Globally and locally, a need exists to reduce or eliminate health disparities in vulnerable populations, including rural and multicultural groups. Within the United States, approximately 25% of Americans, or 61 million individuals, live in rural communities with fewer than 2,500 residents. In general, rural populations experience higher rates of heart disease, cancer, injury-related deaths, diabetes, and depression than do urban populations. Furthermore, rural communities are characterized by lower rates of personal income, educational attainment, health-insurance coverage, access to emergency and specialty care services, and selfreported health status than are urban communities (Magilvy, Congdon, Martinez, Davis, & Averill, 2000; Steel, 2001; U.S. Department of Health and Human Services, 2000). As a social group with special concerns, rural elderly populations in the United States are likely to fall out of the societal mainstream, intensifying the need for goods and services to which access is already compromised. Approximately 15% of the U.S. rural population is at least 65 years of age, and both the median age and the ethnic diversity of that population has increased significantly in recent years (O.S. Census Bureau, 2001).
Figure. The Big Picture: Merging critical ethnography and community-based action research. Note: Although the activities shown in the Figure are presented in a linear fashion, they may not necessarily proceed in the order suggested. Because data in qualitative studies are context-dependent, and because researcher-participant dynamics may lead to changes throughout the course of the research, flexibility is required, and it may be necessary to revisit earlier actions.
Specific health care challenges for rural elderly individuals often include inadequate access to health care resources; difficulty navigating the dynamics of the managed care system; and barriers related to culture, history, economics, language, geographic isolation, and local norms (Hamman et al., 1999; Kienzle, 2001; Magilvy et al., 2000). Analyzing and resolving the complex problems facing multicultural rural elderly individuals begins with understanding the perceptions they have related to their health care. Their perceptions influence the likelihood of planning and delivering health care that is congruent with local values and priorities and that fits within community contexts and resources (Bushy, 2000; Sen, 2001).
Strategies for investigating health care issues for multicultural rural elderly individuals and resolving health disparities demand efficient, creative efforts grounded in the realities of local residents. At a time when health care resources are stretched, it makes sense to combine the best efforts of both researchers and clinicians in the work of improving health status for this vulnerable population. In her address to a recent national conference on rural minority health, Singleton (2000) identified the following priorities in both research and practice for multicultural elderly individuals:
* Cost-effectiveness of the service network.
* Culturally competent providers and researchers.
* Accessibility of care within the communities of residence.
* Comprehensive services to serve the particular health needs of residents.
* Participation of patient groups and community members in care planning.
Angel (2003) further advocated the need for changes in policies directly effecting the planning and delivery of care to elderly immigrants who often lack access to needed services and goods. Based on these priorities and recent research findings, the purpose of this article is to explain how critical ethnography and community-based action research can merge to help capture the perceptions of elderly individuals and initiate the reduction of health disparities. Implications for both researchers and clinicians are included.
An illustrative diagram of these ideas appears in the Figure above. The process depicted in the diagram is intended to pinpoint critical activities, which usually occur in a circular, not linear, fashion. Any effort to reduce disparities must incorporate multiple perspectives and voices, honor local preferences, and be flexible enough to adapt to unanticipated changes. It should not be expected that the process proceeds predictably and sequentially, only that the actions suggested in the diagram are necessary components of a collaborative problem-solving effort, whether in research or practice.
It is the author's contention that the research strategy described in this article represents an approach to health care that benefits both practice and analysis. Central to both is the idea that in all community-based efforts to reduce health disparities and improve health status, a partnership or collaboration between the targeted population and the care providers or researchers is the surest, most ethical way to create needed change. Therefore, the description of critical ethnography and community-based action research extends an option for how to understand the needs of multicultural rural elderly individuals and how to respond sensitively and effectively to those needs.
The author's research thus far has involved two critical ethnographies in communities in the southwestern United States. Both studies involved groups with documented disparities in health care services, and both studies evolved from the need to acknowledge and articulate the perspective of the residents themselves. One study focused on a group of retired migrant farm workers in Colorado (Averill, 1997), and the other focused on a group of multicultural rural elderly individuals in an area of southwestern New Mexico severely compromised by recent economic decline, located near an international border (Averill, 2002a,2002b,2000c).
