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Appalachians Larry Purnell, PhD, RN, FAAN
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company
Transcultural 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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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.
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Communications
Carry over from Elizabethan English
Spellin for spelling
Warsh for wash
Badder for bad
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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.
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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”
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Barriers
Fatalism
Self-reliance
Lack of infrastructure
Health profession shortages
Culture of “being”
Poverty and unemployment
Care not acceptable from outsiders
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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