After reading this chapter, the nurse will be able to:
Describe the history of the Appalachian region.
Describe Appalachian communication patterns.
Describe the Appalachian orientation to time and space.
Explain values related to family that may be held by persons with Appalachian heritage.
Describe the Appalachian traditional health care system, including folk beliefs, herbal remedies, and lay practitioners.
Describe factors affecting Appalachian use of biomedical health services.
Discuss illnesses that tend to have higher mortality among Appalachians.
Overview of Appalachia
In 1963 the President’s Appalachian Regional Commission (PARC) report concluded that “Appalachia is a region apart—geographically and statistically” ( , p. xvii). The basis for this distinction in socioeconomic terms was Appalachia’s poverty, deficits in living standards and education, and lack of urbanization. Since this report, dramatic changes have occurred in economic development, resulting in associated social and cultural transitions. Yet Appalachians, especially in the central region, are characterized by unique features.
Approximately 27 million people live in the federally defined Appalachian region, which is nearly 200,000 square miles across 410 counties in 13 states, including all of West Virginia and selected counties in Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia ( ; ; ). Originally, the Appalachian region was defined as 360 counties in 11 states in a bill enacted by the U.S. Congress in 1965, titled the Appalachian Regional Act, and subsequently revised. Today, data on the Appalachian region are collected with federal authority by the Appalachian Regional Commission ( ).
The Appalachian area has three subregions: Northern, Central, and Southern Appalachia. Northern Appalachia is the largest region and consists of portions of New York, Pennsylvania, Ohio, and Maryland and most of West Virginia. It is the most urbanized, populated, and relatively economically advantaged of the three subregions. Southern Appalachia includes counties in southern Virginia, eastern Alabama, Georgia, Tennessee, Mississippi, and North and South Carolina. Of the 13 states, West Virginia is the most rural and the only state residing entirely within the Appalachian region.
Central Appalachia includes parts of Kentucky, Tennessee, Virginia, and the southern area of West Virginia. It is the smallest and poorest of the three areas, is predominantly rural, and has a coal mining economic base. Central Appalachia, particularly the rural areas, stands out most distinctly as a severely distressed economic area, along with particular areas of Northern Appalachia (the rest of West Virginia and portions of Ohio) and Southern Appalachia (clusters of counties in northern Mississippi and Alabama) ( ; ). In 2000 the Appalachian Regional Commission identified nine Appalachian states as having distressed counties—that is, counties with immediate concerns because of the high infant mortality rate, poverty, unemployment, and low income.
Originally home to American Indian tribes such as the Cherokee, the Appalachian area is now populated overwhelmingly by non-Hispanic Whites, with only 1% of the population American Indian and 8% African-American. Most African-American Appalachians reside in the urban areas or in the rural counties in Southern Appalachia. However, the population is experiencing rapid demographic change, with an increase of nearly 50% in the minority population in the last decadal census, with increases of 239.3% for the Hispanic population and 18.7% for the African-American population. Minority population growth surpassed that of Whites for all Appalachian states and was particularly high for children with persons of younger working ages (18–43 years) ( ; ).
For the most part, the Appalachian region is classified as a rural, nonfarming area, although some large cities are encompassed in the area, including Pittsburgh, Pennsylvania; Charleston, West Virginia; Knoxville and Chattanooga, Tennessee; and Birmingham and Montgomery, Alabama. Many Appalachians live in and around the rocky, mountainous terrain, and the roads to their small homes are long, rough, steep, narrow, and often difficult to navigate. Because of the terrain, many communities have only recently been able to support public utilities, such as municipal heating, water, and sewage systems. Only until the 1980s were paved primary highways, telephones, electricity, and running water widely accessible.
Because of the isolation, lack of distinguishing physical characteristics, and low visibility of the people, Appalachians have been relatively overlooked as an American ethnic minority. Although the Appalachian region is federally designated, the Appalachian people are not awarded the status of a federally defined ethnic/minority group. Further, Appalachians do not generally identify themselves as being “Appalachian” or “mountaineers” or any other ethnic designation. Yet this designation may be useful to providers because of the shared history, core values, beliefs, and behavioral patterns that have been identified for this group. Although persons who are considered Appalachian generally reside in the Appalachian region, some have migrated to other parts of the United States. On the other hand, some Americans from other areas have migrated to Appalachia; however, migration to the region does not in itself result in classification as an Appalachian.
In 1749, Thomas Walker was the first known European American to penetrate the Appalachian maze of hogback ridges and deep valleys. Some 20 years later Daniel Boone blazed the Wilderness Trail through the Cumberland Gap, soon to be followed by more than 100,000 settlers ( ; ). The forefathers of the new settlers came from Northern European countries such as England, Wales, Scotland, Germany, and France, often seeking religious or personal freedom and available land ( ; ). Life in the rural wilderness areas and the continuing isolation of Appalachians, particularly the central and southern mountaineers, has distinguished Appalachians from the mainstream of American society ( ; ).
