Laura Light

Wynelle Klopfer
Mental Health 121
Fall 2014
Healthcare and Appalachian Culture
I. Introduction

A. Hillbilly stereotypes have been a part of our culture since the early 60s. The

Hollywood version of the Beverly Hillbillys and the 80s hillbilly version
of the movie Deliverance. We tend to be driven by these stereotypes as we identify
this part of the US demo graph. Some of our stereotypes are: snaggletooth, worn
overalls, coon-skinned caps, superstitious, broken dialect, and opossum eating,
uneducated, and one-eyebrow.
B. Reason to Listen: Healthcare is slow to come to the people of Appalachia. But

like most individuals, they have many healthcare needs. It is our responsibility as
nurses to help educate, promote, prevent and rehabilitate health to these people. To
do this better, we need to understand the culture we are serving.
II.

What is Appalachian Culture

Appalachia is a cultural region in the eastern United States with undefined borders
stretching across 13 states from New York to Mississippi covering 205,000 square
miles, home to roughly 25 million people [1].
A. People of Appalachia

Historically the region has been predominantly white (about 91%) from
mainly Scot-Irish, English, Welsh and western European descent. [1].
B. Specific beliefs

Appalachian beliefs are deeply rooted in religious teachings from the original
British borderland settlers. The Bible is taken literally and they believe in
living a pure life. If one has faith, God will heal [2]. After religion, much
emphasis is placed on the importance of family, independence, self-care, selfreliance, and resourcefulness [3]. The importance of justice, loyalty, strong
work ethic, a sense of community, social ties and a feeling of belonging in the
mountains are other notable positive values. Certain problematic stereotypes
such as distrust in outsiders/strangers, and doubt in formalized medical
systems are common cultural norms that have been reported [4].

1. Beliefs towards healthcare

With the strong distrust towards outsiders, Appalachians more

often than not turn to church leaders for help with medical
problems after asking family. Traditionally medical professionals
have communicated with Appalachians using direct speech which
causes Appalachians to feel disrespected, often not returning for
continued treatment. This form of speech or questioning portrays
the healthcare provider as the expert and that they (the provider)
is above them (the client) [5].
2. Folk medicine

Due to the long-established lack of access to modern medicine

throughout most of Appalachia, the tradition and collection of
cures have been handed down by customs in the way of storytelling. The most common of these customs is the use of herbal
and homemade medicines believed to have healing powers and
positive effects on health. Tonics made from the roots, fruits,
leaves, bark, flowers or seed are combined and consumed to treat
common ailments ranging from constipation, sore throat, kidney
problems, colic and stomach problems [6].
III.

Healthcare issues
Numerous factors come into play regarding matters in healthcare amongst
Appalachians. Developing a rapport as well as a sense of personal connection with
the client will likely increase the chances of a trusting relationship [6].
A. Barriers to care

Some noted barriers involve the client developing a sense of fear or apprehension
of the stigma often associated with certain medical diagnoses, for instance a
mental health issue or psychiatric disorder [7].
B. Transportation

This is one of the greatest obstacles in obtaining healthcare, especially if it

involves a mental health problem. Public transportation is often scarce in many
areas of the region, in particular the rural stretches [4,7].
C. Facilities

Lack of providers and facilities along with recruiting and retention of staff for
existing facilities is a constant and ongoing struggle for many areas of Appalachia
[7].
D. Education and poverty

These are some of the most immense problems that plague vast sections of
Appalachia. Clients may not know if they are even receiving adequate healthcare
for a particular condition that ails them, nor do they have the monetary means for
specialists, copays or preventive care [7].
IV.

Illness and disease

Appalachia represents significant levels of socioeconomic diversity, as well as
endured considerable excesses in adverse health outcomes along with substantial
economic lag behind the majority of country.
A. Obesity, cancer, diabetes, heart disease

Collectively these diseases are higher in Appalachia as compared to the rest of the
country. A study from Virginia counties exhibited residents from certain
communities showed they were 23% more likely to die from heart disease, 28%
more likely to die from diabetes and 44% more likely to die from lung disease
(COPD, lung cancer) [4].
B. Oral and vision

Utilization for oral and vision care is virtually nonexistent for many communities
throughout the region. A study conducted in southwestern Virginia indicated a
substantial proportion of the population have not obtained routine oral or vision
care within the last five years, and many could not recall the last time they had
received any oral or vision care, if any all [4,8].
C. Mental health disorders

Appalachians prefer to talk to no one when it comes to problems regarding

mental health. If they do decide to talk, it is usually with someone that is close to
them, a religious leader or a general practice physician before they would ever
consider talking to a mental health professional. Then this would only be
accomplished after the problem has reached its highest severity. This is largely
impart due to the stigma and discrimination associated with mental health
disorders [7].

