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By: Trish Willette

ETSU: BSPS 4210-905

May 2, 2010

The Health Disparities of Rural

Appalachian Women

ETSU
[ May 2, 2010
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Contents
ETSU: BSPS 4210-905........................................................................................1

The Health Disparities of Rural Appalachian Women.................................................................................1

This report covers four major health determinants barriers: access to healthcare organizations; Social

Behavioral and its health effects in the area of physical, mental, and spiritual health; Socioeconomic

factors: the relationship between the rural Appalachian economy and the role it has play in the social life

and challenges to the health care system; and the Demographic and geographic depression of sub-regions

of the rural Appalachian region. The report evaluates the research on what current public health services

are available and the possibilities for better future services. The strategic plans are design at East

Tennessee State University and other partnerships to determine what services would best fit the rural

regions. Plus, research groups are determining the plans that would become helpful to the population in

reaching their goal for these women in becoming the healthiest locally, regionally, and nationally.

The health disparities of rural Appalachian women are unique. Health disparities concentrate on the

barriers of bringing accessible, high quality healthcare to those who have socio-economical challenges.

Strategic planning will significantly improve the health determinants and health risks in women of the

rural Appalachian region. Researchers will divert negative health issues and increase public awareness.

Also, work groups have implemented internal and external resources locally, regionally, and nationally.

This will help meet our mission of bringing high quality accessible health care to the women in the

mountainous region.
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In this research, the study consulted experts at East Tennessee State University. The research utilized

experts from the following departments: College of Nursing, College of Public Health, and The Office of

Rural Health and Community Partnership (ORHCP). Those interviewed we asked questions about their

research and opinion on which actions they feel would be best and why. Also considered were the actions

which are being taken locally and which conflicting barriers existed.

Vulnerable Women consist of those who are a higher risk for health disparities when compared to the

national average. In social dimensions and healthcare barriers, the most vulnerable women are those of

the secluded rural Appalachian region. These women are a population predisposed to acute and chronic

illnesses. In this analysis, the regional programs in breast and cervical cancer among this rural population

will be reported. This vulnerable population of women faces both actual and perceived risks. The risks

are evident in the areas of prevention, treatment, and quality of life which can lead to premature and

unnecessary mortality rates. They are vulnerable because of the barriers in health care services that have

left gaps and have resulted in health care disparities. The research answers the following question: is this

population of rural women at risk for developing acute and chronic illnesses simply because of their

demographics, geographic location, and/or characteristics of cultural lifestyle?

In order to close the health care barriers that gap rural Appalachian women from the rest of the

region and mainstream America, there must be a leverage among government, research organizations,

universities, community based organizations and communities to provide specific needs that are

identifiable as unique to this region. What the priorities of the agencies and universities involvement are

to address more policy- specific and short-tern to medium-term strategic plans to close the gap of health

disparities into this female population. Specifically, there are two groups of Appalachian women; the

metropolitan and the non-metropolitan. The non-metropolitan women represent the folklore culture of the

stubborn, strong-willed, pride and independent woman. They are rich in family values, strong in faith and

very independent. Could these attitudes be the cause which results in often complicated factors unique to

the surrounding beauty of the mountainous in accessibility to quality health care? The purpose of this
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analytical research is to explore the Appalachian region and how demographics and cultural life style

might predispose the women as a population endangered in receiving lesser quality health care. Secondly,

what programs are communities based and university assisted with the partnership provided by

government related agencies like Appalachian Region Commission (ARC)?

Appalachian identity has been portrayed for many centuries and exists in today’s society. According

to the Center for Disease Control (CDC), for more than a century, Appalachia has been mythologized by

journalists, scholars, and policy makers as an area apart from the rest of America in terms of geography,

economy, and culture (CDC, 1-4). In addition, beginning in the 1870s, the local color literary movement

characterized Appalachia as "a strange land with a peculiar people," isolated from mainstream America

and its modernization (PCD, 1-5). In addition, the website indicates characteristics attributed to

Appalachians included fundamentalism, isolationism, familism, and homogeneity. It is through journalist

that these characteristics soon calcified into stereotypes. They are still known by the media and

recognized by people living in this region.

