The Efficacy of the Psychosocial Risk Factor Survey in Measuring the Progress of Appalachian Cardiovascular Rehabilitation Patie

The Efficacy of the Psychosocial Risk Factor Survey in Measuring the Progress of

Appalachian Cardiovascular Rehabilitation Patients

A dissertation presented to

the faculty of

The Patton College of Education of Ohio University

In partial fulfillment

of the requirements for the degree

Doctor of Philosophy

Bethany L. Fulton

December 2017

This dissertation titled

The Efficacy of the Psychosocial Risk Factor Survey in Measuring the Progress of

Appalachian Cardiovascular Rehabilitation Patients

BETHANY L. FULTON

has been approved for

the Department of Counseling and Higher Education

and The Patton College of Education by

Yegan Pillay

Associate Professor of Counseling and Higher Education

Renée A. Middleton

Dean, The Patton College of Education 3

Abstract

FULTON, BETHANY L. Ph.D., December 2017, Counselor Education

The Efficacy of the Psychosocial Risk Factor Survey in Measuring the Progress of

Appalachian Cardiovascular Rehabilitation Patients

Director of Dissertation: Yegan Pillay

In an extension of research validating the Psychosocial Risk Factor Survey

(PRFS), the present study examines the use of the PRFS as an effective counseling assessment tool for participants in a cardiovascular rehabilitation program located in

North Central Appalachia. Participants were administered the tool on site by program staff during orientation prior to beginning the program and at its conclusion on the last day of attendance. Completion of the pre-and post-assessments by participants was voluntary. Permission to use the data was given by all participants in written form.

A mixed method design with explanatory focus proved effective in the compilation and analysis of data. The PRFS scores assisted in the determination of behavioral progress through the 12-week cardiovascular rehabilitation program. Specific risk factors measured by the PRFS are: depression, anxiety, anger/hostility, social isolation, and emotional guardedness. Statistically significant differences were found between the pre-and post-assessments overall. Participants with less change in scores continue to have all the specified risk factors present in post -scoring. Participants with more change in scores present less specified risk factors in post scoring.

The use of Bronfenbrenner’s bioecological model offers a framework to analyze qualitative archival data. The research used participant files from the program, 4

specifically counseling summaries. Integrating the information given from the scoring with themes that emerge from the archival summaries offers some insight to the patterns that may distinguish progress or regress in participant evaluation. Further research recommendations center on furthering insight into psychosocial risk factors within this specific sample, the impact of CHD on the North Central Appalachian population, and using the PRFS with Appalachian and other rural area client populations.

Keywords: Appalachia, Bronfenbrenner, counseling, PRFS, psychosocial risk factors 5

Dedication

For my mother, Judith A. Fulton,

and in memory of my father,

Doyle L. Fulton

Acknowledgments

Thank you to my advisor, mentor, and committee chair, Dr. Yegan Pillay. Your unfailing support, thoughtful questions, and gentle nudges keep me moving forward and continue to inspire me as a counselor and a person. Thank you to Dr. Gordon Brooks, Dr.

Laura Harrison, and Dr. Paul Chase. Your insights, knowledge, and experiences increase the quality of my work and my motivation. Thank you to Dr. Andrew Byrne for assistance in navigating SPSS. Megan Beatty, Kathy Partuch, Erica Baker, Selena Baker, and Levi Funk. The cardiovascular rehabilitation program used for this research provides encouragement, support and hope to many in North Central Appalachia. Many thanks to the administrative staff of the Patton College of Education for their diligence and wonderful support to students.

Thank you to my parents, Judie and Doyle Fulton for not questioning my need to keep learning, reminding me why it is important that all people receive education and healthcare without discrimination, that honest work is good work no matter what you do, and kindness to strangers is a way of being that improves life for everyone. Thank you to

Jane and Donald Richter, the best in laws, loudest cheerleaders, and most generous providers of Casa Nueva breakfasts and hugs. Thank you, Stephen Richter, my partner in life, and my constant reminder of how love manifests in many ways.

Paulo Frere writes, “No one can say a true word alone.” The people mentioned here as well as countless others are a part of my words. To the best of my ability, and with great appreciation, I am blessed to share this with them.

Table of Contents Page

Abstract ...... 3 Dedication ...... 5 Acknowledgments ...... 6 List of Tables...... 10 List of Figures...... 11 Chapter One: Introduction ...... 12 Cardiovascular Heart Disease ...... 12 Cardiovascular heart disease in North Central Appalachia...... 14 Behavioral Cardiology ...... 17 Cardiovascular Rehabilitation Programming ...... 18 The Psychosocial Risk Factor Survey ...... 19 Risk factors...... 20 Theoretical Framework ...... 21 Purpose of the Study ...... 23 Research Question(s) and Hypothesis ...... 24 Quantitative...... 24 Qualitative...... 24 Significance ...... 24 Limitations ...... 26 Delimitations...... 27 Definitions of Key Terms...... 27 Behavioral Cardiology...... 27 Cardiopulmonary Rehabilitation...... 27 Coronary Heart Disease (CHD)...... 27 Emotional Guardedness (EG)...... 28 Psychosocial Risk Factors...... 28 Social Isolation (SI)...... 28 Summary ...... 29 Chapter Two: A Review of the Literature ...... 30 Psychosocial Risk Factors Related to Coronary Heart Disease ...... 30 Risk Factors and the North Central Appalachian...... 31 Rethinking culture and health care...... 32 Bronfenbrenner’s Bioecological Theory ...... 34 Current Risk Factors in Appalachia ...... 38 Perceptions of Appalachian Americans ...... 39 Absence of care in Appalachia...... 40 The Psychosocial Risk Factor Survey ...... 42 Summary ...... 43 Chapter Three: Methodology ...... 45 Research Design ...... 45 8

Ethical Considerations.: ...... 47 Research Question(s) and Hypothesis ...... 48 Criteria for Participation ...... 49 The Cardiovascular Rehabilitation Program ...... 49 Researcher Participation in Data Collection ...... 51 Data collection analysis...... 54 Summary ...... 55 Chapter Four: Results ...... 57 Description of the Participants ...... 57 Research Questions ...... 58 Research Question One (Quantitative) ...... 59 Pre- and Post- Scores of the PRFS...... 59 Review of risk factor scales...... 61 Research Question Two (Qualitative) ...... 62 Sample One ...... 63 Adam...... 64 Angela...... 64 Bob...... 65 Brenda...... 65 Cathy...... 66 Chad...... 66 David...... 67 Donna...... 67 Eric...... 67 Frank...... 68 Sample One results showed using mixed methods illustrates multiple changes in the data...... 69 Score Changes of the PRFS in Sample One ...... 71 Sample Two ...... 73 George...... 73 Harry...... 74 Joe...... 74 Keith...... 75 Larry...... 76 Janet...... 76 Mike ...... 77 Ned...... 78 Patrick...... 78 Karen...... 79 Sample Two Results ...... 79 Summary ...... 82 Chapter Five: Discussion ...... 84 Appalachian Patients and Cardiovascular Heart Disease ...... 85 9

Question One- Evident Changes in Score Comparisons...... 88 Question Two- Emerging Themes and Connections from the Samples ...... 89 Sample One ...... 90 Sample Two...... 91 The Risk Factors of Depression and Anger/Hostility ...... 91 Sample One ...... 93 Sample Two ...... 93 Distributive Justice in Northern Appalachian Healthcare...... 94 Risk factors and cultural values...... 97 Efficacy and limits in Appalachia...... 98 Suggestions to Improve Future Research...... 100 Conclusion ...... 101 References ...... 103 Appendix A: A Letter of Support for the Use of De-identified Archival Data of the Research Participants ...... 112 Appendix B: The Institutional Review Board Approval Letter for Research...... 113 Appendix C: Statistical Data Displaying the Changes in Scores for the Various Psychological Risk Factors Related to Cardiovascular Heart Disease...... 120

List of Tables

Page

Table 1 Paired Samples Test of PRFS Scales Using Pre- and Post-Program Scores ...... 60 Table 2 Score Changes of the PRFS in Sample One ...... 71 Table 3 Score Changes of the PRFS in Sample Two ...... 71

List of Figures

Page

Figure 1. Sub-regions of Appalachia ...... 15 Figure 2. A Model of the Bronfenbrenner Bioecological Theory ...... 36 Figure 3. A Bioecological Model of North Central Appalachian Participant Systems ..... 37 Figure 4. The Results of a Wilcoxon Signed Ranks Test ...... 62 Figure 5. Bronfenbrenner’s (2005) Model Showing the Placement of Psychosocial Risk Factors for Sample One ...... 72 Figure 6. Bronfenbrenner’s (2005) Model is Showing the Placement of Psychosocial Risk Factors for Sample Two ...... 81

Chapter One: Introduction

In this chapter is a brief background of cardiovascular heart disease, counseling in cardiovascular rehabilitation, the rationale for the research, a statement of the problem, the research hypotheses, significance, and purpose of the study, limitations, and delimitations, and a definition of terms. Growing awareness of the ongoing effects of heart disease regarding cultural attitudes and the use of behavioral cardiology indicates a need for further study in these areas. Extending the body of research regarding psychosocial interventions within cardiovascular rehabilitation for Appalachian populations are core objectives of this formative study.

Cardiovascular Heart Disease

The number one cause of death in the United States, and in the North Central

Appalachian Region is cardiovascular heart disease (Ohio Department of Health, 2013).

Cardiovascular heart disease (CHD) occurs when plaque builds up in the arteries. This condition (also known as atherosclerosis) narrows the arteries, making it harder for blood to flow through (AHA, 2016). Blood clotting forms and can stop the blood flow or a piece of the plaque may break off and close the passage. This blockage often leads to a heart attack or stroke (AHA, 2016).

Nearly 610,000 Americans die from heart disease each year. That number translates to one in four deaths nationwide due to heart disease (CDC, 2016). The

American Heart Association’s (AHA) Heart Disease and Stroke Statistics Update shared that in 2010, roughly 2,200 Americans die of cardiovascular disease each day, an average of one death every 40 seconds (Benjamin et al., 2017). The state fact sheet for Ohio from 13

AHA lists heart disease as the primary cause of mortality in Ohio and 26,164 people in

Ohio died from heart disease in 2010 (American Heart Association Ohio State Fact Sheet,

2010).

Within the state of Ohio’s Plan to Prevent and Reduce the Burden of Chronic

Disease: 2014-2018, heart disease is again documented as the single leading cause of death in Ohio, with a mortality rate of 190.9 (per 100,000 Ohioans). The Ohio Behavioral

Risk Factor Surveillance System (BRFSS) and the Ohio Family Health Survey are resources for the analyses presented in the 2009 Burden of Heart Disease in Ohio

(BHDO) report (DiFiore- Hyrmer & Pryor, 2009). Per An Analysis of Disparities in

Health Status and Access to Health Care in the Appalachian Region (2004), high rates of all-cause mortality are prevalent in North Central Appalachia, and cardiac-related death rates have the highest rates of premature death in Central and Southern Appalachia, particularly Eastern Kentucky (Halverson, 2004).

Data on adult heart attack survivors who responded to the previously mentioned

BRFSS indicated participation in an outpatient cardiovascular rehabilitation program is relatively low (DiFiore-Hyrmer & Pryor, 2009). A factor for the low numbers in cardiovascular rehabilitation programs could reflect the restrictions of insurance coverage among Ohioans. Issues surrounding healthcare in the region intertwine with factors such as access to care, poverty, reduced educational opportunities, organizational policy, unemployment, and rationing of attention in response to inadequate insurance coverage

(Behringer & Fridell, 2006; Bradley, Werth, & Hastings, 2012; Halverson, Ma, &

Harner, 2008; Helton & Keller, 2010; Mudd- Martin et al, 2014; Russ, 2010; Sims, 2002; 14

Smith & Holloman, 2011;). Most of the 34,000 adults surveyed with cardiovascular disease in the BHDO indicated Medicare as their primary insurance coverage program.

The highest mortality rates for Ohio are visible in southern Ohio and parts of Ohio's

Appalachian Region (Ohio Department of Health, 2013).

Cardiovascular heart disease in North Central Appalachia. The availability of resources unique to rural or Appalachia populations is a major issue for many individuals living with heart disease in Appalachia (Helton & Keller, 2010; Mudd-Martin et al.,

2014; Russ, 2010; Sheikh & Marotta, 2008; Smith & Holloman, 2011). Specifically, lack of psychosocial resources such as counseling for stress or chronic illness, access to existing appropriate healthcare programming continues to inhibit persons in rural areas, including much of the Appalachian region. North Central Appalachia (see Figure 1) consists of 32 counties in Ohio, the state of West Virginia, three counties in Maryland, and 25 within the state of Virginia (Appalachian Regional Commission, 2016). 15

Figure 1. Sub-regions of Appalachia. North Central Appalachia is the area of this study. Reprinted from www.arc.gov, by B.L. Fulton 2016. Retrieved https://www.arc.gov/research/MapsofAppalachia.asp?MAP_ID=31. Copyright 2006 by Appalachian Regional Commission. Reprinted with permission.

The health of the Appalachians, in general, is reflective of the lack of access to medical care and systemic poverty that characterizes the region (Coyne, Demian-Popescu

& Friend, 2006; Mudd-Martin et al., 2014; Russ, 2010). These characteristics of poverty and lack of access to medical care are reflected in the North Central Appalachia counties and include where the data for this study of psychosocial risk factors originates. The scarcity of behavioral and rehabilitation resources is an additional fundamental problem 16

for Appalachians living with cardiovascular disease (Halverson & Bischak, 2008; Mudd-

Martin et al., 2014; Smith & Holloman,).

Appalachian culture continues to fascinate many Americans due to the portrayals of the people of Appalachia in a primarily negative stereotypical manner (Martin, 2016;

Mudd- Martin et al., 2014; Vance; 2016; Williams, 2002). Unique aspects of patient responses are present in the cultural influences from daily life. Documented cultural characteristics of Appalachian populations such as self-sufficiency, deep connection with family members, and mistrust of perceived outsiders can affect rehabilitative program measures such as counseling and education classes (Halverson & Bischak, 2008; Mudd-

Martin et al., 2014; Smith & Holloman, 2011).

Contemporary scholars of the Appalachian region propose that the area is concurrently a “distinct and government-defined region” (Walker, 2013), and a cultural region reflecting socially constructed assumptions (Batteau, 1990; Billings et al., 1999;

Martin, 2016; Passi, 2003; Williams, 2002). Possible concerns with perceptions may include relying on older stereotypes and little understanding of current issues in

Appalachia.

Counseling interventions which are efficient and address the needs of people with a cardiovascular disease may assist in the reduction of deaths from heart disease and improve the quality of life for all Appalachians. To better understand the implications of the Appalachian cardiovascular patient psychosocial experiences and the potential impact, it is necessary to explore how the patient is commonly observed. The emotions that the patient experiences during treatment, and the biases of others may hinder 17

recovery and progress in cardiovascular rehabilitation treatment (Mudd-Martin et al.,

2014; Russ, 2010; Smith & Holloman, 2011). The tendency of psychosocial risk factors and physical risk factors (obesity, high blood pressure, diabetes) to aggregate in the same individuals and groups has important implications for strategies to modify risk and improve the quality of life (Albus, 2010).

Behavioral Cardiology

Behavioral cardiology has rapidly evolved into multiple specialized disciplines

(Harrington, Silverman & Wooley, 2011). In recent years, the term "behavioral cardiology" has been used to describe the crossroads between mental and cardiovascular health, the influence of psychosocial factors on the rate of cardiovascular diseases, and patient behaviors that can indicate compliance with health care recommendations

(Rozanski, 2014). Behavioral cardiology is, "the study and application of psychosocial factors in the assessment and reduction of CHD risk" (Thomas, 2006, p.1).

The ongoing development of this specialty conveys to counselors and other health care professionals that adverse psychological factors are common in persons living with

CHD. Studies show that counseling and behavior change affect the growth, progression, and damage of CHD (Albus, 2010; Eichenauer et al., 2010; Thomas, 2006; Rozanski et al., 2014). The transition of behavioral cardiology from an outside interest to an integrated and clinically respected field within the realm of cardiovascular medicine in the United States is happening now (Rozanski, 2014). The increasingly early diagnosis of cardiac disease, medical treatment, and the awareness of preventative measures leads to 18

mortality decrease rather than increase (Centers for Disease Control and Prevention,

2009; 2016).