V.

Improving healthcare to Appalachia

Many organizations have teamed up with scholars, systems planners and leaders from
the government, healthcare businesses to explore ways in which to improve the health
status of the population in the Appalachian region. Two such organizations are the
Appalachian Regional Commission and the Healthy Appalachia Institute.

A. Teleconferencing

Innovative and expanding technology has made it possible to provide

telemedicine to some of the most remote areas of this region bringing skilled
professionals together with local physicians to deliver services previously that
were out of reach to many. Telepsychiatry and telenursing are two examples of
such services helping to improve care delivered to Appalachians [9].
B. Outreach programs

One of the largest private organizations dedicated to empowering communities of

Appalachia and to serve humanity is the Remote Area Medicine organization.
Their philosophy is to provide free health services and support to their patients
alleviating their pain and suffering while enhancing their lives. Mobile clinics are
setup around the region throughout the year providing screening programs for
cancer, diabetes, obesity, and heart disease along with educational events and
prevention programs to inform Appalachians on healthcare problems in their area
[10].

VI.

Connecting with the client

Egalitarianism is one of the greatest principles to possess when interacting with
Appalachian residents. The use of indirect questioning and initiating small talk in
the beginning of the client-provider relationship is paramount to gaining the trust and
respect of the client. Being aware and sensitive to personal and family preferences
and being culturally competent and understanding to the unique cultural challenges
that are faced in the Appalachian region, is essential for not only nurses, but all
healthcare professionals that are involved with in the process of enhancing healthcare
for the Appalachian region.

References

1. http://www.arc.gov Appalachian Regional Commission

2. Gobble, C. D: The Value Story in Providing Culturally Sensitive Advanced

3.

4.

5.
6.
7.
8.
9.
10.

Practice Nursing in Rural Appalachia, Online Journal of Rural Nursing and

Healthcare, vol. 9, no 1, Spring 2009.
Hauser-Whitaker, Whitrow-Fletcher, Slusher: Appalachian Women: Health
Benefits, Self-care, and Basic Conditioning Factors, Journal of Cultural
Diversity, vol. 17, no 3 Fall 2010.
Cohn, Killos, Leon-Verdin, et al,: Health Disparities Between Appalachian and
non-Appalachian Counties in Virginia USA, Journal of Community Health,
(2011) 36 p. 348-356.
Russ, K.A. (2010) Working with clients of appalachian culture. Retrieved from
http://counselingoutfitters.com/vistas/vistas10/Article_69.pdf
Stone, M. B., Appalachian folk medicine. Retrieved from
http://home.wlu./~lubint/Touchstone/AppalachianFolkMed-Stone.htm
Waters, M.R., Mental Health Services in Appalachia (2011) Online Theses
and Dissertations. Paper 16.
Huttlinger, Lawson, Schaller-Ayers: Healthcare in Appalachia: A PopulationBased Approach, Public Health Nursing, vol. 21, no 2, p. 103-110 (2004)
http://www.healthyappalachia.org
http://www.ramusa.org

NURS 121
Appalachian Heritage
Recipes
Wynelle Klopfer
Laura Light

Elderberry Jelly: Posted by Elise

Elderberry Jelly Recipe
Yield: Makes 5 8-ounce jars.
Do not double this recipe. Make one batch at a time.
Save Recipe
Ingredients
3-4 lbs ripe (not green) elderberries (after de-stemming)
1/4 cup freshly squeezed lemon juice
1 packet MCP pectin*
4 1/2 cups white granulated sugar
1/4 teaspoon butter
*If using a different brand of pectin, follow ratios on package instructions for making
blackberry jelly.