Historically, like many ethnic groups, Appalachians have borne the brunt of discriminatory characterizations. As with much labeling of minority groups, this stereotyping has emphasized negative behaviors and serves as a barrier to our understanding the health needs, core values, beliefs, and behaviors that the Anglo-Celtic rural mountain-dwelling people may share. This holds true not only for those who live in Appalachia but also for the approximately 4 million Appalachian people who migrated to major urban areas of the North Central United States beginning in the late 1950s and peaking in the 1980s ( ). Early migrants from the Appalachian region to urban areas such as Cincinnati, Columbus, Detroit, and Cleveland often remained at the poverty level and often congregated with other persons from Appalachia ( ; ); more recently, they continue to be absorbed into working- and middle-class neighborhoods because of their increased access to employment and education.
Historically, Appalachia was a rural, agricultural area. Then, beginning in the late 1800s, the economic base and the landscape were changed by the dominant industries of mining, lumber, and textiles. The local communities were often not advantaged by these industries. Generally, the wealth that was generated was not reinvested in the region but exported to the urban areas, largely in the East. This resulted in a low tax base and high rates of poverty ( ; ). Often there was corporate ownership of the resource-rich land; in some counties in West Virginia, coal companies and railroads own up to 90% of the surface land. As a result, much of the usable land was unavailable to the local Appalachians. In addition, health services, schools, and other public services were underfunded because of the lack of a solid tax base (resulting from incentives given to the corporations) ( ).
In general, rural populations across the United States tend to be poorer, older, less educated, and more likely to be uninsured. Rural residents generally have poorer overall health status, less access to care, and difficulty with paying for services (even if they have insurance), and they participate in fewer health promotion activities ( ; ; ; ; ). In contrast, metropolitan areas have more public utilities and better health infrastructure, the population is generally better educated, and more are employed at higher paying jobs ( ).
In 2013, the per capita income of those persons residing in the federally defined Appalachian regions was approximately $4000 less than the per capita income for the rest of the general United States ( ). Yet taken at face value, these figures are somewhat misleading. Appalachia is characterized by extremes of wealth and poverty. Because the per capita income is slightly lower than the national average, the poverty rate is at least twice the national average at 15.4%. In 2013, the unemployment figure for persons identified as rural Appalachian was 8.1% compared with 6.7% for the rest of the general U.S. population ( ; ; ; ). With increasing environmental concerns and international competition, there has been a loss of mining and textile jobs.
In 1970, the proportion of the adult population that completed high school in the Appalachian region was 27% in the rural areas and 52% in the metropolitan areas; by 2000, this proportion had risen to 53% and 79%, respectively ( ). Currently, in all of Appalachia, 11.4% of persons 25 years of age or older have less than an eighth-grade education; 35.4% have some high school education but no diploma; 84.6% hold a high school diploma or general equivalency diploma (GED); and 21.7% hold a 4-year college degree or higher ( ). Although more Appalachian children now graduate from high school, the 17% dropout rate is still higher than that for children of other ethnic groups ( ; ; ). Although education is increasingly seen as important, school attendance may also tax a family’s meager resources. noted that the need for new clothing, transportation, homework, and peer conflicts placed additional burdens on many families.
In the 1960s, 39% of persons in all of Appalachia (and 63% in rural areas) lived in houses without complete indoor plumbing, yet by 1990, this figure had transitioned to only 2%. Even in the rural areas of Central Appalachia, only 5% of homes today are without complete indoor plumbing ( ). Yet according to the Bureau of the Census ( ; ; ), nearly 630,000 occupied households in Appalachia lack complete plumbing facilities, which means that they are without one or more of the following: a toilet, a tub or shower, or running water. Similarly, the proportion of households with telephones has now risen, so that only 10% to 15% of occupied housing units currently lack phones ( ). In Central Appalachia, 14% of occupied homes do not have a vehicle or any available means of public transportation ( ).
Core Cultural Patterns
Four interacting core cultural patterns provide the underlying structure of much that will be discussed throughout this chapter, but first, two caveats: the intention here is not to provide a rigid stereotype of Appalachians but to identify patterns that may serve as guides to understanding. Furthermore, cultural value patterns are identified for aggregates and, as such, are not directly transferable to individuals ( ; ). Rather, these patterns provide a contextual understanding by which health care providers may assess an individual’s unique health care abilities and needs.
In the classic work of , four interacting Appalachian cultural patterns were identified: independence, the ethic of neutrality, familism, and personalism. Independence developed out of a history of escaping religious persecution and as a survival mechanism. There is a pride in self-sufficiency ( ). At a time when most people hire others to fix their cars or build their homes, Appalachians take pride in doing things for themselves. This helps explain the difficulty encountered by many Appalachians when it is necessary to ask for financial help or welfare. However, this pattern is context specific and may not apply in unfamiliar clinical settings, particularly in a crisis. For example, while Appalachian nurses wanted to promote more decisional control for hospitalized patients, Appalachian patients reported a desire for much less control ( ). found that interdependence, not independence, characterized rural Southern Appalachian family members who had a member in the intensive care unit. Other rural Appalachian family member needs that were different from urban families included a preference for informal support systems (family, friends, and religion) over formal systems, close personal relationships and a desire for frequent communication with professionals, flexible visiting hours, permission for emotions, and provision for time alone.
