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An ethnographic approach to health needs assessment of rural elderly

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Title:
An ethnographic approach to health needs assessment of rural elderly
Physical Description:
xi, 215 leaves : ill. ; 29 cm
Language:
English
Creator:
Bezon, Joan (Joan F.)
Publisher:
University of South Florida
Place of Publication:
Tampa, Florida
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Subjects / Keywords:
Rural elderly -- Medical care   ( lcsh )
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF   ( fts )

Notes

General Note:
Thesis (Ph. D.)--University of South Florida, 1992. Includes bibliographical references (leaves 199-210).

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University of South Florida
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University of South Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 029203366
oclc - 27923401
usfldc doi - F51-00180
usfldc handle - f51.180
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SFS0040066:00001


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AN ETHNOGRAPHIC APPROACH TO HEALTH NEEDS ASSESSMENT OF RURAL ELDERLY by Joan Bezon A dissertation submitted in partial fullfillment of the requirements for the degree of Doctor of Philosophy in the Department of Anthropology the University of South Florida December 1992 Major Professor: Linda M. Whiteford, Ph.D.

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Graduate Council University of South Florida Tampa, Florida Certificate of Approval Ph.D. Dissertation This is to certify that the Ph.D. Dissertation of Joan F. Bezon with a major in Applied Anthropology has been approved by the Examining Committee on November 2, 1992 as satisfactory for requirement for the Ph.D. degree Examining Committee: McU Professor: Linda M. Whiteford, Ph. Alvin W. Wolfef/Ph.D. Henderson, Ph.D.

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To my husband and my mother for all of the support that made this research possible. ii

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ACKNOWLEDGEMENTS Dr. Vivian Ross: for stimulus to start and encouragement to carry through Dr. Linda Whiteford: for scholarly input, excellent guidance, and positive strokes Dr. Neil Henderson: for insight and understanding of the nature of the project and for assistance with qualitative aspects Dr. Alvin Wolfe: for network background, patience, and many kindnesses Dr. Joan Gregory: for reading drafts, support, and stimulating hope Maureen Kelly: for West Central Area Agency on Aging support Kathleen Crivello: for enthusiasm, assistance in the community, and provision of local statistics though NuHope of Highlands, Inc. Debbie Cook: for insight and understanding of the "real world," introduction to key informants, and for formulating the questions to be asked Charlotte Cook: for review of the findings and positive support of the project and thank you to To the 62 rural, isolated, elderly people of Highlands County who shared their lives with me iii

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TABLE OF CONTENTS LIST OF FIGURES LIST OF TABLES ABSTRACT CHAPTER I INTRODUCTION Problem Statement Purpose of the Study Assumptions Invisible Rural Elderly Anthropological Difference Method Selected Definition of Terms Significance of the Study CHAPTER II BACKGROUND AND SETTING Migration Increase in the Number of Aged Setting Conununity CHAPTER III REVIEW OF THE LITERATURE Evolution of Anthropological Aging Study Social Isolation/Networks Ecological Anthropology Cultural/Ecological Dimensions Adaptation Cultural Core Limitations and Advantages of Cultural Ecology Contemporary Ecologists Medical Ecology Rural Elderly Rural/Urban Health Care Services Natural and Social Environments of the Rural Elderly Attitudinal Characteristics of Rural Elderly Economics and the Rural Elderly Nursing Sununary and Conceptual Framework iv iv v vi 1 4 5 5 6 7 9 11 12 14 17 18 19 26 31 32 36 38 40 44 44 47 49 so 52 55 57 59 64 65 70 72

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CHAPTER IV METHODS 75 Needs Assessments 76 Major Problems in Needs Assessments 79 Pilot Study 81 Highlands Rural Elderly Study 84 Sample 84 Setting, Access to Home 85 Description of the Sample 89 Research Design 93 Self-Perception of Health 97 Networks 98 Quantitative Data 99 Qualitative Data 99 Reduction of Data 99 Reliability/Dependability 100 Analysis 101 Limitations 101 CHAPTER V RESULTS AND DISCUSSION 104 What is it Like to be Elderly and to be Living in A Rural Area? 104 Other Descriptions of Rural Living 111 How do Rural Elderly People Handle their Day-to-Day Activities? 115 What is the Status of their Health? 120 Chronic Diseases 120 Medications 120 Incontinence 126 Dental Health 129 Hearing 131 Health Care Providers 135 Preventive Health Practices 140 Immunizations 144 How do these Rural Residents Perceive their Health? 146 Who Helps the Rural Elderly in Time of Difficulty? 151 What are the Reasons Rural Elderly do not Participate in Offered Services? 163 How Does Failure to Use Available Services Impact on their Health? 165 Chronic Conditions 168 Depression 169 Loneliness 170 Activities of Daily Living 171 Instrumental Activities of Daily Living 173 Discussion 174 Importance of Ethnography 175 Past Studies of Aging 177 Stereotypes and Myths of Rural Living 177 Environment 179 v

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CHAPTER VI CONCLUSIONS AND RECOMMENDATIONS 186 Profile of Isolated Rural Elderly 186 Health Status 187 Recommendations 192 Summary 195 Anthropological Difference 197 LIST OF REFERENCES 199 APPENDIXES 211 Appendix A Introductory Letter 212 Appendix B Letter of Invitation to Participate 214 vi

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LIST OF FIGURES FIGURE 1 Geographical Location of Informants 86 FIGURE 2 Distance Between Home and Resources 91 FIGURE 3 Instrumental Activities of Daily Living 116 FIGURE 4 Medications 121 FIGURE 5 Most Common Dental Problem s 129 FIGURE 6 Immediate Family Presen t for Assistance 161 FIGURE 7 Cultural Core 181 vii

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TABLE 1 TABLE 2 TABLE 3 TABLE 4 TABLE 5 TABLE 6 TABLE 7 TABLE 8 TABLE 9 TABLE 10 TABLE 11 TABLE 12 TABLE 13 TABLE 14 TABLE 15 TABLE 16 LIST OF TABLES HRS District Six People age 65 and Older 15 Demographic Characteristics of Highlands County 26 Sex, Age, Marital Status 90 Run Out of Money 92 Research Design 94 Comparison of Functional Status 115 Participation in Daily Activities 117 Self-Perception of Health 147 Perceived Health Status Compared to Measures of Health Status 148 Networks: Church, Neighbors, Friends Number of Living Children Contact with Children Special Friends Neighbors Instrumental Activities of Daily Living Synopsis of Health Findings viii 152 153 155 157 158 174 182

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AN ETHNOGRAPHIC APPROACH TO HEALTH NEEDS ASSESSMENT OF RURAL ELDERLY by Joan Bezon AN ABSTRACT Of a dissertation submitted in partial fullfillment of the requirements for the degree of Doctor of Philosophy in the Department of Anthropology the University of South Florida December 1992 Major Professor: Linda M. Whiteford, Ph.D. ix

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Evidence and experience have shown that the behavior of rural elderly reflects a cultural system different from that of urban elderly and that this system, which precludes the use of services, results in poorer health. This study describes the culture and health status of isolated elderly people in all census tracts of Highlands County, the county with the highest percentage of rural persons age 65 and older in the state of Florida. Anthropological and nursing theory supports the understanding of rural elderly by describing the impact of the ecology on their adaptation and by eliciting the rural elderly's (ernie) point of view. Network analysis identifies personal and community network systems which can be used to augment available institutional services. Sixty-two informants were visited in their homes at three different times for an average of 10 hours of contact time. Qualitative field notes collected by this means were triangulated with quantitative surveys (demographic, medical, social data), objective and subjective measurements of health in order to strengthen the study' s findings. While communities vary with respect to support services available to elderly residents, certain patterns emerge from X

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the data. Ninety percent of the informants live on fixed incomes and pay their bills first, then buy food, leaving the purchase of health care and medicines as a last priority. Seventy five percent of these rural elderly informants did not have family nearby to assist them. Since the informants live 20 miles from the nearest health care, stores, and other amenities, transportation is a major problem. The composite rural elderly person is deficient in two instrumental activities of daily living and one activity of daily living, has an average of three chronic diseases that are not well controlled, and does not participate in preventive health measures. The rural elderly appear mistrustful of offered services and are wary toward health providers, a finding that appears to be linked to their cultural adaptation to the environment. Abstract c 0 Major Professor Date of Approval xi

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CHAPTER I INTRODUCTION 1 This study describes the culture and health status of rural elderly people of Highlands County, Florida during the summer of 1991. This site was chosen for study because it has the largest number of rural elderly in the Department of Health and Rehabilitative Services (HRS) District Six. Directors of West Central Florida Area Agency on Aging and NuHope of Highlands Inc. (which is part of HRS District Six) had identified the need for the study and sponsored the investigator. Isolated elderly informants (N=62) located in all census tracts of Highlands County were visited in their homes at three different times for an average of 10 hours of contact time. Survey (demographic, medical, social data), objective and subjective measurements of health, and extensive field notes comprised the data collection techniques. Ecology, specifically distances from services, impacts the health of these isolated rural elderly. Distances

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2 preclude regular health care, including preventive care. Chronic diseases are not well controlled and mild depression is a characteristic. Most of the informants were on fixed incomes, a fact which also affects their purchase of health care. Dietary habits are influenced both by income and by limited access to supermarkets. Basic activities of daily living (ADL's) and instrumental activities of daily living (IADL's) were found to be deficient, and there was a general mistrust of offered services as well as wariness of health care providers. The study of isolated rural Floridian elderly is important because the state of Florida's percentage of people age 65 and older is 18%. This is in comparison to a national average of 12.7% (AARP 1990). Rural elderly people make up 25 percent of the elderly population throughout the nation, and including Florida (Coroni-Huntley 1986). The delivery of services is a topic of concern to planners of aging service. The mandated use of federal money to increase independence and thus keep elderly out of institutions is an important objective (Fritz 1979:141). Needs assessments often are conducted based on data from those elderly who attend functions or use services; but these people are primarily from urban areas. Many rural elderly people do not use public services or attend service related functions and have not had a voice in these assessments. Then, too, these rural elderly infrequently

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participate in surveys, thus, their needs are often not assessed (West Central Florida Area Agency on Aging 1990). However, an isolated rural environment affects both the delivery of services and participation in services. Both the ecology and adaptation to the environment generate a unique lifestyle and value system which, in turn, prevents the use of services by rural elderly (Ansello 1980, Brown 1985). On a more personal level, rural elderly people are often sensitive to outsiders (people not from the local community) who provide social services. The delivery of human services is often complicated by urban service providers bent on making conditions better. Urban service providers are unable to identify rural elderly needs and often are ignorant of the formal and informal lines of communication, authority, and self-help that are in place (Ansello 1980; Hill 1988; Nelson 1980; Weinert & Long 1987; 3 _Windley & Scheidt 1980; Steinhauer 1980). The unique culture of the rural area frequently is ignored, the planned services are inappropriate, and thus, available services are not used. An understanding of the ecological influences on the culture is crucial if these obstacles are to be overcome. Julian Steward (1955:34) describes the purpose of cultural ecology as differing from human and social ecology. Cultural ecology tries to seek and explain the origin of

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4 certain cultural features and patterns which characterize particular areas rather than to derive general principles applicable to any cultural-environmental situation. The task is to ascertain whether the adjustments of human societies to their environment require particular modes of behavior or whether they permit latitude for a certain range of possible behavior patterns. This study focuses on the social and physical adjustments the less visible rural elderly of Highlands County, Florida have made to their environment, their range of behavior patterns, and how their modes of behavior and adaptation to the environment preclude their use of services and subsequently influence their health. Problem Statement Service providers (West Central Florida Area Agency on Aging 1990) and gerontologists (Krout 1986) agree there is a need to describe rural elderly people and to interpret their reactions to the rural living experience as it impacts on health. There is a paucity of descriptive research of rural elderly which identifies their health care needs. In an ethnographic context, this study identified health needs of the elderly that result from adaptation to the rural environment. These findings suggest recommendations for appropriate service interventions to enhance the rural elderly person's health and function ability and to deter premature institutionalization.

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5 Purpose of the Study The purpose of the study is twofold. The first purpose is to assess the health needs of the rural elderly and to provide an ethnographic view of these elderly in relation to their rural environment. The second purpose is to present a method of accurate needs assessment of rural elderly that will assist planners in determining appropriate services. The second purpose is consistent with the overall goal and the mission of various planning agencies to provide a wide array of social and community services to those older persons in the greatest economic and social need in order to foster maximum independence and avoid unnecessary and costly institutionalization (U.S. Senate Committee on Aging, Special Report 1985:310). Therefore, using an anthropological framework, this study describes sociocultural variability, adds to the literature that cautions about overgeneralization, and measures the interplay between biological and sociocultural forces in accounting for aged human behavior. Assumptions The basic assumptions underlying this study are: (1) that there is a need for accurate assessment of rural elderly people and the cultural ecological adaptations they have made to their environments; (2) that cultural ecology provides a framework to understand how environment influences cultural adaptation (Steward 1955:39); (3) that

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6 _ecological characteristics of less populated, lower density areas, (and the associated economic, social, and cultural systems associated with them) are assumed to affect rural elderly lives (Bealer, Willits and Kuvlesky 1964:255; Harbert and Wilkinson 1979:36; Krout 1986:7); (4) that the ability to improve health care services is dependent as much on understanding cultural and social variables in planning and implementing policies as on medical knowledge (Hill 1988); (5) that service providers usually base their provision of services upon needs assessment data from urban groups (Ansello 1980:342; Lareau and Heumann 1982:324); (6) that assessment of the needs of the elderly requires a firm foundation of empirical evidence, a base that now does not now fully exist (Coward and Cutler 1987:786); (7) that neither the precise needs of rural elderly nor the impact of this inadequate assessment is presently known (Kivett 1985:9; Lareau 1983:518; Nelson 1980:200; Weinert and Long _1987:450); (8) that anthropologists are well suited to study rural elderly people because anthropological study of human lives in their natural context emphasizes the complex interplay between cultural norms and social behavior. Invisible Rural Elderly Data are incomplete concerning the life circumstances, health status, and health care needs of elderly residents of rural communities, and an insufficient base of knowledge exists about the development and delivery of rural health

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7 services (Lassey and Lassey 1985:100). In order for a needs assessment to be appropriate, accurate, and detailed, observation is essential to describe rural elderly. Confirmation of observations is strengthened by the use of appropriated survey data and objective measurements. The investigator's experience has shown that phone surveys and mail surveys of elderly people are inadequate. For example, a short conversation over the phone produces some data, as do mail surveys. However, since these data may be distorted by the individual's politeness or sensory deficiencies (such as poor vision or hearing), they do not provide a justifiable basis for service delivery. People who usually respond to written surveys have higher levels of education and higher income than those who do not respond. Those with limited education shy away from completing surveys. Consequently, one misses the opinions of those who refuse to do such surveys and who most.need the services. These .are the people referred to as the "invisible rural elderly." These are the people who rarely share information over the phone, respond to mail surveys or participate in services (Sinott et.al. 1983:43). The Anthropological Difference The Behavioral Sciences Research program of the National Institute on Aging in 1981 organized a workshop that illustrated how anthropologists are well suited to study rural elderly people. Anthropologist participants

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8 included those widely noted for their work in gerontology and anthropology: Jennie Keith, David Kertzer, Paul Baltes, Cynthia Beall, Meyer Fortes, Christine Fry, Richard Lerner, Glen Elder, James Fernandez and Renate Fernandez. Another noted anthropologist who examines aging, Matilda White Riley (1984), discussed the significance of anthropology and aging as presented by the above experts. According to Riley, the four major principles which guide the research focus of aging and anthropology are: 1. Aging can be understood only in dynamic terms. The aging process cannot be separated from the social, cultural and historical changes that surround it. People do not grow old in laboratories. Therefore, we must learn how different cohorts age and how society itself is changed by these differences. 2. Aging can be understood only from the perspective of its socioculturally patterned variability, both within a single society and across societies. 3. Aging can be understood only within the framework of the total life course. People do not begin to age at any specific point in life. Rather, aging occurs from birth up until death. Within the total society, people of all ages are interdependent. 4. Individual aging, consists of a complex interplay among biological aging, psychological aging, and the changing social and cultural environment (Kertzer and Keith 1984:7).

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9 Riley (1984:9), based on the above basic principles, states that anthropologists have a great, and as yet largely untapped, contribution to make to the interdisciplinary study of age and aging. She notes that anthropologists have contributed to knowledge of sociocultural variability, cautioned about overgeneralizations drawn from a limited range of societies regarding universal processes of age and aging, and studied the interplay between biological and sociocultural forces in accounting for aged human behavior. Anthropological theory aids in understanding rural elderly by describing the impact of the environment on their adaptation. Getting an emic point of view or eliciting the rural elderly's point of view is a key part of the study (Sanday 1979:527). Gerontological nursing theory and techniques are appropriate for gathering health needs assessment data (King 1981). The premise here is that rural elderly people exhibit cultural style different from that of urban elderly and that these cultural differences impact on the use of services by the elderly and ultimately on their health. Method Selected Qualitative and quantitative research processes were used to investigate the health and living experiences of elderly rural residents of Highlands County, Florida. The combined methods were chosen because elemental descriptive information is needed.

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10 T. Franklin Williams (Coroni-Huntley 1986:vii), a previous director of the National Institute on Aging, states there is a basic need for increased understanding of aging and the demographic revolution going on in our society. The numbers and proportions of old (60-74) and very old (75 and over) people have more than doubled in the last 15 to 20 years and expected to continue as the baby boomers age. According to Williams, basic descriptive information about this population is needed. One way of describing rural elderly within this context is to combine ethnographic methodology and anthropological concepts. A quantitative approach does not adequately answer questions about what composes the realities of the experience of rural elderly and the thoughts and feelings of that elderly person about that experience. A combination of qualitative and quantitative methods provides the basis for a holistic description of informants lives. The in-depth ethnographic study of rural isolated elderly people in Highlands County describes these people's real life experience. Detailed field notes about their lives and the context in which they live provide the qualitative data. The use of quantitative techniques such as semi-structured observations and survey questions, health histories, physical examinations, selected screening tests, and functional assessments validates and supports the subjective descriptions.

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11 Definitions of Terms Rural elderly -A person age 65 or older, living in a single family dwelling located at least 20 miles from health services and amenities. Services specific for the aged -Those activities provided for rural elderly and sponsored by the Older American's Act and Community Care for the Elderly are considered services specific for the aged. These services include transportation, meals, housekeeping, personal care, heavy chores and congregate meals with activities. Other services or amenities -Access and availability (escort and transportation) to health care, churches, stores, recreation, etc is considered other services or amenities. Rural -Any geographical area with a population of 2500 or less is considered rural. This definition is used by the United States Bureau of the Census most often used when describing rurality. Holistic perspective -Holistic perspective is an attempt to describe as much as possible about a culture or a social group, including the group' s history, religion, politics, economy and environment. Contextualization -Contextualization entails placing observations into a larger, more inclusive perspective. Cultural style -Rural elderly embrace a value structure which differs from the urban elderly in nature and degree.

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12 .Rural people are characterized as being especially independent, self-reliant, neighborly, family-oriented, hard-working, mistrustful of government, and leery of programs seen as "welfare" or as part of the social service bureaucracy (Krout 1986:168). Health -Health is the physical ability and mental capacity to carry out basic activities of daily living and instrumental activities of daily living. Significance of the Study This study is important today for the following reasons: 1. It demonstrates a methodology that gathers accurate, culturally appropriate physical, psychological and social needs assessment data about rural elderly. This research builds on and extends other anthropological research by providing an emic point of view of the life of Florida's rural elderly. 2. Because this study examines an invisible rural elderly population that has not been described before, it builds on and adds to the literature on rural elderly. This population is rapidly increasing in size, and the group studied will soon become the "old-old" who require special service in the future. 3. The research results demonstrate that large distances exist from health care and social services, lower or fixed incomes, lack of family nearby to help, mild depression,

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13 difficulties with ADL's and IADL's, chronic diseases not well controlled, inadequate preventive health measures, and mistrust or wariness of health care or service providers are useful to the sponsoring agencies in documenting the needs and planning for services. The data assists planners' understanding of the need for culturally appropriate services. Ultimately this approach may lead to an increase in the use of services, thus promoting better health and preventing premature institutionalization. In turn, these changes will help to achieve the goals of the Older Americans Act and Florida's Community Care for the Elderly, and provide fair distribution of services for all elderly and to increase their independence within their home environment. This chapter has identified the purpose of the study and its importance to the health status of isolated rural elderly people. The next chapter will describe the background and setting of the investigation.

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CHAPTER II BACKGROUND AND SETTING 14 The site of this study, Highlands County, Florida, has the second highest percentage of rural elderly located in the largest land mass in HRS District Six (Florida Statistical Abstract 1989, District VI Health Plan 1990). Forty-four percent of the population in Highlands County (total 31,220) are age 65 and older. This is a stark contrast to the national percentage of 12.7 percent (AARP 1990). Highlands County also has the greatest number of people age 85 and older, higher than the percentage for the state. Those individuals age 65+ and living alone, 34.7%, have incomes below poverty level (Area Plan Summary Document 1992: 8). It is projected by 1993, due to development of retirement communities and an ongoing influx of retirees, the 60+ population will constitute 38% of the total population with a majority living in rural areas. These elderly are expected to age in place and thus require services in their homes. Services are needed now and more will be needed in the future. If health

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15 services are not initiated, this aging population will need nursing home care in a few years. There are not enough nursing homes in Highlands County and the economic burden of nursing home care would bankrupt the county. In Highlands County 68.7% of people age 65 and older live in a rural area as shown in table 1. Table 1 HRS District six People age 65 and older urban rural density land area Highlands 31.3% 68.7% 67 1,029 Hardee 24.8% 75.2% 36 637 Polk 71.6% 28.4% 226 1,823 Hillsborough 89.4% 10.6% 812 1,053 Manatee 93.55% 6.5% 258 747 Highlands County, as a whole, is considered rural because of the small populations and the distance from large urban settlements of 50,000 or more (Hewitt, 1989:5). The urban (Sebring) population reported for 1990 was listed as 25,047 and the rural population was 45,908. The total population of all ages for the county is 70,955 (District VI PSA 1991-1994, 1990). One other unique aspect of Highlands County is that it is pocketed by several enclaves of Florida natives and in-migrants who have "aged in place" in remote

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camp-like settings. These populations are geographically remote from municipalities and are often not accessed by municipal services including paved roads, utilities, etc. Lack of adequate transportation systems, lack of adequate tax revenues, and lack of infrastructures for delivery of social services makes meeting needs of rural elders a challenge (District VI PSA 1991-1994, 1990). 16 Researchers, in the past few years, have focused increasing attention on an improved taxonomy to study rural America (Cordes 1989:760). Taxonomic categories have increased because today's rural Americans are much more diverse than yesterday's. The u.s. Department of Agriculture has included in its taxonomy several groups of non metropolitan counties: farming-dependent counties, manufacturing-dependent counties, and mining-dependent counties. There are specialized government counties (where government agencies help significantly by employing residents) and persistent poverty counties. Obviously, some counties fit into more than one class. Highlands County, Florida fits Cordes' (1989:767) of a non metropolitan farming-dependent county. It has a smaller urban population urban and fewer persons per square mile than a county like Hillsborough which has large metropolitan areas. Median family income is lower than metropolitan family incomes, fewer households are headed by females and a higher proportion of elderly live in

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17 Highlands County. Highlands County also fits Cordes description of a destination retirement-county, a place chosen for retirement. Only 16 of the study's informants were native Floridians. Forty-six had chosen Highlands County for retirement. This supports Cordes' caution about diversity in rural areas; the issues of geographic distance and spatial isolation call for consideration of different mechanisms for the delivery of services than those used in primarily urban areas (1989:781). Migration The percentage of older people in rural areas may increase as a result of a net domestic migration to rural from urban areas of pepple age 65 and older (Lee and Lassey 1980:63). This migration of elderly persons is a fairly new phenomenon. Aday and Miles (1982:332) describe the patterns of these elderly migrants and suggest that the reasons most often cited for the migration to the country include a desire for a more carefree and recreational life and climatic amenities. The bulk of the migration is to the sunbelt states. As the rural migration increases it appears likely that rural elderly will increase in absolute numbers, as a proportion of the increasing elderly population, and, due to declining birth rates and other demographic factors, as an increased proportion of the total population (Lee and Lassey 1980:64). Retirees coming to the Sunbelt are swelling the

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Eopulations of certain counties and towns, resulting in an "odd couple" social mixture of local elderly and migrants essentially from urban communities in the north. In many cases, the result has been the emergence of two separate population types, each with specific community needs and demands (Aday and Miles 1982:333). This "odd couple" scenario is evident in Highlands County. 18 The traditional notion of Florida as the state with the largest concentration of elderly persons is supported by statistics. It is predicted that the proportion of 65-plus persons in the United States in the year 2020 will be 29 percent. In fact, Florida's elderly population is now 18 percent, and is fast approaching the estimate for the rest of the States in the year 2020. (Profile of America' s Elderly 1990). The accelerated in-migration to Highlands County underscores the need for a better understanding of isolated rural elderly. Increase in the Number of Aged The number of "old-old" is increasing exponetially in Highlands County (Area Plan Summary Document 1992:8) and by 1993 the 85+ population is expected to be at 49.5% due to "aging in place." The over 85 group is the fastest growing segment. Since the "old-old" require more services than young-old, this major demographic shift constitutes an important challenge to health care planners and service providers, especially those in Highlands County. Chronic

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19 illness is twice as prevalent in older populations as in those under age 65. The ability of the elderly to function with chronic disease is an important as is this population segment's greater need for services (Krout 1986:17). Setting Highlands County, Florida is a vision of blue skies, rolling green fields and spaciousness. Houses are at great distances apart and it is possible to drive for 20 miles and not see a building. Ranchers use horses to tend cattle because the pastures extend for miles into the bush and are not approachable by a vehicle. The owners of ranches are wealthy, while others in the area are not. The elderly who have migrated to Highlands County for retirement the and natives who have aged in place have fixed incomes that are inadequate by today' s standards. These elderly live primarily in either single wide or double wide mobile homes. Only four of the informants, owned wood framed houses that are commonly termed as Florida "cracker" homes. Typically, the homes are located at some distance from the road and are accessed by either a dirt road or a grassy lane. Driveways are non-existent. One home was reached by first traveling a dirt road, then a grassy lane, opening a pasture gate, traveling through a pasture filled with grazing cattle, and finally parking in front of a fenced, cracker style house. The herd of cows and calves (20-30)

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20 were friendly and curious. They bounced along in front of the car and nuzzled the investigator when she got out of the car. The woman who owns this farm is a native Floridian who inherited the land from her family and she reported that all of her livestock were pets. Several other informant's homes were similarly inaccessible. Another home could be reached only by a dirt road through a swamp area. The house itself was situated on a small knoll in the center of a swamp. "We were the first ones out on this end. When my husband was alive, we cleared this land and planted trees and shrubs." Ironically one of the homes was located on a dirt road that was called "Boondocks Road." One "cracker" home was painted a bright pink. Boards were falling off the house, the front door was loose from its hinges, the porch steps were rickety, and there were flour sack curtains on the doors and windows. The kitchen had a wood stove that was used for cooking. Clean clothes were hanging on a line in back of the house. It was common to see clothes drying on the line at many of the informants homes. Electric dryers were not common-place. Another woman, who lived alone, had knee high grass surrounding her house. She was unable to mow it herself and could not afford to pay anyone to cut it. Her house was reached by traveling 41.5 miles south from Sebring, and then five miles along a dirt road. She told of deer, snakes,

