Date of Graduation


Document Type


Degree Type



School of Medicine


Community Practice

Committee Chair

Kimberly Kelly.


In the Appalachian region, many cultural, religious, and psychological factors have been identified to affect health. These factors are expected to play a role in health disparities, such as higher rates of colorectal cancer (CRC) incidence and mortality. Appalachia-specific factors such as geographic isolationism, poverty, and Appalachian stereotypes have been reported to negatively affect preventive health care including CRC screening. Although previous research has investigating the impact of some of these Appalachia-specific factors on seeking health care, impact of symptom interpretation and psychological states of the Appalachian population on health care seeking behavior needs to be clarified. The objective of this study was to identify Appalachians' knowledge, health care seeking behavior, and emotions with regard to CRC. The focus in this study was on two main issues. First, the study investigated appraisal delay due to incorrect symptom interpretation (not inferring illness when experiencing symptoms) and thoughts and feelings about CRC. These points are discussed in manuscript # 1. Second, due to the heavy influence of psychological state on health behavior, manuscript # 2 examined of the impact of perceived health, fatalism, religiosity, access to health care, and other demographic, cultural, and psychological variables on CRC worry. A qualitative analysis [Manuscript #1] was conducted on a sample of Appalachian men to explore their thoughts and feelings about CRC, appraisal delay, and symptom interpretation. The investigation of men's perspective in this manuscript was due to the greater likelihood for men to undergo CRC screening as compared to women (Seeff et al., 2004). The investigation of these points enabled determining the uniqueness of the Appalachians' health seeking behavior. Using a cross-sectional pilot study design, fifteen men above the age of 50 were interviewed. Interviews included semi-structured audio-taped recordings. Interviews were transcribed and analyzed through utilizing constructionism as an epistemology. Further, due to the fact that women report CRC worry more frequently than men do (McQueen, Vernon, Meissner, & Rakowski, 2008), a sample of Appalachian women was surveyed in the second part of this study [Manuscript # 2] in order to collect demographic, cultural (e.g., fatalism and religiosity), and psychological (e.g., CRC worry and general mood) quantitative data. The purpose was to investigate factors that were associated with CRC worry. The sample for this manuscript included 137 women who were at least 18 years old at the time of the study. The study was based on a cross-sectional structured mail survey. The epistemology utilized in this manuscript was objectivism. Participants for both manuscripts had no personal history of CRC. The Self-regulation Model (Leventhal et al., 1997) was utilized in both manuscripts to guide analysis.;Findings from the qualitative analysis [Manuscript # 1] on Appalachian-specific barriers to seeking healthcare showed that powerlessness was a common thought among many participants. Most participants indicated that the presence of barriers to seeking health care - barriers that participants had no ability to control or fix - was the reason for not adhering to recommended screening guidelines. Symptoms interpretation, and consequently referring an illness, was variable among participants. However, the presence of (1) Severe symptoms that negatively impact the functionality of the body or (2) persistent symptoms that last for a long period of time were the most two important symptom-related cues to seeking health care. Results from the analysis on CRC worry [Manuscript # 2] suggested that the following factors were associated with CRC worry: Higher education, greater magnitude of perceived absolute risk, tension/anxiety, and uncertainty about the access to health care. In conclusion, manuscript # 1 indicated that unawareness about health insurance programs, mistrust about health care providers and medical procedures, not having access to health care, and health illiteracy were some of the factors that influenced people's health care behavior. Some thoughts have not been reported in the literature. Example are letting symptoms "take care of themselves" and asking "old folks" instead of seeking care from health professionals, thinking about CRC as a stigma, and believing that it was socially inacceptable to talk about CRC-related issues. Manuscript # 2 confirmed what previous research has found about the effect of education and absolute perceived risk for developing CRC on CRC worry, and suggested two other factors (perceived easiness of access to gastroenterologists and increased scores on the tension-anxiety sub-scale of the Profile of Mood States instrument) that were associated with CRC worry among Appalachian residents. The use of mixed methods [qualitative and quantitative] in this study helped not only in identifying statistics regarding health beliefs, but also in clarifying the reasons for certain beliefs and behaviors among the Appalachian residents. The use of qualitative methodology helped in clarifying the uniqueness of the Appalachian population regarding health beliefs and health behavior. Results of this study will aid in designing more targeted interventions in the future, which will help Appalachian residents follow health care professionals' recommendations, and then, have better health care outcomes.