In his early ethnographic work, reported that Appalachians demonstrate what he termed an ethic of neutrality. This is evidenced in four behavioral imperatives: (1) avoiding aggression or assertiveness, (2) not interfering in another person’s business unless requested to do so, (3) avoiding domination over other people, and (4) avoiding arguments and seeking agreement. Consequently, there may be low tolerance for paternalistic or prescriptive behavior patterns. Rather than messages attacking an organization or individual, politeness is valued ( ). For example, according to , an occupational therapist and native of Appalachia, “It is more important to get along with others than to make conflicting true feelings known” (p. 62).
Familism emphasizes the importance of relationships with consanguineous nuclear and extended family members rather than self-actualization through individual accomplishments ( ). The high reliance on family may influence choice of employment, religious affiliation, marriage partners, and health care practices. A sense of family is central to the Appalachian sense of self, which in turn is intricately linked with the land, homestead, and trusted neighbors ( ; ). Appalachians who have migrated elsewhere often strongly continue to value their connection to the “hills” and homeland and go to great lengths to maintain those connections ( ).
While trust is extended cautiously, it may be built through a personal orientation in contrast to a bureaucratic or service-oriented relationship ( ). In health interactions, a person-focused rather than disease-focused approach is preferred. This preference for a personal orientation may explain why nursing care has been noted to be preferred to medical-based cure modalities ( ).
Appalachians are English-speaking people; however, they have several idiomatic differences in the meanings of specific words. Throughout the Appalachian region, there are various dialects with high concentrations of words of Scottish or Elizabethan English heritage ( ). Thus phrases used by some Appalachians may be interpreted entirely differently by non-Appalachians. For example, an Appalachian person may say “running off,” which may be interpreted by a non-Appalachian as leaving home or running away but may actually mean diarrhea. These examples of stylistic differences represent generally rare opportunities for miscommunication. On the other hand, the Appalachians’ use of folk categories of illness may be the basis for greater misunderstanding. As will be described in greater detail in the folk belief section, “Appalachian Folk Health System,” several illnesses sound like, but are conceptually distinct from, the biomedical terms. For example, high blood pressure and hypertension are two folk illness categories in the Appalachian region that are distinct from the biomedical category of hypertension.
Variations in metacommunication patterns are generally more important than the idiomatic differences just described. Metacommunication patterns include mode, style, strategy, explanation, problem exposure, and orientation. typified cultures on the basis of high- or low-context communication. For high-context cultures (HCCs), most of the meaning of a communication comes from the context; it is unspoken. For low-context cultures (LCCs), most of the meaning comes from the actual words used. provide a framework for comparing how high- and low-context cultures differ in their approach to negotiation ( Table 11-1 ). Because the dominant communication mode for Appalachians is high context and that for health providers is low context, opportunities for misunderstandings are maximized.
|Low-Context Cultures||High-Context Cultures|
|Explanation||Linear, analysis||Nonlinear, synthesis|
|Orientation||Action and solution focused||Relationship oriented and process focused|
Nonverbal communication patterns may also vary. Although common among many groups, direct eye contact is often viewed by Appalachians as impolite or lacking good manners ( ; ) or even as aggressive or hostile behavior ( ; ). Many Appalachians use a verbal pattern that is much more concrete than the patterns displayed by middle-class Americans, who tend to be more abstract. For example, in health education materials, politeness, succinct facts presented without “sugar coating it” or “getting preachy,” and “Talk … just like one-on-one” was preferred ( , p. 299).
Implications for Nursing Care
As the textile, mining, and lumber industries began to grow in the Appalachian regions, many Appalachian persons were stripped of their land and other natural resources. Company towns controlled the stores, educational systems, and financial capital, exploiting the people and the land. This historical context fostered mistrust of outsiders. Positive interactions between an Appalachian person and an outsider often require that a trusting relationship first be established. Strategies to improve communication include making the time to listen and talk about matters that are important to the individual and the family. It may be helpful to use a direct approach, giving the facts, discussing within the context of prior family experiences, and soliciting the opinion and advice of family members before making recommendations.
Again, the nurse should be aware that some Appalachians, because of the ethic of neutrality, might wish to avoid confrontation and tell nurses what they believe the nurse wants to hear. The nurse can diminish this possibility by adopting a high-context communication style: speaking indirectly, emphasizing collaboration, avoiding confrontation, and developing the relationship ( ; ). Finally, because many Appalachian folk illnesses sound like biomedical disease categories, nurses need to take special care to understand what clients truly mean in their use of illness categories.
Personal space is very important to Appalachians, which is evident in their maintaining a personal distance when interacting ( ). As addressed earlier, familism and the sense of self are intimately linked to the land and homestead ( ; ; ). Appalachians love the land, and some prefer to live apart from the rest of society, nestled in the privacy of the hollows and hills. Appalachians are considered present-oriented ( ) and focused on “being” rather than “doing” ( ; ; ; ). They have been described as believing that because tomorrow is not promised, they must live for today. While this has been interpreted as fatalism, it may also be interpreted as a realistic understanding of life circumstances. Poverty, harsh living conditions, rudimentary municipal supports, and isolation may make “unhurried” adaptive patterns of behavior necessary to conserve energy and accomplish the everyday work necessary to meet basic needs for survival.
