Appalachian women's perceptions of their community's health threats

CONTEXT

Decades of behavioral research suggest that awareness of health threats is a necessary precursor to engage in health promotion and disease prevention, findings that can be extended to the community level.

PURPOSE

We sought to better understand local perspectives on the main health concerns of rural Appalachian communities in order to identify the key health priorities. While Kentucky Appalachian communities are often described as suffering from substandard health, resource, and socioeconomic indicators, strong traditions of community mobilization make possible positive, home-grown change.

METHODS

To assess what women, the key health gatekeepers, perceive as the most significant health threats to their rural communities, 10 focus groups were held with 52 Appalachian women from diverse socioeconomic backgrounds. Tape-recorded narratives were content analyzed and a codebook was developed. Measures designed to increase data trustworthiness included member checks, negative case evidence, and multiple coding.

FINDINGS

The following rank-ordered conditions emerged as posing the greatest threat to the health of rural Appalachian communities: (1) drug abuse/medication dependence; (2) cancer; (3) heart disease and diabetes (tied); (4) smoking; (5) poor diet/overweight; (6) lack of exercise; and (7) communicable diseases. These health threats were described as specific to the local environment, deriving from broad ecological problems and were connected to one another.

CONCLUSION

Drawing on participants' community-relevant suggestions, we suggest ways in which rural communities may begin to confront these health concerns. These suggestions range from modest, individual-level changes to broader structural-level recommendations.

Determinants of Exercise Among Older Female Heart Attack Survivors

Despite the well-known health benefits associated with regular daily physical activity, most Americans do not engage in sufficient exercise. Of particular concern are the low levels of exercise among older women, who have a heightened risk of adverse cardiovascular events. To improve our understanding of the determinants of exercise among this particularly vulnerable population, the authors undertook face-to-face interviews with 45 women who had survived a heart attack (age range = 48-88, M = 73). Upon completion of standard qualitative analytic procedures, several themes emerged as influential in shaping exercise behavior. There were multiple and connected determinants of exercise, including cognitive factors (competing demands, perceived health maintenance), life course issues (exercise as inappropriate given traditional gender expectations, positive lifelong experiences with exercise), and social and ecological environment determinants (social support, weather-related barriers). Enhancing exercise requires addressing these multifaceted and complex barriers faced by older women. Specific recommendations are provided.

The vicious cycle of inadequate early detection: a complementary study on barriers to cervical cancer screening among middle-aged and older women

INTRODUCTION

Although rates of invasive cervical cancer have declined precipitously over the past 50 years, nearly 10,000 new cases and 3700 deaths result from this cancer annually. Given the efficacy of early detection, invasive cervical cancer should no longer constitute a health threat; however, national studies reveal that many women, especially older women, do not receive Papanicolaou (Pap) tests.

METHODS

In this complementary study, we examined data from the National Health Interview Survey focusing on the correlates of screening for women aged 55 years or older, an age group in which invasive cervical cancer rates escalate and rates of obtaining Pap tests decline. To more richly understand grounded perspectives, we queried 25 women who were rarely or never screened about factors and circumstances underlying their decision not to obtain a Pap test.

RESULTS

Quantitative data indicate an association between Pap test use and demographic factors (being married, being younger, and having suburban or urban residence) and access to preventive care (obtaining mammograms, having a regular source of health care, and having contact with an obstetrician/gynecologist). Participants who provided qualitative data echoed this theme of inadequate use of preventive services, particularly among women with weak social ties, who were older, and who lived in rural areas. Shortages of health care professionals and a lack of continuity of care and privacy contribute to suboptimal prevention.

CONCLUSION

A vicious cycle emerges: many women decline to pursue preventive care because of competing health and financial demands and insufficient resources to seek care. When such women do go to the doctor's office, they feel chastised by providers, which alienates them and thwarts future preventive care.

Burden of Common Multiple-Morbidity Constellations on Out-of-Pocket Medical Expenditures Among Older Adults

PURPOSE

On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults.

DESIGN AND METHODS

We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations - hypertension, arthritis, and heart disease.

RESULTS

An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of-pocket expenditures (2,164 dollars in 1998, increasing by 104% to 3,748 dollars in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations.

IMPLICATIONS

Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders.

Human papillomavirus vaccine: knowledge and attitudes in two Appalachian Kentucky counties

OBJECTIVE

A vaccine against common high-risk types of human papillomavirus (HPV) associated with cervical cancer risk was recently approved. We assessed women's acceptance of HPV vaccination for themselves and for adolescent girls, in an Appalachian population with cervical cancer incidence and mortality rates among the highest in the United States.