Preventive care for cardiovascular heart diseases (CHD) such as behavioral cardiology and cardiovascular rehabilitation can reduce death rates due to CHD, while simultaneously increasing the quality of life (CDC, 2009; 2016). An improved psychological adjustment reaction may be present in the cardiovascular patients who seek the help of counselors (Bagalman, 2013; Carlson, Smith & Holloman, 2011; Mudd-

Martin, 2014; Russ, 2010; Stromwell, & Leitz, 2013). Understanding this local culture is valuable toward a better understanding of the North Central Appalachian cardiovascular patient and better interactions within counseling (Russ, 2010; Sheikh & Marotta, 2008).

Cardiovascular Rehabilitation Programming

Few cardiovascular rehabilitation programs integrate a balanced approach of teaching mind and body interventions (Casey et al.,2009). To reduce cardiovascular heart disease risk, properly identifying positive and negative risk factors is necessary (Thomas,

2016). Programs that provide one to one and group meetings retain healthcare professionals to assess levels of psychological stress and teach stress management are beneficial for CHD patients (Casey et al.,2009; Rozanski et al. 2014). A regional cardiovascular rehabilitation program is the source of data for this research. The program is in a regional hospital and is affiliated with a wellness program available to a nearby

University and the surrounding community.

In the core competencies update from AACVPR, Hamm et al., (2010) state that effective measurements for comprehensive cardiovascular patient assessment consist of 19

management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues. (p. 3) Participants in the program consent to attending the specified cardiovascular rehabilitation program three times a week.

Before 2015 the cardivascular rehabilitation program’s psychosocial component involved several single or two measure instruments. Non- parametric tools such as the

Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI-II)

,or a multifactor assessment such as the MacNew Quality of Life After Myocardial

Infarction (MacNew) to gather the information necessary for treatment planning addressing risk factors are common in many programs (Eichenauer et al.,2010). The

Psychosocial Risk Factor Survey is a multifactor measure psychosocial assessment recommended for use on the AACVPR website. The PRFS is a self-administered assessment tool designed specifically for use with the cardiovascular rehabilitation population (Eichenauer et al., 2010).

The Psychosocial Risk Factor Survey

Psychological interventions are rarely mentioned when addressing the prognosis and mortality of heart patients (American Heart Association, 2013; Bagalman, 2013;

Carlson, Smith & Holloman, 2011; Centers for Disease Control & Prevention, 2013;

Mudd-Martin et al., 2014). The physiological indicators for cardiovascular- related diseases leads to easier objective detection with the uses of stress tests, physical examinations, angiograms, and other means by physicians (American Heart Association,

2016). However, objective measures of psychosocial factors that could influence cardiac 20

health are more elusive because of the bias commonly associated with subjective assessments of psychological or social variables. The lack of specific psychosocial measures available for cardiovascular rehabilitation patients led to the development of

The Psychosocial Risk Factor Survey (PRFS) by psychologists Glenn Feltz and Kent

Eichenauer. Their goal was to create a single assessment tool “to comprehensively and efficiently measure the known psychosocial risk factors within cardiopulmonary rehabilitation programs” (PRFS Manual, 2006, p. 3).

Risk factors. The PRFS measures depression, anxiety, anger/hostility, social isolation, and emotional guardedness. When applying cardiovascular heart disease risk factors to common issues in North Central Appalachian healthcare, connections exist that show the ways risk factors measured by the PRFS and cardiovascular health concerns fit together. The data from the Appalachian cardiovascular rehabilitation program, whose participants may possess the psychosocial risk factors of isolation and emotional guardedness as Appalachian cultural traits, can provide counselors and other health care professionals with insightful details

Limited availability of specialized cardiovascular care (social isolation, depression, anxiety), frustration regarding treatment procedures (anxiety, depression, emotional guardedness), a lack of communication between patient and caregiver (anxiety, emotional guardedness), time limitations (social isolation) and barriers in the form of resistance to treatment (emotional guardedness, anxiety) and lack of transportation

(social isolation, emotional guardedness) are notable issues affecting risk factors for

North Central Appalachian cardiovascular patients (Algeo,2003; Albus, 2010; Bradley et 21

al.,2012; Helton & Keller,2010; Halverson & Bischak, 2008; Hendryx & Zullig,2009;

Mudd- Martin et al., 2014;Smith & Holloman, 2013).

Additional research regarding the efficacy of the PRFS with North Central

Appalachian cardiovascular patients may help with reduction of rehabilitation time and expense, shorter hospitalization times, greater access to patient specific psychosocial care, reduction of family conflict, and the decrease of inappropriate drug use. Increasing the interest in providing quality healthcare in the region by shedding light on the unique aspects of patient responses to the Psychosocial Risk Factor Survey will further enhance the value of using psychosocial components in cardiovascular rehabilitation.

Theoretical Framework

The bioecological theory of Dr. Urie Bronfenbrenner provides a framework for studying the impact of relationship, process, and influences shaping the development of the counseling aspect of cardiovascular rehabilitation with patients in North Central

Appalachia. Mental health care for Appalachian cardiovascular patients is a widely unexplored area in counseling research (Helton & Keller, 2010; Smith & Holloman,

2011; Mudd-Martin et al., 2014). The current inquiries into the recovery of the

Appalachian cardiovascular patient give little attention to the experiences of those who live in isolated health service areas or the existing programs treating persons living with heart disease in these rural underrepresented research areas.

Opportunities exist for health care professionals to improve culturally appropriate integrated care for the various subcultures within rural Appalachia. A further look at the population may have implications for experiences of minority patients with heart health 22

issues and the added challenges of being an ethnic or racial minority in a rural environment. Counselors may be better equipped than some health professionals to acknowledge and confront personal bias with their patients and could make a significant contribution to generating evidence-based interventions for this subculture in the United

States (Hicks & Ambrose, 2005; Hill et al.1997; Russ, 2010; Sheikh & Marotta, 2008).

Understanding the experiences of the cardiovascular rehabilitation patient may contribute to developing medical treatment and influence counseling best practices that are effective for the North Central Appalachian patient (Russ, 2010; Sheikh & Marotta,

2008). Per Helton and Keller (2010). Appalachians face many challenges such as lower income levels, higher unemployment, higher infant mortality rate, and less access to health care than in the United States population. Insights to such experiences assist counselors and other healthcare practitioners to provide more socially competent care for the Appalachian patient. Many scholars of Bronfenbrenner’s work agree the core component of stressing person–context interrelatedness is a constant within the progressive and ongoing evolvement of the theory (Tudge & Scrimsher, 2003).

The findings from this study viewed in the framework of Bronfenbrenner’s model may assist in defining some respects the role of the mental health professional in cardiac health care in a rural region of Appalachia and the United States in general.

Understanding psychosocial risk factors for cardiac health is needed as our federal and state governments, leaders, and healthcare providers refine existing programs towards creating improved healthcare measures that meet the requirements of cardiovascular patients in Appalachia. In 2017, the proposed budget will most likely again reduce 23

healthcare for this population that has been available under the Affordable Care Act.

More detail and an explanation of the framework comes in chapters two and three as the significance of cultural factors become clearer.

Purpose of the Study

Some questions remain unanswered toward understanding the experiences of

North Central Appalachian cardiovascular patients. The goal of this study is to explore the risk factor scales of the Psychosocial Risk Factor Survey from two populations created by looking at the pre-and post-scores of the Psychosocial Risk Factor Survey.

Various influences on Appalachian patients in cardiovascular rehabilitation appear through the lens of Bronfenbrenner’s bioecological model.

Understanding the experiences and expectations of the Appalachian person to develop better rapport, communication, and development of effective treatment is a fundamental component to improving existing practices (Hicks & Ambrose, 2005).

Distinguishing related interactions and reactions of the North Central Appalachian patient to improve healthcare outcomes involving psychosocial risk factors will be understood in the greater context of the bioecological model developed by Bronfenbrenner.

Heart disease and psychosocial factors are intertwined with social, economic and personal realms (Krucoff et al., 2013). The reduction of heart disease and a decrease in inequality to adequate care can emerge from research to discover measures of change and the underlying influences or patterns that exist in cardiovascular disease (Das & O'Keefe,

2008; Krucoff et al., 2013; Purdy, 2013). The link between the behavior of a person and the health of their heart reveals negative risk factors that are likely responsible in part for 24

CHD. Positive change such as behavioral counseling and cardiovascular rehabilitation programs are life changing for participants.

Research Question(s) and Hypothesis

Quantitative. Are changes evident in the comparison of psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients?

Null hypothesis: There is no change evident in the comparison of the psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients.

Qualitative. What themes of emerge from document review of the highest and lowest populations created by the analysis of question one?

Significance

The significance of the information found in this study is likely to shed light on identifiable and malleable factors of cardiovascular rehabilitation formed through the research of the Appalachian Regional Commission and other organizations such as local rehabilitation programs and hospitals in rural areas. Results of assessments such as the

PRFS enable counselors to integrate counseling skills like using attending behaviors, encouragers, and reflection of meaning while continuing to ask focused and semi- structured questions to fill in missing information (Eichenauer et al., 2010; Hill et al.,

1997; 2005; McCluskie, 2010).

The knowledge garnered from this study will increase the existing body of literature regarding cardiovascular rehabilitation in North Central Appalachia and may provide some foundational blocks to support further research with North Central 25

Appalachian cardiovascular rehabilitation patients. So far, comparisons of mental health measures within culturally defined areas of Appalachia is not a prevalent issue for many researchers (Mudd- Martin et al., 2014; Smith & Holloman, 2011). Counselor educators, mental health practitioners, and health care providers ought to continue to explore ways to improve their practices and consistently offer the best possible quality of attention for this segment of the Appalachian population.

Increased understanding of the unique needs of cardiovascular patients will clearly impact treatment planning and delivery of services in Appalachian contexts.

Participants may gain personal insight into their experiences through the process of completing the PRFS questionnaire that would, in turn, impact the nature and quality of services offered. Additionally, the findings of this research may influence change within behavioral cardiology counseling practices and in the structures of cardiovascular rehabilitation in Appalachia.

This researcher hopes to find evidence through archival research and statistical comparison of test scores of the PRFS that the survey is a useful and inclusive tool for cardiovascular rehabilitation counseling in the location of North Central Appalachia.

Additionally, the information gathered from this research will provide the healthcare professional with informed perspectives to focus their ideas of improving the psychosocial practices affecting the cardiovascular patient experience in Appalachia.

Knowledge generated from this study will provide a necessary addition to the current academic literature regarding the needed improvements for counseling persons living with cardiovascular diseases in Appalachia. Developing a greater understanding of the 26

variations of social isolation experiences of Appalachian cardiovascular rehabilitation patients to improve the counselor response to this growing subculture is a core focus of this research.

Limitations

Cardiovascular rehabilitation programs available in this region are as unique as the population in that they have different components of care, unique facets of education and perspective offered by staff, and physical setting specific to location. No cardiovascular program is e exactly like another nor are the participants. However, the overarching goals of patient wellness, rehabilitation success, cardiovascular education, and positive change are commonalities within these communities and among staff

(American Association of Cardiovascular and Pulmonary Rehabilitation, n.d.). A cardiovascular program with a trained counselor on staff, like the one accessed for this study, is a unique model and findings in this study may have limits regarding external validity.

It can be difficult to contact or to recruit for participation in research studies from a group has become stigmatized either by personal circumstance or by association.

People who are traditionally underserved, such as those of Appalachia, may be harder to reach because of distrust (Bradley, Werth, & Hastings, 2012; Halverson, Ma, & Harner,

2008; Helton & Keller, 2010; Russ, 2010; Smith & Holloman, 2011). Use of the cardiovascular rehabilitation program may have provided an efficient countermeasure to this potential problem but has limitations in comparison with an experimental research methodology. A notable limitation of the research is the number of participants who had 27

both pre-and post PRFS scores for comparison. Various reasons such as not completing the PRFD correctly, not finishing the program, leaving questions on the PRFS unanswered, or choosing not to return the assessment contributed to the reduction of the sample size.

Delimitations. Using one cardiovascular program provides a specific sample for study with a preset time limit, program admission, consistent programming, and the same staff providing education, administration, and assistance of interventions. The sample size is 48. In consideration of the small sample, the decision to not use age or gender as variables is a delimitation. Another delimitation is the use of existing data. The information gathered benefits the cardiovascular rehabilitation program providing the data for the study. Access to the records allows for a review of archival information uninfluenced by the research query.

Definitions of Key Terms

Behavioral Cardiology. Behavioral Cardiology is the study and application of psychosocial factors in the assessment and reduction of coronary heart disease risk"

(Thomas, 2006).

Cardiopulmonary Rehabilitation. Cardiovascular rehabilitation may occur after diagnosis of coronary heart disease or as a preventive measure against coronary heart disease. It is a medically supervised program that offers exercise, education, and counseling (American Heart Association, 2016).

Coronary Heart Disease (CHD). CHD is a common term for the buildup of plaque in the arteries of the heart. Plaque leads to blockage which can lead to 28

complications with oxygen and blood flow to the heart, hardening of the arteries and other risks. (American Heart Association, n.d.).

Emotional Guardedness (EG). Emotional guardedness is a tendency to reserve sharing or admitting imperfections or personal flaws. EG can influence cardiac health in negative ways, such as an increase in blood pressure, and possible underreporting of symptoms. EG may also indicate patients who are less likely to endorse or consider negative symptoms (Eichenauer et al., 2010).

Psychosocial Risk Factors. Psychosocial risk factors are behaviors connected to stress that may affect the progress of wellness in patients living with coronary heart disease is associated with the experience of coronary heart disease (Das & O'Keefe, 2008;

Thomas, 2006). Risk Factors include depression, anxiety, anger emotional guardedness, and isolation among others (American Heart Association, 2016; Das & O' Keefe, 2008.

Eichenauer et al. 2010; Krucoff et al., 2013). This research focuses on the factors of emotional guardedness and social isolation.

Social Isolation (SI). Social isolation is a presence of physical factors, in conjunction with emotions such as lack of sense of belonging, and feeling deficient in the quality of social relationships (Nicholson, 2012; Uchino et al., 2012). The ability to reach medical care or experience connection with care providers is a barrier for rural patients and furthers isolation experiences (Mudd-Martin, 2014). Reduced social support can increase the risk for cardiac events (Rozanski et al., 2014). 29

Summary

This chapter introduces the areas of investigation in this study and provides substantial reasons for continued study and the need for further investigation into access and care for the Appalachian patient appear in this section. Research questions and a null hypothesis encapsulate the present quandary. The significance of the study provides the consideration of limitations and delimitations of the study.

The gaps of missing health information about North Central Appalachia creates an opportunity for this study to provide valuable insight toward identifying the presence of psychosocial risk factors for cardiovascular heart disease patients residing in North

Central Appalachia. As previously mentioned, exploring related interactions and reactions of this population to improve healthcare outcomes involving psychosocial risk factors will be understood in the greater context of the bioecological model developed by

Bronfenbrenner.

The literature review in the next chapter examines previous academic works significant to the research and preparation for this study and establishes further reasoning for pursuing the answers to the proposed research questions.

Chapter Two: A Review of the Literature

To establish the rationale for studying the psychosocial risk factor changes this chapter starts with looking at how these risk factors affect participants and connecting the risk factors to healthcare issues participants are facing. This chapter also discusses the psychosocial risk factors associated with cardiovascular heart disease through the proximal lens of developmental psychologist Urie Bronfenbrenner’s Bioecological

Theory. A model of Bronfenbrenner’s bioecological theory with the stages reflecting the experiences of the North Central Appalachian cardiovascular rehabilitation patient appears in this section. The chapter closes with a discussion of the Psychosocial Risk

Factor Survey as an assessment tool for the Appalachian cardiovascular rehabilitation patient.