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raccoons, armadillos, pigs, horses, and cows coming to her front door. "The armadillo dug a hole under my home and I tried to hit it with a shovel, but missed." 21 Old model automobiles were the rule rather than the exception. These elderly informants reported that they limited their driving to absolute necessities and then would drive only at times during the day when traffic was light and would use the back roads because they feared an accident. "My reflexes and vision are not as good as they use to be." The interiors of homes varied in to cleanliness, orderliness, and furnishings. One woman invited the researcher into her living room and then said, "Oops, I forget I don' t have any furniture." The room was empty except for two tables and pictures. She had been selling her furniture little by little to pay her bills. She confided that she was planning to sell her sewing machine next. An 88 year old woman lived in a single wide small trailer with a screened porch along the side. Paper sacks filled with soda and beer cans lined the walls of the porch, (She denied drinking alcohol). The stairs leading into her trailer were covered with carpet and clutter. The interior of the trailer was dark, dirty, and littered. Food was strewn over the counters, cigarette ashes and butts overflowed in ashtrays, (She denied smoking). She spoke of

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22 her desire to live in town: "Me and Nellie [her friend] would like to live in town. That way we could walk to the grocery store and bank. Especially in the evening we could walk to things and I would be where I could do more." An elderly black woman told the investigator that her road was name "Quarters" road because the black folks who worked on the farms lived there and worked for the white farmers who owned large acreage surrounding the black quarters. There are only four homes on the dirt road which ends abruptly at a grassy lane where a large sign warns to "Keep Out." One couple resided about 10 miles from Lorida, but a more specific description of the location is problematic. It was not entirely clear to the investigator if she was driving in the right direction, because she was not sure if she was on a road. At this particular home, she was greeted by three large turkeys and four puppies, all pets. The owner had to call the turkeys off in order for the investigator to enter the home. Another 91 year old man who lived alone in a small cottage that was painted red, kept his carpenter tools in his living room along with books and shopping bags full of items to do handiwork with. He said it didn't matter where things were, as long as they were close by to work on. One 92 year old man who lived alone explained that he had bought his home prior to retirement and had planned to retire in

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23 this area. Over the years he had added rooms to his single wide trailer and had planted many fruit trees. He had added a workshop for his tools and told how he had done woodworking for years. The house was neat, but, it was very dirty. He explained that it was hard to get someone to come "way out here to clean and I can't do it anymore. Since my wife died, things have gone downhill. All of my friends have died too." He described the difficulties of growing old, becoming unable to care for yourself, living without friends. "My daughter gives money for people to help me, but what good is that when you are lonely?" A younger woman (68) lived 25 miles from the nearest town and amenities. Her single wide mobile home was located in a clump of woods about one half mile from the dirt access road. Cement block steps leading into her home wobbled precariously. Because her arthritic condition limited her mobility, the steps presented a daily hazard. The interior of her home was tastefully decorated with many bookshelves, books and modern furniture. Almost every house visited had the television or radio playing loudly when the investigator approached the home. It was necessary to knock very loudly and repetitively to gain informants attention, especially those with impaired hearing. An 80 year old woman lived in one room attached to a small trailer which was located 30 miles from the nearest

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24 town. The access road to her home was off of a dirt road, down a grassy lane, and through a pasture with horses in it. She lived on property owned by her son. When the investigator arrived the woman had two fans going and the windows opened. As it got closer to noon, she closed the windows and put on the air conditioning. Twenty-eight of the informants had air conditioners', however only ten were operating during visits. Informants reported that they used their air conditioners only when the heat became intolerable because it was so costly to use. One couple put the air conditioning on "in honor of the investigator." Because the area was primarily agricultural, it was common to find homes surrounded by pasture. At one home the horses would come to the open windows, stick their heads in, and whinny. "We spoil our horses and talk to them and they talk back to us." At this particular home fans were used and the windows left open without screens. The temperature was comfortable, but, the woman told me it was almost impossible to keep things clean, because the wind blew the dirt in. Animals played an important part in 10 (N=62) of the informants lives. One Bull Mastiff who shook hands and said "Howdy" played a central role in the lives of his owners. One man bought "a sack of corn a week" to feed the squirrels. One cat slept beside her mistress during the interviews. One woman talked to her parakeet. Although she

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25 was on a fixed income, she had been able to get the bird and cage inexpensively. "He is companionship to me." She demonstrated how she whistled to her bird and how he whistled back to her. One dog was named Corky scratched a lot, didn't smell too good, was fat, and laid at his owner's side. He was frisky and demanded a lot of her time. She disciplined him frequently and the love and affection between the two was obvious. One person stated "Old people need animals to care for. They have to get up and care for them and then they don't end up sitting around. The animals are company too. You have to let a dog in and out and you get exercise. Every old person should have an animal." One dog's name was Mr. Tony. His owner was 96 and Mr. Tony was 20 years old. "We both can't see too well or hear too well. We have trouble walking, too. All of the homes had pictures of family and friends scattered about. The homes varied in states of cleanliness and clutter. Men living alone tended to have sparsely decorated homes, while often decorated with doilies and knick-knacks. One 76 year old man who lived alone did not have a door knob on his front door. He had two bedrooms, one bed was covered with junk and the other had soiled sheets where he had been incontinent. The kitchen had dirty dishes in the sink, groceries in boxes on the floor, a rusty refrigerator, and a gas stove which he said "worked good." One remote home was surrounded by overgrown greens that

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26 at one time had been a garden of flowers and shrubs. Flowers survived and bloomed in uncontrolled patches. The house was invisible from the dirt access road. There was no driveway. Old chairs were placed strategically in the yard, and the owner told the investigator that he could walk from chair to chair and sit in the yard, but he could no longer tend his garden. He reminisced at length about the beauty of his former garden and lamented that he was physically unable to "keep it up." A 95 year-old man had an old Red Cross Disaster Trunk in the middle of his living room. Pictures and mementos from the trunk were strewn about the room. He indicated that he was sorting them out and burning a lot of them so they "didn't get into the wrong hands." Community There are three basic communities in rural Highlands County, Venus, Lorida, and the rural areas surrounding Lake Placid, Avon Park, and Sebring. Table 2 Demographic characteristics of Highlands county Total All Ages: 70,955 Rural All Ages 48,746 Total 60+: 26,657 Rural 60+ 18,328 % of county % of county That is 60+ 37.6% that is Rural 68.7%

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The Venus area is composed of individuals who are related to each other and individuals who have moved into the area from other places. Everyone is acquainted with everyone else. 27 The Lorida area composed of several fish camps, a mobile home park, and individual residences. Although some residents are related and have lived in the area for a long time, the majority of people do not know each other. When the investigator went to the Venus Post Office, the mailman knew everyone on his route and their approximate ages. At the Lorida Post Office, the Post Mistress and the mail delivers did not know who the elderly were or where they lived. "We deliver a lot of mail to mailboxes a long way from the houses and never see the people who live in there." The isolated elderly in the rural areas surrounding Avon Park, Sebring, and Lake Placid constitute were the third group. Again, the postal service was unable to identify elderly from non-elderly. Those who lived in these areas have little participation in community unless they are active in a church. Informants from close-knit communities, like Venus report the following: "We are all related. They are old family names who settled here. My mother came here when my brother was one year old. The rest of us were born here. I know just about

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28 everybody." "If somebody died before dark, everyone would know and the kitchen would be full of food." "We helped when a friend had a stroke and gave money." "The people here are home bodies, they stay to home and do things with each other. This is a very friendly church and town. "They do things differently. They will have a picnic at the drop of a hat. For one person's birthday, they roasted a pig on a spit to honor him for all the work he has done for the church." "When I didn't have any income for over a year, the neighbors kept me going. They would bring extra stuff and say they bought extra and didn't need it. For my birthday, the neighbors drove in the yard and pulled out two tires and a certificate to have them put on. I never lived in a neighborhood where people really care. I try to give back. I do little things when I can. I take Mrs. A. to Lake Placid on Thursdays. When I was at Bible study one of the people came up to me and said he knew I was having trouble with my car. He told me he was a mechanic and he took my car and put new parts in it and wouldn't take a penny for it. I try to help people in return, maybe not the same people, but others who need it." "My husband goes to the store because that is where everyone meets. The old people meet at the store and they

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29 have tables and benches and coffee." "We couldn't afford to build a pavilion and people pitched in and did parts of it. One man did the electricity, another the cement, and another the carpentry." "We eat together a lot, we all bring a casserole of what we fix best. The barter system is alive and well with no money ever changing hands, just services." Reasons for the closeness of this community are that their families homesteaded the land and passed it down to their children. The families are all interrelated in some way. These closeknit families were neighborly to the migrants and included them in activities through such means as church and fire department affairs. In contrast, informants from communities where closeness is less apparent report the following: "Can't get the people together to do anything, like a meeting of some kind. They don't want to go and be counted." "When we had a school down here you would have an auditorium full of people, not any more, they just won't get together." The informant was lamenting the centralization of school systems, feeling that the school use to be a hub of social activity in the community and helped to get people together. Natives born in the area indicated that most migrants do not have much family nearby. They refused to talk about

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30 the migrants and when questioned about helping the migrants, changed the subject. "We are not the visiting type out here. We go occasionally, but not too often." "The people in the country are very polite and kind, but they are not friendly. It is different, they are good people, but different. Their customs are different and yet they are still your friends even if they are not friendly." "They are very private and I respect their privacy." "I am just a country boy and country people rarely go and visit and have coffee like people in the city do. Country people stick to themselves and work to maintain their properties and their households." It seemed that if one was a native of the area with established family roots, the sense of community was increased by everyone knowing of everyone else. If one was a migrant or new to the area, there was less participation or sense of community. This chapter has discussed the demographic background of Highlands County and described the setting in which the elderly_!ural informants lived. The next chapter will review the literature from anthropology, gerontology, and nursing.

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CHAPTER III REVIEW OF THE LITERATURE 31 Aging is an anthropologist's subject because it subsumes the entire range of subdisciplines that are relevant to successful gerontology. Old people need someone who can understand their individuality and variety, and anthropologists thrive on variation. The holistic perspective often assumed by ethnographers corrects tendencies to study old people as isolated categories. A gap in our knowledge exists concerning our understanding of rural elderly people and their interpretation of the rural _living experience. Before service interventions which enhance function ability and deter premature institutionalization of rural elderly can be developed, an anthropological description of their lives is essential. An ethnographic approach to rural elderly and their emic point of view is supported by the literature (Keith 1979,1981, Fry 1981, Shenk 1987, Vesperi 1985). In this section, literature in the fields of anthropology, gerontology and nursing will be reviewed for

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their contributions to our understanding of issues that relate to rural elderly and to their use of services. 32 Anthropological cross-cultural studies and studies done in the United States that examine elderly people provide background for this study. These studies demonstrate the importance of ethnography as a basis for understanding the lives of rural elderly. Anthropological theory is explored that relates to ecology and its impact on aging and adaptation. The literature provides research background on rurality, natural and social environments, and social and physical characteristics of rural elderly. These three elements impact the everyday lives and ultimately, the health of aged rural people. The final part of the literature review discusses nursing and the health needs of rural elderly. Evolution of Anthropological Aging Study The anthropological study of the aged is still in its infancy. Leo Simmons {1945) was the first to report on the status and treatment of the aged within a world-wide selection of non-complex societies. Using detailed studies of elderly tribal peoples, Simmons addresses the following question: What in old age are the possible adjustments to different environments, both physical and social, and what uniformities or general trends may be observed in such a broad cross-cultural analysis {Simmons 1945:preface)?

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Although his study has been criticized for methodological flaws (e.g. absence of careful sampling procedures, a lack of statement of coding procedures and errors in several 33 statistical operations) the study is important because it suggests a direction which would be followed again and again by subsequent researchers (Holmes 1976:212-213). In his 1945 essay A Prospectus for Field-Research in the Position and Treatment of the Aged i n Primitive and Other Societies, Simmons states that programs for the study of old age lead to three broad inquiries: What do old people want for themselves? How may their interests be safeguarded? And what are the implications of the old-age problems for society in general? These questions are related to Keith's (1982:1) suggestion that old people are an exotic group in most industrial societies because we make them outsiders, keep them at a distance, and so know very little about them. It is time to know more about our aged. Margaret Mead, in a 1951 legislative document entitled Cultural Contexts of Aging: No Time to Grow Old, suggests that the old have much to contribute and that there are many ways the elderly can assist the young by providing a positive model of what it is to grow old. Her pragmatic approach, however, has not dispelled the American stereotypes of aging. Arnhoff, Leon, and Lorge (1964) look at cross-cultural I acceptance of stereotypes of aging. Their conclusions are

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34 that the stereotypes accepted in America are reflective of the general role and status of the aged and that of a youthoriented society. In 1970, Barbara Anderson related that age is culturally loaded in the United States. The aged are eased out by a network of stratagems that seem designed to make the old concur with society's assessment of them as inherently ineligible for any meaningful cultural membership. According to Anderson, they are deculturated (Anderson 1970:213). Margaret Clark in 1976 suggested that anthropologists could contribute to the solution of our ageds' problems by gaining a better understanding of those societies where the values which are forced upon our aged are already the core values of the culture (Holmes 1976:218). Maxwell and Silverman (1970:375), defining culture as a system, argue that one of the most important properties of the individual members of a sociocultural system is progression through time, or aging. Environmental change generates a high rate of sociocultural change because of the sociocultural system's tendency to adapt itself and survive. Faced with a highly mutative technology, the older person clings to those skills and beliefs he or she learned during youth, thus lessening the ability to adapt. They support their argument with discussion of other societies, where the elderly are abandoned or killed, and propose that the more

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35 useful an aged person is to society, the more status he/she retains in society. Using the Human Relations Area Files (HRAF), Maxwell and Silverman look at differences in the treatment of the aged cross-culturally. They identify the contributions of the elderly and the degree of control that accompanies these contributions and find that the more the aged were able to contribute, the higher status and esteem they retained while aging. Press and McCool (1972) also investigate factors associated with high and low status for aged in a number of Middle American societies and find that with the development of modernization, esteem of the aged decreased. In the last 20 years anthropologists have increasingly attended to the roles of the elderly in the societies that they have studied (Cowgill 1986). Cowgill, through his analysis of the HRAF data on aging, supports the theory that modernization has lead to lessened status of the aged, both in the United States and cross-culturally. Glascock and Feinman (1981) suggest that the major weakness of anthropological study of the treatment of the aged results from a lack of propositions that can be systematically studied. They recommend the use of holocultural analysis or a research design that statistically measures the relationship between two or more theoretically defined and operationalized variables in a world sample of human societies. In their study using

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36 h .olocul tural methods, they too recognize that treatment of elderly cross-culturally is dependent upon their usefulness in their society and the extent of the modernization of that society. Amoss (1980) describe the Coast Salish (of the Northwest Coast of the United States) elderly progressively from a period of cultural deference and support of the aged, through a period of culture contact in which the cultural idea of deferring to the old persists. For a period of time, the social arrangements and cultural beliefs supporting the ideal became inoperative and the elderly were not deferred to or esteemed for their wisdom. They are now back to a period where the aged are once more esteemed and supported, by virtue of the fact that knowledge of the old ways is economically beneficial to the entire tribe. The resurgence of "Indianness" offers an opportunity for the current cohort of elders to assume once more the central position their predecessors enjoyed as transmitters of cultural tradition. Anthropological study of the elderly has focused on the role and status of the aged in societies, myths and stereotypes of aging, and general adaptations of aging. Social Isolation/Networks Social isolation of the elderly is central to research and discussion in America. Sokolovsky and Cohen (1980) have looked at the informal social support for delivery of

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37 services to the aged in non-institutionalized environments. Their study did not provide an easy answer to whether or not, and to what extent, those aged persons living in single rooms are really isolated. Sokolovsky and Cohen discover that when the social world of single room occupants (those elderly who occupy single rooms in old hotels) is seen from the inside (emic point of view), old people did not have the problems they're reported to have. Social intervention based on the assumption that single room occupants do not have networks, ignores available and acceptable social supports that might be bolstered in crises in favor of institutional assistance likely to promote dependence or rejected entirely (Keith 1980:286). The existence of informal support networks is useful in understanding and helping isolated elders. Isolated rural elderly people have networks that are almost invisible unless identified by careful questioning. Although urbanization was the stimulus for development of network analysis, the concepts may be transferred to evaluate rural communities. Government funding for services for rural elderly suffer from the "boom or bust" phenomena. Inconsistent cycles of funding can be offset by stabilizing and coordinating limited resources more effectively and by locating an utilizing natural human resources whenever they exist. The only consistent source of support is the natural network system of friends, family, neighbors, or others.

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Network research is still in its infancy in terms of conceptualization and design. None has been thoroughly tested for reliability and validity (Bowling and Browne 1991). Bowling and Browne (1991) effectively measure the networks of "old-old" in England and clearly demonstrate that network analysis is pivotal in the documentation of need for services even though there is question of reliability and validity. Freeman (1989) strongly suggests a set of explicit guidelines for looking at social networks. He defines social networks as a collection of more or less precise analytic and methodological concepts and procedures that facilitate the collection of data and the systematic study of such patterning. 38 Wolfe (1991) further expands on the remarks of Bowling and Browne and Freeman. "Fortunately, ways of analyzing complex networks are being developed" (Wolfe 1991:24). He suggests the identification of links and their strengths and weaknesses to examine social networks. Important features of networks are frequency of contact, proximity of links, intensity or closeness of links, and reciprocity. All of these help to identify tactics that rural elderly people use for adaptation and survival. Ecological Anthropology "Most medical anthropologists have agreed that the concept of adaptation, defined as changes and modifications

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39 that enable a person or group to survive in a given environment, is a core theoretical construct of the field" (McElroy and Townsend 1989:17). Although McElroy and Townsend provide examples from developing nations, there are many parallels with rural elderly Americans. They too, have learned strategies for adaptation and survival (Alland 1970:3). They form alliances and exchange goods (reciprocity) with neighbors and thus create survival promoting relationships within an environmental system. These are relationships within the group and with neighboring groups (links). It might be said that rural elderly are struggling with the ecological parameters of distance from services and distances from interactions with people (proximity). A key concept from McElroy and Townsend's is that health is a measure of environmental adaptation and that health can be studied through ecological models. Using McElroy and Townsend's conceptualization, the health and well-being of rural elderly people who live in Highlands County are adaptations to a rural environment, and should be studied using an ecological model. McElroy and Townsend support the framework used for this study; that environment influences institutions such as subsistence, social supports, and health care, and subsequently affects health status. Although, cross-cultural study of aging is still in its

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40 infancy, most of the comparative research on old age has focused on status, prestige or treatment of older adults as the dependent variables (Fry 1981:3). Dena Shenk (1987), however, has completed an intensive qualitative study of rural elderly women in Minnesota. Instead of focusing on status, prestige, or treatment, she describes the special needs of rural women and the distinctive rural features of her informants. She currently is comparing her informants with Yugoslavian rural elderly women. This study, too, will focus on the distinctive features of the informants. Cultural/Ecological Dimensions The anthropological school known as cultural ecology which has developed over the years is of major significance to medical anthropology and provides the organizing framework for this study. This section of the literature review will examine cultural-medical ecology from the historical perspective to contemporary times. While Julian Steward is the central figure within this school, the contributions of other anthropologists demonstrate the development of cultural-medical anthropology over time. Julian Steward defines cultural ecology as the study of "the adaptive processes by which the nature of society and an unpredictable number of features of culture are affected by the basic adjustment through which man [sic] utilizes a given environment (1955:37)." Steward explains that cultural ecology links ernie phenomena with the etic

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41 conditions of nature. That is, the concern is with the way cultural systems adapt to the total environment and the way the institutions of a given culture adapt and adjust to one another. Cultural ecology seeks to explain how different cultural configurations emerge, are maintained, and become transformed. Humans are viewed as unique and a product of biological evolution who come to terms with their environment. The focus is how humans modify and adapt to their environment through the enabling device of culture and a feedback of reciprocal causality, a process by which human conceptions and perceptualizations modify the environment (Steward 1955). Cultural ecology strengthens the association between social science and the harder disciplines and promotes collaborative research with the general medical sciences such as biology, nutrition, demography, agronomy, etc. The tendency to adopt an ecological perspective in anthropological analysis began to gain momentum in the late 1950's and early 1960's. The terms of reference for this new point of view were broadly outlined by Julian Steward when he defined cultural ecology {Netting 1988:6). A.L. Kroeber, a Dean of American anthropologists, "molded" Julian Steward. Kroeber was an early observer and recorder of the close relationship between ecology, culture, and civilization. Kroeber was a student of Boas and historical particularism, and like other anthropologists of

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42 his day, he subscribed to the Boasian credo that the environment exists merely to be acted upon by human culture. Unlike other Boasians, Kroeber completely subordinated the individual to his cultural milieu (Moran 1979:36). He conceived culture as being created by human beings in the mass over long periods of time. Kroeber confined the term culture to symbols, values, ideas, beliefs, and rules. In his theory culture is the most abstract of four levels of phenomena: culture, somatic, psychic, and social. According to Kroeber, human thought and behavior distinguish what is culture or superorganic from what is merely organic (Bohannan & Glazer 1973:101). A second important influence on Steward was Clark Wissler (Moran 1979:36), who was convinced of a correspondence between cultural and natural areas throughout the world. Wissler postulated that traits tend to diffuse outward in all directions from their point of origin. The more widely distributed a trait is from origin the older it is. Wissler used geographical features to explain population density and cultural traits. He reasoned that cultures become adapted to their environment (Honigman 1976:205; Moran 1979:36). He felt that there was some kind of determinist environmental influence operating on culture. Wissler's mapping of the culture-environment preceded the determination of culture-environment relations (Voget 1972:356).

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43 C. Daryll Forde also influenced Steward. Forde warned that cultures were not mere reflexes of environment as each culture chose certain aspects which would influence historical writings. He proposed the study of relations between cultural patterns and physical conditions to have greatest importance for understanding human society. Furthermore, each culture must be studied as an entity and as a historical development (Forde 1934). Ellen (1986), even though influenced by Wissler, Kroeber, and Forde, has suggested that Steward developed several crucial differences. Kroeber, Wissler, and Forde worked essentially in geographic terms. Steward, by contrast, was much more interested in the subtle relationships between environment and culture. His work was much more ecological. Kroeber attempted to demonstrate correlations between environment and culture but did not suggest, as did Steward, that similar combinations of environments and technologies tend to be functionally and causally related to similar social organizations. Steward was concerned with explanation, rather than correlation. Whissler and Kroeber set their culture-environment equations within an overall particularist framework, linked to a study of culture history and diffusion. Steward was more overtly materialist, focusing on the ecology and environment and its influence on culture. He tried to break loose from the culture tautology. Steward was concerned with application

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44 of his ideas to the solution of particular concrete ethnographic problems and the establishment of particular culture types. His ideas were linked to an explicit notion of cultural evolution in which ecological relationships are seen as part of a network of cultural adjustments and adaptations (Ellen 1986). Evolution and ecology are analyzed in Steward's work. In his theory ecological factors are primarily responsible for adaptive changes in which he was chiefly interested (Honigmann 1976). Adaptation Steward's ideas depend upon a notion of cultural evolution in which ecological relationships are seen as part of a network of cultural adjustments and adaptations. The terms of reference of Steward's concepts are outlined when he defines cultural ecology as the study of "the adaptive processes by which the nature of society and an unpredictable number of features of culture are affected by the basic adjustment through which man utilizes a given environment. The following concepts are fundamental to his analysis: Cultural Core Through empirical analysis, a "cultural core" of features most closely related to subsistence activities and economic arrangements can be specified. The core includes such social, political, and religious patterns as are

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45 _empirically determined to be closely connected with these arrangements. Steward is concerned with how different cultural cores create similar or different institutions which lead to multicultural evolution. Steward sees cultures starting from different ecological bases and traversing separate paths. Cultures evolving in tropical forest zones, or in central deserts will have different sequences because their ecologically based cores will differ. Each basic cultural core is a result of environmental adaptation. However, because common cores of institutions are derived from social and ecological necessities, the separate cultures go through similar stages in their evolution. Steward thus transfers the theory of parallel evolution of Developmentalists into an institutional key (multilineal evolution). Steward called multilinear evolution a methodology concerned with regularity in social change, the goal of which is to develop cultural laws empirically (Bohannan & Glazer 1973:321). By identifying levels of sociocultural complexity and integration, Steward attempts to isolate like units for comparison. He uses categories like family level to correspond to band organization, multifamily level to correlate with tribe and chiefdom, and state level to correlate with empires and urban organization. Each level has a different means of organizing and integrating the culture through kinship, economic institution, political and

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46 forces, bureaucracies, religious hierarchies, and various forms of monarchies and priesthoods. Societies are organized differently according to the complexities of their ecocultural adaptations (Applebaum 1987:200). Cultures having similar core features belong to the same cultural types and are assumed to have the same structural and functional interrelationships. Culture type is defined as the combined product of the culture core and socioecological integration. Uniformity of type comes from similar exploitation of the environment by groups. The number of types may be huge and cannot be organized in broad evolutionary categories (Bohannan & Glazer 1973:321). Steward published his first essay in 1936, The Economic and Social Basis of Primitive Bands. This is his first statement of how the interaction between culture and environment might be analyzed in causal terms. The cultural ecological approach to ethnographic analysis did not really begin until the decade following the publication of The Theory of Culture Change. Steward's persistent attempts to systematize ecological theory and method are largely responsible for the increased attention to ecology and social systems that took hold in the fifties. The clearly specified steps in the Stewardian formula with its stress on adaptation proved attractive. Steward was concerned with the application of his ideas to the solution of particular concrete ethnographic problems

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47 and the establishment of particular culture types. In Cultural Causality and Law (1949), Steward discusses the 19th century evolutionists, and the scientific functionalists, and the irreconcilability of their theories. He discusses causality and law and suggests that it is impossible to discuss these issues as isolated or unilinear; that these occur because of mulitlinear evolution; that there is an interrelatedness between cultural types; and that ecology influences the individuality of different cultures through environmental adaptation. According to Steward, the use of diffusion to avoid coming to grips with problems of cause and effect fails to provide a consistent approach to cultural history and provides an explanation of cultural origins that explains nothing. There are, however, some that find fault with Steward's theory. Limitations and Advantages of Cultural Ecology Moran (1979) discusses limitations and advantages of cultural ecology. Limitations of cultural ecology include many unanswered questions. No one adapts to environmental circumstances in a wholly unbiased, rational, and calculating manner. Ecological factors never operate in a cultural vacuum nor do the enduring patterns of language, kinship, and cultural values that every individual acquires prevent adaptation to a material environment. On the other hand, ecologically-oriented research has the potential for speaking directly to contemporary concerns about

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environmental degradation, energy supplies, pollution, and social disorganization. 48 According to Moran (1979:42) the cultural ecological approach is helpful in reconsidering the subsistence system of hunter/gatherers, pastoralists, preindustrial cultivators/ and even that of modern farmers. At the same time, the approach neglects several ecological variables, such as disease, physiological change, genetics, and energy quantification. Critics have found that crucial cultural variables could be neglected as a result of the a priori importance assigned to those subsistence activities. Steward has been criticized by some scholars because his approach is difficult to operationalize in the field and because it assigns primacy to subsistence behaviors. Steward's method overlooks several environmental interactions that affect cultural development of human groups such as demographic makeup, epidemiology, competition with other groups in the area, or human physiological adaptation. His critics argue that the comparative approach cannot yield cause-and-effect relationships. He never follows a clear statistical sample, and his correlations omit the number of cases in which the correlation did not hold. He usually succeeds in showing functional relationships, but not in establishing causality (Moran 1979:44). The contribution of Steward was to delimit, more than

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anyone before him, the field of human/environment interaction. He did so by emphasizing behavior, subsistence, and technology. The weaknesses of such an approach became apparent within a decade and spawned other research strategies (Moran 1979:45). Contemporary Ecologists 49 Merrill Singer (1989) has stated that most ecological interest in cultural anthropology since Steward directly or indirectly follows his lead and takes as its objective the explanation of culture. However, an alternative trend began in the 1960's when researchers attempted to build a unified ecological analysis that could explain human demographics rather than human culture. In 1968, Vayda and Rappaport wrote that the focus of anthropologists engaged in ecological studies can be upon human populations and upon ecosystems and biotic communities in which human populations are included. Alland (1970:47) was influenced by the ideas of Vayda and Rappaport and added "the thorough study of human adaptation is essentially a biological problem involving a very important series of nongenetic processes. Wellin (1977) suggests that the scope of the ecological model includes societies and the ecological approach is valuable for delineating elements of a dynamic system, determining how the various elements work together, and identifying hazards or potential stress areas. These statements delineate the direct influence cultural ecology

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so has on medical ecology. Medical Ecology Singer (1989j is quick to point out the differences between cultural ecology and general ecology. Cultural ecology has as its primary goal the explanation of culture, while general ecology is concerned with issues of human behavior and demographic rather than cultural variables. In spite of the clear influence of cultural ecology, medical ecology most directly emerges from the general ecological rather than the cultural ecological trend in anthropological concern with the environment. Singer (1989) charges that medical ecologists will either ignore social factors and use only ecological variables or they will pay considerable attention to social factors without recognizing that they have moved beyond their ecological framework. His concern is that the discipline avoid the biomedical error of assuming that health and disease are natural and not social entities. He challenges the capacity of medical anthropology to adequately and productively use an overarching theoretical approach (Singer 1989:223). Singer reminds us, however, that those aspects of culture which affect fertility, death, and disease rates are major factors in the adaptation of human populations. The task of analyzing adaptation involves the study of specific encounters between populations and their environments with the ultimate aim of discovering general rules capable of

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51 generating specific strategies (Alland 1970:4). Ann McElroy (1990:243) identifies two models of biocultural research in health studies: one which integrates biological, environmental, and cultural data, and one more segmented model in which biological data are primary and data on culture and environment are secondary. This study uses the first model. Alland (1990:344) believes that etically oriented medical anthropology will provide the discipline of cultural anthropology with the tools to better understand better the complicated relationships and feedbacks that exist between the human species' two major forms of adaptations, biological and cultural. This study's etically focused, integrated with emically generated data, will provide a better understanding of isolated rural elderly people. Critical medical anthropologists must consider ecological factors more than they do to date (Baer 1990: 346). An anthropological approach which combines ecological, biological, and cultural research can provide us with very important clues for our understanding of variations in patterns of human health and illness (Laderman 1990:357). Thus, it can be said that applied medical ecological anthropology has evolved from the 1900's to the present day along the ecological path with arguments both for and against the inclusion of culture, biology, genetics, adaptation, etc. Other discussions of ecology further define its importance.

