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Transcultural Health Care: A Culturally Competent Approach, 4th EditionTranscultural Health Care: A Culturally Competent Approach, 4th EditionTranscultural Health Care: A Culturally Competent Approach, 4th EditionTranscultural Health Care: A Culturally Competent Approach, 4th Edition

Copyright © 2013 F.A. Davis Company

Appalachians

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th EditionTranscultural Health Care: A Culturally Competent Approach, 4th Edition

Overview

Heritage from England, Wales, Scotland, Ireland, France, and Germany

Came to the United States for religious freedom and better economic opportunities

Purposely isolated themselves in the mountains to live and practice their religions as they chose


Overview Continued

Appalachia includes 410 counties in 13 states and extends from southern New York to northern Mississippi.

Continuous migration from the country to the city and vice versa

High proportion of aging in Appalachia Farming, mining, textiles, service industries, etc.


Overview Continued

High poverty and unemployment rates Originally most educated group in America, now

some of the least educated due to isolation Area still lacks infrastructure


Communications

Carry over from Elizabethan English Spellin for spelling Warsh for wash Badder for bad


Ethic of Neutrality

Avoid aggression and assertiveness Do not interfere with others’ lives Avoid dominance over others Avoid arguments and seek agreement Accept without judging—use few adjectives and

adverbs, resulting in less precise description of emotions and thoughts


Communications

Sensitive about direct questions and personal issues

Sensitive to hints of criticism. A suggestion may be seen as criticism.

Cordiality precedes information sharing so “sit a spell” and chat before doing business, which is necessary for developing trust


Communication Continued

A few may avoid direct eye contact because it can be perceived as aggression, hostility, or impoliteness

More being than doing oriented, more relaxed culture and being in tune with body rhythms

Be formal with name format until told to do otherwise.


Communication Continued

Healthcare provider must be flexible and adaptable

Come early or late for an appointment and still expect to be seen

Family lineage is important Formality with respect—Miz Florence or Mr. John


Family

Varied decision-making patterns but the more traditional Appalachian family is still primarily patriarchal

Women make decisions about health care and usually carry out the herbal treatments and folk remedies

Women marry at a young age and have larger families than the other white ethnic groups


Family Continued

Children are accepted regardless of what they do Hands-on physical punishment is common Motherhood increases the status of the woman in

the eyes of the community Take great pride in being independent and doing

things for oneself


Family Continued

Family rather than the individual is the treatment unit

Having a job is more important than having a prestigious position

Consistent with the ethic of neutrality, alternative lifestyles are accepted, they are just not talked about

Extended family is the norm


Biocultural Ecology

High incidence of respiratory conditions due to occupations

Increase of parasitic infections due to lack of modern utilities in some areas

High incidence of cancer, otitis media, anemia, obesity, cardiovascular disease, suicide, accidents, SIDS, and mental illness


High-Risk Behaviors

Tobacco is a main farming crop in some areas of Appalachia

Smoke at a young age Alcohol use at a young age—binge drinking Believe in the mind, body, spirit connection


Ten Steps in Seeking Health Care

Use self-care practices learned from mother or grandmother

Call mother or grandmother if available Then trusted female family member, neighbor, or

a nurse Then go to OTCs they saw on TV Then use a neighbor’s prescription medicine


Ten Steps in Seeking Health Care Continued Pharmacist or nurse for advice Physician or Advanced Practice Nurse Then to a specialist Then to the closest tertiary medical center DO NOT BE JUDGMENTAL, if you want to keep

them in the system


Nutrition

Food may be synonymous with wealth Wide variety of meats, do not trim the fat—low-fat

wild game is also eaten Organ meats are common Bones and bone marrow used for making sauces Preserve with salt


Nutrition Continued

Lots of frying (using lard or bacon grease) and pickling

Anytime is the time to celebrate with food, especially in the rural areas

Many teens have particularly poor health Status symbol to have instant coffee and snack

foods for some


Nutrition Continued

Early introduction of solid foods May feed babies teaspoons of grease to make

them healthy and strong Diet is frequently deficient in Vitamin A, iron, and

calcium


Childbearing Family

Must eat well to have a healthy baby Do not reach over your head when pregnant to

prevent the cord from wrapping around the neck of the fetus

Being frightened by a snake or eating strawberries or citrus can cause the baby to be marked

Use bands around the belly and asafetida bags


Death Rituals

Must stay with the dying person Family should not be left alone Funerals with personal objects at the viewing and

buried in their best clothes May take the deceased for viewing at home After the funeral there is more food and singing

and for some a “wake” to celebrate life


Death Rituals Continued

Flowers are more important than donations to charity

Particularly good at working through the grieving process

Funeral directors are commonly used for bereavement

Cremation is acceptable and ashes may be saved or dispersed on the “land”


Spirituality

Baptist, Pentecostal, Episcopalian, Jehovah’s Witness, Methodist, Presbyterian

Each church adapts to the community Most are highly religious even though they do not attend

church Common to attend Sunday and other days Preacher has a calling to “preach” Ministers are trained


Spirituality Continued

Meaning in life comes from the family and “living right with God,” which varies by the specific religious sect

Nature is in control—fatalism Religion and faith is important in a hostile

environment I will be there if the “creek does not rise” or if

“God is willing”—fatalism


Healthcare Practices

Good health is due to God’s Will Self-reliance fosters self-care practices Family important for health care May be very ill before a decision is made to see a

professional resulting in a more compromised health condition

Direct approaches are frowned upon


Healthcare Practices Continued

Herbal medicines, poultices, and teas are common

See Table 8–1 in the textbook; these practices are still alive and well

Folk medicines used in conjunction with biomedical treatments


Barriers

Fatalism Self-reliance Lack of infrastructure Health profession shortages Culture of “being” Poverty and unemployment Care not acceptable from outsiders


Responses to Health and Illness

Take care of our own and accept the person as whole individual

Not mentally ill, the person has “bad nerves” or are “odd turned”

Having a disability with aging is natural and inevitable—if you live long enough

Must establish rapport and trust


Responses to Health and Illness Continued Pain is something that is to be endured Some may be stoical Pain legitimizes not working or fulfilling one’s

responsibilities Withdraw into self when ill Culture of being works against rehabilitation


Healthcare Practitioners

Lay and trained nurses and midwives still provide much of the care in some parts of Appalachia

Breckenridge Frontier Nursing Service Prefer people known to the family and community

—the insider versus outsider concept


Healthcare Practitioners Continued

Culture of “being” says the healthcare provider should not give the perception of being rushed

Physicians may not be trusted due to outsided-ness, not to being foreign

Must ask the clients what they think is wrong

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Documents

transcultural health

competent approach

competent aapppprrooaacchh

family lineage

high poverty

female family member

talkedabout extended

areas high incidence