Hametz-ShenkFINALCapstone2016

Running Head: Barriers to Diabetes Mellitus in Appalachia 1
Barriers to Diabetes Mellitus in Appalachia
By
Jessica Hametz-Shenk
Submitted to the Department of Nursing
in partial fulfillment of the requirements for
DNP
School of Nursing and Health Services
Robert Morris University
April 26, 2016

Barriers to Healthcare in Appalachia
Introduction
Demographics of the Appalachian Region
The Appalachian region is home to 25.4 million of 31.6 million total Americans in
2013, reflecting an increase of 200,000 people since the 2010 Census (Population
Reference Bureau, 2015). This region encompasses areas from New York to
Mississippi, yet it is a low-density region in terms of population. The region’s economy is
diverse and depends on mining, forestry, agriculture, and chemical industries
(Appalachian Regional Commission, 2011). Appalachian residents are proud of their
culture. They have a strong sense of community, strong family support systems, social
ties, religious affiliations, pride in self and family, and independent self-reliance. They
also realize the importance of justice, loyalty, religion, faith in God, strong work ethic,
trustworthiness, and possess a feeling of belonging in the mountains (McGarvey, Leon-
Verdin, Killos, Guterbock, & Cohn, 2011). The geographical focus of this project is
Appalachian region, which covers about 100,000 square miles in the states of Maryland,
Virginia, West Virginia, Kentucky, Tennessee, North Carolina, South Carolina, Georgia,
and Alabama (Martin, 1996).
In West Virginia, the leading cause of death is heart disease and followed by
cancer, mortality rates are significantly higher than those in the United States as a
whole. The years of potential life lost for diabetes in this state is well above the national
rates (West Virginia Department of Human Health and Human Resources, 2012). This
state is ranked second highest when it comes to the general health of adults as either
fair or poor (West Virginia Department of Health and Human Resources, 2016). In 2014,
West Virginia had the highest rate of diabetes at 14.1% up from11.7% in 2011(Trust for
America's Health and Robert Wood Johnson Foundation, 2016). The Appalachian region
is part of the "diabetes belt," which consists of 644 counties in 15 mostly southeastern
states with a prevealence of diabetes of 11% of the population or more (‘Diabetes belt’
identified in southern US, 2011). Just living in the diabetes belt and having a few risk
factors places people at greater risk of diabetes than similar people living outside the
belt; this is likely associated with social and cultural factors (Albright, 2014).
Specific Aim/Purpose
The primary aim of this interventional project is to uncover knowledge and
attitudes related to diabetes from the emic view of the Appalachian Region within the
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diabetes belt by interview. The secondary aim is to determine if the geographic region
influences the attitude and knowledge towards diabetes in Appalachian residents. This
may guide a new way to inform and educate patients in the Appalachian region.
Theoretical Support
The theory of cultural care diversity and universality was developed by Madeleine
Leninger (1988). Leninger’s theory demonstrated that through research, practice, and
education that cultural caring is essential in nursing and health care (Leininger &
McFarland, 2006). Transcultural nursing practice occurs only when the client beliefs and
values are thoughtfully and skillfully incorporated into nursing care plans. Leninger’s
theory was used as theoretical framework for the study.
Leninger’s (1991) model is referred to as, the sunrise model, which serves as a
cognitive map to orient and depict the influencing dimensions, components, facets, and
major concepts of her theory, with an intergrated total view of these dimensions. The
seven rays of the sunrise conceptual model focus for the semi-structured interview
guide. The top portion of the model focuses the worldview, social structure, and cultural
factors. The seen rays of the sunrise model are universalities that have been identified
throughout all cultures. Through an inductive study of the sunrise model, the knowledge
that unveils itsself will serve as a guide on how to provide culturally congruent nursing
care to Appalachian residents.
Leninger stressed the importance of obtaining data directly from people, what’s
called emic knowledge. The emic approach allows the researcher to gather rich data
directly from the informants in their natural setting. This is essential to correctly assess
and understand the participants. With this assessment, healthcare workers will be able
to design and implement culturally congruent care that enriches health and well-being.
Leinenger (1991) asserted that only emic knowledge can provide the truest knowledge
base for culturally congruent care and stresses the need for nurses to use the
ethnographic paradigm. Culture congruent care refers to those cognitively-based,
assistive, supportive, facilitative or enabling acts or decision that are tailor-made to fit
with the individual, group or institution (Leninger, 1991).
