Address the Social Determinants of

Appalachian Health

Sharon A. Denham, PhD, RN, CNE

Professor, Houston J. & Florence A. Doswell Endowed Chair in Nursing for Teaching Excellence
Texas Woman's University, College of Nursing, Dallas Campus
 Objectives
Identify social determinants that affect type 2 diabetes self-
management and prevention of related complications.

Describe effective family-focused interventions for self-management

of type 2 diabetes for those living in the Appalachian region.

Discuss promising community-focused interventions for prevention

of type 2 diabetes complications.
 Culture of Appalachia
Traditional life ways of utmost importance

Self- and Family - Reliance

Social ties: Take care of their own

Gods will

Rural lifestyles (67% of counties)

Health perceptions

Lack trust in outsiders

 Social Determinants of Health
25 million, 42% live in rural areas

Environmental & occupational risks

Housing

Finances

Stress of daily life (lack off self discipline, inactivity,

depression)

Education levels

Healthy vs. unhealthy lifestyles

Health is More than Health Care Services

 Poverty
19.7% live in poverty

Generational Poverty Situational Poverty

Distressed Counties - Poverty (exceeds national averages)

More than racial or ethnic disparities

 Closing the Rural Gaps
Leading causes of death within a typical rural community - Heart disease,
cancer, stroke, respiratory diseases, diabetes, Alzheimers, & possibly suicide.

Disabilities - Depressive disorders, anxiety disorders, & substance use

disorders

Risk factors for premature death and disability - Smoking, overweight,

poor diet, sedentary lifestyle, & substance abuse
Appalachian Health Status

High rates of diabetes, heart disease, & stroke

Death from coronary heart disease exceed national

averages (15 - 21%)

Cancer rates exceed national average (166.7/100,000

population) = Rural Appalachia (176.3) & All
Appalachia (173.1)
 Complex Care Needs
People under 65 often have Disabilities
Frail Older Adults
Multiple Chronic Conditions
Physical and Mental Health Care Needs
Economic and Social Needs
Serious and Advanced Illnesses
 Care Barriers
Health professional shortages

Inadequate health care coverage

Lack of health/science knowledge

Distrust of medical system

Perception of health - Fair to Middling

Conditions undiagnosed/late diagnosis & treatment

Misunderstand risk factors

 Type 2 Diabetes in
Appalachia
Ignore early symptoms

Slow getting a diagnosis - Often have complications

Overweight and obesity

Stretch medicine or do without

High $$$ = Fail to seek health care

Disease prevention & complications seldom a priority

Living with Chronic Illness
 Type 2 Diabetes

Dont understand care needs

Question the value of medical help

Where to get help?

Lack knowledge about community resources

Inadequate family support

Societal sabotage - Lack support to self-manage conditions

 Reasons for Delayed Care

Fear the Diagnosis - Do not go to the doctor.

Not burden family with more troubles.

Fear - The consequences of disease ( e.g., diabetes = shots,

amputation, blindness, kidney disease)
 Change Care Outcomes

Provide rationale for self-management and disease

prevention.

Increase timely access to information and resources.

Address myths - Create social interest around health and

wellness.
 Conceptual Framework
Family Health Model (Denham, 2002)

Family Context

Family Functioning

Family Structure - Family Health Routines

 Family Care

Family = Potential for health - promoting effects, but

also..

Family-focused care across the life-course + Make it

central to medical care

Educate family about how to support health measures

Adult families need care similar to children

 Family - Focused Care

A care approach that occurs through relationships

among health care professionals, individuals,
families, and communities:

Respect
Respond to individual - unit of care
Recognize & empower the familys
Include the community
Remove clinical practice silos
 Family-Focused Interventions
Avoid bias, judgments, & assumptions

Value family perspectives (listen)

Address low health literacy

Explain rationale for desired outcomes

Who do we include in education?

Assess understanding - Answer questions

How likely is it you will follow directions?

 Wealth Inequality
Exacerbates Health Inequities
USA spends nearly 50% more than the next country.

USA is ranked 3rd for wealth inequalities (after Chile and Mexico)

USA is ranked 37th in the world for healthcare.

USA is the only western democracy in the world that does not
assure universal access to affordable healthcare (worst health
inequities in relation to overall wealth)

USA prefers individual values (liberty & freedom) rather than

community values (equality & equity)
 UNFAIRNESS IN HEALTHCARE
Unequal access guarantees inequitable outcomes.

Low-income families gets the worst health outcomes.

Wealthy families get the best outcomes.

Those who need the least get the most

and those who need the most get the
least.
Of all the forms of injustices, inequities are the
most damaging to our health, our well-being and
our evolving human consciousness.
Martin Luther King

Gender and Health Equity is the attainment

of the highest level of health and well-being for all people.
 Polarities between Mindsets
Individual values: Self-reliance, self-centeredness, freedom, liber

Whats-in-it-for-me: Independent, individualistic, win/lose

approach

Community values: Service, people-centered, equality,

equity, interdependence & transparent accountability.

Whats-in-it-for-us: Interdependent, collaborative,

win/win approach
Address Social Determinants of Health
Where do people live, work, play & pray

Eliminate health silos

Need coordinated care - Family household

Establish new partnerships (public health, businesses, social

services, environmental health, legal aide, elected leaders,
civic leaders, city planners)

Merge health and social services

Leverage technology & data

 Change - Makers Needed
Individualistic approaches are ineffective.

Need political action & public policy changes.

Health is political - Politics affect health.

Need Changes:
Address the ethical, political & social determinants of health
Focus attention on equity
Gender & Health Equity in All Policies
Use a Primary Care Perspective.
 Community Care Teams

Develop Social Network Power

Create a Social Movement

Interprofessional collaborative leadership

Support synergy

Share stories about healthcare inequities

Moving Forward

Step out of our silos

Leave our comfort zones

Challenge personal thinking

 Citizen Action

WE ARE THE CHANGE WE ARE WAITING FOR

 Community Work:
Families & Coalitions

Redefine clinical practice - Aim for coordinated care

Build social networks across the community
Use friendship models to galvanize resource use
Engage community worker-bees
Help develop leadership skills
Capacity building
Sustainability
 IN It For The Long Haul

Change how we think about clinical care

See self as essential key to the solution
Empower everyone
Pledge to tell our stories about what's unfair.

Focus on health, not just disease

Aim to improve family households..

Advocate for greater good for all..

WE need to address the inequities in healthcare..
What are the drivers of disease?
How do we prevent disease and complications?
How can we promote health?

Share our success stories.

Collective Responsibility:
Advocate For
and Invest In our communities.
I am at least part of the
solution