Implications for Nursing Care
In contrast to the typical behavioral characteristics of Appalachians, which is to be family oriented and concerned with the well-being of others, when an Appalachian is ill, personal space collapses inwardly ( ), meaning that the Appalachian person expects to be waited on and cared for by others. Thus the focus of both the individual and the members of the family is on the ill person. In a hospital setting, this may create obstacles to planning and executing nursing care because it is not unusual for a large number of family members to arrive with the client and to expect to maintain proximity with the client throughout the duration of the hospitalization. This desire for proximity is also evidenced when a client is scheduled for a clinic appointment, even if the condition is perceived by the health care professionals as minor.
The major unit of Appalachian social organization and group identity is generally the family rather than the community or Appalachian region ( ; ). The nuclear and extended families are both very important. Some Appalachians are so intensely loyal that they feel a personal responsibility for in-laws, nieces, and nephews, as well as other distant family members. Appalachians tend to place a greater importance on the extended family than do most middle-class Americans; the extended family is considered important regardless of the social, educational, or economic level of the individual. Thus relatives are sought for advice, validation, and support on many matters, particularly those pertaining to health and illness ( ; ). Kinship groups are the major social organizing force in the region ( ) on which to build community-level involvement. The dedication to family is of such paramount importance to most Appalachians that note most Appalachians rarely move more than 30 miles from their families.
The extensive ties to the nuclear and extended family are evident when a family member becomes ill or dies, in that members of the entire family may take leave from their jobs to be with the ill or dying relative for the duration of the crisis. This tendency to miss work for a family illness may have negative job consequences. If a family member is chronically ill, continued employment may be sacrificed for the “good” of the family ( ). This intense loyalty for being with ill family members may remain long after an Appalachian person migrates from the region ( ). This loyalty is also carried over into housing in northern areas; a landlord may find a property deserted, with all personal belongings intact, because the tenant had returned to the Appalachian region to be with a sick relative.
The Appalachian family is basically patriarchal ( ; ), but mothers and grandmothers make most health decisions ( ). conducted three ethnographic studies over a 5-year period in two southeastern Ohio counties. She found that most families focused on present rather than future health. The concept of “family health routines” involves multiple interacting individuals that constitute a family perspective. She notes that for the Appalachian families studied, mothers assume primary roles in establishing the behaviors viewed as important for children’s health needs. Mothers are the main health care teachers and decision makers and are pragmatic in caring for family health. For example, mothers are more likely to encourage family members to incorporate health information into family routines when it is viewed as meaningful, aligned with family values, and applicable to members’ needs and when adequate resources or supports are available ( ). Determination of need for medical care was made after a “wait and see” time period, upon the counsel of close friends and family, and based on the mother’s judgment ( ).
Children are viewed as security for the future ( ). While marriage before childbirth is preferred, in the case of an early pregnancy, the family tends to become more cohesive, providing love and security to the expectant mother. The grandparents often care for grandchildren, particularly if both parents work. The children appear to have a sense of who they are and a greater sense of belonging. The desired family size has decreased dramatically; the norm is now two to three children ( ; ).
Elderly family members are generally respected and often reside with their children or nearby. The attitude among Appalachians toward elders is reported to be one of honor, attributable to the elders’ role in cultural transmission to later generations. found that spatial separation of elders from their adult children when they relocated generated critical dilemmas for the Appalachian elders. It was difficult to reconcile their fear of leaving the familiar environment (with its physical, social, and emotional support) with their desire to be close to the family. The study was based on a 4-year observation of elderly persons in a rural northern Appalachian community and was intended primarily to explore the tensions between factors that reinforced locational stability and factors that encouraged relocating to the homes of children residing outside the Appalachian region.
Initially on arrival in the United States, many Appalachian persons were Presbyterians, Episcopalians, or members of some other formally organized denomination. However, these churches required educated clergy and a centralized organization, both of which proved to be impractical in the wilderness ( ). As a result, in rural areas locally autonomous nondenominational churches emerged throughout the Appalachian region. For the most part, these individualistic churches stress the centrality of grace, authority of the Bible, religious experience, a call to preach, and local church governance ( ). Whereas some social reformers have viewed the local churches as a hindrance to social progress, others recognize their adaptive features, making life worth living in grim situations ( ). Mainstream denominations, particularly Southern Baptist and United Methodist, are more prevalent in the urban areas of Appalachia and generally attended by more economically advantaged congregations.
explored health-related and religious activities in the local autonomous churches to include prayer requests, anointing, and testimony. They proposed that religious health partnerships could provide a channel for health promotion effects in rural Appalachia. On the other hand, churches differ in their willingness to engage in progress that is “of the world” and not inspired by God.