The health and well-being of one's culture is influenced by their own personal
beliefs. All cultures and subcultures vary in numerous degrees. Non-congruent care can
lead to dissatisfaction and frustration on part of the client and provider of care.
Throughout health care, both the providers and recipients, will both benefit tremendously
if healthcare providers are able to implement practices that are identified by specific
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cultures. By allowing this to happen will make health care highly personal, meaningful,
and successful.
Review of Literature
The Health Wagon was established to enhance access to health care for the low
income and marginalized rural population of Central Appalachia (Gardner, Gavaza,
Meade, & Adkins, 2012). The top nine diagnoses treated on the Health Wagon in 2009
were: hypertension, diabetes, major depressive disorder, dyslipidemia, obesity, chronic
obstructive pulmonary disease, hypothyroidism, gastro-esophageal reflux disease, and
acute illnesses. In 2009, a total of 157 clinics were held and 2,900 patients were seen
(3,165 patient encounters) with an additional 268 telemedicine specialty consults
(Gardner, Gavaza, Meade, & Adkins, 2012).
Obesity
Obesity is a contributing factor in many chronic illnesses that lead to poor health
outcomes and to higher healthcare costs (O'Brien & Talbot, 2011). The Centers for
Disease Control and Prevention revealed that 81% of the counties in Kentucky,
Tennessee, and West Virginia have the highest rates of diabetes and obesity in the
United States (Herath, Brown, & Hill, 2013). Griffith, Lovett, Pyle, and Miller (2011)
conducted a survey to evaluate self-rated health status and health behaviors of 1,576
Appalachian adults. The findings suggested that a large portion of the respondents
considered themselves to be healthy. Yet between 57% and 66% of the respondents
who thought they were healthy had at least two disease conditions or poor health
behaviors. This includes being sedentary (65%), hypertensive (76%), overweight (73%),
or hyperlipidemia (79%) (Griffith et al., 2011). A cross sectional survey was conducted to
examine barriers to physical activity among the low-income women. Researchers
interviewed 52 middle-aged women and found that the lack of support and willpower
were the greatest barriers to physical activity (O'Brien & Talbot, 2011).
Type 2 Diabetes Mellitus
According to a Behavioral Risk Factor Surveillance System (BRFSS), which was
used in 2006-2007 by Baker, Crespo, Gerzoff, Denham, Shrewsberry, and Cornelius-
Averhart (2010), residents in distressed Appalachian counties had 33% higher odds of
reporting diabetes than residents of non-Appalachian counties. In 2010, the estimated
prevalence of diabetes in West Virginia is 11.7%, one of the highest in the nation (Stohr,
2012). Jessee and Rutledge (2012) conducted a nonrandomized, prospective, three
phase, quasi-experimental intervention study on a convenience sample of 26
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participants to improve clinical outcomes, increase knowledge, and enhance self-efficacy
related to diabetes. Researchers found that post-intervention mean blood sugar (146.36
mg/dL) improved 50.37 mg/dL from pre-intervention (196.73 mg/dL). In contrast, usual
care participants’ mean blood sugar was 195.2 mg/dL at the study onset and improved
only 21.6 mg/dL after three months (Jessee & Rutledge, 2012).
Cardiovascular Disease
Chronic cardiovascular disease mortality rates were significantly higher in mining
areas compared to non-mining areas and significantly highest in mountaintop mining
regions (Esch & Hendryx, 2011). A qualitative study by Schloman, Virgin, Schmitke, and
Patros (2011) was conducted to evaluate adult Southern Appalachian uninsured clients
living with hypertension. While 34 clients initially agreed to be contacted, 29% were lost
to follow up and 24% scheduled for a group failed to show. Ultimately, 16 clients
participated in the research study (Scholmann et al., 2011). The investigators found that
although some of the challenges of the study were at the individual level and many were
affected by the larger social context, which included the healthcare system (Scholmann
et al., 2011).
