A Short Study of Appalachian Culture

Defining the Appalachian Region

The Appalachian region is located in the United States and is typically considered to be a region which encompasses multiple states along the Appalachian Mountain region. The region of Appalachia originally started as being defined by cultural parameters in 1861 by a Minnesota newspaper that demarcated a region of “Alleghenia” in which Southern and Northern sentiments would factor into the American Civil war if the regionwere forced into the war through invasion. Then in 1895, Berean College president William G. Frost and a former student of Berean College, C. Willard Hayes, defined “Appalachian America”, further expounding on the idea of the Minnesota newspaper’s “Alleghenia” (Williams, 2002). From that time on the idea of a particular region having been the originof the Appalachian culture has been continually debated in regard to its boundaries. Largely, the Appalachian Regional Commission’s definition of the Appalachian region is the most widely accepted, but the region, shown in Figure 1, is defined by the economic needs of the counties within it versus cultural parameters (Abramson& Haskell, 2006).History of Appalachian Culture

The History of AppalachiaThe historical origins of the Appalachian culture can be traced back to the Native

Americans with the Iroqouis and Cherokees largely composing the demographics of what is modern Appalachia. The first contact with European settlers occurred around 1540 with the Hernando de Soto and Juan Pardo expeditions, but it wasn’t until 1700-1761 that contact and conflict accelerated (Williams, 2002). At that time, European settlement began in Great Valley of Virginia by a predominately German and Scotch-Irish population from the Pennsylvania region. The Great Valley area began to fill by 1763 and settlers began migrating to western North Carolina, the river valleys bordering Tennessee and Virginia and eventually central Kentucky (Drake, 2001).From the 1760’s until the 1820’s population growth in the southern mountains increased steadily, largely due to the immigration of the aforementioned Scotch-Irish and German peoples but also because of miscellaneous peoples, such as the English Quakers and French Huguenots. These miscellaneous people groups ended up composing roughly one third of the Appalachian demographic at that time. From 1775-1783 the American Revolutionary War took place, however, it had little impact on the Appalachian region and population growth continued despite the war (Drake, 2001; Straw, 2006).

Throughout the time of population growth from the 1760’s until the 1820’s, many mountaineers grew concerned about protection from Native American attacks in the mountain regions. In 1830, the Andrew Jackson presidency passed the Indian Removal Act,which when acted on in 1838, resulted in the infamous “Trail of Tears”, displacing many Native Americans, most notably the Cherokee Nation, from their original home in south eastern Appalachia (Straw, 2006). While the Indian Removal Act was passing through congress and being enforced, sectionalism began to emerge in the South, creating the beginnings of the issues leading to the American Civil War. Slavery played little role in the Civil War politics withthe peoples of Appalachia, ultimately it came down to the issue unionism.The largest division in Appalachia was between the low country and the mountains. The division was largely over issues such as building roads, schools, canals, a dominance of slaveholders in state politics, and the debate over the economics of slavery not the morality. While the region of Appalachia was divided, just as the rest of the country was, general support was given to preserving the union of states over preserving the institution of slavery. However, those supporting the Confederacy were largely found in the low lands where slave owning farms were located (Williams, 2002). Regardless, Confederate and Union troops followed a “live off the land” policy which ravaged the crops, livestock, homes, and civilians within the Appalachian region leaving those that survived the war confronting food shortages. Reconstruction efforts began shortly after the war but were short lived by a change in party control which prompted cuts in funding of public schools, transportation, and public services in general. The division between Appalachian low land peoples and mountain people surfaced at this point. The Lowland Democrats had come back into power along with the change in party power and largely viewed the mountaineers as traitors to the “lost cause” of the Confederacy. This resulted in not only federal neglect of Appalachia but also entered Appalachia into neglect at the state level.At this time investors, notably northern and foreign investors, began seeking investment opportunities in Appalachia. Most investments were drawn toward the natural resources,of these resources, coal mining came out as the leader and was the driving force of Appalachian industrialization. The industrialization of Appalachia is typically seen as the singly most important event to shape the modern structure of Appalachia (Drake, 2001; Straw, 2006).

