579712
research-article2015
TCNXXX10.1177/1043659615579712Journal of Transcultural NursingDenham
Education Department
Does a Culture of Appalachia Truly Exist?
Journal of Transcultural Nursing 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615579712 tcn.sagepub.com
Sharon A. Denham, PhD, RN1
Abstract Some disagreement exists about whether an Appalachian culture exists. Common notions about Appalachia’s people are tied to myths that disguise truths about those that claim a heritage tied to place. Living in the region is different from having multiple generations of ancestors and a family legacy associated with place. Conclusions suggest that cultural traits of some residents are recognizable as unique from others in the nation’s mainstream, but they are not generalizable to all people living in the Appalachian region. Keywords health disparities, transcultural health, family health
Introduction The author of this article has decades of experience living and working in Appalachian communities. Clinical nursing practice in families’ homes and community settings, teaching nursing students from the Appalachia region, studying Appalachian literature, and researching family health and illness concerns provided opportunities to hear and learn from people throughout the northern, central, and southern regions of Appalachia (Manoogian, Harter, & Denham, 2010; Vance, Basta, Bute, & Denham, 2012). Nurses in diverse care settings often come into contact with people from the Appalachian region. While many people seek medical care in their local rural communities, they often seek specialty care in urban settings. The primary purpose of this article is to increase nurses’ awareness and knowledge about those with ancestry and generational ties to the Appalachian region. A second purpose relates to using this knowledge to consider ways clinical practice relationships are built and care delivered.
Appalachia and Its People In 1965, a national policy formed the Appalachian Regional Commission and identified Appalachia as a geographic region (United States Code Title 40 Subtitle IV, 1965). From a political perspective, those living in the 420 counties that currently comprise this territory are viewed as residents of the Appalachian region. This article aims to show the diversity of those inhabiting the area and show that the popular culture often associated with negative stereotypes of its people need to be reexamined. The temptation to over generalize, misunderstand, and form stereotypical images is an inherent danger linked with all cultures, but has long been viewed as a recurrent problem when Appalachia is considered (Batteau, 1991).
In 1873, Lippincott Magazine published an article titled A Strange Land and Peculiar People by Will Wallace Harney; it depicts Appalachian people in ways that still characterize current stereotypes. Historical ideas tied to the people of Appalachia have been long-lived (e.g., moonshiners, feuds, bluegrass, poverty) and they continue to fuel present perceptions and myths of residents as ignorant hill people. For instance, when the topic of Appalachia occurs, many recall the 1970s film, Deliverance. This story about four city men on a weekend canoe trip adventure in Northern Georgia often persuades viewers that mountain people are dangerous. Many do not recognize that Appalachia also has flatlanders and many that live in areas of rolling hills without mountains. The film contrasts urban and rural, kindness and cruelty, nature versus nurture, beauty and violence. The businessmen’s encounter with what some have called “a bunch of inbreds” is still shocking and unsettling to viewers even after several decades. The film’s story line and the Dueling Banjos characterize the conflict and misunderstandings between the privileged and the poor, a conflict still tied to ideas about Appalachia held by many. Living in a large geographic region does not imply all residents possess the same culture or can be defined by an Appalachian caricature. Films (e.g., American Hollow), magazine journalists (e.g., Life, Look, Time), reality television (e.g., Duck Dynasty, Here Comes Honey Boo Boo), hillbilly 1
Texas Woman’s University, Dallas, TX, USA
Corresponding Author: Sharon A. Denham, College of Nursing, T. Boone Pickens Institute of Health Sciences–Dallas Center, Texas Woman’s University, Dallas Campus, Office #7124, 5550 Southwestern Medical Avenue, Dallas, TX 75235, USA. Email: [email protected]
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cartoons (e.g., Snuffy Smith, Li’l Abner), and humorists (e.g., Jeff Foxworthy) have long contrived stories about the “peculiar” mountain people. Stories of Southerners, poverty, and those living in Appalachian are often described negatively, while ideas about their resilience, pride, and self-sufficiency are overlooked. Some stereotypical perceptions about Appalachians have prevailed in academia, the media, and public opinion are not helpful; in fact, they are hindrances to understanding those living in the region (Billings, Norman, & Ledford, 1999). Popular fiction of the late 1800s and early 1900s by local color writers provided fascinating tales about residents and pigeonholed perceptions with stories unsupported by facts (Shapiro, 1978). Jack Weller’s (1965) ideas about the culture of poverty have influenced the thinking of many about the region even though modern scholars have discredited his ideas (Billings et al., 1999). Although many changes have occurred in the past century, the fascination with “hillbilly” archetypes lingers. In the mid-1970s, Shelby Lee Adams (1993), photographer captured pictures of the region and its people that many believe misinterpret and perpetuate myths about the area’s people. Newer films such as the series, Appalachia: A History of Mountains and People attempt to correct myths, but stories like the Dollmaker, Matewan, Songcatcher, and the Hatfields and McCoys tell stories that many view as today’s realities.
Appalachian Heterogeneity More than 25 million people currently live in the 204,455 square miles of Appalachia, a 6.8% increase since 2000 (Pollard & Jacobsen, 2011). Much of the region is rural with few large metropolitan areas. Appalachia is significantly less diverse than the nation and two thirds of the counties have less than 10% minorities. In the region, home ownership is more common, 71.3% of the housing units, with 399 of the 420 counties exceeding the national average of 65.1% (Pollard & Jacobsen, 2011). Lower levels of mobility, higher numbers of mobile homes, aging structures, and property long held by families help explain this conundrum. The constant in- and out-migration make it nearly impossible to define a truly distinct regional culture (Obermiller & Howe, 2000). The notion that the region was ever homogenous has always been erroneous as diverse populations spread from Southern New York southward through 13 states including counties in Mississippi, Alabama, and Georgia. While the Appalachian Mountains provide a point of geographical reference, the region is not all mountainous nor all residents mountaineers. The five subregions have diverse demographic profiles, geological formations, weather patterns, economies, and settlements as early settlers came with different cultures, purposes, and intentions. Educational barriers have long existed in Appalachia, but improvements have occurred with time. A report based on the 2000 census identified that 24.4% of the adult population ages 25 years and over were college graduates, but only
17.7% of the Appalachian population had college degrees (Haaga, 2004). Population differences have been noted based on income distribution, geographic locale, and migration in or out of the region (Haaga, 2004). The 2010 census indicated that 27.5% of the nation’s adult population more than 25 years had a bachelor’s degree, whereas only 20.4% of those residing in Appalachia had such a degree (Pollard & Jacobsen, 2011). The latest 2010 census indicated that 84.6% of persons 25 years or older in the nation had a high school diploma, while fewer of those living in Appalachia (82.3%) had this degree. While this number is only slightly below the national average, 93 counties exceeded the national average but in 161 of the 420 counties, more than a third of the counties, fewer than three fourths of the residents had a diploma (Pollard & Jacobsen, 2011). Much of Appalachia has been slower than other parts of the nation to develop industry and large metropolitan centers. Today well-built roads enhance geographic mobility and allow passage through even the most difficult mountain ranges for residents and others (Appalachian Regional Commission, 2013). That said, some parts of the region are still less accessible due to poor roads, inadequate transportation, and inadequate resources. Modern technology allows young and old to communicate and use information and digital technologies in ways similar to the rest of the nation (Appalachian Regional Commission, n.d.). Generational differences may be similar to others in the nation, but most have access to cell phones, computers, and digital devices are common. Yet in some mountainous regions cellular services and web-based connectivity may be unpredictable and vary with broadband availability and access.