Stroke
In West Virginia, the rate of stroke slightly decreased from 2006 to 2010, but was
higher than the rate in the United States every year (West Virginia Department of Human
Health and Human Resources, 2012). The “stroke belt” is a region that crosses the
southern states where stroke is more prevalent than in other regions of the United States
(Virginia Department of Health, 2013). A population-based study of stroke mortality over
a seven-year period (2000-2006) illustrated a significant increase of stroke morality in
Appalachia (96.67 per 100,000 person-years), which was higher than outside
Appalachia (80.25 per 100,000 person-years) (Sergeev, 2013).
Barriers
Health disparities, many of which are preventable, have been related to both
social class and region (McGarvey, Leon-Verdin, Killos, Guterbock, & Cohn, 2011). This
region of Appalachia lacks social, financial, and technical resources due to its
geographical isolation, disproportionate social and economic distress, low household
income, and declining tax base (Herath & Brown, 2013). A descriptive survey by
Huttlinger, Schaller-Ayers and Lawson (2004) evaluated the needs, availability, and
access to health care in this region. Of the 2,188 respondents, more than one-third
(38%) reported a delay in obtaining necessary health care because of the cost concerns
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and lack of insurance (Huttlinger, Schaller-Ayers, & Lawson, 2004). It was also found
that among people with lower social economic status, individuals are less likely to
participate in disease prevention programs (McGarvey, Leon-Verdin, Killos, Guterbock,
& Cohn, 2011). Health literacy appears to have a greater effect among Appalachians in
terms of their level of difficulties interacting with physicians, coping behaviors, and self-
reported health (Ludke, Obermiller, Jocobson, Shaw, & Wells, 2006).
Conclusion
There is a great need in Appalachia and West Virginia, in particular, for
healthcare education to help stop preventable diseases, such as diabetes. The current
literature found there is a great need for healthcare resources in the Appalachian region,
related to the increase in number of patients with complex illnesses and preventable
diseases. The leading causes of death are cardiovascular disease, cancer, accidents,
lung disease, pneumonia and influenza, suicide, and diabetes (The Health Wagon,
2010).
Methodology
Study Design
A qualitative study was conducted, using ethnographic design, to understand
how people recognize and treat diabetes. A qualitative study done by Ross (2015) stated
that ethnography provides an opportunity to identify, learn, and understand predictable
patterns of human thought and behavior. This method allowed for the evaluation of the
knowledge and attitudes about diabetes mellitus in Appalachia in West Virginia.
Informants’ demographics were explored in relation to their home counties to identify
theoretical saturation within the two counties. In depth, open-ended questions (Appendix
A) were developed prior to interviewing the clients to identify themes related to
knowledge, attitudes, and behaviors about diabetes within the Appalachian region.
Subjects
The informants in this study were included from a convenience sample in the
Appalachian region of West Virginia. There were a total of 17 informants from County A
and a total of 10 informants from County B. The basis for this sample size was based on
theoretical saturation that had been discovered. The informants were recruited with the
assistance of local acquaintances. No coercion or rewards were given for participation.
Criteria to be a part of this study included being a resident of the county that was being
researched. Permission to conduct the study was obtained by Robert Morris University’s
IRB committee.
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Setting
Interviews were conducted over the summer and fall of 2015 in two different
counties in West Virginia. Ohio County was identified as County A and Upshur County
was identified as County B. Ohio County is in the northern panhandle in West Virginia
and is 109 square miles, with the county seat being Wheeling. As of 2014, the total
census reported the population as approximately 43,328 (United States Department of
Commerce, 2016a). Upshur County is comprised of 355 square miles in north central
West Virginia, about an hour and fifteen minutes away from Morgantown. As of 2014,
the current population was approximately 24,731 (United States Department of
Commerce, 2016b).
Intervention
Residents living in two separate counties in West Virginia, within the diabetes
belt, were interviewed during the summer and fall of 2015. The open-ended questions
were developed prior to starting the interviews. A pamphlet prior to interview described
the purpose of the study and welcomed the participation of the residents. Agreement to
participate in this field study had been obtained prior to interview with a consent form
(Appendix B). It was noted that it was voluntary and informants joined of their free will.
The belief is that the informant is credible, dependable, and trustworthy when complying
to be interviewed about the subject prior to the set date.