The portrayal of rural Appalachian women’s socio-economic environment may attribute as

underlying factors in this region as reason why some women succumbs to health disparities. Is it the

lifestyle that they have known that prevents them from having quality health care and accessibility to

health care? Why it is there evidence that urban Appalachian women in cities, like Atlanta, Nashville,

Charlotte, Knoxville and Roanoke have better accessibility to treatment of acute illnesses and receive

better care than their rural isolated counterparts? What roles has foundations, universities, communities,

and research groups played in closing the gap in health disparities in the most vulnerable population of

the Appalachian region? Do socio-demographics and health characteristics associated with rural

Appalachian women prevent quality health care for chronic and acute illness?

It is important to understand the challenges that non-metropolitan Appalachian women face in

acquiring health care. Why they are treated different? What has national and community research done to

bring quality care treatment for acute and chronic illnesses to the area most venerable population.
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According to the article in the Appalachian Region Commission, the demographic and socioeconomic

background is stated in Appalachian Rural Commission. The areas consist of mostly rural mountains with

lower population density. This is also the consensus of organizations and magazines on health studies.

According to ARC, most of Appalachia is rural. Of the thirteen states with counties located in the

Appalachian region, ten states have Appalachian counties with lower population density than their

respective state averages. Appalachia is also characterized by many geographically isolated counties.

Access to cancer care is limited because of the region’s history of a shortage of health care professionals

and distance to referral centers from rural areas. The small towns’ social values of family and community

bring together group efforts that excel in the cancer leadership coalitions. The challenge in the sub regions

of Appalachia is to build a set of cancer care services realistic for rural settings while ensuring access to

highly specialized services at regional centers. Cancer control experts need to promote the value of cancer

prevention, risk reduction, and screening services as important parts of cancer care that can be delivered

by local providers in rural communities. The effort in packaging these needed services may help rural

residents see community cancer control as feasible and important. The population will not see the

problem as something available only through very expensive and distant cancer centers. Moreover, it is

important to connect between community based centers and rural communities. This added advantage

would be a mutual opportunity with health care organization. Health care is largely organized, funded,

and monitored through political channels. All public health programs, Medicaid funding, and vital

statistics reports are organized by state. Health care service boundaries and health outcome patterns are

not as clearly defined. Any attempts to organize health status data across state lines within the formal

boundaries of Appalachia proved to be a logistical and statistical nightmare. It was not until the National

Center for Health Statistics (NCHS) produced national maps to display mortality rates that the truth about

Appalachia’s health status emerged. The ARC study shows that the maps proved statistically what

residents knew intuitively, Appalachia, the place they called home, suffers disparately poor health

compared with the rest of the nation. (ARC website)

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Appalachian Region consists of three subdivided regions. First there are the Appalachian metro

counties which include are the large metropolitan cities. Second, there are the sub-regions in the

mountainous terrain consisting of small towns and cities. The isolated rural areas have limited

transportation highways. Thirdly, there are the distress counties with smaller communities with rugged

terrain with coal mining production.

Appalachian Region Commission (ARC) describes:

The Appalachian region is a 200,000 square mile of beautiful mountainous rugged geographic

terrain. Their regions consist of 13 states: Alabama Georgia Kentucky Maryland West Virginal

Ohio, Pennsylvania, Southern tip of New York, North Carolina, South Carolina, Mississippi,

Tennessee and Virginia. Most of the states lie within its region, but, West Virginia is completely

within its borders. It is a long stretch of mountains some 2,000 miles long and 360 miles wide. It

has a population of about 22 million people in which an estimated forty-three percent live in rural

areas. The rugged mountainous terrain is cited as the most important reason why access to health

care has been difficult. According to ARC is estimated that some two-hundred and ninety of its

counties are classified as non-metropolitan, while the remaining one hundred nine countries are

metropolitan. (ARC, see Appendance Map1.1, 1.2)

Geographic isolation minimizes exposure to outside healthcare services. This includes limited

exposure to healthy lifestyles and prevention publication that may be more prevalent in urbanized areas. It

is because of rural setting and isolation, community population in every socio-economic sector and ethnic

background, share many common exposures and experiences with healthcare barriers. Geographic

characteristics of the region’s population are rural and small communities. The rugged mountains

channels; valleys and rivers isolate and separate communities from metropolitan cities and health care

resources. Smaller communities, such as hollows (pronounced hollers) within communities are separated

from neighboring towns. Today, the Appalachian regions, especially the sub-regions face disarray of poor
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health because of geographic isolation. Transportation issues have been cited as one of the main issues to

access to care. Limited roads made transportation to health care facilities a major problem. The distance

to accessible health care facilities has been important barrier work groups have addressed.

