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Rural medical self-help linkages

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Title:
Rural medical self-help linkages
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Gibbs, Tyson Lee, 1951-
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English
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xiv, 211 leaves : ill. ; 28 cm.

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Subjects / Keywords:
Aged -- Medical care -- United States ( lcsh )
Community health services for the aged ( lcsh )
Rural health services -- United States ( lcsh )
Anthropology thesis Ph. D ( lcsh )
Dissertations, Academic -- Anthropology -- UF ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Bibliography: leaves 204-210.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Tyson Lee Gibbs.

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Full Text
RURAL MEDICAL SELF-HELP LINKAGES

BY
TYSON LEE GIBBS
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA

1979




ACKNOW LEDGMENTS

The writer wishes to thank the members of the Citrusyulle Community for giving him the opportunity to enter into their private lives while conducting this research. I wish to acknowledge the particular assistance given to me by the Assistant Principal of the local high school, the teacher in charge of special education at the high school, the high school librarian, the librarian of the local public library, the local pharmacist, the local Citrusville Fire Department, the local public health clinic, and the Older Americans Council for Citrusville County. Their attention to my many probing questions helped me to gain a better understanding of the community.
MVy advisor, Dr. Otto Von Mering, has been my mentor
and guide throughout my graduate career. It is because of him that I have learned the value-of asking the questions which have no sharp features but which often give a better insight into the problem being considered. His tireless efforts on my behalf cannot easily be summed because I have learned much from him both inside and outside the classroom.
The other members of my dissertation 'committee have each contributed to my development. Dr. Leslie Lieberman has given me many opportunities to "test" my ideas and has




suggested alternative ways of' examining and measuring phenomena in the social world. Dr. Carol Taylor counseled me throughout my graduate education and has helped me to sort out and understand the more formal institutions of'
health care delivery. Dr. Charles Mahan has given me a vehicle to research some of' my ideas and has offered me advice on the formulation of' my research projects. Finally,
I wish to thank Dr. Paul Magnarella f'or reading the final draft of' my dissertation.
There are others who have been instrumental in my
career development. Dr. Angelo O'Rand helped me to formulate my dissertation research project. Dr. Elizabeth Eddy encouraged me to stay in anthropology and complete the
Ph.D. Dr. Jerry Melanich frequently gave me a push so that I would not slow down. Mrs. Lydia Deakin and Mrs. Idella Bivens always gave me a sympathetic and understanding ear.
Finally, I wish to thank Mrs. Theresa Bridges who was
my research assistant on this project. She was instrumental in helping me develop a research sample and in gathering the necessary data for the project. Without her assistance, this project would have taken much longer to reach completion.

iii




TABLE OF CONTENTS

PAGE
ACKNOWLEDGMENTS ............. ...... .. ..... ...... .... ii
LIST OF TABLES ... .. . ........ ... . ix
LIST OF FIGURES ........... .. xi
ABSTRACT x..................... ............ xii
CHAPTER
ONE INTRODUCTION ........ ...... .......... .... 1
Rural Elderly Social Behavior ........... 2
The Nature and Scope of Studies in
Medical Anthropology.............. 3
Purpose of This Study................... 6
Why Study the Rural Aged .............. 8
Basic Assumptions Which Structure
This Research Inquiry............... 9
TWO RESEARCH SITE: CITRUSVILLE, FLORIDA ...... 13
Reason for Choosing Citrusville as
Town to Study ......................... 13
Reaction of the Citrusville Residents
to the Research ....... . . . 14
A Brief Historical Sketch of Citrusville. 14
THREE METHODOLOGY .................... . . 18
Introduction: Descriptive vs. Quantitative Data ......... ......... 18
Research Technique ...................... 20
Participant Observation: A Definition. 21
Participant Observation as a Research
Task-Oriented Role .................. 21
Participant Observation as a Research
Technique .......... .... ......... .... 22
Research Sampling Procedure ............. 24
Key Informant Research Technique ...... 25
Other Uses for the Key Informant
Technique ........................... 27




Determination of Research Population
Sample ....................... ... 27
Composition and Size of Research
Population .. . ..... ... ... 30
Interview Guide ......................... 33
Precision and Accuracy of the
Interview Guide ..................... 34
Components of Interview Guide ......... 36
Interview Technique ..................... 36
Other Data Resources ................... 38
Summary Review ............... ..... ...... 39
FOUR DEFINING AN ELDERLY CO1vUNITY STRUCTURE:
CITRUSVILLE ................... ..........e 40
Data Resources for Chapters V-VIII....... 41
Stability of Neighborhoods in
Citrusville .............. 41
Living Arrangements of the Citrusv i l l e A g e d . . . . . . . . . . . . 4 1
Housing and the Citrusville Elderly
Individual ................... 42
Economic Survivorship of Cittusville
Elderly ................. ... 42
Presentation of Comparative Data ........ 43
Definition of Terms to be Used in This
Report . . . ... .. .. . .. 43
Social Network ................... 43
Close Friends .................... ..... 44
Just Friends ...................... . 47
Strangers .... ...... ..... .. a.. .. 47
Social Networks and Community
Structure .. aa...... .... ... 48
FIVE THE STABILITY OF NEIGHBORHOODS IN
CITRUSVILLE .................. .. ..... 50
Population Trends in Citrusville ........ 50
Length of Time in Present Residence ..... 54
SIX THE LIVING ARRANGEMENTS OF CITRUSVILLE
AGED . . .. .. . .. .. 57
Typical Household Size for the Citrusville Elderly Person.................. 57
Household Types Found Amongst Citrusville Aged .......... . . . .. 58
Purpose for Various Living Arrangements 61
Health Problems ....................... 63
Economic Reasons ...................... 63
Performance of Service ................ 64
Natural or Man-made Disaster .......... 64
Emotional Attachment .................. 65
Duration of Living Arrangements ....... 65




