Diabetes: A Family Matter

Appalachian Culture

People living in Appalachia are not all the same. They vary in their traditions and approaches to daily life. However, a culture and way of life associated with many generations of families living in the regions exists in the region. Some speech patterns and ideas about life can be traced to earlier times. Ideas and values often vary from county to county. Family roots are linked to Native Americans, Elizabethian England, Scotch-Irish, German, French, Italian, Hungarian, Southern Slaves, Melungeon, and other ethnic groups. This rich heritage includes family stories that tell of the immigration to the area and ways a promising life was sought in a new land.

Returning home

The independence that brought people to the hills and mountains is intertwined with a more modern history, one that continues to influence lives of those in Appalachia. Many are strongly linked to place and family. Many tell stories of family generations living, working, and dying in the region. Extended family, kin, and long-time friends still play important roles in the daily lives of many that reside in Appalachia. Some born or reared in Appalachia move away for a time, but often return home. Those that move away may still value some of the traditions that speak of family and place.

Rural Appalachia

Much of the Appalachian region is rural, but some larger cities are located here also. For example, places such as Pittsburgh and Birmingham are urban cities. Some cities have had large populations of people that have migrated there from Appalachian regions. Places such as Cincinnati and Columbus in Ohio are places where many people have roots tied to Appalachia. Other places such as Parkersburg and Huntington in West Virginia or Ashland in Kentucky are not nearly as urban as some cities in the rest of the nation, but they are some of the largest cities in the Appalachian region. It is good to recall that many people that live in cities may come from other places, but some will have moved from rural places. This program and toolkit might be useful if working with people who have a history linked with the Appalachian region. However, those living in Appalachia from other places in the nation or the world may not be as likely to relate to the toolkit materials.

Cultural Competence

Becoming culturally sensitive and understanding culture is important. Working with and within communities requires some competence in understanding one’s culture and a sensitivity to those of others. The materials and toolkit activities included in the Diabetes: A Family Matter program are intended to be culturally sensitive to those in Appalachia. Cultural traits tied to Appalachian traditions need to be considered in the development and use of health education materials (Denham, Meyer & Toborg, 2004), but they may not be appropriate for everyone.

Enhancing Cultural Competence:

  • Develop awareness of personal fears, biases, stereotypes, and prejudices.
  • Appreciate diversity and what this means in terms of cultural norms, beliefs, attitudes, values, and behaviors.
  • Learn how others ideas about culture differ from yours.
  • Engage in activities and events that allow you to learn about other cultures (e.g., attend cultural events and festivals, travel, read, take classes and seminars, etc.)
Cultural Competence

Cultural competence can be described as the ability to work effectively with individuals from different cultural or ethnic backgrounds. Some disagree about whether Appalachia is a distinct place and whether it has a unique culture. The persistent images of Appalachia shaped by 19th century writers as a place where caricatures of feuding and whiskey-drinking mountain hillbillies dwell still linger. While the accuracy of these stories was never questioned nor evaluated, the fiction written to entertain continues to be unquestioned by many across the nation. Many people born and raised in the Appalachian region have little or no connection to these images and most find them outside their personal experiences. Unfortunately, these stereotypes remain and continue to be ideas held by many outsiders.

It is important to separate stereotype from reality! Much like other places, Appalachia has great diversity. Some might question whether distinct cultural traits actually exist in the region. Others will likely say that these traits do not uniformly describe the region’s people. Still others might say that too many differences exist within the geographic region of Appalachia to ever say a shared or common culture exists. During the volunteer SUGAR Helpers educational sessions it will be useful to explore the myths and realities of cultural ideas.

Cultural Traits of Some Appalachian People:

  • Family oriented
  • Attached to place
  • Value independence
  • Modest
  • Kind, friendly, and outgoing
  • Patriotic
  • Proud people
  • Less confrontational
  • Enjoy good humor and storytelling
Appalachian Culture

Changes have occurred and continue to occur throughout Appalachia. The history of earlier immigrant populations that settled along the Appalachian Mountains is less visible in the lives of people that now dwell here. While many hold to traditions and still include practices and ideas of earlier people, most are influenced by mainstream notions. Newer settlers in Appalachia have brought other lifestyles and patterns. For example, Appalachian Ohio has many Amish and Mennonite settlers, people with many distinct cultural traits. During the spring, summer, and fall, migrant Hispanic workers work in farming industries. Other Appalachian communities have had an influx of Hispanic, Latino, and Asian settlers. Southern Appalachia has large numbers of African American residents. These settlers may have distinct cultural needs, but some of the ways may be adapted by others in the region and vice versa.

Culture and Health Needs

Culture plays an important role in understanding, addressing, and meeting the health care needs of any people. While some argue whether there is a culture of Appalachia, a large body of literature seems to affirm its existence. Although the culture may not be as distinct as those tied to some specific ethnic groups, many traditions and lifeways have long been associated with people in the Appalachian region and their uniqueness is widely recognized.

High rates of disease incidence and mortality in poor Appalachian regions of the United States have been linked with cultural, social, and economic factors. While some cultural values and beliefs may increase risks for poor health, some factors may actually be protective. Several traits have been used to characterize Appalachian people and symbolize what many outsiders view as a monolithic stereotype of the regions people. Characteristics like fatalism, isolationism, familism, and fundamentalism have been viewed as shared attributes without considering the diversity that has always existed in the Appalachian region.