Psychosocial Risk Factors Related to Coronary Heart Disease

Greater recognition of the psychosocial risk factors is necessary for the improvement of assessment and intervention with CHD (Eichenauer et al., 2010; Purdy,

2013; Rozanski, 2014). Psychosocial approaches are within the realm of behavioral cardiology and are increasingly important in evaluation and treatment of cardiovascular disease (Eichenauer, Feltz, Wilson & Brookings, 2010; Kent & Shapiro,2009; Rozanski,

Blumenthal & Kaplan 1999; Rozanski, 2014; Swenson & Clinch, 2000; Purdy, 2013;

Thomas, 2006; Uchino et al., 2012). The inclusion of psychosocial interventions unique to the cardiac rehabilitation setting is integral to the recovery and care of the rehabilitation participant. 31

Psychosocial risk factors may act as barriers to treatment interventions (Albus,

2010; Fricchione, 2006; Purdy, 2013; Rozanski, 2014). Psychological stress is considered by many to be associated with cardiovascular disease (Albus, 2010; Artham, Lavie &

Milani, 2008; Casey et al., 2009; Clay,2013; Das & O’Keefe, 2008; Kent & Shapiro,

2009; McCraty & Zayas, 2014; Mudd- Martin et al., 2014; Swenson & Clinch, 2000;

Uchino, Bowen, Carlisle, & Birmingham, 2012). Results of clinical research reinforce the belief that management of behavior links to increased wellness (Albus, 2010; Eichenauer et al., 2010; Rozanski et al., 2014). A significant number of studies about mind- body medicine supports the theory that the presence or absence of stress regardless of being acute or chronic in status is connected to various emotional states

Risk factors and the North Central Appalachian. Living in Appalachia comes with some cultural and emotional heritage that is positive as well as negative. Emotional regulation has an impact on health (Rozanski et al., 2014). Risk factors such as diabetes, obesity, and smoking may indicate lower quality of life and less focus on personal wellness (Hendryx & Zullig, 2009; Mudd- Martin et al., 2014; Smith & Holloman, 2011).

These traits are common to many of the health issues Appalachians experience (Hendryx

& Zullig, 2009; Mudd- Martin et al., 2014; Smith & Holloman, 2011). Multiple studies show “low socio-economic status, lack of social support, stress at work and family life, depression, anxiety, and hostility”contribute to the risk of developing coronary heart disease and an increase in patient decline post diagnosis (Hendryx & Zullig, 2009; Mudd-

Martin et al., 2014; Smith & Holloman, 2011). 32

The emotional guardedness scale is described as an intended supporting score to help clarify underreporting on the other PRFS scales (Eichenauer et al., 2010). The presence of the fifth factor in the PRFS, emotional guardedness, helps to predict levels of accuracy or to gather more information while respecting the independence of the patient

(Eichenauer et al., 2010). A better understanding of the emotional guardedness scale may increase counselors to engage patients who may otherwise not show signs of seeking help.

Social isolation may lead to decreased survival and poorer quality of life among those living with CHD (Albus, 2010; Holt-Lunstad, Smith, Baker, Harris & Stephenson,

2015). Research also indicates people who are isolated or emotionally guarded are at increased risk of dying prematurely from CHD (Albus, 2010; Sgofio et al., 2009). Some of these experiences are a result of personal choice and some risk factors emerge from a culture of poverty

Rethinking culture and health care. Connected to seeking help from others is the perception of having or lacking social support or feeling isolated from others. Those living with low levels of support have higher mortality rates from CHD (Uchino et al.,

2012). Understanding the positive and negative factors associated with social isolation may increase our ability to assist in returning to or developing patterns or habits that promote a higher quality of life (Swenson & Clinch, 2000).

The quality of life is important in discerning the extent of the effect living with

CHD has in social, psychological, and physical realms of patients. The capacity to accept and increase social support may act as an intervention against chronic stress and increase 33

the ability to cope better with an illness (Swenson & Clinch, 2000; Uchino et al., 2012).

The value of independence and self- reliance may mask as social isolation to those unfamiliar with them in the community context and importance to people living in North

Central Appalachia (Helton & Keller, 2010).

Values may confuse or mislead healthcare workers reaching out to rehabilitation participants with CHD (Das & O’Keefe, 2008). The ability of healthcare providers to recognize social isolation apart from established Appalachian cultural values, such as outsider mistrust, loyalty to family, and self- reliance, is valuable for those working in

North Central Appalachian communities (Algeo, 2003; Denham, 2005; Russ, 2010).

Helping professionals trying to reach out may be discouraged due to various barriers, including cultural confusion or assumptions that may be interpreted as a lack of consideration or care (Anderson et al., 2003; Helton & Keller, 2010; Keefe, 2005).

Review of patient values is necessary for successful treatment (Anderson et al.,

Farin et al., 2011). The ability to discern the difference between isolation and independence or self- reliance is a key to helping the North Central Appalachian patient.

Efforts to improve lifestyle through counseling and education may meet with high resistance. Multiple sources emphasize the need for stress reduction education and identifying behavioral risks (Fricchione, 2006; Purdy, 2013; Rozanski, Blumenthal &

Kaplan, 1999; Sperry, 2001; Swenson & Clinch, 2000; Thomas, 2006; Uchino, Bowen,

Carlisle, & Birmingham, 2012; Wielgosz & Nolan, 2000).

Limited availability of counseling, education, and specialized cardiovascular care influences multiple risk factors. For example, the lack of adequate care relates to the risk 34

factors of social isolation, depression, and anxiety. Frustration regarding treatment procedures can elicit anxiety, depression, and emotional guardedness. A lack of communication between a person and a caregiver, or a healthcare professional, may increase anxiety and emotional guardedness.

Barriers in the form of resistance to treatment or lack of transportation to an appointment can increase the risk factors of anger, anxiety, depression, emotional guardedness and social isolation. These examples of obstacles are notable issues affecting risk factors for North Central Appalachian cardiovascular patients (Algeo, 2003; Albus,

2010; Bradley et al., 2012; Helton & Keller, 2010; Halverson & Bischak, 2008; Hendryx

& Zullig, 2009; Mudd- Martin et al., 2014; Smith & Holloman, 2013). When applying the common risk factors to issues in North Central Appalachian healthcare, connections may detect the ways risk factors measured by the PRFS reflect the connections between

Bronfenbrenner’s bioecological theory and the bioecological systems of the rehabilitation participant.

Bronfenbrenner’s Bioecological Theory

Bronfenbrenner’s theory revisions as covered in his final work, Making Human

Beings Human: Bioecological Perspectives on Human Development (2005), is an optimal framework for this research. Bronfenbrenner (2005) states the “evolving” theory is developmental and ongoing, like life is and “deals with the developmental process of… the phenomenon under investigation…and the scientific tools assessing continuity and change” (p.4). Risk factors, navigation of health care issues, interactions with others, and research are components of this research that fit within the scope of Bronfenbrenner’s 35

Bioecological Theory. Bronfenbrenner believed close interactions exist in the larger social structures of community, society, economics, and politics. “Social development applies not only to the individual but also to the social organization of which he is a part”

(Bronfenbrenner, 2005, p. 22).

Applying Bronfenbrenner’s bioecological theory enables research to uncover richer data as the patterns of intersecting systems reveal the subtle influences of health, culture and family in the daily experiences and actions of cardiovascular rehabilitation patients in Appalachia. The use of Bronfenbrenner’s theory as a framework allows research to envision the impact of the PRFS within the various systems of research participant’s social and emotional interactions. Combined with other factors, personal wellness is a useful gauge of the quality of life. (Hendryx& Zullig, 2009; Mudd- Martin et al., 2014; Smith & Holloman, 2011).

The microsystem refers to the individual. Our own perceptions, values and established patterns of self-care affect us and those closest to us. The microsystem incudes the self, parents, siblings, and those closest to us. The mesosystem is where the influences of school, home, work, and what we spend most of our time participating in intertwine. Many microsystem elements weave in and out of the mesosystem. Within the exosystem is the presence of healthcare, social services, local community, employment systems of spouse, family members or peers. Macrosystems are the larger influences that 36

Figure 2.A model of the Bronfenbrenner Bioecological Theory showing the various potential systems affecting the individual. Adapted from, “The importance of context: Vietnamese, Somali, and Iranian refugee mothers discuss their resettled lives and involvement in their children’s schools,” by J.L. McBrien, 2011, Compare: A Journal of Comparative and International Education, 41:1, p.79.

the individual may be conscience of but not fully aware of all the time such as social values, ideologies, culture and recognized larger but often distant influences like government policies or offices, or rights and responsibilities as a citizen. The

Chronosystem is the affect all these systems have upon the individual over the course of time. We change opinion and belief, we combine values and integrate new pieces of culture, information and global influence at ever evolving rates that are often hard to recognize.

This recognition of wellness as a quality of life issue brings behavioral cardiology into the treatment of those living with CHD. The bioecological theory and its application 37

to psychosocial risk factors may, like other representations, affect treatment plans, goal - setting and program outcomes (Bronfenbrenner, 2005; Orto & Power, 2007). Using

Bronfenbrenner’s theory to reveal systems affecting CHD and North Central Appalachian people enables a better understanding of how counseling benefits the participants of this research.

A model of Bronfenbrenner’s bioecological theory reflecting these issues and proximal relationships of North Central Appalachian cardiovascular rehabilitation participants may look like this-

MICRO Appalachian Cardivascular Rehabilitation participant

MESO Rehabilitaiton program and staff, counselor, family, friends, religious community EXO Healthcare system, Medcaid, cardiac education , psychosocial assessments

MACRO Appalachian cultural values, access to care, government, work CHRONO Current and historical perceptions of culture and the adaptations occuring to the individual from personal and professional changes over time

Figure 3. A bioecological model of North Central Appalachian participant systems in a cardiovascular rehabilitation setting using a framework established by the Bronfenbrenner model. Adapted from, “The importance of context: Vietnamese, Somali, and Iranian refugee mothers discuss their resettled lives and involvement in their children’s schools,” by J.L. McBrien, 2011, Compare: A Journal of Comparative and International Education, 41:1, p.79, B. Fulton, 2017. 38

Current Risk Factors in Appalachia

The high rates of CHD in Appalachia may reflect sociocultural, environmental, physical and behavioral factors (Hendryx & Zullig, 2009; Mud- Martin et al., 2014;

Smith & Holloman, 2011). Problems faced by rural residents, such as poverty, lack of transportation, lower quality education, substance abuse, diabetes, obesity, lack of mental health providers, and the absence of healthcare providers in general, may complicate physical or mental health care (Smith & Holloman, 2011). The term “rural” suggests many things to many people. Earlier studies use descriptions and characteristics such as agricultural landscapes, isolation, small towns, and low population density (Algeo, 2003;

Bradley et al., 2012; Hart, Larson, & Lishner, 2005).

Research from Smith and Hollowman (2011) indicates rural populations, in general, are thought to have greater amounts of older adults and children, higher unemployment, and underemployment rates, and “lower population density with higher percentages of poor, uninsured, and underinsured residents”. (p.102) Forty-two percent of the Appalachian regions population is rural, compared with 20 percent of the nation’s overall rural population (ARC, 2012). Distrust of people not familiar with or not from the countryside creates difficulty in building rapport with clients of Appalachian culture

(Russ, 2010).

Stereotypes and stigma continue to follow the rural people of Appalachia wherever they are, at home or abroad, on television, or in print (Algeo, 2003; Halverson,

Ma, & Harner, 2008; Helton & Keller, 2010; Knotts & Livingston, 2010; Martin, 2016;

Smith & Holloman, 2011). In 1964, the magazine LIFE used the photographs of John 39

Dominis (Dominis, 1964) to illustrate poverty prevalent in Kentucky, further entwining the observations of poverty and all regions Appalachia. The photojournalism of Dominis brought the living conditions of persons living in Appalachia to the center of attention the public. More people outside of the region took notice of the environment of poverty and poor health prevalent in the areas of Appalachia due to the illustrated story of the photographers chosen pictures.

Perceptions of Appalachian Americans

It is important to remember that photojournalism, and other types of media often provide another example of someone from an outside perspective choosing how a group of people portrays to others. This type of social injustice in the bioecological systems of the Appalachian peoples continues to the present day. Current popular media continue to build and grow the myths of the barefoot and violent hillbilly, or the noble savage

(Algeo, 2003; Cooper, Knotts & Elder, 2001; Mudd-Martin, 2014, Russ, 2010). Many of the stereotypes have not changed in decades. Even with economic, political and social change, the Appalachian American, even when praised, is placed in isolation and regarded as lesser by the American population, at large (Biggers, J., 2005).

Of interest to note is that Appalachia has higher rates of high school graduates than much of the nation (Annual Strategy Statement for Implementation of Appalachian

Regional Commission Programs to the Appalachian Regional Commission. 8, 2014)

When people, in any situation or place, abuse their own power and perpetuate stereotypes, real damage is done as a result of such embellishments. Truth can be distorted, and injustice grows and spreads. Often, the people oppressed by such words fail 40

to recognize their own oppression. In this sociopolitical state of half-truth, it is critical that healthcare professionals utilize their skills of deconstructing bias, stereotypes and labels.

How do we know what the Appalachian cardiovascular rehabilitation participant is experiencing in recovery and health changes? We return to the words of the

Appalachian person. When people embrace, or discover the power to tell their own stories, deep healing and increased wellness can occur.

Absence of care in Appalachia. A 2015 executive summary for the ARC titled,

Appalachia Then and Now: Examining Changes to the Appalachian Region Since 1965, states that when the Appalachian Regional Commission was formed in the 1960’s,

“living standards in Appalachia, as measured by the health and well-being of the population”, were “well below those of the rest of the nation”. (p.5) Appalachian living standards remain below the standards of the nation, including the area of this study

(ARC, 2015). Mortality rates continue to remain at higher averages in Appalachia even as they continue to reduce outside the region (ARC, 2015). Possible explanations include lack of access to care and advancement of age in the overall population (ARC, 2015;

Mudd-Martin et al., 2014). High rates of substance abuse and cancer are not necessarily unique to Appalachia, yet the lack of care available and the challenges of health care combine to create a barrier for many in the region.

An absence of cardiovascular resources could help to explain the high mortality rate from heart disease as mentioned in chapter one (Halverson, Ma, & Harner, 2004;

ODH, 2013). This information can help the arrangement of teachable and relevant 41

methods of best practices, assist in bridging the gaps of care, confronting the lack of advocacy, and showing the need for increasing ways to adequately address the high mortality rates from CHD in North Central Appalachia. The tendency of psychosocial risk factors and physical risk factors such as obesity, high blood pressure, and diabetes to aggregate in the same individuals and groups has important implications for strategies to modify risk and improve the quality of life (Albus, 2010).

Studies show depression, anxiety and social isolation are risk factors for increased cardiac-related health issues (Ginsberg, 2105; Rozanski, Blumenthal & Kaplan, 1999;

Swenson & Clench, 2000). To reduce risk, properly identifying positive and negative risk factors is necessary (Thomas, 2016). Few cardiovascular rehabilitation programs integrate a balanced approach of teaching mind and body interventions (Casey et al.,

2009). Few hospitals have the finances, staff, and basic materials needed to implement such changes now (Skinner, Franz & Keller, 2017). However, as behavioral and ecological models show, community involvement and support can assist in overcoming many challenges once the primary needs or core components of a program are met.

Through volunteerism, fundraising, and support from other local agencies and businesses, programs focusing on healthy eating, stress reduction, exercise and other preventive measures can thrive in rural areas.

Programs that provide one-to-one and group meetings, retain healthcare professionals to assess levels of psychological stress and teach stress management are beneficial for CHD patients (Casey et al.,2009; Rozanski et al. 2014). The process of the program at the chosen location for this study measures behavioral outcomes as specified 42

by the American Association of Cardiovascular and Pulmonary Rehabilitation

(AACVPR) includes “comprehensive cardiovascular patient assessment; management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues”. (p.5-8)

Using the PRFS as an assessment tool is part of the psychosocial education component of the cardiovascular rehabilitation program this takes its data from for analysis. Using the scores of the PRFS and then reviewing the patient summaries for richer depth will allow for a better understanding of the theoretical bioecological interactions of emotional guardedness and social isolation of this specific group fit together.