The Appalachian Sub-region is smaller terrain of geographic regions. The northern sub-region

includes 144 Appalachian counties that span southern New York, Three-fourths of Pennsylvania,

Southeastern Ohio, the Maryland counties between Pennsylvania and West Virginia. The central

sub-region contains eight-five counties located in the parts of Appalachian often considered the

core or those counties most responsible for the initial interest in poverty in Appalachia. These are

largely counties in the secluded mountains and coal regions of eastern Kentucky, southern West

Virginia, through North Carolina and eastern Tennessee, to the outskirts of Atlanta, and through

northern Alabama, and northeastern Mississippi. (ARC, see Appendance, Map1.3)

The examination of the sub-regions is necessary to achieve an overview of the demographic and

economic characteristics. Transportation issues also hinder many others from leaving the area to obtain

resources such as: employment, education, housing, and quality health care which are essential to

increasing their quality of life. Health care in this region is largely provided by nonprofit organizations,

such as missionary groups. Religious groups like the Catholic Church were among the first who brought

health care to small towns in the Southwest Virginia area. Growth and decline of the economy are often

the cause of health disparities in this region. It is often difficult to attract young, experienced physicians

during periods of economic downturn.

Many families within the Appalachian region feel that the mountains have molded their lives. Within

these families you will find a strong, proud personal identity with a unique culture and placement. The

source of economic income throughout the Appalachian region puts those with a strong work ethic at a

higher risk of cancer. The risk comes from their continuous contact with hazardous materials in the

workplace. For instance, in this region, coal mining is the main economic source. There are also factories
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which expose residents and workers to hazardous chemicals. This region is rich in agriculture; therefore,

pesticides are used to keep crops healthy. Last, the mountainous regions natural environment exposes the

population to radon gas.

Social and cultural factors influence health and propose challenges to the Health System. One major

barrier which challenges health care providers is the cultural characteristics of the region. Personal

confidence and trust may be challenging to build with rural Appalachian residents. Trust is earned over

time and through multiple positive encounters with health professional. Once this trust is gained, it is

rarely severed. There is a general lack of assertiveness among the population which influences their

health care. This results in uncertainties in patient-provider communication, issues of compliance with

therapeutic regimes, and difficulties in patient goal setting and decision-making. One of the underlying

tendencies in this culture is the unintentional lack of using health care services and doctors’ referrals. The

population’s sense of privacy, pride, and low expectation of good health causes an increase in diseases

that are normally curable in early stages. Appalachian populations recognize their small numbers may

result in lower amounts of hometown health professionals with whom they can create trust. Often a

patient has a health care provider who may be foreign or from a metropolitan region of America.

Why do health disparities exist? The health care organizations seek to find solutions to dilemmas’

and challenges that rural Appalachian women face. The female populations that live in this location

intuitively know why access to health care was difficult to obtain. They know that their female urban

counterparts receive the best quality and accessibility in health care. They know that it is through

incentives and direct interventions which have had a significant impact on rural Appalachian women’s

quality of care.

There are studies which show that we have too many physicians in the United States. This is certainly

not the case in community and rural health areas. Doctors avoid areas that do not support urban life and

up-to-date high technology. Keeping and recruiting doctors takes a strategic plan aim at giving incentives.
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Some universities encourage or required medical students’ time working at rural community health care

organizations. Also, newly graduates of medicine are offered medical tuition forgiveness and other tax

credits to set up practice. Innovated rural health care programs serve as a base which health students

develop the skills as professionals. East Tennessee State University has taken a different approach in

health care education. In a partnership with the Kellogg Foundation, they have focus on preventing

chronic illnesses in under-served populations. East Tennessee State University has opened the opportunity

for the college of Medicine, College of Nursing, college of Public Health And Allied Health to practice in

the rural Appalachian sub-region. They are bringing health care home to the communities.