Implications for Nursing Care
Rather than an individualist experience, health and illness are a family affair, negotiated and understood within a family context and often under the purview of women, especially mothers. In health care, family members’ involvement may include consultation regarding etiology, severity, and treatment options. Integration of concrete examples of risk behavior, health problems, and treatments within the experiences of the nuclear and extended family system may be an effective health care strategy for providers ( ).
In contrast to the well Appalachians’ emphasis on independence, ill Appalachian interdependence is emphasized. The family surrounds the person and often provides needed care ( ; ). In a hospital or clinic setting, it is not unusual for a large number of family members to arrive with the client and expect to maintain proximity with the client throughout the duration of the hospitalization. Consequently, mechanisms for family involvement need to be incorporated into the plan of care and hospital policies.
Familism, the ethic of neutrality, and poverty may influence health behaviors. Because Appalachians tend to be family oriented, it may be important to elicit family opinions in regard to health care. If the family’s ideas and opinions are not incorporated into the plan of care, the family and client may not accept the health care recommendations or services. It may be helpful to blend the informal and formal systems ( ) or recruit family members or other trusted care providers as care brokers.
It may be helpful to develop mechanisms for supporting and encouraging family involvement in care ( ; ). Minimally, the nurse must recognize that changes in health behaviors affect the entire family system, and consequently the nurse should incorporate family members in health education. For example, if a person is admitted to the hospital for diabetes, not only should the client be given instructions on diabetes care, but the family members should also be given the same level of instruction. Instruction must take into account the resources the family has in the home, including the informal care network and assets such as running water, finances to purchase supplies, and refrigeration.
In addition, since the family context, health beliefs, practices, and religion are often intertwined, it is important that an assessment of these be done on admission to the health care system. For example, a study done with Appalachian women found that premature birth is associated with a woman’s negative feelings about pregnancy, low self-esteem, and depression ( ). On the other hand, Appalachian pregnant women who had a greater sense of spirituality and lower levels of personal stress were found to participate in fewer risky health behaviors (e.g., smoking) ( ). As such, integrating stress reduction and spirituality in prenatal health care promotion visits may be helpful. This may be particularly important for Medicaid-supported pregnant women who were found to have an increased incidence of smoking, depressive symptoms, and physical abuse compared with private-pay pregnant women ( ). Confusion regarding professional stereotyping of fatalism for clients’ lack of personal resources of time, money, or access to health care beliefs must be recognized and avoided. Finally, church–health partnerships may be useful in the delivery of health promotion information.
found a strong difference in interpretations of time perceptions between Appalachians and non-Appalachian health care providers. Non-Appalachian health care professionals interpreted missed appointments negatively and were judgmental in their characterization of Appalachians as not having skills for long-term planning. On the other hand, the Appalachian professionals understood that Appalachians focus on the present to meet overwhelming needs and the uncertainty of what tomorrow will bring. Furthermore, Appalachian professionals understood that Appalachian persons may miss appointments or be late because they are working to meet everyday needs, may lack transportation, or are concerned about being fired if they take off from work.
The way in which rural Appalachians structure time differs from the urban population. explains that the Appalachians view modern humans as having lost the technique of enjoying time for oneself, the art of “sitting for a spell” to visit with another person or to cherish a moment in solitude. An isolated, self-sufficient lifestyle still requires hard work and offers few modern conveniences. However, those people in Appalachia who continue this lifestyle achieve a self-directed balance in their lives and establish their own individualized patterns of work, leisure, self-care, and rest.
Implications for Nursing Care
Because of Appalachians’ perspectives on time, they may live at a pace that facilitates an awareness of body rhythms as opposed to clock time. Because some Appalachians are present-time oriented, it is best and often necessary for the nurse to assess kinesthetic needs and gently access personal and emotional space by visiting with the client before an examination or treatment is performed. Another consideration is that it is common for some Appalachian clients to arrive for an appointment at a time that is different from when the appointment is scheduled. If they are turned away, they may not access those services again. There are a number of alternative methods for delivery of health services that are being explored and tested. Modes of health care delivery to facilitate community-level and client access to health care include family involvement in care planning, teleconferencing and telehealth, assistance with transportation, flexible scheduling and extended clinic hours, open walk-in clinics, outreach clinics close to clients’ homes, home visits, parish nursing, and clinics done in association with churches and other sites of congregation ( ; ; ; ; ; ; ).
Environmental Health Threats
Factors contributing to the Appalachians’ having health status lower than the U.S. average include low-paying jobs, lack of employment, lack of health insurance, environmental toxins, noise, and numerous occupational health hazards. Workers in the textile mills were often exposed to high levels of cotton, flax, or hemp dust, leading to the highest rates of “brown lung disease” in the country. Brown lung disease, or byssinosis, is irreversible and characterized by shortness of breath, coughing, and wheezing ( ). Analogously, between 1950 and 1970, the mines were locations where “black choking death was accepted as normal and inevitable” ( , p. 145). The high-impact machines created inches of dust on the tunnel floors that covered the miners’ bodies. Lung disease incapacitated the miners. Black lung disease (pneumoconiosis) is a progressive incurable condition that is characterized by extreme shortness of breath. In addition, approximately 90% of coal miners over the age of 54 report hearing problems ( ). Although coal miners identified that hearing loss is a serious concern and voiced the importance of protective devices, they also reported a greater need for unencumbered hearing while in the mine. It was perceived to be important to remain aware of “roof talk,” or noises that warn of the mine ceiling caving in ( , p. 748). In addition to decreasing noise from the machinery, miners recommended that information be given to miners about decibel noise exposure throughout the mine, ongoing hearing screening services, and public campaigns to increase awareness about the problems and need for prevention to decrease hearing loss.
