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Food, Identity, and African-American Women With Type 2 Diabetes: An Anthropological Perspective

	Abstract

Top Abstract Introduction EATING AS RITUAL METHODS FINDINGS IMPLICATIONS CONCLUSION References

 
In Brief

Dietary practices are deeply rooted in history and culture. Anthropologists have long recognized that food choices and modes of eating reflect many symbolic, affective, familial, and gender-specific associations. African-American women with type 2 diabetes may find that modifying their dietary patterns is particularly challenging given the highly ritualized nature of eating and food selection and the meanings encoded in foods and food-centered events in the African-American experience. When health care providers understand the historical and social shaping of food patterns, they can work in partnership with people with type 2 diabetes to shift cultural norms toward healthy eating.

	Introduction

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The humans’ basic biological need to eat cannot be separated from symbols and metaphors of status, gift-giving, feasting, social and kin relations, and sacred ritual.

—Peter Farb and George Armelagos¹

African-American women bear a disproportionate burden of type 2 diabetes and its associated risk factors and complications.²–⁴ According to the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994, 7.8% of African-American women 20 years of age were diagnosed with type 2 diabetes by a physician, compared to 5.0% of their white counterparts.⁵ In addition, African-American women have long been burdened by a high prevalence of obesity, a primary risk factor for type 2 diabetes. For example, the NHANES for 1999– 2000 indicates that among African-American women aged 40 and older, the rate of obesity (body mass index 30 kg/m²) is now more than 50%, and the combined rate of overweight and obesity is currently > 80% compared to 61% for non-Hispanic white women aged 40 and older.⁶

Unfortunately, the causes of the disparities in diabetes prevalence are both complex and difficult to isolate through traditional public health and clinical measures or methods of data collection.⁷ Similarly, the ability of health care providers to effectively guide African-American women with diabetes toward better health outcomes requires the engagement of perspectives and ways of knowing beyond clinical medicine. As health care providers search for innovative strategies to improve patient outcomes, they might be well served by examining the theories and methods of anthropology, other social sciences, and the humanities—subject areas that might enhance their understanding of the broader social context in which health and disease risks are experienced.

Adherence to dietary recommendations is a key component of the prevention and control of type 2 diabetes in that it improves glycemic control and facilitates weight management. But achieving and sustaining a healthy eating pattern is often challenging for people with diabetes, given that individual food preferences and practices are deeply rooted in history and culture.¹ Anthropologists have long recognized that food choices and modes of eating reflect many symbolic, affective, familial, and gender-specific associations. For many African-American women, their perceptions of and relationships with family and social networks, society, and health may be better understood by examining the rituals they have adopted that relate to food selection, preparation, and consumption.

	EATING AS RITUAL

Top Abstract Introduction EATING AS RITUAL METHODS FINDINGS IMPLICATIONS CONCLUSION References

 
In this article, dietary practices among a group of African-American men and women situated in the geographical and cultural South are interpreted from the theoretical stance of a ritual. The group participated in an ethnographic study entitled "Understanding the Shaping of Body Size Among African-American Women," which was conducted in the summer of 2001 in Atlanta and Albany, Ga. The primary objective of this study was to explore the cultural meanings and determinants of body size in the African-American community.

Rituals, which are distinguished from other behaviors by being stylized, repetitive, and stereotyped, convey information about the participants and their cultural traditions. Rituals performed year after year and generation after generation translate enduring messages, values, and sentiments into observable actions. Participation implies the acceptance of an order that transcends one’s status as an individual.⁸,⁹ Finally, although rituals are created, they feel natural when practiced within the broader cultural context in which people live and maintain social relationships.

African-American women with type 2 diabetes may find that modifying their dietary patterns is particularly challenging given the highly ritualized nature of eating and food selection in the African-American experience. Consistent with this study and selected literature, food-centered gatherings are a forum wherein the history, wealth, spirit, creativity, resilience, and collective ethnic identity of the community is perpetuated. This article describes the historical construction of the eating ritual as documented from the time of slavery. Connections between food and both African-American female identity and African-American ethnic identity, as well as the role of food in the intimate relationships of African-American women, are presented in the voice of the study participants. The article concludes with implications of this study for diabetes education.