Wealth and Poverty Although pockets of wealth across Appalachia exist, the region is also inhabited by large numbers of people who are retired, disabled, unemployed, and with low income. Regional poverty was one in three in 1965, but by 2009, it was much closer to the national average with high poverty rates declining from 295 to 120 counties (Appalachian Regional Commission, 2011). In recent years, guidelines to determine poverty have been redefined but rates in some counties remain consistently high. Since the mid-1960s, the number of counties classified as economically distressed on measures of employment and poverty has decreased by more than half; however, a fourth of the counties categorized as distressed four decades ago remain so today (Appalachian Regional Commission, 2008a). The term “distressed” generally fails to capture the objective factors linked with longterm, cyclic, or short-term deprivation. The term “distressed” was originally intended to describe regional underdevelopment (Partridge, Lobao, Wilner Jeanty, Beaulieu, & Goetz, 2008). However, different indicators could more accurately explain current and future distress (i.e., population change, educational attainment, income and earnings, housing
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Denham market conditions, entrepreneurship, self-employment, improved measures of labor market strength, and poverty rate; Partridge et al., 2008). One might argue that underdevelopment linked with health care or medical services providers still exists and one needs to be aware of what types of services and health professionals are available in particular parts of the region (Denham, Remsberg, & Wood, 2010; Denham, Wood, & Remsberg, 2010). In 2007, the average per capita personal income was 20% lower in Appalachia than in the nation as a whole, with wages averaging $29,274 per year for those in Appalachia compared with $36,601 per year for those in the nation (Appalachian Regional Commission, 2009). Over the course of the recession beginning in 2008, the Appalachian region lost all the jobs gained since 2000 and two thirds of these counties have unemployment rates higher (9.7%) than the national average (9.6%; Appalachian Regional Commission, 2011). From 2000 to 2008, 473,000 manufacturing jobs and more than 59,000 jobs in farming, forestry, and natural resources were lost (Appalachian Regional Commission, 2011). This economic picture paints a bleak portrait for many living in Appalachia. Generational poverty means some families have suffered through decades of stressful lives, others have links to mental health disparities (e.g., psychological distress, major depressive disorder) and substance abuse rates higher than the rest of the nation (Appalachian Regional Commission, 2008b).
2004). Appalachia is also home to a small but growing immigrant Asian population (Barcus, 2007; Jackson, 2006; Straw, 2006). Amish and Mennonite communities, culturally distinct groups, are located primarily in the northern part of the region, with large populations in Appalachian Ohio and Pennsylvania (Jackson, 2006; Meyers, 1990). Therefore, nurses providing health care in various regions of Appalachia need to be aware of the area’s history, current settlement patterns, and traditions of those in the area as these differ.
Diversity
Abuse and Violence
Early Appalachian settlers are often described as Scots, Irish, English, and German, but African Americans, Native Americans, Italians, Poles, Hungarians, and other ethnic groups also settled in the region (Jackson, 2006; Straw, 2006). For instance, the French Five Hundred, mostly wealthy French families, were early settlers in Gallipolis, Ohio (Sibley, 1933). Eastern European Jewish retailers settled in Southwestern Virginia, Southern West Virginia, and Southeastern Kentucky from the 1880s to 1920s in rural topographies similar to previous European homes (Weiner, 2006). Many African Americans in Southeast Ohio are more likely to see themselves more aligned with rural Appalachian traditions than with those of African Americans living in urban areas outside of Appalachia (Denham, 1997). An essay collection discusses the contributions of Blacks to the region and their interactions with Native Americans and Whites (Turner & Cabbell, 1985). Each ethnic group settling in the region had its own heritage, but over time, some new ways were adopted and old ways altered. One might say that Appalachia is more like a salad bowl than a melting pot with distinctions and uniqueness exhibited geographically in various counties of the region. Furthermore, the human diversity of Appalachia is dynamic and changing. While the Appalachian population is primarily non-Hispanic White with African Americans constituting the largest minority group, the number of Latinos is growing rapidly in some areas (Jackson, 2006; Pollard,
Care providers with extensive professional education may possess a world view that differs from other regional residents (Greenlee & Lantz, 1993). For example, nurses from the region might have different perspectives, beliefs, attitudes, and behaviors than some persons living in the Appalachian region. A study compared ideas and attitudes about abuse and violence in pregnant Appalachian Ohio nurses and other pregnant women found variations in the ways these acts were perceived (Denham, 2003). Findings indicated that while all shared some similar experiences and traditional ideas, nurses reported personal abuse and violence more often than pregnant women receiving care. The study concluded that advanced education enabled the nurses to name their personal abusive or violent situations, but the findings indicated they were still ill-prepared to intervene on behalf of those in their care (Denham, 2003). Signs and symptoms were often ignored and nurses often failed to question behaviors, assess concerns, counsel, or refer for help. It seems that being a nurse from Appalachia and even experiencing some forms of abuse or violence does not assure preparation to address these concerns in those sharing a similar heritage or geography.
Social Contact It is a mistake to consider Appalachian people socially isolated. They have always been connected to the outside world through industry, trains, newspapers, and workers that traversed the region (Billings et al., 1999). Most Appalachians hold beliefs and share values similar to others in the nation (Denham & Rathbun, 2005). For example, some have identified a common distrust of strangers as an Appalachian trait (Brown & May, 2005; Lohri-Posey, 2006; Owens, Richerson, Murphy, Jageleweski, & Rossi, 2007), but once trust is established, individuals living in the region are friendly and welcoming. Distrust of strangers, might be a trait recognized by others outside of Appalachia. Building trusting and respectful professional relationships should be a priority when providing clinical care in this region.
Communication Patterns Some Appalachian people have distinctive speech patterns and communication styles (Keefe, 2005). Differences can
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often be heard from county to county as well as between the northern, central, and southern regions of Appalachia. Foreign-born clinicians often obtain special visas and educational support which requires them to practices in rural places, Appalachia being one. Communication with those speaking English as a second language can pose barriers and be a deterrent to Appalachian residents seeking medical advice (Tessaro, Smith, & Rye, 2005). All nurses practicing in Appalachia are not native born and may lack behaviors or traits tied to local traditions and values. The scholarly Dictionary of Smokey Mountain English provides evidence that some words and idioms that sound archaic have been linguistically influenced by speech patterns of Ulster, Scotland, and Southern England (Montgomery & Hall, 2004). Nonnative English-speaking clinicians must be aware of their nonverbal cues, avoid derogatory comments or humor about local accents, and learn something about local speech patterns (Blakeney, 2005; Coyne, Demian-Popescu, & Friend, 2006). Those unfamiliar with local dialects may need to spend time learning common idioms or phrases. Language can influence care quality and is important when communicating health information about diagnosis, treatment, informed consent, and self-management to Appalachian people (Osborne, 2000). Local dialects are not necessarily a reflection of intelligence or education. Making assumptions about individuals’ knowledge or abilities based on dialect could be a serious mistake.
Common Notions About Appalachian People Culture is slippery and articulating what is meant by being an Appalachian can be a difficult task. Ability to identify a culture can be tied to pertinent racial, ethnic information, a workplace, profession, and not just geography. The question rises: How does one identify an Appalachian person? Who should be defined as Appalachian if a distinct culture is not associated (see Box 1)? Being Appalachian is often tied to family heritage and place. Many regional people can trace four or more family generations that have lived and died in the same communities or counties where they live. If asked, those long associated with Appalachia will tell you the county where they live rather than the town where their home is located. These places often influence the beliefs, values, traditions, and behaviors of kin, past and present. In literature about Appalachian people, three notions are often described: fatalism, rugged independence, and being nonconfrontational. The ideas have been repeated so often that they tend to be viewed as truths. However, differences among people living in the region have always existed (Billings et al., 1999). Misconceptions and stereotypical perspectives often occur when trying to describe a population of people as a whole. Failure to recognize the diversity of Appalachian people, can result in wrongful assumptions and interpretations.
Box 1. What Characteristics Define Being an Appalachian? Residence
Living in a geographical region identified as part of the Appalachian region means you will be counted in county, state, and census records or other statistics aligned with the place.
Ancestors
Persons with multiple generations of ancestors born and raised in areas defined as Appalachian implies that you have acquired particular and distinguishable cultural traits.
Does being born in an Appalachian region and relocating to a place outside of the Appalachian region imply you are of Appalachian culture? If you relocate to an Appalachian region and spend the greater part of your life here does this mean you have acquired an Appalachian culture? If you are born and raised in the Appalachian region, but later leave the area and move to another place for education or employment does this suggest that you have an Appalachian culture? If you are a child of parents that have relocated from a place outside of the Appalachian region but have settled here and you were raised here, should you be viewed as having an Appalachian culture? If one parent has a heritage of multiple generations tied to the geographic region recognized as Appalachia and their partner is from another place but they live in Appalachia, are their children Appalachian? If a parent has multiple generations of ancestry tied to the Appalachian region but their partner is from someplace else and the children are raised in another place, are children Appalachian?