Death, Dying, and Death Rituals
While there is increasing and considerable diversity, Appalachian death rituals have been well characterized by and . When death is imminent, a vigil sometimes called a “death watch” is held by family and friends either in the home or, more commonly today, in the hospital. Participants in the vigil often observe for signs of impending death, such as premonitions, visions, and the death rattle. Usually the evening before the funeral, a wake or visitation period is often held at a funeral home or church; this is a time for paying respects to the dead and his or her family and to view the deceased. Funeral services are generally held in funeral homes or churches; these often include prayer, music, scriptural reading, and a sermon or eulogy. Following the funeral service, close mourners may proceed to the site of interment—sometimes on foot, but more often by car. Today, graves are typically dug by service workers rather than friends. Before the casket is lowered, ministers may preside over a committal service. Graves are often marked with headstones with chiseled writing (name, birth and death dates, and sometimes an epitaph) and sometimes a picture ( ; ).
Barriers to Care
Lack of available services; ethnocentric providers; difficult terrain; geographic isolation; cost; and lack of transportation, insurance, and telephones are common barriers to utilization of health care services by Appalachians ( ; ; ; ).
In rural areas of Appalachia, 67% of the counties are federally designated shortage areas; the proportion of primary care physicians per population is less than half that in the rest of the United States ( ; ). Rural clinic offices are often staffed by single providers with no laboratory support ( ). In one study, most family members indicated they were unable to access primary care physicians because few providers accepted medical cards (Medicaid/Medicare) as payment; further, 80% had no or unreliable transportation ( ). In addition, the ethnocentrism of many providers and the higher proportion of foreign-trained physicians in underserved areas may deter Appalachians from returning for services ( ).
Locus of Control
Appalachians’ locus of control has been characterized as fatalistic, with strong roots in fundamentalist religion. Many Appalachians believe that God has control over their lives and that however things turn out, it is the “Lord’s will.” While most middle-class Americans believe that science can most often control events and health, many Appalachians do not believe that they have control over their future or their health. However, this idea of fatalism is more complex than usually described and may not be related to lack of health efforts. Several studies report that while Appalachians may believe they cannot prevent an illness, they have strong self-determination about coping with and managing an illness ( ; ; ; ). This has been termed by as “adaptive acceptance” (p. 456). This interpretation fits well with other research indicating a strong sense of self-reliance and inner strength among Appalachians ( ).
While Appalachians may not believe they are capable of maintaining their health without God’s help, many believe they may be to blame for many chronic illnesses (such as diabetes). documented that diabetes is often perceived by Appalachians as a self-induced illness, indicating a moral weakness and brought on by “laziness and lack of self discipline” (p. 295). Sometimes, if they believe that nothing can be done about a serious health condition, Appalachians may prefer not to be told the diagnosis ( ). Finally, when hospitalized, Appalachian patients may desire less decisional control than what nurses view as ideal (notably, in this study, physicians and patients preferred about the same level of patient decisional control) ( ).
In addition, we see variations in reports related to the coping styles of the Appalachians when confronted with critical illnesses of family members. In a study of the critical care coping styles of 30 family members of critically ill patients in two rural Appalachian hospitals, dominant coping styles were supportive, optimistic, confrontational, and self-reliant, with fatalism and evasive styles being ranked much lower ( ). Supportive strategies emphasizing the importance of close personal contacts were key. Action-focused coping centered on seeking information about the problem, handling things one step at a time, and keeping busy.
In contrast to middle-class America’s “doing” activity orientation, Appalachians are considered “being” oriented, which means they focus more on interpersonal relationships than on personal accomplishments. In contrast with middle-class individualistic emphasis, Appalachian culture emphasizes the lineal-collateral orientation, indicating that an individual’s most significant relationships are with family-related groups, kinship groups, or close neighbors. Many middle-class Americans seek self-actualization through individual accomplishments and autonomously set goals, whereas Appalachians tend to seek fulfillment through kin and neighbor interactions.
The “being” and lineal-collateral orientations, coupled with the present-time orientation, may influence health care practices, promoting a reactive rather than proactive stance. A nurse’s initial encounter with an Appalachian client may be an emergency situation, such as a birth.
Appalachian Folk Health System
The Appalachian folk health system encompasses traditional beliefs about how to maintain health; the definition, nature, cause, and treatment of illnesses; traditional remedies; and lay health specialists. Again, many of these elements are in transition.