Healthcare tends to be of higher quality in the wealthier areas of rural Appalachia. It is well known in

the healthcare world that rural communities lack the ability and wealth to attract the best health care

providers. The sub-regions of Appalachia cannot attract the top rated physicians as their wealthier

metropolitan counterparts. Therefore, outreach services like ETSU college of Nursing, ETSU Office of

Rural and Community Health, ETSU James Quillen college of Medicine, ETSU College of Public

Health, and Allied Health have combined effort with other Appalachian universities and research

organizations to bring health care to the population most vulnerable.

Access to care for some residents is limited by economic factors such as lower per-capita income,

higher unemployment, and health insurance issues (non-acceptance of public insurance plans, high

deductible policies, etc.).(arc .com) There is a general level of mistrust among Appalachians, described as

the fear of “being taken advantage of” in the health care system. This belief seems to result in an

underutilization of health care services. Too few health providers demonstrate cross-cultural

communication competence in their practice. Most frequently, health care providers fail to recognize or

value beliefs and communication issues in the region.

Within the Appalachian region there is a strong faith in God. Health professionals acknowledge this

faith as part of a rural Appalachian’s life and philosophy may be better received by the larger community
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and the patient-base. Many scholarly studies have been completed about faith and fatalism as barriers to

health care utilization. In an interview about fatalism, Bruce Behringer, Assistant Vice President of the

ETSU Rural Health and Community, confirmed that the role of religion in the Appalachians population

was found to be a strong benefit. However, faith was not found to be a barrier as authors in the past

interpreted and exaggerated. The combination of faith and the benefits of medical care services,

especially patients diagnosed with cancer, were found to have a balance in obtaining treatment and

seeking care. For example, the Preventing Chronic Diseases (PCD) article;”Social and Cultural Factors

Influencing Health In Southern West Virginia: A Quality Study” cited in 1958, Thomas Ford conducted

the first scholarly studies on Appalachian attitudes and beliefs. Ford's survey was designed to measure

fatalism, religiosity, individualism, and self-reliance; values which traditionally identify Appalachians

and link them to sub-regions. Ford's study refuted the existence of certain values, fatalism, and supported

the existence of strong religious beliefs. His study suggested that cultural attributes are dynamic and adapt

to a changing social and economic environment. (vol. 3:no.4, p.1)

Health-care system characteristics for the Appalachian region have been government regulated

and availability of health-care services has been historically limited in the mountains. Almost half

of all Appalachian rural countries remain federally designed as health professions shortage areas.

Another characteristic for the region is distance to care remains a common problem for those

residing in rural counties.

Health care is largely organized, funded, and monitored through political channels. Public

health programs, Medicaid funding, and vital statistics reports are organized by state. Health care

service boundaries and health outcome patterns are not as clearly defined. Attempts to organize

health status data across state lines within the formal boundaries of Appalachia proved to be a

logistical and statistical nightmare. It was not until the National Center for Health Statistics

(NCHS) produced national maps to display mortality rates that the truth about Appalachia's health

status emerged. (nchs.com)

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There is a sense of fatalism about using the health care system. Participants stated poor expectations

of outcomes of care, particularly relevant to cancer. This sense is based on collected community

experiences. For example, physicians trying to navigate the cancer care services. The low expectation of

survival has resulted in high community visibility in cases of cancer incidence and mortality. The

interview with Bruce Behringer, MPH, Vice President of ETSU Rural health and Community cited that

we must intertwine cultural characteristics and health systems characteristics to have reduced barriers and

quality of care. It is very important that health care system embrace communication style and

acknowledge the role it plays in internal environment. Communication, earning the trust of the rural

population, and using inside interpreters in community base systems has been the keys to developing

programs. According to Dr. Behringer, in the near future, East Tennessee State University will be

combining efforts with a grant from the American Cancer Institute to combine the services of Oncology

care, healthcare providers, and storytelling to address communications issues. Using rural Appalachian

cancer survivors as storyteller, they will design a module to teach health care providers to listen to the

patient. In my interview, Bruce Behringer said.”We educate not train when it consists of nurses. We train

physicians”. (Interview, Behringer)

The ARC Appalachian Magazine article, “Rx for Rural Health- Care Shortages” by Ron Richards,

implies new medical education efforts in university group work studies and the Kellogg Foundation,

provided evidence that we must bring an array of program suites to the communities to make ever

program unique and successful. (arc.com) Revolutionaries’ in Health Systems play a key part in advising

best fit programs. The tools used in foundations lead to the challenge of closing the gap in Health care

disparities. In the 1960’s, the status of the Appalachian health care became evident. The war on poverty

brought new light to the disparities of rural Appalachian lives and the challenges the health systems faced.

