“Now There's a Good Woman”: How Rural Life Course Events Shape
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“NOW THERE’S A GOOD WOMAN”: HOW RURAL LIFE COURSE EVENTS SHAPE THE RESPONSE TO COGNITIVE DECLINE IN OLDER WOMEN A DISSERTATION IN Nursing Presented to the Faculty of the University of Missouri-Kansas City in partial fulfillment of the requirements for the degree DOCTOR OF PHILOSOPHY by CHRISTINE MARIE EISENHAUER B.A., Mount Marty College, 1997 M.S.N., University of Nebraska Medical Center, 2003 Kansas City, Missouri 2012 ©2012 CHRISTINE MARIE EISENHAUER ALL RIGHTS RESERVED “NOW THERE’S A GOOD WOMAN”: HOW RURAL LIFE COURSE EVENTS SHAPE THE RESPONSE TO COGNITIVE DECLINE IN OLDER WOMEN Christine Marie Eisenhauer, Candidate for the Doctor of Philosophy Degree University of Missouri-Kansas City, 2012 ABSTRACT Aims: This dissertation aimed to: (1) analyze the life-course experiences of rural, older women and the impact of those experiences on their values, health-illness behaviors and decision-making, particularly surrounding cognitive decline; (2) compare and contrast the values, health-illness behaviors and decision-making of the older women with those of three younger generations of rural women; and (3) examine findings with the local community to explore ways of working with the formal health care system to identify culturally acceptable ways to deal with cognitive decline. Background: Cognitive decline is a continuum that includes levels of memory problems, poor judgment, confusion, personality change, and difficulty with planning and social functioning. In a pilot study, rural, older women identified cognitive decline, or “losing one’s mind,” as the most significant fear and concern for which they desired interventions. The isolation of the rural lifestyle has made these women value independence and self-reliance as essential characteristics for survival. Chronic illnesses, such as progressive types of cognitive iii decline, significantly threaten the functional and cognitive independence, safety, and quality of life of this population. Method: An ethnographic design utilized in-depth life history interviews with four key informants across one year, focus groups with cross-generational cohorts (n=20), participant observation, and review of cultural artifacts. Interviews were transcribed verbatim and thematically analyzed. Findings: Findings include: (1) historical knowledge indicates belonging, (2) drifting about but not out, (3) gender roles- men protect from outside, women protect from inside, (4) neighbors as a network, (5) trust as an exchangeable commodity, (6) the new outsiders: health service insensitivity reinforces distrust, (7) then and now: loss of social capital, (8) come and eat, (9) there’s no place like home, (10) self-determination, (11) all natural please, (12) suffering continuum, (13) stoicism begets emotional disconnect with the health-illness experience, (14) I need help but it is a private matter, and (15) protective silence-avoidance. Conclusion: The findings provide a greater understanding of rural culture, help to personalize health care through sensitivity to culture and generation, decrease disparities in access to care related to rural isolation and improve health outcomes for rural women facing cognitive decline. iv APPROVAL PAGE The faculty listed below, appointed by the Dean of the School of Nursing, have examined a dissertation titled “Now There’s a Good Woman”: How Rural Life Course Events Shape the Response to Cognitive Decline in Older Women, presented by Christine Marie Eisenhauer, candidate for the Doctor of Philosophy degree, and certify that in their opinion it is worthy of acceptance. Supervisory Committee Jennifer Hunter, RN, Ph.D. Committee Chair School of Nursing Pat Kelly, RN, Ph.D. School of Nursing Terry Nelson, Ph.D. Mount Marty College Mary O’Connor RN, Ph.D. School of Nursing Carol Pullen, RN, Ed.D. University of Nebraska Medical Center v CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF ILLUSTRATIONS ............................................................................................ vii LIST OF TABLES ............................................................................................................. ix ACKNOWLEDGEMENTS ................................................................................................ x Chapter 1. INTRODUCTION .................................................................................................. 1 2. REVIEW OF LITERATURE ............................................................................... 13 3. METHODS ........................................................................................................... 48 4. ENTRÉE TO THE FIELD .................................................................................... 65 5. LIFE HISTORY OF THE RURAL, OLDER WOMEN ....................................... 74 6. RESULTS ............................................................................................................. 95 7. FOCUS GROUP COMPARISONS .................................................................... 139 8. SUMMARY, DISCUSSION, LIMITATIONS, RECOMMENDATIONS, AND IMPLICATIONS FOR PRACTICE ................................................................... 165 Appendix A. LIFE HISTORY INTERVIEW GUIDE............................................................... 188 B. DEMOGRAPHIC INFORMATION .................................................................... 196 C. UMKC SSIRB APPROVAL ................................................................................ 199 REFERENCE LIST ........................................................................................................ 201 VITA ............................................................................................................................... 230 vi LIST OF ILLUSTRATIONS Figure Page 2.1 Culture Emergent Theory ....................................................................................... 44 3.1 Maps of Knox County, Nebraska ........................................................................... 51 3.2 Rural Context Surrounding Cognitive Decline ...................................................... 60 4.1 Neighbor Reciprocity ............................................................................................. 68 4.2 Rugged Hillsides That Lead To the Women’s Homes .......................................... 71 4.3 Native Prairie ......................................................................................................... 71 4.4 Symbols of Farming Practices Years Ago ............................................................. 72 4.5 Country Home ......................................................................................................... 72 5.1 Neighbor Lady Cookbooks ..................................................................................... 78 5.2 Jelly Making ............................................................................................................. 80 5.3 Playing Keyboard as Entertainment ......................................................................... 85 5.4 Quilting as a Coping Measure .................................................................................. 87 6.1 Concentric Nature of Cultural Themes .................................................................... 96 6.2 Knox County Lay of the Land ................................................................................. 97 6.3 Picnic Table Corner.................................................................................................. 99 6.4 Centennial Books ................................................................................................... 100 6.5 Neighborhood Deer Season.................................................................................... 106 6.6 Farm Mechanization............................................................................................... 108 6.7 Demolishing Farm Places ....................................................................................... 109 vii 6.8 Changing Landscape ............................................................................................... 110 6.9 Hand Shake-Trust as an Exchangeable Commodity ............................................... 111 6.10 Canning Cellar and Storage Caves .......................................................................... 117 6.11 Family Archives of Recipes .................................................................................... 118 6.12 Extension Club Cookbooks ..................................................................................... 119 6.13 Raccoon ................................................................................................................... 122 6.14 Porcupine Story ....................................................................................................... 122 6.15 Spring Fed Home Water Supply ............................................................................. 125 6.16 Retrofitted Tractor Step .......................................................................................... 128 viii LIST OF TABLES Table Page 8.1 Variations Between Rural and Medical Culture ................................................. 181 ix ACKNOWLEDGEMENTS I would like to thank my chair, Dr. Jennifer Hunter, for her guidance and support throughout the past four years. Her creative insight and passion for inductive inquiry have been a great motivation and source of