The Psychosocial Risk Factor Survey

The PRFS identifies depression, anxiety, anger/hostility and social isolation as factors connected to CHD’s occurrence, progress, and cause of mortality (Eichenauer et al., 2010). The Psychosocial Risk Factor Survey (PRFS) is a self-administered assessment designed specifically for use with the cardiovascular rehabilitation population

(Eichenauer et al., 2010). The PRFS is a validated instrument with a fourth-grade reading level. Initial validation of the instrument occurred in two stages during two different time periods (Eichenauer et al., 2010). The sample population used during the validation process of the PRFS consisted of patients from cardiac rehabilitation programs in the

Midwest United States from 2002 to 2004 and again from the Midwest region from 2004 to 2006 (Eichenauer et al.,2010). 43

Overall, 364 cardiac rehabilitation patients from programs located in the Midwest of the United States completed the PRFS and at least one other risk factor instrument for comparison. Participant composition was 61.8 % percent men and 38.2% women. The mean age was 61.2 years with a standard deviation of 11.1 years (Eichenauer et al.,

2010). The results of the analysis show concurrent validity correlations between the

PRFS and the comparison instruments were statistically significant.

A possible limitation of the PRFS validation process study is the specificity of the sample population of participants and their location in the Midwest of the United States

(Eichenauer et al., 2010). Acknowledging this limit, Eichenauer and the research team for the PRFS raises the question of whether significant differences exist in larger urban areas, or on either coast. (Eichenauer et al., 2010). The experiences of the North Central

Appalachian and health care provider determining the appropriate course of treatment seems marginally explored in cardiovascular research. The PRFS may assist in reducing some conflicts or confusion in determining best practices for patient care (Eichenauer et al., 2010). It is of value to note the Eichenauer and his associates state that patients who underreport psychosocial risk factors are likely to exhibit higher mortality rates that patients who do not.

Summary

In this chapter, some of the significant environmental and health disparities as part of living in Appalachia (Morrone, Kruse, & Chadwick, 2014; Mudd-Martin et al.,

2014) emerge through the lens of Bronfenbrenner’s bioecological theory. In the context of psychosocial functioning, a change of mind can mean a change of heart (Das & 44

O’Keefe, 2008). An individual’s psychosocial outlook is critical and modifiable by addressing CHD risk factors and the systems surrounding them.

This chapter illustrates further benefits of the PRFS. The PRFS provides a streamlined psychometric assessment which negates the need for several psychometric instruments, and is cost-effective as well as efficient. The risk factors addressed by the

PRFS are key issues in assessing cardiovascular rehabilitation potential (Eichenauer et al., 2010). The results of this research may lead to better translation of patient communications and behaviors. A better understanding of the patient will enable more efficient strategies to enhance individual and community decisions on health.

Promising research findings are helpful and have meaning if they are shared with the people the research was carried out to support. Hopefully, some of this work will add to progress in reduction of heart disease in North Central Appalachia. The methodology for further assessing the use of the PRFS with the North Central Appalachian population is the largest component of the next chapter.

Chapter Three: Methodology

This chapter supports the chosen methods of research design used to explore the data and test the proposed hypotheses. The research hypotheses for this study ask if important differences exist between pre-and post-scores for the PRFS. Also, the research questions whether the risk factors are identifiable in themes that may emerge from document review of participant program files.

Further exploration investigates the possible factors present in the highest and lowest score sets that may explain differences. This research is descriptive in nature as it concerns the use of the PRFS with a specific population (North Central Appalachian cardiovascular rehabilitation patients). The hypothesis proposed in this study tests the increase and decrease of the five risk factors of the PRFS survey.

The procedure for selecting the population for the study is described and presented as appropriate for this research. Motivations for assembling data from patients and for measuring the data are in this chapter. The characteristics of mixed method research provide the reader and future researchers a clear line of a process for a better understanding of the data and what it may reveal.

Research Design

Methodologist John Creswell proposes the following systematic framework of four questions to develop mixed methods research: These questions focus on sequence, methodology, integration, and theoretical perspective (Creswell, 2003).

Answering Creswell’s four questions reveals foundational information for this research and supports the validity of undertaking this work to add to the body of existing 46

data regarding psychosocial risk factors and the use of the PRFS survey. The most efficient way to study the research hypotheses regarding North Central Appalachian cardiovascular patients and the efficacy of the PRFS is the use of a mixed methods research approach with a sequential design. Using this design allows for document review and analysis of existing data to evaluate the fit of the instrument to gauge psychosocial changes. These changes are possibly influenced by behavioral health education and counseling with North Central Appalachian patients in a cardiovascular rehabilitation program.

Data collection moved from the qualitative interviews and file summaries of patients to the quantitative data gathered from the PRFS. Some forms of integration between quantitative and qualitative data included a review of patient intake and closing interviews, following the formation of populations to gather additional detail affirming statistical findings, and linking data to create an understanding of contextual factors.

Interpretation of the results appears through a narrative that uses information collected from document review to support the concepts that emerge as well incorporating data transformation (Fetters, Curry & Creswell, 2013).

Counselors and counselor educators are reminded by researchers Frels and

Onwuegbuzie (2013) that combining qualitative and quantitative methods is not a novel or exclusive occurrence in counseling research. Responding to Creswell’s four questions

(2003) informs us that the process of gathering data is largely within the realm of qualitative research, and the analysis components are quantitative and qualitative. The 47

product of this exploration helps generate new ways of treating patients with cardiovascular health issues in rural areas, specifically North Central Appalachia.

Ethical considerations. The basic ethical principles underlying the acceptable conduct of research involving human subjects according to the Belmont Report (1978) of respect for persons, beneficence, and justice, are acknowledged as the three essential requirements for the ethical conduct of research involving human subjects. The Belmont

Report define them as follows:

Respect for persons involves recognition of the personal dignity and autonomy of

individuals, and special protection of those persons with diminished autonomy.

Beneficence entails an obligation to protect persons from harm by maximizing

anticipated benefits and minimizing possible risks of harm. Justice requires that

the benefits and burdens of research be distributed fairly. (Part B. Basic Ethical

Principles)

Counselor educators use five guiding ethical principles to frame our decisions:

Nonmaleficence is our obligation not to inflict harm intentionally. Beneficence entails the doing of active good. Fidelity shows our faithfulness to our duties to be truthful and to respect the rights and responsibilities of others. Justice is the responsibility of the counselor to treat people fairly; and Autonomy is honoring the rights of our clients to make choices for themselves freely. (Beauchamp & Childress, 2001; Kitchener, 1984).

Adherence to these guiding ethical components of the counseling profession is continuously present in the methodology of this research. An institutional review board proposal requesting expedited review was submitted to Ohio University’s review board 48

for approval following the dissertation proposal. The reasoning for expedited review was the use of existing data gathered for purposes other than research.

Sharing an emotional experience is not without hazard; multiple aspects of the counseling provided to cardiopulmonary rehabilitation patients sought to minimize potential discomfort or distress including the offering of a local resources handout and several individual encounters with the program counselor throughout the rehabilitation process. Offering further information to clients is a component of best practices and occurs as part of the program protocol. The motivation of the researcher at the time of patient experience in the program was not to gather data for research, but to provide the best care possible.

Research Question(s) and Hypothesis

The research questions address the use of the PRFS with Appalachian cardiovascular rehabilitation patients in a single program located in North Central

Appalachia. The first question in quantitative and leads to further query.

1. Are changes evident in the comparison of psychosocial risk factor survey

pre-and post-test scores of Appalachian cardiovascular rehabilitation

patients?

Null hypothesis: There is no change evident in the comparison of the psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients.

The statistical significance of the findings leads to an archival review of documents in the qualitative second research question. The second question seeks to determine if one or 49

several risk factors emerge as higher prevalence than the others. Using Bronfenbrenner’s

Theory allows for patterns emphasizing the risk factors to emerge from within the system constructs of Appalachian culture.

2. What themes emerge from document review of the highest and lowest

populations created by the analysis of question one?

Criteria for Participation

The criteria set for inclusion in the study requires that the participant has coronary heart disease, is from North Central Appalachia, and has successfully completed the cardiopulmonary rehabilitation program at the research location using the psychosocial risk factor survey instrument as part of the assessment process. Prospective participants have data on file collected by the staff of the program. Participants have completed a pre- and post-program psychosocial risk factor survey.

The Cardiovascular Rehabilitation Program

Participants enter a cardiopulmonary rehabilitation program that includes cardiovascular monitoring, physical exercise, dietary counseling, smoking cessation, stress reduction and counseling, and health education activities. The levels of exercise participants do are in correlation to the condition of their lungs and heart as determined by the staff and Medical Director. Participants agree to engage three times per week in the rehabilitation program. Professional staff provide leadership to direct activities and monitor levels of wellness to clarify levels are within safe parameters. The program is 12 weeks but may take longer or less than 12 weeks actual time if participants miss program days or improve at faster rates than what is considered typical. The medical director may 50

determine if early completion is possible, meaning that improvements made within in a shorter time frame meet program requirements for conclusion of the rehabilitation process of the program.

Due to incompletion of the PRFS some participants had one set of scores and were therefore not included in the study. This specific instrument has been used by the

Heart Works program within the past two years. Participants are a part of the study who have been attendees of the program within that time frame Due to location of the program, participants live within the defined sub region of Appalachia know as North

Central Appalachia.

Counties in the state of Ohio that are considered part of North Central Appalachia include: Adams, Ashtabula, Athens, Belmont, Brown, Carroll, Clermont, Columbiana,

Coshocton, Gallia, Guernsey, Harrison, Highland, Hocking, Holmes, Jackson, Jefferson,

Lawrence, Mahoning, Meigs, Monroe, Morgan, Muskingum, Noble, Perry, Pike, Ross,

Scioto, Trumbull, Tuscarawas, Vinton, and Washington counties (Appalachian Regional

Commission, n.d.). People who are traditionally underserved may be harder to reach because of a variety of personal or socio-demographic characteristics (Russ, 2011; Smith

& Holloman, 2011).

The criteria of being Appalachian is an indicator of possible reluctance to participate in research due to the characteristic of distrust of outsiders (Mudd- Martin,

2014; Russ, 2011). Equally difficult to contact or to recruit for participation in research studies are those in which the target group has become stigmatized either by personal circumstance, such as an illness (Hill et al. 2005). Factors contributing to illness such as 51

lack of transportation, or poverty may also cause stigma (Russ, 2008). The power of these concerns and mistrust influences the sample size and diversity of the patient data gathered for investigation.

Researcher Participation in Data Collection

From August 2014 to August 2016, the researcher was the counselor for the specified cardiopulmonary rehabilitation program used for this research. The counseling opening was filled by the researcher as a graduate assistantship. The specified cardiopulmonary rehabilitation program is located within a local hospital. The key responsibilities of the counselor were to assist patients, teach the four psychosocial lectures in the patient education curriculum and update exiting programming and measures to incorporate current methods, practice and therapeutic techniques associated with psychosocial aspects of patient care.

The incentive for gathering such data was to adhere to best practices as a licensed professional counselor and to fulfill requirements of the graduate assistantship. The information shared or gathered during the graduate assistantship was not intended as potential data for research outside of hospital use at the time interviews, PRFS scores and subsequent data was gathered by the researcher and other program staff.

The researcher noticed significant score changes on some of the psychosocial risk factor survey (PRFS) measures in the process of creating summary reports for the program director and for their academic supervisor. While conducting research with cardiovascular patients and behavioral techniques was considered for future studies, the value of learning why such significant changes were seen with the PRFS became a more 52

compelling motivation for further work with this specific assessment and its use in a cardiopulmonary program as time progressed.

The decision to pursue the gathered data for research was made after discussion and approval with the dissertation chair and committee methodologist in May of 2016.

The validity of the research also depends upon the presence of the researcher within the data (Patton, 2002). With this awareness, the researcher continued to use the same interview questions and data scoring and entry of the PRFS was done by an intern as well as other staff to promote distance by the researcher from the PRFS. All material has been coded and identifying information removed to preserve anonymity and patient privilege by the program director prior to being presented to the researcher for analysis.

Bias regarding the research focus, trust in patients, levels of involvement, and mutual respect of each other are just a few of the ways the data can be affected in the use of qualitative research (Charmaz, 2006 Patton, 2002). The researcher explored their own bias and expectations of the study, so these influences were acknowledged as part of the biases encountered is research such as possible rating effect occurring during document review.

Data collection procedures. Informed consent contains three elements: information, comprehension, and voluntariness (Belmont Report, 1978). The research incorporates these components when the verbal and written consent of the research patient is attained. The cardiopulmonary rehabilitation program gives each patient to sign a consent form allowing information to be used for research and educational purposes. 53

An additional feature of data collection is the use of a disclosure of information for educational purposes document is signed prior to beginning the program. It is not anticipated that serious discomfort would be an aspect of sharing for patients. The researcher has no contact with the program patients regarding any specific program aspect until they meet for their intake assessment.

In the intake assessment, a semi-structured interview was planned for each patient inquiring about experiences regarding: the cardiac event and other possible existing health issues, concerns regarding health and wellness, family health, relationships and support systems, diet, exercise and sleep habits, experiences with depression, anger, or suicidal ideation. Reliable research results come from fieldwork and quality depends on skillful interviewing, knowledge, practice, and creativity (Charmaz, 2006; Patton, 2002).

The semi -structured interview offers the opportunity for the interviewee to exercise their voice and experiences and be heard (Charmaz, 2006; Patton, 2002). The use of a semi-structured interview format for data collection enables collection of consistent data from patients as well as the opportunity for deeper exploration of singular experiences (Charmaz, 2006; Patton, 2002). The face-to-face interviews ensure that the data gathered contained as much detail as possible for each patient. This process often allows for rapport to begin building between counselor and patient (Charmaz, 2006)

For individuals identifying as Appalachian or being from the region of

Appalachia, there is a precedence of not being heard by outsiders (Russ, 2011). This may add to the emotional guardedness within the larger and more intimate systems of

Appalachian culture. Another positive use of the semi-structured interviews presents 54

participants with the freedom to express their views in their own terms, providing reliable, comparable qualitative data that supports, and often clarifies, quantitative measures (Frels & Onwuegbuzie, 2013; Hill et al., 2005)

Data collection analysis. Computers used for research at the specified cardiopulmonary rehabilitation program are password protected and all data is encrypted for added security and data restriction. A copy of the report and the notes from the interview are placed in the patients’ medical file. All files are stored in locked drawers in the main area of the program center until patient discharge from the program. Then files are sent to medical records for storage.

The researcher access to all patient information ended in August of 2016 with the conclusion of the graduate assistantship. This action reduces further contamination of data involving the researcher. The computer of the primary researcher uses a password and encryption software as security measures safeguarding the information received from specified cardiopulmonary rehabilitation program and the resulting data analysis.

Data collection analysis for this research was carried out through document

review after the psychosocial risk factor survey scores were analyzed.in April 2017,

following the approval of the research proposal. The PRFS scores of 65 participants who

attended the program between May 2015 and May 2016 were sent to the researcher by

the program director after all identifying data was removed and the data coded as

required by the program and the Health Insurance Portability and Accountability Act

(HIPAA). 55

The process of further cleaning data included removal of 15 participant records because of not having two PRFS scores for comparison, having a pulmonary diagnosis, or incorrect scoring of the PRFS. The remaining 48 participants of the recorded scores sent to the researcher met all criteria for inclusion in the study. The information was transferred from a Microsoft Excel document to the IBM SPSS program to discover the results for research question one.

Finding the answer to question one involved running paired T- Tests using the

SPSS program to analyze the pre-and post PRFS scores of 48 participants. The t test enabled the creation of specific populations from the data. A Wilcoxon signed ranks test was used to order the observations for further establishing the validity of the populations.

The resulting ten highest and ten lowest ranks were then submitted to the program director using their assigned identification code. The program director then gathered the reports from their medical files and removed identifying information in accord with program and HIPPA legislation. The 20 program report summaries were reviewed for exploration of common themes. Analysis of the qualitative data retrieved from specified cardiovascular rehabilitation program files revealed several themes and provided richer information integral to the practice of behavioral cardiology in North Central Appalachia.

Summary

Chapter three focused on the methodology used for analyses of collected data from 48 participants to create populations that explore CHD patients increase or decrease of isolation and emotional guardedness before and after participating in a cardiovascular rehabilitation program. Different factors of data collection and use were described. 56

The ethical stance of using the information gathered for review and the motivation of the researcher were explored and clarity of intellectual honesty established. Researcher roles and protection of data while in use was explained. The value of discovering further knowledge regarding North Central Appalachian behavioral cardiology and increasing awareness of psychosocial risk factors signifying cardiovascular issues is presented.