From 1865 to 1920, driven by technological innovations and urban growth and fueled by labor, minerals, and timber, the United States climbed to the largest industrial nation in the world. While Appalachia contained all these resources, coal mining, as mentioned previously, was the largest resource sought. Coal mining began in 1870 and Appalachia was gradually infiltrated by railways in the lowlands and by 1910 all coal-mining regions in Appalachia fully productive. Along with coal mining came the “Coal Town” and with forestry “Logging Towns” and so on. Over six hundred company towns, predominately coal towns, were built from 1880 to 1930, out numbering independent towns by a margin of five to one (Straw, 2006). By the end of the industrial era, around 1920, two-thirds of the Appalachian people were dependent on a paycheck from one of the many companies to come into Appalachia in its industrialization. It is important to note that those people no longer knew, in large part, how towork the land. So, when the “industrial system thathad lured thousands off the farms of [Appalachia] and thousands of others [from various parts of the United States] to the mountains [of Appalachia] collapsed under the weight of overproduction and increasing competition” (Straw, 15) hunger, homelessness, and starvation pervaded the region.By the end of the 1930’s, seventy-five percent of Appalachia was receiving some form of government assistance. Those that had remained on the farms continued their lives without much interruption by either the industrial collapse of Appalachia or the economic collapse of the United States in the 1930’s (Williams, 2002).

The two largest pieces of legislation that affected Appalachia during the 1930’s was the Wagner bill which legalized unionization in the remaining coal fields of Appalachia and the New Deal program the Tennessee Valley Authority (TVA). The Wagner Bill made increased wages and made living and working conditions better in the coal towns and mines for many Appalachians fortunate enough to still have a coal job and the TVA employed Appalachian peoples in community development schemes, most notably 9 coal powered electricity plants in 1949 increasing the demand of for Appalachian coal fields to produce leading them shift to the less expensive mining method of strip mining (Drake, 2001; Williams 2002).

During World War II many coal companies began mechanizing their production with technological innovations leading to an estimated 60% reduction in need for man power due to their replacement by machine. Thus, unemployment in Appalachia increased, leading to the out-migration of nearly 3.5 million people between 1945 and 1965 in an attempt to find employment elsewhere. However, in the 1950’s Appalachia had a turning point in the Kennedy, Humphrey, and Johnson presidential race where it was thrown into the political fray which caused attention to be taken of the extreme poverty present in the region. Subsequent political agendas formed the Appalachian Regional Development Act leading to the formation of the Appalachian Regional Commission and ushered in the War on Poverty. The War on Poverty included social programs such as the Office of Economic Opportunity, Volunteers in Service to America, the Job Corps, and Head Start, all of which sought to bring jobs and education to the region and lift it up out of its poverty (Eller, 2008). The overall success of the War on Poverty was, at best, limited and many historians agree that it failed in Appalachia. However, it led to the formation of grass-roots organizations who petitioned for attention to such things as the environmental impact of strip mining, the prevalence of black lung and so on, but most of those groups disappeared in the 1970’s. From that time on, little has happened in Appalachia other than a coal boom in 1974-1978, a tourism boom in East Tennessee and western North Carolina, growth in textile production, and the growth of large-scale chain stores and fast food restaurants in the more prosperous areas. The poverty is still present, so Appalachia remains a contradiction, rich in resources yet wading in poverty (Drake, 2001; Straw, 2006; Williams 2002).