A strength of this approach is that the author is the original researcher, with ready access to the raw data from the two studies. Increased richness and depth of understanding may be obtained from two studies, especially for the collective refinement and generalizability of rural health contexts (McCormick, Rodney, & Varcoe, 2003). Community-based action research has been successfully applied in settings involving underserved and marginalized populations (Bourke, 2002; Krieger et al., 2002; Nelson, Ochocka, Griffin, & Lord, 1998; Schulz et al., 2001). It is proposed as part of an overall strategy to improve the health status and health outcomes for multicultural rural elderly individuals. Although this recommendation involving qualitative interviews and contextual analysis yields valuable results, it also poses methodological or operational challenges.
METHODOLOGICAND OPERATIONAL CHALLENGES
The methodological and operational challenge can be divided into three essential domains:
* Evoking participants' perspectives in natural field or community settings.
* Conducting ethnography in the criticalist tradition.
* Integrating relevant sociopolitical contexts (e.g., rurality, aging, history, culture, economics, healdi disparities).
A brief explanation of each domain, applied to the two studies for illustration, may serve as a stimulus for other investigators or health care providers interested in collaborative strategies.
Tyler (1986) argued, "The whole point of evoking rather than representing is that it frees ethnography from mimesis and the inappropriate mode of scientific rhetoric that entails objects, facts... verification...." (p. 130). Identifying participants for critical ethnography and evoking their authentic perspectives in settings familiar to them demands a synthesis of epistemology, research ethics, and effective communication (Scheper-Hughes, 1992). Doucet and Mauthner (2002) referred to this process as "knowing responsibly" (p. 124). It is the process by which the investigator develops and nurtures supportive relationships with participants, emphasizes accountability, and employs a measure of reflexivity. Issues of power, privilege, and process are woven into all phases of the research process, resting on the values of empowered relationships, commitment to social change, and ongoing learning for all concerned (Nelson et al., 1998). In the case of this research, the ultimate outcome is to improve the health status of rural elderly individuals while democratizing and rebalancing the relative power of local stakeholders in shaping the consequences of their health care decisions.
For the two studies, this was accomplished by first establishing workable, trusting relationships between the researcher and key community members. This activity is shown as the essential first step (A) in the Figure on p. 12. Visiting the rural communities before the actual investigations for the purpose of explaining the research, meeting important stakeholders in the health care community (e.g., care providers, care managers, community planners, elderly advocates), and identifying local viewpoints related to health care for rural elderly individuals provided needed access to the elderly individuals themselves.
By Grafting open dialogues with the stakeholders, becoming accessible through a variety of communication modalities, and being physically present in the communities for extended periods of time, the researcher was able to identify multicultural elderly individuals through home-health agencies, hospice agencies, hospitals, primary care clinics, community educational outreach clinics, and senior centers. Partnerships were established not only between the researcher and the elderly individuals, but also between the researcher and care providers, for the purpose of better understanding the challenges of rural health care and making improvements based on the circumstances unique to the communities.
General research questions, generated by the researcher in the context of known facts, literature, and curiosity guided the interaction with informants. However, the participants contributed their own perspective to the wording and prioritization of the actual questions. After this foundation was in place, ethnographic data generation (B in the Figure on p. 12), or dialogue with the participants, began.
The first study was a critical ethnography designed to explore the meaning of health, health care perceptions, and health care experiences of a group of rural Hispanic elderly individuals in northeastern Colorado. Research methods included ethnographic interviews, participant observation in daily life, photography, and critical analysis. Critical analysis consisted of conceptually linking the various data, key ideas, and contextual phenomena (e.g., history of exploitation of migrant farm workers) in thematic analysis and derivation of meaning (Kincheloe & McLaren, 2000). The research elicited responses from 23 elderly participants and 20 family members, acquaintances of the elderly individuals, and clinicians.