Fatalism For instance, labeling Appalachians as fatalistic has been tied to beliefs that life is predetermined and things cannot be altered. Operationalizing fatalism often occurs in terms of hopelessness, lower optimism, passivity, and avoidance (Phillips, 2007), but it is also used to refer to an attitude of
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Denham resignation about future events. A fatalistic perspective is often attributed to Appalachian people, but empirical evidence is lacking. Calvinistic roots may be tied to some fatalistic doctrines, but most modern-day Appalachians agree that few of life aspects are so fixed that they cannot be altered (Denham, 1996; Diddle & Denham, 2010). Belief in “God’s will” provides some evidence of a fatalistic view toward health, but research has found that Appalachians consider both faith and the benefits of medical care whenever they seek solutions to health or illness problems (Behringer & Friedell, 2006). Neither faith nor fatalism was identified as a barrier to treatment for those diagnosed with cancer (Behringer & Friedell, 2006). Many people long connected with the Appalachian region value their traditions and heritage, but this does not imply they ignore or abhor modern ways. It seems unreasonable to assume that while some Appalachian people might have fatalistic views that this perspective is consistently shared by all. Furthermore, fatalistic perspectives about some life situations do not necessary hold true with all things. Appalachian women often get mammography tests, children are vaccinated, and medical care is sought. Assumptions that the entire Appalachian population has a fatalistic proclivity seems just as wrong as assuming this trait is not true of other ethnicities or cultural groups.
one tell’en me what to do,” most cooperate and generously support others as they struggle to “make do” with available resources.
Individualism
The idea that Appalachia is homogenous is more a myth than reality (Leonard, 1999). Appalachia offers religious plurality (e.g., mainline, evangelical, Pentecostal, mountain churches) similar to other parts of the nation. Faith is a living theology, the fabric and solace of daily life, to many. Emotional worship services, testimonies, altar calls, acts of extreme faith, literal interpretation of the Bible, and baptism by immersion exist in the Appalachian region. Subdenominations of oldtime Baptists and many independent or nondenominational churches exist throughout various areas of Central and Southern Appalachia, but few snake-handling churches still exist. Mostly mainstream religions (e.g., Catholicism, Protestantism) are found. Faith provides solace and a way to address the mysteries tied with difficult lives much like it would for others in the mainstream. In Appalachia, religion is closely tied to daily life for many. Some quote Bible scriptures to explain events or discuss behaviors. “Prayer cloths,” a symbol of faith, are valued by some. Small bits of cloth are blessed through prayer by pastors, believers sometimes pin these to a pillow or clothing of ill persons. Religious pictures and other symbols are likely to be observed in homes. Religious beliefs influence daily life behaviors of some believers (e.g., form of dress, hairstyles, things consumed, dancing, music, church attendance). Oral histories tied to faith are often tangled into long-held family memories of illness, disease, crisis, birth, and death. Faith legacies are generally identified as a sign of caring support when illness or crisis is experienced. Expressions like, “I’ll keep you in my prayers,” “God bless you,” or “Praise
In the late 19th century, self-reliance and rugged individualism were often used by local color writers to describe Appalachian people, works penned to entertain the middle class and not critically evaluated (Lewis, 1999). Writers such as Harney (1873) and Fox (1901) wrote travelogues and often described Appalachia as “a strange land with peculiar people.” In 1899, William G. Frost, the third president of Berea College, described Appalachians as remote loners and stalwart pioneers surviving in the wilderness. Early stories about Appalachian people contrasted lives of people living on top of and nestled between mountains with those living in urban places. Writings often failed to account for differences in lives lived in coal mining towns, industrial communities, or farming communities. Not all Appalachian people have lived in socially isolated places, yet the caricature of proud, independent Appalachians uninterested in human connections still exists (Billings et al., 1999). Modern historians show the value of place and family differently (Inscoe & McKinney, 2003, Slapp & McKinney, 2010). Instead of characterizing Appalachian people as rugged independents, it might be more correct to say they are community-minded people, willing to “lend a hand” or “help out.” A tradition of reciprocity learned early in life is honored and demonstrated by families, neighbors, and larger communities. Deep-seated interdependence among families was important historically as they shared similar adversities, hardships, and challenges. While some may say, “ain’t no
Nonconfrontational People often speak about Appalachian people as nonconfrontational and interpret this to mean that they fail to speak for themselves. While some regional residents might be nondirective in their responses, others differ. A sense of humility, courteous, and kind behavior is often recognized even in public places. People in some families discourage rudeness, but teach members to keep opinions to themselves. Many living in Appalachia might not immediately express negative responses to offensive behaviors, but others might respond assertively to unscrupulous actions. Some individuals “hold their tongue” because they believe being blunt is poor manners and disrespectful, but silence does not necessarily mean indifference or acceptance. While Appalachian people in some counties or regional areas might openly share their opinions with family, friends, or neighbors, others might hesitate to share personal information with nurses not viewed as trustworthy or respectful.
Religion and Health
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the Lord” are often heard in daily conversations. Pastors and church members may want to pray aloud for salvation or healing as they hold hands and encircle ill persons. In acute care settings, these faith expressions could be viewed as disruptive. However, believers that pray for others in times of despair and uncertainty offer hope and demonstrate care. Knowledge about various religious beliefs and faith practices in a particular geographic region is useful as regional variances influence values, attitudes, and behaviors held. For example, some believers are intolerant of alcohol use, but others may imbibe (Meyer, Toborg, Denham, & Mande, 2008). Variations about what is permissible, prudent, forbidden, or tolerated can vary within families and in single communities. The needs to assure salvation or make peace with God can be heightened at times of crisis, uncertainty, or when death is near. Less religious family members may respectfully tolerate exuberant prayer sessions and the quest of others’ desire to see them “saved” before death. A confession of faith and request for forgiveness is viewed by many as essential for salvation and assurance of heaven. Like others outside Appalachia, holding a worldview does not assure consistency between actions and doctrinal ideals. Most Appalachian counties are dotted with numerous churches, ones in town and smaller ones in rural more isolated areas (e.g., up hollers). Many church congregations were established decades earlier and are attended by small numbers of extended family members. Ministers may report that they have been “called by God,” but lack formal religious training or theological education. However, ministers often have great zeal, are trusted by local people, and influence social behaviors. Church members, traditional and nontraditional, seek pastors for guidance in times of need even when they lack formal counseling preparation. Relationships with local ministers can enable nurses to provide health promotion information, share information about prevention or care management, and explain illness conditions in beneficial ways to specific communities. Church groups, congregations, and extended families play important roles in many Appalachian communities as caregivers and resource supports. Meals are often prepared and shared with those in need, but facts about nutrition or special diets may be lacking (Denham, Manoogian, & Schuster, 2007). Nurses can cooperate with religious leaders and church members to teach about healthy actions, clarify misconceptions, and share relevant information about tobacco use or other health concerns (Denham, Meyer, & Toborg, 2004; Johnson & Denham, 2015). The oral tradition still implies that information is often gained by word of mouth. This sharing is an important venue for infusing health information into local communities. For example, a diabetes prevention program called Healthy for GOoD was initiated in several Appalachian communities to spread information about care management of type 2 diabetes (e.g., nutrition, active lifestyles, medical care) and prevention of complications. Church
health ministries offer support and can minister to body, mind, and spirit. Churches often have nurses and other health professionals as members, as such, they can collaborate in health assessments and education. Faith leaders can partner with hospitals, public health agencies, coalitions, and others as they offer community health fairs, screenings, and distribute culturally sensitive health information. Throughout the Appalachian region, some individual entwine religious expression with health and illness. Thus, assessment of faith beliefs and traditions is essential. Religious beliefs, church membership, and associated values, attitudes, traditions, and rituals can be organizing factors affecting behaviors linked with health and illness. Faith beliefs can cause some to delay seeking care when personal values differ from what is viewed as conventional wisdom. Science and medical care may seem less important than faith for some individuals. Nearby extended family members and valued friend networks can greatly influence individual actions. Beliefs that God has allowed something to occur because they have been “bad” or acted “outside of God’s will” may motivate some behaviors. Nurses must examine assumptions about faith beliefs as people throughout Appalachia differ just as they do in mainstream America and assessments are needed to clarify unique individual beliefs.