Sociological Perspective on the Appalachian CultureThe prevailing statistic demarcated in the Appalachian culture would be the

poverty prevalent throughout. How this poverty came into place is laid out in the history section of this paper and according to the 2000 United States census, poverty is at an average of 13.6% and can only be thought to have been further exacerbated by the economic downturn of 2008 (Pollard, 2003). In the second quarter of 2009 the Appalachian Regional Commission reported the Appalachian region having an unemployment rate of 9.8%, 0.7% higher than the United States national average (Appalachian Regional Commission, 2009). As of 2009, labor force participation by women was 53% while participation by males was 67% and of those 29% were employed as managers or professionals, 20% were employed by production-transport-moving occupations compared to a 14% average nationally, 50% were employed in the services sector and 1% were employed in miscellaneous jobs (Pollard, 2003). Minimal fluctuations in these averages have occurred from 1990 on but “the general conclusion seems to be that large-scale modernization of the regional economy by attracting large manufacturing facilities to growth centers has little chance of success…in its place [there should be] modest projects to encourage development of particular areas” (Shannon, 80). Largely, the Appalachian Regional Commission has implemented this philosophyacross the turn of the century by expanding and modernizing highways, building vocational schools, health facilities, and the building up of public infrastructure (Eller, 2008). However, “an inadequate tax base, a low-wage economy, environmental abuse, civic fraud, political corruption, absentee landownership, and corporate irresponsibility [continue] to weaken the region and to limit the lives of its residents” (Eller, 221-222).

Little difference exists in the outward appearance of Appalachian culture from its counterparts in the rest of the nation: teenagers wear the same clothing and Wal-Marts sell the same internationally made goods. Most of the stereotypically quirks of the Appalachian culture conjured up by those outside of it are in relation to the “folklife” in Appalachia. Appalachian folklife is a result of the unique mix of immigrants that came to Appalachia and consists largely of storytelling, food preservation techniques, traditional building designs, fiddle tunes, banjo “licks”, basketry, wood carving, dance steps, and the use of native plants. Yet this distinct culture, which sets Appalachia apart from the rest of the United States, is threatened by the destruction of the mountains, rising drug dependence, and the loss of traditional values and culture (Eller, 2008; Thompson & Moser, 2006).

CommunicationThe dominate language of Appalachia is English, but with a “backcountry” dialect

that can be traced back a to a Scotch-Irish origin. Richard Drake summarized the origin of the Appalachian dialect in this manner:

“The Scotch-Irish spoke a dialect in the eighteenth century that was then a version of a dialect “already old by the time of Elizabeth”…the love of the “r”, as in fire (far), hair (har) and bear (bar); triphongs and quadrithongs, as “abaout” (for about) and “haious” (for house); the use of “h” for specific emphasis, as “hit” (it), “hain’t” (ain’t), and “hyander” (yonder); the double and triple negative for emphasis (as in Chaucer); omission of the “g” in “ing” endings, all attest to the ancient form of English established in the Appalachian Mountains in the late eighteenth century.” (Drake, 36-37)

Appalachian writing is affected by the Scotch-Irish speech patterns largely in the folklife circles, but remains largely untouched outside of those circles. Non-verbal speech is similar to Appalachia’s national counterparts with no especially noted culture-wide variations (Eller, 2008; Thompson & Moser, 2006).

Access to newspapers, phone, TV, radio, and internet is largely common when the financial means are present. Broadband access may be limited by the rural location of homes but satellite access and DSL service are convenient options instead of cable access. Broadband access has expanded significantly since the beginning of the millennium in all major parts of the Appalachian Regional Commission region. Availability of broadband has been increased in many rural counties that previously did not have access to broadband service, but the issue of access to advanced telecommunications services in underserved areas remains an important concern. However, this situation is not much different from the rest of the country where access is dependent on financial means and location (Appalachian Regional Commission, 2004; Oden & Strover, 2004).

Marriage and Family BeliefsAccording to the 2000 census, Appalachia hadapproximately 9

million household units, of that, 6.2 million or 69 percent were family households, households defined ashaving at least one of the members related to the household head. Of that 6.2 million, a reported 2.8

million of those family households had at least one of their ownchildren present in the household. Traditional families, being defined as families headed by a married couple withat least one of their own children at home, were numbered at just over 2 million in 2000 census, 23 percent ofthe total number of Appalachian households. Also according to the 2000 census, Appalachia had 726,000 single-parent households composing 8 percent of Appalachian households. Single mothers headed approximately more than 552,000 of these households, or 6 percent of all Appalachian households. At the time of the 2000 census, there was a 3 percent difference between Appalachian single-parent households and its national counterparts, therefore, in the rest of the country,single-parent families were at 9 percent of all households and single-mother families were at 7 percent of all households (Mather, 2004; Pollard, 2003; U.S. Census Bureau, 2001).