Illnesses are thought to result from the “will of God,” a natural imbalance, or the body’s response to personal habits, specific situations, or external exposures, particularly cold weather or “the cold” in general. Lack of “personal care” is an additional cause of illness. It includes (1) keeping the body strong, (2) eating right, and (3) taking fluids ( ). There are several Appalachian folk illnesses; three are discussed in more detail next.
One of the major health concerns of the Appalachian region is the state of the blood. The characteristics of the blood at issue may include whether it is thick or thin, good or bad, and high or low. Among Appalachians, the characteristic of high or low blood is a measure of blood viscosity and/or increased blood volume rushing to the head. High blood can be caused by diet, particularly pork and rich meats, fatty foods, and salt. These foods increase the viscosity of the blood by thickening it (pork and rich foods) or drying it up (salt). Many believe that emotions (anger, nervousness, stress) contribute to the etiology. Leading symptoms include dizziness, followed by headaches, visual disturbances, red or hot face, nausea, and nervousness.
Treatment focuses on restoring the proper balance so the blood is the right consistency. Keeping calm is thought to prevent a future attack. Some report an astringent (pickle brine, vinegar, Epson salts, garlic) may be an effective treatment; others do not find that ( ; ). High blood is distinguished from hypertension, which is a high “tension” or stress state ( ).
A lay idiom of distress, nerves is most often characterized by stressful social situations or events. Symptoms may include disturbed sleep patterns (falling and staying asleep), nervousness, tiredness, abdominal pain, shortness of breath, and anxiety attacks ( ).
Sugar or sweet blood.
The disorder of sugar or sweet blood results from the accumulation of sugar particles in the blood through one’s life from eating sweet foods. Symptoms include dizziness, visual disturbances, and aching feet. The hazy vision is believed to be caused by the accumulation of sugar particles in the blood, which eventually settle in the eyes. Lay diagnostic signs include bruises that do not heal and having ants attracted to one’s urine. Bitter herbs and foods (vinegar, gentian, Cerasee, or aloe teas) may be used to temporarily restore balance ( ).
Knowledge of Biomedical Diseases
The level of biomedical health information and knowledge, particularly in rural Central Appalachia, is often very low ( ). There may be little knowledge of the biomedical explanations for how persons become ill, the complication of pregnancy, or how to prevent cardiovascular illness or diabetes. This unfamiliarity with the biomedical system may explain what has been termed “lack of interest” in the specifics of a biomedical diagnosis or interpreted as “denial” ( ; ; ).
Herbal remedies used in Appalachia are an integration of remedies derived from three primary sources: (1) American Indians, (2) nineteenth-century standard medical practice, and (3) ancestral practices rooted in northern Europe. The text Medicinal Plants and Home Remedies of Appalachia is an extensive resource. In this book, details the medicinal use of 90 plants in Central Appalachia and compares uses of each plant there with uses by American Indians, nineteenth-century medical practitioners, and Appalachians in the southern region. For example, Lycoperdaceae (puffball, devil’s puff) spores are used as a hemostat to stop bleeding in all groups. Phytolaccaceae (pokeweed) is used to treat rheumatism by all groups and as a spring tonic in Central and Southern Appalachia. Other common remedies include white pine as an antiseptic, black pine as a cough medicine, ginseng for infant colic and general health, windroot for pleurisy, may apple root for rheumatism, elderberry as a disinfectant, and boneset (fever wort) tea for rheumatism or the flu, all of which have been shown to have some medicinal value ( ). However, the strength of the drugs that are used in home remedies is more variable than that of the drugs used in pharmaceutical preparations ( ). Herbs and over-the-counter medications may also be used in combination or sequentially.
In this domain, as in most other ethnic communities across the country, there is a shift from home remedies and use of wild medicinal herbs to over-the-counter remedies. This pattern was reported in the research of , , and . Importantly, in the study of ethnomedical beliefs and clinic visits for folk illnesses, over-the-counter therapies were the most commonly used treatments (40%) prior to coming to the clinic. Further, the patients with ethnomedical conditions did not use home remedies or self-treat more than the others who presented only with biomedicine conditions ( ).
Chronic illness management often integrates financial exigencies; norms of self-reliance; and a preference for “natural” foods, herbs, and vitamins over processed substances such as prescription medications ( ). Noted are chromium, garlic, and vitamins to control blood glucose levels.
The Appalachian folk medicine system had a tradition of folk healers commonly referred to as “granny women” and “herb doctors.” These folk healers were commonly used because they were accessible, familiar with the culture, and well known to the family; lived in close proximity; used personalized interactions; and provided accepted remedies. However, lay practitioners are used much less frequently today. In a group of clinic patients in which nearly half reported ethnomedical complaints, only 4% reported consulting a faith healer or other alternative practitioner prior to their clinic visit ( ).
