Cultural Values Influence How People Receive and Process Health Information
Attention-Deficit Hyperactivity Disorder (ADHD) can be a complicated diagnosis to assess and treat. Many different pieces of the puzzle need to be considered to provide successful treatment and outcomes for children and adults diagnosed with ADHD. One puzzle piece that needs more consideration no matter where one practices is providing care based on the culture of that population or group of people. Learning about and considering the cultural values, beliefs, and lifeways of populations to provide culturally congruent care is one area that has not received much attention. Cultural values influence how people receive and process health and healthcare information. Culture is “the learned, shared, and transmitted knowledge of values, beliefs, practices, behaviors, and lifeways of a particular group that are shared intergenerationally and influence thinking, decisions, and actions consciously and unconsciously in certain ways or patterns” (Leininger, 2006).
Awareness and Sensitivity to the Cultural Context of Appalachian Individuals and Families
Understanding and providing culturally appropriate care is especially important in the Appalachian region. Appalachia is a huge region with over 26 million people. The entire state of West Virginia along with parts of 13 other states make up the Appalachian region. It is critical for providers in West Virginia to gain an understanding of the Appalachian population to have successful communication and interactions which will improve outcomes.
“Awareness of and sensitivity to the cultural context of Appalachian individuals and families should take priority over assessments and interventions guided by professional practices that are customary for mental health professionals from the mainstream culture. How problems are assessed and formulated should be based upon the “insider’s view,” using language, values, and assumptions that belong to the local culture to the extent possible (American Psychiatric Association, 2025).”
Distrust in Appalachia
Appalachia has a long and complicated history of exploitation by outsiders that has led to much distrust and fear when it comes to interacting with people who are not from the region. No matter how caring and well-meaning a provider may be who is not from Appalachia, many barriers that are in place consciously and unconsciously can affect the communication and interactions between the provider and their clients and families. For many generations, well-meaning and not so well-meaning people have come into the Appalachian region with a measure of superiority and attempted to fix problems in Appalachia without seeking the input of the people who live in the region. When providers interact in a hierarchical manner and “tell” Appalachians what they need to do, it can create a lot of resistance. One of the negative results of this is that Appalachians tend to wait much later to seek professional help for problems. Unfortunately, this can result in worse symptoms and the need for more intensive treatment once they find themselves at the healthcare provider’s office.
An important cultural factor that is helpful to understand is that Appalachian people tend to be much more relational and desire relationships when interacting with others. Providers addressing ADHD would have much more success in their first encounter with an Appalachian patient and family if they first asked a few non-threatening questions to get to know the family, their likes, dislikes, etc. If a provider moves straight into clinical questions this will further contribute to this barrier of distrust. Providers really need to keep the focus of building trust in the forefront of all their interactions with Appalachians.
Implicit Bias
Sadly, the negative stereotypes that surround Appalachia are quite numerous and widespread. Written literature over the years, as well as television shows and other media have exaggerated some of the negative aspects of Appalachian values and lifeways. Providers who move to Appalachia from other locations would be well served by assessing their own biases and thought processes and learning as much as they can about the Appalachian population to help dispel these stereotypes. These negative stereotypes can have profound impact on interactions between providers, patients and their families.
Importance of Family in Appalachia
From the early days of the settling of the Appalachian region, the family has remained extremely important. Many large extended families remain close to one another and provide much help with child raising. In the Appalachian family, there is a lot of emphasis on keeping problems inside the family and not “sharing dirty laundry outside of the family.” This lack of openness may contribute to difficulty in providers being able to fully assess individuals for ADHD. Unfortunately, providers may misinterpret this closed interaction and hesitancy by the family to share information, as evidence that responsible family members are not concerned about the child. When this misunderstanding occurs, it may be necessary to work harder at trust-building to improve trust and communication between the provider and family. This Appalachian value of closeness and reliance on the extended family may create problems with family members acceptance of an ADHD diagnosis. The family may be hearing conflicting advice from other family members that encourage the parents or caregivers to just discipline the child more or to “pray about it and have more faith.”
Conclusion: Culturally Congruent Care Improves Outcomes
Although people in Appalachia may be initially resistant to sharing information with outsiders, once trust is built, it usually remains and is helpful for building trust with other extended family members. Evidenced based research has shown that providing culturally congruent care contributes to many positive outcomes such as improved adherence to treatment plans, improved appointment attendance, and increased provider and client satisfaction among other positive results which all result in improved outcomes. Learning about and utilizing Appalachian culturally relevant approaches and strategies is a huge puzzle piece that can and will contribute to improved outcomes in the treatment of ADHD. It is vitally important to remember that “Appalachian people have their own way of looking at the world & acting in it. Those who hope to work successfully with them must learn to understand & appreciate these cultural differences” (Keefe, 2005).
References
American Psychiatric Association (2025). Retrieved February 10, 2025 from https://www.psychiatry.org/psychiatrists/diversity/education/best-practice-highlights/working-with-appalachian-patients
Appalachian Regional Commission. (2017). Health disparities in Appalachia. Appalachian Regional Commission https://www.arc.gov/report/health-disparities-in-appalachia/
Betancourt, J. R., Corbett, J., & Bondaryk, M. R. (2014). Addressing disparities and achieving equity: Cultural competence, ethics, and health-care transformation. Chest, 45(1),143–148. https://doi.org/10.1378/chest.13-0634
Edwards, G. T., Asbury, J. A., & Cox, R. L. (Eds.). (2006). A handbook to Appalachia: an introduction to the region (1st ed). Knoxville: University of Tennessee Press.
Keefe, S. E. (2005). Appalachian cultural competency: a guide for medical, mental health, and social service professionals. Knoxville: University of Tennessee Press.
Leininger, M.M., & McFarland, M. R. (2006) Culture Care Diversity and Universality: A Worldwide Nursing Theory. (2nd ed). Jones & Bartlett Publishers, Inc.
Tripp-Reimer, T., & Friedl, M. (1977). Symposium on cultural and biological diversity and health care. Appalachians: a neglected minority. Nursing Clinics of North America, 12, 41–54.
Tripp-Reimer, T. (1982). Barriers to Health Care: Variations in Interpretation of Appalachian Client Behavior by Appalachian and Non-Appalachian Health Professionals. Western Journal of Nursing Research, 4(2), 179.