All of the elderly individuals shared a history of migrant farm work in northeastern Colorado, with an average of 4 to 6 years of public education and little involvement in mainstream community activities. Conceptually, the most significant definition of health in this population was the ability to get out of bed each day and engage in family activities, work, and chores. Many Hispanic families in the region routinely experienced economìe, linguistic, or ethnic discrimination from the mainstream community, complicating their interactions with health care providers. Based on the findings, implications for clinicians included the use of community outreach activities, family-inclusive strategies in practice settings, recruitment and retention of more bilingual and culturally competent health care providers, and the establishment of dialogue involving Hispanic residents (including elderly individuals), health care providers, and employers in the region in an effort to clarify and resolve problems (Averill, 2002b, 2002c). Efforts to improve practice and care delivery in the region are ongoing.
Building on the initial investigation, the purpose of the second study was to examine the meaning of health, health care perceptions, and health care issues for rural elderly individuals in southwestern New Mexico, a region suffering economic hardship with the demise of the mining industry. A total of 22 individual interviews with rural elderly individuals, family members, and health care providers in the community contributed valuable knowledge about significant problems. Rural elderly participants identified the following issues as most concerning to them:
* Social isolation and loneliness.
* Depressed local economy secondary to the decline of the copper mining industry.
* Limited access to basic primary care, home health care, specialty care, and hospice care.
* Limited public transportation in the towns and no public transportation for outlying areas.
* Fragmented service network for health and social services and severe deficiency of assisted living options in the region.
* The escalating cost of prescription medications in a setting where most elderly individuals live on low, fixed incomes.
* Barriers related to language, difficulty understanding managed care, turnover of care providers, and unsettling interactions with care providers.
The definition of health for this culturally diverse population of rural elderly individuals encompassed the ability to be active in the family and home, the stamina to avoid contact with the health care infrastructure, the inclusion of mild exercise and social interaction in daily life, eating favorite foods, and maintaining a spiritual connection to either a church or other fundamental beliefs. Health status was often linked to the ability or inability to obtain an ongoing supply of prescribed medications to manage chronic conditions, such as heart disease, hypertension, diabetes, or lung disease. Findings compare with those occurring in other rural elderly populations (Averill, 1997; King & Wynne, 2004; Magilvy et al., 2000; National Rural Health Association, 1999), and suggest the need for clinicians to consider patient teaching, history taking, and health planning in the context of the elderly individuals' identified perceptions.
Specific procedures used to invoke the perspectives of elderly individuals and other stakeholders included (Harper, 2000; Pink, 2001):
* Field notes.
* Reflective journal.
* Ethnographic interviews and dialectic about perceived health issues.
* Participant observation in daily life, including health care encounters.
* Selected photographs of elderly individuals and their pets, dwellings, surroundings, and local ecology to bring visual knowing into the overall data generation process.
* Archival review (e.g., local newspaper accounts of economic factors, policies of agencies related to eligibility for health and social services, books by local authors on the history of the region).
In the New Mexico study, an additional strategy involved participating in a community dialogue group recently convened by local residents to address transportation needs of elderly individuals unable to drive to appointments or businesses. The group welcomed the researcher's efforts to identify and articulate the elderly individuals' specific health-related concerns. This early relationship with the community-based group will be valuable in subsequent phases of investigation aimed at problem solving and reduction of disparities (Krieger et al., 2002; Mullingset al., 2001).
Ethnography in the Criticalist Tradition
Descriptive ethnography arose in the social sciences as a method to study and describe cultures and groups that differed from the mainstream society familiar to the researcher and the consumers of research literature, often without a sense of context and engagement with participants (Patton, 2002; Scheper-Hughes, 1992; Singer & Baer, 1995). However, ethnography in the criticalist tradition openly questions the inequities of power, access, privilege, wealth, and use of research findings that exist between investigators and potential participants (Patton, 2002). Based on the tenets of critical social theory (CST), see the center of the Figure on p. 12, that aim at exposing disparity and emancipating affected populations (Thomas, 1993), critical ethnography "becomes a civic, participatory project, a project that joins the researcher -with the researched in an ongoing moral dialogue" (Denzin & Lincoln, 2002, p. ix).
