The young learn from the old as skills are passed from generation to generation.
In the lush coves and shady hollows of rural Appalachia, life moves at an easy pace. Tb the outsider, the area may appear poor, behind the times, and moribund. To the mountaineer, the area is rich and alive in music, folklore, love, and tradition. The elderly Appalachian holds dear these cultural traditions.
Appalachia extends more than 1000 miles across 397 counties in 13 states to include parts of Kentucky, Alabama, Georgia, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and the entire state of West Virginia.1 Although Appalachians have migrated to large cities such as Cincinnati, Detroit, and Chicago, they have retained their unique cultural characteristics, always seeing the mountains as the home to which they will one day return.
The dramatic growth of the aging population in the United States has made the psychological and physical health of older persons a cause of particular concern for health care professionals.
The elderly residents are more susceptible to illness as they are characteristically subject to a variety of significant life changes, including loss of the work role, declining income, changes in physical functioning, death of friends, and illness or death of a spouse.23 In caring for Appalachian patients and their families, it is important to understand their culture and its impact on the care given by the nurses and other health care workers. Differences in cultural styles can create misunderstandings between nurses and their patients particularly when the nurses have not invested the time to learn about the culture of their patients. Attempts to incorporate traditional, middle class values may be met with resistance by Appalachian patients.
The term "Appalachian" covers a wide spectrum of individuals, all of whom may not fit the stereotype presented in this paper. Although there are definite cultural patterns in the area, patients should be treated as individuals. It is important to realize that those characteristics which are the most unique and the most beautiful about the culture can be the same things that create many of the problems for its people.
Living conditions for some elderly may be below standards by middle-class values. Some older Appalachians have no runniiig water, no electricity, and no indoor plumbing.
In ancient societies, the elders often occupied positions of power and dignity, since it was through their memories that the culture was preserved and transmitted. In Appalachia, the elderly also hold positions of honor. One expert states that, in general, the Appalachian attitude toward the elderly is one of great respect and caring. They are much more likely to be kept at home, "looked out after" and cared for by their families.
Cultural Impact on Health Care Delivery
A number of historical factors influence the culture of Appalachia. Those who originally settled the area were a rural, farm-oriented people who purposefully built their homes in dispersed farmsteads far away from neighbors. Still, today many families live on small farms away from neighbors, often located in what is referred to as "up the holler". Although the mountaineers value their privacy and prefer to be left alone, this has contributed to their isolation. Even the very nature of the terrain in the Appalachian mountain region has created a physical isolation.4 This has contributed to the social and cultural isolation, causing the mountaineers to respond to change less rapidly than the rest of society.
This isolation affects nurses in a multitude of ways. The distance from health care centers, coupled with bad roads, renders it difficult for patients to obtain services. Other patients live in such isolated areas that once the road ends, visiting nurses must walk or ride horse back a mile or more up the mountainside to reach their homes.
Availability of health care staff, inpatient facilities, and services are limited in Appalachia, forcing nurses to work with minimal or no peer support. Frequently, physicians are available only on a part-time basis or by telephone. Recruitment of staff is a continual problem and those hired may not be adequately prepared to deal with the situations presented. Understaffing of agencies creates a blurring of roles between health and human service agencies so that nurses may have to assume the role of social worker, welfare officer, or even taxi driver.
Folk Culture, Medicine and Remedies
The Appalachian people who descended from the Celts exhibit the early Scottish-Irish tendencies toward superstitions, magic, and the occult. In the mountains some of the old burial customs can be seen. For example, graveyards may be built on hilltops rather than in valleys because of a fear of the grave being covered with water. Another superstition seen in some elderly Appalachians is that if a body is "dug up" and reburied, that person won't go to heaven.
The elderly especially seek out the old "granny-woman" or "herb doctor" for medical remedies even when they have been given a medical treatment plan to follow. These folk "healers" are relied on because they are home-folks, known to everyone, speak the language, and therefore, can be trusted. The herbs used by these folk healers (ginseng, foxglove, yellow root, and others) have been shown to have some medicinal value, although the strength of the drug used in home remedies may be weaker than in a pharmaceutical preparation.
In Huntington, West Virginia, one such herb-doctor is known as "Catfish Man of the Woods." A resident physician on one occasion thumped his fist on the desk and exclaimed loudly to a patient, "You tell me where I can find this 'Catfish' !" The doctor was angered because the patient, following hospitalization and treatment for congestive heart failure, had elected to cease taking his prescribed medication and went to Catfish for "herb medication." Consequently, he developed an exacerbation of his condition, resulting in readmission to the hospital. Dealing with such cultural beliefs and superstitions can be both fascinating and exasperating.