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52 Campbell (1983:6) defines ecology as the study of the relationship between a species and its total environment; human ecology as the study of all relationships between people and their environment; cultural ecology as the study of the way the culture of a human group is adapted to the natural resources of the environment and to the existence of other human groups; and social ecology as the way the social structure of a human group is a product of the group's total environment. Rural elderly have adapted to the natural resources of the environment and to the existence or non-existence of other human groups. Rural Elderly Processual ecological anthropology examines the relation of demographic variables and production systems, formation and consolidation of adaptive strategies and the emerging interest of anthropologists in political economy and structural Marxism (Orlove 1980:245). Processual ecological anthropology examines what it is like to be elderly and living in a rural area and how rural elderly respond and adapt to their environment. The natural environment, in the context of less populated, lower density areas, provides a framework or a feedback mechanism that, in turn, impacts other dimensions. The relationship between humans and their environment produces these effects on rural elderly. The adaptation of elderly in rural areas can largely be traced to culture.

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53 The social environment of rural elderly is modified by human cultural adaptation to environmental circumstances. A number of dimensions of the rural environment have surfaced throughout this discussion as determinants of the status of the rural elderly including natural and social environments. However, diversity must also be taken into account. The literature does not make a distinction between rural and urban elderly, and there is controversy about the importance of such a distinction. While there is a critical body of research on the rural elderly, it does not compare to the large amount of research which exists on the urban elderly (Aday & Miles 1982; Dehaney 1987; England et.al. 1979; Fischer 1978; Krout 1986; Lee & Lassey 1980; McCoy & Brown 1978). It does, however, provide stimulus for further exploration of the differences between rural and urban elderly. There is diversity in rural America, both within and between small towns and rural communities as well as diversity in the aged rural residents themselves. It is important not to overgeneralize. According to Coward (1979) this discrepancy in research has placed social scientists and practitioners in a weak position to determine whether or not there are significant differences between the rural and urban elderly. Coward's analysis of research on rural aging suggests: 1. There is great diversity in rural America, both

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within and between small towns and rural communities. 2. The "aging life span" covers 30 or 40 years, and this span is not a static period but one of growth. Therefore community services must reflect the changing needs of advancing age. 3. Many of the commonly held myths about the rural elderly are not supported by the results of empirical research. Practitioners must be sure that their services are based on reality and not assumption. 4. There are significant advantages in strengthening horizontal rural community ties by supporting already established and naturally occurring helping systems. 54 5. Including in the delivery process those who are significant others in the lives of the aged may increase the impact of the intervention program and provide a more efficient system for delivering services (Coward 1979:277). These cultural differences impact the use of services by elderly and affect their health. Coward has pointed out that service provision should be based on real needs rather than on rural myths and comprehensive generalizations. We need to describe rural elderly people and to interpret the meaning of the rural living experience as they react to it in order to begin to develop appropriate service interventions that will enhance health and function ability and deter premature institutionalization. These considerations prompted the inclusion of qualitative and

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quantitative data in this study's ethnographic needs assessment. 55 Keith (1979:3) cautions that old people are often treated as a homogeneous category and in gerontology as in many other areas, anthropological research has provided important reminders of diversity. Anthropological research is barely beginning to document the range of variation needed for interpretation of cultural influences on the aging process and on the role of the aged in different societies and sub-groups. Keith (1979 :1) has suggested that an ernie perspective on old age should also come from anthropological investigation. She has stated that little is known about how aging looks to the aged in any society, but particularly in the modern world where old people are less often listened to than discussed as a problem. A discussion of rural/urban differences will serve to explain the distinctions between rural and urban elderly. Rural/Urban Rural elderly age differently than do the urban elderly because of their environment. They exhibit a cultural style different from that of urban elderly. These differences are a result of an ecological dimension of small population size and relative isolation. The concept of "rural elderly" has been defined in many ways (Rathbone-McCuan & Hashimi 1982:83). There are two general approaches to describing this segment as a distinct

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56 subgroup of the aged population. The first is the demographic approach which focuses on population size and community type. The second approach is qualitative and considers personal characteristics of individuals and groups in relation to subcultural status. The demographic approach is the one most commonly accepted by researchers. An agreed upon set of characteristics that define elderly people as rural is not available. Since there is considerable diversity among rural aged, no single or simple profile of characteristics describe rural elderly in the nation. This diversity exists in various regional areas and even within the states (Rathbone-McCuan & Hashimi 1982:83). Social scientists have attempted to delineate the dimensions of rural elderly life. Miller and Luloff (1981:609) try to identify "who is rural?" They explore the presence of a rural culture in contemporary society and question the extent to which the ecological and/or occupational aspects of rurality affect and relate to the sociocultural dimension. They suggest that the notion of rurality encompasses an ecological, an occupational, and a sociocultural dimension. Counties with high percentages of elderly are distributed throughout the country. There are now over 500 rural and small town counties in which persons 65 and over make up at least 16 percent of the total population. Taietz and Milton (1979:430-431) define a county as urban if more

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57 than 50 percent of its population lives in places of 2500 or more persons. An area is considered rural if 2500 persons or less live in the described area. This is the most common definition for rural and the one offered by the Bureau of the Census. Health Care Services The aging of the U.S. population clearly has many important social and economic implications. In 1990 the United States spent $666.2 billion on health care. This sum represented 12.2% of the gross national product. Roughly one-third of this amount went to care for the elderly. Per capita payments are more than 3.5 times that of the younger population (Fein 1992:34). About one out of every four elderly people in the United States lives in rural America. Coward and Cutler (1985: 785) suggest there are differences in mortality and morbidity rates between rural and urban elders. They state it is uncertain how place of residence affects these rates although it is more certain that significant differences exist in the area of health services in direct relationship to geographic location. Lassey and Lassey (1985: 83-104) report a deficiency of data on the life circumstances of rural elderly people and a correspondingly small base of knowledge about service needs, health status, and health needs of rural elderly. In the area of health services, there is more certainty that significant differences do

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58 exist in direct relationship to geographic location (Coward & Cutler 1989:785). The health status and health care needs of elderly residents of rural communities are not well documented. The problem is compounded by the small base of knowledge about the development and delivery of effective and efficient health services in a rural context. The high percentage of rural elderly, low density per square mile, large geographic land mass, differences in morbidity and mortality rates, and inadequate knowledge base about health needs supports the necessity of this study. In 1979 Anita Harbert and Carroll Wilkinson cautioned that rural elderly are the most disadvantaged of an already disadvantaged minority. There is no question that services are not always made available to those people living in remote areas or to elderly residents who have been too isolated or proud to seek them out (1979:36). Health care, economic status, educational attainment, housing and transportation are cited as areas of need. Due to an indifferent attitude toward government institutions that have neglected them for so long, there is an attitude of hostility and suspicion toward large cities, politicians, and social programs. Carole Hill (1988), in her study of a southern rural community, analyzes health problems, health-seeking behaviors and beliefs and attitudes about health, and finds

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59 striking differences between assumptions of policy makers and planners. She argues that being able to improve health care services is dependent as much on understanding cultural and social variables in planning and implementing policies as on medical knowledge. The importance of health to a population and its concepts of what health is must be examined if the health care system is to solve the overall health problems of a population (Hill 1988:2). Hill states that during this century, people in rural areas are becoming difficult to distinguish from city folk. Rural people simply live farther apart, pay more for utilities such as telephones, water and electricity and have further to travel to stores, hospitals, physicians, libraries, etc., for services. Hill reduces the concept of rurality to a simple fact of location (1988:34). Natural and Social Environments of the Rural Elderly Natural and social environments that are varied contribute to behavior variance. Barker (1968:3-4) asks what are the environments like? How do environments shape the people who inhabit them? What are the structural and dynamic properties of the environments to which people must adapt? His questions pertain to the ecological environment and its consequences for individuals. The rural ecological environment is as unique as are the people who reside in it. Rural places are natural environments with more vegetation and open space. Rural environments are characterized by

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60 blues, greens and browns. Rural physical settings tend to present lower levels of cognitive complexity and stimulus input. The physical context of most rural settings remains fairly stable through time. Change in such environments tends to be gradual. The population structure of the rural environment is characterized by few residents at lower densities and geographical dispersement (Rowles 1984:132). In addition, the population tends to be stable although spatially isolated. Rural refers to a population aggregate that derives its livelihood from agriculture production or from the extractive industries such as mining, fishing or forestry (Miller and Luloff 1981:611). The bulk of literature portrays rural culture as being provincial, socially conservative, slow changing and somewhat fatalistic. These characterizations are typical of rural elderly in Highlands County. Historically, technological advances in agriculture have pushed young people off the farm at the same time that economic growth of metropolitan areas has pulled them to the cities. While there is some indication of a slight reversal of this demographic trend, the general outflux of younger people has resulted in the graying of rural communities (Nelson 1980:204). Rowles (1984:132) defines the sociocultural as the accepted norms of behavior and values that permeate and

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61 condition relationships among individuals and social groups. The sociocultural milieu of rural environments exerts the greatest influence upon old people's transactions with the physical setting. According to Nelson (1980:200), the rural aged tend to be somewhat younger, more likely to be male, married and less educated than their urban counterparts. They are more likely to be poor, and their economic position is further jeopardized by their having fewer safe guards against inflation such as savings, private pensions, and health insurance. In recent decades, most rural areas in the United States have undergone substantial changes. There has been a notable shift from the older way of life to a more modern and technologically advanced society. Recent trends toward modernization in most rural areas are reflected in industrialization, fewer farms and more part-time farmers. New services have emerged as more complex social organizations such as schools, churches, improved transportation, social service agencies, and communication facilities have resulted in a more multifaceted rural society (Aday and Miles 1982:333). Historically, rural society has been viewed as being characterized by a consensually derived set of values unique to rural life. There are several theoretical arguments which suggest that the rural environment's impact on values

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is dwindling, adherence to rural values is declining and differences between rural and urban residents are diminishing (England et. al. 1979:122). However research evidence indicates that there are still some value differences between rural inhabitants and urbanites which are attributable to the rural environment. Values that 62 have been identified as particularly important to rural people are practicality, self-control, kindness, honesty, efficiency, hard work, friendliness, honesty, patriotism, deep religious commitment, independence, social conservatism, self-reliance, and being neighborly, family oriented, mistrustful of government and leery of programs seen as "welfare" or part of the social service bureaucracy (England et.al. 1981; Kim 1980; Krout 1986; Hill 1988; Stein 1982; Rosenblatt 1982). Krout (1986:168) relates that a number of authors have argued that the rural elderly hold a value structure which _differs from the urban elderly in nature and degree. Urban elderly, on the other hand, are characterized as being residents who are less friendly, more defensive, and less likely to become involved in the problems of others. Urban areas are said to undergo rapid social change, to be heterogeneous, to have complex organizations, and to be orientated to individuality and secondary group interaction. Krout (1986:4) argues that rural/urban differences cannot be attributed to population size and density alone and have not

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63 been adequately investigated. Even though rural changes have occurred, a controversy still exists over rural values. The conventional rural value system tends to stress independence, honesty and religiosity as well as prejudice, ethnocentricity and intolerance of heterodox ideas. Larson (1978:110) discusses the values of rural or farm people. His analysis of research on this topic suggests that generalizations about rural-urban value differences must be accepted cautiously in light of the lack of adequate research findings. He offers the following generalizations: 1. Rural America differs from urban in the emphasis given to major values, in value related beliefs and behaviors, and in general outlook. Rural people are characterized as being especially independent, self-reliant, neighborly, family oriented, hard working, mistrustful of government and leery of programs seen as "welfare" or part of the social service bureaucracy. 2. No unanimity, no solid front, exists among rural people on any statement from which values or any value related belief or behavior may be inferred. Cultural pluralism is a characteristic of rural America. 3. Although farm men and women generally take a position corresponding with that which prevails among rural adults as a whole, they are more distant from the values and beliefs position taken by the majority of large city dwellers. 4. Rural adults generally take a similar position to the

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64 national majority, on questions of values and beliefs. Attitudinal Characteristics of Rural Elderly Arnold Auerbach (1976:105) suggests that the rural elderly have attitudinal characteristics that may be seen as problematic: "There is an intensification in the attitudes of the rural aged that emphasizes the insularity, independence, isolation, xenophobia and individualism that is a reflection of the psychology of rural living." Auerbach (1976:105) further suggests that rural elderly are generally apt to know less about available social services, be more indifferent or hostile to government supported programs, and to be more difficult to mobilize for participation in social programs. Most have been very self-reliant all their lives and they are inclined to see those receiving government support of any type as "sponging off public funds." The rural elderly are viewed as suspicious of large cities, politicians and social programs which often infringe on privacy and frequently threaten the very fibers of a long-standing way of life. Rural elderly residents, more so than the general elderly population, mistrust the government and value self-sufficiency and independence (Coward 1979:280). Threaded throughout these arguments is a common theme. Rural environment does have an impact on values. A stable set of values and attitudes exist which are distinctive to aging rural people even though much of rural America is

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65 highly diverse in its composition. The predominant value system of the rural area is different in degree, if not kind, from that found in urban places. Krout (1984:4) summarized the values that are particularly important to the lives of rural people: practicality, efficiency, work, friendliness, honesty, patriotism, deep religious commitment, social conservatism and a mistrust of the government. Be attributes these values to the combined effects of geographic isolation, sparse population density, dominance of agriculture, ethnic homogeneity, and limited geographic mobility. Fengler and Jensen (1981) studied life satisfaction among 1405 randomly selected urban and rural elderly. Rural elderly perceive their life situation more positively than their urban counterparts. No statistical differences are found in areas of income, health, transportation and housing. They attribute rural elderly values of independence and individual responsibility for one's fate as affecting a positive outcome. The changes in the rural areas in technology and communication have been said to affect values, but in essence the distinctive value structure is still in place. Economics and the Rural Elderly The economic status of older adults is influenced by the environment. Older rural people have traditionally received substantially lower incomes than their urban

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66 counterparts. This is due, in some part, to lower lifetime earnings leading to lower Social Security benefits. Lack of financial resources is the most serious difficulty facing older rural people (Lee and Lassey 1980:64). Harbert and Wilkinson (1979:37) suggest that rural elderly are more economically oppressed than most older people. One of the myths about rural life is that it costs less to live in rural areas. Living in a rural area is not less expensive and in some ways costs more. Fuel costs are much higher because many live in substandard housing which is not properly winterized. Rural elderly also suffer the physical hardships of lack of central heating and air and inadequate plumbing. They generally do with less because they have !esse Rural elderly people tend to be socialized to a lifestyle and value system that typified rural society in the formative years of their youth. Because of this socialization, many rural elderly won't ask their willing friends, family, or neighbors for assistance until there are no alternatives. This may be why early health intervention is so difficult and preventive care nearly impossible. Not asking for help is behavior consistent with their values, but it stands in the way of their receiving needed help (Rathbone-McCuan and Hashimi 1982:90-91). Rural elderly may have to travel 30, 40 and even 50 miles to obtain necessities; they often live in relative isolation with few neighbors and few social contacts; and

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frequently fundamental requirements such as food are more expensive (Bezon 1989). The neighbor of an older rural person is very likely to be another older person and, therefore, unable to be of help (Harbert and Wilkinson 1979:36-40). 67 Krout (1986) concludes that income data alone may not be sufficient to provide an adequate explanation for rural/urban differences of economic well-being or to prove that the rural elderly are worse off. He suggests that more research is needed to determine the nature and degree of economic status differences of the rural versus urban elderly. Krout raises several questions. Do lower incomes mean significantly different standards of living and do these factors affect basic needs such as health, recreation and transportation? Are there factors in the rural environments that counteract the potential effects of lower incomes (e.g., lower cost of living, informal supports, supplemental income sources, nonmonetary sources of subsistence)? Do the rural elderly compensate by different expenditure patterns? If so, what are they? The environmental context of rural aging part of the exploration. In 1979, Atchley and Miller summarized knowledge concerning housing of the rural aged. They conclude that housing of the rural aged is older, of lower value, and more likely to be substandard than the housing of urban older people. Older rural households are viewed as

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68 mainly older couples, and nearly all of them live in single-family dwellings. At least a quarter of the rural aged live in inadequate housing. Lack of central heat, plumbing facilities, and telephones are particularly serious and prevalent shortcomings. Rural older people have much lower incomes than urban people, and the value of their housing is correspondingly lower. Older people live in older homes, and they generally live in them a long time. Housing programs are mainly developed for urban needs, but rural people need housing programs that provide for maintenance of older single-family dwellings. Differences among older rural nonfarm and farm residents are not consistent in any direction. However, rural nonfarm older people have lower incomes and generally less adequate housing. Krout (1986), in his review of the literature related to rural incomes and housing, is unable to cite recent studies related to rural income and housing. The most recent is the Ecosometrics study (1981) which concludes that rural/urban differences may not be as large as differences based on other factors such as race, sex, and whether or not someone lives alone. Transportation costs, too, may be a problem. Costs are high since one must own a car for transportation. The need for transportation to services may intensify as aging individuals become more dependent on others and as the cost

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69 of transportation escalates (Windley 1983:183). Inadequate transportation makes it difficult to gain access to those few services which do exist for the rural aged. The absence of adequate public transportation and the presence of geographic barriers to services, such as long distances, unpaved, and in some cases impassable roads may be the most significant transportation problems of the rural aged. Such factors result in high transportation unit costs in rural areas (Nelson 1980:201). Distance complicates meeting basic needs for food and medical care, restricts social interaction and frequently increases living expenses. The distance between people and towns and people and services can create insurmountable problems for rural elderly (Harbert and Wilkinson 1979:36). Controversy surrounds the status of rural elderly physical health. Several studies have reported a higher incidence of chronic illness and lower levels of overall self-assessed health in rural elderly than urban elderly (Bezon 1989; Cordes 1989; Harbert and Wilkinson 1979; Krout 1986; Kivett 1985; Lassey and Lassey 1985). That rural elderly have poorer health and lower nutritional levels than the urban elderly is undoubtedly related to lower income levels, but also related to health services being less accessible in rural areas (Bezon 1989; Krout 1986). Rural elderly frequently neglect health care because they cannot afford it. According to Harbert and Wilkinson

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70 (1979:38), rural people 65 and older also have more chronic health conditions and limitations on their activities than non-rural elderly. Access to medical care is very restricted and even further complicated by the low income levels of the rural elderly. The unequal distribution of Medicare funds to urban and rural elderly has been noted. Older persons in urban areas receive about 40 percent more in Medicare benefits than their rural counterparts (Rathbone-McCuan and Hashimi 1982:107). Lack of preventive services causes rural aged to be sicker when they finally use Medicare, thus they use Medicare in larger dollar amounts. A wide variety of factors seem to influence the health of the rural older adult: lack of accessibility due to geographic isolation, poor transportation resources, a high value placed on independence and negative attitudes toward established health care provider. However, many studies have been criticized for their use of unclear definitions of rural-urban, inadequate sample studied, and failure to use tests of statistical differences. There are studies that do not find significant rural-urban differences, a finding which compounds the controversy (Krout 1986:81). The prevailing theme, however, is that the environment along with culture, influences the health status of rural elderly. Nursing In nursing there is a strong impetus to provide

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71 preventive health care for older adults in order to increase independence and to prevent the exacerbation of chronic disease. However, nurses rarely have asked the elderly their views on this process. Nor have they asked the elderly for input in identifying the services they see as needed. Too often, nurses adopt a paternalistic attitude and think they know what is best for the older people to whom they provide health care services. Non-compliance is the outcome of paternalism, and the use of the nursing process is thwarted. One of the major propositions of King's theory (King 1981) is that individuals are involved in the environment within which the nursing process is activated, and the nursing process will differ relative to all individuals in the environment. A minor proposition is that nursing action is more effective if goals are communicated. King assumes that individuals have a right to participate in decisions that influence their life, health and community services. She also argues that the goals of health professionals and goals of recipients of health care may be incongruent. These propositions and assumptions highlight King's valuing of the clients' participation in their care and her belief that transactions for their care occur in individual environments. Client participation in identifying needs and services is a major thrust of the present study. The ascertainment of a comprehensive health history is

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72 an art and requires special knowledge of interviewing and parameters of health. Obtaining a health history on an elderly person requires knowledge of aging theories, both biological and developmental. Nurses educated in the care of the elderly are best qualified to do this task. A basic tenet of interviewing elderly people is to provide a therapeutic interview so that the client leaves feeling that someone has truly listened and that there is a caring nurse who treats him or her with respect (Burnside 1988:151). Summary and Conceptual Framework Anthropology has enabled the comparison of elderly cross-culturally and provided sensitivity to the emic point of view of the elderly. However, little research has been done to identify isolated American rural elderly and describe them from an emic focus. In addition, few anthropological studies have precisely described rural elderly by combining ethnography and a cultural-ecological point of view. This study has collected objective and subjective data that identifies the needs of rural elderly that impact on health. It has described the sociocultural and special features of their residential environments. The literature has supported the study by delineating how the anthropologist is best suited to study elderly. The propensity to look at individuality and variation, the focus on holism and' putting things in context, and attentiveness

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to the ernie or elderly person's point of view are major features of anthropological study. 73 An examination of the adaptation or changes and modifications that enable elderly to survive in rural environments is enhanced by the use of Julian Steward's cultural-ecological model that over time has developed to the cultural-medical ecological model and fosters a consideration of the ways that adaptation to the environment can affect health. Ecology influences the individuality of different cultures through environmental adaptation and ecology has influenced the subculture of isolated rural elderly through environmental adaptation. Three basic institutions compose the cultural core of the informants this study; subsistence, social support (both networks and church), and health care. The environmental adaptation of isolated rural elderly involves accommodation to large distances from services and amenities and lack of _transportation affected by both the subsistence level and social support. This in turn influences seeking health care, especially preventive care, which ultimately impacts on wellness. The institution of health care is limited in the Highlands County area with accessibility and outreach difficult. Socialization into preventive adjunct services which promote health is impeded because of ecological adaptation to distances which does not support the use of services. The !eeriness or mistrust of offered services

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offered results from a knowledge deficit and value system that precludes the use of services. 74 Rural/urban differences related to transportation, economics, housing, economics, and values are clearly documented in the literature. However, the reasons for these differences which are related to the ecology and adaptation to the environment, can be traced by to Steward's basic premise. The need for health care and services flows too, from the theme of adaptation to the environment, distances and transportation. This chapter has provided a view of anthropological theories and studies about adaptation to the environment and aging. The focus has been on the issues of rurality that affect health of elderly isolated rural people. The next chapter will delineate the methods used in the ethnographic approach to identify of needs.

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CHAPTER IV METHODS 75 A three visit, multiple-method data collection process was used to holistically describe isolated rural elderly. This chapter includes a discussion of needs assessment, informant selection, research design, data collection and analysis, reliability, and methodological limitations of this applied anthropology project. Angrosino (1978:291) points to applied anthropology attempts that define the nature of client communities and delineate the appropriate anthropological perspective on service delivery transactions. Anthropologists have long been involved in program evaluation and studied factors related to program acceptance in target communities. The method of data collection described below identified factors that impact program acceptance and which ultimately affected the health of isolated rural elderly people. But first, in order to explain the method selection, it is important to describe the present status of needs assessment of elderly people that are used to determine services.