Data Collection
Informants from each county were separated in two groups, Group A and Group
B. Each informant received the same in-depth open-ended questions during the
interview. The interviews took place within local establishments in the counties, lasting,
on average, 30 minutes. To maintain consistency in data collection, the primary
investigator performed each interview. A private tape recorder was used so all attention
was on the informant and surroundings. Notes were made in a private notebook to
collect demographic information. All information obtained during interview is kept
anonymous, with no identifying characteristics. Once the interviews were completed, the
recordings were transcribed by the primary investigator in NVIVO. Analysis of the
content was performed to identify the themes that developed during the interviews.
Evaluation Instrument/Tool
A theoretical citation was used for data collection in this study. Both Group A and
B received the same interview questions to determine the perception and knowledge of
diabetes to assist in cultural competent care in the Appalachian region.
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Data Analysis
The ethnographic data analysis allowed the ability to focus on the data to identify
and develop themes. The goal was to develop a cultural theme of the social group
incorporating the views of the informants of that group and the believed interpretation of
the participants, while reviewing the content obtained during the interviews. After
identifying the themes into categories, the NVIVO computer analysis system was used
for analysis of data for this study. The interviews were read multiple times by the primary
investigator and the second researcher to obtain a sense of the data as a whole.
Categories than were identified through out the interviews and than interpreted to create
the themes.
Outcomes
Results
A total of 27 informants participated in this study. In County A, 17 people which
consisted of fourteen women and three men, with ages ranging from 18 to 60 year,
participed. The informants in County A, were residents of County A and volunteered to
be interviewed at a local church with the help from a local aquantence. There were 10
participants from County B, which consisted of eight men and two women, with ages
ranging from 20 to 70 years. The informants in County B, were locals who volunteered to
be interviewed at a local gathering place, C.J. Maggies. Four major themes emerged
from both County A and B through the data analysis related to barriers to diabetes
mellitus in Appalachia. Identical themes were identified in both counties. This may
indicate that the remainder of the Appalachian region may have the same barriers to
diabetes. Table 1 lists emerging themes from the data analysis.
Themes that emerged
• Lack of knowledge leads to uncontrolled diabetes
• Low economic status impacts management of diabetes
• Resistance to lifestyle leads to self management
• Access leads to poor diabetic management
Theme #1: Lack of knowledge leads to uncontrolled diabetes
When asked to describe their concerns about diabetes, many of the informants
made reference to why people have diabetes. Many of the informants believed the risks
of getting diabetes is related to genetics, obesity, and willingness to care about their
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health. Not one informant acknowledged that their own lifestyle caused them to have
diabetes. One informant who worked in the healthcare field laid blame on genetics. “It is
in my genes, so I don’t know how much more I can do. I am just trying to deal with it and
treat it. I already outlived all of my family.” Another informant who has diabetes, blamed
it on being married and not on himself. “Me having diabetes started out as hereditary,
and then being married for 40 years, now divorced, didn’t help.” One of the informants
offered a concrete example from her experiences with her job in home care. She felt that
people are not taking control of their diabetes because they doint understand what it is.
“They think that it is the way it is when they have diabetes, if they loose a leg it is not
because of them it is because of the diabetes. One person thought taking her insulin
was optional.” Another concern that was mentioned in the interviews was understanding
of one’s health. Informants felt that it just happens and then they don’t know why it
happened and what can be done for it now. A particular informant mentioned, “I think it
pops up on them before they realize how to prevent what is happening. By the time they
get to full blown, they are already too far. Prevention and knowledge needs to be
addressed.” It was also very common through out the interview that many informants felt
that diabetes “means that the people are overweight,” which causes them to have
diabetes. Through out all of these responses, it was identifed that there is a lack of
knowledge surrounding diabetes, which leads to people having uncontrolled diabetes.
Theme #2: Low economic status impacts management of diabetes
When asked to describe what they thought contributes to diabetes, informants
consistently insisted it is related to the economic status in this region. People believe
that healthier foods are more expensive and that processed foods cost less. People
expressed throughout the interviews that “the economic condition make it a whole lot
easier to grab a bag of chips or cookies. The perceived notion that eating more healthy
is more expensive than eating fast food or junk, It’s a lot cheaper to open up a can of
spam or a pack of hot dogs.” Another informant stated, “Why would they buy fruits and
vegetables when they could buy rice and beans and eat it for five weeks instead of five
days. They can and preserve. That is their fresh. Processed food is very cheap and
more affordable in this region.” Many concrete examples were given on what they have
seen or experienced when it comes to actions of others. One man stated, “I go to
Walmart and see people pushing carts of [Little] Debbie[‘s] diabetes cakes and a case of
Mountain Dew, it is a heart attack waiting to happen or diabetes or something.” Another
example from a informant felt that, “a lot of diabetic people I know are related to income.