	METHODS

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Procedures
Participation in the 2001 study was not limited to people with type 2 diabetes or those who are overweight or obese, since people not in those categories are still members of the larger (African-American) cultural community and therefore subject to the same cultural values, symbols, and history. Candidates were identified through a nonprobability sampling method. Semi-structured, in-depth interviews were conducted with 23 African-American men and women who ranged in age from 21 to 80 years and represented a cross-section of the community.

One 80-year-old participant, a woman, was the only participant older than 68 years. Over half were college graduates, including two who held master’s degrees and two with doctorates. Two were undergraduates, two were graduate students, and four worked in the service industry (e.g., custodians, security workers, or public transportation workers). Three were retired. Eleven were natives of Georgia; other states of origin included North Carolina, New York, Michigan, Illinois, Maryland, and Florida. Interviews were audiotaped and then transcribed professionally.

Findings from this qualitative, ethnographic study cannot be generalized to the larger community of African-American women and men because of the geographic location of the study, sample size, and sampling method, as well as the cultural and social diversity that exists in this population.

The Interviews
Three questions addressed dietary practices specifically among the 23 participants:

1. How important is eating in social interactions?
   
2. Where do people go to eat?
   
3. What are the preferred foods and drinks?
   

The importance and centrality of eating in social interactions of African Americans emerged in the larger study as such a pervasive social norm that additional questions were asked of food experts to explore this phenomenon in greater detail. Two African-American chefs (one male, one female), one African-American food writer for Southern Living magazine (female), and a culinary historian of European descent (female) who specializes in Southern cuisine and has written on the influence of African slaves in shaping Southern cooking, were asked the following questions [abridged]:

1. How might you explain what food represents in African-American relationships?
   
2. Why do you think food preparation might be a space for creativity and artistic expression for black women?
   
3. What food comes to your mind when you think of "soul food?"
   
4. What is the "soul" in soul food?
   
5. How is it that certain foods actually define an event?
   

Analysis
We analyzed those questions addressing eating, food preferences, and food preparation from the theoretical stance of a ritual. The content analysis consisted of coding excerpts from the transcripts that aligned with any of the following thematic categories:

• the performance of men and women in food preparation and consumption
  
• the symbolism of food, such as food as "wealth"
  
• the spiritual dimension of food as possessing "soul"
  
• the preparation of food as an artistic performance
  
• the communication of acceptance, friendship, and community through food
  

A range of cross-cultural anthropological works on food in culture, black feminist ethnographies, and other interpretative cultural science was consulted to inform the analysis. Consistent with usual procedures in reporting ethnographic research, direct quotes from the transcribed interviews of respondents are incorporated in the theoretical analysis and interpretation of findings.¹⁰ Actual names are replaced with pseudonyms.

	FINDINGS

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The Historical Construction of the Eating Ritual in African-American Culture

"I think in southwest Georgia, as in all southern states, a long time ago black people didn’t have very much, so in order to extend their hospitality, they shared the food that they probably grew in their gardens, or they shared meats that they raised, and it was just a form of showing love and sharing and compassion. It’s connected with religion. Love thy neighbor as thyself. You feed yourself as you feed your neighbor. That was a cultural tradition that was probably brought right over here with slavery."

—Joyce, 46-year-old African-American woman; native of Georgia

"I think historically food may have been one of our few simple pleasures in life. You know, something that we could share legally that wasn’t a problem. Sometimes out of necessity, we became used to sharing food because other people may not have had food, so it was almost like a collective, communal type of event where everybody brought what they had together so that everyone could share in, and I think those are the things that continued on, even though they’re no longer necessary."

—Marva, 32-year-old African-American woman; native of Chicago, Ill.

The historical experience of slavery had a profound impact on the shaping of African-American life even as we know it today, but comprehensive review of slavery and how it continues to inform contemporary African-American thought and culture is beyond the scope of this article. Still, some aspect of slavery is often mentioned as an originating site of African-American rituals, in particular, the ritual of eating.