The emancipatory, participatory implications of CST are central to the entire process - this accounts for placement of CST at the heart of the diagram. Thus, establishing repeated discourse with community residents and incorporating their thinking into the planning and implementation of both research and practice remains an essential moral imperative of critical ethnography. In these studies, the researcher sends periodic newsletters to community advisors and stakeholders, conducts telephone consultations and updates with key community members every few months, and travels to the rural communities periodically to speak personally with informants and to share updates on the progress or phase of the research.
In the context of CST, the focus of the inquiry is on the discovery, interpretation, and application of local knowledge to resolve local problems - even when those problems and the knowledge behind them may be analyzed in a larger frame of reference, such as national and international rural health. The partnership forged between the researcher and participants is aimed at reducing documented health disparities, such as accessibility to culturally appropriate primary and specialty care, the acquisition of needed prescriptions, and transportation to health-related appointments. This approach is the basis for community-based action research, based on Stringer's (1999) scheme of Look-Think-Act. Findings from the two studies constitute the Looking phase, in which initial assessment, description, and preliminary analysis pinpoint focus areas for subsequent intervention. Thinking and Acting, in partnership with the communities for both research and practice, remain future goals of the work.
Integration of Relevant Contexts
Contexts refer to all relevant features, conditions, situations, events, creations, and surroundings that affect a particular setting (Agnes, 2000) as part of collecting necessary information (C in the Figure on p. 12). Minkler and Wallerstein (2003) identified familiarity with local residents, situations and conditions; unique needs; and strengths and assets as pivotal contextual components. In the case of this research, contexts critical to analysis of issues for rural elderly individuals included rurality, aging, history, culture, economics, and health disparities. As data were generated in the two settings, knowledge emerged about the following contextual elements:
* Local individuals (i.e., elderly individuals, family members, local health care providers and planners, other key community members) and their length of residency, which influenced responses to research questions. For instance, residents who had lived in either study area for a lifetime or for at least 40 years viewed health as avoidance of contact with the health care system and ability to be active and autonomous in daily life, regardless of chronic health conditions. More recent retirees to the areas tended to define health as a function of proper diet, exercise, and regular checkups with their providers.
* Local conditions, such as the severe recession in the mining industry, major changes in agriculture techniques (e.g., more automated farming, decreased use of human labor), the decrease of ranching and farming as economic mainstays, societal changes associated with increased technology, water shortages for agriculture, and the changing family structures as younger family members moved away to secure better employment - sometimes leaving behind elderly individuals or changing the way in which daily care needs for the elderly individuals are managed.
* Local events, such as the closing of indigent health care clinics and local hospitals; the closing of mines and resultant layoffs of workers; the hiring of more and younger workers to support industries such as meat production, computer technology, and housing manufacturing; and the decrease in benefits for workers' families (e.g., health care benefits).
* Health care needs for an increasing population of multicultural rural elderly individuals, such as the need for more primary and specialty care providers; increased demand for assisted-living facilities; need for education about chronic disease management (e.g., cardiac disease, diabetes, arthritis, sensory impairment); need for resources to assist with the acquisition of prescription medications to manage chronic conditions; need for transportation for elderly individuals unable to drive or access other means of travel; and concern for a health care system increasingly perceived by the elderly individuals to be inefficient, insensitive, and culturally ignorant.
* Strengths, assets, and resources available to assist with problem solving, such as elderly individuals' own life experiences and health maintenance strategies; dedicated groups of local health care providers actively working to integrate and streamline available health care resources; in one location, the existence of a community-based group focused on identifying and resolving problems of interest to the greater community (e.g., a van to transport elderly individuals to and from medical appointments) (Averill, 2003).