After sorting of data into two populations representing the highest and lowest overall scores, 20 patients’ program summary files were used to conduct further studies.

Bronfenbrenner’s bioecological model shows the emerging themes from archival document review. Results of the data analyses are presented in Chapter four.

Chapter Four: Results

The outcomes of paired t-tests, Wilcoxon-signed ranks test and the results of the qualitative analysis are core components for this chapter. A description of the sample populations emerged from reviewing the bioecological systems of participants. Further details of document analysis revealed possible themes that affected the PRFS scores.

Brief point by point summaries present the results.

Description of the Participants

All participants in the research were graduates of the cardiovascular rehabilitation program located in North Central Appalachia. Due to incompletion of the PRFS, some participants had only one set of scores and were therefore not included in the study.

Participants had data on file collected by the staff of the cardiovascular rehabilitation program that was part of the qualitative analysis. These documents were the semi- structured interview from the intake assessment and the summary of progress from the closing session with the program counselor. Participants lived within the defined sub- region of Appalachia known as North Central Appalachia.

The quantitative sample was 48 participants from North Central Appalachia who had a diagnosis of CHD, pre- and post-program PRFS scores, and were graduates of the same cardiovascular rehabilitation program. The quantitative analysis created samples of the ten participants with the most change in overall score and ten participants with the least change in overall score. The Wilcoxon signed ranks test provided further weight to the t-tests, adding to the assurance of the cases selected for further study. 58

Qualitative samples emerged from the analysis of the original 48 participants. The

20 participant records chosen for qualitative document review consisted of ten overall scores that showed the most amount of change in total score from the beginning of the program and the ten overall scores that showed the least amount of change in score from the start of the program to the end of the program.

Age and gender were representative of selected socio-demographic data as self- reported by participants. These items were in the PRFS and the cardiovascular rehabilitation program files. Their inclusion allowed for more accurate data in comparison to state or nationwide figures for these areas. These items were not considered as variables for this study due to the small sample sizes the research covers.

However, the information regarding age and gender provided context and depth to the data.

The age of the participants in this study ranged from 42 to 94 years old with the most frequently reported age out of 48 cases being 66 years of age and mostly male.

Qualitative data may further tell how the median age group perceives cardiovascular heart disease. Further consideration of gender as a factor merits attention for more research.

Research Questions

The primary goal of the research presented was to study the change scores in psychosocial risk factor scales of North Central Appalachian cardiovascular rehabilitation patients and review existing documents to look for bioecological patterns that may support the changes. The first research question used several methods to determine what 59

changes were evident in the comparison of psychosocial risk factor survey pre-and post- test scores of Appalachian cardiovascular rehabilitation patients. These results created the samples for further research.

Research Question One (Quantitative)

The first question was quantitative and led to the development of the samples for qualitative analysis.

Are changes evident in the comparison of psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients?

Null hypothesis: There is no change evident in the comparison of the psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients.

Descriptive measures confirmed the rejection of the null hypothesis. There was change evident in the comparison of the psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients. Further quantitative analysis of the data showed the t- the nonparametric Wilcoxonsigned ranks test supported test ranking of the coded cases. The variables used were the pre-and post-programs total scores of all five scales.

Pre- and post- scores of the PRFS. A series of paired-samples t-test were conducted to compare the scores of the psychosocial risk factor survey subscales before and after a cardiovascular rehabilitation program (see Table 1). The scores of the pre

PRFS (M=109.04, SD=29.784) and post PRFS overall scores (M=102.13, SD=29.798) conditions; t (47) = 2.5, p = 0.014 indicated there was an overall reduction in PRFS 60

scores. However, considering the subscales individually, differences emerged for the depression and anger/ hostility subscales.

Specifically, there was a significant decrease in depression scores after (M =

16.90, SD = 8.45) as compared to before (M=20.83, SD =9.36) the cardiovascular rehabilitation program. Additionally, there was a marginal decrease in anger /hostility scores after (M= 20.48, SD = 8.78) as compared to before (M =22.06, SD = 9.88). These results suggested that the cardiovascular rehabilitation program interventions reduce some but not all psychosocial risk factors measured by the psychosocial risk factor survey.

Table 1

Paired Samples Test of PRFS Scales Using Pre- and Post-Program Scores PRFS Scales Pre-and Post M D SEM t Sig. (2-tailed) Total scores of all scales 6.917 18.782 2.711 2.551 .014

Depression 3.938 6.262 .904 4.357 .000

Anxiety 1.333 7.003 1.011 1.319 .193

Anger and Hostility 1.583 5.508 .795 1.992 .052

Social Isolation -.354 5.310 .766 -.462 .646

Emotional Guardedness -.292 4.385 .633 -.461 .647

Note: n=48 and p=.005. The cases are from the specified cardiovascular rehabilitation program located in North Central Appalachia.

A closer look at the results of the table above shows the depression scales results as t =2.551, p = <. 001. The results convey that in the depression scales pre- and post- 61

scores, the p value was low enough that for the depression scales we might accept the hypothesis. However, this also indicated that to reach such strong conclusions it was necessary to continue our mixed methods and search for practical information regarding depression in the archival documents of our qualitative data.

The Wilcoxon signed ranks test further supported the arrangement of cases that allowed the two samples for a qualitative study to emerge. It showed that of our 48 cases,

10 had positive differences in the overall test scores while 36 cases had negative differences. Two cases had the same pre-and post-score. Looking at the information below, the data showed the Wilcoxon signed ranks test indicated the median post-test ranks were significantly higher than the median pre-test ranks Z =97, p <.011.

Review of risk factor scales. Each risk factor comparison of pre-and post cores had the potential to reveal more information specific to this population. While the results focused more on the greater disparities found in the Depression and Anger/ Hostility scales, looking at the remaining scales provides an overview and greater context. These comparisons are in the appendices. 62

Figure 4. This shows the results of a Wilcoxon signed ranks test supporting the null hypothesis for research question one. The Wilcoxon signed ranks test shows many cases indicates a higher amount of negative differences are present when comparing the pre- and post- PRFS scores. This nonparametric test strengthens the validity of the paired t-tests. B. Fulton, 2017.

Research Question Two (Qualitative)

This question indicated a search to find themes and possible connections in the

bioecological systems of participants.

2. What patterns emerge from document review of the highest and lowest

populations created by the analysis of question one?

The statistical significance of the findings led to an archival review of materials in the

qualitative second research question. Coding of the archival documents occurred before

the researcher reviewed the materials. Coding includes removal of data that may reveal

identity. The removal of these details reduced bias on the part of in the investigator. Bias

has the potential to contaminate findings. The coded documents included the intake 63

summary, the scores of the PRFS from the start of the program, any progress notes taken by the counselor, the closing summary and the PRFS scores from the end of the program.

A semi- structured interview was part of the intake and assessment process that helped to create the intake summary. Areas such as general health information, family, and social background, as well as perceptions of counseling and wellness were within the realm of inquiry during the intake interview. Additionally, the intake interview sought information regarding present issues and past matters affecting the participant’s psychological, emotional, behavioral and physical health.

The interview summaries were a useful guide in the search for the patterns the

Bronfenbrenner bioecological model indicated may be present. This process of content analysis created the pattern or identified the themes that were meaningful to the research.

Documents are reliable sources; they can be “read and reviewed multiple times and remain unchanged by the researcher’s influence or research process” (Bowen, 2009, p.

31).The process of analysis continued with a review of the chosen cases for themes that emerged. An examination of words, phrases, experiences, and environments that reoccur in the cases followed the initial review. Further protection of identity for participants and an increase of distancing from the origin of information for the researcher was found by giving each case number an appropriate pseudonym for reference.

Sample One

The summary of these cases revealed some common themes through analysis.

Indicators of risk factors, such as depression, and other meaningful connections, provided information that helped improve programming. The first sample consisted of 10 cases 64

whose overall PRFS scores changed the most at the end of the program from the beginning of the program. The following summaries constructed the emerging themes, risk factors, and information that illustrated the influence of biopsychosocial systems.

Adam. This participant was married, male, a former smoker, and had no children.

He stated feeling hyper- aware of his health history in the intake interview. He had marriage counseling in the distant past but no other kind of counseling until the program.

At the time of the intake interview for the program, he shared being recently retired from a small college where he taught computer-assisted design classes. Adam also had a certification and license in massage therapy. He showed interest in no specific faith tradition, but was raised in what he describes as a fundamental Christian home. He defined himself now as being open to the universe.

Regarding stress, he said his outlook was "that things are neither good or bad and much of our stress depends on how we previewed it." In the intake interview, he shared he is ironic and observant but not very social. Walking, riding bikes with his wife and being outdoors were ways Adam kept physically fit. He said he felt younger after the program due to having improved stamina.

Angela. This participant was female, married with children and had no response when asked about her feelings regarding her health history. She has received clinical mental health outpatient counseling before from a local agency. Angela began smoking at age 14 and continues to do so. Her daily use at the time of intake interview was lowering from a pack a day down to three cigarettes a day. Social involvement consisted of time spent with her family. 65

Her husband is an evangelical preacher, and Angela indicated stress is part of their lives due to his job. To reduce stress, she played games on a computer and enjoyed coloring to relax. Her stress during the program did not decrease according to Angela, and her stress continued to grow due to her husband's job.

Bob. This participant was married and was living with diabetes as well as CHD.

He shared being angry regarding his health history. Bob experienced poor sleep achieving two to three hours a night which led to naps during the day. He said stressors for him included: isolation, relationship issues, anger, and grief. Bob's close friend recently died, and he continued to miss his sister who died several years ago. He shared he had limited social involvement, and he was aware of his anger issues.

Bob played computer games and watched television to relax. He related he felt healthier at the end of the program and he used deep breathing once in a while to relax.

Stress reduction, anger, and ways to communicate in a healthier way were topics Bob discussed with the program counselor.

Brenda. This female participant possessed an extensive family history of CHD and was last living member of her family. From seeing the health issues of the family to being a caregiver for her first spouse before his death, Brenda came to the program with awareness of the need for self-care. She shared that she slepts well, recognized her stress when feeling overwhelmed, and she was thankful for her strong support system.

She enjoyed attending church and found happiness in helping others. Brenda walked for exercise and took the time to pray. She often prayed about her health and journaled her health habits. After the program, she felt better than before as well as 66

feeling stronger physically. Brenda said she is more relaxed. She said that the mindfulness and spirituality topics were helpful parts of the program for her.

Cathy. This participant was married and shared that her CHD event was unexpected even though there was a dense family history of CHD and heart attacks in both parent’s families. Cathy expressed her difficulties in adjusting to retirement but that she enjoyed having time to travel and do hobbies with friends. Her spiritual background was connected to being Methodist and strongly believing in her faith.

Cathy stated she believed general stress and anxiety were a part of her personality.

She was a light sleeper and found time management, details, and personal pressure to be her biggest stressors. During the program, she reduced responsibilities to relax and liked the concept of mindfulness. Cathy shared having a pet is not relaxing for her, and she was

"not a fan!" of her dog.

Chad. This participant was male and married with children. He was anxious regarding his health and shared he felt much worry in different areas of his life including poor sleep. He was unhappy with his employment. Finances were tight. He knew smoking was not good for him and worried about its effects. Chad worried about his children, their addictions and how that impacted the rest of the family. Social interaction with others consisted of time with family and few close friends.

By the closing of the program, Chad stated he was sleeping better, noticed a reduction in stress and enjoyed the program. He found the staff and the environment helped him relax and said, “I walk through the door, and the weight falls off my shoulders!’ 67

David. This participant was male and married. David did not engage with the counselor as noted in his files. The information the counselor used for his summery was from the nurse's report. That report was within documents not retrieved for this archival research review. David had a health history that included a diagnosis of diabetes, but it was unclear what type of diabetes. He also lived with hypertension and expressed he was lonely. The discharge assessment showed more communication with the counselor than at the beginning of the program. David shared he is feeling stronger, and that the program overall was good for him.

Donna. This participant was a married female who had a health history that included convulsions, ongoing knee pain, shoulder pain, and surviving Hodgkin's lymphoma as well as living with her CHD. Donna was experiencing grief due to her mother's death and concern for a close friend who lives with Alzheimer's disease. She was active in her church and stated Roman Catholic as her faith practice. Friend’s joined

Donna to knit blankets and scarves for a local Head Start program. Donna said she liked to imagine what the child who received her knitting was e like and she recognized the positive emotions from giving. She said helping others was a big part of her contentment.

More positive thinking when feeling stress was a key takeaway of the program for

Donna. As she continued to pursue healthy habits, she planned on walking with a friend and being more mindful. Her reductions in depression and anxiety were noticeable to

Donna and others in the program with her.

Eric. This participant was a divorced male who had a health history of diabetes and CHD which he said scared him to think of. He did not sleep well and was feeling 68

sad. He moved to a new place and missed his ex-wife. He has a group of friends and spends much of his time playing games online. Eric shared that his friends are an excellent support system and help him.

As the program progressed, Eric explored different ways of using mindfulness and creativity to reduce stress and anxiety. His depression lessened, and he started to address some cognitive distortions he knows he frequently uses, such as all or nothing thinking and predicting the actions of others by the end of the cardiovascular rehabilitation program.

Frank. This participant was a married male whose family history has a substantial amount of CHD-related illnesses. He mentioned his children in the interview sharing that he had three daughters who live close by with their families and had a daughter that died of Hepatitis C. Frank said he does not worry about himself, but shared he feared his wife’s diagnosis of Lupus and what that meant for her health. His reaction to his health history was that, “this is just another day and it makes no difference.”

Frank is a heavy sleeper, a former smoker who currently uses chewing tobacco.

His family lives on a farm that is passed down through several generations. He kept physically active doing things on the farm. Frank relaxed by reading, watching television, and caring for the family pets. Socially he is participated in two shooting clubs, and was a member of the Mason’s.

Frank’s file contained a note stating the program policy for suicidal ideation was initiated. The policy was put into place when question 12 on the PRFS is answered with a three or a four out of a possible four. Question 12 reads, “I think more about ending my 69

life lately." When question 12 was answered with a three or four, the counselor notified the program director and the supervisor.If possible, the counselor mes face to face with the participant to determine what the next step in care may be for the individual.

Frank was contacted by phone as this event occurred with his closing PRFS and he completed the program. He stated it was an error and he had no thought of self-harm.

A note regarding the policy, program procedures, and the participant response to the query of suicidal ideation as negative was placed in the participant file. A follow-up discussion occurred with the program director and supervisor. It was deemed that no further action was needed for this participant regarding this issue by the cardiovascular rehabilitation program staff.

Sample One results showed using mixed methods illustrates multiple changes in the data. The further from the microsystem the risk factors were, the fewer of the identified risk factors of the survey were apparent in the larger systems. The

Bronfenbrenner model established a framework for the qualitative data. The research categorized relationships and interactions into four systems that expanded from the microsystem of individual home and family, to the mesosystem of neighborhood, workplace and related environs, which shifted to the exosystemic layer of mass media, community services, and the social and business interactions of friends and extended family. Influences of cultural values, belief systems and laws were elements of the largest, the macrosystem.

Similar emotions to the risk factors such as sadness and grief appeared in the micro and macro levels. Phrases like, "just another day" and notes from the counselor 70

indicating negative reactions to the program were possible indicators of emotional guardedness. Faith traditions, support from family and friends, and positive outlook might all be indicators of healthy biopsychosocial systems at time of testing for the participant’s in sample one.

Using Bronfenbrenner’s model provided a visual and a narrative that helped contextualize the data and indicated areas where the risk factors may be affecting participants. The microsystem and macrosystem levels showed all factors of the PRFS were present. The presence of the factors reduced from four in the exosystem down to two in the largest level of the model, the macrosystem.

Simply put, the risk factors of anxiety and emotional guardedness remained in place for this sample. Depression, anger or hostility, and social isolation diminished as they were processed through the systems consisting of business interactions, schooling, and larger cultural influence. The further from the microsystem, the further from the individual, the factors of depression, anger, or hostility and social isolation were present in lesser quantities. The overall PRFS scores of sample one participants post program lowered by at least one level of severity for each person.