METHODS

We conducted a population-based, random-digit telephone survey of over 600 adult women residing in two Appalachian Kentucky counties. The analysis focused on questions of HPV vaccine acceptance, and their relationship to several factors.

RESULTS

The majority of women indicated an interest in HPV vaccination for themselves (85.2%), but they were less accepting of a vaccine being administrated to girls of ages 10-15 (67.6%). Women who were younger, lower-income and smokers were more likely to support vaccination.

CONCLUSIONS

Although a relatively high percentage of women found the HPV vaccination acceptable for their own use, there was less enthusiasm for supporting vaccination to girls. This finding is of concern since the vaccine is being recommended for adolescent girls and young women, prior to sexual initiation. Educational campaigns will be needed for a successful vaccine implementation.

An in-depth and updated perspective on determinants of cervical cancer screening among central Appalachian women

Although cervical cancer rates in the U.S. have declined sharply, certain groups remain at elevated risk, including Appalachian women. To establish culturally-relevant cervical cancer prevention programs requires a comprehensive, current understanding of the factors which influence women's decisions to undergo Pap tests. Since most studies that found low rates of Pap test use in Appalachia were carried out decades ago, an in-depth update is warranted. Local, trained interviewers conducted interviews with rarely or never screened Appalachian women from Kentucky and West Virginia. Sessions were tape recorded, transcribed, and content analyzed. Participants (N = 25) suggested the following positive influences on obtaining screening: having an orientation toward the use of preventive health services; having health insurance and access to a good medical environment; and maintaining a flexible enough schedule to keep appointments. Screening barriers included: fear of subjecting oneself to medical scrutiny because of obesity or being a smoker; inadequate health care access such as clinician shortages, scarcity of specialty providers, long travel time to services, and clinic schedules that do not accommodate working women; and lack of providers' recommendations. Rarely mentioned were some previously reported factors including male relatives' refusal to permit Pap tests, concern over privacy, and lack of belief in Pap tests.

Factors predicting unmet health services needs among incarcerated substance users

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998-1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed.

Prospective study of black-white differences in food insufficiency among homebound elders

OBJECTIVE

This study examines race differences in the association of sociodemographic and health-related characteristics with change in food sufficiency status over 1 year in homebound older adults.

METHOD

Using sociodemographic and health-related data collected during two in-home assessments as part of the North Carolina Nutrition and Function Study, logistic regression models (binary and nominal outcomes) adjusted for covariates and examined the characteristics associated with 1-year change in risk (RFI) and presence (FI) of food insufficiency among a random sample of 268 home-delivered meals participants.

RESULTS

Not having enough money for food and having to prepare cheaper and smaller meals was associated with increased RFI and FI at 1 year; having to borrow money for food, loss of food stamps, and inadequate income increased the odds among Whites, and increased medication use among Blacks.

DISCUSSION

The findings suggest that race, independent of other characteristics, is associated with diminished food sufficiency over 1 year.

Situating stress: lessons from lay discourses on diabetes

In response to the serious toll diabetes takes on health and resources, researchers increasingly are examining physical and psychological pathways that affect and are affected by diabetes, including stress. Although biomedical researchers and practitioners are beginning to recognize the association between stress and diabetes onset and management, laypersons have long-standing and extensive insights into the multiple ways in which stress is associated with the diabetes disease process. In this article, we examine lay perspectives on stress and diabetes among a multiethnic sample of 80 adults. Participants suggest varying arenas in which stress intersects with diabetes, including stress as implicated in the origin of diabetes, as a threat to maintaining glycemic control, as a challenge to self-management, and as a precursor to and a consequence of diabetes complications. An improved understanding of such perspectives may enhance appropriate disease management and develop a more valid conceptualization of stress in research efforts.

Complementary and alternative medicine use among a multiethnic sample of older adults with diabetes

OBJECTIVE

This study describes complementary and alternative medicine (CAM) use for diabetes self-management among a multiethnic sample with an aim of better understanding lay perspectives on CAM's utility and determining whether CAM practices undermine conventional diabetes self-management.

DESIGN

During in-depth interviews with 80 older adults, data were collected on sociodemographics, the full range of self-management practices, and attitudes toward CAM. Analysis included descriptive measures of association and line-by-line coding.

SETTING/LOCATION

Trained interviewers recruited respondents from four health or social service sites. Sites were selected because they contained a large clientele of the targeted ethnic group and had been involved successfully in previous research studies.