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76 Needs Assessments This ethnographic study of rural elderly provides data that is comprehensive and describes the specific dimensions that affect rural elderly from an ernie point of view. This approach is vastly different from other methods of determining needs based on inadequate surveys, biased opinions of key informants, data extracted from program attendance, and "paternalistic" opinions of agency personnel. Services are not always made available to people living in remote areas or to elderly residents too isolated or proud to seek them out (Harbert and Wilkinson 1979:36). Population size and the degree of isolation can affect service awareness and utilization, both directly and through the organizational, social, and cultural variations that accompany them. Krout (1988:529) suggests that ecological dimensions are an important determinant of service awareness among elderly adults. Unfortunately, the question of how these ecological factors operate has not been addressed. Rural and urban individuals may have similar programs needs, but the planning and delivery of programs which are effective in meeting these needs w ill require distinctly different strategies (Coward 1979:276). Needs assessment is the process of evaluating the problems and solutions identified for a target population. Assessing needs moves beyond the information gathering of need identification and requires evaluative judgments about

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77 problems and solutions (McKillip 1987:20; Whiteford 1992). There are three models of needs assessments: the discrepancy model, the marketing model, and the decision-making model. The discrepancy model, the most straight-forward and widely used, involves three phases: goal setting (identifying what ought to be), performance measurement (determining what is), discrepancy identification (ordering differences between what ought to be and what is). The discrepancy model is used for this study. Needs assessments provide evidence of need when arguing for additional federal support or merely meeting federal planning requirements for entitlement grants. Despite widespread use and obvious importance, little is known about the quality of needs assessment of rural elderly. In 1982, Lareau and Heumann surveyed Area Agencies on Aging to determine the kinds of needs assessments that were being done in the United States. They report that few needs assessments were comprehensive and many may be counterproductive, resulting in misleading or incorrect funding. Their study disclosed that inadequate needs assessment of the elderly is endemic to all planning agency types. Specifically, data is gathered primarily on urban elderly residents and assumptions are made for rural elderly based on that data. The differences between rural and urban elderly are overlooked. Lareau and Heumann (1982) find that most agencies base needs on statistical data derived from

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use of services by urban elderly with weak input from the elderly who should receive the services. Further, these studies are done by those people whose jobs were dependent upon a need for their services. Laureau and Heumann state there is little research on needs assessment, no body of theory and little consistency among service providers in their data collection methods (1982:328). 78 A different strategy that might be utilized to determine the needs of rural elderly is an ethnographic interview. Keith (1981:289) suggested that attention to cultural contexts that produce diversity in any aspect of human social life is central to the holistic approach in ethnography. Cultural context exerts a powerful influence on the lives of older people. Therefore, the information obtained by ethnographers of the elderly is important. The emic perspective, documentation of diversity, and contextual data, veto stereotypes and offer implications for more accurately guided action (Keith 1981:288). Unfortunately, often those who are required to conduct needs assessments (social workers, gerontologists, public health administrators) are not anthropologists. Moreover, there is little consistent guidance about what to do and how well to do it (Laureau 1983:518). According to Laureau (1983) the concept of needs assessment does not originate in a coherent body of theory and, thus, universal agreement does not exist on its meaning.

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79 At the present time, agencies primarily use surveys of elderly respondents, analyses of secondary data, interviews with key informants (persons active in the communities with experience to provide an understanding of the population, the problems, needs and desires), group process meetings at public hearings, and analyses of service user statistics (Laureau 1983:520). Major Problems in Needs Assessments There are major problems inherent in these methods. Surveys tend to have low response rates, and those who do respond do not make up a representative sample of the target group. The use of secondary data encourages a paternalistic philosophy toward needs assessments that disregards the right of elderly persons to be considered as adults who have a keen firsthand knowledge of their own problems and needs (Laureau 1983:521). Very few secondary data sets describe geographical regions or contain the type of functional ability variables necessary for description of the problems of the elderly. Agencies that deal with elderly programs often have few trained staff members under pressures of time. This situation frequently produces needs assessments that provide little useful information (Laureau and Heumann 1982:329). Untrained staff members with little or no knowledge of gerontological issues are unable to adopt an ernie point of

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view and, consequently, develop needs assessments with an etic point of view which is paternalistic and reflects the planner's attitude that "I know what's best for the elderly." Unfortunately, that is a prevalent attitude in our society. 80 If needs assessments of the elderly are to become the powerful planning tools they were intended to be, they must present a better, more comprehensive picture of the needs of the elderly. An ethnographic approach would achieve more comprehensiveness and describe the ecological dimensions of rurality that impact services. The following factors are weaknesses or deficiencies in presents methods of previous needs assessments of rural elderly: 1. absence of generically defined and prioritized social welfare programs for the rural elderly. 2. inconsistent geographic definitions of "rural" found in the literature. 3. failure to identify uniquely rural factors underlying the needs of rural elderly. 4. conceptual and operational problems of judging rural elderly needs in reference to an urban standard. 5. failure to recognize the considerable population and territorial diversity of rural America. These weaknesses and deficiencies call into question the adequacy and appropriateness of traditional needs

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81 assessment methods for studies of rural elderly. Therefore, the choice of methodology choice of combination of qualitative and quantitative data collection was chosen to attempt to compensate for these weaknesses and deficiencies. This methodology was framed by the conceptual framework and research questions and a pilot study was undertaken to refine the research questions in the rural setting. Pilot Study In the summer of 1989, a pilot study was completed in Highlands County Florida under the auspices of the West Central Florida Area Agency on Aging and the NuHope of Highlands Inc. The purpose of the An Ethnographic Approach to Needs Assessment of Highlands County Rural Elderly: A Pilot Study (Bezon 1989) was to learn about the health needs of isolated rural elderly. Survey, observations, and subjective and objective measurements of health accomplished this task. The goal was to describe isolated, rural, elderly residents of Highlands County and delineate their health needs. Prior to the study a key informant from the NuHope of Highlands, Inc. agency provided a tour of the County and introductions to other key informants. The County Commissioners endorsed the project. A letter of introduction was provided by the agency. The study was approved by the University of South Florida Investigational Review Board.

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82 Census tract data, with ecological specifications that described rurality, determined the selection of participants. Impartial informant selection from each of the census tracts was attempted. included: 1. Informants, 65 years or older. Criteria for selection 2. Informants in a single family dwelling. 3. The dwelling located at least twenty miles from services. 4 Informants had not participated in service related programs. Informants in each geographical location were located and selected by key informants such as local agency workers and native residents of the county. Other sources for identifying informants were the Post Office, Emergency Medical Service, Electric Company, Telephone Service, and County Highway Department. A total of 19 informants met the above criteria. They did not know of the study in advance except for a small announcement in the local paper. When the researcher contacted the subjects in their homes and explained the purpose of the study, access was granted and informants cooperated fully and graciously. Isolated rural elderly were visited on three different occasions. On the first visit survey data was solicited and entered directly into a lap top computer. Trust was established. During the second visit subjective and objective

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measurements of health were completed. The final visit occasion detailed field notes and observations. The data were analyzed and the following research questions were answered. 1. What is it like to be elderly and living in a rural area? 2. How do rural elderly people handle their day-to-day activities? 3. What is the status of their health? 4. How do these rural residents perceive their health? 5. Who helps the rural elderly in time of difficulty? 83 6. What are the reasons rural elderly do not participate in offered services and programs? 7. How does failure to use available services impact on their health? The following conclusions were drawn from the pilot study data. Isolated elderly individuals living in rural areas of Highlands County need services. Transportation is a central issue, both for the provision of services and for user access to services. The elderly population in this pilot study were not an indigenous nor an homogeneous population. They often exhausted their money for food, medical care and living expenses. Eighty-five percent did not have children nearby that they could count on for help. There was an overall mistrust of the medical system. Many were lonely. 'Not all of the elderly population attended church.

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84 Self-rated health was lower than other urban groups measured by the investigator. Mental status was intact, however, depression was present in thirty percent of the subjects. Fifteen percent required help with basic activities of daily living. Forty-two percent required aid with instrumental activities of daily living. Based on these findings, the following services would help to keep rural elderly functional in their homes: housekeeping services, heavy chores and yard work services, personal care services, transportation, socialization, advocacy, meals, health education, and health prevention measures. Biahlands Rural Elderly Study A larger study using a more representative sample was completed to validate the pilot study's findings and to expand the data. The procedure follows for selecting a representative sample. Sample A purposive, nominated, sample was done. An attempt was made to use a random sample, but it was impossible to obtain lists and addresses of people 65 years of age and older in order to fully randomize the sample. Informants were contacted with the help of NuHope of Highlands, Inc. personnel, the Highlands County Health Consortium, home health agencies of Highlands County, congregate meal site managers and participants, and

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85 churches. The investigator met with agency personnel and reviewed potential informants. Informants also contributed names for future participants as the project progressed. Other rural elderly heard about the study and requested "the nurse to come and visit." Informants were not notified of the visit ahead of time. The investigator went to each individual's home and explained the study. Only one person refused to participate. A total of 62 rural elderly individuals were visited in their homes for 2-3 visits, with visiting time from 4 to 12 hours. A concerted effort was made to use informants from different geographical locations of the county. Figure 1 shows the geographical location of the informants. Setting, Access to Home The investigator presented a letter from the Nu-Hope Agency verifying authenticity and offering documented support for the project (Appendix A). The letter of invitation to participate was read, and the investigator explained the project. The letter included a statement of approval by the University of South Florida Health Sciences Center Institutional Review Board (Appendix B). Each informant's home was the setting for observation and data collection. Three days were spent with the informant. Several hours were spent with the informant each day. The span of time was dependent on the circumstances and the individual subject. The first day was

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r--2 ---__ 7 ___ -------------1 AVON 1---=-i .... 60 .... -:. I ... .. I I I I I I 22 62 31 56 55 0 I /_ 25 27 26 18 3 1s I 5 I 14 17 8 I 12 19 9 I r--------. i 15 10 I 43 1 I 13 29 1 . ,_ -------'---------'-------' Figure 1 Geographical Locations of Informants 86 Venus 18, Lake Placid 10, Lorida 26, Sebring 5, Avon Park 3

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87 used to obtain survey data. During the first visit a warmup process occurred. The informant and the investigator got to know and trust each other. Basic survey data such as demographics and medical history were entered into the computer. Initially the computer was of some interest to the informants but as the interview progressed, the informants forgot the intrusion even though data entry was done continually. When there was information that an informant wanted to share with the investigator, but not have entered into the data, she/he would ask the investigator to "turn off the computer and/or stop writing. The second visit was longer. Subjective and objective health measurements were recorded along with field notes. Subjective data included expanded medical and social history. Objective measurements such as mental status, depression scales, activity of daily living, and instrumental activities of daily living scales were _completed during the second visit. Physical examination were completed during the third visit. Height and weight were measured. Postural blood pressures were taken. Heart and lungs were examined with the peripheral vascular system. All of these procedures are considered basic screening examinations appropriate for the elderly. Field notes were detailed during this visit, rapport was established, and a sense of intimacy prevailed.

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Comments from participants of the study included, "I've never told these things to anybody!" Pictures were shared and reminiscence occurred. Painful memories as well as joyful ones were reviewed. Observational field notes on each visit were either hand written or entered directly into the computer. Field notes were expanded immediately after each visit and analyzed each night for themes or for areas of deficiency. Spacing the sessions several days apart provided an opportunity for reflection and allowed for the building of rapport. 88 The third visit was valuable in that informants reflected over issues discussed in the earlier two visits and had questions for the investigator. Health education was provided at the request of informants at this visit. Informants expressed the desire to validate what they were doing was right. At this point the informants wanted to make sure the investigator had accurately recorded their story about certain issues. The tone was one of helping the researcher with her project. This is a trait that is just recently being discussed in the literature. Once a person understands that the investigator is a student they are eager to help. Shenk (1987) in her research project with rural elderly women tells how the women were her able and dedicated teachers about the aging experience. Elderly people want to help and to give something in return.

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89 Vesperi (1985) relates that the desire to establish a structure of reciprocal exchange occurs with elderly informants. In City of Green Benches Vesperi (1985) brings another point related to gathering data from old people and one with which the investigator is familiar. Vesperi discusses the way that older people have a need to tell their story accurately and give lots of background to lead to their present situation. Many service providers and care-givers tune-out this monologue and Vesperi calls this a central factor in our cultural construction of old age. It's no wonder service programs fail when providers fail to fully understand our elderly and abandon them in mid-sentence or when needs assessors are paternalistic in their approach and assume they know what's best for our elderly. This is the reason why in-depth interview and observation was the source of data for this study. This process allowed the elderly time to tell their story, yielded a rich and thick description, and let the story be told from the elderly person' s point of view. This closely follows the methodology recommended by Miles and Huberman (1984:27) and Spradley (1980). The process is open but focused. There is no interview schedule, but neither is the interview a casual conversation or open to indefinite length. Description of the Sample A total of 62 informants were studied. Seventy-four

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90 percent of the women were age 75 and older and 66% of the men were 75 and older with four men in the 90 to 96 age range. The oldest woman was age 86. This age distribution is consistent with the projection for Highlands County to have an increasing number of old-old or age 85 and older. Only 4% of the 60+ population of Highlands County are minorities and only 6% of the informants were minorities. sex fem. 38 male 24 Table 3 sex, Age, Marital status Age Range Mean Married Widowed 65-86 *59-96 77 79 16 15 21 6 Divorced 0 2 Single 1 1 The 59 year old male was visited because of the insistence of other informants who knew of his extensive needs. His data was included because it demonstrated an acute need for services in the outlying areas. Twenty-six percent of the informants were native _Floridians, and 26% of the informants were born in the South, however, 47% were born in the North. One informant was born in England. Duration of residency in Highlands County ranged from two months to 81 years. The average length of residency was 24.1 years with a mode of 11 years and a median of 24 years. The informants had lived at their current addresses for an average of 15 years. Twenty five informants lived alone, 31 lived with a spouse, three lived with their daughters, one with a

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granddaughter, one with a sister, and one with her son. Three informants lived in households of three or more people. The distances between home and resources was notable. 91 Informants had to travel an average of 17.1 miles to reach the nearest hospital with a range of three to 35 miles. The nearest supermarket distance averaged 15 miles and the nearest church seven miles as shown in figure 2. Miles Figure 2 Hospital Supermarket Church Distances Between Home and Resources

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Years of education ranged from two years to 18 years. The mean was 10.2 years with a median of 10.5 and a mode of 12 years. 92 Medicare was used by 60 informants. Six individuals used supplementary Social Security Insurance. Of note was the fact that 45 had ancillary insurance. Informants reported that it was difficult to make premium payments, but "I don't dare not have extra insurance!" Social Security was the main source of income. Eighteen informants received pensions as well as Social Security. When asked if they ever ran out of money to pay for food, pay bills, or for health care, replies were in the affirmative. Thirty-five percent ran out of money for food once in a while, 42% ran out of money for medical care, and 39% to pay monthly bills. Thirty-seven percent never had money left over at the end of the month, 50% never had just enough to "make it," and 40% never ran out of money as shown in table 4. Three informants told of family members giving them money to "make it". Four people were employed to get extra income. Five people had extra income from rental property, three income from farming, and 12 income from investments. Veterans benefits and disability were a source of income for eight informants.

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93 Table 4 Run out of Money Never Occ Often Very Often Food 40 22 0 0 Medical 36 23 0 3 Bills 38 18 1 5 Money Left 23 23 3 13 Just Enough 31 17 5 8 Not Enough 25 14 7 15 Research Design The dimensions of the research design included survey, identification of network, scales, interview, objective measures and observation, and field notes all designed within the framework of the research questions and the conceptual framework. The variables and measures of each dimension follow in table 5. The survey included basic descriptive demographic data and included questions that related to self-perception of health, networks, disease processes, activities of daily living and instrumental activities of daily living, medications, and health habits. refined from the pilot study. The survey questions were

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95 The questions are a compilation of questions that have been used in surveying elderly people and that have proven reliability and validity (Coroni-Huntley et.al. 1986, Echevarria & Bezon 1988). The survey questions relate directly and indirectly to the research questions. For example, questions relating to rurality, economics, and activities, combined with observations and field notes provided answers to the first question which asks "What is it like to be elderly and living in a rural area?" The second question "Bow do rural elderly people handle their day-to-day activities?" is answered by survey questions and questions about the usual day. A complete statement regarding usual day is elicited in the history when the elderly person is asked to detail their usual day activities. "What is the status of their health?" was partially answered with functional assessments including the Mini-mental exam (Folstein 1975), a mental status examination widely used throughout the country by those specializing in the care of the elderly because of its reliability and validity; Yesavage and Brink's (1983) Geriatric Depression Scale was administered; the Barthel Activity of Daily Scale was used (Mahoney and Barthel 1965:61); and Lawton and Brody's (1976) Instrumental Activities of Daily Living Scale was completed. The ratings of these assessments follow:

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Geriatric Depression Scale (GDS) (0-9 normal, 10-19 mildly depressed, 20-30 severely depressed). Sensitivity (84%), Specificity (95%) Folstein Minimental Exam (MMS) (10 or less organic mental syndrome, 10-20 possible depression or functional psychoses). Sensitivity for community elderly is 95%. Specificity is 90%. 96 Lawton and Brody;s (1969) Instrumental Activity of Daily Living Scale (IADL) (0 totally unable, 8 fully able). Instrumental activities include shopping, using the telephone, banking, laundry, etc. Lawton and Brody report a 94% reproducibility as well as high inter-rater reliability. Barthel Activity of Daily Living (ADL) Scale (0 unable to 100 fully able). Activities of daily living including personal hygiene, eating, walking, etc. The Barthel correlates well with clinical judgment and is predictive of mortality. These scales have established reliability and validity and are widely used with the elderly (Folstein 1975; Lawton and Brody 1976; Mahoney and Barthel 1965; Yesavage and Brink 1983). "What is the status of their health?" was expanded with survey questions. For example, past medical histories were explored along with surgeries and major illnesses during the lifetime. The current medical history provided a review of systems and an inquiry into medication side effects. The

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97 social history was ascertained at this time as well and served as a source of social information as well as a vehicle for reminiscence to occur. (Social history is important to place medical history in context.) Many stories evolved out of questions like "Where were you born and raised? Where did you go to school? Tell me about when you got married? What do you do for fun?" Personal habits were reviewed in detail to identify clues that would enhance or deter wellness. This included sleep, alcohol use, tobacco use, diet, exercise, hobbies, and a description of the informants usual day. Objective measurements and observation of health included a brief screening physical examination that included height and weight, blood pressure, heart, lung, peripheral vascular, and neurological examinations. Appearance was described, including attire, affect, gait, and function. Self-Perception of Health Self-rated health is advocated as a tool that provides insight into the elderly person's frame of mind. Informants' self-rating of health answered the question "How do these rural residents perceive their health?" Self-rated health provides a barometer of measurement that reflects the elderly individual's point of view (Bezon & Flow 1990). Self rated health was triangulated with field note data and compared with urban group measurements. Self-perception of

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health was measured in several different ways: a visual analog scale, a Likert type scale, and verbal comment. These measurements were made at different times during the 98 study and were compared to identify differences and to see if informants were consistent with their self-perception of health (table 4). Numerous studies looked at people's life situations and their perception of health (Krause, 1987). Consistently these studies show that poor health and function, low income, and a lack of social interaction make people more vulnerable with a decrease self-perception of health. Self-ratings of health increase with higher socioeconomic status, increased social interactions, and of course, better health and function. Networks "Who helps rural elderly in time of difficulty?" was answered by network data. Information was collected about spouse, adult children, family, friends and special friends, neighbors, and church contacts. Frequency of contact was elicited, as was geographical distance between the informant and network member The perceived closeness of the relationship .. also known as strength or intimacy, was specified (intensity). The exchange of goods and services was noted (reciprocity). Both survey data and field note data were used to describe networks. "What are the reasons rural elderly do not participate

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99 in offered services and programs and How does failure to use available services impact on their health?" were answered directly by informants, and the answers were supported by field note data. These answers are discussed in Chapter V. Quantitative Data The surveys offered quantitative data about categories. Quantitative numerical data were also elicited through the administration of psychometric tests and the measurement of physiologic variables. Quantitative analysis utilized descriptive and inferential statistics. Frequencies and percentages describe the findings. Qualitative Data Field notes were detailed and completed following each visit. Notes included environmental data, descriptions of homes, expansions of survey data, scales, or interviews. Any event or interactions with other people was described. These data were analyzed with help of the Ethnograph computer program. Classes of data were determined and redefined until no new classes emerged. Reduction of Data A system of open coding was used. The data were examined line by line, and the substance of the data identified and coded. Substantive codes included environment, house, community, economics, physical descriptions of subjects, children, friends, family and so

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forth. Data were coded and compared with other data and then categorized. Persistent categories emerged which responded to the research questions. Categories 100 materialized as values, rurality, distance, environment, and community. Other codes included children, family, friends, neighbors, and daily activities. Qualitative data from these categories were combined with the quantitative survey data to strengthen the results. Health status survey data were triangulated with both field note data and physical and psychological measurements. Vulnerability described the need for services and value was the category for not using services. The following strategies were used during the analysis (Miles & Huberman 1984). 1. Counting; the number of times that an event happens in a consistent way. 2. Noting patterns and themes; recurrent patterns, themes or Gestalts which pull together a lot of separate pieces of data. 3. Clustering; conceptualize objects that have similar patterns or characteristics, form and use categories, aggregate and compare. 4. Subsuming particulars into the general; shuttle back and forth between the first-level data and more general categories until the category is saturated.

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101 Reliability/Dependability The consistency and representativeness of the data from each informant (N =62) speaks to the reliability of the data. By the last informant, no new categories emerged. Substantive codes remained the same. During the pilot study, a gerontological nurse specialist assisted in the gathering and analysis of data. Field notes and coding was shared and debated to identify investigator bias and strengthen the results. Obtaining feedback from informants assured the confirmability of data. At the third vist, the investigator shared data with the informants and corrected misconceptions. One informant was given the field notes from the pilot study to read. She confirmed the entries and then expanded to make sure "the researcher had her story rightl" Three separate visits provided an opportunity for sensitive issues to be discussed, enhancing the reliability of the data. Triangulation of data assisted with cross checking or double checking of data. For example, survey questions such as network members was supported in the field notes. However, by the third visit, trust was established and informants would exclaim, "I have never told this much to anyonel" Analysis The quantitative and qualitative data were reviewed

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together as results of the study. The interplay of variables in their natural context was systematically examined as a focus for analysis. The intent was to clarify, refine and validate findings. The process of analysis included: 1. Identification of percentages and frequencies in the survey data. 102 2. Determination of individual networks by identifying persons of contact and functionality of the network. Both survey and field note data were used. 3. Identification of scores of functional and psychometric scales. 4. Coding of field notes to determine major themes or substantive codes. 5. Correlating all data with the research questions. Limitations The present study faced limitations resulting from the _paucity of research on rural elderly and inadequate accounts of diversity. Too often, the literature does not make a distinction between rural and urban elderly and there is even controversy about the importance of such a distinction. The following two recent studies and their methodology are presented as typical in contemporary literature and exemplify problems with comparative research. Roberto et. al. (1992) and their study of Northeast Colorado rural elderly they determined that problems can

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103 occur in accessing appropriate services due to geographic remoteness and isolation. However, the study was limited to 28 subjects and two questions. "How are your health care needs met? Do you have any service needs not being met? If yes, why?" The study concluded that health care providers and rural elderly differed on identification of health care needs. The findings were not generalizable due to the small number of subjects and the limited questions. Another study done in 1991 (Johnson) looked at HealthCare Practices of the Rural Aged. The telephone survey determined that most older rural adults do not regularly have positive health care practices and that this may be due to the unavailability of health care providers or health promotion programs in isolated rural areas. This study used telephone survey as the means of obtaining information, which limited the study to those who would respond. These studies did not reach out to isolated rural elderly and selected participants that were using senior centers or that were amenable to being interviewed over the phone. This chapter has provided a discussion of needs assessment, the methodology employed during the study, research design, the selection of informants, data collection and analysis techniques, reliability, and limitations. The next chapter will discuss the results of the study.

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CHAPTER V RESULTS AND DISCUSSION 104 Results of the study will be presented in this chapter using the following research questions as a the framework. (1) What is it like to be elderly and living in a rural area? (2) Bow do rural elderly people handle their day-today activities? (3) What is the status of their health? (4) Bow do these rural residents perceive their health? (5) Who helps the rural elderly in time of difficulty? (6) What are the reasons rural elderly do not participate in offered services and programs? (7) Bow does failure to use available services impact on their health? Included are both numerative and descriptive data that respond to the research questions and describe adaptation to the environment. Data is discussed in terms of the conceptual framework and three basic institutions; subsistence, social support (networks and religion), and health care. 1. What is it Like to be Elderly and Living in a Rural Area? According to Steward, cultural ecology links emic phenomena with natural etic conditions. Individuals

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105 modify and adapt to their environment. All of the informants in this study did not fully adapt to the environment as indicated by their responses when asked what it was like to be elderly and living in a rural area. Half of the informants had modified their lives and adapted to -their environment by forming alliances and exchanging goods and, thus, creating survival relationships within an isolated environment. The other half were negative in their responses, demonstrating a less successful adaptation to their environment. Select representative cases are presented next to depict rural elderly living. "It's all right with me because I don't like the crowd." The woman quoted above lives with a companion. She is in remission from cancer and needs assistance with activities of daily living and instrumental activities of daily living. When she realized that she could no longer care for herself, she asked a long-time friend to move in with her and help her in return for room and board. The friend is younger (55) and able to drive so that even though they live 30 miles from Lake Placid, they are able to "get to town" when needed. It has proved to be a satisfactory arrangement for both. The other unique aspect of this woman's adaptation is that friends visit her regularly. She was planning a barbecue for the weekend, and her friends would bring the "makings" for the party. "We will play cards and talk and eat. It will be so much fun." She had

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106 adapted to her environment through her reciprocal arrangement with her live-in friend and her strong social network. Even though she often "ran out of money before the end of the month" and needed assistance for daily living as a result of poor physical function, she rated her health at nine on the visual analog scale, and when asked to describe her health she responded, "I'm doing all right except for my leg." "Sometimes pleased." At first, this informant would not let the investigator in the house. "We don't want nothing from nobody!" When this woman finally consented, she did consent, she made it clear that her name was not to be used. At 69 she cared for her 90-year-old husband, who was extremely hard of hearing, almost blind, and needed total assistance with daily living activities, including walking, and her 30 year old daughter who had Down's Syndrome. During one visit, she seemed preoccupied. She answered questions, but kept looking out the window like she was waiting for something. When questioned about her anxiety, she confessed to the investigator that "This is the day the checks come and I need to get groceries and the only way I can get to town is with the neighbor and he will pick me up in a little bit." She was extremely polite and did not want to offend the investigator. During the next visit she explained that she shops once a month when the neighbor drives her to town. She is dependent on him for

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107 transportation for routine shopping and pays him for this service, although her grandchildren take her. "I have lived in the country all my life, first in Georgia and now here. I worked in the fields picking crops. That's how I met my husband." She concluded that she "knew how to make do with what she had and didn't need any help!" Country living was satisfactory to this informant. "Wonderful. I am contented, fulfilled." This 75 year old woman lived alone in the middle of a pasture, deep within a very wooded isolated area, and about 30 miles from the nearest town. She cared for approximately 30 head of livestock. She rated her health at 10 or the best health even though "I stagger when I walk, all the time, run into and hit the wall. I fell in the garden this morning when I lost my balance. I fall quite often now, more than I use to." She suffered from multiple medical problems. However, she loved living in a rural area and reported that she was not afraid to die. She was able to drive, participate in church activities, and talk to friends on the telephone. "You never visit anyone anymore, we talk on the telephone instead." She had lived in the area most of her life and was related to the early settlers. She knew everyone and had a strong familial and social network. She had gradually adapted to the environment over the years and knew no other way of life. "I like it. I like the outdoors. No complaints."