Table 2

Score Changes of the PRFS in Sample One 10 9 8 7 6 5 4 3 2 1 0 Severe Moderate Mild Normal

Before Program After Program

Note: This table shows the change in participant (n=10) scoring levels of the PRFS from the beginning of the program to the end of the program. A positive reduction of one level or more took place for five of the participants. B. Fulton, 2017.

MACRO depression anxietiety, anger/hostility emotional guardedness EXO depression, anxiety, anger/hostility, social isolation, emotional guardedness

MESO depression, anxiety, anger/hostility, social isolation, emotional guardedness

MICRO depression, anxiety, anger/hostility, social isolation, emotional guardedness

Chronosystem- Over time the behaviors and experiences of culture affect and change the reactions and choices regarding health and wellness behaviors.

Figure 5. Bronfenbrenner’s (2005) model is showing the placement of psychosocial risk factors appearing in program summaries of North Central Appalachian cardiovascular rehabilitation participants. This sample contains cases in which scores from pre-and post-program show the greatest amount of change.  The Microsystem contains all five PRFS factors and the system affects the individual, immediate family, home life, neighborhood, and so on.  The Mesosystem contains all five PRFS, and the system affects home, the workplace, and neighborhood. 73

 The Exosystem contains four of the PRFS factors. Depression is not clear in this system which affects workplace, community services, and mass media  The Macrosystem contains two PRFS factors, anxiety, and emotional guardedness. This system consists of widely shared cultural values, belief systems, customs, and so on.  The Chronosystem shows the changes over time from current and historical perceptions of culture and the adaptations occurring to the individual from personal and professional events. This system warrants further investigation to discover what influences, if any, in the chronosystem affect sample one.  Adapted Bronfenbrenner model incorporating PRFS risk factors, B. Fulton, 2017.

Sample Two

Sample two cases were the ten cases whose overall PRFS scores changed the least at the end of the program from the beginning of the program. Analysis of these cases revealed several key differences from sample one. Differing support systems and personal attitude toward the program experience may have also influenced this data.

George. This participant was a widowed male who lived with hearing issues that may have created some difficulty in communication. He also had a health history that included CHD, a malignant tumor with placement in the neck area, as well as hyperlipidemia. George slept well and enjoyed eating out at different local restaurants, which he called "mom and pop places." He quit smoking three years ago smoker and was a retired coal miner. Socialization included time with family, and playing cards with a few friends. 74

When he could move around more easily, he enjoyed fishing and being outdoors.

George still drove his truck and lived on his own. While in the program, George shared that he did not really experience stress. He breathed with less difficulty, walked more, and though was aware of progress; he continued to express dissatisfaction with his level of stamina. He did not engage in lectures or counseling on a personal level while in the program. George shared feeling that he met some nice people and the program was “ok."

Others in the same lectures as George commented that as the program progress he relaxed more and seemed more comfortable.

Harry. This participant did not care to engage in the counseling process. Harry was married to a psychologist and shared that he is "very aware of how he presents himself regarding psychological issues." The counseling files showed information retrieved from the cardiovascular nurses indicated health history for Harry was significant for various cardiac issues, and he felt he was realistic regarding his health. He is a former smoker and stated he sleeps well.

The intake and discharge summaries for Harry were very sparse. There was little to no interaction with the counselor during the program, however, the discharge summary shared that Harry felt positive differences due to the program.

Joe. This participantwass in the program for the second time. His first time through the program was last year. Joe had ongoing and increasing heart issues and shared that his parent's deaths were primarily due to CHD. He felt sad and frustrated regarding his health history. Joe said he slept well. His stressors during the program 75

included his work and upcoming retirement, being recently married and remodeling his house.

He spent time with grandson hunting and fishing, and with his family. The program structure improved the quality of life overall, according to Joe. He felt his interest in deep breathing, practice of relaxation techniques and discussions about healthy habits assisted his positive outlook,

Keith. This participant was divorced and lived with his sister. He had loss of vision in his right eye and chronic back pain. His health history included a (self-reported) diagnosis of Bipolar Disorder with re-occurring episodes as well as a co-occurring addiction to drugs. No documentation was present to support this diagnosis. He was not taking any medication at this time and had no primary care physician or psychiatrist at this time. Keith hasda caseworker from a local facility whom he saw occasionally, but transportation to the clinic was an issue.

He shared that occasionally used marijuana to help him sleep and he felt discouraged about his health. Stressors included family issues, living with his sister, lack of money, family members who were using meth, caring for a small child that is "not blood" feeling grief and anger over the death of his mother and dealing with problems with her estate. Keith stated he used alcohol daily and likes to go to American Legion to get out of the house. He said he has a few close friends but “when push comes to shove, nobody stands up for you.”

In his closing summary, Keith shared he was feeling fine, and things were ok. A note by counselor indicated possible self- protection through denial was in place. The 76

archival review showed that Keith’s time in the program with the counselor included sessions discussing family perspectives of participants, health, anger, and positive steps toward decreasing social isolation.

Larry. This participant was going through several rough transitions including separation and divorce at the time of the program. Larry was in treatment with a counselor and a psychiatrist on a semi-regular basis. He took Cymbalta and Xanax but did not like to do so. He was depressed regarding his health history and shared that CHD was present in his family, especially through the paternal side. Larry was worried about his child and some things they were going through, as well as his marriage failing.

He was recently fired from his last job at a college and felt it was unfair, saying many factors surrounded his termination. He has consistently worked in high-stress jobs with police force (hostage situations, sex abuse of children) over the course of his career.

Stressors for Larry included having low self-esteem, feeling lonely, experiencing situational anger, and depression. He had difficulty with sleep and said he often felt tired though he tried to have a steady sleep routine. His social involvements included volunteering with the local sheriff’s office and helping others in local bicycle program that gave free bikes to those in need. The archival review showed that Larry completed the program while the counselor was not present but the files also indicate he discussed with the counselor ways to make decisions less stressful and learned coping skills while in the program.

Janet. This participant was female and married. She was experiencing depression and self- esteem issues. Past health history for her included emotional eating as well as 77

CHD which led to feeling depression and anxiety over it. Janet said her stressors included financial worries, poor sleep, feelings of guilt, and fear of having panic attacks.

There have been difficult transitions including change of lifestyle due to lack of money. Janet shared that, “2015 was a difficult year, with health diagnosis of lupus, I had emergency abdominal surgery and then a heart attack”. Janet felt she had emotional support from a small group of friends and lots of family. She enjoyed reading, walking, and gardening.

The discharge summary noted that patient was a cardiovascular nurse so

“knowledge and overthinking of heart-related issues may color results in some way." Her summary also said Janet reflected on the program being a “great experience” and “I needed this. I have changed for the better, and I know I am a person, not just a diagnosis”. Success in identifying stressors and increasing exercise and using stress management tools was indicated.

Mike. This participant was male and divorced. This was his second time through the program A note in the intake assessment suggested the scoring on the intake PRFS along with a high emotional guardedness score suggested the test may indicate the participant was not being honest in self-reporting. When asked Mike said he was resigned toward health history. He experienced poor sleep due to constant pain. His stressors included lack of occupation or activity. Mike was a former smoker. He stated he was not interested in education or counseling aspects of the program. A note in the closing summary indicated poor attendance and a lack of adherence to the overall program. He chose not to engage with the counselor after the intake assessment. 78

Ned. This participant was a married male who felt accepting of his health history.

Both of Ned’s parents died due to complications from CHD. He said he slept well and did not smoke. He was a mechanic and worked for the state in the transportation department.

Ned had a support system of several close friends and his family. He and his family are

Christian and attended church often. He has a large extended family in the area with several generations living under one roof and others nearby. One of his sons races stock cars and the whole family is involved, making it a family and a social event on a regular basis. The family was very important to Ned. He liked that his children and grandchildren lived close to him.

Ned shares he did not prefer to have much to do with counseling and liked to deal with things on his own”. A stressor Ned mentioned is quitting smoking but he previously indicated he was not a smoker. The closing summary shared Ned’s initial reluctance to discuss counseling topics or to share information changed to more accepting and open dialogue. He and the counselor had discussions regarding self- perception and Ned said he was thankful for each day he had.

Patrick. This participant was a married male who said he was very surprised regarding his cardiac health issues. He said there was no pain and he did not know it happened at the time.

His emotional guardedness score was very high, counting for half of his total score on the intake PRFS.

Pattrick said he felt stress when his wife interrupted him and other than that he was fine. He slept well at night and often took a nap during the day, His social and 79

emotional support was church and family. Patrick had been married for 63 years and shared that a key is that both liked alone time. He said he thought about his first love and the what if…? He stated that he succeeded in things he tries and moved on if he did not.

Patrick was accepting regarding health history, and in the closing summary shared that he had an increase in stamina and better communication with his spouse. “ I feel fine, don’t get excited about much” Discussions with the counselor included talking about spirituality and how stressors affected life events.

Karen. This participant was a married female according to the PRFS sheets from her file. The files from medical records had no intake or discharge summaries. There was little information available from the documents provided which are the PRFS assessments and a discharge report. The report showed that Karen attended two lectures during the program out of the possible four. There were no sessions with the counselor.

The discharge report also noted the lack of communication and showed the participant chose not to engage with the counselor.

Sample Two Results

Combining the above information showed the psychosocial risk factors remained in all systems. Emotional guardedness and social isolation were present in the highest numbers in the microsystem along with depression. In this sample, there were more instances of scores increasing, even though the amount of increase is small. Post program scores increased to a higher level of concern for two participants in sample two.

The macrosystem, which is representative of all the systems in the areas of cultural values and beliefs, contained each of the risk factors. The presence of emotional 80

guardedness reflected not only in the statements of this sample but also in the archival documentation of reluctance to engage in counseling or other program components such as educational lectures.

Table 3

Score Changes of the PRFS in Sample Two

0 Severe Moderate Mild Within Normal Levels

Pre Score Post score

Note: This table shows the change in participant (n=10) scoring levels of the PRFS from the beginning of the program to the end of the program. A negative increase of one level or more took place for two of the participants.

MACRO depression, anxiety, anger/hostility emotional guardedness

EXO depression, anxiety, anger/hostility, social isolation, emotional guardedness MESO depression, anxiety, anger/hostility, social isolation, emotional guardedness

MICRO depression, anxiety, anger/hostility, social isolation, emotional guardedness

Chronosystem- Over time the behaviors and experiences of culture affect and change the reactions and choices regarding health and wellness behaviors.

Figure 6.Bronfenbrenner’s (2005) model is showing the placement of psychosocial risk factors appearing in program summaries of North Central Appalachian cardiovascular rehabilitation participants. This sample contains cases in which scores from pre-and post-program show the least amount of change.  The Microsystem contains all five PRFS factors and the system affects the individual, immediate family, home life, neighborhood, and so on.  The Mesosystem contains all five PRFS, and the system affects home, the workplace, and neighborhood.  The Exosystem contains all five PRFS factors. Depression is more apparent here for sample two than in sample one.in this system which affects workplace, community services, and mass media 82

 The Macrosystem contains all five factors. This system consists of widely shared cultural values, belief systems, customs, and so on. Depression remains at a higher presence than other factors.  The Chronosystem is the effect of time on the events and experiences of the individual. In sample two little change is seen in the chronosystem. Further investigation will help define this system with this sample. (adapted Bronfenbrenner model incorporating PRFS risk factors, B. Fulton, 2017)

Based on the information from the sample, quantitative results present two populations of ten each for further research. These populations show there is enough variation from initial PRFS scores to post program PRFS scores to indicate changes are present. Some participants have scores that reduce in severity while others display increase. Qualitative results indicate the Bronfenbrenner model arranges these changes in different systems of interactions and experiences. These findings will be discussed further in chapter five.

Summary

The most efficient way to study the research hypotheses regarding North Central

Appalachian cardiovascular patients and the efficacy of the PRFS was the use of a mixed methods research approach with a sequential design. Using this design allows for document review and analysis of existing data. Both statistical and document data explore and seek explanations for changes as they influence each other.

The results establish that the answer to the first question is to reject the null hypothesis. The quantitative research question poses that there is no change in scores of the Psychosocial Risk Factor Survey from the preprogram score to the post program score. A series of paired-samples t-test were conducted to compare the scores of the 83

psychosocial risk factor survey subscales before and after a cardiovascular rehabilitation program.

The evidence shows the score difference is significant at the p <0.05 level. We can also see that the p <0.001 for depression scales points to the need for further analyses to discern reasoning for the decrease of that subscale. The use of Bronfenbrenner’s model also enables researchers to find possible reasons for the noticeable change in the depression scale scores.

Emerging themes, indicators of possible risk factors for CHD, and psychosocial behaviors develop with the review of available data. The results of the research analysis detect cardiovascular rehabilitation program interventions reduce some but not all psychosocial risk factors measured by the psychosocial risk factor survey.

Bronfenbrenner's bioecological theory and the information from the archival documents enable an explanatory model of the research to demonstrate avenues for further research in chapter five.

Chapter Five: Discussion

The purpose of this study was to examine the psychosocial changes in North

Central Appalachian cardiovascular rehabilitation patients by using the pre-and post- scores of the Psychosocial Risk Factor Survey (PRFS) and an archival document review of existing rehabilitation participant files in mixed methods study.

Some forms of integration between quantitative and qualitative data included a review of participant intake and closing interviews, following the formation of populations to gather additional detail affirming statistical findings, and linking data to create an understanding of contextual factors. Interpretation of the results appeared through a narrative that used information collected from document review to support the concepts that emerged as well incorporating data transformation (Fetters, Curry &

Creswell, 2013).

The present study first examined the differences in psychosocial risk factors of cardiovascular rehabilitation patients as determined by the pre-and post-test scores of the

PRFS. The information provided distinctions that could help inform the decisions of counselors and other healthcare workers in the region regarding cardiovascular care and other healthcare programs.

This chapter presents deductions related to the two research questions. Using archival data, emerging themes led to a deeper look at the psychosocial risk factors of

CHD. Depression and anger/ hostility indicators were further explored in the context of

Bronfenbrenner’s model as well as local availability and accessibility of health care. 85

The reasoning to conduct this study is due to the limited empirical data about this specific segment of the Appalachian population concerning risk factors for CHD. A closer look at the impact of distributive justice (fair distribution of resources) illustrating the regional lack of healthcare affecting CHD is given. Recommendations for counselors and other healthcare workers to incorporate some findings of this research into current practice are offered to the reader.

Appalachian Patients and Cardiovascular Heart Disease

The current research inquiries give little attention to the recovery of the

Appalachian cardiovascular patient and the experiences of those who live in isolated health service areas or the existing programs treating persons living with heart disease in these rural areas. As mentioned in chapter one, contemporary scholars of the Appalachian region suggested that the area is concurrently a “distinct and government-defined region”

(Walker, 2013), and “a cultural region reflecting a socially constructed idea” (Batteau,

1990; Billings et al. 1999; Martin, 2016; Passi, 2003; Williams, 2002).

Appalachians face many challenges such as lower income levels, higher unemployment, higher infant mortality rate, and less access to health care than in the

United States population. Increased understanding of the unique needs of North Central

Appalachian cardiovascular patients will clearly impact treatment planning and delivery of services in Appalachian contexts. A benefit of looking at a relatively small sample of a specific population was that it enabled the researcher to have an in-depth window into the experiences of the participants and the reader to better understand needs of the 86

population. Effective programming that considers the needs of a population will help to decrease the rate of mortality due to CHD within that population.

For health education to be effective, programming serves the intended goals when an understanding of health and social characteristics, beliefs, attitudes, values, skills, and past behaviors are taken into consideration (Glanz, Rimer, & Viswanath ,2008; Morrone,

Kruse & Chadwick, 2014, Neal & Neal, 2013, Rosa & Tudge,2011). This study used the results of a specific assessment, the Psychosocial Risk Factor Survey (PRFS) and archival information gathered from participant program files of a specific cardiovascular rehabilitation program, in North Central Appalachia.