HOUSING AND THE CITRUSVILLE AGED ..........

Quality of Housing as Measured by
Physical Condition of Facility ........ 68
Quality of Housing as Measured by the
Elderly Persons' Feelings about
Their Homes .... ..... ................. 70
EIGHT ECONOMIC SURVIVORSHIP OF CITRUSVILLE
ELDERLY .... ... ... .. . . 73
Citrusville Elderly Income .............. 74
Income for Older Persons: National
Picture .. . . .. ... .. . 74
Income for Older Persons: Local
Picture ................. 76
Sources of Income for the Citrusville
Resident .. .. .. .. . 78
Employment Opportunities for Citrusville Elderly ...... .. .... .. 79
Occupations of Citrusville Residents
and Citrusville Elderly Study
Population ..... ........... .. 81
Elderly Participation in Other Federal
Programs ..... ..... . .. ..... ...... 81
Inkind Services for the Elderly
Individual in Citrusville ............. 85
Exchange of Goods and Services ........ 85
Cooking of Foodstuffs ................. 86
Providing Transportation ............. 87
Summary Review .................. ........ 88
NINE CUSTOMARY BEHAVIOR OF THE CITRUSVILLE
AGED POPULATION ..... ...... .......... .... 90
Social Networks and Routine Behaviors ... 91
Daily Activities .. .... ....... 92
Morning .......a.s... .. .... ... 93
House Cleaning Activities ,........... 93
Cleaning the Dishes ................... 94
Cleaning the Yard ........ @* e. ...... 94
Gardening Activity ................ 95
Reading Behavior ..... ................. 95
Writing Letters ............. .... .. .... 95
Talking on the Telephone .............. 96
Afternoon ..... .... . . .. .. 97
Watching Television ................... 97
Sewing, Knitting and Crocheting ....... 98
Shopping Behavior ..................... 98
Club Activities .......... .... ......... 99
Visiting Behavior ..................... 101
Number of Close Friends of the
Elderly Person .......,.......... .... 102

SEVEN




Age of Close Friends Who Receive
Visits from Elderly ................. 102
Number of Visits to Home of Close
Fri end ..... 0a ... .. .. .. ... . .. 10 3
"Just Friends" and the Elderly
Visiting Practices .................. 104
Visiting Behavior: Offering Aid ........ 105
Role of Social Network of Close
Friends and Relatives During an
Illness Episode ..................... 105
Evening .. .. .. .. .. .. .... 108
Weekend Activities ...................... 108
Holiday Pursuits ......... .... ... ..... 110
Discussion and Review................... 111
TEN THE ELDERLY AND LOCAL HEALTH CARE
RESOURCES ...................... ....... 115
Social Networks and Health Seeking
Be havi or *..a...*..9 0e...... . .. .. .. ll a00 1 6
General State of Health: Male and
Female Subjective Differences ......... 117
General State of Health: Age
Differences ........ .... .... ....... .... 120
Toward a Definition of Illness: The
Decision to Seek Health Care .......... 121
Resources for Health Care Advice ........ 125
Health Care Activities of Citrusville
Aged .................................. 126
Elderly Usage of Herbal Remedies and
Over-the-Counter Drugs .............. 127
Elderly Persons and the Local Pharmacist. 128
Reasons for Visiting or Not Visiting
a Doctor's Office ................... 132
Number of Individuals Per Physician ... 133
Distance Traveled to a Doctor's Office .. 133
Number of Visits to a Doctor's Office 134
Local Public Health Clinic .............. 134
Citrusville Fire Department ............. 135
An Overview of Findings ...o ...... ........ 137
ELEVEN CONCLUSIONS ............... . ..... .... 139
Adaptation to a Rural Environment:
Wellness Behavior and Health Care
Seeking Activities ......... 139
Rural Self Help Linkages and the
Individual Aging Experience ........... 142
Growing Old in Citrusville ............. 143
The Utility of Studies on the Health
Care Maintenance Behavior of Rural
Aged Persons ........ .. . ......... .. 145
Health Education Programs ............. 146
Social Network System and Upgrading
Elderly Health Care Services ........ 149
vii