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108 This 75-year-old woman lived in a single wide mobile home that was owned by her sister. The home was dark and close and the lights kept going out. "I am waiting for my brother-in-law to fix the lights." She rated her health at five or fair. When her husband died four years ago, she moved to Florida to be near her sister. "Ever since my husband died, I have been getting sicker and sicker. When I first get up I get dizzy and I fall a lot. I sleep an awful lot. I am so tired all of the time." She described her limited finances, indicating that she had no extra money and was unable to fix her car or go to the doctor. "I don't go to the doctor because I know they will prescribe medications and I cannot afford them." She last saw a doctor four years ago. "I don't know anyone except my sister and she comes and gets me and does things with me 2-3 times a month." Although she verbalized that she liked living in the country, her story revealed that she was not adapting well and had failed to create survival promoting relationships. "Great, you are out of the traffic, have fresh a ir, and friendly people." This 81 year old woman lived alone in a single wide mobile home. Her tiny yard boasted a white wrought iron patio set situated in a neatly landscaped garden. A late model small car was parked in the driveway. She was a retired registered nurse and had sold real estate because "nursing did not pay enough." She indicated that money was "not a problem." Her major concern is not being

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109 was whether she could remain in her own home when she can no longer can do for herself. She does not want to relinquish her independence. Although geographically isolated, she had transportation and a strong social network that she interacted with. She spoke of visiting her friends for dinner that night and of how she "nursed" the lady down the road who has Parkinson's. Her adaptation to the environment reflected strong exchanges of services that in turn promote survival relationships. "It is hard when you do not have money." This 81 year old woman rated her health at three (very poor health). She was wheelchair bound and limited in her activities. At the time of the visits, she had a house guest with her, "My dear friend from Lakeland." Her daughter lived five miles away and her sister close by. Many of her friends stopped in to see if she needed anything since they knew she was alone. She survived solely on Social Security income even though she paid $150.00 for medicines each month. In spite of insufficient income, she had in place a very strong support network that assisted in her adaptation to the environment, as well as, to her physical limitations. "I can't wait to move away from here." "I would like to live in a condo where someone else does the yard work. I like the hustle and bustle of the city where there is so much to do all the time." This 72-year-old woman moved to a remote area to be near her daughter after her husband died

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110 after living in urban areas most of her life. She complained that her daughter "was bleeding her of money" and that she could not afford health care or dental care. "My teeth hurt every time I drink something hot or cold and I have nine cavities to be filled." She reported being treated for depression. Her lack of adaptation to the environment was partially due to economic limitations, an unsupportive family system, a lack of social network, geographical remoteness, and her own difficulties with accessing services and amenities. "Alarming when something happens to you. It is a great distance from the ambulance." This 77-year-old woman lived alone in a double wide mobile home. Her only surviving blood relatives were younger brother who lived in Ohio and a sister who lived in a nursing home. She would like the sister to come and visit with her in the winter, but, "because I am so far from town and the hospital and help, that she won't come. I chose to be out here by myself, however, the thought of an emergency is frightening. I like to plan for these things ahead of time. No doctor comes to the house, the ambulance is far away, these are the disadvantages of living in the country." Her adaptation to the environment of her choice, depends upon the relationship she has with "two retired nurses. They come and see me regularly and watch over me. I know I can call them if I need them."

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111 "If it wasn't for my loneliness and the plumber and the TV man costing so much it would be OK." The 96-year-old man giving this statement lived alone in a small home on a lake. "I lay down at night and pray that the Lord will take me to my sweetheart." His grandson visited him three times a his daughter once a month. "The rest of the time, I am alone. I would like someone to live with me, but who would want to live with a crazy old man?" He rated his health at five, or fair, and scored 15 on the Geriatric Depression Scale, or mildly depressed. His lack of interaction with people and distances from centers or amenities where he could be with people negatively impact his health and well-being. His struggle to adapt was hampered by his inability to get someone to live with him and the distances he had to travel. "It is damn inconvenient. I need help and I can't get it." This man was 84, lived alone, had multiple chronic diseases and was in remission from leukemia. "I outlived everybody, that's why when I found out I had cancer, it didn't make any difference." He rated his health at five and said it was good. However, he scored 70 on his activities of daily living (normal 100), was unable to bathe without help, and needed help dressing, especially putting on therapeutic elastic hose. He reported selling his gun collection "because I have to pay someone to drive over here and help me bathe and dress." Adaptation for this man

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112 included paying for services and selling assets to do so. Other Descriptions of Rural Living One informant indicated, "I went to the convenience store once for a loaf of bread, but it was so expensive, I never went again. I plan ahead and we go into Sebring once a week and buy what we need. It's not too bad if you have a car." Adaptation to the environment in this case involved planning ahead to reduce costs. "I have to get into my savings to buy health insurance. Four hundred and eighty seven dollars a month from Social Security doesn' t go far. I could use more money, but I get by on what I've got. I just learn to do without." "I buy food first, then medical care, and I owe a lot of bills. I have a hell of a time with the monthly bills." "I have to hire the young people to get groceries. I don't get away at all, just to get groceries or take my husband to the doctor. The drug store delivers, but they charge for the service. I always end up paying for everything." "I have to pay a driver to take me 26 miles to Avon Park where I go to the dentist." "We have enough to eat, however, Mr. A. sometimes goes without medical care and the only bill I have to pay is the light bill and I am able to do that every month, but it's tight every month." "I have not had a hot water tank since 1980 when the

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113 hot water tank leaked and made a hole in the floor. I had to use my charge cards to fix the floor and was unable to buy a new hot water heater. I take a sponge bath at the sink. I wash a little bit and rest and then wash some more." "Loneliness is the worse trouble. I haven't been able to do anything since my wife died. I can't concentrate. I'm looking for death most anytime, don' t believe I am going to last much longer because I am going down fast." One woman was concerned about possibly needing help in the future and not being able to get help and subsequently having to enter a nursing home. Another woman said, "I lay down in the winter to sleep, just to pass the time away because I am so lonely." A 90-year-old man admitted "Sometimes I think I stay in bed because of having nothing to do, nothing to get up for, very little meaningful day activities." When asked what he did all day, one man replied "I have coffee, read the paper, go out in back and pull a chair out, and watch the grass grow. There ain't nothing to do down here." "It would be OK living in the country if we were nearer civilization, if we were within walking distance of a store. We tried to sell our house, but we would have to give it away. Nobody has the price of a down payment." The single most prevailing theme was that of loneliness. Informants lived at great distances from the

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114 nearest towns or amenities. Forty two percent did not have close neighbors or people that they saw each day. They did not belong to organizations. Less than half attended church. The traditional outreach and educational strategies that utilize churches, clubs, and groups to contact older persons bypass this portion of the population. Summarized responses from informants indicated that advantages of rural living consist of better environmental qualities such as cleaner air, lower noise levels, scenic beauty, and safer neighborhoods, while disadvantages include deficiencies in emergency care needs, longer distances to travel, reduced alternative housing arrangements, and less availability and narrower range of formal helping services. These findings demonstrate various types of adaptation to rural environment and depict the rural living experience as reported by isolated rural elderly. This picture supports Lee and Whitbeck's finding that rural elderly people are more economically depressed than most older people, experience more deprivations than urban elderly, and have fewer compensating advantages than commonly believed (1987:95). These findings also demonstrate the diversity among the rural elderly themselves, their feelings about the rural living experience, and their adaptation strategies. The subtle relationship between environment and culture that causes adaptive changes demands the integration of biological, environmental, and cultural data to holistically

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describe isolated rural elderly. 2. Bow do Rural Elderly People Handle Their Day-to-Day Activities? 115 "I take one day at a time... 11I pace myself and rest in between... "I don't worry about keeping a clean house because I know I can't do it anymore... 11The highlight of my day is the mailman coming." Day-to-day activities included personal activities of daily living (ADL) such as bathing, dressing, mobility, eating, and toileting and instrumental activities (IADL) such as using a telephone, banking, shopping, driving, cooking, etc. When the Highlands County informants ADL's and IADL's are compared with responses from the National Medical Expenditure Survey (Agency for Health Care Policy and Research, 1990), it is clear that the Highlands County residents are above the national average (18% compared to 12.9%) in walking or at least one deficiency in ADL's and in IADL's, (48% compared to 17.5%), as shown in table 6. Table 6 Comparison of Functional Status Characteristics Walk or One ADL One IADL Highlands County 18% 48% National Survey 12.9% 17.5%

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116 The ADL needs were simple; one woman was unable to take baths because she was afraid that she would fall and not be able to get up, and another woman needed help washing her hair. A 90-year-old man was unable to leave his home, not because he couldn't walk, but because he was unable to navigate the steep stairs that led into his mobile home. Very simply, these individuals were at high risk for institutionalization as a result of these factors. The major deficit related to IADL's was lack of transportation for shopping or banking. Thirty informants required no help with IADLs, 17 required help with 1 to 3 IADLs, and 12 required help with four or more IADLs as demonstrated in figure 3. Number of Informants Figure 3 no help help 1-3 help 4+ Instrumental Activities of Daily Living (IADL)

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117 Although, the informants' daily routine revolved around meal times, notablly most ate only two meals a day, breakfast and mid-afternoon dinner with a light snack at night. Assistance with heavy chores was a recurrent need described by informants. "If I could get someone to take down the drapes and wash the windows. I need someone to help with the yard. They charge fifty dollars just to come out here and then extra to do the work." "I can't bend to tuck the sheets on the other side of the bed. If someone could just help me when I change the bed." "I hired a young woman to clean and I found out she was cleaning out my pants pocket." (Ninety-four year old man who observed a cleaning woman while she took money from his pants). Activities that brought pleasure were feeding the squirrels, going to church, shopping, bowling, writing letters, traveling, playing the guitar, singing, and baby sitting. Informants participation in other daily activities is included in table 7.

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118 Table 7 Participation in Daily Activities no yes no yes garden/housework 26 36 sew, quilt 36 26 house repairs 32 30 read, crosswords 8 54 can or bake 31 31 watch TV 3 59 take walks 22 40 listen radio 30 32 exercise 46 16 arts, crafts 43 19 collections 42 20 cards, bingo 33 29 hunt, fish 44 18 sports, movies 50 12 horseshoes/golf 51 11 Work emerges as a major theme in discussions of day-today activities. Forty-seven of the informants talked either about work that they did in the past, work they were presently doing, how much they missed working, or how important it was to work and feel useful. "Because I am a retired nurse, people call on me when they need help. I don't mind. I still feel useful." "I help out with the Bingo. It gives me something to do and it helps the church." "I use to work in the oranges and in the nurseries. Now I don't do anything." "We use to pick oranges in Florida in the winter and pick cotton in Arkansas in the summer." "When I get up, I dust, wash clothes and do other

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119 chores. I have trouble running the vacuum because it is so heavy." "I feel so useless because I can't do any work because of this emphysema." "I built the shelves in the storage shed because I didn't have anyplace to put things. I preserve everything and my cupboards are always loaded." "I do the lawn a piece at a time and when I get tired I stop and rest and the go back later." "I still work. I make quilts and sell them." "I got a job as a waitress last year and just loved it. I liked getting dressed and going to work, but after a few months my back gave out and I have been unable to work." "I worked as a practical nurse. I never lacked for work wherever I went. It was gratifying work and I didn't ever think I'd be on the other end of it." "I did farm work most of my life. Liked working in the fields the best, picked oranges and beans. "My daughter caught me up on the ladder cleaning the gutters and she made me get down. She didn't know that I climbed the ladder to clean the sides of _my trailer and my windows." "We sold our farm 10 years ago and now my husband just sits around and that's not good for old people." "I prepare my Sunday School classes and Bible study. It takes me about three days."

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"I can't do anything with this dizziness and my body parts are wearing out and there are no spare parts." 3. What is the Status of their Health? 120 Controversy surrounds the physical health status of rural elderly. However, this study found that rural elderly have poorer health and lower nutritional levels than urban elderly, a finding that appears related to both lower income level and to the accessibility of health services and supermarkets. Lack of preventive services causes rural aged to be sicker when they finally access health care. The following descriptions of health and health deficits related to wellness help to characterize the health status of the rural elderly. Chronic Diseases Each informant averaged 4.9 chronic diseases; 82% complained of arthritic pain, 55% had shortness of breath that required them to stop and rest, 50% suffered from hypertension, and 40% had heart disease. Other diseases reported were bronchitis, emphysema, prostate, ulcers, anemia, asthma, diabetes, migraines, glaucoma, phlebitis, stroke, Parkinson's, and tuberculosis. These findings are essentially the same as reported for both urban and rural groups (Coroni-Huntley et. al. 1985). The differences emerge when control of chronic diseases is examined. One way to control chronic disease is through medication.

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121 Medications The number of medications taken for these various chronic diseases ranged from 0 to 11 with an average of 4.8, a mode of 4, and a median of 5.5. Medications were prescribed by a physician and ordered to be taken regularly for 77% of the informants. Forty percent were prescribed medications to be taken as only as they needed. The types of medications were varied. Medications used for cardiovascular problems were prescribed the most and aspirin and Tylenol were the most commonly used of over-the-counter medications as shown in figure 4. cardiovascular 43 psychotropic 10 other 19 antid iabetics 10 aspirin/tylenol 57 G I preparations lung 15 6 topicals 29 diuretics non-steroidal 16 16 vitamins/supplements 45 Figure 4 Medications, Average 4.8

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122 Compliance (taking medications as ordered) varied among informants. Forty-three percent took medications as ordered, 16% took them occasionally, and 6% rarely complied. Informants had a 57% non-compliance rate and attributed their non-compliance to their inability to pay for medications or to their need to decrease dosages in order to make the medicine stretch farther. Prescriptions often were not filled because of cost. If informants felt good, they would not take the medicine in order to save money. This compliance rate is lower than the 50% non-compliance rate for adults in general and correlates well with the major contributing reasons offered (Simonson 1984), that of living alone, adverse medication effects, financial considerations, type of disease, poor understanding etc. However, financial considerations played a primary role in non-compliance for these rural elderly. The following scenarios depict problems with medications that relate cost to compliance. "The doctor changed me to Mecavor for my high cholesterol. It costs $145.00 to have a prescription filled. They will fill one half a prescription, but it is more costly to have it filled two times. I guess because the pharmacist has to count out the pills. That's why I don't always take my medicine. It costs too much." "I take Nolvadex to keep my breast cancer in check. It costs $76.00 for 60 tablets. I take Vistacon for my nerves and it costs $47.00 for 100 tablets and my insurance does

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123 not pay for it. It takes almost half of my social security check to pay for my medicines." "I am suppose to take Trental twice a day for my circulation, but only take it once a day because it is so expensive. I think a lot of these doctors overdose a lot of people. I only take Voltaren when I feel I need it. I don't like to take too much medicine. I only take the Meclizine when I am dizzy and I am suppose to take it three times a day. I was a little dizzy when I got up this morning until I go going. I almost passed out in the wash room." "The Procardia for my blood pressure costs $1.00 a tablet and the pharmacist from the Sebring Hospital delivers and charges $1.00 for delivery. I got potassium pills from my daughter and was taking them because I was so tired and weak. The doctor told me not to take them anymore." "It takes $550.00 a month for my medicines alone. It is a good thing I have supplemental insurance. But, even with the deductible, it costs a lot of money. That's why I stopped taking some of it." "I ran out of Maxide that I take for the swelling in my legs and couldn't afford to buy more and so I substituted a pill that I sent for from Nutrition and Health magazine. It is a water pill with potassium, buctu leaves, uva ursi leaves, parsley leaves, and juniper berries. It works the same as the Maxide."

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124 "I had to take Cipro for a urine infection and they cost $2.00 a pill. I was suppose to take two a day for seven days, but I only had enough money to buy seven and so I only took it once a day for seven days." "I only takes so many of this and that. I skips a day now and then. The doctor told me to do that. When you take all those pills together, it's almost like you is too full and so I'm scared to use too much. I breaks them and takes half at a time." "I'm suppose to take Procardia and Minitran, but I only take them when my heart is like a bird fluttering. I'm suppose to take Lasix daily, but if I am going someplace, I don't take it. When I don't take it my ankles swell." "I borrowed the Pepto-Bismal from the neighbor and it helped my indigestion. I will take it back to her tomorrow. I take Ativan to help me sleep and two Anacin as a relaxer. When I take the calcium, I don't get leg cramps at night. I am suppose to take two a day, but can only afford one a day." "I got bit by a raccoon and had to have rabies shots. They cost $421.80. I had to pay for all of it. They billed Medicare when I went to the office to get the shot, but I had to pay for the medicine." "I was prescribed to take Calan 240 a day for my heart, but the prescription costs $116.00 for 100 pills. I stopped taking it and instead take "Dr. Clayton's Pressure-Eaze that

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125 I order from a catalog. They sent me 125 pills for $13.00. The pills contain cayene, Oregon grape root, parsley, ginger root, siberian ginseng, golden state root, acaera, and vegetable oil. They work just as good." "Two years ago, when I was under stress, my heart skipped a beat and they put me on digitalis and quinidine. I don't take the digitalis anymore and I only use the quindine when I am constipated. Quinidine costs $26.00 for 60 pills. I can't afford that." In lieu of taking costly prescriptive medicines, informants use home remedies. "I am convinced that my wife is cured because of the nutrients and vitamins." The husband then showed the investigator an array of over-the-counter pills: ORA-FLO, 300 tablets at #24.50' L-Glutamine, 100 tablets at @12.95; special stress vitamins from Sears, 90 tablets for $45.00. She took lecithin, alfalfa, vitalea, and vitamin C tablets as well. Another woman said "I believe in herbs and not using medicine. She reported how she made a tea and took it every hour until she felt well. "My wife had hepatitis and was jaundiced and I cured her with vitamins and vegetables." "I take potassium (over-the-counter) because I feel better and it seems to increase my energy. I also take brewer's yeast and vitamins. I give them to my husband as

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126 well. I think they keep us healthy." "I soak my feet in kerosene to keep them in good shape. Once a year I take castor oil with a pinch of turpentine to purify the blood. I was raised doing that." One informant described an unorthodox treatment. "They put minerals in your veins and it cleans you out, takes the impurities out of your body and you feel better. It helped my arthritis and it doesn't hurt. It cost $75.00 for each treatment." "I got potassium pills from my daughter and was giving them to Merrill because he was so tired and weak. The doctor told me not to give them and that she monitors him for potassium." "I use Russian penicillin and I feel better. I have used garlic buds since 1900 and I eat them with bread and it keeps me from getting sick." The cost of medication is a major issue for the rural elderly. Informants were clever in finding solutions to this problem, but often their health and well-being were compromised as a result. Incontinence One major health problem identified in this study was that of incontinence. Problems with holding urine were reported by 32% of the informants. Another 31% occasionally had trouble in holding urine; thus, 63% of the informants endured the inconvenience of losing urine or

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127 urinary incontinence. They leaked urine when they coughed, sneezed, or laughed, had difficulty making it to the bathroom, would wet their clothing and would omit taking their "water" pill if they knew they were going to travel a long way in a car. Sixty-three percent is higher than the national average of 5-15% of community elderly suffering the inconvenience of losing urine (Mitteness 1987:185). Importantly, Mitteness' ethnographic study (1987), reported a higher rate of elderly (31%) which was double the national average. Was this finding related to Mitteness' (a medical anthropologist) use of an ethnographic approach? The Highlands study doubled Mittness' findings (63%). Was this because the investigator is a medical anthropologist and a gerontological nurse specialist who used an ethnographic approach? The following comments are reflective of the informant population's (63%) problems with urination. "I wake every hour on the hour because of urination problems (69 year old female). I can't completely empty my bladder at night or even during the day. It takes forever to get it emptied out." "I have to be careful with what I drink because I leak bad (81 year old female). I was told I needed to have my bladder tacked up and I haven't had it done because I cannot afford it." "I have a leaky bladder (79-year-old female). It's not a bad situation, it's just aggravating. The doctor told me

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128 there is nothing I can do." One 77-year-old female said "When I hear water running, I have to run to the bathroom or wet my pants. I use to walk the dog, but now, I have to stay close to the bathroom." The story of a 92-year-old man included his admission that "I didn't sleep last night. I have bladder trouble and had to get up to the bathroom. I can go to church and sit for two and one half hours, but when I am home I have to go every thirty minutes on the hour. My urine dribbles out of me, I have to wipe off after I go." One 82-year-old man told that "occasionally I will have a waterfall and not be able to control it. I did it in the store while I was waiting for my beer. When I've got to pee, it's right then. Sometimes I pee in my clothes. An 86-year-old woman denied incontinence, however, a Turkish towel padding her chair was saturated with urine. A 77-year-old woman said, "If I know I am going someplace, I don't drink any fluids." These stories are reflective of the 63% of rural elderly with urination/incontinence problems. Incontinence is not a normal part of aging and can be treated successfully. However, these isolated rural elderly, because of limited health and supportive services, did not know that, and consequently suffered from the problem.

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129 Dental Health Another health problem that affected both nutrition and socialization of the population was the condition of their teeth. Ten people experienced embarrassment because they were missing teeth or their teeth were in poor repair. They reported not seeing a dentist for years. Figure 5 shows the most common dental problems. not seen past 20yrs not seen 20-40yrs 14 11 loose dentures 14 embarrassed/mouth 10 need dental work 24 n = 62 Figure 5 Host Common Dental Problems seen dentist past 2yrs 23 never saw dentist 4 trouble eating 24 Twelve out of 62 informants visited their dentist in 1991. Seven informants were unable to remember when they last saw a dentist, and two had not visited a dentist in 40 years. Thirty-one percent reported difficulty eating solid foods and 39%told of not being able to eat some foods that

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130 they enjoyed because of problems with their teeth or dentures. When queried about getting regular dental care, 24 informants said they needed to go to the dentist but were unable to because of not having enough money or a means of transportation or both. One 81-year-old gentleman took out his teeth and showed that they were broken. "I have a partial plate on the bottom, but he (dentist) did a poor job of it and when I tried to tell him about it, he got angry with me. My plate broke once and he charged me $40.00 to fix it and then it broke again and I glued it myself with miracle glue. I cannot afford to go to the dentist." A 69-year-old man stated, "I am losing my teeth and there is nothing I can do about it. My teeth are bad, extremely bad, and I can't afford to have them done." "My teeth do bother me I wear a filler under the tops and the bottoms pop out at the most embarrassing times. My lower teeth are broken and I glued them with airplane glue. I can't afford to go to the dentist." A 79-year-old woman stated, "I would like to have all the money from the teeth that are stashed away in drawers because they hurt. Mine hurt and I take a knife and pare them down so they will feel better, because I can't afford to go to the dentist." One wife told how her husband saved his money ($600.00) to have his teeth fixed, only to learn that the fee covered

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131 .only the extraction and that the dentures were $1000.00 more. He could not afford to purchase the dentures and so "I have to make his food soft so he can eat." One 75-year-old, suffered from two loose teeth. "They hurt terrible and need to come out, but I can't afford it. I need to get my upper plate fixed too." An 86-year-old woman reported that "the dentist is ridiculous. We use to have insurance before my husband died and it would pay for the care. Now I don't go because it is so expensive. They won't stand by what they do anyway and I get so annoyed. They are so certain that what they are doing is right and will work and sometimes it doesn't." An 85-year-old woman stated, "I have two sets of false teeth and I can't wear either one of them. I feel like my mouth is full of cement. I miss eating peanuts and cashews. They (dentists) won't help poor old people." The prevailing theme related to dental status is frustration, the inability to do anything about dental problems. Costs were prohibitive, but also evident was a mistrust of the dental health care system. Rural elderly informants were locked into a situation which they felt helpless to do anything about. In addition, poor dental health affected both dietary intake and self esteem. Hearing Thirty-seven informants related they had a hearing loss; 21 always had difficulty hearing, and the rest had

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132 frequent or occasional hearing difficulties. Sixteen owned hearing aids at one time or another, but encountered many difficulties with the appliances such as "hurts," "bothers," and "doesn't help." Other reasons given for not wearing or using hearing aids were the cost involved in maintenance and the difficulties encountered when trying to get the hearing aid adjusted. During the interviews, the investigator had to sit close to and directly face 14 of the informants so that they could lip read. Twenty-seven informants indicated they had difficulties hearing in a noisy situation, and others complained that people mumbled or talked too softly. Hearing impairment greatly affects adaptation. The following examples suggest negative adaptive strategies that may preclude access to programs or services that provide preventive adjuncts to health care. Mrs. G. is an 80-year-old woman who is extremely hard of hearing. She was suspicious of the investigator at first and gave the impression that she did not want to be bothered with answering questions. Once she realized that the investigator would face her and speak slowly so that she could lip read, she settled down and smiled. She would mouth the words the investigator spoke and by the third visit it was obvious that she felt a need to tell her story. She told of her frustration with trying to communicate and of how she avoided speaking to people because "I only get half of the words." Her adaptation to the environment was

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133 to isolate herself socially. Mistrust of those who fit and sell hearing aids is revealed in a story told by an 86-year-old woman. Her hearing was tested by a physician in Orlando and she was given the results. But when she went to a hearing aid technician to get the hearing aid, she was told that she would have to have another test. She did not see any reason for another test and suspected some kickback for referral. She left and went to a second vendor where she was successfully fitted with an hearing aid and without undergoing a repeat hearing test. One 76-year-old man said, "My hearing is not as good as it use to be. I hear it but I can't unravel the words. I can understand anybody better if I am looking at someone. Others mumble. Crowded rooms don't bother me." A younger man (68) talked about his hearing problem. "I had my hearing checked by a doctor in Sebring and he told me I had a deficit in the right ear. He wanted to send me to a specialist to see if I had nerve damage. I never went. Those doctors are all rip offs. They give you a hearing aid whether you need one or not. The other day I called an office. The first woman talked too low and I had to guess at what she said and the second woman had a bass voice and I was able to hear her." A 90-year-old man reported, A man came to the house to sell me a hearing aid, but it costs too much and we can't

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134 afford it. One of my daughters talks to me in a deep voice and I can understand her." When his wife spoke directly into his good ear, he was able to understand. "He doesn't talk as much as he use to because he can't hear." One 76-year-old man tried to be attentive, but he explained, "I miss a lot of words and then the conversation doesn't make sense to me. I have this roaring in my ears and sometimes it sounds like bells." His wife confided that he had several hearing devices, but they don' t help because of his nerve damage. "We bought this last one and the doctor knew it wouldn' t work, but said to at least try it. It cost $1500.00." A 71-year-old woman had her hearing checked at a mall in Sarasota. "They checked it for free, but, I cannot afford a hearing aid, they are too expensive. I can never hear on the telephone and if the radio is too loud, I don't get it. I have ringing in my ears." Another 80-year-old man put his hearing aid on in order to communicate with the investigator He read lips and mouthed words. He described using two telephones simultaneously "when I talk on the telephone. I tell people to talk slowly and then I can hear." Sixty percent of the informants had a hearing difficulty which affected their lifestyles and their adaptation. The above accounts of hearing problems suggest that there is also a mistrust of those who provide hearing

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135 .care, that hearing aid equipment is cost prohibitive for some, and that socialization is diminished for those who cannot hear. Hearing impairment ultimately affects health by decreasing the interactions needed for preventive measures or health promotion. Health Care Providers Eleven informants did not have a regular doctor to call on when they had a health problem. However, all of the informants had an emergency plan in place if they were to develop a medical emergency. Ninety-six percent had visited a physician in the past year. The informants all related stories about their interactions with physicians and chiropractors. "The doctor was giving me 80 of Lasix a day and it ruined my kidneys. He should have used more common sense. They couldn't get the minerals back into my system after that." "My husband was in surgery for three hours and I found out that they had trouble with the anesthetic because he was on Inderal and Peritrate, both drugs should have been discontinued before surgery and he went into shock or something. Something happened and he became like this. He had to be in intensive care and no one would give me any answers. His speech is slurred and he falls and he is just not the same. It is so hard for me to take care of him." "I went to the hospital because my doctor told me I had

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136 a blood clot in my leg and had to be admitted. I waited for two hours on a stretcher and then I got up and put my clothes on and went home. I had a scan a week later and the blood clot showed up. I never took any medicine and I guess it dissolved itself. You know, you can't trust doctors anymore." "I began to have lipomas in my thighs and they were as big as grapefruits. I had four of them removed over a period of years. During this time I had a bad experience with Dr. K. who has since been sued and run out of town. He left stuff in the thigh which became infected. He would cut hunks of tissue in his office without anesthesia. He messed my legs up." "I went to the doctor for an allergy and he biopsied me for cancer on the back of my tongue. I got lots of bills and didn't hear anything from the doctor. He told me to call a cancer specialist from Winter Haven. The specialist called to Sebring and told them what to do." "I was laid up for 28 days after they operated on my stomach. Three years later, I couldn't eat and when I did eat I would blow up. They operated again and found that in the first operation, they had sewn my bowel so tight there was only an opening like the size of a pencil. The doctor rearranged my intestines, said it was a sloppy job of surgery, and told me I would have to take stool softeners for the rest of my life."