The impact of poverty creates barriers in the form of lack of funds for healthcare services and meeting basic living needs, such as food and shelter that are necessary to be healthy. The heart disease mortality rate for distressed counties in the region was 29 percent higher than non- distressed Appalachian counties. The county in which the cardiovascular rehabilitation program is located qualified for the designation of a distressed county based on three economic indicators; three-year average unemployment rates, per capita market income, and poverty rates. These indicators are used by the

Appalachian Regional Commission (ARC) as explained by the recent 2017 ARC report

Creating a Culture of Health in Appalachia: Disparities and Bright Spots. (p.27)

Heart disease was reported as the leading cause of death in Ohio in various articles pertaining to Appalachia like the ARC’S (2000) Underlying Socioeconomic

Factors Influencing Health Disparities in the Appalachian Region report and Ohio 87

government reported such in the Plan to Prevent and Reduce the Burden of Chronic

Disease: 2014-2018 (2014).

Research in North Central Appalachia. Appalachia is a vast swath of land that stretches over several states. Using the PRFS with this specific rehabilitation population in North Central Appalachia provided an opportunity to gain a better understanding of

Appalachian health care as well as this specific area of North Central Appalachia. Culture shifts, population changes, and access to programming indicated different results might be expected (Morrone et.al, 2014). Simply put, what may work for CHD rehabilitation patients in the Southern section of Appalachia may not be as effective in Northern

Appalachia and this research assesses information that may improve service throughout the Appalachian region.

Using the PRFS enables researchers to access universal emotions, such as depression or anger, in the unique regions and sub regions of Appalachia. Information from the summaries layered a richer context and opened possibilities for improved healthcare. Accessing the participant files increased the depth of information and led to further discoveries that may assist other survivors of CHD.

The advantages and disadvantages of using archival information were as relevant as the scores of the PRFS to developing the key points of the research. Using abstraction of the participant summaries afforded a look at a specific event that could be compared with similar summaries. The participant provided context, background, and more detail regarding healthcare practices. The discoveries from the archival documents also supported many of the findings from the review of PRFS scores. 88

However, disadvantages to using abstraction are present as well. Using documents increased the potential of bias affecting results. The writer of the original document, the selection of the document components, and the interpretation of the material can all contribute to affecting the information (Bowen, 2009). Great care was taken in this research to provide transparency of document use and disclosure of possible research bias. A disadvantage specific to this study was the amount of missing information.

Several files contained limited information, possibly due to program issues, participant lack of cooperation with the program counselor, or other unknown reasons. Despite these conflicts, the use of archival documents as a source proved beneficial for this study.

Question One- Evident Changes in Score Comparisons

The culminating information showed the Psychosocial Risk Factor Survey category looking at depression reduced overall. The risk factors of anger/ hostility reduced to a lesser extent than the risk factor of depression. Notable changes were not present for the risk factors of anxiety. When the quantitative data and the qualitative research archival information combined, patterns affecting social isolation, anger, and depression emerged.

Data from the PRFS assessment revealed that of the 48 participants, 10 of them had a positive change overall in the outcome of their scores, meaning the scores reduced, which indicated improvement emotionally. However, it was surprising to discover that 38 participants had a negative score change. Negative score change is an increase in scoring that shows the participant is marking more items on the PRFS with less positive answers. 89

In answering the first research question, “Are changes evident in the comparison of psychosocial risk factor survey pre-and post-test scores of Appalachian cardiovascular rehabilitation patients”? The answer is most likely, yes. There were changes evident in the comparison of the psychosocial risk factor survey pre-and post-test scores of

Appalachian cardiovascular rehabilitation patients. Therefore, we could say the null hypothesis indicating no change is evident was a false one. The data clearly showed a change in the subscale of depression and to a lesser extent, the subscale of anger/ hostility indicated changes as well.

Question Two- Emerging Themes and Connections from the Samples

As past and current research demonstrates, depression occurs often as a part of a chronic condition such as cardiovascular heart disease. In this research, depression emerged as a risk factor that was present with all participants at some point in the study.

The difference this research clarified is that, of the sample of people who had less change in the PRFS overall score from the beginning to the end of the program, the ten participants of sample two, had more indicators or examples of depression in their PRFS scores and within the systems of the Bronfenbrenner model.

Of the states included in the Appalachian region, the state of Ohio shows the highest prevalence of depression (ARC, 2017; Centers for Medicare & Medicaid

Services, 2017). Major life changes, trauma, stress, medications, and health issues indicators of the possible presence of depression. Research establishes that emotions such as depression and anger are directly connected to the development and presence of disease (Ginsberg, 2105; Hendryx & Zullig, 2009; Mudd- Martin et al., 2014; Rozanski, 90

Blumenthal & Kaplan, 1999; Smith & Holloman, 2011; Swenson & Clench, 2000).

Studies indicate low socioeconomic status, lack of social support, stress at work and family life, depression, anxiety, and hostility contribute to the risk of developing coronary heart disease and an increase in patient decline post diagnosis (Hendryx &

Zullig, 2009; Mudd- Martin et al., 2014; Smith & Holloman, 2011). As persons who lived in North Central Appalachia, in the state of Ohio, and attended a cardiovascular rehabilitation program in the distressed county of Athens, the presence of all the factors were found within the archival information of these sample participants.

Sample One

Sample one participants were the ten cases selected for qualitative research whose scores changed the most from the beginning of the cardiovascular program to the end.

Changes in the subscale of depression demonstrated that participants in sample one who attended on a regular basis and participated in the education classes of the program as well as the exercise experienced a decrease in PRFS depression scores.

Eight of the ten participants in sample one, those who had the greatest change overall in score from the beginning of the program to the end, experienced depression at the micro and macro level. Some zones such as the workplace, social interactions with friends, church involvement, or using a local business, may be conduits for depression in the mesosystem of the participants. Depression was present for eight participants of sample one in their personal lives, appearing at home, work, and in the framework of immediate family as part of their micro system. 91

Sample Two

Sample two was represented by the participants who showed the least amount of change overall in their PRFS scores from the beginning of the program to the end. From the personal area in the microsystem of the individual, family members, and close relationships, to the widely shared cultural norms social values, and greater influences located in the macrosystem, depression was consistently present in sample two. Among these ten participants, unlike sample one, depression was present within the findings of each person in sample two. Depression was identified in every system of the

Bronfenbrenner model from micro to macro for sample two, unlike sample one where depression remained only within the micro and meso systems.

The Risk Factors of Depression and Anger/Hostility

Grief, loneliness, and sadness were archival indicators of emotional risk factors that remained despite the program participation, specifically the continued presence of depression. Some participants decreased in their severity of experienced depression according to their PRFS scores, however, depression persisted in many participants.

Depression is noted by past research as affecting recovery, process of information, interactions with others, and could also be an underlying emotion connected to anger.

Combining the two samples revealed that 18 out of 20 participants continued to live with some form of depression within Bronfenbrenner’s ecological model of micro (personal), meso (social), exo (professional) macro (cultural) and the (course of time) chronosystems. 92

In this research, the discovery of the anger/hostility scale presented some notable change that was also important to review. Hostility is a risk factor that interests health providers and researchers across various disciplines of cardiovascular care. According to

Das and O’Keefe (2008), psychosocial stressors like depression, anxiety, and hostility are consistently related to increased risk of CHD. Studies also show that hostility and anger worsen recovery prognosis after myocardial infarction (Das & O’Keefe, 2008; Rozanski et al., 1999).

Expression of anger is healthy; however, visible and prolonged feelings of anger magnify or increase negative outcomes of CHD (Casey & Benson, 2004; Das & O’Keefe,

2008; Eichenauer et al., 2010; Rozanski et al., 1999). Carol Tavis, author of Anger: The

Misunderstood Emotion, writes that expressing anger usually does more harm than good due to the cycle or repetitive pattern that emerges after expressed anger is experienced by the other as an attack and so they in turn retaliate, the first person responds and “both people feel isolated from one another” and a hostile habit emerges (Casey & Benson,

2004; Tavis, 1989).

Suppression of anger is not ideal, either. Rather, developing or refining communication skills to express feelings in a productive and clear way has multiple benefits including reduced psychosocial risk factors (Casey & Benson, 2004; Sperry

2006). The PRFS scores of anger and hostility showed a slight increase in the 48 cases, overall. Of the 20 sample cases chosen for archival review, anger was present in varying degrees. 93

Sample One

In sample one, those whose scores showed the greatest change from the beginning to the end of the program, archival documentation indicated only one of the ten participants used the specific word anger to describe feelings present during the program.

However, looking at PRFS risk factors and Bronfenbrenner’s model for sample one showed the presence of anger in the micro, meso, and exo systems.

Sample one participants described themselves as ironic, observant, stressful, overwhelmed, and anxious. The emotions of anger and hostility may connect with these identifiers participants chose to describe themselves. By not directly citing the word anger, this writer suggests the further from the microsystem the participant may place correlating or similar emotions that come under the general terms of anger or hostility.

Sample Two

Though the sample two participants had little change in score from beginning to end of the rehabilitation program, the presence of anger was clearly cited in two participant archival records. One participant described situational anger as a part of their emotional state and the other said anger was present due to family issues. Other anger/ hostility related descriptors found in the files of sample two participants included dissatisfaction, frustration, “when push comes to shove, nobody stands up for you”, unfairness, stress, and anxiety.

The phrase “I’m aggravated, not mad” is one that this writer heard many times when providing counseling for the program. Some participants chosen for this study may have been present at the same time as the writer was the counselor for the program. It is 94

not possible to discern specific identities due to time, the fallibility of memory, removal of identifiers and coding. The unique use of the word aggravating in many cases indicated some presence of anger or hostility when the counselor attended to nonverbals, tone inflection, and context of discussion during the program.

The emotional guardedness scale is described by the authors of the PRFS as as means to determine a patient's tendency to underreport the risk factors of depression, anxiety, anger/hostility and social isolation. Using the emotional guardedness score is useful when the patient may answer the PRFS in a way to present little to no concerns, or for lack of a better term, “faking good” to appear healthier (Eichenauer et al.,2010). The authors of the PRFS emphasize that the emotional guardedness scale is for secondary interpretation (Eichenauer et al., 2010).

North Central Appalachian cardiovascular patients may culturally connect to health care in a much more reserved, private, or distant manner. The emotional guardedness scale may be useful in the counseling setting. The factor of minimal access to health care may also impact the readiness or openness of answering questions like those related to anger and hostility on the PRFS.

Distributive Justice in Northern Appalachian Healthcare

As I delve deeper into the study of CHD and behavioral counseling in cardiovascular care, I find that lack of programming, staff, and facilities is a regional issue from the North to the South of Appalachia. It is surprising to discover the reports of

Ohio being one of the more depressed states in all of Appalachia. Athens County as a distressed Appalachian county in Ohio is a label I am familiar with economically yet 95

health wise, the impact of minimal health care is more visible than ever before due to this research. According to Skinner, Franz and Kelleher (2017) Appalachian hospitals experience challenges from community health needs assessments. Collaborative efforts can minimize the cost of the required assessments and again points to the usefulness of success found though pooling resources. However, this measure of resourcefulness may not be helpful for health care facilities when seeking financial assistance based on need.

Combining resources also may be prohibited by some guidelines, rules or operation, or governmental body (Skinner, Franz& Kelleher, 2017).

Cardiovascular care is unaffordable for many of the Appalachians as well as inaccessible (Mudd- Martin et al., 2014). Poverty affects psychosocial risk factors. Risk factors of poverty connect to CHD. Strong correlations to CHD and multiple characteristics widely identified as Appalachian illustrate the connection of heart disease to a quality of life (Skodova et al., 2008).

Within Bronfenbrenner’s macrosystem lie the sociocultural contexts impacting health and wellness of a population. As reports from ARC (2012; 2017) and the state of

Ohio (2009; 2014; 2017) explain, the macrosystem we were investigating in this research was in an identified Appalachian county in North Central Appalachia with fewer health providers, less programming, and low economic sustainability. The level of care was directly connected to the level of economic despair (Cooper et al., 2011; Morrone et al.,

2014; Mudd- Martin et al., 2014). Helpful information for future research may include finding what the health coverage is offered and what health care necessities are covered. 96

Other contributing factors to the lack of care received may come from the potential patient. It is recognized that the system of picking and choosing health care options is a way of life for many in Appalachia (Mudd-Martin et al., 2014). Choosing to go to the dentist over getting groceries, skipping medications, or sharing prescriptions are examples of this ideology. Sometimes there is nothing to choose because it simply is not there. Education offered by trusted community resources may assist in changing patterns of healthcare usage.

The current 2017 development research report on this specific county, generated by the state of Ohio (https://development.ohio.gov/files/research/C1006.pdf) states that

90.8 percent of adults’ ages 18 to 64 have health insurance. Having health insurance does not mean having better healthcare or better quality of life. It means a requirement is met.

Future research into CHD and measuring the use of insurance to cover expenses like cardiovascular rehabilitation may assist in gathering helpful data to ensure greater usage of insurance and the increase of available providers, not only regarding CHD but also use of insurance towards preventative measures.

The distressed counties of Ohio have a higher mortality rate that non-

Appalachian, non-distressed counties (ARC, 2017) which possibly indicates a lack of health care providers. Within Ohio, those counties considered Appalachian have 41 percent less (99 per 100,000) than their non-Appalachian counterparts who have 167 mental health providers per 100,000 population (ARC, 2017). Part of recovery for a traumatic event is participation in some form of therapeutic intervention. Behavioral counseling, rehabilitative counseling, and counseling that uses collaborative team based 97

person centered focus are integral healthcare options with little presence in the

Appalachian region. The lack of distributive justice in Appalachia is evident considering these facts.

Risk factors and cultural values. The increase in CHD in Appalachia may propose that the levels of care are deficient in the areas of accessibility and number of healthcare providers. Health insurance problems and lack of trust in medical practitioners or hospitals, in general, may also present barriers to care. These interactions may result in the acceptance or reinforcement that medicine, or nonlocal medical practitioners, are not to be given trust with personal information. Therefore, minimal contact may occur with healthcare providers for preventive or rehabilitative care.

Identity as Appalachian can be confusing. As an identifier, the social identity of being Appalachian is as important a representation as family, community, state, and nation (Cooper, Knotts, & Elders, 2011). When identifying as Appalachian, people are connecting themselves not only geographically but also to characteristics. Common sociocultural characteristics like living in poverty, living in a poor environment due to natural resource extraction (coal, natural gas, oil, timber), unemployment, and poor health care are attributed to Appalachian people (Morrone et al., 2014).

Cultural values are beliefs that a group invests in emotionally. One can have

Appalachian values and not ascribe to Appalachian stereotypes, such as the mountaineer or hillbilly. One can have Appalachian values and not relate to Appalachian characteristics, such as poverty, or low levels of education. Of course, the values, stereotypes, and characteristics can combine and do exist in a variety of ways. 98

Understanding the cultural values of the Appalachian people helps reflect the cultural diversity needed to increase the awareness of how psychosocial factors contribute to

CHD (Anderson et al., 2003; Morrone et al., 2014; Skodova et al., 2008).

The cultural value of resiliency and independence in the face of adversity is a value that may hopefully benefit the slow progress of increasing regional health care. For the Appalachian client, the value of resilience does not have to be tied to ‘going it alone’ or having trouble without assistance from others outside of family. The cultural concept of resiliency and independence in the face of adversity is one that may hopefully change with the assistance of more available health care professionals and facilities. For the

Appalachian client, the value of resilience does not have to be tied to ‘going it alone’ or having trouble or barriers without assistance. Barriers may come in the form of program issues, lack of programming, and lack of cultural understanding. Resilience can also be a force towards improving the presence of beneficial healthcare programming suitable to the region of Appalachia by slow and systematic removal of barriers.

Efficacy and limits in Appalachia. Healthcare providers attending to the specific needs of the population they serve, in this case North Central Appalachia, may better diagnosis, treat, and care for a variety of illnesses, including CHD and co-occurring risk factors (Anderson et al., 2003; Morrone et al.,2014; Skodova et al., 2008). Though the state reports that a high percentage of Ohioans have healthcare according to the development report of 2017 found at www.ohio.gov, it is unknown what the quality of healthcare is. Providing services that address cultural values and beliefs, thereby showing cultural competence, has the power to improve health outcomes, increase 99

program effectiveness and efficiency, and instill trust in the community toward the program. Another integral component of the process is the skill of recognizing when a cultural value or belief may mimic a sign or indicator that may cause misdiagnosis.

