Simons et al 2021). Hypertension is the most common chronic disease among African-Americans (Ogunniyi et al 2021) and is particularly prevalent among African-American men (Sulaica et al 2020).

Hypertension is marked by pressure in the blood vessels that is ≥140/90mmHg. This high blood pressure leads to increased stress on the heart and other organs. People with hypertension may not experience symptoms. When symptoms are present, they can include headaches, chest pain, abnormal heart rhythm, shortness of breath, nosebleeds and dizziness. Whether or not patients experience symptoms, untreated hypertension can lead to serious health problems such heart attacks, heart failure and kidney damage. Risk factors for developing hypertension include obesity, diets high in sodium and saturated fats, lack of physical activity, smoking, excessive alcohol consumption, stress and family history (World Health Organization 2023).

Research has shown that among people with hypertension, African-American men are less likely to attain blood pressure control compared with African-American women and with people from other ethnic backgrounds (Sulaica et al 2020). The rates of hypertension-related deaths are higher in African-American men (50.1 per 100,000) than in African-American women (35.6 per 100,000) or in white men (19.1 per 100,000) (Sulaica et al 2020). Hypertension therefore disproportionately affects African-American men.

Cultural factors may significantly contribute to these higher rates of hypertension-related deaths among African-American men. Gender socialisation, specifically the promotion of traditional norms regarding masculinity and manhood, can significantly influence the health-seeking behaviours of African-American men, which in turn can affect their overall health and well-being (Connell et al 2019). Gaining a comprehensive understanding of African-American men’s attitudes and beliefs pertaining to health could therefore serve as the foundation for developing interventions designed to encourage them to start or improve their self-care, ultimately leading to better health outcomes.

Self-care existed long before formal health systems and is an important contributor to health outcomes. Nurse educator Dorothea Orem, who pioneered the self-care deficit nursing theory, defined self-care as ‘the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well-being’ (Orem et al 2001). Considering the importance of self-care in the effective management of chronic conditions such as hypertension (Becker et al 2004), and taking into account the disproportionate impact of hypertension on African-American men, it is important to explore strategies aimed at enhancing self-care in this patient population.

This article explores cultural and psychological factors that are likely to negatively affect the self-care behaviours of African-American men, with the goal of informing interventions aimed at improving their health outcomes.

Traditional views of masculinity

Most societies and cultures assign specific attributes and roles to people according to their sex at birth, and children’s socialisation is influenced by the dominant gender-based views. This gender socialisation has been highlighted by Bem (1981) in the gender schema theory (GST), which provides a social-cognitive perspective on how people in society acquire gendered norms from a young age and how these can influence their cognitive and categorical thinking throughout life.

Traditional views of masculinity prescribe specific self-perceptions and behaviours that men are expected to adopt. Men are typically seen as strong and are expected to appear unaffected by emotion (Levant 1996) and shun behaviours or thoughts traditionally attributed to women (Wade 2008). Masculinity in the traditional view is associated with achievement and self-reliance. In terms of health-related behaviours this can translate, for example, into less willingness to consult healthcare professionals (Addis and Mahalik 2003) and less use of preventive healthcare (Mahalik et al 2006).

The traditional idea of manhood depicts men as being unwilling to ask for help and reluctant to talk about their feelings – characteristics that both imply a risk of negative outcomes. Difficulty in talking about one’s feelings can negatively affect relationships with family, friends and colleagues. In terms of health-related behaviours, an unwillingness to ask for help and a reluctance to talk about one’s feelings can manifest as a tendency to avoid seeking support from healthcare professionals, whether for physical health or psychological health issues.

Research into various psychosocial factors has shown that adherence to traditional views of masculinity is the most significant predictor of risk-taking behaviour (Austin and Probst 2021). When traditional views of masculinity are salient, there is a greater probability that people will engage in risk-taking behaviour (Schermerhorn and Vescio 2023).