More than 2.3 million Appalachians lived alone in 2000, these households made up the overwhelmingmajority of the Appalachia’s 2.7 million nonfamily households. Single-person householdswere more prevalent than twoparent households throughout theAppalachian region during the 2000 census. This statistic along with the aging population (see Table 1) suggests thatthe older populationis aging at home after the departure of their adult children and/or the deathof a spouse. Approximately 968,000 Appalachians who lived alone during the 2000 census were age 65 or older, composing 41 percent of the total households in which people lived alone. Outside of the Appalachian region, the older population composed 35 percent of those living alone in their household (Mather, 2004; Pollard, 2003; Williams, 2002).

The 2000 census revealed Appalachia had 392,000 unmarried partnerhouseholds, defined as consisting of the householder and “aperson who is not related to the householder, who shares living quarters, and who has a closepersonal relationship with the householder” (U.S. Census Bureau, B-11). Thesecohabitating households, of which some contained children, composed 4 percent of all households in the Appalachianregion compared to their composing 5 percent of the rest of the nation(Pollard, 2003).

Family structure plays a large part in poverty throughout the Appalachian region (see Table 2)with female-headed households showing the largest poverty percentage of all household structures. There is also a correlation between the presence of children and poverty within a household. Female-headed households with children demonstrate a 10 percent increase over female-headed families in general throughout the Appalachian region (Lichter & Chimbaluk, 2009; Mather, 2004)

According to the 2000 census, the median ageof first marriages within Appalachiais 27 for men and 25 for women and family size tends to be on average 3 persons per household. The traditional view of

marriage and family held by the Appalachian culture consists of a patriarchal structure where punishment is delivered by household heads and role expectations extend to cousins and in-laws as well as nuclear family. Largely, protection from external threats is given through the family, acceptance of outsiders is slow to occur, and mutual aid is provided between family and neighbors. Most traditional families develop a strong sense ofindependence and self-sufficiency that is tempered by basic neighborliness and hospitality(Lichter & Chimbaluk, 2009; Marek, Brock, & Rosemary, 2006).

EducationAccording to the 2000 census, 77 percent of Appalachian residents over 25 have

completed high school and 18 percent of Appalachians have acquired at least a bachelor’s degree. Despite these figures, the educational attainment of Appalachia remains lower than the national average where 81 percent of adults over 25 have a high school degree and 25 percent have at least a bachelor’s degree (Pollard, 2003). Perhaps the greatest factor relating to elementary and high school education is the lack of funding for educational jobs. Another factor is that schools have become consolidated leading to less parental involvement and making it more difficult to reach school for some people due to the school’s relocation. When it comes to the colleges and universities in the Appalachian area a large majority will seek out students from the Appalachian region in the application process The reason being that many of the counties which house college or universities continually see high school and college attainment rates above the national average. Well known institutions of higher learning within Appalachia include Cornell University, Ithaca College, Pennsylvania State University, Virginia Tech, Radford University, West Virginia University, and the University of Tennessee(Pollard, 2003; Teets, 2006).

ReligionReligion is varied across the Appalachian culture just as it is with their national

counterparts. However, many historians have come to a general consensus when it comes to characterizing Appalachian religion in the region. These characteristics include

“fundamentalism; Puritanism; an emphasis on a personal relationship with God and on otherworldly salvation rather than on social problems; fatalism and an ability to withstand hardship and privation; an experiential and emotional expression of religious faith that includes rituals such as homecoming, memorial days, and graveyard decoration days that symbolize the connection between the history of the church (reaching back to Christ’s day) and departed loved ones; management by God of the temporal world and everyday life; and humility and simplicity in belief, ritual, and church architecture” (Wagner, 187).

