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Social Determinants

of Appalachian
Health

SharonA.Denham,PhD,RN,CNE
Professor,HoustonJ.&FlorenceA.DoswellEndowedChairinNursingforTeachingExcellence
TexasWoman'sUniversity,CollegeofNursing,DallasCampus
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 Appalachian people.

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 Situational
Poverty Poverty

Distressed Counties - Poverty (exceeds national average

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
Higher 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

Less health care coverage

Lack of health/science knowledge

Fear/distrust of medical system

Perception of general health - Fair to


Middling

Failure to have conditions


diagnosed/treated

Misunderstandings about risk factors


Type 2 Diabetes in
Appalachia
Ignore early symptoms

Slow in getting a diagnosis - Often have


complications

Overweight and obesity

Stretch medicine or do without

High $$$ = Failure to seek health care

Prevention of disease & complications seldom


a priority
Living with Chronic Illness
Type 2 Diabetes
Prevention
Inadequate education about care needs

Slow to seek medical help (question the value)

Do not know where to get help

Lack knowledge about community resources

Lack right forms of family support

Societal sabotage

Lack social networks & environments to support


self-management & prevention efforts
Reasons for Delayed Care
Fear the Diagnosis - Do not go to the doctor.

Not burden family with their troubles.

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


amputation, blindness, kidney disease)
Change T2DM Care Outcomes

Increase information about diabetes self-


management and disease complications.

Increase community access to information and


resources for self-management.

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 relationships have the potential for health
-promoting effects, but also..

Family-focused care across the life-course is not central


to medical care

Need to know ways to operationalize family - focused


care

Adult families need care similar to child - centered care


Family - Focused Care
A care approach that occurs through
relationships among health care
professionals, individuals, families, and
communities:

RRRIR

Respect individuals
Respond to individual and family as a unit of care
Recognize the familys roles and empower them
Include the community
Resolve to destroy clinical practice silos
Family-Focused
Interventions
Remove bias, judgments, & assumptions

Value family perspectives

Consider low health literacy

Explain rationale for desired outcomes

Who else needs to be included?

Assess understanding - Answer questions

What is the likelihood of following


directions?
Wealth Inequality
Exacerbates Health
Inequities
USA spends nearly50% morethan the next country.

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

USA is ranked 37thin the world for healthcare.

USAis the only western democracy in the world that does not
assure universal access to affordable healthcare (worst health
inequities in relation tooverall 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.
Polarities between
Mindsets
elf-reliance, self-centeredness,freedom, liberty, individualautonomy

me: Independent,individualistic,win/lose

Community values: Service,people-centered,equality,


equity, interdependence &transparent accountability.

Whats-in-it-for-us: Interdependent,collaborative,
win/win approach
Community Interventions
Create a shared vision of community health

Eliminate health silos

Multi - sectoral (leverage best in coordinated


fashion)

Establish new partnerships (public health,


businesses, social services, environmental health,
elected leaders, civic leaders, city planners)

Merge health and social services

Leverage technology & data


Change - Makers Needed
Old individualistic approaches areineffective.

Political action & public policy changes are needed.

Health is political and politics affect health.

Needed Changes:
Address the ethical, political & social determinants of health
Use our network power to focus our collective attention on equity

Advocate For & Implement Change:


Gender and Health Equity in All Policies from a Primary Care
Perspective.
Place-Making

Placemaking: Inspire people to collectively reimagine & reinvent


public spaces as the heart of every community

Community-Based Participation: An effective process to capitalize


on community assets, inspiration, & potential to create quality public
spaces that contribute to peoples health, happiness, and well being.

http://www.pps.org/reference/reference-categories/placemak
ing-tools/
Community Care Teams
Develop Network Power

Leadership + Professional + Social


Movements

Develop interprofessional collaborative


leadership

Support synergistic actions

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
Leadership skills
Capacity building
Sustainability
IN It For The Long
Haul
Change ways we think about clinical care
Empower everyone
See self as an essential key to the solution
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

GenderandHealthEquityistheattainment
ofthehighestlevelofhealthandwellbeingforallpeople.
Pledge to tell our stories about what's unfair.

Aim to improve family - focused & community - centered


healthcare.

Advocate forthe greater good of all.


WE need to address the inequities in healthcare..
What are the drivers of high type 2 diabetes rates?
How do we prevent type 2 diabetes?
How can we prevent diabetes complications?

Tell our success stories at


individual, family, & population-based levels.

ollective Responsibility: to Advocate For


nd Invest In our communities.
I am at least part of the solution

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