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Some are not. I feel in this region is more economically related. It is a cheap fix. One of
the faults I have with food stamps is that they will pay for the soft drinks and candy bars.
Food stamps are abused.” A study conducted in the Appalachia region by McGarvey,
Leon-Verdin, Kilos, Guterbock and Cohn (2010) stated that health disparities, many of
which are preventable, have been found to be related to both social class and region.
These findings suggest that due to the poor economic state of this region that they have
no choice but to eat and buy what is cheap. It doesn’t matter if it is healthy or not, they
just need food on the table. The misconception that healthy food is more expensive
needs to be addressed to possibly prevent future diabetics and help correctly manage
people who have diabetes.
Theme #3: Resistance to lifestyle changes leads to self management
While conducting interviews, it was very prevalent through the informants
examples of themselves or others that there is resistance to change even though it may
cause harm. Many informants spoke about how they manage their own health problems.
When asked about his current health, the informant mentioned, “I went on metformin; I
could not handle it. I couldn’t eat. It really messed up my stomach. I now have it on my
do not take list. Losing weight is out the door. People who tell me what to eat are crazy.”
This same informant even mentioned that he, “had a friend that passed away six months
ago because he refused to do anything because he said he wasn’t about to take all them
drugs and that he felt worse when taking them. He didn’t need them.” This informant
didn’t realize that his own resistance to caring for himself sets himself up for poor
management of his health problems. A study by Behringer and Friedell (2006)
mentioned that people in the Appalachians do not seek attention and they try to manage
their own problems. When addressing a informants health, a informant said “I personally
don’t like anyone telling me what to do and that includes doctors, so I focus on being
well.” It didn’t matter what kind of health problem these informants had, they felt that they
could manage their own care. A informant that recenetly had gotten a mechanical valve
and started on Coumadin mentioned that he “self regulates the coumadin depending on
my diet.” The informant felt that he could control it better than anyone else. When
expanding on diabetic management, it was expressed that the informants felt that no
one wanted to take responisiblity for their problems, everyone wants the quick fix. “They
want a perscription or a procedure that will allow them to continue to behave the same
way without changing.” Resistance to change leads to poor management of one’s health
problem, causing poorer health outcomes that could be controlled and or prevented with
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acceptance to care. This was illustrated from a informant’s view when talking about his
knowledge about diabetes. He stated: “I don’t know if anything is difficult it is just that
you can’t lead people to water and make them drink. Most of these people have given
up, so they don’t want to accept responisiblity and they have this fatalistic attitiude that it
is what it is and I might as well live. It is self destructive. The barriers are themselves, not
willing to accept what is going on.”
Theme #4: Access leads to poor diabetic management
During the interviews, it became clear through the responses that access to diabetic
specialists is rare. When talking to the informants, only one out of the 27 informants
admits to seeing a diabetic specialist. In this particular case, her husband’s job is at risk
if he is put on insulin related to the health requirments with maintaing his commercial
drivers license. She mentioned that, “a lot of people see their primary care, which I have
nothin’ against it, she just has so much information. They don’t know they are out there.
He was a diabetic at least four years before anyone suggested we see a specialist.”
Many participants admitted to only seeing their family doctor to manage their health
care. When asking one of the informants, who has diabetes, if she saw an
endocrinologist, she responded, “I do not. I did. He retired and the only other one is
crazy. I feel like my doctor manages it very well. I think she could do better if I let her. I
take a total of 232 units of insulin a day and I take metformin. I stopped taking Jenuvia
because of the black box warning.” This informant works in the healthcare field, and
didn’t feel that her current regiment for her diabetes was a problem. She even
commented that just this year when it comes to the cost of her health insurance,
premiums, and total out of pocket, she has spent almost $22,000 out of pocket related to
her diabetes. Correct access and knowledge about diabetes can assist in correct
diabetic management. In addition to access to the diabetic specialists, it became clear
that it was hard to see a primary care physician since they are overwhelmed with
patients. “I just know little bits. The doctors are so busy, and say that they will just watch
your labs and tell you to try to eat better, but they don’t tell you why or what.” With poor
access, there is not enough time to be educated on the importance of your labs and
current health status. This leads to poor management of their health. Informants
consistently mentioned that there is a lack of availablity to the resources they need.