Mountaineers have an initial mistrust of strangers, which may at times include persons not only from afar, but even as close as the next county. Years ago outsiders came to Appalachia and exploited the people, taking their lumber, coal, and land. One must realize that mistrust of outsiders is not unjustified given these circumstances. Health professionals in Appalachia are frequently cultural outsiders whose purpose and unfamiliarity make them suspect. Foreign-born physicians have an especially difficult time developing rapport with Appalachian patients because of language, skin color, and cultural differences. Nurses must allow ample opportunity for establishing rapport and a working relationship with elderly Appalachians if they are to be effective caregivers. This can most easily be done by taking time to listen and converse with these patients and their families, using language that they understand, and even asking the patient's advice. For example, one health professional discovered a patient's knowledge and interest in repairing automobiles, and had the patient tell him how to repair his vehicle. This not only helped to establish rapport between the health care professional and the patient, but it also gave affirmation to the patient's own sense of worth. In addition it utilized the Appalachian concept of bartering for services or "swapping."
Language Use and Abuse
As mentioned above, the language of Appalachian patients is important in health care. Appalachians are "personoriented" as opposed to the urban middle class who are "object-oriented." They view and accept others as "whole individuals," not seeing them in "roles." Because of this, they are more accepting of individual differences and more tolerant of deviant behavior in others. Their use of language reflects this. Emotional problems are referred to as "bad nerves" while neurotic behavior may be viewed as persons being "odd-turned" or just "getting old." This can mean that illness is severe before hospitalization is sought. In Appalachia it is "not o.k." to be "crazy" or "have something wrong with one's mind", while it is permissible to have "bad nerves." One elderly Appalachian patient moved with her family to Chicago. She was referred to the local community mental health center and received a diagnosis of severe depression. At home in the mountains she was merely seen as "quiet turned" and actually functioned quite well in that environment.
William Sexton and Margaret Adams celebrated their one hundredth birthday on April 16, 1985. They are the oldest living fraternal twins on record. Both have lived their lives in Kentucky.
The Appalachian person-oriented viewpoint and inability to see others in roles can create problems for nurses who are employed by the federal or state government. Nurses are often seen as representatives of the entire governmental system with all of its power and may be expected to single-handedly solve any problem presented. And, if nurses don't, patients may believe they have "something against them."
An ambulatory health care nurse practitioner at a West Virginia Veterans Administration Medical Center who was a native New Yorker, examined one elderly gentleman whose chief complaint was "bats." On closer questioning she discovered that "bats" was not slang for a clinical condition but that the gentleman had come to the clinic because at night bats flew down his chimney into his house. He viewed the nurse as "the government" and therefore an appropriate source to solve his problems!
Health practitioners will find it most beneficial to use the language the mountaineers use, and only in appropriate situations correct the language or educate toward more scientific usage.
The Appalachians' person-oriented outlook and easy going pace makes them more aware of body rhythms than of time schedules and clocks. It is often necessary to "sit down and visit a spell" with the patients before proceeding with an examination or treatment. It is quite common for Appalachian patients to arrive for medical or psychiatric appointments when they "feel ready" rather than when the appointments are scheduled. If the practitioners refuse to see the patients when they do come, they may not return.
Staring is considered impolite in Appalachia and patients may not make eye contact when talking with nurses. Thus, in Appalachia, lack of direct eye contact must be evaluated differently than in middle-class America.
Appalachians value their rugged individualism. They also have an intense feeling about privacy and what is "their own business." They fear being misunderstood, offending someone, or encroaching on another's rights. For this reason, patients may tell nurses what they think nurses want to hear rather than what actually "is." Their intent is not to lie, but rather, not to offend. In working with Appalachian patients, nurses should phrase questions tactfully to elicit their patients' true feelings. They should drop hints when possible, rather than give direct orders. The outspoken approach of some "outsiders" may be interpreted as anger, rudeness, or criticism, and is offensive to Appalachians. Mountaineers are generally clannish, as described by the phrase "blood is thicker than water. " Everything is taken very personally by them and they believe they should settle their own problems and conflicts.
