Transcultural Health Care

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Copyright © 2013 F.A. Davis Company

Appalachians
Larry Purnell, PhD, RN, FAAN

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview

• Heritage from England, Wales, Scotland, Ireland, France, and Germany
• Came to the United States for religious freedom and better economic opportunities
• Purposely isolated themselves in the mountains to live and practice their religions as they chose

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• Appalachia includes 410 counties in 13 states and extends from southern New York to northern Mississippi.
• Continuous migration from the country to the city and vice versa
• High proportion of aging in Appalachia
• Farming, mining, textiles, service industries, etc.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• High poverty and unemployment rates
• Originally most educated group in America, now some of the least educated due to isolation
• Area still lacks infrastructure

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications

• Carry over from Elizabethan English
• Spellin for spelling
• Warsh for wash
• Badder for bad

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Ethic of Neutrality

• Avoid aggression and assertiveness
• Do not interfere with others’ lives
• Avoid dominance over others
• Avoid arguments and seek agreement
• Accept without judging—use few adjectives and adverbs, resulting in less precise description of emotions and thoughts

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications

• Sensitive about direct questions and personal issues
• Sensitive to hints of criticism. A suggestion may be seen as criticism.
• Cordiality precedes information sharing so “sit a spell” and chat before doing business, which is necessary for developing trust

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication Continued

• A few may avoid direct eye contact because it can be perceived as aggression, hostility, or impoliteness
• More being than doing oriented, more relaxed culture and being in tune with body rhythms
• Be formal with name format until told to do otherwise.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication Continued

• Healthcare provider must be flexible and adaptable
• Come early or late for an appointment and still expect to be seen
• Family lineage is important
• Formality with respect—Miz Florence or Mr. John

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family

• Varied decision-making patterns but the more traditional Appalachian family is still primarily patriarchal
• Women make decisions about health care and usually carry out the herbal treatments and folk remedies
• Women marry at a young age and have larger families than the other white ethnic groups

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Continued

• Children are accepted regardless of what they do
• Hands-on physical punishment is common
• Motherhood increases the status of the woman in the eyes of the community
• Take great pride in being independent and doing things for oneself

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Continued

• Family rather than the individual is the treatment unit
• Having a job is more important than having a prestigious position
• Consistent with the ethic of neutrality, alternative lifestyles are accepted, they are just not talked about
• Extended family is the norm

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

• High incidence of respiratory conditions due to occupations
• Increase of parasitic infections due to lack of modern utilities in some areas
• High incidence of cancer, otitis media, anemia, obesity, cardiovascular disease, suicide, accidents, SIDS, and mental illness

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

High-Risk Behaviors

• Tobacco is a main farming crop in some areas of Appalachia
• Smoke at a young age
• Alcohol use at a young age—binge drinking
• Believe in the mind, body, spirit connection

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Ten Steps in Seeking Health Care

• Use self-care practices learned from mother or grandmother
• Call mother or grandmother if available
• Then trusted female family member, neighbor, or a nurse
• Then go to OTCs they saw on TV
• Then use a neighbor’s prescription medicine

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Ten Steps in Seeking Health Care Continued

• Pharmacist or nurse for advice
• Physician or Advanced Practice Nurse
• Then to a specialist
• Then to the closest tertiary medical center
• DO NOT BE JUDGMENTAL, if you want to keep them in the system

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

• Food may be synonymous with wealth
• Wide variety of meats, do not trim the fat—low-fat wild game is also eaten
• Organ meats are common
• Bones and bone marrow used for making sauces
• Preserve with salt

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Lots of frying (using lard or bacon grease) and pickling
• Anytime is the time to celebrate with food, especially in the rural areas
• Many teens have particularly poor health
• Status symbol to have instant coffee and snack foods for some

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Early introduction of solid foods
• May feed babies teaspoons of grease to make them healthy and strong
• Diet is frequently deficient in Vitamin A, iron, and calcium

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family

• Must eat well to have a healthy baby
• Do not reach over your head when pregnant to prevent the cord from wrapping around the neck of the fetus
• Being frightened by a snake or eating strawberries or citrus can cause the baby to be marked
• Use bands around the belly and asafetida bags

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

• Must stay with the dying person
• Family should not be left alone
• Funerals with personal objects at the viewing and buried in their best clothes
• May take the deceased for viewing at home
• After the funeral there is more food and singing and for some a “wake” to celebrate life

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued

• Flowers are more important than donations to charity
• Particularly good at working through the grieving process
• Funeral directors are commonly used for bereavement
• Cremation is acceptable and ashes may be saved or dispersed on the “land”

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

• Baptist, Pentecostal, Episcopalian, Jehovah’s Witness, Methodist, Presbyterian
• Each church adapts to the community
• Most are highly religious even though they do not attend church
• Common to attend Sunday and other days
• Preacher has a calling to “preach”
• Ministers are trained

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality Continued

• Meaning in life comes from the family and “living right with God,” which varies by the specific religious sect
• Nature is in control—fatalism
• Religion and faith is important in a hostile environment
• I will be there if the “creek does not rise” or if “God is willing”—fatalism

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices

• Good health is due to God’s Will
• Self-reliance fosters self-care practices
• Family important for health care
• May be very ill before a decision is made to see a professional resulting in a more compromised health condition
• Direct approaches are frowned upon

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Herbal medicines, poultices, and teas are common
• See Table 8–1 in the textbook; these practices are still alive and well
• Folk medicines used in conjunction with biomedical treatments

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Barriers

• Fatalism
• Self-reliance
• Lack of infrastructure
• Health profession shortages
• Culture of “being”
• Poverty and unemployment
• Care not acceptable from outsiders

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Responses to Health and Illness

• Take care of our own and accept the person as whole individual
• Not mentally ill, the person has “bad nerves” or are “odd turned”
• Having a disability with aging is natural and inevitable—if you live long enough
• Must establish rapport and trust

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Responses to Health and Illness Continued

• Pain is something that is to be endured
• Some may be stoical
• Pain legitimizes not working or fulfilling one’s responsibilities
• Withdraw into self when ill
• Culture of being works against rehabilitation

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practitioners

• • Lay and trained nurses and midwives still provide much of the care in some parts of Appalachia
  • Breckenridge Frontier Nursing Service
  • Prefer people known to the family and community —the insider versus outsider concept

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practitioners Continued

• Culture of “being” says the healthcare provider should not give the perception of being rushed
• Physicians may not be trusted due to outsided-ness, not to being foreign
• Must ask the clients what they think is wrong

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