African bodies—both male and female—were engaged in the production, harvesting, and preparation of food for the slaveholders. Division of labor by sex that characterized the public and private spheres of the slaveholders was not present. In Mistresses and Slaves, Weiner found that "slave women did almost every type of work required on antebellum South Carolina farms to produce rice, sea island cotton, upland cotton, foodstuffs, and various other crops. They also cared for their own households."¹¹

It was in the private space of the slave quarters that these women fought against the dehumanization of slavery by preserving African values and culture. A form of African slave domesticity emerged during this period that evolved to create the centrality of eating as a social contract between African Americans. The kitchen and eating areas of many African-American homes are still the family gathering place and the location where traditions and values are passed down.

African slave women were involved in the work of the field and in the "big house," but were expected to carry out the domestic duties of their individual households as well. Although the work of house slaves was specialized, most learned at least the basics of all types of work so they could substitute for one another when necessary. Analysis of the class system and the division of labor between "house slaves" and "field slaves" also exceeds the scope and intent of this article, but we know that both groups were intimately involved in food production and food preparation and, thus, ultimately in the social construction of the palates of all who consumed their meals.

According to culinary historian Karen Hess in her study of "rice kitchens" in South Carolina, "Slaves’ skills in fishing or hunting or snaring of game were legendary, enabling them to eke out their rations and add variety to their diet, even supposing that much of what they caught was sold. . . . slaves were given the use of a lot of land, generally running about an acre per family, where they were encouraged to grow rice and to garden for themselves, so that they were able to grow their own vegetables, a circumstance of which they seem to have made good use. Above all, they grew greens, but presumably they also raised such African favorites as okra, sorghum, black-eyed peas, eggplant, and benne seed, for example. They also usually kept poultry and perhaps a hog."¹²

The forced connection among the slaves, the land, and the domestic sphere was ultimately transformed by the slaves into a culturally defined symbol of wealth for themselves and their community. Food became wealth in that it was available for them to share and enjoy when no other tangible resources were truly their own. Power over the production, consumption, and distribution of food likely served to affirm the personhood and identity of the slaves in an environment that relegated them to the status of property.

Food in the African-American Female Identity
The historical and gendered relationship between food and African-American women supports the observation that African-American women who cook take great pride in the performance of cooking. The dishes prepared become a self-portrait—a creation of art just for the ritual occasion of eating together with friends, acquaintances, and family members. Hess, also a participant in the study, responded to the question, "Why do you think food preparation might be a space for creativity and artistic expression for black women?" with this answer:

"Because that’s what it is. Some people have more flare than others. Some people are musicians; some people are natural-born cooks. I mean, they don’t need training. They do, but they need training from their mothers, their grandmothers, or if they’re going to be chefs, they need training from chefs. But, there is a flare for cooking. It’s an art. It’s not a science. I mean scientific principles are involved, obviously, in the application of heat and so forth, but it is not a science. It’s an art."

The performance of cooking ties African-American women to the past and to their ancestors and reproduces an art form that is privileged and unique to their cultural and historical identity. Study participant Marva offered a similar comment on this aspect of the ritual:

"[Food is] a way to attract and to draw people to a social function. And for some people, I think it’s a form of art, if that makes sense, for the persons who prepare it. You know, when they may not have skills in certain areas that society deems important, you know, computer skills or that sort of thing, culinary art is highly esteemed, I think in the black community."

Sandra, a 38-year-old African American born in Georgia, described her mother’s intense passion for cooking and its aesthetic this way:

"I know I told my Momma, I said all that time you spend preparing all these dishes and in a second it’s gone. It’s beautiful, but you know, as soon as the crowd gets there, it’s gone. You know, but that is the big thing . . . to have a spread. They can’t wait to get there to destroy it [the food]. But it is the center of attention because they know my mom can cook."

Cooking can be quite labor-intensive, but for special ritual occasions, cooks take pleasure in the effort. When the identity of the cook is attached to the preparation of the food, even more energy is required. Sandra reported that her mother would prepare food for the family even when she was ill. It seems that sustaining the traditional meals at the established time (Sunday after church) and place (her home) superseded the pain and discomfort her mother was experiencing at that time:

". . . but she’s always been a cook. She had surgery back there on the first of this month in outpatient. They thought it was going to take her three weeks and she just went back to work about two weeks, and I said, ‘Mom, they said you’ve got to stay on bed rest.’ And she said ‘I can’t be still.’ We went in there and called her—she was still cooking."

