Objective: The purpose of this analysis was to critically review existing research on health perceptions and health status measurement of rural Appalachian elders and identify key questions for future research. Over the last decade, the rural Appalachian culture has undergone dramatic changes in terms of the fabric of the rural community and tumultuous changes in the health care delivery system. For the rural Appalachian elder, residential mobility and population turnover have changed the social structure so that proximate friends and neighbors may no longer be well known or "trusted" (Fitchen, 1991; McInnis-Dittrich, 2000). Redefinition of the traditional rural community and practice of "social credit" and reciprocity have left many Appalachian elders without a buffer to hardship (Lozier & Althouse, 1974, 1975; McInnis-Dittrich, 2000). Change in Medicare reimbursement has forced the closing of many health care facilities in rural areas (Rural Policy Research Institute, 1999). Community health clinics that serve rural Appalachian elders are struggling to survive the "do more with less, yet see more patients" approach to health care delivery. Ten years ago, Rowles’ (1991) analysis provided direction for a model of health care delivery. A decade of change in the ethos of the rural Appalachian community and the delivery of health care mandates a reanalysis of health perceptions and health status measurement among elders. Design: Retrospective analysis of qualitative rural Appalachian empirical work regarding health perceptions and results from quantitative outcomes of health status measurement were synthesized to develop a conceptual framework and key research questions for future nursing research. Population, Sample, Setting, Years: Included in the analysis were findings from rural studies of elderly people conducted in Appalachian settings over the last 10 years. Concepts Studied: Rural Appalachian elders description of their perception of health were analyzed in comparison with results from measurement of rural Appalachian elderly health status using a variety of instruments. Methods: Reports of health perceptions and measurement of health status among rural Appalachian elders using computerized searches of CINAHL and Medline databases were reviewed. Building on the research by Rowles (1991), studies published between 1991 and 2001 were included if they met specific criteria including selection of rural Appalachian elders as a major study variable. Findings: The 8 studies in this critical integrative review of the literature were conducted in different and remote parts of Appalachia. Traditional views about health in terms of cultural values are still prominent in the perceptions of rural Appalachian elders. Independence, family and faith in God are prevalent cultural values displayed in the literature regarding perceptions of health by rural elders. Research reports conflicting values between elders and providers about health perceptions in terms of a healthy lifestyle. Recent changes in the health care system such as telemedicine and reimbursement patterns have altered delivery of care. However, these remain ambiguous to the rural Appalachian elder. Barriers to care for the rural elder identified in the literature were cost of care, inability to pay due to fixed income, inability to travel to the clinic or hospital, and chronic poverty. Measurement of health status for rural elders remains limited and provides little useful information for clinical practitioners about maintaining the health status of rural Appalachian elders. Conclusions: There is recent research on health perceptions and measurement of health status of elderly residents living in Appalachia. These findings pertain to elderly in different and remote parts of Appalachia. Consequently, they do not permit generalizations to be made about elderly rural Appalachians without further study. Based upon this analysis, a conceptual framework and key research questions are offered as next steps for future nursing research. Implications: Nurses who care for rural Appalachian elders must be prepared to deliver appropriate and adequate health care based on current research. Rural Appalachian elders need to have routine access to health care so that negative affects of aging and chronic conditions can be reduced or eliminated. Rigorous methodological studies using a synthesis of both qualitative and quantitative data that documents health perceptions in comparison with health status measurement are needed.
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