Key points

  • Hypertension is the most common chronic disease among African-Americans and is particularly prevalent among African-American men

  • The traditional idea of manhood depicts men as being unwilling to ask for help and reluctant to talk about their feelings

  • Men who hold strong traditional views of masculinity are more likely to exhibit defensive avoidance when exposed to health promotion messages

  • The higher prevalence of hypertension among African-American men may be partly due to insufficient self-care, a tendency to avoid seeking support from healthcare professionals and risky health behaviours

  • When caring for patients, nurses need to gain insight into the factors that underpin their health beliefs, behaviours and decisions

Human response to threatening messages

Messages from healthcare professionals about taking steps towards preventing negative health outcomes in the future can be perceived as worrying or even threatening. For example, advising people to check themselves for cancer or encouraging them to participate in diabetes or cardiovascular disease screening programmes can remind them of their vulnerability and mortality (Novak et al 2019).

People’s responses to health promotion messages vary. Two typical types of responses to threatening messages have been described by Leventhal (1970) and Witte (1992, 1994). Leventhal (1970) conceptualised how people deal with threatening information according to the parallel process model, which was later expanded by Witte (1992, 1994) into the extended parallel process model. According to Leventhal (1970) and to Witte (1992, 1994), people’s responses to what they perceive as threatening messages are dominated either by danger control processes or by fear control processes:

  • Danger control processes are cognitive processes that take place when a person perceives a danger but believes that they have the ability to overcome or mitigate it effectively. This motivates the person to confront the danger, for example by making behavioural changes aimed at managing and/or minimising it

  • Fear control processes are cognitive processes that take place when a person experiences a heightened sense of fear and low effectiveness. They trigger emotional responses and coping mechanisms characterised by defensive avoidance, as a result of which no behavioural changes occur.

In terms of health behaviour, a person whose decisions are influenced by danger control processes will tend to take proactive measures to minimise risk and protect themselves from harm. Conversely, a person whose decisions are influenced by fear control processes will tend to avoid medical appointments or screening due to a fear of receiving a negative diagnosis or of being stigmatised.

Millar and Houska (2007) investigated how danger control processes and fear control processes influenced people’s intention to engage in health-promoting behaviours. Their findings suggested that people who strongly adhered to a traditional masculinity ideology tended to respond through fear control processes (Millar and Houska 2007). This implies that men who hold strong traditional views of masculinity are more likely to exhibit defensive avoidance and less inclined to engage in adaptive behaviours when exposed to health promotion messages. Further research is necessary to explore strategies for effectively managing fear resulting from healthcare messages perceived as threatening.

Views of masculinity among African-American men

Being male and African-American has been found to be significantly associated with holding traditional views of masculinity (Pleck et al 1994). Within African-American communities there is a tendency to encourage young men to exhibit qualities such as strength, autonomy, self-reliance, leadership, emotional composure and assertiveness. Conversely, any demonstration of emotions or vulnerability tends to be regarded as a sign of weakness and is typically discouraged (Howard 2012).

Connell et al (2019) found that African-American men placed a low priority on disease prevention and that they described feeling defensive when it came to preventive care. According to Rose et al (2000), African-American men’s decisions regarding seeking help for health issues were influenced by concerns about preserving their pride and not wanting to be perceived as ‘weak’ or ‘not macho’. Seeking medical attention was viewed as a feminine attribute and perceived as reducing masculinity (Rose et al 2000).

Risk-taking behaviours can be perceived by African-American men as a way of affirming oneself as a man in a traditional sense, particularly when there is a parallel degree of marginalisation and a lack of mainstream outlets to enact male gender roles (Courtenay 2000). Examples of risk-taking behaviours include smoking, excessive alcohol use, drug misuse and not wearing adequate safety equipment when participating in precarious activities. Not seeking support from a healthcare professional when needed or neglecting self-care can be equally risky, albeit less obviously so. Traditional views of masculinity therefore support attitudes and behaviours that are associated with suboptimal health outcomes (Wade 2008).