Considerations for Clinical Practice and Research Several areas for clinical practice should be noted. Further research and study is needed to better understand various influences on health. For example, better understandings about the influence of close extended kin and friendship networks on health risks and care management is needed. Questions about some environmental influences (e.g., coal mining, industrial exposure, fracking) on health and illness of those living in some geographic regions still need answers. Local knowledge, behavioral practices, traditions, and family behaviors need consideration. Assumptions or speculations that Appalachian people are a monolithic group need to be questioned and perhaps dispelled. The ways lifestyle, faith traditions, and personal valuing of wellness, prevention, health, and illness need more consideration. Generational experiences of stress linked to insufficient jobs, inadequate pay, and high-risk work that have resulted in injuries, disabilities, and poverty need to be evaluated. Almost a decade ago, things like toxic waste, air quality, occupational exposure, runoff from farms, mines, and factories were noted to affect water quality and increased cancer risks for the prior three decades (Behringer & Friedell, 2006). More needs to be known about the resilience of Appalachia’s residents in diverse geographic regions of Appalachia. Barriers caused by access to health care services and costs of technologies need consideration. Questions about what technologies (e.g., computers, digital, mobile devices) can be used to empower
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Denham regional access to nursing care services need answers. Attention to literacy and low health literacy when sharing information needs attention. More needs to be known about ways nurses can involve families in establishing healthy lifestyles, care management routines, and communities where health rather than illness is the focus. Compelling studies linking complex variables (e.g., development, economic diversity, education, health behaviors) of multiple member households could help us better understand specific needs of diverse groups living in the region. Better understandings about the influences of faith and traditional beliefs as health protecting agents rather than threatening behaviors could also be useful.
Acknowledgments
Policy Recommendations
Funding
Policy is often considered from national or state positions, but this may be less useful than thinking about policy from local advocacy stances. Parts of Appalachia are disparate from some parts of the nation, but the needs of all parts of the region are not the same. Whether a distinct culture exists in Appalachia exists has long been debated, but many recognize that some unique traits do exist. Serious concerns about meeting health care needs of those in Appalachia has long been associated with the number, distribution, and availability of health care professionals (Denham, Remsberg, et al., 2010; Denham, Wood, et al., 2010). Policies that support education of local persons to become nurses and health professionals are needed. The idea of “grow your own” has long been understood as a way to see that people are educated in ways needed by local communities. State policies that support opportunities for nurse practitioners and registered nurses to practice at the highest level of their knowledge and licenses are needed. Nurses with knowledge of the needs of the Appalachian region can advocate for solutions and support the use of public funding to address the disparate resources and population health needs in distinct regional areas.
Conclusions Appalachia is a political boundary assigned from outside the region. Labels intended to address residents’ disparate needs have at times set this region apart from the rest of the nation. This raises the question previously asked: Does a culture of Appalachia truly exist? The region and its people are as diverse as other groups across the nation. One might agree that some cultural traits of Appalachia’s residents are recognizable, but they are not generalizable. Nurses living and working in Appalachia must be culturally sensitive to the diversity of local people’s needs. Nurses can consider that distinct needs tied to traditions, local heritage, and values often retained even when persons relocate or migrate to places outside the boundaries of the Appalachian region.
I would like to thank the many people who have been my mentors and colleagues as I learned about Appalachia during my career and investigated the health needs of regional residents. I would especially like to acknowledge the support and learning shared with Michael Meyer, PhD, Margaret Manoogian, PhD, and Lesli Johnson, PhD. Years of collaboration with each of these colleagues has helped me gain great insights over time. Last, but not least, I want to thank Ann Rathbun, PhD, for her assistance in editing this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: While I received support from many sources over the years, I especially want to acknowledge the funding and support from the Centers for Disease Control and Prevention National Diabetes Education program to develop the Diabetes: A Family Matter program and opportunity to do other diabetes prevention work in the region.
References Adams, S. L. (1993). Appalachian portraits. Jackson: University Press of Mississippi. Appalachian Regional Commission. (2008a). County economic status and distressed areas in the Appalachian region, fiscal year 2009. Washington, DC: Author. Appalachian Regional Commission. (2008b). An analysis of mental health and substance abuse disparities and access to treatment services in the Appalachian region. Retrieved from http://www. arc.gov/research/researchreportdetails.asp?REPORT_ID=71 Appalachian Regional Commission. (2009). Appalachian region income report, 2009. Retrieved from http://www.arc.gov/ search/index.asp?keywords=Appalachian%20region%20 income%20report Appalachian Regional Commission. (2011). Economic overview of Appalachia. Retrieved from http://www.arc.gov/search/index. asp?keywords=Economic%20overview%20of%20Appalachia Appalachian Regional Commission. (2013). Appalachian development highway system. Retrieved from http://www. arc.gov/search/index.asp?keywords=Appalachian%20 Development%20Highway%20System Appalachian Regional Commission. (n.d.). Telecommunications: Information age Appalachia. Retrieved from http://www.arc. gov/telecom Barcus, H. R. (2007). The emergence of new Hispanic settlement patterns in Appalachia. The Professional Geographer, 59, 298-315. Batteau, A. (1991). Appalachia and the concept of culture: A theory of shared misunderstandings. In B. Ergood & B. E. Kuhre (Eds.), Appalachia: Social context past and present (3rd ed., pp. 153-169). Dubuque, IA: Kendall/Hunt. Behringer, B., & Friedell, G. H. (2006). Appalachia: Where place matters in health. Preventing Chronic Disorders, 3(4), A113.
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Billings, D. B., Norman, G., & Ledford, K. (1999). Back talk from Appalachia: Confronting stereotypes. Lexington: University Press of Kentucky. Blakeney, A. B. (2005). Educating culturally sensitive health professionals in Appalachia. In S. E. Keefe (Ed.), Appalachian cultural competency: A guide for medical, mental health, and social service professionals. (pp. 161-178) Knoxville: University of Tennessee Press. Brown, J. W., & May, B. A. (2005). Rural older Appalachian women’s formal patterns of care. Southern Online Journal of Nursing Research, 6(2), 1-21. Coyne, C. A., Demian-Popescu, C., & Friend, D. (2006). Social and cultural factors influencing health in southern West Virginia: A qualitative study. Prevention of Chronic Diseases, 3(4), A124. Denham, S. A. (1996). Family health in a rural Appalachian Ohio County. Journal of Appalachian Studies, 2, 1-12. Denham, S. A. (1997). An ethnographic study of family health in Appalachian microsystems (Master’s thesis). Available from ProQuest Dissertations and Theses database. (UMI No. 9734429) Denham, S. A. (2003). Describing abuse of pregnant women and abuse of their health care workers in rural Appalachia. MCN: American Journal of Maternal Child Nursing, 28, 264-269. Denham, S. A., Manoogian, M., & Schuster, L. (2007). Managing family support and dietary routines: Type 2 diabetes in rural Appalachian families. Families, Systems, & Health, 25, 36-52. Denham, S. A., Meyer, M. G., & Toborg, M. A. (2004). Tobacco cessation in young adolescent females in Appalachian communities. Family & Community Health, 27, 171-183. Denham, S. A., & Rathbun, A. (2005). Community health assessment: Report of the findings. Athens, OH: Appalachian Rural Health Institute. Denham, S. A., Remsberg, K., & Wood, L. (2010). Diabetes education in the Appalachian region: Providers’ views. Rural and Remote Health, 10, 1321. Denham, S. A., Wood, L., & Remsberg, K. (2010). Diabetes care: Provider disparities in the US Appalachian region. Rural and Remote Health, 10, 1320. Diddle, G., & Denham, S. A. (2010). Spirituality: Considering relationships with health and illness on those in Appalachia. Journal of Transcultural Nursing, 21, 175-182. Fox, J. (1901). The southern mountaineer. Scribner’s Magazine, 29, 387-399. Frost, W. G. (1899). Our contemporary ancestors in the southern mountains. Atlantic Monthly, 83, 311-319. Greenlee, R., & Lantz, J. (1993). Family coping strategies and the rural Appalachian working poor. Contemporary Family Therapy, 15, 121-137. Haaga, J. (2004). Educational attainment in Appalachia. Retrieved from http://www.arc.gov/assets/research_reports/ EducationalAttainmentinAppalachia.pdf Harney, W. (1873). A strange land and peculiar people. Lippincott Magazine, 12, 429-438. Inscoe, J., & McKinney, G. B. (2003). The heart of confederate Appalachia: Western North Carolina in the Civil War. Chapel Hill: University of North Carolina Press. Jackson, S. R. (2006). Peoples of Appalachia: Cultural diversity within the mountain region. In G. T. Edwards, J. A. Asubury, & R. L. Cox (Eds.), A handbook to Appalachia (pp. 27-50). Knoxville: University of Tennessee Press.