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137 "If it weren't for my daughter, I would not even be walking. I had been doctoring for a knee problem and the doctor would tap my knee and inject medicine. Every three months, I would go to him and he would charge me $75.00. Finally my daughter took me to another doctor and he operated and I am better. That doctor tried to get me to come back for another appointment, but I wouldn't go. They are just trying to get your money. I won't go unless I am sick." I went to the doctor and he flushed my ears out and instead of seeing if it worked, he sent me for a brain scan. The roaring stopped shortly and I never had it again. Yet he couldn't wait to find out." This 81 year old man went on at great length to tell "how it was better when you had family doctors who took care of you and took their time with you. They even have toe specialists now. I am concerned about my throat, but the doctor wants to send me to a throat specialist and I won't go." "I went to the doctor to have outpatient surgery and I was in the hospital for five hours and it cost $5200.00. I thought they made a mistake with the bill and so I went back to talk to them. It was no mistake. They charged me $49.50 for the gown I wore and $1.95 for the cup I put my teeth in." "I had to have a growth removed from my face. First I went to my regular doctor and he charged me $45.00 to tell

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138 me to go see a plastic surgeon. The plastic surgeon removed the skin cancer and charged me $2200.00 for a procedure done in his office. I then had to return to his office to have the stitches out and he charged me another $45.00. My insurance didn't cover it and I had to get into my small savings." "When my regular doctor was on vacation, the doctor who replaced him gave me a treatment and even the nurse scowled while he was doing it because he was so rough. He did a manipulation and told me it had to do with the connection between the spine and rib. He charged me $45.00. These cases are typical of the stories told about doctors by rural elderly. There was a general wariness, a mistrust of services provided, and a definite concern related to the costs of these health care services. An interesting point is that there were no "good stories" about physicians. This is probably the reason that 44 of the informants (71%) chose to use the services of a chiropractor. "I take a pain killer when I hurt and go to the chiropractor. It always works." "I had carpal tunnel syndrome and went to the chiropractor and he told me to soak my wrists in epsom salts. He did x-rays of the wrists, chest, and spine and did manipulations of my wrists by pressing in my groin. I could feel it in my wrists and then I got better."

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139 "I frequently go to the chiropractor when I don't feel well. He does manipulations and then I am able to move about freely again." "I went to the chiropractor when I had a pinched nerve. I had four treatments and it cost $40.00 a treatment. He took x-rays and told me I had a pinched nerve. I couldn't walk and I couldn't sit. He told me to use ice and heat on it. It got better." "I went to a chiropractor for treatments one year ago for my back and it was a blessing. He manipulated my back and then I never was bothered again." "I had a chiropractor who pulled my hip out of its joint. It still gives me trouble. He bent my knees up to my chest, stood between my legs and pushed on my legs and I cried and I heard my hip pop out." "I went to the chiropractor last year several times and he took x-rays and told me that my muscles were contracted. I didn't feel any better after he finished. Each treatment cost $35.00 and the insurance paid for it." "Several years ago I had pain in my back and went to a chiropractor and was told I had a curve in my back. The doctor straightened my back and then I had pain in my hip. The pain went away and then I had numbness from my knees to my toes, which I still have." "To keep the pain at a tolerable level, I spend $20.00 a week at the chiropractor."

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140 These chronicles describe informants interactions with health care provider services (medical physician, osteopathic physician, or chiropractor) when they attempt to obtain relief and a recapture a feeling of wellness. The problem with these efforts may be that wellness factors or preventive health care practices were not used by most of the informants or encouraged by their health care providers. Preventive Health Practices Preventive health practices include healthy diets, exercise, avoidance of substances that affect the body adversely (tobacco, alcohol, caffeine, and social drugs), getting enough sleep, immunizations, and regular screening health examinations. Exercise that causes a person to perspire and their heart to beat faster is part of a health routine. Twenty-one informants regularly engaged in enough exercise to work up a sweat. Twenty-five informants reported they never did. Most (38) worked around their house. Twenty-six took walks frequently, thirteen never walked. Thirty informants felt that their daily activities gave them enough exercise for them to feel their best. Thirty-ope felt they should get more exercise. Comments included the following. "I take a fast walk in the morning, about two miles in 25 minutes and I take a slower walk in the evening." "I use to walk, but since I've lacked the energy, I just walk around the house. I gave up walking and dropped

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141 out of most things." "I use to walk the dog, but I don't even do that anymore." "I walk the dirt road up to the blacktop and back. The doctors want me to lose some weight." "I don't sit. I work around the flowers and try to keep as active as I can." "I walk every afternoon. My granddaughter says, don't you want to go for a walk with me? and I go for a walk, not for long way from the house." Although it was common knowledge among the informants that they should exercise, only half of the informants did any regular exercise. Substance abuse was not described as a problem. Less than 11% used alcohol and then used it in small amounts. For example, only two informants drank six cans of beer a day. Wine and liquor were occasionally consumed in moderation, between one and three drinks at the most. Thirty-nine percent reported formerly drinking more than they do now. They denied the use of social drugs. Several informants used cigars, chewing tobacco, pipes, or snuff. Eleven informants smoked cigarettes with two informants smoking 1 1/2 packs per day, three informants smoking one pack per day, and six informants smoking between three and 15 cigarettes a day. Those who used tobacco acknowledged it was not healthy but did not inquire about smoking cessation programs or indicate they might stop using

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142 tobacco. Sleep disturbance was a problem for 58% and included trouble falling asleep, waking during the night, waking too early and not being able to go back to sleep, and not feeling rested in the morning. Forty-five percent took something to help them to sleep. Sixty-three percent took a daily nap. Poor dental health, compounded by inaccessibility of supermarkets and social isolation, led to a dietary intake less than conducive to good health. A careful dietary history, coupled with observations and field note data, revealed multiple dietary deficiencies and unhealthy eating habits. Of importance were 26 informants who lived alone. Their comments included the following: "It's no fun to cook for one person and so it's easier to have tea and toast or a bowl of cereal." This woman lived alone, was underweight, and her daily dietary intake was not conducive to maximal health. "I don't like to eat alone and sometimes I forget to eat. I don't care if I eat or not. My teeth are sore and it hurts to eat." "When I don't have anyone to eat with, I eat sweets." This man was 96 years old and had jelly donuts, candy, and cookies on his kitchen table. "I eat off and on all day, a little something." "I eat two times a day, breakfast and dinner in the mid

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143 afternoon. For breakfast I have cornflakes or raisin bran with milk and sweetener and 1/2 banana. At the big meal I have lots of vegetables and bread. I don't eat much meat. Later in the evening I will have a snack of milk and cookies or fruit." "I eat breakfast and lunch together, toast and coffee. I like macaroni and bread with some vegetables. I drink milk when I have it, usually drink tea or something like that. I usually eat at 10 am and then at three in the afternoon. Very seldom go out to eat because I can't afford it. II "Here I am, 85 years old, and I can take care of myself, except I don't do so good cooking. But, I get the ready to eat stuff and so don't do so bad." "I don't cook from scratch and eat a lot of frozen chicken pot pies. I don't eat many vegetables, eat them mostly when I go out. The neighbors invite me for supper and then I eat vegetables, they are vegetable eaters. I take them out to eat occasionally because they are always doing something for me." "I cook enough for the young man who lives down the road. I see that he has one good meal a day. He helps me with things I can't do. We help each other." One 85-year-old woman reported that she relied on a neighbor to get her groceries at a convenience store. "I hate to trouble them to go to town to buy groceries and it

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144 is more expensive to buy things here." "They know I can't get to town and so they raise the price to make a profit and take advantage of me. They never have a selection of fresh fruits and vegetables. I have to go to Sebring to get lettuce and I can only go when someone takes me. I don't like to ask too much, because I feel I have to pay to have someone take me and I can't afford it." One 87-year-old man opened his refrigerator to show me where he kept his medications, and it was empty except for milk. "I eat out a lot," he explained. The heterogeneity of the sample was reflected in the dietary assessment. Although all of the informants had food to eat, the dietary balance was not conducive to good health. Problems with dentition, transportation to grocery stores, and diminished income also led to diets that were less than ideal. Immunizations Only 13% of the informants received both influenza injections and the pneumonia vaccine. Twenty-seven percent received influenza vaccine. Fifty-six percent did not receive immunizations, and 14 individuals had specific reasons for not having immunizations. "I had a friend that had the shots and she reacted and was sick and told me not to have them." "I don't believe in immunizations." When asked why, she changed the subject.

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145 "My doctor doesn't insist on them. In fact, he told me not to get them." "I didn't take a flu shot, because I have never had the flu." "I never was where I could get one." "Someone I know had the pneumonia shot and then later got pneumonia. The doctor never told him he could get pneumonia." "I don't believe in either the flu or pneumonia shots." "I can't afford those shots. The doctor charges $25.00 for them in his office. I can't get a ride to the health department to get one." "I am allergic to shots." "I have not had a flu shot or a pneumonia shot. They were not recommended by my doctor." "I don't get the flu or pneumonia vaccines because I don't have that many colds." "We don't believe in them." "I have a friend who knew someone who died from the flu shot." "I can't afford anything extra." The prevailing attitudes were those of not valuing the protection of immunizations, not having enough money to purchase immunizations, having a health care provider who did not encourage immunizations, and fearing adverse effects from the immunizations because of reports they heard from

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146 other people. The overall general health of these individuals can be considered less than optimum health, an evaluation which may be due in part to the physiological chronic illnesses and/or loss of function. However, many of the problems can be attributed to lack of health promotion and preventive activities, lack of tighter chronic disease management, decreased socialization, poor dietary intake, lack of intervention for sensory and dental impairments, and lack of routine primary care. The natural environment as well as the lower density population, impact on health by decreasing the availability of services and increasing distances to travel for services. One of the myths about rural living is that it costs less to live in a rural area. Not only do older rural people tend to have less income, but in some ways it costs more to live in a rural area. Rural elderly cannot afford the compounded costs of health care, basic health care costs compounded by the need to travel great distances to services. 4. How do these Rural Residents Perceive their Health? Self-perception of health was measured by three methods: a visual analog scale, a Likert-type scale, and field notes. The visual analog scale is rated with one being the very poorest health and 10 being the very best health. Informants were asked to select a number that described their health. The average response was 5.1. This

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.result contrasts to measurements of urban groups who their health at an average of 8.5 (Bezon & Flow 1990). 147 Later, informants were asked to rate their health as excellent, good, fair, poor, or very poor on a Likert type scale. Forty-seven percent rated their health as fair or poor. In a study done by Wade (1990) in Highlands County, using a mail survey to elderly users of a rural health clinic, self-perception of health was rated using a similar type scale. Wade found that 12.5% rated their health as excellent, 33% as good, 38.9% reported feeling fair, and 15.3% rated their health as poor. At the conclusion of the interview, informants were asked to describe their health and to comment. The comments were further broken down into good (37%), fair (19%), and poor (40%). Table 8 compares the visual analog, Likert type scale, the Wade Study ratings, and qualitative comment data visual Analog mean 5.1 mode 5 median 5.5 Table 8 Self-Perception of Health comparison of Ratings Likert Rated excellent 26% geed 44% fair poor 27% 19% Wade 12.5% 33% 38.9% 15.3% ec-ents geed 37% fair 19% poor 40%

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148 Self-rated health was consistently rated lower in these isolated rural elderly people. Self-rated health was correlated with functional assessments, age, marital status, economic status, the number of children who telephoned their parents, and the number of chronic diseases that each informant had. Table 9 shows perceived health status correlated with the above functional assessments. Table 9 Perceived Health status compared to Measurements of FUnction Analog Respondents Ukert Scale Geriatric Mlnlmental Activities of ln t rumental Adlvles Rating n = 62 Self-Rating Depression Scale Stale Exam Dally Uvlng of Dally Comments eluted 2 YefY poor 15 15 90 3 5 not so good 1 2 poor 22 195 49 2 poor 2 good 6 25 100 6 lor my age, good 3 2 YefY poor 10 145 70 2 how long before I die 4 2 poor 19 a; 52. 5 0 CQnstanl 5 3) good 10.3 24 93 6.4 lOneliness 6 .. lair 6 29 100 6 5 depressiOn 7 e good 5 22 100 5 4 pretty good e 9 good 6 6 21 100 7 2 no oomplalnts 9 3 good 2 21 98 6 good "-lh 10 9 good 4 2 25 99 7 rMigood 3 5 Two informants who refused the visual analog scale rated their health as "very poor," were mildly depressed, measured possible depression or functional psychoses on the Minimental Examination, were unable to do 10% of their activities of daily living, and were able to do less than half of their instrumental activities of daily living. Their comments included "not too good" and "I

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149 cannot walk too far." Ratings of five or below on the visual analog scale correlated with depression, lower Minimental status scores, impaired ability to do both ADLs and IADLs, and negative comments regarding health. Those informants who rated their health above five on the analog scale were not depressed, had higher scores on the Minimental exam, and were fully functional in ADLs and IADLs. Their comments were positive about their health. Another conclusion was that there were more old-old, age 85 and older in the group that rated their health at five or below, although marital status did not seem to make a difference. Whether or not children telephoned their parents was directly related to ratings of five or below. Forty-eight percent of the low raters did not receive phone calls from their children in comparison to only 21% of those who rated their health five or higher. In fact, 55% of those rating five and over received daily phone calls from their children with 24% receiving calls often or occasionally. Economic status did not impact on self-rated health. Running out of money by the end of the month occurred equally in those below five and those above five on selfrated health. In fact, those above five answered yes more times to running out of money for food, bills, and medical care. The number of diseases each informant had was

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150 correlated with self-perception of health. The higher the self-perception of health, the lower the number of chronic diseases. Informants averaged 4.9 chronic diseases or health problems. The reported diseases or health problems are as follows: arthritis (82%), cataracts (62%), hypertension (50%), incontinence (42%), heart disease (40%), tumors (37%), and bladder infections (17%). Varied and repetitive measurements confirmed the lower self-rating. Lower self-perceptions of health correlated with a decrease in functional activity, an increase in age, fewer telephone calls from children, and an increased number of chronic diseases. Informants described their health as follows: "I think of myself as in good health for a man of 89 years, a man is a machine, no matter how good the machine is, it is going to wear out. We're a good machine, the good Lord saw to that." "I think I am in pretty good shape." "For my age, I think I am in damn good condition." "My health awfully poor, but I do the best I can." "My health is good for an old woman. I can't do like I use to do. I was use to doing my house in one day, and now I have to do a little at a time." "I feel the same as when I was younger." "Compared to some people, pretty good." "For an old girl, I am doing pretty good." "I've got good health for my age."

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151 "I can't do what I use to do, but I can do pretty much what I want." "It's not good and it's not bad, it's just a happy medium, that's how I feel. I can't do everything I use to do, but that's beside the point." "I am able to care for myself." "As long as I can get around and take care of myself, I feel pretty good." "I am better off than most people because I can care for myself." "My hearing, mind, and my eyes are pretty good for my age." Overall, the self-perception of health was lower than urban groups measured. The basic theme throughout the informant's discussion of their health was that as long as they were able to do for themselves, they were doing well. 5. Who Helps the Rural Elderly in Time of Difficulty? Survey and field note data were used to describe networks or helpers. Information was collected about spouse, adult children, family, friends and special friends, neighbors, and church contacts. Frequency of contact was elicited as was geographical distance between the informant and network member (proximity). The perceived closeness of the relationship also known as the strength or intimacy was specified (intensity). The exchange of goods and services was noted (reciprocity). Church involvement varied with

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informants, the proximity of children was notable, and although neighbors were considered friendly, they did not visit frequently. Table 10 describes the network or contacts that informants reported. Church: Table 10 Networks: church, Neighbors, Friends attends church regularly never attends church rarely attends church 42% 31% 27% Neighbors: considers neighbors friendly 95% Friends: never visits neighbors 39% occasionally visits nieghbors 27% often visits neighbors 24% rarely visits neighbors 10% lots several few none 24% 39% 26% 11% While ten informants did not have children, the remaining 52 informants had a total of 155 children. Informants with children did not have children nearby to assist them. Table 11 shows the number of children, the children nearby, children living in Florida, and children living out of state. 152

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153 Table 11 Number of Living Children N =lSS Number of children n = 62 (%) of Children Children Chi ldren informant. informants Nearby Living in Florida Out of State none no living children 1 child 2 children 3 children 4 children 6 children 8 children 9 children 10 children 13 children 10 19 13 7 3 2 3 1 2 1 1 16% 31% 21% 11% 3% 2% 3% 2% 2% 0 0 10 12 14 14 12 14 1 1 1 4 4 0 0 10 10 7 1 2 In the following quotes the informants tell the story of their interactions with their children. "I have five biological children all living in Florida, two stepchildren living in Florida, and 2 stepchildren living out of state. I see the children living in Florida about once a month. They help financially when they can, but they don't have anything themselves and they are helping my niece who has melanoma." "My son has a big house with a swimming pool but I've never seen it. He's separated from his wife. My oldest son passed away in November. My husband and daughter passed away within the last two years." 0 7 12 7 11 9 14 8 8 3 11

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154 "Three of my children are dead and my last daughter lives in Indiana and I have not seen her in years. I have a nephew from Okechobee who comes once in a while." "I talk with my only sister once every two months. I only have the one son and I don't see him much." "I have a sister in Green Acres that I don't see much. She just had a lump taken off her breast. My daughter had leukemia and her kidneys stopped. They wouldn't let me go see her in the hospital and then she died. I never saw her before she died and your mind really dwells on that stuff and you wonder on birthdays how they looked." "My daughter lived with me until February 1988 and then she met this truck driver and he would stop here and block the road with his truck and they didn't pay attention to me and went fishing and I told him to move the truck and my daughter said 'if it goes, I go' and I still don't communicate with her. She sees my sister and that's how I know what's going on." "I love my great-grandchildren. We have so much fun when they come." of contact was striking. Forty four percent saw their children once a year or less, whereas, 81% felt fairly close to their children (intensity) and 70% felt their children were an important resource to them. Most informants (63%) did things for their children (reciprocity) instead of their children doing things for them. Only 1% of

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155 the children did things for their parents. Children were given authority and control of their parent's interests in 37% of the cases as shown in table 12. ae ct111dren 13once a yr 1 O-len than yearly e tw l ce a year 6 monthly 4 twlce a month 5 weekly 6 2xJWk a> dosenen 42-ta lrly dose 6 not too do .. 4-not dose Table 12 contact with children Uke tot 34-mae olten 17 -ame 1-len olten talk on phone a correspond IS-every day 13-every week 9 every month e-aev X/yr 1< thanyr lm portance a a a resource scale 1-9 1 =leaat I mp! 9=moat lmpt 36 = 9 1 =e 1 = 7 6 =6 1 =5 3 =4 3 = 1 1 =0 give authalty a control t o ct111dfen yea 19 no =33 do thlnga Ia ct1Udfen yea= 33 no "'19 goode .. 3 1 money 24 Forty informants reported having close relatives, and 22 stated they did not have close relatives. Of those that had relatives, 40 were near by, 37 lived in Florida, and 38 lived out of state; 22 informants said that they saw relatives monthly. Of those with immediate family, 18 percent had family nearby to assist. "My people are all gone. I only have one niece left." "My niece was just here. We raised her from a baby when her folks broke up. She was my niece from my first marriage. She is all I have. When I die, she will get what

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156 few things I've got." "I am close with one sister who lives in Michigan and not close with the other one. The only time I hear from her is when she wants to come and stay in Florida." "I spent Christmas with my nephew's son and they have four small children that got on my nerves. I got tired and the little girl that wasn't walking yet and I fell asleep on the couch. They come to see me a couple of times a month and mow the lawn and help with the painting or stuff." "I have one sister whom I seldom see." A daughter-in-law explained that "none of the other children will care for mother-in-law and we have been caring for her for four years and our marriage is beginning to feel the strain. It hurts her that they will not take her, even if for a few days. One informant who lived near her son said, "They don't have much money, but they buy me some little things they think I might like." "I have three sisters and two brothers who live in Florida, but I don't see them. I have an Uncle and Aunt that live in LaBelle that I would like to see. They don't get around much anymore." "I lost one son from a massive coronary and the other son lives in Alabama and his wife is good to me but when I go there, they are always working and so there isn't much sense of me going and sitting around."

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Table 13 summarizes the contact informants reported with friends. Contact daily every other day 2-5 x per week weekly 2 x per month Table 13 Special Friend Humber of Informants 17 1 8 9 2 2-5 times per year 3 rarely 8 157 Close friends were the privilege of 51 informants, but eleven informants had no close friends. Thirty informants had special friends that they had known for a long time whom they speak on the phone with or see on occasion. Some close friends lived at great distances from the informants (11) or out of state Informants could count on close friends for emotional support and 28 indicated they shared confidences with their close friends. Informants reported phone contact with close friends as follows: often (27), occasionally (15), and never (6). They had known their special friend for an average of 29 years. "I help her out with her sewing and little things like taking her mail to the post office and she does things for

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158 me. I see her every Sunday after church and she gives me food that she has cooked when she fixes a meal and I take it home and warm it up for my dinner." "I take care of a friend who had a stroke. I walk with her and help her around." Neighbors were considered "friendly" by 95% of the informants, but frequent interactions between neighbor and informant were rare. Many of the informants "never" visited neighbors, helped them, or received help from neighbors as shown in table 14. Table 14 Neighbors Visit Help Them Help You often 15 19 17 CCC 16 17 28 never 30 25 17 "Joe and Nancy are mighty good neighbors. They invite me for supper and then I have vegetables." "My neighbors are friendly, but unable to do anything. They are physically, mentally, and financially unable to do anything. It takes money to bring a guy a loaf of bread if he needs it." "I always make extra and take it to the neighbor. She had a stroke and he is not much of a cook." "His girlfriend is in jail (younger man) and so he is

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159 alone and I cook for him once a day. Yesterday I made beef stew and took half to him. That way we both eat good." "My nice white neighbors look in on me and bring me vegetables and chickens or eggs. I appreciate whatever they bring." "When I bake, I take an extra dish to my neighbor, especially the woman across the way that has her leg cut off." "I cook for the neighbors and carry it over. I never go anyplace without carrying something to them." Although it is commonly assumed that the church is a major support to rural elderly, it is clear that in this sample, the church is a source of support for less than SO%. Thirty-one percent never attended church although 69 percent said that church was a source of comfort and strength. Of the 42 percent who attended church regularly, 44 percent knew all of the church members. Comments about church included the following: "Church does a lot for me. The people and the pastor visit me." "The people in the church have changed and are not as friendly." "Without the lord, there is nothing. Salvation means a lot to me." "The church doesn't give help. They just bring the sacraments. I could use a ride to go shopping."