SUBJECTS

Twenty (20) adults age 50 and older from each of the groups most adversely affected by diabetes (African Americans, Hispanics, Native Americans, rural whites) participated in the study.

OUTCOME MEASURES

Self-management strategies (included CAM) were assessed through a semistructured interview guide. Structured instruments obtained data on sociodemographics and health history. The 15-item Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) assessed the frequency of completing recommended self-management activities.

RESULTS

One in four elders reported using CAM, with respondents' cultural background associated with the CAM modality. We found no relationship between standard biomedical regimens and CAM use, supporting respondents' suggestion that CAM supplements rather than substitutes for biomedical self-management. Respondents suggested that use of CAM was limited by CAM's inaccessibility, and, underlying all, the dominance of conventional biomedical therapies that undermines belief in CAM's effectiveness.

CONCLUSION

Older adults with diabetes use a flexible configuration of diabetes-self-management techniques, including culturally specific CAM modalities. CAM use, however, occupies a limited role in diabetes self-management, largely because of the predominance of conventional biomedical regimens.

The pivotal role of cardiac self-care in treatment timing

In Western nations, cardiovascular disease (CVD) is the leading cause of death and disability, and myocardial infarction (MI or heart attack) is responsible for the most significant proportion of these deaths. Over the past decades, however, mortality rates from CVD in general and MI specifically have been decreasing due in large part to the proliferation of time-dependent therapies. As their description suggests, the use of such effective therapies is associated with early hospital presentation, thus reducing treatment time has significant benefits. Previous research most often has focused on sociodemographic or clinical factors influential in treatment timing, while the activities that individuals undertake during the critical hours prior to presentation for formal medical treatment remain insufficiently examined. Since self-care activities provide a window into how cardiac symptom sufferers conceptualize and act on their distress and, subsequently, how these conceptualizations shape treatment timing, we sought a more complete understanding of the relationship between self-care behaviours and treatment timing. Employing a complementary design, we examined data from 2972 survivors participating in the MI Onset study in the United States and 35 survivors from the MI Illness Narrative Study. Results indicate that cardiac self-care played a defining role in time to treatment, while other factors (i.e., sociodemographic and clinical factors) did not. Specifically, taking over-the-counter medications (i.e., analgesics and antacids) was associated with a longer treatment time. A closer look at who was likely to pursue these strategies and their reasons behind so doing leads us to conclude that (1) social location and self-identity; (2) previous health experiences, including personal health history and prior use of self-care strategies and; (3) social interaction play important roles in cardiac self-care responses which, in turn, shape treatment timing.

Lay referral patterns involved in cardiac treatment decision making among middle-aged and older adults

PURPOSE

This study examined age and contextually related factors that are influential in lay referral patterns during cardiac treatment decision making.

DESIGN AND METHODS

A complementary design was used. The Myocardial Infarction (MI) Onset Study identified demographic correlates of who sought medical care for 1,388 MI (heart attack) survivors. Thirty-five in-depth MI illness narratives explicated lay referral patterns.

RESULTS

Data revealed a linear association between older age and reliance on another person to seek medical attention for cardiac symptoms, with gender also shaping lay referral patterns. Although spouses and children were the most frequently cited decision makers for older respondents, friends and other family members also influenced care-seeking decisions. Qualitative results substantiated and provided explanations for such patterns.

IMPLICATIONS

Our results highlight the need for researchers to attend to the complex social processes of lay consultation and for health education messages to extend to venues where lay cardiac decisions are made, including the worksite and social gathering places such as religious institutions. Enhanced outreach includes tailoring health messages to elders and their significant others and casting a broader net to include nontraditional significant others.

Body image among older, rural, African-American women with type 2 diabetes

Type 2 diabetes and obesity co-occur in high prevalence among African-American women. The positive value placed on large body size has both historic and contemporary biosocial relevance. The maintenance of weight at medically recommended levels is a cornerstone of both prevention and treatment of Type 2 diabetes. This study of overweight, elderly, rural African-American women with Type 2 diabetes found they generally preferred smaller body sizes compared to previous studies. Normal to slim body images as presented in a photographic array were selected as being more attractive, less likely to have diabetes and hypertension, healthier and to be more medically compliant than obese, grossly obese or very thin images. Body image is a psychosocial variable that should be included in weight control initiatives.