Data generated in interviews, meetings, archival review, participant observation, and photography were merged with these contextual findings in an effort to integrate relevant details into study findings. Consistent with qualitative traditions, data were analyzed (noted as D in the Figure on p. 12) using the processes of reflection, analysis of interviews for conceptual clustering of ideas (e.g., high cost of prescriptions, inadequate access to care), and synthesis of major patterns in the responses of participants (Silverman,2001; Swanson, 2001). The resultant critical ethnography, verified and validated by revisiting a sample of participants, is the creation of a local story, holistic narrative, and social critique inclusive of the distinctive features, trademarks, and characteristics that define the scene for multicultural rural elderly individuals in the southwestern United States (E and F in the Figure on p. 12). Key to this translation or interpretation is the inclusion of the local perspective in the crafting of the story. Clinicians can use this expanded knowledge of elderly individuals to more effectively assess, plan, and implement primary and specialty care.
AAAJOR CRITICAL FINDINGS FROM THE TWO STUDIES
Summarizing the Colorado study (Averill, 1997), the two major issues for the Hispanic rural elderly individuals were a lack of equitable, accessible, culturally congruent health care; and barriers and disparities related to economic, linguistic, and ethnic discrimination. Issues identified in the New Mexico study (Averill, 200Oc) included the escalating cost of prescription medications; barriers related to care access, language, economics, and culture; and social isolation. Commonalities were noted in terms of care access, care barriers, and the costs associated with health care and medications.
MERGING CRITICAL ETHNOGRAPHYWITH COMMUNITY-BASED ACTION RESEARCH
The first step in merging critical ethnography with community-based action research involves a kind of praxis in recognizing that the community members, including participants, are the contextual, cultural experts in their own settings and that they are full partners in both the research and the problem-solving process. From that perspective, the necessary actions include Looking, Thinking, and Acting (Stringer, 1999). No suggestion is made that the actions noted in the Figure on p. 12 are strictly linear, they should unfold in a progressive manner. However, the reality is that as data change, individuals come and go, and local priorities evolve, the Look-Think-Act method may require adjustments. Thus, flexibility and patience are essential characteristics of this method of research and problem solving. The underlying assumption is that the only way to promote lasting beneficial change in the rural health care delivery system is to actively involve local residents in the work of innovation and progress, both in appropriate context (Coral, Bryant, & Henderson, 2001; Sen, 2001; Wallerstein & Duran, 2003).
Looking (Stringer, 1999) addresses such questions as (White, 1995):
* What is going on here?
* Who are the key participants?
* Whose voices are heard and whose are silent?
* What are the local values, norms, and priorities?
* What are the various points of view embedded in this situation?
* What important contextual factors effect the health of rural elderly individuals?
* What are the major strengths and assets, limitations, and needs of the community?
Although the researcher has key questions to ask, what other important questions should be asked about health care issues for rural elderly individuals, based on participants' perceptions?
The researcher becomes the facilitator and the linker of dialogue among the groups of interest, aiming eventually for a collective identification, description, and analysis of specific problems, priorities, strengths and assets, and needs. The most important task for this phase of work is establishing, nurturing, and solidifying the community-based relationships with key informants. This is the phase of discovery, of partnership building, and of consensus making, !fundamental to subsequent actions and inquiry. It is an activity that may take months to actualize, given the demands of multiple work environments, travel to rural communities, and busy schedules of participants. Currently, the researcher has completed the Looking stage (G in the Figure on p. 12 in both study locations.
The Thinking stage (H in the Figure on p. 12), poised to begin in southwestern New Mexico, entails extending the Looking to a wider geographic area and more multicultural elderly individuals. In addition, it includes carefully interpreting, explaining, translating, and refining the identified problems, priorities, and strengths in concert with key community members, including clinicians in practice. This Thinking should build on the preliminary findings, noting areas of contrast and comparison, extend the contextual analysis as needed in the regions explored, and engage mutual planning and brainstorming between the researcher and community members.
An important mission throughout this work is the establishment of multiple communication strategies between the researcher and community members to increase the likelihood definitive progress can be achieved. For example, in-person encounters, telephone conversations, informative letters, in-services, flyers, and electronic messaging (e-mail) represent possible options for remaining in contact The involvement of multiple researchers and interested graduate students can extend the research initiative, benefiting and enriching the overall purpose and process of Look-Think-Act method (Minkler & Wallerstein, 2003; Stringer, 1999).