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"I don't have the clothes to go to church." "I don't want to be bothered." "I would be lost without my tie to church." 160 Proximity to churches was greater than to supermarkets and other amenities. However, frequency of contact between church members and the elderly person, intensity of contact, and reciprocity were not measured. Church people were counted on for special services by some of the informants. Informants reported being able to count on people for extra help if they needed it (90%), but stated they would not ask except in an emergency. Some were entirely without close friends, neighbors, or relatives to help out with small things or provide emotional support, transportation, or financial assistance (10%). When asked if there was someone that they felt close to and intimate with, someone with whom they shared confidences and feelings, the following responses were given: friend = 28 sister = 3 no one = 15 daughter = 3 spouse = 5 church person = 2 in-law = 2 nephew = 1 neighbor = 1 Sixteen of the informants did not have anyone to provide emotional support if they needed it. Ten indicated that they could use more emotional support. Twenty eight stated that they could use more help with daily tasks and that a neighbor or spouse was most helpful with daily tasks. Sadly, six informants spent last

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161 Christmas alone, and four were alone with their spouse. Lee and Whitbeck (1987:95) suggest that rural elderly are not disproportionately embedded in supportive networks of friends, neighbors, or kin. % yes no Figure 6 Immediate Family Present for Assistance This study supported Lee and Whitbeck's suggestion and dispelled the myth that rural elderly are surrounded with a strong network of kin to help them in time of need. Of these informants only 18% had family nearby that could assist them (Figure 6). They reported the following about their families. "My daughter lives in Tampa and is 67, gets Social Security, and works part time. She gets up at 4 in the

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162 morning to be at work at 5. My grandson took me to visit her and all I did was sit around. She would not let me do anything. She fixes all my favorite foods and puts them in the freezer." "My son is 70 and he drinks and smokes, that is why we can't live together. I don't see him too often." "Our son and daughter-in-law live in Miami, but we don't get to see him very often because he is so busy. The daughter-in-law use to send us cards with $20.00 in and no note. What we really wanted is to hear from them what was going on. We have great-grandchildren, but they don't visit much." "Our only son lives in Georgia and we are going to move there when we sell our property." "My daughter lives in Carrollwood, but she is so wrapped up in her children and grandchildren, she doesn't have time for me." Of note is that twenty three of the informants saw their children once a year or less. Informants said that although neighbors would help if asked, they were not called upon to help unless it was absolutely necessary. There were those without close friends, neighbors, or relatives to help out with small things or provide emotional support, transportation, or financial assistance (10%). Of importance is that predictors of institutionalization are the absence of a viable informal support network, incontinence, the need for

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163 constant supervision, cognitive impairments and behavioral problems. Although they did not need constant supervision, cognition was intact, and there were no behavioral problems,these informants experienced less than desirable networks, lack of transportation, limited finances, and an unusually high rate of incontinence for community elderly. 6. What are the Reasons Rural Elderly do not Participate in Offered Services? Eighteen percent of the informants stated they did not need any services and 23% would not use them if offered. "We never got into it." "I don't think I would participate. I don't even take anybody fishing with me." "At this stage of my life, no." "What for?" "Why would I have them come out here?" However, nineteen percent were aware that services were not available and would use services if available or attend events at Senior Centers. Six percent indicated that they were "too busy." Eight percent indicated they would take part in congregate meals or senior activities if they had transportation or if they lived closer. "The expense of driving is too much, if I was in town for something, I could. "It doesn't pay to go 14 miles for dinner." Four percent were wary or mistrustful. "The help is

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164 not good. "They won't help me and tell me I live too far out." Other comments included the following: "I am not eligible, but I need the help." "We could use help but we can't get it." "NuHope didn't help me before when I needed it. II "Others need it worse than we do." Informants repeatedly voiced anxiety about the system. It was difficult for them to talk over the phone or to persist when negative responses where given to them. The need for advocacy or spokesman is clear. Those that needed heavy chore services were put on a long waiting list, and as one said "By the time they get to me, I will be dead." They shared fatalistic belief that they could not get help and so it was useless to try. All of these factors impinge on preventive measures that could be instituted to promote health and functional ability and deter institutionalization. Informants were, however, very verbal on health care costs and what they meant to them. Three of the informants complained about the cost of hospital care. "They charged me $10.40 for one Maxide pill, $39.00 for an eggcrate mattress which I never saw, $6.84 for a bottle of peroxide which I pay $1.99 for in the store, and $10.50 for a disposable telephone which I never used." "I'm so fed up with the hospital that I could scream. I got my bill from last week's stay and they charged me for a urinal and a fracture bedpan which I didn't use. I was in the hospital one day and they charged me $1700.00. I had

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165 .three pills while I was in the hospital and they charged me $13.88 or $4.96 a pill." Another informant said "they charged me $9.87 for a bedpan I never used and $5.36 for one chux." There was a general mistrust of hospitals and suspicion about the costs involved. However, each informant was concerned that they have supplemental insurance in case they had to go into the hospital. They were willing to sacrifice to make sure they had supplemental insurance. 7. Bow does failure to use available services impact on their health? First of all, the number of services and amenities was very limited for this group of elderly rural informants. There were long waiting lists for services such as personal aide, housekeeping, and heavy chores. It was difficult to access transportation. Senior center meal sites and Meals -on-Wheels had long waiting lists. There was no affordable public transportation. Supermarkets were at great distances. The following are examples of service needs voiced by rural elderly informants. "I wish I could get someone to come out and help me keep up. It is so hard for me to run the vacuum and wash windows. It's just so darn far for anyone to come out. They want $50.00 just to come out and do the lawn." "I needed help with my husband in the last stages of his Alzheimer's disease. I called and never got any

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166 response. I tried to hire someone to give me a rest, but I couldn't get anyone. You know, I've paid taxes for all these years, you would think I could get some help someplace." "I don't want the place to go downhill, but I can't do it any longer. I would accept help rather than go to a home." "It would be fun to go to a Senior Center for lunch and to play cards. It would break up the day. But, I would need a ride." "It would be nice if someone would bring me a meal all cooked and everything. That's the hardest part for me, to cook a meal. That's why I don't eat so good. It's easier to eat junk food." "I don't think I would participate in congregate meals, but I would use Meals-on-Wheels if I needed them." "Ray is a veteran and he was told to forget it, when we wanted help. There are no organizations for him, no programs. It's frustrating to say the least. You get old and things start to fall apart and you have to hire help. I've never had to ask for anything and it is kind of hard to ask even if you pay." "I was told I was not eligible for help and I live on Social Security alone, from check to check and have no other income. It is hard to ask for help, but as you get older, it gets easier."

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167 "If we had just a few things to help us out, it would be OK. I understood that only people who qualify could go to the meal sites. If I had transportation, I could go. It would be fun to get out." Congregate dining is limited in Highlands County to a specific number of people, whereas, in other areas of the Florida or United States meal sites are open to anyone who desires to participate. "I need someone to help with the cleaning. I am 96 and cannot do it anymore. I had a woman who helped, but she was taking money from me. One day I caught her taking money from my pocket." "If only I had someone to live with me. I fell in the bathroom one night and spent all night in the bathroom. If someone was with me, I could have called for help." "I wish there was somewhere I could go to see a doctor that didn't charge too much. I know in the city they take older people to a special clinic and they pick them up and take them home in a van." "I would like to go to a Senior Center to have a meal and do crafts or something, but I would need someone to take me." "I take a sponge bath at the sink, because I am afraid of falling in the shower. It is hard for me to wash my feet." "I would like to go on trips with older people and do ceramics and stuff and have lunch with other people."

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"I use to donate to them and then when I needed help with my wife they told me it was too far out to send somebody." "I would like meals if I could get them, but I don't like to participate in social things." 168 These service deficits and service needs impact on health in several different ways; they affect the informants chronic health conditions, depression, loneliness, nutritional status, basic activities of daily living, and instrumental activities of daily living. Chronic Conditions Failure to use services affects chronic conditions such as hypertension, arthritis, and diabetes. These conditions are less well monitored because of travel distances to health care, lack of public transportation, and the costs of the actual care itself. One woman was in poor diabetic control because of knowledge deficits in the areas of self monitoring, diet, and exercise. She had a physician, but saw him rarely. She knew that she had to monitor her blood sugar and had the equipment to do so but told the investig!ltor, "The strips cost $25.00 a bottle and I can't afford them. Every time I go to the doctor's office, I have to pay to get there and then pay for the diabetic medicine. I simply cannot afford it. I cut my tablets in half and they last longer. I know I am not in good control because I feel so bad. There are no classes for me to go to and no

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help for me." Subsequently, her health declined and she was showing signs of diabetic neuropathy along with persistent hyperglycemia. Depression 169 Failure to use services aggravates depression. Thirtyfive percent of the informants were depressed. Out of the 35%, 19_ percent were mildly depressed, and nine percent severely depressed. Comments about depression from the informants included the following: "I have let myself get into a bad slump. I have grief, sadness, and sorrow. Sometimes I can't stand it." "Did you see that show about suicide in the elderly that was on TV last night? I know a lot of older people who are depressed and think of suicide." This 82 year old woman scored 20 out of 30 on the Geriatric Depression Scale (GDS) or severely depressed. She was facing leaving her home of many years and moving into an apartment built onto the home of her son. This would entail moving to another state. "I know I am down in the dumps and don't know what to do." Another woman (81) talked about suicide. "I've thought about suicide a couple of times. What have I got to live for. I am just taking up space and food that someone else could use." She scored 18 on the GDS. "I have been treated for severe depression for the last five months and I know it's because I am so alone and do not have any money or transportation to do things, so I take a

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170 pill." During the administration of the GDS, one woman started crying. "I guess I am depressed or something. I guess I get depressed when there is nothing to do. You might call it seasonal depression or something. It passes away after a while. I am let down by my children, I would have liked to live closer to them." She scored 15 on the GDS or mildly depressed. A 75-year-old woman scored 25 (severely depressed) on the GDS. "I worry about my husband. It really began when I put him in the nursing home. I can't get over it. It was so bad in the nursing home. I'm scared here alone without anybody." "I got into a depression and got goofy and went down to the hospital. I haven't been anywhere but Okeechobee in I don't know when. I have spent every Christmas alone since 1975. I am unable to travel to be with my family in Baltimore." He scored 15 on the GDS or mildly depressed. Loneliness Failure to use services promoted loneliness. When asked where she spent last Christmas, one informant replied quickly, "I like to stay at home on holidays and watch TV, like the parades and stuff" and then in the next breath said "If someone was to come and get me I'd go." She scored 18 or mildly depressed on the GDS. "I had a chance to buy this trailer cheap and I did. I

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171 didn't realize it would be so lonely." "My daughter gives money for others to help me, but what good is money when you are lonely. She's so busy with her own life, she doesn't have time for me." "I have been in the chair since last September and then depression set in when I could no longer walk." Lack of activity or lack of socialization with others seemed to be the common theme among those who showed evidence of depression or loneliness. Losses were central to the problems surrounding depression. Activities of Daily Living Failure to use services led to deficiencies in activities of daily living, which in turn led to diminished self-esteem, depression, and a lessened feeling of wellbeing. Seventy-one percent did not need services that would help with such things as bathing, general hygiene, toileting, eating, walking or mobility. However, twentynine percent did need help and gave the following accounts related to these activities. "I want to wash my hair and I don't dare because I get dizzy I bend over. I can't get to the hairdresser. I have to depend on someone to take me and I don't always have the money." "I cannot walk outside, as much as I would like to. When the sun is hot, I wobble and get faint. I must have another person to help me. I am at the mercy of those who

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172 will come and help me. I am afraid to ask for too much help, because then they will take me to the nursing home." "I have numbness and tingling in my hands and feet and when I get up, I have to get steady before I move. My muscles go weak and I drop things quite a bit." My wife helps me as much as she can, but you know, she is 82 and cannot do much herself." "I use a cane when I walk and I am so afraid that I might fall and no one would find me. The dizziness goes with the diabetes and you have to expect it." I get a warning in my head when I have to sit down. I get light-headed, sometimes keel over, or lose my balance. That's why I need help to get in and out of the tub." "Ray falls and I can't leave him alone. If only someone could come and stay with him while I shop or do things." "In order for me to take a bath, I have to get in the tub and then put the water in and before I get out, I let all of the water out and get mostly dried so I don't slip. It takes me over an hour to take a bath." "I can't bend over to cut my toenails, I get so dizzy." The percentage of falls among the informants was 27 percent, indicating that some sort of surveillance is needed, especially for those who live alone. "I wobble when I walk. I think it is in my head as much as anything else. I fall once in a while. I had to go

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to the hospital last year because I fell." "I fall quite often now, more than I use to. It doesn't really hurt." 173 "I slipped and fell in the bathtub. That's why I had the tub taken out and a shower installed." "I fell four or five times in the last year, didn't hurt myself, just bumps and bruises." "I lose my balance and fall. If I fall it just happened." "I fell and hit my head one night during the night and couldn't get up. I had to wait until the neighbor came in the morning and she helped me up." Instrumental Activities of Daily Living Inability to do IADL's affected independ travel, which in turn affected the ability to get to a health care provider or to a store to purchase food. Fifty percent of the informants were able to do their instrumental activities of daily living, including shopping for and preparing meals, transportation, laundry, use of the telephone, housekeeping, responsibility for own medications, and ability to handle their finances. Lawton and Brody's (1976) Instrumental Activities of Daily Living Scale was used, which scores informants from 0, or unable to do any of the above activities, to 8, which is able to do all of the above activities. Table 15 describes the informants IADL activities.

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174 Table 15 Instrumental Activities of Dailiy Living Score t Informants Score t Informants 0 4 5 3 1 2 6 5 2 2 7 4 4 4 8 32 Of the 50 percent who scored seven or less, two were unable to use the telephone, 20 were unable to shop, 10 were unable to prepare food, 28 were unable to do housekeeping or laundry, 30 were unable to travel independently, 5 were unable to be responsible for their own medicines, and 10 were unable to handle their own finances. In summary, the need for services is strong in the areas of primary health care, transportation, home care services, personal care services, visiting services, health care preventive/promotion programs, congregate meals or Meals-on-Wheels, shopping services, and respite services for spouses. Discussion This study was done for the purpose of identifying a special subculture of rural elderly and of describing how the environment affected their health. In this section, cultural ecology and cultural core, or institutions of subsistence, social support (network and church), and health

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175 care, will be used as an explanation of the findings. But first, it is important to understand how ethnography and past studies of aging were helpful in describing this special subculture of elderly. Importance of Ethnography Putting the informant in context provided insight into the actual situation of isolated rural elderly. Visiting three different times was a mechanism that allowed a first cursory assessment, a secondary reassessment, and then at the final visit, a mor e intimate understanding of the reality of rural living as it applies to an older person. The first visit was focused on "getting to know you" and gathering the survey data. By the third visit trust had been established, and the informant wanted to make sure the researcher had the story right." Obtaining an emic point of view, or how the older rural person perceived the rural living experience, helped put their lives in context. All of them were not pleased with living in an isolated area. They told of the day-to-day experiences that directly and indirectly related to their health status. A particularly important finding was their inability to purchase food that would keep them healthy. The rural value of independence made it distasteful for them to ask someone for a ride to the supermarket and compounded the difficulty of obtaining healthy food. Another important factor that precluded asking for a ride was the underlying

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176 concept of reciprocity. "I hate to ask for a ride when I cannot give anything back in return." The emic point of view revealed how financial restraints affected food buying. It took three visits before informants would talk about not having enough money, what their expenses were, and how many times food was a last priority. They also admitted not enjoying meals because of eating alone and not preparing many nutritionally sound foods because, "it is too much bother for one person." Loneliness and social isolation affected their nutritional intake and thus their overall state of health. Their point of view regarding health care also helped to explain their position relative to preventive care. After trust was established with the researcher, the informants told of their dissatisfaction with the health care system, their fear of accessing the system, their inability to pay for care, especially medications, and their inability to get to health services. This study elicited the point of view of rural elderly, described rural living for elderly persons as they saw it, and then put those descriptions in context to provide a holistic picture of isolated rural elderly people. The description depicts a group of people who are geographically distanced from services and amenities that would enhance health. They are living on fixed incomes, without transportation, without preventive health services,

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177 .and without sufficient family nearby to help in times of need. Not all attend church or use the services of a church. They are distrustful of services offered and have reservations about accepting or even needing any help. When compared to urban elderly, they are less health conscious and less participative in health related services. Past Studies of Aging Past studies have demonstrated the usefulness of an ethnographic approach to find out what it is that old people want for themselves, how their interests can be safeguarded, and what the implications of old-age problems are for society in general. The informants in this study expressed what they wanted for themselves. Transportation to shopping, health care visits, and congregate meal sites was a priority. A "little help with" heavy chores, meals, and personal care was wanted. The implications of not safeguarding their interests in these issues is the deterioration of function ability and impairment of their ability to remain in their homes. These implicatures directly affect society in that if the elderly do not remain functional and in their own homes, they will require nursing home care, which is more costly for society, and is perceived as a traumatic step by the informants. Stereotypes and Myths of Rural Living Older people achieve high levels of functioning for a variety of reasons: eating healthy diets, regular exercise,

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178 routine health care, assistance with activities of daily living and instrumental activities of daily living, family support, and socialization with others. The informants in this study were compromised in achieving high level function/wellness despite myths to the contrary. Several myths prevail about rural elderly people. It is commonly assumed that rural living is conducive to health. Rural people are thought to have abundant food and healthy diets because they are able to grow their own food. Older rural people are expected to be more functional and to have the ability to work until an older age than urban elderly. Another common belief is that rural elderly people are surrounded by kinfold to help in time of need. Rural people are thought to be "church goers and to participate in agricultural community activities. Rural living is believed to be the American dream -peaceful, serene, without the stress and pressures of city life (Krout 1986). In actuality, rural elderly people are a very heterogeneous group, as these informants proved to be, and do not meet the mythical stereotype described above. Answers to the research questions showed that food was not abundant, diets were not healthy, function ability was compromised (especially instrumental activities of daily living such as transportation and shopping), all of the rural elderly. informants did not have kin around them to help, and they all did not participate in church activities

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179 or other community activities. Stressors and pressures were directly related to rural living especially if one was elderly. Environment As defined by Julian Steward (1955:37), the study of cultural ecology includes a consideration of the adaptive processes by which humans adjust to their environment. The etic conditions of nature in the rural setting as described in this study, linked with the informant's narrations of ernie phenomena illustrate the basic adjustments rural elderly have made to their environment. The etic conditions of nature in this study are those external conditions that affect the lives of the informants, such as distances from services, isolation, loneliness, and fewer amenities or services. The ernie phenomena are the perceptions or stories that isolated rural elderly tell about their lives and health. Adaptation to the environment include adjustments to institutions of subsistence, social groupings, and religion. In this study, fixed incomes precluded purchases of health care and other goods or services to enhance health or general well being. The isolation from social groups that included family, friends, and neighbors added to the distancing from health care, goods, and services. Organized religion along with its supportive services was not an institution that all participated in, and, therefore half of the informants did not benefit from these helping services.

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180 Like Steward's, this study was concerned with an examination of the etic and emic phenomena that affected adaptation. As in Steward's study, the identification of a cultural core or group of institutions held in common by rural elderly helped to explain how the environment affected their health. Similar core features distinguish the informants as belonging to the same cultural type with cultural type being defined as the combined product of the cultural core and socioecological integration. The core features of subsistence, social activities, and religious activities were identified. These isolated rural elderly might be conceived as sharing "cultural core" or a group of people who have developed over time to have institutions that play out in similar ways. According to Steward, the constellation of features that compose the common core are primarily subsistence and economic features that are affected by the environment, although social supports such as networks, religious activities, and health care, come into play. These core features distinguish this rural subculture of aged from its urban counterpart. Although subtle, the relationship between environment and culture explains the poorer health status and increased need for services to enhance health and well being among the rural elderly (figure 8).

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Subsistence + 181 !Environment 1----Social Support Networks Religion Health Status + Health Care Figure 8 Cultural Core These cultural core institutions of subsistence, social supports that include networks and church activities, and access to health care are unique when compared to young rural people or elderly urban residents. Younger rural people are not on fixed incomes, have the ability to transport themselves wherever they choose to go, and are able to socialize and participate in church activities as they desire. Urban elderly, although on fixed incomes, have public transportation and subsidized transportation for the elderly. It is easier for an older urban person to walk to a neighborhood Senior Center or to a church to attend activities. The proximity of activities helps to deter some of the problems that affect health, such as depression and loneliness. There are multiple services available to the

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182 urban elderly person such as congregate dining, meals on wheels, chore services, or personal care services. Health fairs and screenings are offered more frequently in urban areas, usually at local Senior Centers or churches. Health care providers, too, are closer, and arrangements for transportation to appointments can be made with the subsidized transportation service. Since most needs assessments are based on statistics derived from urban groups, the funding and subsequent services are heavily weighted in favor of urban elderly {Area Plan Summary Document 1992; Bezon 1989; Echevarria and Bezon 1988; Laureau and Heumann 1982). Contemporary medical anthropologists {McElroy and Townsend 1989) employ, an ecological perspective to analyze adaptation by studying specific encounters between populations and their environments with the ultimate aim of discovering general rules capable of generating specific strategies. These models integrate biological, environmental, and cultural data to understand variations in patterns of human health and illness. The biological health of the informants was measured in this study and found to be deficiencient. A synopsis of health findings, depicting deficiencies is shown in table 16.

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183 Table 16 synopaia of Health Pindinge Aaaeaaed Health Pindinge Rea a one averaged 4 chronic diaeaaea poor control of Chronic arthritic pain 82\ chronic dieeaeee Dieeaeee hyperteneion 50\ d .t. lack of heart dieeaee 40\ coaapreheneive cataract 63\ priaary care, r.t. 37\ coate, traneportation, accaee, availability Medication average taken 4.8 aajor factor in non-compliance rata 43\ coarliance ie coat, home ueed inetead Mon toring of aedieationa not alternative medicine ueed done by priaary baaltb care providera, knowledge deficit of inforaante, need for health teaching Incontinence rata of 62\ informant felt incontinence higher than the national average vae part of normal aging, not ad by rriaary health care prov dere Dental Health only 37\ of informant viaitad dentiet informant were not able to in the paat 2 yeara purchaee dental care 63\ either had no vieite or tiae fraa eelf-eate .. wae affected laet vieit wae ? to 20 yeare becauee of appearance 31\ had difficulty eating aolid food dietary intake and vaa eaapraaiaad a utritioa Bearing 60\ had trouble hearing coat affected obtaining help bearing difficultiee affected for bearing lifeetylea there vae a general of hearinq epecialiate Preventive Bealth 34\ felt they ahould get more exereiae there wae a general knowledge eubatance abuae wae not a probl .. deficit related to health alaep wae a for 58\ praaotion practice dietary daficienciea vera preaent in 60\ Accaaaible priaary health onli ll\ were immunized for pneumonia care wae fragaented or nfluanza primary health care vaa lackinq Baaltb C:ara Provider 17' did not have a priaarY health ear Bealtb care prOYidare ware provider not available to all becauee of coate 96\ had viaited a phyaician in the paat year aceaae wae difficult general concern related to coete and continuoue care with the .... aafe health care practice& provider waa not poeeible caaprehenaiva care waa needed Specific health measurements among the Highlands County rural elderly, demonstrate lower compliance in taking medications for chronic diseases. The major reasons for non-compliance are cost factors or not being able to afford

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184 the medications important for control of the chronic disease. Fixed income (subsistence) directly produced poor compliance and thus poorer health by precluding visits to the health care provider. Another factor that affected the biological health of these informants was social isolation (core institution of social supports including network and religion). Depression and loneliness from social isolation led to somatic problems caused by lower nutritional intake and inertia in caring for other biological problems such as incontinence, dental deficiencies, and hearing deficiencies. The informants have poorer health and lower nutritional levels than urban elderly. This can be related to both lower income levels and less accessible health services and supermarkets. Lack of preventive services caused rural aged to be sicker when they finally access health care, and their compliance rate with medications was lower due to cost factors. Incontinence was found to be higher than reported in national studies, dental health poorer because of costs, and hearing deficits not treated, again because of fixed incomes. Immunizations were not sought and preventive measures not known or carried out. A major problem in accessing care was transportation, compounded by cost factors and a general distrust of the health care system. Environmentally, the distances to basic services and amenities were too costly to negotiate and the rural elderly value system precluded asking for rides from family,

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185 friends, or neighbors. Informants often lived great distances from family who might help if they lived closer. These factors, combined with a rural sub-cultural value system that appreciates independence, self-sufficiency, and hard work and a general mistrust of the government or programs seen as "welfare or part of the social service bureaucracy" make it is easy to understand how health degenerates among the isolated rural elderly. The isolated rural elderly person adapts to the natural environment with strategies that prevents the use of health promoting services. This chapter presented the informants emic responses to the research questions using informant statements to exemplify circumstances and events as they relate to adaptation to the environment. The discussion, framed in Steward's ecological model and expanded with contemporary medical anthropology's use of the ecological perspective, demonstrated to explain how the environment affects the health of isolated rural elderly people. It demonstrated that deficiencies in institutions of subsistence, social and health care are a common cultural core that affect'health. The next chapter will present conclusions and recommendations.

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CHAPTER VI CONCLUSIONS AND RECOMMENDATIONS 186 This study was undertaken for the purpose of identifying a special subculture of rural elderly and describing how the environment affected their health. The objective was to create a profile of isolated elderly rural people from Highlands County who do not use services; to describe their health status; to describe their perceived needs and compare these with researcher-identified needs; to recommend ways to present services to maximize use and thus prevent premature institutionalization. A composite profile of isolated rural elderly from Highlands County describes those who do not use services. Profile of Isolated Rural Elderly The composite description of the average isolated rural elderly person follows: Average age: Sex: Married: Born in Florida 78 years 60 % female/40% male 50% 26%

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187 The composite, based on averages, is a person who lives about 17.1 miles from the nearest hospital, about 15 miles from the nearest supermarket, and about 7 miles from the nearest church. Social Security ($497.00 a month) is her main source of income and she told of running out of money for food once in a while, of not having money for medical care, and being unable to pay bills. "There is never any money left over at the end of the month and sometimes I just "make it." Her children live out of state and She is privileged to have one close friend upon whom she depends. The neighbors are "friendly" and will help if necessary, however, she would not call upon them unless absolutely necessary. She attends church sporadically and does not participate in church activities. Health Status She suffers from five chronic diseases: arthritis, hypertension, heart disease, cataracts, and has had skin cancers removed from her face. She takes five medications that she cannot afford, and so she tries to ration what she does take and looks for less expensive over-the-counter medicines or alternative ways of healing. She is incontinent and does not realize that incontinence can be cured or treated successfully. She has not seen a dentist in the last ten years and has dentures which do not fit well and compromise her nutritional intake. She has trouble

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188 hearing and was fitted for a hearing aid, but it never worked right and she does not trust the hearing technician so she won't return for re-evaluation. She also cannot afford the batteries and the upkeep on the hearing aid. She feels that she should get more exercise, but is not motivated to get going and "it is no fun exercising alone." She does not abuse alcohol, tobacco, or social drugs, and has difficulty sleeping. Her nutritional status is compromised because she only eats two meals a day and does not ingest in enough nutrients to keep healthy. She has difficulty purchasing fresh fruits and vegetables because they are not available at the convenience store and because she has difficulty getting transportation to the supermarket. Her value system precludes the use of vaccines to prevent pneumonia and influenza. She sees her primary health care provider infrequently because of transportation difficulties and costs. Accessibility to health care is difficult and available care is not comprehensive or suitable for her age group. She perceives her health as "five" on a scale of oneto-ten which is lower than urban groups. She is glad that she can do things for herself, since otherwise she would have to go into a nursing home. Her mental status is intact, but she is mildly depressed. She indicated that a major problem is transportation. "I have to pay someone to take me where I want to go and the

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189 worse part is asking for a ride. I try not to do it often." Other problems that are stressful to her are getting help with the heavy chores and having nothing to do or being lonely. "I don't want help for nothing. I would be willing to pay some. It would be fun to have lunch at a Senior Center with other people and then do crafts or play bingo or something. I worry, too, if I really needed help and could not do for myself, would someone come, or would I have to go to a nursing home?" In putting isolated rural elderly residents into context, it is easy to see how the environment impacts on their health. A cascade of environmental events leads to poorer health and the need for increased services. Geographical distances between services, amenities, and the elderly person's home are barriers to quality health because of the lack of public transportation and because services are not outreached to isolated geographical sites. _Not all elderly are able to drive, and only 11 informants had their own car and were able to transport themselves. The other informants depended upon family, neighbors, and friends for transportation. Most disliked asking for transportation, and they would not go as often as they should or would delay going, so that when they finally accessed health care, they were sicker. They were unable to purchase fresh fruits and vegetables as often as needed. Not having transportation

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. impacted their choice of food or lack of it as described above. Although there were local convenience stores, the costs were higher there than at supermarkets: thus, the older person avoided shopping there unless absolutely necessary. 190 There was a real need for help with heavy chores such as yard work or heavy housekeeping, especially for the oldold. Other areas of lack were personal care aids to help with bathing, dressing, and grooming. There were several reasons that both home delivered meals and congregate meals are needed: inability of the older person to purchase and prepare food; the older person's need for someone stopping in every day with delivered meals for socialization and to check on the individual; and needed socialization for those who attend congregate dining sites. Although 41% indicated they would not attend Senior Center activities or meal sites, 59% related that they would, but stated that they would need a ride. Another area of need is advocacy. Informants recounted difficulties accessing service systems because of fear of being rebuffed over the phone or when they went for help. They needed advocacy or a resource to contact when they suspected they were being taken advantage of by sales people or even their own children. They were concerned because of hospital charges and costs. Unfortunately fewer services were available for rural

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191 people. There were restrictions on meal sites and home delivered meals. There were long lists waiting for home health aides or homemaker services and heavy chore services. Free clinics or clinics that are user friendly or specific for the elderly did not exist. There were no satellite clinics or transportation to clinics for these isolated rural elderly. In the County of Highlands, there was only one Geriatrician to serve the large percentage of elderly. Health care providers educated to care for the special needs of the aged were scarce. Advocates for the elderly were found in the Nu-Hope of Highlands County Inc., but they were hampered with low staff and low budget and were unable to do outreach and preventive programs. This indeed is a tragedy because this population is growing older and increasing in numbers, and it will cost more in the long run for care of the detrimental effects of chronic disease which might have been prevented. Instead of aging in place and in home, these rural aged will have to be institutionalized at a higher cost than if they were kept at home. And finally, there were no outreach programs to find elderly who are at risk for e xacerbation of chronic disease. This current study demonstrated that isolated rural elderly can be approached, and indeed are concerned about their health. However, they are not knowledgeable about preventive health measures or services that would help them to stay functional and remain at home and so need to be

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identified and contacted. 192 If isolated rural elderly people are to enjoy quality health and function and thus be able to remain in their homes for the duration of their lives, they need to be supported by outreach, services, and primary health care so they can remain functional. It is important that the services be congruent with the environment and culture of the community. Recommendations It is clear that "rurality" has a cultural meaning and impacts on health status. The distances to health care facilities, to social services, and to support systems, without question affect the use of services, especially if transportation is a problem. These distances eventually influence health status. Steinhauer in 1980 discussed the obstacles to the mobilization and provision of services to the rural elderly. These obstacles are present in Highlands County and should be mentioned in 1992. She points out that mistakes have been made when programs successful in urban areas are diluted and presented in rural sites. The most difficult administrative problem is filling out an application to get a program. The up-front dollars match of 5 to 25% may not be available. Local officials may not be sensitive and ignore requests for politically invisible services such as outreach and information and referral. There is an absence of an infrastructure of existing service providers.