Variations in nutritional risk among black and white women who receive home-delivered meals

The maintenance of good nutritional status is a cornerstone of health, function, and quality of life. To assess indicators and correlates of high levels of nutritional risk, sociodemographic, functional status, and nutritional data were collected from a diverse sample of 729 older women. Results from ordered logit analysis indicated that being Black, having an income < or = 125% of the federal poverty level, living alone, and being in the younger-old age group (ages 60 to 74 years) were associated with moderately high and very high levels of nutritional risk. An examination of individual and multiple nutritional risk indicators suggested a heightened vulnerability of Black women to inadequate dietary intake, even net of income and other influential variables. With demographic projections of an increasingly numerous and diverse older population who may face health and nutritional challenges, researchers must strengthen efforts to assist policymakers and service providers to properly target nutrition services.

Unraveling the mysteries of timing: women's perceptions about time to treatment for cardiac symptoms

Women in the USA are at disproportionate risk of dying from a myocardial infarction (MI), of suffering disabilities following an MI, and of reinfarcting and dying within a year of their initial MI. Various explanations, including women's older age at clinical manifestation of coronary heart disease (CHD) and higher likelihood of co-morbidities, have been offered for women's heightened risk of poor outcomes. Less frequently, research has focused on examining women's prolonged time elapse between symptom onset and biomedical treatment, a phenomenon that renders women less likely to undergo lifesaving reperfusion strategies. [1] To explore factors and circumstances that may shape CHD time to treatment, 40 middle age and older women living in Kentucky, USA, half with diagnosed CHD and half with chronic conditions considered to be risk factors for CHD, participated in a series of in-depth interviews. While much of the existing CHD literature implicates individual responsibility as the determining feature in time to treatment, these women's narratives suggested that treatment decisions inextricably are linked to broader social and structural constraints. Such supra-individual forces that shape the CHD experiences of women include the social construction of "standard" cardiac symptoms based on male norms that ultimately confuse symptom detection, women's negative encounters with health care providers who discount their knowledge, the competing social demands women face when threatened by a serious illness, and structural barriers delimiting women's health care choices.

Articulating silences: experiential and biomedical constructions of hypertension symptomatology

In this article, we explore the flexible configuration of a local knowledge system about hypertension symptoms, foregrounding it against prevailing biomedical assertions regarding the asymptomatic or "silent" nature of hypertension. The complex and coherent knowledge system held by older African Americans living in a southern, rural community stands in contrast to the current scientific discourse and local biomedical perspectives on hypertension symptomatology. The older African American participants in this study apply local knowledge of hypertension symptomatology to make health decisions nearly every day. Despite this, most biomedical practitioners maintain a distance from these lay sources of knowledge, often remaining stalwart in their refusal to recognize the existence or influence of symptoms. We conclude that authoritative knowledge ultimately lies in the minds and bodies of the elders, who have encountered symptoms as guideposts that direct action, rather than with a biomedical "reality" that is yet unresolved.

Lay explanations for Kentucky's "Coronary Valley"

Kentucky and its neighboring states have some of the highest coronary heart disease (CHD) mortality rates in the United States, leading researchers to nickname the region "Coronary Valley." Currently, little is known about factors that account for "Coronary Valley"; however, understanding lay perspectives on CHD risk factors may provide insights into this high prevalence of CHD and may guide prevention efforts. In December 1999, a statewide telephone survey was administered to a random sample of Kentucky residents to elicit lay explanations for the high rates of CHD. Standard protocol for descriptive statistics was undertaken. Respondents (N = 624) identified most of the biomedically acknowledged risk factors, with an overwhelming majority acknowledging that high rates of smoking and poor diets contribute to CHD. Older respondents and those who reported having heart disease were more likely than others to identify factors beyond their control, including stress and pollution (p < .0005 and p < .00 1, respectively). After controlling for the presence of heart disease, age differences remained significant only among those who reported no heart disease. Education had marginal significance (p = .027) on explanations for CHD, while gender, racial or ethnic background, and type of community residence had no significant effects. Since most Kentuckians are aware of traditional risk factors underlying CHD, prevention efforts should be directed at removing structural and information barriers to behavior change (e.g., by providing smoking cessation programs) rather than limiting prevention efforts to traditional health education approaches (i.e., increasing knowledge of CHD risk factors).

