African American beliefs about diabetes.

In this presentation, a diabetes explanatory model of rural, African American adults at high risk for diabetes is described. Kleinman's explanatory model of illness was used as the organizing framework. African American men and women (N=42), between the ages of 18 and 51, participated. Participants described their knowledge and beliefs about diabetes, preventing diabetes, and whether diabetes could be cured or controlled. A common explanatory model of diabetes was not shared among the participants, and gender and age differences were apparent. Common themes included diabetes "running in families", "eating too much sugar", and "not taking care of yourself" as causes of diabetes. Weight and physical activity or exercise were not seen as contributing to the development of diabetes. Participants were not sure if diabetes could be prevented. These results provide information to address primary prevention of diabetes in this at-risk group.

Identifying diabetes knowledge network nodes as sites for a diabetes prevention program.

This paper reports on the methods used and results of a study that identified specific places within a community that have the potential to be sites for a diabetes prevention program. These sites, termed diabetes knowledge network nodes (DKNNs), are based on the concept of socio-spatial knowledge networks (SSKNs), the web of social relationships within which people obtain knowledge about type 2 diabetes. The target population for the study was working poor African Americans, Latinos, and European Americans of both sexes in a small rural southern town who had not been diagnosed with diabetes. Information was collected from a sample of 121 respondents on the places they visited in carrying out their daily activities. Data on number of visits to specific sites, degree of familiarity with these sites, and ratings of sites as places to receive diabetes information were used to develop three categories of DKNNs for six subgroups based on ethnicity and sex. Primary potential sites of importance to one or more subgroups included churches, grocery stores, drugstores, the local library, a beauty salon, laundromats, a community service agency, and a branch of the County Health Department. Secondary potential sites included gas stations, restaurants, banks, and post offices. Latent potential sites included three medical facilities. Most of the DKNNs were located either in the downtown area or in one of two shopping areas along the most used highway that passed through the town. The procedures used in this study can be generalized to other communities and prevention programs for other chronic diseases.

Diabetes beliefs among low-income, white residents of a rural North Carolina community.

CONTEXT: Every social group shares beliefs about health and illness. Knowledge and understanding of these health beliefs are essential for education programs to address health promotion and illness prevention. PURPOSE: This analysis describes the diabetes Explanatory Models of Illness (EMs) of low-income, rural, white Southerners who have not been diagnosed with diabetes. METHOD: In-depth interviews were conducted with low-income white women (n = 19) and men (n = 20) aged 18 to 54 years who resided in a rural Southern town. The tape-recorded interviews were completed by trained interviewers and were transcribed verbatim. Computer-assisted text analysis was used, and all transcripts were coded by 2 investigators. FINDINGS: Although all the participants had heard of diabetes, their EMs were vague and undeveloped. Women were more knowledgeable than men were. Family and heredity were widely believed to be causes, with heredity including genetic and learned behavior components. Participants disagreed about the role of diet and weight in causing diabetes; exercise was not perceived as related to causation. Participants had knowledge of those symptoms, complications, and treatments that could be observed. CONCLUSIONS: These rural, white Southerners did not share well-developed EMs for diabetes, with most having a vague and incomplete understanding of this disease. The diabetes beliefs of these rural Southerners differ significantly from current medical knowledge. To be effective, culturally appropriate primary prevention programs must recognize these lay beliefs.

Children's health and workers' productivity: an examination of family interference with work in rural America.

This article examines the association of children's health with their parents' performance in the workplace using data from a random survey sample of adults living in rural western North Carolina (N=206). Guided by the effort-recovery model, the authors hypothesized that parents whose children are more ill have poorer performance in the workplace because their parenting requires greater effort and they have less opportunity for physical and psychological recovery. Child health was unassociated with parents cutting back at work because of physical health. Poorer child health was associated with parents cutting back at work because of emotional health, and a portion of this association, as hypothesized, was explained by more limited opportunities for parental recovery. There was no evidence suggesting that associations differed by parental gender.

A suite of methods for representing activity space in a healthcare accessibility study.

BACKGROUND: "Activity space" has been used to examine how people's habitual movements interact with their environment, and can be used to examine accessibility to healthcare opportunities. Traditionally, the standard deviational ellipse (SDE), a Euclidean measure, has been used to represent activity space. We describe the construction and application of the SDE at one and two standard deviations, and three additional network-based measures of activity space using common tools in GIS: the road network buffer (RNB), the 30-minute standard travel time polygon (STT), and the relative travel time polygon (RTT). We compare the theoretical and methodological assumptions of each measure, and evaluate the measures by examining access to primary care services, using data from western North Carolina. RESULTS: Individual accessibility is defined as the availability of healthcare opportunities within that individual's activity space. Access is influenced by the shape and area of an individual's activity space, the spatial distribution of opportunities, and by the spatial structures that constrain and direct movement through space; the shape and area of the activity space is partly a product of how it is conceptualized and measured. Network-derived measures improve upon the SDE by incorporating the spatial structures (roads) that channel movement. The area of the STT is primarily influenced by the location of a respondent's residence within the road network hierarchy, with residents living near primary roads having the largest activity spaces. The RNB was most descriptive of actual opportunities and can be used to examine bypassing. The area of the RTT had the strongest correlation with a healthcare destination being located inside the activity space. CONCLUSION: The availability of geospatial technologies and data create multiple options for representing and operationalizing the construct of activity space. Each approach has its strengths and limitations, and presents a different view of accessibility. While the choice of method ultimately lies in the research question, interpretation of results must consider the interrelated issues of method, representation, and application. Triangulation aids this interpretation and provides a more complete and nuanced understanding of accessibility.