Their new goal was to bridge the gap between access to health care and mainstream America. This

research found organizations like National, The Kellogg foundation, the RAND Organization, Center for

population Health and Health Disparities (CPHHD), REACH, Health People 2010, ARC, and National
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Center for Health Statistics (NCHS). These organizations are striving to meet the challenges of bringing

together education, research, rural patient care, and community base care head on. By working effectively

with partnerships such as East Tennessee State University, ETSU Office of Rural and Community Health

they have identified major needs in rural Appalachian health disparities. The prevention, treatment, and

cure of cancer from many universities and research groups has improved performance across the health

care system. Their continuous endeavors to close the gap of health disparities are structured into new

programs for the prevention, treatment, and cure of cancer as well as other treatable diseases.

Work Groups are used for statistical research, evaluation, observation and collection of cluster results.

Many steps were created to assist in the success of addressing inequalities. These developments are very

important in evaluating and accessing significant relationships between health care and disparities such

as: breast and cervical cancer in the rural Appalachian areas. The work groups targeted various age

groups within the rural regions. The groups created a battery of questions and completed testing at

campus facilities (like the Appalachian regions universities) or community service centers. On average,

the participating subjects were between the ages of 18 and 79 years of age. The research groups would

cluster the observations to provide a linear relationship on the research topic being tested. Collectively,

they would review data and identify what experiences are unique to the rural area. They would work in

conjunction with health care providers to develop and implement methods. This created community

health care work groups in the area for a comprehensive health care service plans.

Cancer in rural Appalachian region is uniquely different in the sub-region compared to their urban

counterparts and nationally. Sub-regions in the Appalachian region are mostly poor and medically

underserved. The area residents tend to be older, poorer, less educated and more likely to be uninsured

medically. Therefore, the populations are less likely to have contact with specialists and in general, family

practitioners. The Appalachian region has been identified as having the highest death rate for preventable

and treatable cancers. Some of the local residents place blame on the environment and the type of jobs

available, mainly coal production. Its residents often mention a major factor cited is transportation. The
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distance of travel matters most in getting high quality, accessible health care to the population of this

region.

In the PCD article Research on Social Work Practices, the report speaks about how complex the

gathering of accurate data can be. Although the need for evaluation of prevention programs is clear, the

implementation of evaluation is a challenge. These challenges are evident particularly for large, complex

projects with multiple investigators. Program evaluators in these circumstances do not have the same

degree of control as experimental psychologists and must find ways to obtain data while being sensitive to

local environmental influences. The Appalachia Community Cancer Network is used as a case example,

and illustrations of its approach using formative and process evaluation are presented. (vol. 18, no.5, pp

507-517)

The above mentioned work groups learn lessons on how the influences of mountainous culture and

stories affect health behavior and create barriers in the health system. The CDC reports how medically

underserved rural areas of the Appalachian region have higher than national average of lung, breast,

cervical, and colorectal cancer. It was cited that the lack of health providers’ specialist in the poverty

stricken areas was the reason.