Illness and Wellness Behaviors
Several lifestyle factors place Appalachians at risk for health problems. These include a diet that is high in fats and carbohydrates, higher use of tobacco, lack of a regular exercise program, low use of seat belts, coal mining–associated hearing loss, and the poorest oral health in the United States, with the highest rate of toothlessness among elders ( ; ). For example, smoking is initiated earlier and more widely than in the general U.S. population. Although aware of the antismoking lung cancer health campaigns, some Appalachians ignore this information because of personal experiences. They know neighbors who have “smoked all their lives” and do not have lung cancer, and others who never smoked but died of lung cancer or other lung ailments. The proportion of Appalachian smokers in the “precontemplation” stage of the transtheoretical model (TTM) of behavior change is higher than in the United States as a whole ( ). investigated patterns of smoking among Appalachian adolescents in Ohio, Tennessee, and Virginia. They found that (1) the social community in tobacco-growing communities is a significant influence in tobacco use; (2) the family is important among young people in tobacco-growing communities and influences cessation positively and negatively; (3) parental smoking was an influence to smoking; (4) whereas some parents condone and even facilitate tobacco use by their children, others actively discourage use; and (5) concern for the health of younger brothers and sisters elicits a strongly protective reaction from youth in discussions of health risks related to secondhand smoke. Further, smoking is often used to relieve stress and is viewed as positive for weight control and alleviating boredom ( ). Thus, the benefits of smoking may be perceived to outweigh future health risks ( ).
Appalachian providers and consumers participate less often in preventive health screening programs. In a focus group study of rural Appalachian primary care providers, the perceived barriers to performing cancer screening were as follows: (1) provider-perceived patient barriers, including patients’ fatalistic view of cancer; religious beliefs; low educational attainment; lack of cancer knowledge; a present, day-to-day orientation; and patients’ not considering screening and health prevention a priority, and (2) provider-driven barriers, including a lack of time, lack of screening as part of the regular routine, a lack of provider continuity, and conflicting guidelines. Conversely, consumers’ reasons for low participation in accessing preventive and routine health care include a lack of primary and/or specialty care providers, geographic or financial accessibility, long waiting periods for appointments, and level of health knowledge ( ; ; ). In addition, a recent study reported considerable knowledge deficits for breast cancer screening and personal risk factors among even well-educated Appalachian women ( ).
Another perspective on cancer screening comes from studies reporting high rates of participation by low-income Appalachian women in preventive screening programs (cervical, breast, and rectal screens) when resources (clinics) were geographically and financially available ( ). Further, the lack of mammography screening (less than half of the other screens) was largely attributed to lack of availability of those services at the same facilities. Innovative practice settings have demonstrated that Appalachians will use preventive services if they are available, accessible, and affordable ( ). Recent structures, such as community coalitions ( ) and the Appalachian Cancer Network ( ), show particular promise.
When ill, Appalachians expect and receive aid from family members ( ). In a study of 257 randomly selected rural and urban Appalachian patients in eight hospitals in West Virginia, a significantly larger proportion of rural Appalachians reported that family help would be available at home for recovery. In follow-up interviews, there was generally at least one adult child who was available to assist a parent ( ).
conducted a study to determine if ethnomedical beliefs and practices play an important role in primary care. In their study, 33 of 73 clients from a rural Appalachian area who presented themselves at a university primary care internal medicine program had 54 ethnomedical complaints. Of the ethnomedical complaints presented, 24.1% were of high blood pressure, 22.2% were of feeling weak and dizzy, 16.7% were of “nerves,” 5.6% were of “sugar,” and 3.7% were of “falling out.” These 33 clients also reported biomedical complaints; the remaining 40 clients had biomedical complaints only, without evidence of ethnomedical complaints. No clients presented ethnomedical complaints alone. In the study, approximately two thirds of the clients consulted laypersons, primarily family members and friends, for their complaints, and at least 70% engaged in self-treatment before any clinical consultation. About 4% consulted a lay specialist. Approximately 130 biomedical complaints were presented and recorded by the clients’ physicians; however, none of the 54 ethnomedical complaints was formally recorded. The high incidence of ethnomedical complaints among Appalachians and the failure of physicians to recognize these complaints indicate the need for providers to improve their history-taking skills, particularly regarding ethnomedical illnesses.
used Giger and Davidhizar’s Transcultural Assessment Model to identify six cultural phenomena of interest among Appalachians in southern Ohio. Results indicated that these participants had some characteristics commonly identified as Appalachian, such as having strong character, being stoic, being nonassertive, and having a strong belief in a Supreme Being. However, they also were found to communicate more openly, have a greater internal locus of control, be more future oriented, use no significant home remedies, be more time-conscientious about appointments, and be more likely to follow medical protocols than the stereotypic view of Appalachians. These findings may reflect the rapid transition occurring in the Appalachian region and provide a caution to practitioners not to forget about the dynamic nature of culture.
Implications for Nursing Care
The traditional Appalachian folk health system is in transition. While some traditional practices remain, others are diminishing. The health beliefs and any herbal therapies should be explored in depth in relation to the current clinical situation. Appalachians have a high need for health information and actively seek information resources. Aiding the client to find an appropriate level of health information is a central function of the nursing role. Folk therapies that are neutral or beneficial should be encouraged. In the case where folk therapies or over-the-counter combinations may prove harmful, the nurse should provide health information in a clear, nonjudgmental manner.