When talking about the problems of having diabtetes one informant stated: “Access to
the right types of food, and how to prepare them. Access to the right healthcare.”
Poor diabetic management is a result from poor access to healthcare providers and
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specialists, and the lack of availability of resources to assist in understanding diabetes.
Discussion
Nurse practitioners practicing in rural Appalachian areas need to be able to
provide cultural competent care in order to provide diabetic care. Assessing the
knowledge and perception about diabetes in this population uncovers the possible
barriers that are assosciated with diabetic prevention and care. During the interviews the
participants offered personal insight to their understanding and beliefs about diabetes.
Four major themes emerged when conducting this research (1) lack of knowledge leads
to uncontrolled diabetes; (2) low economic status impacts the management of diabetes;
(3) resistance to lifestyle changes lead to self management; and (4) access leads to poor
diabetic management.
Della (2011) provided insight into what was consisdered to be a risk in
developing diabetes in the Appalachian population. In this study, the researchers found
that the participants believed that genetics and obesity not a person’s physical inactivity
and diet leads to diabetes. This perception is reflected in theme one in the participants
concerns about diabetes.
The limitations for this study include, but are not limited to, the following aspects:
The sample was obtained from only two specific locations in West Virginia that fell in the
Appalachian region and most participants were female. Time contraints with collecting
the data due to only going to each of these counties once. This made it hard to establish
a friendship, since interviews were scheduled back to back. Lastly, the researcher is
inexperienced in qualitative methodology and analysis; however, the primary researcher
was supervised by an expert in qualitative research who aided in data analysis.
Implications
The information gathered in this study and the results that it produced can have
an impact in nursing practice, education, and further research. Reaching out to the rural
Appalachian community in nursing practice is not found throughout the literature. With
the results of this study, nurse practitioners have the opportunity to incorporate the
Appalachian culture, allowing the ability to deliver the highest level of care possible.
Cultural preservation is a key finding that emerged from this population. It is important to
have more emphasis on the aspects of negotiating with the Appalachian population, so
they can maintain their pride. Helping this population discover new ways to accept and
acknowledge diabetes, while staying commited to their beliefs, can help guide
preventative measures and treatments for diabetes.
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Conclusion
The key findings of this study, acknowledges the perception and knowledge
about diabetes in the West Virginian Appalachian region. By understanding the barriers
throughout this region can assist in personalizing preventiive measures and
interventions in the Appalachian culture.
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Scholmann, P., Virgin, S., Schmitke, J., & Patros, S. (2011). Hypertension amonth the
uninsured: Tensions and challenges. Journal of the Acadamy of Nurse
Practitioners, 23, 305-313.
Sergeev, A. V. (2013). Stroke mortality disparities in the population of the Appalachian
15

Mountain region. Ethnicity and Disease, 23, 286-291.
Stohr, A. (2012). Diabetes and Health Equity in West Virginia: A Review. Retrieved from
West Virginia Health Statistics Center:
http://www.wvdhhr.org/bph/hsc/pubs/briefs/028/brief28_20121220_health_eq_sta
t.pdf
The Health Wagon. (2010, October 25). Bringing Healthcare To The Mountains Of
Appalachia. Retrieved from
http://sfc.virginia.gov/pdf/health/2010%20Session/Oct_24_25_mtg/102510_No3c
_Gardner.pdf
Trust for America's Health and Robert Wood Johnson Foundation. (2016). States with the
Highest Type 2 Diabetes Rates. Retrieved from State of Obesity:
http://stateofobesity.org/lists/highest-rates-diabetes/
U.S. Census Bureau. (2014, January). United States Census Bureau. Retrieved from
http://quickfacts.census.gov/qfd/states/42/4222608.html
United States Department of Commerce. (2016a). QuickFacts. Retrieved from United
States Census Bureau:
http://www.census.gov/quickfacts/table/PST045215/54069,54097
United States Department of Commerce. (2016b). QuickFacts. Retrieved from United
States Census Bureau:
http://www.census.gov/quickfacts/table/PST045215/54097,54069
Virginia Department of Health. (2013). Cerebrovascular disease in Virginia. Retrieved
from
http://www.vdh.virginia.gov/ofhs/prevention/collaborative/documents/2013/pdf/C
erebrovasc%20Disease%20-%20Stroke%20Burden%20Report.pdf
West Virginia Department of Human Health and Human Resources. (2012). 2012 West
Virginia State Health Profile. Retrieved from
http://www.dhhr.wv.gov/publichealthquality/statepublichealthassessment/Docum
ents/2012%20State%20Health%20Profile%20Final%20May%202013.pdf
West Virginia Department of Health and Human Resources. (2016). Fast facts. Retrieved