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193 Logistical obstacles include sheer distance between people and services and increases service expense. There are obstacles to compliance with federal mandates such as building codes. The Older American's Act itself stifles creativity in problem-solving. A final problem is the paperwork requirement of federal programs. Many projects cannot support both service and administrative staff people. Before services can be provided, it is necessary to identify those at need. One of the most difficult tasks in providing services in rural areas, especially isolated communities, is case finding. A unique program (Young, Goughler & Larson, 1986) in a rural area in Pennsylvania used volunteer organizations to case find and to provide services. Service organizations were asked to inventory their communities. Area Agency on Aging caseworkers accompanied volunteers to the home and conducted a needs assessment and intake. Services such as friendly visiting, telephone reassurance, chore services, recreation, transportation, and less technical services were provided by the volunteers. The natural helping network in Highlands County needs to be ascertained, nurtured, and maximized. The emphasis on community outreach made Young's model project successful. This investigator believes that outreach patterned in this manner would work in Highlands County. This would be one way to restructure current programs to meet the home care

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194 demands of the growing oldest-old population. If home care needs are not met, the costs for institutional long-term care will be phenomenal. Using Young's model extensive chronic care needs of the elderly can be met in a community setting by relatives, friends, and agency personnel. Next, publically-subsidized institutional long-term care services should be reoriented toward community services and should take into account extra funding for transportation and outreach services. In a bureaucracy fueled by the numbers game, rural areas continue to be unduly penalized because of distance and terrain. Using the level of need and the cost of providing a given service as the base for funding decisions would serve the rural elderly more advantageously. An optimal solution and the one preferred by this investigator, would be to return to the district nurse concept. Years ago, in this country, and now in other countries, nurses were responsible to geographic districts of people and in essence were their primary care providers. The nurse knew all of the families in her district and they knew her, so that she was able to intervene on their behalf and they trusted her to do so. She was able to institute preventive health measures, reduce institutionalization, and to act as a catalyst in the community to initiate and support informal helper networks. A mobile outreach model is one way of reaching isolated

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rural elderly people. 195 In the center of the model, a team of health care providers with expertise in the care of the elderly works with both informal and formal resources to identify, reach out, and provide health services for isolated rural elderly people. The system's model is circular and ongoing, reaching out to both isolated elderly and network helpers to keep the process going. The rationales for using a Rural Outreach Model are the following. (1) Rural elderly people may mistrust the system and not participate in offered services. (2) They may not recognize that services are available. (3) Rural elderly may not recognize that they need services to stay healthy and functional and thus avoid being institutionalized. (4) They may have a knowledge deficit regarding healthy aging. (5) Rural elderly need advocates or those who will help them to access the health and service system. (6) They may not have network support or their network may need bolstering to help them remain at home. Summary This limited sample size study makes an important contribution to the field of aging research, both in terms of research design and methods, as well as findings. This study addresses methodological problems by: 1. Using consenting informants that are sought for their fit to this study and who are not volunteers. 2. Using the ethnographic method to obtain an ernie point of

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196 view, using etic observations, and putting the rural elderly and their environment in context. 3. Using a variety of multidimensional measures to confirm rich and thick descriptions of persons, places, and events. The study's findings are significant in that they dispel myths of rural living as idyllic, are consistent with the findings of other studies in regards to identified needs, and contribute evidence for providing services. While this study is distinguished by innovative methods, there are limitations in the sample size and sample selection. The results are generalizable to those rural elderly who reside in Highlands County. A larger randomly selected sample would support and add increased validity to the findings. Recommendations for future research include following these 62 rural elderly at yearly intervals to update the data and identify needs for services as these elderly rural residents age. A statistically oriented network analysis should also be done to determine more exactly the natural helper network. Longitudinal exploration would provide more data to educate developers of the long-term care system, ensuring the efficient delivery of formal services while complementing and reinforcing an important informal care giving system. Anthropological Difference Old people need someone who can understand their

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197 individuality and variety, as well as the world they live This study describes the variations and similarities of isolated elderly rural elderly and puts them in context in the applied anthropological mode. Anthropology, of all social sciences, has been by far the one most concerned with variation in human experience, and the holistic perspective assumed by the investigator/ethnographer should help correct tendencies to describe this population inaccurately. Aging is a cultural as well as biological process (Clark & Anderson 1967:3). The aging condition in human societies cannot be understood as a simple biological fact or as an accidental by-product of technological development. It must be understood in terms of human culture (Clark & Anderson 1967:5). Weak kinship ties, spatial distances from children and grandchildren and the phenomenal increase in the number of elderly contribute to the normlessness of America's aged. This study identified weak kinship ties, especially in relationship to children available to help. It demonstrated how spatial distances, not only from kin, but from services and amenities impacted on health. Lopata in the foreword of Dimensions of Aging, Culture and Health (Fry 1984) reported a shortage of anthropological, in-depth analyses of transitions and processes as experienced in different cultures, historical periods and social systems. The present study analyzed a group of 62 isolated rural older people, the culture in

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198 which they live and the problems they must negotiate. One of the primary concerns of the rural aged is the maintenance of their physical health so that they may function independently and remain in their own homes. The findings of this study indicate that most rural elderly do not have access to health promotion activities that foster function and independence, and some individuals do not recognize the need for assistance to remain independent. Financial constraints on both the elderly person and service providers is a major barrier. Long distances and lack of transportation complicate the problem. Cultural traits including fear of dependence and mistrust of service providers are common among isolated rural elderly. Ecologically adaptive traits, however, prevail with the isolated elderly person doing with less because there is less to be had. In Highlands County, the isolated rural elderly are marked by an overarching ethos of conservation of their food, energy, and reliance on others, resulting in an adaptation to their environment that removes them from much needed services.

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199 LIST OF REFERENCES AARP and AOA 1990 A Profile of Older Americans. Aday, Ron H. and Laurie A. Miles 1982 Long-Term Impacts of Rural Migration of the Elderly: Implications for Research. The Gerontologist 22 (3):331-336. Agency for Health Care Policy and Research 1990 Alland, Alexander Jr. 1970 Adaptation in Cultural Evolution, An Approach to Medical Anthropology. NY: Columbia University Press. 1990 Biocultural Adaptation and Medical Anthropology. Medical Anthropology Quarterly. 4:342-344. Amoss, Pamela T. 1981 Cultural Centrality and Prestige for the Elderly: The Coast Salish Case. In Dimensions: Aging, Culture, and Health. Christine L. Fry ed., Pp. 47-63. Massachusetts: Bergin & Garvey Publishers Inc. Anderson, Barbara Gallatin 1972 The Process of Deculturation-Its Dynamics Among United States Aged. Anthropological Quarterly 209-216. Angrosino, Michael V. 1978 Applied Anthropology and the Concept of the Underdog: Implications to Community Mental Health Planning and Evaluation. Community Mental Health Journal 14(4):291-199. Ansello, E. F. 1980 Special Considerations in Rural Aging. Educational Gerontology: An International Quarterly 5:343-354. Applebaum, Herbert ed. 1987 Perspectives in Cultural Anthropology. Albany: State University of New York Press.

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Area Plan Summary Document 1992 West Central Florida Area Agency on Aging, Inc. Arnhoff, F.N., Leone, H.V. and I. Lorge 1964 Cross-Cultural Acceptance of Stereotypes Toward Aging. Journal of Social Psychology 63:41-58. Arth, M.J. 1968 Ideals and Behavior. A Comment of Ibo Respect Patterns. The Gerontologist 8:242-244. Auerbach,Arnold J. 1976 The Elderly in Rural and Urban Areas. In Social Work in Rural Communities. Leon Ginsberg, ed. NY: CSWE. Atchley, Robert C. and Shelia J. Miller 200 1979 Housing and Households of the Rural Aged. In Environmental Context of Aging. Thomas 0. Rykerts et. al., eds. Pp. 62-79. NY: Garland STPM Press. Baer, Hans 1990 Biocultural Approaches in Medical Anthropology: A Critical Medical Anthropology Commentary. Medical Anthropology Quarterly. 4:344-348. Barker, Roger G. 1968 Ecological Psychology Concepts and Methods for Studying the Environment of Human Behavior. CA: Stanford University Press. Bealer, R. C., Willits, F. K. & Kuvlesky, W.P. 1965 The meaning of "rurality" in American society: Some implications of alternative definitions. Rural Sociology 255-266. Bezon, Joan 1989 Highlands Pilot Study: Needs of Rural Elderly. Report Submitted to West Central Florida Area Agency on Aging and Suncoast Gerontology Clinic. Bezon, Joan and Jenette Flow 1990 Sucessful Aging, Self-Perception of Health and Mortality. (Unpublished Manuscript) Bohannan, Paul and Mark Glazer 1973 High Points in Anthropology. NY: Alfred A. Knopf. Bowling, Ann and Peter D. Browne 1991 Social Networks, Health, and Emotional Well-being Among the Oldest Old in London. Journal of Gerontology 46(1) :S20-32.

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201 Brown, Arnold s 1985 Grassroots Advocacy for the Elderly in Small Rural Communities. The Gerontologist 25(4):417-423. Burnside, Irene 1988 Nursing and the Aged. NY: McGraw-Hill Book Co. Campbell, Bernard 1983 Human Ecology. NY: Aldine Degruyter. Census of Population and Housing 1990 Profiles of America's Elderly. U.S. Government Printing Office, Series CPH-L-74. Clark, Margaret and Barbara Anderson 1967 Culture and Aging: An Anthropological Study of Older Americans. Springfield, Illinois: Charles C. Thomas. Cordes, Sam M. 1989 The Changing Rural Environment and the Relationship Between Health Services and Rural Development. Health Services Research 23 (6):757-784. Cornoni-Huntley, J. et. al. 1986 Established populations for epidemiologic studies of the elderly resource data book (NIH Publication NO. 86-2442) National Institute On Aging. Coward, Raymond T. 1979 Planning Community Services for the Rural Elderly: Implications for Research. The Gerontologist 19:275-282. Coward, Raymond T. and Stephen J. Cutler 1989 Informal and Formal Health Care Systems for the Rural Elderly. Health Services Research 23(6): 785-806. Cowgill, Donald O. 1986 Aging Around the World. Belmont California: Wadsworth Publishing Company. Dehaney, W.T. 1987 Romanticizing the Status of the Rural Elderly: Theory and Policy Implications. The Gerontologist 27:322-329. District VI Health Plan 1990 PSA 1991-1994, Health Council of West Central Florida, Inc., St. Petersburg, Florida.

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Echevarria, Katherine and Joan Bezon 1988 Successful Aging: Implementing Strategies for Health Promotion. The Gerontologist 28(10):256A (Special Issue). Ecosometrics 202 1981 Review of Reported Differences Between the Rural and Urban Elderly: Status, Needs, Services and Service Costs. Final Report to the Administration on the Aging (Contract No. 105-80-c-065), Washington, D.C. Ellen, Roy 1986 Envrionment, Subsistence and System. Cambride: Cambridge University Press. England, J.L., Gibbons, W.E. and B.L. Johnson 1979 The Impact of the Rural Environment on Values. Rural Sociology 44:119-136. Fein, Rashi 1992 Prescription for Change. Modern Maturity 35(4):34. Fengler, Alfred and Leif Jensen 1981 Perceived and Objective Conditions as Predictors of Life Satisfaction or Urban and Non-Urban Elderly. Journal of Gerontology 36(6):750-752. Fischer, C.S. 1978 Urban-to-Rural Diffusion of Opinions in Contemporary America. American Journal of Sociology 84:151-159. Florida Statistical Abstract 1989 Bureau of Economic and Business Research College of Business Administration, University of Florida, Gainesville, Florida. Folstein, M.F. et. al. 1975 "Mini-mental state": A Practical Method for Grading the Cognitive State of the Patient for the Clinician. Journal of Psychiatric Research 12:189-198. Forde, C. Daryl! 1949 Habitat, Economy and Society. London: Methuen. Freeman, Linton C., Douglas White and A. Kimball Romney 1989 Research Methods in Social Network Analysis. Fairfax VA: George Mason University Press. Fritz, D. 1979 The Administration on Aging as an Advocate: Progress, Problems, and Prospects. The Gerontologist

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203 19:141-150. Fry, Christine, ed. 1981 Dimensions Aging, Culture, and Health. Mass: Bergin & Garvey Publishers, Inc. Glascock, Anthony P. and Susan L. Feinman 1981 Social Asset or Social Burden: Treatment of the Aged in Non-Industrialized Societies. In Dimensions: Aging, Culture, and Health. Christine L. Fry ed., Pp. 13-31. Massachusetts: Bergin & Garvey Publishers Inc. Harbert, Anita and Carroll w. Wilkinson 1979 Growing Old in Rural America. Aging 1:36-40. Hewitt, Maria 1989 Defining "Rural" Areas: Impact on Health Care Policy and Research. Washington, D .C.: Health Program Office of Technology Assessment Congress of the United States. Hill, Carole E. 1988 Community Health Systems in Rural American South. Boulder Colorado: Westview Press. Holmes, Lowell D. 1976 Trends in Anthropological Gerontology: From Simmons to the Seventies. International Journal of Aging and Human Development 7:211-220. Honigmann, John J. 1976 The Development of Anthropological Ideas. Homewood, Illinois: The Dorsey Press. Hooyman, Nancy and Wendy Lustbader -1986 Taking Care: Supporting Older People and their Families. New York: Free Press. Johnson, Julie E. 1991 Health-Care Practices of the Rural Aged. Journal of Gerontological Nursing 17(8):15-19. Keith, J. 1979 The Ethnography of Old Age: Introduction. Special Issue Anthropological Quarterly 52:1-6. 1980 The Best is Yet to Be: Toward an Anthropology of Age.American Review of Anthropology 9:339-364. 1981 The "back to anthropology" movement In Gerontology. In C.L. Fry, (Ed.) Dimensions, Aging, Culture and health. MA: Bergin and Garvey Publishers, Inc.

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1984 Old People as People. Boston: Little Brown and Company. Kertzer, D.I. & Keith, J. 1984 Age and Anthropological Theory. Ithaca: Cornell University Press. Kim, Paul K.H. 1980 Toward Rural Gerontological Education: Rationale and Model. Educational Gerontology 5:387-397. King, Imogene 204 1981 A Theory for Nursing, Systems, Concepts, Process. New York: John Wiley & Sons. Kivett, V. R. 1985 Rural-Urban Differences in the Physical and Mental Health of Older Adults. Journal of Applied Anthropology,4, 9-19. Krause, Neal 1987 Satisfaction with Social Support and Self-Rated Health in Older Adults. The Gerontologist 27(3):301308. Krout, John 1986 The Aged in Rural America. NY: Greenwood Press. 1988 Community Size Differences in Service Awareness Among Elderly Adults. Journal of Gerontology 43(1):2830. Laderman, Carol 1990 How Biocultural are the Articles in this Issue? Medical Anthropology Quarterly 4:354-358. Lareau, L.A. 1983 Needs Assessment of the Elderly: Conclusions and Methodological Approaches. The Gerontologist, 23(5), 518-526. Laureau, L.A. & Heumann,L.G. 1982 The inadequacy of needs assessments of the elderly. The Gerontologist, 22(3), 324-330. Lassey, W.R. and M.L. Lassey 1980 Rural-Urban Differences Among the Elderly: Economic Social, and Subjective Factors. Journal of Social Issues 36:62-74.

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Lawton, M. Powell and Elaine M. Brody 1969 Assessment of Older People: Self-Maintaining and Instrumental Activities of Daily Living. Gerontologist.9:179-186. Lee, G.R. & Lassey, M.L. 1980 Rural-Urban Differences among the elderly: 205 Economic, Social, and Subjective Factors. Journal of Social Issues, 36(2), 62-74. Lee, Gary R. and Les B. Whitbeck 1987 Residential Location and Social Relations Among Older Persons. Rural Sociology 52(1):89-97. Leon, J. and T.Lair 1990 Functional Status of Noninstitutionalized Elderly: Estimates of ADL and IADL Difficulties. (DHHS Publication) No.90-3462. Mahoney, F.I. and D.W. Barthel 1965 Functional Evaluation: The Barthel Index. Maryland State Medical Journal 14:61-65. Maxwell, Robert J. and Phillip Silverman 1970 Information and Esteem: Cultural Consideration in the Treatment of the Aged. Aging and Human Development 1:361-392. McCoy, John L. and David L. Brown 1978 Health Status Among Low-Income Elderly Persons: RuralUrban Differences. Social Security Bulletin 41:14-26. McElroy, Ann 1990 How Biocultural are the Articles in this Issue? Medical Anthropology Quarterly 4:354-358. McElroy, Ann and Patricia K. Townsend 1989 Medical Anthropology in Ecological Perspective. Boulder: Westview Press. McKillip, Jack 1987 Need Analysis Tools for the Human Services and Education. Beverly Hills: Sage Publication. Mead, Margaret 1951 Cultural Contexts of Aging. No Time to Grow Old. Legislative Committee on the Problems of Aging. Legislative Document No. 12, Albany, NY.

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Miles, Matthew B. and A. Michael Huberman 1984 Qualitative Data Analysis. Beverly Hills: Sage Publications. Miller, Michael K. and A.E. Luloff 1981 Who is Rural? A Topological Approach to the Examination of Rurality. Rural Sociology 46(4):608-625. Mitchell, Jim 1991 Differences in Service Awareness and Utilization Among the Elderly in Eastern North Carolina. Paper presented at the 44th annual meeting of the Gerontological Society of America, SanFrancisco, CA. Mittenness, Linda S. 1987 The Management of Urinary Incontinence by Community-Living Elderly. The Gerontologist. 27(2):185. Moran, Emilio F. 206 1979 Human Adaptability. North Scituate, Mass: Duxbury Press. Nelson, Gary 1980 Social Services to the Urban and Rural Aged: The Experience of Area Agencies on Aging. The Gerontologist 20: 200-207. Netting, Robert M. 1986 Cultural Ecology. Menlo Park, California: Cummings. Orlove, Benjamin S. 1980 Ecological Anthropology. Annual Review of Anthropology 9:235-273. Press, Irwin and Mike McKool Jr. 1972 Social Structure and Status of the Aged: Toward Some Valid Cross-Cultural Generalizations. Aging and Human Development 3:297-306. Profile of America's Elderly 1990 Census of Population and Housing, Series CPH-L-74, U.S. Government Printing Office, Washington, D.C. Rathbone-McCuan, Eloise and Joan Hashimi 1982 Isolated Elders and Social Intervention. Rockville, MD: Aspen Systems Corporation.

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207 Riley, Matilda White 1984 Forward In Age and Anthropological Theory (Kertzer and Keith Eds.) Ithaca: Cornell University Press. Roberto, Karen A. et. al. 1992 Provider/Client Views, Health-Care Needs of the Rural Elderly. Journal of Gerontological Nursing 18(5):31-37. Rosenblatt, Roger A. 1982 Health Care and the Social Fabric of Rural America. Rural Health Care 1-23. Rowles, Graham d. 1984 Aging in Rural Envrionments. In Elderly People and the Environment. Altman et. al., eds. NY: Plenum Press. Sanday, Peggy R. 1979 The Ethnographic Paradigm('s). Administrative Science Quarterly 24:527-538. Shelton, A.J. 1965 Ibo Aging and Eldership: Notes for Gerontologists and Others. The Gerontologist 5:20-23. Shenk, Dena 1987 Someone to lend a helping hand. St. Cloud, Minn: McNight Foundation. Simmons, Leo W. 1945 A Prospectus for Field-Research in the Position and Treatment of the Aged in Primitive and Other Societies. American Anthropologist 47:433-438. 1945 The Role of the Aged in Primitive Society. Humphrey Milford: Yale University Press. Simonson, w. 1984 Medications and the Elderly. Rockville, MD: Aspen Publishing Company. Singer, Merrill 1989 The Limitations of Medical Anthropology: The Concept of Adaptation in the Context of Social Stratification and Social Transformation. Medical Anthropology 10:223-234. Sinott, Jan D. et. al. 1983 Applied Research in Aging, A Guide to Methods and Resources. Boston: Little, Brown, and Company.

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208 Soldo, Beth J. and Kenneth G. Manton 1985 Health Status and Service Needs of the Oldest Old: Current Patterns and Future Trends. Milbank Memorial Fund Quarterly/Health and Society. 63(2):286-321. Solovosky, Jay and Carl Cohen 1981 Being Old in the Inner City: Support Systems and the SRO Aged. In Dimensions: Aging, Culture, and Health. Christine L. Fry ed., Pp. 163-184. M Massachusetts: Bergin & Garvey Publishers Inc. Spradley, James P. 1980 Participant Observation. NY: Holt, Rinehart and Winston. Stein, Howard F. 1982 the Annual Cycle and the Cultural Nexus of Health Care Behavior Among Oklahoma Wheat Farming Families. Culture, Medicine and Psychiatry 6:81-99. Steinhauer, Marcia B. 1980 Ostacles to the Mobilization and Provision of Services to the Rural Elderly. Educational Gerontology: An International Quarterly 5:399-407. Steward, Julian 1949 Cultural Causality and Law: A Trial Formulation of the Devlopment of Early Civilizations. American Anthropologist. 51:1-27. 1955 Theory of Culture Change. Urbana Illinois: University of Illinois Press. 1973 The Concept and Method of Cultural Ecology. In High Points In Anthropology. Bohannan and Glazer, eds. NY: Alfred A. Knopf. Stoller, Eleanor P. and Karen L. Pugliesi 1988 Informal Networks of Community-Based Elderly. Research on Aging. 10(4):499-516.u.s. Senate Committee on Aging 1985 Special Report 310. Taietz, Phillip and Sande Milton 1979 Rural-Urban Differences in the Structure of Services for the Elderly in Upstate New York. Journal of Gerontology 34(3):429-437. u.s. Senate Committee on Aging 1985 Developments in Aging Special Report 310.

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209 .Vayda, A.P. and R.A. Rappaport 1968 Ecology: Cultural and Non-Cultural. In Introduction to Cultural Anthropology. James Clifton, ed. Boston: Houghton Mifflin. Vesperi, Maria D. 1985 City of green benches. Ithaca: Cornell University Press. Voget, Fred w. 1975 A History of Ethnology. NY: Holt, Rinehart and Winston. Wade, Patricia A. 1990 Service Needs of The Well Rural Elderly: The Highlands County Florida Case Study. Project conducted in partial fulfillment of the MPH degree. University of South Florida. Weinert, Clarann and Kathleen A. Long 1987 Understanding the Health Care Needs of Rural Families. Family Relations 36: 450-455. Wellin, Edward 1977 Theoretical Orientations in Medical Anthropolgy: Continuity and Change Over the Past Century. In Culture, Disease, and Healing. David Landy, ed. Pp. 47-58. NY: Macmillan Publishing Co., Inc. West Central Florida Area Agency on Aging 1990 Area planning summary document. Whiteford, Linda M. 1991 Needs Assessment and Program Evaluation in Community Health. In Training Manual in Medical Anthropology. Carole Hill, ed. American Anthropological Association. Windley, Paul G. 1983 Community Services in Small Towns: Patterns of Use by Older Residents. The Gerontologist 23(2):180-184. Windley, Paul G. and Rick J. Scheidt 1980 The Well-Being of Older Persons in Small Rural Towns: A Town Panel Approach. Educational Gerontology: An International Quarterly 5: 355-373. Wolfe, Alvin w. 1991 Network Models and Their Applications. Report of the Human Services Information System. Center for Applied Anthropology College of Social and Behavioral Sciences University of South Florida.

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210 Yesavage, Jerome A. and T.L. Brink 1983 Devlopment and Validation of a Geriatric Depression Scale: A Preliminary Report. Journal of Psychiatric Research 17(1):37-49. Young, Christine L., Donald Goughler, and Pamela J. Larson 1986 Organizational Volunteers for the Rural Frail Elderly: Outreach, Casefinding, and Service Delivery. The Gerontologist 26(4):342-344.

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211 APPENDICES

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APPENDIX A LETTER TO INFORMANTS FROM NU-HOPE OF HIGHLANDS COUNTY INC. 212

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213 APPENDIX A LETTER TO INFORMANTS THO PE 1 u . -4 of I lh)hlands County o414 US Hwv 27 s.,utll .1JH/U (813) JH2-21J4 4CJSCdCJ2 452 II I 1.1 June 1 7 19 91 To Whom It May Concern: Nutrition Communlfy C.1r e for the Elderly CnmmunHI' Cart> for D1sab l e d Adul t s Rctuer.J Srnwr Volunteer Prof}.r a m Br-ttct Living for Scnt o r s JH2 I 281:1 452 1288 465 I I 99 This letter is to introduce Ms. Joan Bezon. Joan is a Registered Nurse working on her Ph.D. in Anthropology at the University of South Florida. I ask your cooperation in answering a few questions. All information is kept confidential. The data she collects will provide statistics that may eventually bring additional service dollars to Highlands County residents. Joan has a brochure of our current services to give you. Nu-Hope of Highlands County, Inc. supports Ms. Bezon in this effort. Si;x:ly, Kathleen Crivello, Executive Director KC/cd

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214 APPENDIX B LETTER OF INVITATION TO PARTICIPATE

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COL LEGE O F NURSING HEALTH S C I E NC E S CENTER APPENDIX B LETTER OF INVITATION 215 BOX 22 1 2901 BRUCE B DOWNS BOULEVARD TAMPA, FLORIDA 33612 -4799 PHO N E (B1 3) 974-2191 Letter of Invitation to PaFticipate (For Informants) Dear I am asking for your help. Please take a minute to read this letter. I am asking you to participate in a research study -An Ethnographic Health Needs Assessment of Highlands County Rural Elderly. The study will evaluate needs of rural elderly. You will be asked questions concerning your health and use of services. Several questions will be asked (in a confidential manner) about your feelings and attitudes. You will be offered selected health screening. Provision for care has been arranged through NuHope of Highlands if you should need it. You are free to choose whether or not you want to participate in this worthwhile project. Your confidentiality will be protected. Only group data will be reported. Thank you for your cooperation. Si_!lcerely, Joan Bezon M.S.,R.N.,C. Principal Investigator This research project/study has been reviewed by the University of South Florida Medical Center Institutional Review Board for the Protection of Human Subjects. Phone: 813 974 2218