The effects of geography and spatial behavior on health care utilization among the residents of a rural region.

OBJECTIVE: This analysis determines the importance of geography and spatial behavior as predisposing and enabling factors in rural health care utilization, controlling for demographic, social, cultural, and health status factors. DATA SOURCES: A survey of 1,059 adults in 12 rural Appalachian North Carolina counties. STUDY DESIGN: This cross-sectional study used a three-stage sampling design stratified by county and ethnicity. Preliminary analysis of health services utilization compared weighted proportions of number of health care visits in the previous 12 months for regular check-up care, chronic care, and acute care across geographic, sociodemographic, cultural, and health variables. Multivariable logistic models identified independent correlates of health services utilization. DATA COLLECTION METHODS: Respondents answered standard survey questions. They located places in which they engaged health related and normal day-to-day activities; these data were entered into a geographic information system for analysis. PRINCIPAL FINDINGS: Several geographic and spatial behavior factors, including having a driver's license, use of provided rides, and distance for regular care, were significantly related to health care utilization for regular check-up and chronic care in the bivariate analysis. In the multivariate model, having a driver's license and distance for regular care remained significant, as did several predisposing (age, gender, ethnicity), enabling (household income), and need (physical and mental health measures, number of conditions). Geographic measures, as predisposing and enabling factors, were related to regular check-up and chronic care, but not to acute care visits. CONCLUSIONS: These results show the importance of geographic and spatial behavior factors in rural health care utilization. They also indicate continuing inequity in rural health care utilization that must be addressed in public policy.

Access to transportation and health care utilization in a rural region.

CONTEXT: Access to transportation to transverse the large distances between residences and health services in rural settings is a necessity. However, little research has examined directly access to transportation in analyses of rural health care utilization. PURPOSE: This analysis addresses the association of transportation and health care utilization in a rural region. METHODS: Using survey data from a sample of 1,059 households located in 12 western North Carolina counties, this analysis tests the relationship of different transportation measures to health care utilization while adjusting for the effects of personal characteristics, health characteristics, and distance. FINDINGS: Those who had a driver's license had 2.29 times more health care visits for chronic care and 1.92 times more visits for regular checkup care than those who did not. Respondents who had family or friends who could provide transportation had 1.58 times more visits for chronic care than those who did not. While not significant in the multivariate analysis, the small number who used public transportation had 4 more chronic care visits per year than those who did not. Age and lower health status were also associated with increased health care visits. The transportation variables that were significantly associated with health care visits suggest that the underlying conceptual frameworks, the Health Behavior Model and Hagerstrand's time geography, are useful for understanding transportation behavior. CONCLUSIONS: Further research must address the transportation behavior related to health care and the factors that influence this behavior. This information will inform policy alternatives to address geographic barriers to health care in rural communities.

Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina.

The prevalence of type 2 diabetes is increasing in the United States, particularly among minority individuals. Primary prevention programs for diabetes must be designed to address the beliefs of the populations they target. Little research has investigated the beliefs of those who do not have diabetes. This analysis uses in-depth interviews collected from Latino immigrants, not diagnosed with diabetes, living in a rural US community. Structured by the explanatory models [EM] of Illness framework, this analysis delineates the EMs of diabetes in this community. A significant number of the participants had little knowledge and few beliefs about diabetes. The EMs of those with knowledge of diabetes were varied, but several beliefs were widely held: (a) diabetes is a serious disease that is based on heredity or is inherent in all persons, (b) diabetes can result from several factors, including strong emotions and lifestyle characteristics (an unhealthy diet, not taking care of oneself), (c) beliefs about strong emotion and the importance of blood are related to diabetes causes, symptoms and treatment, and (d) a major and undesirable outcome of diabetes is weight loss. These results provide information for the design of health programs for the prevention of type 2 diabetes.

Determinants of health care use by children in rural western North Carolina: results from the Mountain Accessibility Project.

OBJECTIVE: To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States. METHODS: Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods. RESULTS: Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >40 000 dollars per year had 76% more visits than those with incomes <20 000 dollars per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >40 000 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group. CONCLUSIONS: This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child's pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation.

Sociospatial knowledge networks: appraising community as place.

This article introduces a new theory of geographical analysis, sociospatial knowledge networks, for examining and understanding the spatial aspects of health knowledge (i.e., exactly where health beliefs and knowledge coincide with other support in the community). We present an overview of the theory of sociospatial knowledge networks and an example of how it is being used to guide an ongoing ethnographic study of health beliefs, knowledge, and knowledge networks in a rural community of African Americans, Latinos, and European Americans at high risk for, but not diagnosed with, type 2 diabetes mellitus. We believe that the geographical approach to understanding health beliefs and knowledge and how people acquire health information presented here is one that could serve other communities and community health practitioners working to improve chronic disease outcomes in diverse local environments.