from http://www.dhhr.wv.gov/hpcd/data_reports/Pages/Fast-Facts.aspx
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Appendix A
Open Ended Interview Questions
1. Can you tell me what diabetes means to you?
2. Do you have any concerns about your diabetes at present? If so, what are
they?
3. Do you have any concerns about the future? If so, what are they?
4. Can you describe your current knowledge about diabetes?
5. Are you currently receiving treatment? If so, what kind of treatment?
6. How do you prevent from getting diabetes or how do you prevent it from
getting worse?
7. What is the most difficult thing for you about having diabetes? What is the
best thing?

Appendix B
Consent form for study about the barriers to treating diabetes mellitus in Appalachia
Barriers to treating diabetes mellitus in Appalachia
Robert Morris University
School of Nursing
You are being asked to take part in a research study that is looking at the West Virginia
population’s understanding about diabetes. We are asking you to take part of this study
because there is a low amount of information about the general population’s understanding
diabetes in this region. Please read this form carefully and ask any questions you may have
before agreeing to take part in the study.
What the study is about:
The purpose of this study is to learn the participants’ knowledge and attitudes about diabetes.
What we will ask you to do:
If you agree to be in this study, we will conduct an interview with you. The interview will include
questions about your family health history, your current health, what diabetes means to you,
whether you have diabetes, whether you have a doctor, what you do to take care of yourself,
concerns about your health and well-being, and your social and leisure activities. The interview
will take about 60 minutes to complete. With your permission, I would also like to tape-record
the interview.
Risks and benefits:
I do not anticipate any risks to you participating in this study other than those encountered in
day-to-day life. There are no benefits to you.
Compensation:
No compensation is being given.
Your answers will be confidential.
The records from this study will be kept private. In any report we make public we will not
include any information that will make it possible to identify you. Research records will be kept
in a locked file; only the researchers will have access to the records. If we tape-record the
interview, we will destroy the tape after it has been transcribed, which we anticipate will be
within two months of taping.
Taking part is voluntary:
Taking part in this study is completely voluntary. You may skip any of the questions that you do
not want to answer. If you decide not to take part or to skip some of the questions, it will not
affect your current or future relationship with Robert Morris University. If you decide to take
part, you are free to withdraw at any time.
If you have questions:
The researchers’ conducting this study is Jessie Hametz-Shenk and Carl Ross. Please ask
any questions you have now. If you have questions later, you may contact Jessie Hametz-
18

Shenk at jmhst895@mail.rmu.edu or at 1-814-397-4680. You can reach Carl Ross at
ross@mail.rmu.edu. If you have any questions or concerns regarding your rights as a subject
in this study, you may contact the Institutional Review Board (IRB) at 412-397-6227 or access
their website at http://irb.rmu.edu. You will be given a copy of this form to keep for your
records.
Statement of Consent: I have read the above information, and have received answers to any
questions I asked. I consent to take part in the study.
Your Signature ___________________________________
Date _______________________
Your Name (printed)
____________________________________________________________
In addition to agreeing to participate, I also consent to having the interview tape-recorded.
Your Signature ___________________________________
Date _______________________
Signature of person obtaining consent ______________________________
Date _____________________
Printed name of person obtaining consent ____________________________
Date__________________
In addition to agreeing to participant, I do not consent to having the interview tape-recorded.
Your signature __________________________________________________________
Date _______________________
Signature of person obtaining consent ________________________________________
Date _______________________
Printed name of the person obtaining consent __________________________________
Date _______________________
This consent form will be kept by the researcher for at least three years beyond the end of the
study.
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