Largely, the Baptist denomination is the most prevalent form of organized religion in the Appalachian culture with Catholicism and Methodism following respectively. However, it has been a general consensus that Appalachian forms of

organized religion are unique from their national counterparts and must be denoted as such. The above quote by Wagner emphasizes this point by alerting the reader to the traditionalism inherent in many Appalachian churches. Direct connections with the Protestant Reformation can be traced through the German Pietism and Scotch-Irish Calvinism that pervaded the Appalachian region during the 1760’s to the 1820’s in most churches. In other words, modernization and conformation with current cultural counterparts is largely absent from Appalachian organized religion. Idiosyncrasiesnoted among Appalachian based denominations are zealous adherence to the Bible and the lack of formal leadership in most churches. This isthought to be an attempt by the churches to not impose a humanly devised hierarchy between congregants and God (Wagner, 2006; Williams, 2002).

It is necessary to address the snake-handling congregations in Appalachia because it has become a stereotype of Appalachian religion. The snake-handling congregations fall under the Holiness Pentecostal denomination, but numbers of congregants are estimated around 3,000 at most. It is worth noting that not all Holiness Pentecostal churches hold the passages of Mark 16:16-18 and Isaiah 43:2 which dictate thebelief in the handling of snakes, the drinking of poison, and fire walking (Wagner, 2006).

According to a 2002 study conducted by Lowry and Conco, adults over the age of 65, a growing demographic within Appalachia, hold spirituality to be“a dimension of life that [is] always present but [is] viewed differently throughout the process of living life…[and] as they became older spirituality became more important to them” (397). Lowry ad Conco also found that during times of crisis, i.e. illness, spirituality was an important method of coping among respondents and many were surprised to find that part of a nurse’s responsibilities include spiritual care (2006).

Nutritional PreferencesThe nutrition of the Appalachian region is predominately affected by the financial

means of individuals just as with its national counterparts. However, overall rates of obesity have been consistently higher in Appalachia than its national counterparts and nutrition is largely considered that causative event of this problem. Generally, studies have reported Appalachian youths are relatively inactive and consume diets high in fat and saturated fat, low in fruits, vegetables, and dairy. Such habits contribute to obesity and health problems and patterns learned early in life tend to continue into adulthood and thus increase the risk of adult obesity. While it was found that a majority of Appalachian inhabitants have a general understanding of healthy and unhealthy diet practices they have been found to lack proper implementation whether through limited access to certain foods, taste preferences, or inadequatefinancial means. When surveyed adolescents within Appalachia were asked in a study conducted by Kelli J. Williams whether they believed their diets were healthy versus unhealthy, a majority of adolescents cited their diets as unhealthy (Tai-Seale & Chandler, 2005; Williams K. J., 2006).

Most areas of Appalachia, especially rural areas, contain few restaurants and the few that may exist are often fast food chains that offer fairly innutritious meal options. Therefore, eating out offers a challenge to reducing the high fat, low vegetable, fruit, and dairy diet that is pervasive in Appalachian culture. Food choices are largely influenced by availability, so less healthy choices will be selected because they are readily available. This was demonstrated by adolescents who regularly chose snack foods such as candy

bars, soda, and chips, as a meal, from vending machines during lunch due to the low desirability of cafeteria food. However, the same adolescents stated that even if they were offered both “healthy” choices and “unhealthy” choices they would be more inclined to choose the “unhealthy” choices, demonstrating that food choices are driven more by preference often without consideration of dietary impact.While the actual components of the Appalachian diet are fairly consistent with its national counterparts, the availability of certain foods, taste preference, or inadequate financial means determine the daily diet of those in Appalachia (Williams K. J., 2006).

Health and Illness Beliefs and PracticesThe Appalachian region suffers excess mortality from motor vehicle accidents,

colorectal cancer, diabetes mellitus, COPD, accidental death, lung cancer, stroke, all other cancers, and heart disease when compared to the non-Appalachian U.S. (see Figure 2). The only area that the Appalachian region has a lower rate of mortality is when it comes to breast cancer. Here, non-Appalachian regions have a greater rate of mortality. Of the aforementioned conditions heart disease, lung disease, all other cancers (besides colorectal), COPD, and diabetes mellitus exhibit large clusters of high death rates in the Appalachian region (Halverson, 2004).