Within the rural Appalachian community there is also a fear of knowing they have cancer. This fear is

perhaps because the disease runs in their family; many rural individuals believe it to be a death sentence;

therefore, some residents believe that not being diagnosed is better than knowing. Although, this presents

a challenge to organization and research work groups in closing the gap of health disparities, healthcare

researchers and providers have been able to address the issues successfully. There are several articles and

books documenting the populations need for cancer education. Some residents are confused and

frightened about the differences in prevention, and treatment of cancer. Among women in the secluded

rural areas, there are misrepresentations of breast and cervical cancer screenings. According to a ORCHP

study, in their PCD article” Appalachia: Place Matters in Health” focus groups and survey participants
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reported that they gain most of their information about cancer from family, neighbors, and friends rather

than health professionals. The horror stories from family, their neighborhood community members, and

close friends have been their only way to gain information. Unfortunately, the information they receive

often includes misperception of and dated knowledge about cancer treatment. This is why the storytelling

will be an important part of the rural community health programs. This method will give correct

information in a relaxed setting using people who are interpreters. (PCD, vol3 (4):A113, Oct.2006)

The ARC research report cited that ”Relative to the non-Appalachian in the U.S., the Appalachian

region experiences generally higher levels of prevalence of obesity, smoking, and physical inactivity and

also experiences less utilization of cancer screening. Within the Appalachian region, there is a great deal

of variation in the prevalence of these behavioral risk factors. In general, the more adverse levels of

prevalence occur in the central portion of the region including areas within Eastern Kentucky,

Southeastern Ohio, Southern and Central West Virginia, and Western Virginia.” (ARC-Report

www.arc.gov/index. )

Bruce Behringer asked,” If you gave away mammogram and cervical screening in the rural

neighborhood who would get them?” In interviewing Bruce Behringer, he says that there have been

changes in cancer over the past 20 years showing that outcomes are better. The cost barrier has been

reduced. He said, “Look at characteristics of the population and the use of the care services. If the

population knows that these rural services exist, but they do not use them, then why?” (Interview with

Bruce Behringer)

The U.S. Census website cited that Breast cancer in the rural Appalachians women has experienced

higher breast cancer mortality rates than the national average. In some counties the mortality rates are

significantly exceeds the national rate. In this analysis, the report investigates the research and community

programs, especially at ETSU, that have been very useful in rural women to get involved with group

providers and healthcare professionals. These women are at the forefront in navigating and breaking
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through barriers. The female community population has been able to interact with oral and written survey;

afterwards, they give suggestions to reach the rarely screened and never screened women.

Breast cancer experiences between patient and health care physician is one of the most important

forms of inter-personal relationships. Health care providers, community based public health organizations

and group works must have collaborated efforts to market vast screening that are free or sliding scale

services. In navigating care and utilization of services, the breast cancer patient should be aware that they

must take control of their own health. According to Dr. Kelly Dorgan, PhD, ETSU Associate professor in

Communications, It is important in the rural communities that the family be involved to insure that the

main caregiver seeks preventive care, and treatment for cancer. Family involvement is crucial to

removing one barrier of quality care. Health care providers working with rural Appalachian females

should incorporate the family in planning the course of health care and treatment. (Interview, Dr. Dorgan)

In rural Appalachian region, important factors are stressed to physicians to provide clear, open

communication with the patients. They must get to know the patient, communicate and walk through the

difficult steps of treatment. The most important factor is to help the patient feel that they are important.

Assuring them that they are not lost in the loop of health services system paragon. It is important for the

health care provider to track the patient’s journey through the cancer oncology treatment process. The

journey begins with their local primary physician which will include surgeon to medical oncology

specialists to oncology radiologist. The local health care services provide breast care education and

advance care to breast cancer patients. These are need-based programs and best fit systems designed to

gain the trust of the patient. East Tennessee State University and its community partnership with area

medical centers train student physicians to communicate with the unique rural Appalachian woman. They

educate nurses to the socio-demographic characteristics that have been cited as barriers to obtain

screening and continuing treatment for breast care. The ETSU/ORCH Partnership has had an impact on

meeting needs in rural Appalachian regions. It has brought together a common ground between rural
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providers and rural partnership programs which help to attract the best health care providers. One of the

most useful methods is the breast and cervical cancer “Early Detection Programs”.

Cervical cancer is one of the most preventable forms of cancer. Mortality rates have dropped

considerably in the United States due to the increase of early detection screening. However, in the rural

Appalachian population the rates have remained lower and mortality rates are higher within the region.