The Kentucky Homeplace Project: family health care advisers in underserved rural communities

The Kentucky Homeplace Project (KHP) is a state-legislated program designed to address well-documented deficits in the health status of and health resources available to many of Kentucky's rural residents. Since its inception in 1994, the KHP has served approximately 80,000 clients, primarily through home visits by trained, locally residing paraprofessionals known as family health care advisers. These family health care advisers employ culturally appropriate strategies to meet immediate needs as well as to foster long-term client empowerment and the adoption of health prevention strategies. This descriptive examination of KHP provides information regarding (a) the advantages of the program, with specific attention to its orientation toward provision of culturally appropriate health services; (b) the disadvantages of KHP, including competing budgetary priorities and its vulnerability to local economic and political trends; and (c) the potential application of similar programs for other rural, difficult-to-reach populations.

Barriers to non-insulin dependent diabetes mellitus (NIDDM) self-care practices among older women

OBJECTIVES

Noninsulin dependent diabetes mellitus (NIDDM) constitutes a significant threat to the health and well-being of older women. Appropriate self-care, the cornerstone of glycemic control, is reported to be modest. We aimed to investigate barriers to recommended self-care for NIDDM:

METHODS

A total of 51 African American and White women age 65 and older, completed the Diabetes Self-Care Barriers Assessment Scale for Older Adults, ethnomedical protocol, and other instruments during in-depth interviews.

RESULTS

African American women were more likely than their White counterparts to indicate financial, pain, and visual barriers to self-care. Both African American and White women expressed a reluctance to check blood sugar and to exercise; however, most indicated that they regularly followed medication recommendations and visited their physician.

DISCUSSION

This study extends our knowledge of the existence of self-care barriers by providing a qualitative, in-depth perspective detailing how these barriers often prevent optimal self-care behaviors and, conceivably, successful glycemic control.

Physicians and clergy as facilitators of formal services for older adults

Researchers have sought to understand the determinants of the use of in-home and community-based services in order to better serve the needs of older adults. One component frequently included in formal service utilization models is the role of individuals who exert an influence on the service use process. An analysis of in-depth interviews conducted with 115 older adults revealed the important facilitating role that physicians and religious leaders play in encouraging the use of these services. The sample, which included African-American and white adults age 65+ from rural and urban environments, described various ways in which these "facilitators" influence the use of formal services. These ways include: (1) supplying instrumental support either by "ordering" a particular program for or linking the elder with the program and (2) providing informational and affective support, including advising or recommending the use of a program, conveying necessary background on formal services, and legitimizing the use of formal services. Regardless of personal characteristics (such as ethnicity and residence), a majority of elders in the sample recognized the important role played by physicians, and clergy. The acknowledgement of the role played by these facilitators should be viewed as an opportunity for physicians and clergy to enhance the knowledge and appropriate use of needed formal services for elders. In addition, these findings have policy implications for the current provision of aging services.

Residential differences in attitudes about barriers to using community-based services among older adults

Despite poorer health, rural elders tend to use fewer community-based services than their urban or suburban counterparts. Researchers have speculated that residential differences in the receipt of community-based services may be attributable to, among other factors, the attitudes of older adults toward such services. Twelve focus groups were conducted to explore residential variation in the attitudes of older adults toward the use of community-based services, specifically emphasizing perceived barriers to the use of services. While both rural and urban residents expressed overall satisfaction with the services that they had received in the past or currently receive and both groups noted insufficient community-based services, residential differences emerged in both the nature of the perceived barriers and the frequency in which they were mentioned. Rural elders more frequently highlighted barriers that diminished their use of community-based services. Such barriers included a lack of awareness of services, inadequate transportation, and perceived rigid program eligibility standards. Urban older adults mentioned far fewer and different barriers to the receipt of services, but those barriers seemed to be consistent with the community context in which they lived. While these findings support speculations that differences in attitudes may account for some of the residential variation in the use of community-based services that has been observed, the conclusion also can be drawn that, regardless of residence, older adults face substantial barriers to services, resulting in unmet needs.

The relationship between perceptions of social support and adherence to dietary recommendations among African-American elders with hypertension

Social support is generally thought to facilitate adherence to recommended treatment regimens. Despite a well-documented tradition of social support among African Americans, much of the existing research indicates a very limited level of adherence, especially to dietary modification. To account for this seeming contradiction, forty-one rural-dwelling African Americans with hypertension age 65+ participated in a series of structured and semi-structured interviews. Results indicate that 1) informants perceived themselves to be well-supported by family and friends; 2) most informants have achieved a moderate to high level of dietary adherence; and 3) no statistically significant relationship existed between perceived social support and dietary adherence. The discussion focuses on three reasons for this lack of association, including: 1) modest sample size; 2) informants' identification of helpful others who defied standard evaluations of support; and 3) incremental and gradual dietary changes that required little need for social support.