Johnson, L., & Denham, S. A. (2015). Developing a culturally competent, sustainable rural model for diabetes prevention. Rural and Remote Health, 15, 3031. Retrieved from http://www.rrh. org.au/publishedarticles/article_print_3031.pdf Keefe, S. E. (Ed.). (2005). Appalachian cultural competency: A guide for mental health and social service professionals. Knoxville: University of Tennessee Press. Leonard, B. J. (1999). Christianity in Appalachia: Profiles in regional pluralism. Knoxville: University of Tennessee Press. Lewis, R. L. (1999). Beyond isolation and homogeneity: Diversity and the history of Appalachia. In D. B. Billings, G. Norman, & K. Ledford (Eds.), Back talk from Appalachia: Confronting stereotypes (pp. 21-43). Lexington: University Press of Kentucky. Lohri-Posey, B. (2006). Middle-aged Appalachians living with diabetes mellitus. Family & Community Health, 29, 214-220. Manoogian, M. M., Harter, L. M., & Denham, S. A. (2010). The storied nature of health legacies in the familial experience of type 2 diabetes. Journal of Family Communication, 10, 1-17. Meyer, M. G., Toborg, M. A., Denham, S. A., & Mande, M. J. (2008). Cultural perspectives concerning adolescent use of tobacco and alcohol in the Appalachian mountain region. Journal of Rural Health, 24, 67-74. Meyers, T. J. (1990). Old Order Amish. Retrieved from http://www. gameo.org/encyclopedia/contents/A4574ME.html Montgomery, M. B., & Hall, J. S. (2004). Dictionary of Smoky Mountain English. Knoxville: University of Tennessee Press. Obermiller, P. J., & Howe, S. R. (2000). Appalachian migration patterns, 1975-1980 and 1985-1990. Retrieved from http://www.arc.gov/assets/research_reports/Appalachian MigrationPatterns.pdf Osborne, H. (2000). In other words . . . it takes more than just words . . . culturally and linguistically appropriate materials. On Call Magazine, 3, 34-35. Owens, J. S., Richerson, L., Murphy, C. E., Jageleweski, A., & Rossi, L. (2007). The parent perspective: Informing the cultural sensitivity of parenting programs in rural communities. Child & Youth Care Forum, 36, 179-194. Partridge, M., Lobao, L., Wilner Jeanty, P., Beaulieu, L. J., & Goetz, S. (2008). An assessment of alternative measures for determining economically distressed counties and areas in the Appalachian region. Retrieved from http://www.arc.gov/assets/ research_reports/AnAssessmentofAlternativeMeasuresfor DeterminingEconomicallyDistressedCounties.pdf Phillips, T. M. (2007). Influence of Appalachian fatalism on adolescent identity processes. Journal of Family & Consumer Sciences, 99(2), 11-15. Pollard, K. M. (2004). A new diversity: Race and ethnicity in the Appalachian region. Retrieved from http://www.prb.org/ pdf04/anewdiversityappal.pdf Pollard, K., & Jacobsen, L. A. (2011). The Appalachian region in 2010: A census data overview. Retrieved from http://www.prb. org/pdf12/appalachia-census-chartbook-2011.pdf Shapiro, H. D. (1978). Appalachia on our mind: The southern mountains and mountaineers in the American consciousness (1870-1920). Chapel Hill: University of North Carolina Press. Sibley, W. G. (1933). The French five hundred. Gallipolis, OH: Gallia County Historical Society.
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Denham Slapp, A. L., & McKinney, G. B. (2010). Reconstructing Appalachia: The civil war’s aftermath. Lexington: University Press of Kentucky. Straw, R. (2006). Appalachian history. In G. T. Edwards, J. A. Asbury, & R. L. Cox (Eds.), A handbook to Appalachia (pp. 1-26). Knoxville: University of Tennessee Press. Tessaro, I., Smith, S. L., & Rye, S. (2005). Knowledge and perceptions of diabetes in an Appalachian population. Prevention of Chronic Diseases, 2(2), A13. Retrieved from http://origin.cdc. gov/pcd/issues/2005/apr/pdf/04_0098.pdf Turner, W. H., & Cabbell, E. J. (1985). Blacks in Appalachia. Lexington: University Press of Kentucky.
United States Code Title 40 Subtitle IV. (1965). Appalachian regi onal development. Retrieved from http://www.arc.gov/images/ newsroom/publications/arda/UnitedStatesCodeTitle40SubtitleIV. pdf Vance, R. A., Basta, T. B., Bute, J. J., & Denham, S. A. (2012). Identifying the health needs in rural Appalachian Ohio: Outcomes of a rural community-academic partnership. American Journal of Health Sciences, 3, 1-10. Weiner, D. R. (2006). Coalfield Jews: An Appalachian history. Urbana: University of Illinois Press. Weller, J. (1965). Yesterday’s people: Life in contemporary Appalachia. Lexington: University Press of Kentucky.
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research-article2015
TCNXXX10.1177/1043659615579712Journal of Transcultural NursingDenham
Education Department
Does a Culture of Appalachia Truly Exist?
Journal of Transcultural Nursing 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615579712 tcn.sagepub.com
Sharon A. Denham, PhD, RN1
Abstract Some disagreement exists about whether an Appalachian culture exists. Common notions about Appalachia’s people are tied to myths that disguise truths about those that claim a heritage tied to place. Living in the region is different from having multiple generations of ancestors and a family legacy associated with place. Conclusions suggest that cultural traits of some residents are recognizable as unique from others in the nation’s mainstream, but they are not generalizable to all people living in the Appalachian region. Keywords health disparities, transcultural health, family health
Introduction The author of this article has decades of experience living and working in Appalachian communities. Clinical nursing practice in families’ homes and community settings, teaching nursing students from the Appalachia region, studying Appalachian literature, and researching family health and illness concerns provided opportunities to hear and learn from people throughout the northern, central, and southern regions of Appalachia (Manoogian, Harter, & Denham, 2010; Vance, Basta, Bute, & Denham, 2012). Nurses in diverse care settings often come into contact with people from the Appalachian region. While many people seek medical care in their local rural communities, they often seek specialty care in urban settings. The primary purpose of this article is to increase nurses’ awareness and knowledge about those with ancestry and generational ties to the Appalachian region. A second purpose relates to using this knowledge to consider ways clinical practice relationships are built and care delivered.
Appalachia and Its People In 1965, a national policy formed the Appalachian Regional Commission and identified Appalachia as a geographic region (United States Code Title 40 Subtitle IV, 1965). From a political perspective, those living in the 420 counties that currently comprise this territory are viewed as residents of the Appalachian region. This article aims to show the diversity of those inhabiting the area and show that the popular culture often associated with negative stereotypes of its people need to be reexamined. The temptation to over generalize, misunderstand, and form stereotypical images is an inherent danger linked with all cultures, but has long been viewed as a recurrent problem when Appalachia is considered (Batteau, 1991).