The final phase of Stringer's (1999) routine is Acting (I in the Figure on p. 12), or implementing planned change. In the case of this research, the action involves specific activities and steps taken to improve the quality, planning, and delivery of health care services to multicultural rural elderly individuals. The following goals represent the outcomes of this design:
* Targeted interventions, aimed at reducing or eliminating particular disparities identified in the Looking and Thinking phases (e.g., a transportation program for homebound senior citizens, financial assistance to obtain prescriptions, increased cultural knowledge for local providers).
* Formative and summative evaluation of the effectiveness of interventions, both short-term and long-term. In this way, the most effective, efficient strategies for health care planning and delivery may be recognized and authenticated (Altschuld & Witkin, 2000; Schulz et al., 2001).
* Dissemination of the findings, both to local residents and communities and to the professional community/literature, to further develop the understanding of rural health problems, especially in relation to rural elderly individuals.
* Analyzing the implications of the findings and the process for practice, research, education, and community planning. This is really the "so-what?" process of examining why this research matters, both locally and within the larger context of rural health experience.
* Preliminary explanatory modeling of health care issues for multicultural rural elderly individuals. The theory and knowledge base for this growing vulnerable population remains a multidisciplinary work in progress, at a time when resources for health care are increasingly difficult to obtaia Explanatory modeling may contribute to the systematic testing and application of contextual knowledge and interventions for greatest benefit to elderly individuals and their communities.
* Appropriate recycling of the findings into community-based dialogues may generate additional questions for inquiry and problem solving. The notion of an ongoing effort to identify and resolve local problems, combining best practice and ideas from both the research and the residential communities, appeals to the core functions and spirit of public health (Westbrook & Schultz, 2000; Zerwekh, 2000).
The growing crisis in rural health care is especially onerous in the expanding population of multicultural rural elderly individuals. At a time of diminishing resources and accelerated demand for services, a need exists to identify and implement strategies for both research and problem solving in the contexts of local communities. An efficient, productive, socially equitable approach (Drevdahl, Kneipp, Canales, & Dorcy, 2001) may involve collaborative efforts between community members and ethnographic researchers. The merging of critical ethnography and community-based action research is proposed as a possible model for this effort.
Community-based action research, also referred to as participatory research and action research (LeCompte, Schensul, Weeks, & Singer, 1999; Minkler & Wallerstein, 2003; Stringer, 1999), has been applied successfully in a variety of settings with underserved, unserved, and marginalized groups. It deserves consideration as a possible means to reduce health disparities among rural elderly individuals in an area where economic hardship, inadequate health care access, and social isolation are major barriers to service. This model combining critical ethnography and community-based action research is currently being implemented in a larger study in the southwestern United States. Research planned for the coming years may support this innovative combination of ethnographic inquiry and contextually sensitive problem solving.
Such a collaborative approach to research and problem solving has important implications for nursing practice. Problem solving may be interpreted as practice at the level of community-as-client. Whereas much of urban-centered practice involves a focus on individual patients or families, often in episodic visits to providers, practice in rural communities often means a more community-oriented, ongoing relationship with residents and patients.
Because rural communities are small, the same nurses may see patients as they move across care settings - hospitals, home health care or hospice, outpatient clinics, assisted living facilities, and skilled nursing centers. Encounters with families and groups are common in scheduled visits, but also in shopping and other daily life activities. Nurses and other care providers benefit not only from broad-based clinical expertise, but also from knowledge of case management, community development, community resources (e.g., possible prescription assistance programs), interdisciplinary communication and negotiation, financial and business factors, epidemiologie indicators (e.g., rural data on morbidity and mortality), and networking partnerships with community stakeholders and researchers. Mastering the art of asking the key questions, eliciting the experiences of multicultural elderly individuals and others, including the recipients of care in the dialogue on planning and delivery of scarce services, and honoring the cultural traditions that characterize an increasingly diverse population can all enhance practice, improve health outcomes, and help reduce health disparities.
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