(Anderson et al., 2003).

A primary focus of rehabilitation staff is slowing or reversing the disease process by identifying risk factors. Staff develop a care plan to help reduce risk factors as well as creating healthier habits to maintain levels of stamina and wellness beyond the program parameters.

The goal of the program is “…to help patients recover more quickly and enhance their quality of life” (https://www.ohiohealth.com/services/heart-and-vascular/our- programs/cardiac-rehabilitation/).Counseling in cardiovascular rehabilitation is not a common component. The cardiovascular rehabilitation program used for this research is unique in having a graduate level counseling student among their staff. The presence of the counselor part time is possible due to its designation as an internship position. Micro skills such as attention to body language and other forms of nonverbal communication are sharpened in this position. Availability of staff, attendance issues and the ‘buy in’ of participants also affect the increase or decrease of progress.

Factors within every system of Bronfenbrenner’s bioecological model are present for the counselor and participant in the rehabilitation program to recognize, accept, hopefully, change. Ways to connect with each participant during the program are at the mercy of the participant and is the level of interaction during assessment and discharge.

Follow up care that connects to community centered programming is an effective way to 100

reach reluctant participants and is reflective of cultural and familial patterns in

Appalachia.

Suggestions to Improve Future Research

Future study of CHD and the PRFS for cardiovascular rehabilitation programs may benefit from some of the obstacles this research encountered. Data collection was incomplete for patient files, in some cases due to lack of patient compliance, and counselor availability. Patterns of inconsistency resulting from staff changes, assessment changes, and program requirements were contributors to the lack of data in some areas.

A significant issue was the lack of knowing how long it took for a participant to finish the program. Due to medical issues and other unavoidable circumstances it is likely that some of the participants for this study did not complete the program in 12 weeks.

Adding length of consecutive time spent in the rehabilitation process could be another insight into behavioral change and progress. Some participants in this research had previous knowledge of the program and had attended the full program more than once.

Limiting the sample to participants with one experience of the complete program may adjust results and provide a clearer sample of changing risk factors.

Despite these difficulties, the current research indicated the use of the PRFS in detecting potential counseling issues provided a valuable and helpful recovery to the participants of cardiovascular rehabilitation programs in North Central Appalachia.

Counseling provided ways of reducing depression and other risk factors identified by the

PRFS when part of a cardiovascular rehabilitation program. 101

Conclusion

As the framework of the Bronfenbrenner ecological model shows, health disparities are a exist and function within the realms of multiple social factors, “including those that are specifically linked to place and culture” (Morrone et al., 2014, p.79). It is a fact that preventative care reduces the chances of death from CHD. In this research, the use of the PRFS to determine if changes are evident from the beginning of a cardiovascular program to the end was examined. Analysis looked at scores of 48 participants to determine if change occurred. Once the answer was confirmed, this research used data from archival documents to further explore what themes or patterns emerged in two smaller samples taken from the 48 original cases.

It is established that, in these two samples, depression and anger/hostility were the most present risk factors of CHD. To further clarify the value of assessing these factors with the specific population of cardiovascular patients in North Central Appalachia, the information was used along with Bronfenbrenner's bioecological model to provide a better look at where risk factors may prevail in the life of the study participants. This work also enables future research in this area with North Central Appalachians and the region of Appalachia where current information is lacking or non-existent.

Using the PRFS with this population may allow for clearer diagnosis of risk factors connected to CHD and enable counselors and other health care professionals to begin the culturally competent process of discerning cultural values from indicators of illness. This research found the Psychosocial Risk Factor Survey was a helpful assessment in caring for North Central Appalachian cardiovascular rehabilitation patients. 102

Health care professionals working with Appalachian populations may find it a cost- effective replacement for several psychosocial instruments.

Accessible and affordable programs that effectively reach the Appalachian client physically and psychologically to decrease cardiovascular heart disease in Appalachia may allow the residents of Appalachia to closer match the mortality rates of rest of the population of the United States. Use of instruments such as the PRFS, increase of counseling in cardiovascular programming, and increasing cultural competency demonstrated a positive difference is achievable in reducing the CHD mortality rates of

Appalachia.

103

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Appendix A: A Letter of Support for the Use of De-identified Archival Data of the

Research Participants

113

Appendix B: The Institutional Review Board Approval Letter for Research

This form shows the approval and parameters of the research undertaken for this work. This letter outlines the methodology and the questions that the research addresses.

Due to the nature of the study, the IRB form qualified for expedited approval. It is also of interest that this study is the first of its kind looking at cardiovascular rehabilitation and psychosocial risk factors in Appalachia.

Toggle Comments People & Roles Project The Efficacy of the Psychosocial Risk Factor Survey in Measuring the Progress of Title: North Central Appalachian Cardiovascular Patients

College: College of Education Name Role CI CITI Training

Fulton, Bethany PI Yes  Expires: 02/23/2018

Pillay, Yegan ADVISOR No  Expires: 04/12/2020 Funding Status, Study Timeline and Health & Safety

Study Timeline Date you wish to begin 01/23/2017

Duration of study Year(s) 3 Month(s)

YES NO

Are you receiving support or applying for funding?

114

Does your protocol require work with human blood, human tissues, cell

cultures derived from human cell lines, or virus/bacteria that is classified as bio risk II or above by the CDC? Ohio University EHS website

Does this project involve activities covered by the Health Insurance

Portability and Accountability Act (HIPAA)?

Review Level REVIEW LEVEL: EXPEDITED

Yes No

The probability and magnitude of harm or discomfort anticipated

in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests (45 CFR 46.102(i)).

Category 5. Research involving materials (data, documents, records, or specimens) that have been collected, or will be collected solely for nonresearch purposes (such as medical treatment or diagnosis). (NOTE: Some research in this category may be exempt from the HHS regulations for the protection of human subjects. 45 CFR 46.101(b)(4). This listing refers only to research that is not exempt.) Recruitment/Selection of Subjects

Maximum number of participants to be enrolled? If screening occurs, include the number of subjects that will need to be screened in order to get the number necessary for statistical significance. Please note that once the protocol is approved this number must not be exceeded without prior approval of an amendment. 80

Characteristics of subjects Adults Criteria for selection of subjects (inclusion/exclusion). The criteria set for inclusion in the study requires that the participant is diagnosed with coronary heart disease, is from North Central Appalachia, has completed the cardiopulmonary rehabilitation program at HeartWorks in Athens, OH, within the last two years and has used the Psychosocial Risk Factor Survey instrument as part of the assessment process. Description of how they will identify and recruit prospective participants. Prospective participants will have data that is available for research purposes on file collected by the staff of HeartWorks. Participants will have completed a pre program and post program Psychosocial Risk Factor Survey. This specific instrument has been used by the Heart Works program within the past two years. Participants will have been attendees of the HeartWorks program within that time frame.

YES NO 115

Are they accessing existing records for this study?

Description of the records and letter of support from the holder or custodian of the records. The existing records for study include an excel sheet of survey scores with identifying information removed. Some pre and post interviews summarized in patient records may be accessed to determine if reasons for increase or decrease in scores took place. These records will have had identifying information removed prior to researcher access by the custodian of the records. Letter of Support-research IRB.pdf

Description of relationship and/or anyone on the research team's relationship with potential participants.

The researcher was a graduate assistant for the HeartWorks program, affiliated with WellWorks, Ohio University's wellness module in Grover Center. The proposed research includes a review of data gathered for HeartWorks as part of the program procedures. From August 2014 to August of 2016, the primary researcher had contact with cardiovascular patients as part of graduate assistant responsibilities. All data that will be accessed for review is preexisting. Data is gathered for the HeartWorks program daily evaluation and as part of reports to staff, medical professionals, and educators. Sharing an emotional experience is not without hazard. Multiple aspects of the counseling provided to cardiopulmonary rehabilitation patients sought to minimize potential discomfort or distress including the offering of a local resources handout and multiple one on one encounters with the program counselor throughout the rehabilitation process. This is a component of best practices and occurs as part of the program protocol. Motivation of the researcher at the time of patient experience in the program was not to gather data for research, but to provide best care possible.

There is no recruitment process as data already exists. Performance Sites/Location of Research Using campus facilities

Project Description

Summary of this project

The project is a review of scores and reports of North Central Appalachian cardiovascular rehabilitation patients from the HeartWorks program. Connecting themes from the reports to positive or negative changes in scores will help counselors better care for cardiovascular rehabilitation patients in the local area. The scores come from an assessment created specifically for cardiovascular rehabilitation patients. Looking at the data will create opportunities for counselors to develop a better understanding of Appalachian culture response to health measures.

Description of the specific scientific objectives or aims of this research. 116

The specific aim of this research is to discern if changes in emotional guardedness and/or social isolation occur between pre and post test scores of the Psychosocial Risk Factor Survey. Additional document review may help with better understanding of what these changes may be if change is present. There is no prior existing research for use of the Psychosocial Risk Factor Survey with this population or with any other population regarding score changes or potential reasoning for occurring changes.

Description of the procedure(s) that will be performed/allowed with human participants.

The data is preexisting. Upon IRB approval the procedure the researcher will request scores from the holder of the information (see letter of support). All identifying data will be removed by the holder of the information and coded for privacy. This also assists in reduction of researcher bias within the research process. The methodology has no procedure that is directly involved with participants.

Description of any potential risk(s) or discomfort(s) of participation and the steps that will be taken to minimize them.

None Anticipated

Description of the anticipated benefits to the individual participants.

None Anticipated

Description of the anticipated benefit(s) to society and/or the scientific community in lay language. 117

A large amount of literature pertaining to mind- body medicine supports the theory that the presence or absence of stress regardless of being acute or chronic in status is connected to various emotional states and has become important in evaluation and treatment of cardiovascular disease. (Eichenauer, Feltz, Wilson & Brookings, 2010; Kent & Shapiro,2009; Rozanski, Blumenthal & Kaplan 1999; Rozanski, 2014; Swenson & Clinch, 2000; Purdy, 2013; Thomas, 2006; Uchino, et al., 2012). Greater recognition of the psychosocial risk factors is necessary for the improvement of assessment and intervention that counselors may implement with clients(Eichenauer et al., 2010; Purdy, 2013; Rozanski, 2014).

A lack of psychosocial resources such counseling for stress or chronic illness, access to existing appropriate healthcare programming, availability of resources specific to rural or Appalachia population is an issue for several individuals living with heart disease in Appalachia (Helton & Keller ,2010; Mudd-Martin et al., 2014; Russ, 2010; Sheikh & Marotta, 2008; Smith & Holloman, 2011). Heart disease continues to be a leading cause of death in the United States (Albus, 2010; Artham, Lavie & Milani 2008; Casey et al.,2009; McCraty & Zayas, 2014; Sheikh & Marotta, 2008). Nearly 610,000 Americans die from heart disease each year. That translates to one in four deaths nationwide is due to heart disease (CDC, 2016). Scarcity of behavioral and rehabilitation resources is an additional key problem for Appalachians living with cardiovascular disease (Halverson & Bischak ,2008; Mudd-Martin et al., 2014; Smith & Holloman, 2011). Researchers have examined factors such as social isolation and emotional guardedness and its connection to coronary heart disease (CHD) but no studies to date have explored these factors in the context of Appalachia. The prevalence rate of CHD in the region and the gap in the literature is the impetus to conduct this exploratory study and to serve cardiovascular patients better.

The existing inquiries into the recovery of the Appalachian cardiovascular patient has given little attention to the experiences of those who live in isolated health service areas or the existing programs treating persons living with heart disease in these rural underrepresented research areas. The contemporary health landscape is changing very rapidly with the movement toward integrated holistic care. The findings from this study could define in some respects the role of the mental health professional in cardiac health care in a rural region of Appalachia and in the United States in general.

Uploaded File(s)

Confidentiality

Data will be recorded with a code replacing identifiers, and a master list connecting the

code and the identifier will be used.

How/where the code list will be securely stored (e.g. locked cabinet, password protected) as well as the approximate month and year it will be destroyed.

The coded information will be securely stored in a password protected flash drive. Upon completion of the research, all information will be deleted and the flash drive reformatted to ensure erasure of all materials. Anticipated completion of the research is March 2017.

YES NO 118

Will participants be audio or video recorded?

Compensation

YES NO

Will participants receive a gift or token of appreciation?

Will participants receive services, treatment or supplies that have

a monetary value?

Will participants receive course credit?

Will participants receive monetary compensation (including gift

cards)?

Will University funds be used to pay or otherwise compensate

participants?

Instruments & Data Analysis

Instruments List of all questionnaires, instruments, and standardized tests. The instrument used is the Psychosocial Risk Factor Survey (PRFS). The top four most common psychosocial risk factors- depression, anxiety, anger and hostility, social isolation are measured by the PRFS. It also measures the fifth risk factor of emotional guardedness as a way of assessing the patients potential minimization of the other four factors (Eichenauer et al.,2010). It asks the patient to rate 70 items using a Likert- like 5-point scale ranging from strongly agree to strongly disagree. The PRFS is accessible at the fourth grade reading level, self-administered assessment tool designed specifically for use with the cardiovascular rehabilitation population (Eichenauer et al.,2010). Validation of the instrument occurred in two stages during two different time periods.

The sample population used during the validation process consisted of patients from cardiac rehabilitation programs in the Midwest United States from 2002 to 2004 and again from the Midwest region from 2004 to 2006 (Eichenauer et al.,2010). Overall, 364 cardiac rehabilitation patients from programs located in the Midwest of the United States completed the PRFS and least one other risk factor instrument for comparison. These 364 participants were used for analysis. Participant composition was 61.8 % percent men and 38.2% women. The mean age was 61.2 years with a standard deviation of 11.1 years (Eichenauer et al., 2010). Promising research findings are relevant only when they reach the people they are designed to serve. Reviewing North Central Appalachian cardiovascular patients PRFS scores, and conducting document review creates a better understanding of local health policies. Document review is described in more detail in the attachment titled 'IRB additional information for methodology". The documents are the counseling sections of medical records that provides a summary of the intake and closing interviews. Each interview used a semi structured question format which is provided as an attachment to the IRB submission titled, "Heartworks INTAKE FEMALE". This document was created by Bethany L. Fulton, LPC, main researcher for this proposal. The intake outline is still being used by the current counselor at HeartWorks. The outline is the same for male participants with only the change being the application of masculine terms. Gender neutral terms are used when possible. 119

The results of this research may lead to better translation of patient communications and behaviors. Permission for use of data is given with the written consent of the patient. The consent form is attached for review.

PRFS side 1.pdf PRFS side 2.pdf Heartworks INTAKE FEMALE.docx HeartWorks Informed Consent.docx Data Analysis Data analysis and statistical procedures. A mixed methods research design will be used to examine the research questions. Given the exploratory nature of the research questions the researcher concluded that the appropriate method to study the research hypotheses regarding North Central Appalachian cardiovascular patients and the efficacy of the PRFS would be the use of a mixed methods research approach. Counselors and counselor educators are reminded by researchers Frels and Onwuegbuzie (2013) that combining qualitative and quantitative methods is not a novel or exclusive occurrence in counseling research. Please see attached document for more details. IRB additional information for methodology.docx

Informed Consent

Informed Consent I do not plan to obtain consent Rationale for not obtaining consent: Consent was given by the patients for their data to be used in educational review or study. Each subject has a signed consent form in their HeartWorks record stating they are aware their data may be used with removal of identifiers for education and research purposes.

ROUTING

Research Status Emails Next Email Comments Member Sent Send

Fulton, APPROVED 0 On 01/17/2017 4:10:13 Bethany PM bf192407 approved the IRB protocol.

Pillay, Yegan APPROVED 1 01/18/2017 On 01/18/2017 05:24:48 4:00:00 PM AM pillay approved the IRB protocol.

Protocol Number:

Review By Date:

120

Appendix C: Statistical Data Displaying the Changes in Scores for the Various

Psychological Risk Factors Related to Cardiovascular Heart Disease

To provide further understanding of the contrasts and the possible influence of these risk factors, the histograms for pre-scores and post scores for the original 48 cases are provided for each psychological risk factor. Each is sorted from smallest to largest value.

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