Food and African-American Ethnic Identity
Interviewer: "What are the preferred foods and drinks? What are the foods and drinks people really like to eat around here?"

Joyce: "Southwest Georgia? Fresh vegetables out the dirt, collards, turnips, mustards, squash, cucumbers, tomatoes, corn, just freshly grown vegetables. Fried chicken, beef, pork, homemade cakes, pies, pastries, barbecues. Just the whole Southern cuisine. . . ."

Commonly referred to as "soul food," selected foods are fixed and invariant in meals among many African Americans. According to Kalesha, an African-American chef:

"From what I understand about it [soul food], it’s basically a tradition that has been passed down since slavery because we were talking about it in one of our classes—how slaves didn’t have anything of their own. That’s the only thing they had that was like theirs, was the food. And they had to work with what they had to try to make a good meal and that’s basically, they were putting their heart and soul into the meal because they didn’t have anything else to put their heart and soul into . . ."

Soul food is not unique in its composition from what is known as Southern cuisine, but consumers of soul food insist it embodies an almost spiritual essence. Andrew, an African-American chef, described the "soul" in the food he prepares:

"When every day I cook, I embody food. I give food a soul. I give food a personality. When you look at that food, you’re like, it jumps out at you because I spent so much time on it, first of all, but I want you to know that. I want you to look at that and say, ‘Man, how long did it take him to do that?’ So, I embody that food. I give that food a soul in so many words."

The "soul" in food enjoyed by African Americans is consistent with Roy Rappaport’s contentions about religious discourse when he states, "Such expressions are peculiar. Because their significata are typically devoid of materiality, they are in their nature objectively unverifiable and empirically unfalsifiable. They also seem to be impervious to logical assault."¹³

Sybil, an African-American food writer, suggests that the "soul" in soul food:

"is something that you can’t really capture. It’s really intangible, I think, and I always say African-American soul food just has a certain pizzazz about it that other ‘soul food’ doesn’t have, I think. Everybody’s got their own version of it, but it’s how you season it. It’s your feelings about it, I think."

Sybil’s statement also acknowledges that across nations and ethnicities, there are foods that code and transfer cultural and historical identities. Cross-cultural differences emerge in how food is produced, prepared, and served, among other things.

Food in the Relationships of African-American Women
Several respondents who cooked said that they "lose themselves" in the preparation of soul food, with their essence experienced by the people who eat the food they prepare. In African-American culture, food is the quintessential symbol of love, and those who prepare it want to heap large amounts on the plates of people they allow in their private space. Rejecting the offering of food can be construed as a rejection of the person offering it. Family, friends, and guests often feel obliged to eat to excess as an act of receiving the love embodied in the food.

Andrew shared this perspective:

"The old people that I work around, they show me they love me and really care for me, they feed me. They feed me a lot. They feed me like five times a day, not thinking, well, this child needs a balanced nutrition meal so he won’t get fat. They don’t think about that. . . . We can’t express to you how much we love you, so let’s all sit down and take part in this dinner."

Yvette, a native of New York, shared a similar sentiment in describing what happens when she and her siblings return home for Thanksgiving:

"I think when a parent is doing it [preparing food] because their kids are coming home for Thanksgiving, they’re going to put all of that love and care and all of the memories and the good times in those black-eyed peas or whatever it is that they’re cooking up. . . . I mean there was much love in that food Momma fixed when we went home for Thanksgiving, you know. I mean that was real clear. I mean she put her heart in it. I mean that was the one thing she could give us and she knew we would have enjoyment in and we did—we sat and we ate it up."

Deborah, a 43-year-old Maryland native, reflected on the emotionality communicated through food in this way:

"My mother expressed how she felt about you through food. For instance, for your birthday, what is it that you want to eat? I never liked cake because I never liked icing, but what kind of pie. And that was so special to me, that she noticed that I didn’t like the cake, so I would get a pie for my birthday. And whenever we all get together, each of us has a favorite food—including the grandchildren. She’ll make one for everybody and it makes you feel, it made us feel, very important and special to her. So maybe it is a sense of expressing love and your uniqueness or something like that . . . ."