In general, it appears that within Appalachia health care coverage is about the same outside the Appalachian region. However, there also appear to be counties within Appalachia that are represented among the lowest rates of health care coverage in contrast with its national counterparts. Of all Appalachia, the lowest rates of healthcare coverage occur consistently among white men and women in eastern Kentucky. According to a 2004 study conducted by Huttlinger, Schaller-Ayers, and Lawson, limited access to health care services has a dramatic effect on morbidity and mortality in Appalachia as well as other rural areas. Furthermore, they argue that access to health care services remains an ongoing problem within Appalachia. Yet, in the focus area the study was conducted, the primary care provider to population ratio was significantly lower than the threshold necessary for the region to be designated as a “health profession shortage area”, but the area still remained sicker than the rest of the state in which it was located. The study concluded that such occurrences could be eased or eliminated by access to all health care procedures being expanded, specialty physicians being available within the region, especially specializing in cardiopulmonary diseases, increasing access to preventative services, and increasing access to low cost prescriptions as well as stressing education on the implications of medication sharing (Blakeney, 2006; Halverson, 2004; Huttlinger, Schaller-Ayers, & Lawson, 2004).

Traditional medicine in the Appalachian region is known as folk medicine and is composed orally passed down knowledge concerning cause, prevention, and treatment of illness. Folk medicine is largely the composition of oral traditions from several streams of folk medical knowledge, most notably English, German, Native American, Scots, Irish, Scotch-Irish. There are two divisions in folk medicine, the naturalistic and the magico-religious, but some procedures exist in a gray area where it is not clear whether it is believed that “magic” is supposed to be the healing agent or natural means are the healing agent. For example, running scissors down one’s back is a common practice in folk medicine to cure a nosebleed. To modern anthropologists and most Appalachians it is

unknown whether it was thought that magical properties were the intervention or whether contact with a cold object was the intervention believed to heal the nose bleed (Cavender, 2003).

The naturalistic component of folk medicine is largely based on humoral pathology, a theory postulated by the Ancient Greeks in which health is dependent on maintaining a balance between the four body fluids: blood, phlegm, black bile, and yellow bile. Large emphasis was placed on the blood and excretory systems in the Appalachian culture and ideas of humoral hot/cold, blood letting, purging, sweating, and cupping emerged from this medical system. The magico-religious division largely holds the idea that “like affects like”. So, an axe or knife placed under a laboring woman’s bed would “cut” her pain. Another prevalent idea in folk medicine is trichotomy, the idea of threes being a “magical” number, so, many cures included the repetition of steps in threes. Another pervasive idea is that illnesses can be passed from one object to another, so warts could be transferred by placing the number of stones amounting to the number of warts on one’s body in a paper bag and placing it by the road and the next person who picks up the bad will take on the warts and the original person will be healed. Faith healing and the belief illness is a result of disobedience to God are possibly the most relevant and pervasive ideas in the magico-religious division Appalachian folk medicine. These aspects will require the most cultural sensitivity in the treatment of the Appalachian culture (Cavender, 2003).

A recent study published in 2008 by Ezzati, Friedman, Kulkarni and Murray, showed a trend in declining life expectancy in the Appalachian region through the analysis of census materials. The study analyzed 4 decades of census materials from 1960 to 2000 showing a 4 percent of men and 19 percent of women experienced either declines or stagnation in life expectancy beginning in the 1980’s within the Appalachian region. The average life expectancy of a male in the United States in 2000 was 74.1 years and for a female it was 79.6 years. In Appalachia, some counties, largely depending on the statistics of drug abuse, averaged a median life expectancy of 40 years. Overall, the Appalachian region showed that significantly higher percentages of people between age 35 and 64 die than in other parts of the nation as a whole. The birthrate of Appalachia is on average about the same as its national counterparts at 13.82 deaths per 1000 of the national population (Ezzati, Fiedman, Kulkarni, & Murray, 2008).