Interpersonal relationships in Appalachian communities are characteristically intense and face-to-face, making it difficult to maintain confidentiality. This high visibility of both health care professionals and patients leads to the rejection, particularly of mental health services because of the stigma attached. Social life and emotional security are centered in reference groups which are important throughout the Appalachian's life.5 The reference group is composed of persons of the same sex; similar age,· circumstances, and status; and are often relatives. It is not unusual for husbands and wives to belong to different groups as segregation of the sexes prevails. These groups are so dominant that spouses tend to pull away from each other toward their reference groups.
The family is extremely important to Appalachians. The system is described as an "extended family" with grandparents, parents, children, aunts, uncles, and cousins living in close proximity to each other and leading interdependent lives. Grandparents often raise children if both parents work. The family system is cohesive during times of crisis, providing a sense of security and caring for its members. This close family network also provides a clear identity and sense of belonging. They know who they are, and feel that no matter what, they can always come home. The interdependence of the family can be detrimental at times, however, by not allowing members the freedom to go to a hospital in a distant city.
When Appalachians are ill, the families rally around to help provide care. If a family member requires hospitalization in a far city, at least one family member will usually accompany him. Nurses should facilitate this whenever possible, giving thoughtful consideration to the family structure and role of its members. Traditionally, mountaineers fear hospitals, believing people only go there to die.
Religion, which has a powerful affect on the elderly in Appalachia, can be described as largely fundamentalist and fatalistic. It is fundamental in that lives must be lived by very clear and distinct rules. It is fatalistic in that people respond to life with the attitude, "If that's the way God wants it, then I reckon that's the way it'll be!"6 The people of Appalachia may often resign themselves to life's struggles rather than trying to make necessary changes. This viewpoint serves as a buffer in times of conflict, disappointment and death, but may be a problem when patients perceive a mental or physical illness as punishment for "not being right with God." Fatalism may also mask or be confused with chronic depression. It can prevent patients from seeking treatment, believing that no one or nothing can help. Nurses must to the best of their ability utilize clergy and religion to aid patients toward wellness.
Appalachian Attitudes Toward Health Care
In Appalachia, there is a very clear distinction between the role of the well, self-sufficient mountaineer and the role of the one who is ill. During illness, personal space collapses inward, creating a role reversal so that the patient expects to be "taken care of" and "waited on."7
Likewise, there is a resistance to preventive medicine. For example, in one county, primary care physicians have found it very difficult to convince the people that cleaning up the dumps might reduce the incidence of infectious diseases.
There is a tendency among the elderly in Appalachia to take medicine only when they think they need it, and then they believe that "if one dose is good, two must be twice as good!" One elderly female who suffered from hypertension and was placed on medication is a case in point. She was given several carefully detailed explanations of the effects of the medication, the reason for it, and why it had to be taken regularly. On questioning by the nurse and family she vowed that she was taking her medicine. Only when she was taken to the emergency room with BP of 180/130 and extreme shortness of breath did she finally admit to taking her medicine only when she felt bad.
When elderly Appalachians go to their physicians, they expect help there and then. If the physician dispenses medication at the office he has "helped" the patient. However, if he gives the patient a prescription this may be seen as rejection.
Community health nurses may find that living conditions for some elderly patients are substandard by middleclass values. These homes may have no running water, no electricity, and no indoor plumbing. They may be heated with an open fire or a coal stove making equipment like oxygen too dangerous to use. Many elderly Appalachians refuse to leave these homes where they have lived all their lives. A story is told of one elderly lady who had problems with the gas company when they claimed that she had not paid her bill. She held steadfastly to the fact that she had paid it and refused to pay it twice. The gas company turned off her gas and seemed to believe when she began to freeze she would pay the money. But this brave soul kept herself warm by heating with coal gathered along the railroad tracks just as she had as a child.
Family Is extremely Important to Appalachian elderly.
In summary, it must be emphasized that individuals within a culture are influenced by the culture, and individual differences persist. Over the years, the Appalachian mountain environment has produced a rich heritage that has a great deal to offer man in today's complex world. Though inevitable and often unfortunate changes may take place in the elderly, the wisdom, independence, caring, and serenity of the Appalachian people are tremendous strengths which nurses can utilize in assisting their patients to cope with the aging processes.
The authors wish to express special appreciation to Larry C Smith MD.
Staff Psychiarist, VA Medical Center, Huntington, West Virginia for his assistance in preparation of this manuscript.
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