Taken together, these comments imply that women use food for "meaning making," that is, to demonstrate how they feel about others, to create fond childhood and adult memories, and to sustain their social ties with their friends and acquaintances.

	IMPLICATIONS

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This article adds to the growing literature that views diabetes treatment and prevention (which must include the prevention of obesity) through alternative intellectual and professional lenses and in the process shows providers how history and culture shape and sustain certain behaviors.¹⁴–¹⁶ Clinicians, diabetes educators, and others who counsel African-American women with type 2 diabetes must recognize that dietary practices are tied to ideologies about African-American womanhood, intimate and community relationships, and ethnic identity. Dietary counseling within this context assumes a stance different from the norm, i.e., it must go beyond the transfer of knowledge and skills. To start, clinicians must be careful to de-stigmatize the condition of having diabetes, reminding clients that the diagnosis of diabetes is not a reflection of any moral or cultural failure. In addition, clinicians might point out that the disproportionate burden of type 2 diabetes in communities of color is complex and still not well understood.

Considerably more time must be devoted to exploring the social importance of food choices, uncovering the social and cultural meanings ascribed to certain foods and food-centered events, and identifying social settings in which making healthy food choices is particularly difficult. Some key questions to ask African-American women are:

• How important is food in your social, business, intimate, and family interactions?
  
• How would your relationship with your family and friends change if you radically changed your diet?
  
• Are you willing to be an instrument of cultural change in your community, which may require that you go through some tense and uncomfortable times with family and friends directly related to the dietary changes you’re trying to make to be healthy?
  
• List the foods you know you are unwilling to eliminate from your diet.
  
• Is cooking something you enjoy doing? If yes, how often do you cook, and what foods do you frequently prepare?
  
• How often do you use food as a gift or to celebrate special occasions? Are you willing to substitute other types of gifts?
  

These questions are not exhaustive, but they are a beginning to the process of learning how clients perceive the experience of having type 2 diabetes and how food is used in their personal, social, and cultural environments.¹⁷ Most important, the answers to these questions create a space for creative strategizing that engages the needed perspectives of both health professionals and people with diabetes and their social networks.

	CONCLUSION

Top Abstract Introduction EATING AS RITUAL METHODS FINDINGS IMPLICATIONS CONCLUSION References

 
Eating in African-American culture meets the criteria for a ritual in that people are involved and called on to perform a particular action. This action is repetitive and encodes a collection of meanings for the participants. Foods communicate history, memory, feelings, and social status. When no other wealth is available to exchange, food provides both a material and a spiritual form of capital.

Because we cannot divorce our biology from our culture, the prevalence of risk factors for diabetes-related complications observed among African-American women in particular likely reflects the embodiment of this ritual. Feminist philosopher Susan Bordo said it best:

"In some areas, biology may play a very great role in our destinies, and it always informs our lives to varying degrees. However, even in those areas where biology may play a more formidable role, its effect is never ‘pure,’ never untouched by history. We are creatures swaddled in culture from the moment we are designated one sex or the other, one race or another."¹⁸

It is not our intention to suggest that the eating ritual is the only challenge to effective diabetes prevention and control. African-American women with type 2 diabetes are subject to multiple sociocultural and environmental influences on their eating and other health-related behaviors. However, the assault on the physical health of African Americans from type 2 diabetes argues for some modification of this ritualized behavior that will eventually improve health outcomes.

How might the eating ritual be reconstructed for future generations of African Americans in a way that perpetuates sociality and a collective sense of community but still reduces the risks for developing chronic diseases? Culture, broadly understood, is dynamic and evolves over time and circumstance. Cultural evolution is generally adaptive, e.g., advances in knowledge improve the survivability of the human species. But sometimes, it is maladaptive, e.g., social structures and institutions are established that contribute to increased rates of obesity and diabetes. Health care providers can help to shift cultural norms toward health promotion and disease prevention if they are sensitive to the many influences that produce and modify the behaviors of people with diabetes. If rituals are in fact created, and not natural, the eating ritual can be re-created as a site for the promotion of health—of the mind, body, and soul—of African-American women with type 2 diabetes.