Largely within the Appalachian culture, medical decisions are made through the traditional patriarchial family system, but flucuations occur depending on situations (Blakeney, 2006).

Neuman System Stressors and Resources

StessorsIntrapersonal stressors within the Applachian culture may include illiteracy,

affliction of illness, or religious belief struggles. Identified interpersonal stressors within the Appalachian culture may include the struggle over traditionalism versus acculturating to their national counterparts, accepting versus rejecting religion changes within one’s family system, or the “out-migration” of a person within one’s family system. Extrapersonal stressors within the Appalachian culture may include abject poverty, pride versus accepting welfare, medicaid, or government assistance of any kind, belief systems

conflicting with the biomedical model of healthcare, lack or transportation to and from school, the hospital, or the grocery store, financially caring for aging family members, or the stereotyping of one’s culture and therefore prejudice toward oneself.

ResourcesIntrapersonal resources include a strong spirituality which is prevelant throughout

the Appalachian culture which has been noted to help individuals through illnesses. Interpersonal resources include a strong family unit within the Appalachian culture. Extrapersonal resources include government financial and medical aid to most Appalachians and continuing support of reform and building efforts in the Appalachian region in an attempt to better the area.

Culture Specific CareIn the consideration of culture specific care of the Appalachian culture there must

be patience taken with making sure one understands the indiosyncrosies of the Appalachian dialect. Care must be taken when the healthcare provider is given responses unfamiliar to them and must make sure to have the patient clarify their responses in order to ensure accurate and competent care.

Other culture specific care must be given in regards to nutritional habits. The suggestions of healthier eating habits must be given, the assessment of financial status, access to healthy food options, transportation, and understanding of nutrional needs must be done. The reduction of cardiopulmonary risk factors must aslo be implemented through education and ensuring understanding of how to reduce such risk factors. Another area that must be considered in care is the medical belief model in which the patient prefers to practice. Assessment and incorporation where possible must be done in order to ensure the compliance of patient. Financial assessment is critical when prescribing treatments for illness and risk factor reduction, if the patient does not have the financial means then alternatives are necessary to ensure compliance.

A final suggestion in regards to culturally competent care must be to consider the spiritual aspect of those being cared for. Fostering that aspect of the client is critical for their health and well being. Such fostering may increase the patient’s trust in the care provider and may increase compliance across the board.

Biblical Perspective

In Genesis 12:2, God has just promised Abraham a great nation and has given His blessing to that nation. In the next verse God tells Abraham that through his nation, the future nation of Israel, “All peoples on Earth will be blessed through you”. However, the nation of Israel was exclusively for people of the Jewish faith until Jesus came to fulfill the law. Upon fulfilling the law, Jesus thereby extended the nation of God, and therefore the nation of Abraham, to the gentiles. Such an extension is encapsulated in Acts 10:44-48 when the Holy Spirit fell on the gentiles. Since this extension occurred and the promise of Abraham’s nation being a blessing to the peoples of Earth still holds true, believer who are healthcare professionals working within a culture other than their own can see their work as fulfilling God’s promise to Abraham. The fulfilling of God’s promise is not in the actions that the healthcare professional does for God, but in God’s outpouring of culturally competent care and a servantile attitude through the healthcare professional. Above all, God’s will must sought continually.

Figure 1: The Appalachian region as defined by the Appalachia Regional Commission

(2008).

Ages 65+

Ages 45-64

Ages 18-44

Under age 18

0 5 10 15 20 25 30 35 40 45

14.3

23.7

38.7

23.7

12.3

21.9

40

25.9

The population in the Appalachian region tended to be older than that of the rest of the nation (rate per millions)

Non-Appalachia Appalachia

Table 1: The population age in the Appalachian region versus U.S. national

average (U.S. Census Bureau, 2001).

Source: U.S. Census Bureau, 2000 census

Table 2: National poverty status in the United States versus Appalachian region by

household type (Pollard, 2003).

Table 3: Appalachian region in contrast with U.S. national death rates for

specific causes 1990-1997, adults 35 and older (Halverson, 2004).