In 1873, Lippincott Magazine published an article titled A Strange Land and Peculiar People by Will Wallace Harney; it depicts Appalachian people in ways that still characterize current stereotypes. Historical ideas tied to the people of Appalachia have been long-lived (e.g., moonshiners, feuds, bluegrass, poverty) and they continue to fuel present perceptions and myths of residents as ignorant hill people. For instance, when the topic of Appalachia occurs, many recall the 1970s film, Deliverance. This story about four city men on a weekend canoe trip adventure in Northern Georgia often persuades viewers that mountain people are dangerous. Many do not recognize that Appalachia also has flatlanders and many that live in areas of rolling hills without mountains. The film contrasts urban and rural, kindness and cruelty, nature versus nurture, beauty and violence. The businessmen’s encounter with what some have called “a bunch of inbreds” is still shocking and unsettling to viewers even after several decades. The film’s story line and the Dueling Banjos characterize the conflict and misunderstandings between the privileged and the poor, a conflict still tied to ideas about Appalachia held by many. Living in a large geographic region does not imply all residents possess the same culture or can be defined by an Appalachian caricature. Films (e.g., American Hollow), magazine journalists (e.g., Life, Look, Time), reality television (e.g., Duck Dynasty, Here Comes Honey Boo Boo), hillbilly 1
Texas Woman’s University, Dallas, TX, USA
Corresponding Author: Sharon A. Denham, College of Nursing, T. Boone Pickens Institute of Health Sciences–Dallas Center, Texas Woman’s University, Dallas Campus, Office #7124, 5550 Southwestern Medical Avenue, Dallas, TX 75235, USA. Email: [email protected]
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cartoons (e.g., Snuffy Smith, Li’l Abner), and humorists (e.g., Jeff Foxworthy) have long contrived stories about the “peculiar” mountain people. Stories of Southerners, poverty, and those living in Appalachian are often described negatively, while ideas about their resilience, pride, and self-sufficiency are overlooked. Some stereotypical perceptions about Appalachians have prevailed in academia, the media, and public opinion are not helpful; in fact, they are hindrances to understanding those living in the region (Billings, Norman, & Ledford, 1999). Popular fiction of the late 1800s and early 1900s by local color writers provided fascinating tales about residents and pigeonholed perceptions with stories unsupported by facts (Shapiro, 1978). Jack Weller’s (1965) ideas about the culture of poverty have influenced the thinking of many about the region even though modern scholars have discredited his ideas (Billings et al., 1999). Although many changes have occurred in the past century, the fascination with “hillbilly” archetypes lingers. In the mid-1970s, Shelby Lee Adams (1993), photographer captured pictures of the region and its people that many believe misinterpret and perpetuate myths about the area’s people. Newer films such as the series, Appalachia: A History of Mountains and People attempt to correct myths, but stories like the Dollmaker, Matewan, Songcatcher, and the Hatfields and McCoys tell stories that many view as today’s realities.
Appalachian Heterogeneity More than 25 million people currently live in the 204,455 square miles of Appalachia, a 6.8% increase since 2000 (Pollard & Jacobsen, 2011). Much of the region is rural with few large metropolitan areas. Appalachia is significantly less diverse than the nation and two thirds of the counties have less than 10% minorities. In the region, home ownership is more common, 71.3% of the housing units, with 399 of the 420 counties exceeding the national average of 65.1% (Pollard & Jacobsen, 2011). Lower levels of mobility, higher numbers of mobile homes, aging structures, and property long held by families help explain this conundrum. The constant in- and out-migration make it nearly impossible to define a truly distinct regional culture (Obermiller & Howe, 2000). The notion that the region was ever homogenous has always been erroneous as diverse populations spread from Southern New York southward through 13 states including counties in Mississippi, Alabama, and Georgia. While the Appalachian Mountains provide a point of geographical reference, the region is not all mountainous nor all residents mountaineers. The five subregions have diverse demographic profiles, geological formations, weather patterns, economies, and settlements as early settlers came with different cultures, purposes, and intentions. Educational barriers have long existed in Appalachia, but improvements have occurred with time. A report based on the 2000 census identified that 24.4% of the adult population ages 25 years and over were college graduates, but only
17.7% of the Appalachian population had college degrees (Haaga, 2004). Population differences have been noted based on income distribution, geographic locale, and migration in or out of the region (Haaga, 2004). The 2010 census indicated that 27.5% of the nation’s adult population more than 25 years had a bachelor’s degree, whereas only 20.4% of those residing in Appalachia had such a degree (Pollard & Jacobsen, 2011). The latest 2010 census indicated that 84.6% of persons 25 years or older in the nation had a high school diploma, while fewer of those living in Appalachia (82.3%) had this degree. While this number is only slightly below the national average, 93 counties exceeded the national average but in 161 of the 420 counties, more than a third of the counties, fewer than three fourths of the residents had a diploma (Pollard & Jacobsen, 2011). Much of Appalachia has been slower than other parts of the nation to develop industry and large metropolitan centers. Today well-built roads enhance geographic mobility and allow passage through even the most difficult mountain ranges for residents and others (Appalachian Regional Commission, 2013). That said, some parts of the region are still less accessible due to poor roads, inadequate transportation, and inadequate resources. Modern technology allows young and old to communicate and use information and digital technologies in ways similar to the rest of the nation (Appalachian Regional Commission, n.d.). Generational differences may be similar to others in the nation, but most have access to cell phones, computers, and digital devices are common. Yet in some mountainous regions cellular services and web-based connectivity may be unpredictable and vary with broadband availability and access.
Wealth and Poverty Although pockets of wealth across Appalachia exist, the region is also inhabited by large numbers of people who are retired, disabled, unemployed, and with low income. Regional poverty was one in three in 1965, but by 2009, it was much closer to the national average with high poverty rates declining from 295 to 120 counties (Appalachian Regional Commission, 2011). In recent years, guidelines to determine poverty have been redefined but rates in some counties remain consistently high. Since the mid-1960s, the number of counties classified as economically distressed on measures of employment and poverty has decreased by more than half; however, a fourth of the counties categorized as distressed four decades ago remain so today (Appalachian Regional Commission, 2008a). The term “distressed” generally fails to capture the objective factors linked with longterm, cyclic, or short-term deprivation. The term “distressed” was originally intended to describe regional underdevelopment (Partridge, Lobao, Wilner Jeanty, Beaulieu, & Goetz, 2008). However, different indicators could more accurately explain current and future distress (i.e., population change, educational attainment, income and earnings, housing
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Denham market conditions, entrepreneurship, self-employment, improved measures of labor market strength, and poverty rate; Partridge et al., 2008). One might argue that underdevelopment linked with health care or medical services providers still exists and one needs to be aware of what types of services and health professionals are available in particular parts of the region (Denham, Remsberg, & Wood, 2010; Denham, Wood, & Remsberg, 2010). In 2007, the average per capita personal income was 20% lower in Appalachia than in the nation as a whole, with wages averaging $29,274 per year for those in Appalachia compared with $36,601 per year for those in the nation (Appalachian Regional Commission, 2009). Over the course of the recession beginning in 2008, the Appalachian region lost all the jobs gained since 2000 and two thirds of these counties have unemployment rates higher (9.7%) than the national average (9.6%; Appalachian Regional Commission, 2011). From 2000 to 2008, 473,000 manufacturing jobs and more than 59,000 jobs in farming, forestry, and natural resources were lost (Appalachian Regional Commission, 2011). This economic picture paints a bleak portrait for many living in Appalachia. Generational poverty means some families have suffered through decades of stressful lives, others have links to mental health disparities (e.g., psychological distress, major depressive disorder) and substance abuse rates higher than the rest of the nation (Appalachian Regional Commission, 2008b).
2004). Appalachia is also home to a small but growing immigrant Asian population (Barcus, 2007; Jackson, 2006; Straw, 2006). Amish and Mennonite communities, culturally distinct groups, are located primarily in the northern part of the region, with large populations in Appalachian Ohio and Pennsylvania (Jackson, 2006; Meyers, 1990). Therefore, nurses providing health care in various regions of Appalachia need to be aware of the area’s history, current settlement patterns, and traditions of those in the area as these differ.
Diversity
Abuse and Violence
Early Appalachian settlers are often described as Scots, Irish, English, and German, but African Americans, Native Americans, Italians, Poles, Hungarians, and other ethnic groups also settled in the region (Jackson, 2006; Straw, 2006). For instance, the French Five Hundred, mostly wealthy French families, were early settlers in Gallipolis, Ohio (Sibley, 1933). Eastern European Jewish retailers settled in Southwestern Virginia, Southern West Virginia, and Southeastern Kentucky from the 1880s to 1920s in rural topographies similar to previous European homes (Weiner, 2006). Many African Americans in Southeast Ohio are more likely to see themselves more aligned with rural Appalachian traditions than with those of African Americans living in urban areas outside of Appalachia (Denham, 1997). An essay collection discusses the contributions of Blacks to the region and their interactions with Native Americans and Whites (Turner & Cabbell, 1985). Each ethnic group settling in the region had its own heritage, but over time, some new ways were adopted and old ways altered. One might say that Appalachia is more like a salad bowl than a melting pot with distinctions and uniqueness exhibited geographically in various counties of the region. Furthermore, the human diversity of Appalachia is dynamic and changing. While the Appalachian population is primarily non-Hispanic White with African Americans constituting the largest minority group, the number of Latinos is growing rapidly in some areas (Jackson, 2006; Pollard,
Care providers with extensive professional education may possess a world view that differs from other regional residents (Greenlee & Lantz, 1993). For example, nurses from the region might have different perspectives, beliefs, attitudes, and behaviors than some persons living in the Appalachian region. A study compared ideas and attitudes about abuse and violence in pregnant Appalachian Ohio nurses and other pregnant women found variations in the ways these acts were perceived (Denham, 2003). Findings indicated that while all shared some similar experiences and traditional ideas, nurses reported personal abuse and violence more often than pregnant women receiving care. The study concluded that advanced education enabled the nurses to name their personal abusive or violent situations, but the findings indicated they were still ill-prepared to intervene on behalf of those in their care (Denham, 2003). Signs and symptoms were often ignored and nurses often failed to question behaviors, assess concerns, counsel, or refer for help. It seems that being a nurse from Appalachia and even experiencing some forms of abuse or violence does not assure preparation to address these concerns in those sharing a similar heritage or geography.