	Acknowledgments

 
The author extends special thanks to the Southern Foodways Alliance and Glory Foods for facilitating access to the food experts quoted in this manuscript and others interested in preserving Southern culture and cuisine during their Southern Foodways Symposium (October 25–28, 2001) held on the campus of the University of Mississippi in Oxford.

	Footnotes

 
Leandris C. Liburd, MPH, is chief of the Community Interventions Section, Program Development Branch, of the Division of Diabetes Translation at the National Center for Chronic Disease Prevention and Health Promotion in Atlanta, Ga. She is also a doctoral candidate in the Department of Anthropology at Emory University in Atlanta, Ga.

	References

Top Abstract Introduction EATING AS RITUAL METHODS FINDINGS IMPLICATIONS CONCLUSION References

 

¹ Farb P, Armelagos G: Consuming Passions: The Anthropology of Eating. Boston, Houghton Mifflin Company, 1980, p. 94

² Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS: Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 289:76–79, 2003[Abstract/Free Full Text]

³ Davidson MB: The disproportionate burden of diabetes in African-American and Hispanic populations. Ethn Dis 11:148–151, 2001[Medline]

⁴ Lavery LA, van Houtun WH, Ashry HR, Armstrong DG, Pugh JA: Diabetes-related lower extremity amputations disproportionately affect Blacks and Mexican Americans. South Med 92:593–599, 1999

⁵ Beckles GLA, Thompson-Reid PE (Eds.): Diabetes and Women’s Health Across the Life Stages: A Public Health Perspective. Atlanta, Ga., Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, 2001

⁶ Flegal KM, Carroll MD, Ogden CL, Johnson CL: Prevalence and trends in obesity among U.S. adults, 1999–2000. JAMA 288:1773–1727, 2002[Free Full Text]

⁷ Centers for Disease Control and Prevention: Public health puzzle: social determinants of health. Chron Dis Notes Rep 15:1–27, 2002

⁸ Kottak CP: Rituals at McDonald’s. In Nutritional Anthropology: Biocultural Perspectives on Food and Nutrition. Goodman AH, Dufour DL, Pelto GH, Eds. Mountain View, Calif., Mayfield Publishing Company, 2000, p. 157–161

⁹ Bocock R: Ritual in Industrial Society. London, George Allen & Unwin Ltd., 1974

¹⁰ Hammersley M, Atkinson P: Ethnography: Principles in Practice, 2nd ed. London, Routledge, 1995

¹¹ Weiner MF: Mistresses and Slaves: Plantation Women in South Carolina, 1830–80. Chicago, University of Illinois Press, 1998, p. 7

¹² Hess K: The Carolina Rice Kitchen: The African Connection. Columbia, S.C., 1992, p. 8

¹³ Rappaport RA: Ritual. In Folklore, Cultural Performances, and Popular Entertainments. Bauman R, Ed. New York, Oxford University Press, 1992, p. 249–259

¹⁴ Murphy FG, Satterfield D: Diabetes educators as cultural translators. Diabetes Educ 19:113–116, 118, 1993

¹⁵ Tripp-Reimer T, Choi E, Kelley LS, Enslein JC: Cultural barriers to care: inverting the problem. Diabetes Spectrum 14:13–22, 2001[Abstract/Free Full Text]

¹⁶ Jack LJ, Satterfield D, Owens M, Airhihenbuwa CO, Lester A: Cultural sensitivity: definition, application, and recommendations for diabetes educators. Diabetes Educ 28:922–927, 2002[Free Full Text]

¹⁷ Kleinman A: The Illness Narratives: Suffering, Healing & the Human Condition. New York, Basic Books, 1988

¹⁸ Bordo S: Unbearable Weight: Feminism, Western Culture and the Body. Berkeley, Calif., University of California Press, 1993, p. 36

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Liburd, L. C. Search for Related Content PubMed Articles by Liburd, L. C. Social Bookmarking                What's this?