Research has shown that more attention is needed to address the causal factors and barriers. Research

work groups have examined the relationship between attitudes, beliefs, and knowledge; about cervical

cancer, cervical cancer screening, and screening practices among the female population in rural

Appalachia. The determinants of cervical cancer screening in the Appalachian sub-regions will take many

different organizations, people, and community effort to remove barriers. This assessment is mentioned in

the Preventing Chronic Diseases article Awareness and Knowledge of Breast and Cervical Cancer. A

regional approach using community based organizations are necessary for the potential of reducing

outcomes. (Lyttle, et al, vol3.no.4, Oct2 006)

In the PCD article, “Assessing Awareness and Knowledge of Breast and Cervical Cancer among

Appalachian Women, it cited how there is a cervical cancer disparity in the region, with an elevated level

of mortality compared to national levels. Work groups analyzed the patterns of cervical cancer mortality

at the county level, in order to identify who is at particular risk. A number of Appalachian counties are

listed among the worst 20% of cervical cancer mortality rates which is twice the national rate. There was

no observed relationship between cervical cancer mortality and Health Provider Shortage Area (HPSA)

status, and no relationship between mortality and whether a county was urban or rural. Our findings

suggest that focusing on the special problems of distressed counties might be a fruitful way to improve

cervical cancer outcomes in Appalachia, and therefore address one of the most prominent cervical cancer

disparities in the nation. (Lyttle, et al, vol 3, no.4, 1-9)

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In-depth interviews revealed extensive convergence with the National Health Interview Survey

(NHIS) data. Participants described how older age, living in a geographically isolated place, and limited

social ties converge to thwart Pap testing. A younger participant mentioned how they knew women who

live in the hollows that had strong beliefs, pride or caregiver obligations that kept them from seeking

preventive cancer screening. In another discussion with a local woman about growing older and the

isolated in the mountains provided evidence that many middle age and elderly females do not see the need

to be screen. The challenge for health care system in screen for cancer is the never been seen and the

limited seen females. The older population presents numerous challenges to organizations, especially

when doctors for this test are male. Additionally, the women don’t understand why it’s important when

they don’t think anything is wrong. (NHIS)

Being older conferred numerous challenges to Pap test receipt, including competing attention from

more pressing health conditions and having higher limited incomes. Being unmarried created more

barriers to these challenges by limiting health vigilance or access. There is no family pressuring the

female to take care of herself. Also, there is no one to transport the woman to her appointments. The lack

of inter-circle support by family and friends decreases the likelihood she will seek preventive care

screening. For single and older women, it is presumed an unreasonable need to undergo a gynecological

pap or cancer screening when there is little or no sexual activity. In order to address unique issues of the

geographic Appalachian region, group workers involve Appalachian communities’ sub-populations. The

under-screening characterized barriers mentioned earlier resulted in higher than average cervical cancer

were common to the small communities.

The best fit practices for the region apparently are communication and acceptance of the culture. In

order to lower cancer rates in the region, the recommendation of a health care professional must be

increased. The absence of supportive family and friends in the rural region will endanger the likelihood of

the main caregiver to get care. It is health professionals who must provide the encouragement to involve

the family support system. In addition, there are expansion support programs with organizations like the
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National Breast and Cervical Cancer Early Detection Program. This program, and many like it, assist

lower-income and rarely or never-screened women in receiving needed cancer prevention services.

Significantly, it addresses the issues of out of pocket money and transportations issues. The universities,

research groups, and community outreach services for breast cancer and cervical cancer in the region has

developed community programs. Using their service will take adapting and implementation of community

based program that intertwine with local care providers. Navigating care in the Appalachian region has a

number of challenges. Work groups must somehow get the communities involved in telling stories and

providing facts that inform in a trusted setting. Schools, churches, women’s groups, and survivor

advocates who can tell their stories must combine efforts to make awareness of the importance of early

detection screening.

Revolutionaries are the ones who impact the lives of others. They have a cause and they make things

happen. This is what has made the rural Appalachian region healthcare align with the health system

delivery. They have adapted, advocated, and advised the health care providers and community public

health care services. These adaptations help to understand the population of this unique culture of the

rural Appalachian region. The health care partnership of different organizations continues to meet the

many challenges and dilemmas for quality accessible rural health care.

In a lecture form in the ETSU College of Public Health Leading Voices, Dr. Nicole Laurie, MD,

MSPH, new scientific evidence says the study of epigenetic, in changing illnesses, scientific observation

notes that changes in epigenetic modification seen in animal and humans have changes occur across a

wide range of illnesses. Those changes can be transmitted into the next generation. There are some things

that science can change through environmental and social changes.