Social Contact It is a mistake to consider Appalachian people socially isolated. They have always been connected to the outside world through industry, trains, newspapers, and workers that traversed the region (Billings et al., 1999). Most Appalachians hold beliefs and share values similar to others in the nation (Denham & Rathbun, 2005). For example, some have identified a common distrust of strangers as an Appalachian trait (Brown & May, 2005; Lohri-Posey, 2006; Owens, Richerson, Murphy, Jageleweski, & Rossi, 2007), but once trust is established, individuals living in the region are friendly and welcoming. Distrust of strangers, might be a trait recognized by others outside of Appalachia. Building trusting and respectful professional relationships should be a priority when providing clinical care in this region.
Communication Patterns Some Appalachian people have distinctive speech patterns and communication styles (Keefe, 2005). Differences can
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often be heard from county to county as well as between the northern, central, and southern regions of Appalachia. Foreign-born clinicians often obtain special visas and educational support which requires them to practices in rural places, Appalachia being one. Communication with those speaking English as a second language can pose barriers and be a deterrent to Appalachian residents seeking medical advice (Tessaro, Smith, & Rye, 2005). All nurses practicing in Appalachia are not native born and may lack behaviors or traits tied to local traditions and values. The scholarly Dictionary of Smokey Mountain English provides evidence that some words and idioms that sound archaic have been linguistically influenced by speech patterns of Ulster, Scotland, and Southern England (Montgomery & Hall, 2004). Nonnative English-speaking clinicians must be aware of their nonverbal cues, avoid derogatory comments or humor about local accents, and learn something about local speech patterns (Blakeney, 2005; Coyne, Demian-Popescu, & Friend, 2006). Those unfamiliar with local dialects may need to spend time learning common idioms or phrases. Language can influence care quality and is important when communicating health information about diagnosis, treatment, informed consent, and self-management to Appalachian people (Osborne, 2000). Local dialects are not necessarily a reflection of intelligence or education. Making assumptions about individuals’ knowledge or abilities based on dialect could be a serious mistake.
Common Notions About Appalachian People Culture is slippery and articulating what is meant by being an Appalachian can be a difficult task. Ability to identify a culture can be tied to pertinent racial, ethnic information, a workplace, profession, and not just geography. The question rises: How does one identify an Appalachian person? Who should be defined as Appalachian if a distinct culture is not associated (see Box 1)? Being Appalachian is often tied to family heritage and place. Many regional people can trace four or more family generations that have lived and died in the same communities or counties where they live. If asked, those long associated with Appalachia will tell you the county where they live rather than the town where their home is located. These places often influence the beliefs, values, traditions, and behaviors of kin, past and present. In literature about Appalachian people, three notions are often described: fatalism, rugged independence, and being nonconfrontational. The ideas have been repeated so often that they tend to be viewed as truths. However, differences among people living in the region have always existed (Billings et al., 1999). Misconceptions and stereotypical perspectives often occur when trying to describe a population of people as a whole. Failure to recognize the diversity of Appalachian people, can result in wrongful assumptions and interpretations.
Box 1. What Characteristics Define Being an Appalachian? Residence
Living in a geographical region identified as part of the Appalachian region means you will be counted in county, state, and census records or other statistics aligned with the place.
Ancestors
Persons with multiple generations of ancestors born and raised in areas defined as Appalachian implies that you have acquired particular and distinguishable cultural traits.
Does being born in an Appalachian region and relocating to a place outside of the Appalachian region imply you are of Appalachian culture? If you relocate to an Appalachian region and spend the greater part of your life here does this mean you have acquired an Appalachian culture? If you are born and raised in the Appalachian region, but later leave the area and move to another place for education or employment does this suggest that you have an Appalachian culture? If you are a child of parents that have relocated from a place outside of the Appalachian region but have settled here and you were raised here, should you be viewed as having an Appalachian culture? If one parent has a heritage of multiple generations tied to the geographic region recognized as Appalachia and their partner is from another place but they live in Appalachia, are their children Appalachian? If a parent has multiple generations of ancestry tied to the Appalachian region but their partner is from someplace else and the children are raised in another place, are children Appalachian?
Fatalism For instance, labeling Appalachians as fatalistic has been tied to beliefs that life is predetermined and things cannot be altered. Operationalizing fatalism often occurs in terms of hopelessness, lower optimism, passivity, and avoidance (Phillips, 2007), but it is also used to refer to an attitude of
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Denham resignation about future events. A fatalistic perspective is often attributed to Appalachian people, but empirical evidence is lacking. Calvinistic roots may be tied to some fatalistic doctrines, but most modern-day Appalachians agree that few of life aspects are so fixed that they cannot be altered (Denham, 1996; Diddle & Denham, 2010). Belief in “God’s will” provides some evidence of a fatalistic view toward health, but research has found that Appalachians consider both faith and the benefits of medical care whenever they seek solutions to health or illness problems (Behringer & Friedell, 2006). Neither faith nor fatalism was identified as a barrier to treatment for those diagnosed with cancer (Behringer & Friedell, 2006). Many people long connected with the Appalachian region value their traditions and heritage, but this does not imply they ignore or abhor modern ways. It seems unreasonable to assume that while some Appalachian people might have fatalistic views that this perspective is consistently shared by all. Furthermore, fatalistic perspectives about some life situations do not necessary hold true with all things. Appalachian women often get mammography tests, children are vaccinated, and medical care is sought. Assumptions that the entire Appalachian population has a fatalistic proclivity seems just as wrong as assuming this trait is not true of other ethnicities or cultural groups.
one tell’en me what to do,” most cooperate and generously support others as they struggle to “make do” with available resources.
Individualism
The idea that Appalachia is homogenous is more a myth than reality (Leonard, 1999). Appalachia offers religious plurality (e.g., mainline, evangelical, Pentecostal, mountain churches) similar to other parts of the nation. Faith is a living theology, the fabric and solace of daily life, to many. Emotional worship services, testimonies, altar calls, acts of extreme faith, literal interpretation of the Bible, and baptism by immersion exist in the Appalachian region. Subdenominations of oldtime Baptists and many independent or nondenominational churches exist throughout various areas of Central and Southern Appalachia, but few snake-handling churches still exist. Mostly mainstream religions (e.g., Catholicism, Protestantism) are found. Faith provides solace and a way to address the mysteries tied with difficult lives much like it would for others in the mainstream. In Appalachia, religion is closely tied to daily life for many. Some quote Bible scriptures to explain events or discuss behaviors. “Prayer cloths,” a symbol of faith, are valued by some. Small bits of cloth are blessed through prayer by pastors, believers sometimes pin these to a pillow or clothing of ill persons. Religious pictures and other symbols are likely to be observed in homes. Religious beliefs influence daily life behaviors of some believers (e.g., form of dress, hairstyles, things consumed, dancing, music, church attendance). Oral histories tied to faith are often tangled into long-held family memories of illness, disease, crisis, birth, and death. Faith legacies are generally identified as a sign of caring support when illness or crisis is experienced. Expressions like, “I’ll keep you in my prayers,” “God bless you,” or “Praise
In the late 19th century, self-reliance and rugged individualism were often used by local color writers to describe Appalachian people, works penned to entertain the middle class and not critically evaluated (Lewis, 1999). Writers such as Harney (1873) and Fox (1901) wrote travelogues and often described Appalachia as “a strange land with peculiar people.” In 1899, William G. Frost, the third president of Berea College, described Appalachians as remote loners and stalwart pioneers surviving in the wilderness. Early stories about Appalachian people contrasted lives of people living on top of and nestled between mountains with those living in urban places. Writings often failed to account for differences in lives lived in coal mining towns, industrial communities, or farming communities. Not all Appalachian people have lived in socially isolated places, yet the caricature of proud, independent Appalachians uninterested in human connections still exists (Billings et al., 1999). Modern historians show the value of place and family differently (Inscoe & McKinney, 2003, Slapp & McKinney, 2010). Instead of characterizing Appalachian people as rugged independents, it might be more correct to say they are community-minded people, willing to “lend a hand” or “help out.” A tradition of reciprocity learned early in life is honored and demonstrated by families, neighbors, and larger communities. Deep-seated interdependence among families was important historically as they shared similar adversities, hardships, and challenges. While some may say, “ain’t no
Nonconfrontational People often speak about Appalachian people as nonconfrontational and interpret this to mean that they fail to speak for themselves. While some regional residents might be nondirective in their responses, others differ. A sense of humility, courteous, and kind behavior is often recognized even in public places. People in some families discourage rudeness, but teach members to keep opinions to themselves. Many living in Appalachia might not immediately express negative responses to offensive behaviors, but others might respond assertively to unscrupulous actions. Some individuals “hold their tongue” because they believe being blunt is poor manners and disrespectful, but silence does not necessarily mean indifference or acceptance. While Appalachian people in some counties or regional areas might openly share their opinions with family, friends, or neighbors, others might hesitate to share personal information with nurses not viewed as trustworthy or respectful.