Method
elderberry-jelly-2.jpg elderberry-jelly-3.jpg
1 Rinse elderberry clusters thoroughly. Working over a large bowl, work on one small cluster
at a time, gently raking your fingers across the clusters to dislodge the berries from the
stems. Only use berries that are completely blue or black. Do not use green berries or
partially green berries as they are not ripe. For each batch of jelly, collect 3 lbs of destemmed elderberries. Once de-stemmed, rinse again.
elderberry-jelly-4.jpg elderberry-jelly-5.jpg
2 Place berries in a large pot and crush with a potato masher to release some of the juices.
Turn the heat to medium and continue to crush as the mixture heats up to a boil. Once it
reaches a boil, reduce the heat to a simmer and let it simmer for 10 minutes. Remove from
heat.
elderberry-jelly-6.jpg
3 Place a large fine-mesh sieve, or 4 layers of cheesecloth, over a pot. Slowly transfer the
mashed berries and juice over the sieve to strain the juice out into the pot. Let strain for
several hours.
4 Prepare jars for canning. You'll need 5-6 8-ounce canning jars and lids. Rinse out the jars
and place on a baking sheet, top up, in the oven. Heat for 10 minutes at 200F to sterilize
the jars. To sterilize the lids, bring a kettle of a couple cups of water to a boil. Place lids in a
shallow bowl and pour the boiling water over them.
5 Measure out the juice. You will need 3 cups of juice to make one batch of jelly if using MCP
pectin, 3 3/4 cups of juice if using SureJell pectin**. Any amount more than that you can

reserve for making syrup, or add to another batch for jelly. Place 3 cups of juice into a large,
wide pot (8-quart). Add the lemon juice and pectin.
elderberry-jelly-7.jpg elderberry-jelly-8.jpg
6 Bring to a boil. Add 4 1/2 cups sugar and 1/4 teaspoon of butter. Stir with a wooden spoon.
Bring to a boil again. Watch the pot as the mixture will foam up considerably. As soon as the
mixture reaches a rolling boil that you cannot diminish by stirring, watch the clock. At
exactly 2 minutes, remove from heat and pour mixture into canning jars to 1/4-inch of
headspace from the rim.
7 Wipe rims with a damp paper towel. Place lids on jars and rings to secure. If you want, to
ensure a good seal and to protect against mold (any potentially harmful bacteria will already
be destroyed by the sugar concentration of the jelly), you can process the jars in a water
bath for 5 minutes. To do so, put a steaming rack at the bottom of a large, tall pot. Fill the
pot halfway with water (enough to cover jars with an inch or two of water when in the pot),
bring to a boil, gently place the jars in the pot (helps to use a jar lifter, tongs, or be wearing
rubber gloves), boil for 5 minutes, and remove.
Let cool. As the jelly cools you should hear a popping sound as the lids seal.
**Note these are the guidelines from the pectin box instructions. I found that even half as
much pectin will cause the jelly to set, though perhaps not as firm as the whole amount.

Pan Fried Apples: Tara Zeigmont

Serves: 8

Ingredients
8 large apples (about 12 cups once they're cored and sliced into thin wedges)
4 tablespoons butter
cup brown sugar
1 tablespoon cinnamon
teaspoon pumpkin pie spice
2 tablespoons corn starch
3 tablespoons water
Apple juice or water as needed

Instructions
Core the apples and slice them into thin wedges. (I left the skins on, but if you want to peel
them, do that now, too.) I ended up with 12 cups of apple wedges.

Heat a very large skillet (or a sauce pot would probably work, too) over medium-low heat.
Melt the butter and brown sugar.
Place all of the apple wedges into the pan and toss them around to coat with the
butter/sugar mixture. Put a lid on the skillet (if you can, my apples had to cook down a bit
before the lid would sit on), and let them cook a few minutes.
Stir the apples to send the top ones down closer to the heat. Once they have begun to cook
down, sprinkle the spices over top and stir them again.
Cook on medium-low or low for 20-30 minutes, stirring at least every 4-6 minutes.
When the apples are starting to get soft, combine the cornstarch and water in a small bowl.
Pour this slurry into the apples to make a nice, thick sauce. {Note: It's perfectly okay to
leave this out. Your apples will be in juice rather than a thicker sauce.}
Continue to cook the apples until they reach your desired softness. Mine took almost 40
minutes.
If your sauce thickens too much, you can always thin it with apple juice or additional water.
Just mix well to incorporate the extra liquid with the sauce.