During their formative years, African-American men acquire cultural norms that shape their understanding of traditional and non-traditional masculinity. According to Wade (2008), those who embrace non-traditional views of masculinity tend to prioritise their health more than those who embrace traditional views of masculinity. Given that being an African-American man is significantly associated with traditional views of masculinity (Pleck et al 1994), the higher prevalence of hypertension among African-American men may be partly due to insufficient self-care, a tendency to avoid seeking support from healthcare professionals and risky health behaviours.

Implications for nursing practice

Health responsibility is a significant factor in determining lifestyle behaviour. People with high health responsibility are more likely to take ownership of their health and adopt self-care behaviours that promote their health and well-being (Erenoglu et al 2019). In a randomised controlled experimental trial, Erenoglu et al (2019) found that a health promotion programme had significant positive effects on participants’ health behaviours, perceptions and self-efficacy. The programme lasted two months and included interactive sessions covering topics such as diet and nutrition, stress management, physical activity and exercise, interpersonal relationships and spiritual development. This shows that it is possible to increase people’s health responsibility by providing them with appropriate education about their health.

There is a continuous need for nurses to provide education and health promotion interventions, particularly among African-American men. To enhance the effectiveness of educational interventions aimed at African-American men with, or at risk of, hypertension, it is important to consider factors such as fear control and danger control. The extended parallel process model (Witte 1994) provides nurses with an additional resource that can enhance their understanding of the personal and cultural attitudes and beliefs of African-American men. Recognising the priorities of African-American men will enable nurses to collaborate with them and encourage them to adopt behaviours that will reduce their health risks. An enriched understanding of health needs, risks and challenges in this patient group could also guide the development of new comprehensive assessment tools that could improve care plans and positively affect health outcomes.

Furthermore, nurses can assume a pivotal role in advocating for healthcare policies and initiatives that effectively address the unique needs and challenges faced by African-American men. This includes promoting culturally sensitive care, improving access to educational environments and resources for self-care, and addressing systemic factors such as discrimination and socioeconomic disparities that contribute to health inequities.

Victor et al (2018) conducted a study involving African-American men with uncontrolled hypertension who frequented African-American barbershops. Participants received a pharmacist-led intervention whereby pharmacists, who were specially trained, prescribed medicines under a collaborative practice agreement with participants’ doctors. The combination of health promotion messages from the barbers and medicines management by the specially trained pharmacists led to significant reductions in blood pressure among participants. This landmark study suggests that health-promoting messages prompting engagement in self-care practices can yield success beyond conventional healthcare settings (Victor et al 2018). Its findings are a source of motivation for offering health promotion information and guidance on self-care practices beyond healthcare institutions.

This article focuses on African-American men in the US, but people of African descent, Afro-Caribbeans and Africans who live in Europe also tend to develop hypertension at a younger age and experience more severe disease than their white counterparts (Ogunniyi et al 2021). Understanding the factors that affect the health beliefs and behaviours of men of African or Afro-Caribbean descent living in countries like the UK, and assessing whether their responses to health promotion messages are dominated by fear control or danger control processes, can provide valuable insights for nurses in the UK and inform the development of care plans and educational programmes that meet the needs of these patients.


African-American men are disproportionately affected by hypertension and experience a higher risk of hypertension-related death. When caring for patients from this population group, nurses need to gain insight into the factors that underpin their health beliefs, behaviours and decisions. One important cultural factor is that holding traditional views of masculinity can lead African-American men to avoid seeking support from healthcare professionals and to engage in risk-taking behaviours.

One crucial psychological factor is that health decisions that are influenced by fear control processes are characterised by defensive avoidance and therefore by a lack of behavioural change. Given their frequent and close contacts with patients, nurses are in a unique position to provide educational interventions that will assist African-American men in taking proactive measures that mitigate or minimise the effect of health risks.


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