Religion and Health
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the Lord” are often heard in daily conversations. Pastors and church members may want to pray aloud for salvation or healing as they hold hands and encircle ill persons. In acute care settings, these faith expressions could be viewed as disruptive. However, believers that pray for others in times of despair and uncertainty offer hope and demonstrate care. Knowledge about various religious beliefs and faith practices in a particular geographic region is useful as regional variances influence values, attitudes, and behaviors held. For example, some believers are intolerant of alcohol use, but others may imbibe (Meyer, Toborg, Denham, & Mande, 2008). Variations about what is permissible, prudent, forbidden, or tolerated can vary within families and in single communities. The needs to assure salvation or make peace with God can be heightened at times of crisis, uncertainty, or when death is near. Less religious family members may respectfully tolerate exuberant prayer sessions and the quest of others’ desire to see them “saved” before death. A confession of faith and request for forgiveness is viewed by many as essential for salvation and assurance of heaven. Like others outside Appalachia, holding a worldview does not assure consistency between actions and doctrinal ideals. Most Appalachian counties are dotted with numerous churches, ones in town and smaller ones in rural more isolated areas (e.g., up hollers). Many church congregations were established decades earlier and are attended by small numbers of extended family members. Ministers may report that they have been “called by God,” but lack formal religious training or theological education. However, ministers often have great zeal, are trusted by local people, and influence social behaviors. Church members, traditional and nontraditional, seek pastors for guidance in times of need even when they lack formal counseling preparation. Relationships with local ministers can enable nurses to provide health promotion information, share information about prevention or care management, and explain illness conditions in beneficial ways to specific communities. Church groups, congregations, and extended families play important roles in many Appalachian communities as caregivers and resource supports. Meals are often prepared and shared with those in need, but facts about nutrition or special diets may be lacking (Denham, Manoogian, & Schuster, 2007). Nurses can cooperate with religious leaders and church members to teach about healthy actions, clarify misconceptions, and share relevant information about tobacco use or other health concerns (Denham, Meyer, & Toborg, 2004; Johnson & Denham, 2015). The oral tradition still implies that information is often gained by word of mouth. This sharing is an important venue for infusing health information into local communities. For example, a diabetes prevention program called Healthy for GOoD was initiated in several Appalachian communities to spread information about care management of type 2 diabetes (e.g., nutrition, active lifestyles, medical care) and prevention of complications. Church
health ministries offer support and can minister to body, mind, and spirit. Churches often have nurses and other health professionals as members, as such, they can collaborate in health assessments and education. Faith leaders can partner with hospitals, public health agencies, coalitions, and others as they offer community health fairs, screenings, and distribute culturally sensitive health information. Throughout the Appalachian region, some individual entwine religious expression with health and illness. Thus, assessment of faith beliefs and traditions is essential. Religious beliefs, church membership, and associated values, attitudes, traditions, and rituals can be organizing factors affecting behaviors linked with health and illness. Faith beliefs can cause some to delay seeking care when personal values differ from what is viewed as conventional wisdom. Science and medical care may seem less important than faith for some individuals. Nearby extended family members and valued friend networks can greatly influence individual actions. Beliefs that God has allowed something to occur because they have been “bad” or acted “outside of God’s will” may motivate some behaviors. Nurses must examine assumptions about faith beliefs as people throughout Appalachia differ just as they do in mainstream America and assessments are needed to clarify unique individual beliefs.
Considerations for Clinical Practice and Research Several areas for clinical practice should be noted. Further research and study is needed to better understand various influences on health. For example, better understandings about the influence of close extended kin and friendship networks on health risks and care management is needed. Questions about some environmental influences (e.g., coal mining, industrial exposure, fracking) on health and illness of those living in some geographic regions still need answers. Local knowledge, behavioral practices, traditions, and family behaviors need consideration. Assumptions or speculations that Appalachian people are a monolithic group need to be questioned and perhaps dispelled. The ways lifestyle, faith traditions, and personal valuing of wellness, prevention, health, and illness need more consideration. Generational experiences of stress linked to insufficient jobs, inadequate pay, and high-risk work that have resulted in injuries, disabilities, and poverty need to be evaluated. Almost a decade ago, things like toxic waste, air quality, occupational exposure, runoff from farms, mines, and factories were noted to affect water quality and increased cancer risks for the prior three decades (Behringer & Friedell, 2006). More needs to be known about the resilience of Appalachia’s residents in diverse geographic regions of Appalachia. Barriers caused by access to health care services and costs of technologies need consideration. Questions about what technologies (e.g., computers, digital, mobile devices) can be used to empower
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Denham regional access to nursing care services need answers. Attention to literacy and low health literacy when sharing information needs attention. More needs to be known about ways nurses can involve families in establishing healthy lifestyles, care management routines, and communities where health rather than illness is the focus. Compelling studies linking complex variables (e.g., development, economic diversity, education, health behaviors) of multiple member households could help us better understand specific needs of diverse groups living in the region. Better understandings about the influences of faith and traditional beliefs as health protecting agents rather than threatening behaviors could also be useful.
Acknowledgments
Policy Recommendations
Funding
Policy is often considered from national or state positions, but this may be less useful than thinking about policy from local advocacy stances. Parts of Appalachia are disparate from some parts of the nation, but the needs of all parts of the region are not the same. Whether a distinct culture exists in Appalachia exists has long been debated, but many recognize that some unique traits do exist. Serious concerns about meeting health care needs of those in Appalachia has long been associated with the number, distribution, and availability of health care professionals (Denham, Remsberg, et al., 2010; Denham, Wood, et al., 2010). Policies that support education of local persons to become nurses and health professionals are needed. The idea of “grow your own” has long been understood as a way to see that people are educated in ways needed by local communities. State policies that support opportunities for nurse practitioners and registered nurses to practice at the highest level of their knowledge and licenses are needed. Nurses with knowledge of the needs of the Appalachian region can advocate for solutions and support the use of public funding to address the disparate resources and population health needs in distinct regional areas.
Conclusions Appalachia is a political boundary assigned from outside the region. Labels intended to address residents’ disparate needs have at times set this region apart from the rest of the nation. This raises the question previously asked: Does a culture of Appalachia truly exist? The region and its people are as diverse as other groups across the nation. One might agree that some cultural traits of Appalachia’s residents are recognizable, but they are not generalizable. Nurses living and working in Appalachia must be culturally sensitive to the diversity of local people’s needs. Nurses can consider that distinct needs tied to traditions, local heritage, and values often retained even when persons relocate or migrate to places outside the boundaries of the Appalachian region.
I would like to thank the many people who have been my mentors and colleagues as I learned about Appalachia during my career and investigated the health needs of regional residents. I would especially like to acknowledge the support and learning shared with Michael Meyer, PhD, Margaret Manoogian, PhD, and Lesli Johnson, PhD. Years of collaboration with each of these colleagues has helped me gain great insights over time. Last, but not least, I want to thank Ann Rathbun, PhD, for her assistance in editing this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: While I received support from many sources over the years, I especially want to acknowledge the funding and support from the Centers for Disease Control and Prevention National Diabetes Education program to develop the Diabetes: A Family Matter program and opportunity to do other diabetes prevention work in the region.
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