Describing who is Appalachian

Who is AppalachianOne question that generally needs to be considered whenever Appalachia is discussed has to do with the question of “Who is an Appalachian?” Many ways exist to consider the answer to this question. For example, is an Appalachian only someone that has been born and raised in an Appalachian region? What happens when one moves away for a while, perhaps even working during their entire career in a distant place and then returns at retirement? Is it possible to me more Appalachian if both parents are born and raised in an Appalachian region? Or even more Appalachian if you can point to a family lineage of several generations reaching back over many years? Do people who relocate from other places become Appalachian when they move into the region? If so, how many years does it take before one can actually claim the status? Does being Appalachian fit with the stereotypical traits often viewed as typical of people that live in the region? Can a child raised by a mother with a family lineage tied to the Appalachian region that marries someone from another place and is raised in another location claim to be Appalachian?

Defining or identifying who is and is not an Appalachian can be a challenging task. Based on the federal guidelines and the Appalachian Regional Commission, living in one of the 420 counties of Appalachia makes one a resident and Appalachian. However, being a resident and demonstrating stereotypical traits often linked with the region are different things. Thus, generally when discussions about who is an Appalachian occur, most are focused on the culture of the people that has been valued and passed through families for generations. While some traditions and folklore of the culture are true and evident, one must take care to not consider all those that live here alike. Many differences exist and people are not all alike. In fact, the diversity that occurs across this nation can also be realized in the geographic regions of Appalachia. However, many have described ideas about the people that live in this region and some would suggest that these have important relationships to the health of individuals and families.

Other Cultural Considerations

According to a paper written by Ronald L. Lewis and Dwight B. Billings entitled Appalachian Culture and Economic Development, a large body of popular and scholarly literature written over 25 years or more has overlooked the complex relationship between Appalachian culture and economic development. They argue that widely held assumptions and beliefs (e.g., isolationism, homogeneity, familism, fundamentalism) derived from popular mythology have been accepted as truth influenced the thinking of many professionals during the 1960s and 1970s and continue to be influential factors even today. However, little empirical evidence exists to support much of what others viewed as true. Many held that cultural views of familism and kinship cooperation at the center of a traditional and personal social life seemed to contradict the principles of individualism, achievement motivation, and universalism thought important to a modern American economy that idealized industrialization, urbanization, educational attainment, mass media, and migration.

However, Lewis and Billings describe findings from other sources that suggest age, socio-economic status, and rural-urban heterogeneity were factors indicating that over time changes in the residents indicated that they were not caught in a time warp but were progressive minded and many were achievement or success oriented. Even at this time, some questioned whether fatalism was a trait maintained by some as a coping mechanism with poverty and gave way when economic success was achieved. Ideas about the culture of poverty deeply influenced ideas and impressions of those in the Appalachian region, but focused primarily on the people as if they were at fault and ignored the social conditions in which they were constrained to live. Ideas that the people of Appalachia were by-passed by modern times or that a homogeneous isolated population purely reliant on local economies resides here need to be re-examined. In fact, one should consider that a stereotypical perspective of the people of this region is inadequate to describe the breadth of differences that were found in the past or might be currently identified in the region.

Several factors important to health were identified in a West Virginia population by Coyne, Demian-Popescu, and Friend (2006). Traits such as kindness, outgoing, openhearted, friendly, helpful, spiritual beliefs, God fearing, family values, good moral values, law abiding, a sense of community, hard working, mutual respect, hospitality, and pride were recognized in their qualitative study. Many take offense when outsiders consider them indigent because of the location of their homes. Those in this study viewed West Virginians as having a strong work ethic, loyalty, dependability, trustworthiness, and dedication when it comes to work. These participants were attached to the place where they lived and "their mountains." Many in the region did not like being called an Appalachian due to its negative perspectives (e.g., uneducated, poor, lacking intelligence) and close association with poverty, but did accept the idea of Appalachia as a geographic descriptor. Traits of being clannish and reluctant to share family problems were noted. Strong generational faith views and traditions continue to be important and part of the daily fabric of life and often influence health decisions. Old views that women stay home and care for the children are less true today as families tend to be more like those in mainstream America. Views of fathers as patriarchs have also changed as the more usual mode is either shared decision-making or the woman even taking the lead role. According to findings of this study, when medical decisions need to be made about serious illnesses it is often a joint decision and families tend to rely on trusted physicians when they are available. Women most often make the decisions about what foods are prepared for meals. Family is important in all aspects of life and strong attachments are generally noted among members that impact many areas of individuals’ lives. This paper has many interesting points and should be consulted for more details about ideas about family, culture, and health.

Many research studies have been conducted and journal articles, conceptual papers, and books are widely found in a growing body of literature pertaining to the Appalachian region and its people. You will find a number of resources available at this site.

One thing for sure, connection between who we are and how we behave certainly have impact on our health habits and ultimately our health. Thus, while many may argue the presence or absence of specific cultural traits, it seems realistic to say that some characteristics of many living in the Appalachian region have potential to impact health and illness. Many references and other sources are provided for consideration.

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