According to Dr. Laurie, Biological embedding occurs early in the first three years of childhood.

Sadly, where you live does matter. We have seen evidence in this research. Location affects your biology

and neighboring socioeconomic health. If you choose to claim yourself as a rural Appalachian woman,
 Willette 19

especially in the sub-region of Appalachia, then these are some of the expected problems. The effects of

stereotyping have been evident in the Appalachian Region. There is a classification called Appalachian

identity. Because of this stereotyping, there can be unequal treatment in the following areas: access to

care, quality of care, stereotyping and discrimination, lack of ownership, and the lack of specialist

healthcare providers. (Lecture: Leading Voices)

Many doctors/physicians are skeptical that inequalities in care exist. One of the problems is outside

the health care profession; the issue of economics comes heavily into play in the area of healthcare. The

educational training at the ETSU College of Public Health requires students to have hands-on study

within the surrounding communities.

Work groups, community base participatory approach, healthcare providers, patients and primary

physicians’ partnerships’ each sector plays a role in addressing inequalities. Quality improvement efforts

improve processes but not the outcomes in communities. The use of tele-health communication has

addressed the lack of specialist problem of secluded rural areas.

The National Health Plan collaborative has cited ways to address disparities inequalities. The steps to

success in addressing inequalities: 1) Identify disparities regions 2) Target and testing intervention 3)

Identifying health disparities and zero in on a major problem. (NHP)

Diagnosing “hot spots” is the approach in the public health field research on disparities. It is a

population approach which can focus intervention on the provider level. The tools used in this endeavor

are grants from the Kellogg Foundation, RAND Corporation, ARC, REACH, Health People 2010, and

National Center for Health Statistics (NCHS) and the CDC partnership with researchers, universities and

community base providers. They help coordinate research efforts in places like ETSU College of Nursing,

Office of Rural and Community Health, and Department of Rural and Community Health. The funding

improves the effort for local medical centers, payors, and public health providers to address unique

cultural issues that affect quality health care.

 Willette 20

REACH Communities 2006 help to address health disparities nationally. The RAND Corporation’s

center For Population Health and Health Disparities work on extensive research of many rural area. The

RAND Corporation has collaborated efforts to examine health disparities of the rural Appalachian area.

The two commonly reported barriers; transportation and cost, in cancer screening for breast

mammography and cervical cancer screening utilization unique to the region have been address by the

work groups who report to health care providers, payors and community based organizations. Policy has

been a means of eliminating barriers. Also, bringing healthcare into the rural communities with

interpreters has assisted the sub-region of the Appalachian area.

This research set the lessons learned from interviews, articles studies, colleges, and departments on

the ETSU campus for delivering better healthcare to sub-regions of rural Appalachian women. These are

the revolutionaries, impacting the lives of the underserved women of this area. They are rising now and

will in the future be able to provide accessible, high quality healthcare by performing these intensive

investigations of health disparities.

Appendance:

http://www.arc.gov/images/programs/distreshttp://www.arc.gov/index.do?nodeId=1088s/dc-fy09.gif

Map 1.1: Appalachian Region Counties in

State and National Context

Map 1.3: Appalachian Sub-regions Map 1.6. Distressed Counties

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Behringer, Bruce. "Appalachian:Where Places Maters in Health." Preventing Chronic Diseases

October 2006: 2.

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Hutson, S.P., et al. "The Mountains Holds things In: the Use of Community research review workgroups

to address Cancer Disparities In Appalachia." Preventing Chronic Diseases 2007: 3.

Lurie, Nicole MD,MSPH. "Disparities In Health and What Can We Do." Leaders in Health

care;Leading Voices:ETSU College of Public Health Forum, Johnson City,Tn, 2009,March 5

Lyttle, NL Ms,Stadelman K,MS. "Addressing The Awareness and Knowledge of Breast and

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Behringer, Bruce, interview February 20, 2009

Lurie Nicole, Dr. MSPH, interview March 5, 2009

Dorgan, Kelly A, Dr., interview March 12, 2009