Social and Health Care Programs
for the Rural Elderly .............. ... 150
Improving Future Research into Rural
Elderly Health Care Seeking Habits:
Some Suggestions ...................... 152
Health Care Policy and Research on
the Rural Aged ......... ......... .. .... 153
APPE NDI CES
A OUTLINE OF INTERVIEW TOPICS ..... ........... 154
B MIGRANT WORKER HEALTH CARE QUESTIONNAIRE ...... 167 C QUESTIONNAIRE FOR STUDY OF SOCIAL HEALTH
CARE NETWORKS IN CITRUSVILLE, FLORIDA ....... 173 D POPULATION TRENDS FOR RURAL AREAS OF FLORIDA .. 193 E RURAL POPULATION OF UNITED STATES 1900-1970 ... 195 F FARM POPULATION OF THE UNITED STATES
1900-1975 .........o..... ................ 197
G APPLICATION FOR FOOD STAMPS ................... 199
LIST OF REFERENCES ..... ................. ....... .... 204
BIOGRAPHICAL SKETCH ..... ..... .... .... ....... ..... .. 211

viii




LIST OF TABLES

TABLE PAGE
1 Population Data for Citrusville Population Sixty and Older ................. ........ 31
2 Population Data for Research Study Population
Group . ................................ 32
3 Population for Citrusville District and
Citrusville County 1910-1970 ....... ....... 52
4 Place of Residence Between 1965-1970 .......... 55
5 Average Household Size for Citrusville Study
Population, Citrusville District,
Citrusville County, and Florida ........... 59
6 Seven Household Types ......................... 60
7 Six Types of Household Living Arrangements for
the Elderly Adult Person in Citrusville ... 66
8 Structural Conditions of Citrusville Housing .. 69
9 Selected Housing Characteristics of the
Elderly, 1973 ............................ 71
10 Components of Income by Age of Head of Household for 1972 (As a Percentage of Total) .. 75 11 Ranking of Major Income Sources by Percent of Individuals Responding to that Category. 77 12 Income of Citrusville Residents by Income
Type ...................................... 79
13 Percentage Distribution by Occupation for Citrusville and Citrusville County-......... 82 14 Percentage Distribution by Occupation for Citrusville Elderly Study Population ...... 83




15 Composite Typical Expenses for Elderly
Person ................................... 84
16 Age Group of Friend and Percentage of
Individuals Who Reported having Close
Friends in Those Age Groups .............. 103
17 Responses to the Question About Feeling
"Sick" ................................... 118
18 Distribution of Answers to Question: "How
Often Do You Feel Sick?" ................. 120
19 Schematic Outline of Rural Elderly Health
Care Seeking Behavior .................... 124
20 Self-treatment Remedies ...................... 129
21 Over-the-counter Drugs and their Uses ........ 131 22 Rescues of Citrusville Fire Department,
1978-1979 ................................ 136




LIST OF FIGURES
FIGURE
1 Research Population Determination
(Schematic) .............................
2 Number of Interviews Accomplished, on
average, by Both Investigators per
week (schematic) ...

PAGE




Abstract of' Dissertation Presented to the
Graduate Council of' the University of' Florida
in Partial Fulfillment of' the Requirements
f'or the Degree of' Doctor of' Philosophy
RURAL MiEDICAL SELF-HELP LINKAGES By
Tyson Lee Gibbs
December, 1979
Chairman: Dr. Otto Von Mering Major Departments Anthropology
Rural elderly individuals, both Black arnd White, live in an environment which compels them to be economically self'-suf'f'icient if' possible and alternatively to rely on the assistance from close friends and nearby relatives. Little research has been done to determine how rural older people are able to survive in spite of' the many social and health care problems which plague them. This dissertation examines the health care networks in which the elderly participate and examines the relationship of' these networks to environmental constraints, routine behavior, and
health care seeking behavior. The data gathering methodology includes participant observation, an Interview Guide, the analysis of' local community studies, and the collection of' information from local health care resource institutions.

xii




The study proceeds from the premise that research into health care maintenance behavior and health care seeking behavior of rural aged people must examine much more than the availability of health care resources or illness and disease behavior. In fact, to limit a research study to only the more salient features of health care seeking behavior would belittle the effect of personal routine habits on the overall state of health. Furthermore, for the rural aged poor, the relations they have with each other in a given social network, including their continued monitoring of each other's health status, assure them of help and sometimes ample time to seek treatment.
Therefore, this research first examines the environmental constraints out of which social networks develop and within which routine behaviors take place. The most important are the housing situation, the stability of the rural neighborhoods and communities, the living arrangements and the mechanisms of economic survival. These, along with the perceptions that the elderly have of their surroundings, are presented as the major factors which support or impede the rural aged individual's activities.
Next, the routine activities are presented as the practical survival techniques which not only describe elderly daily behavior but also serve to solidify the structure of the various social networks. In effect, these routine behaviors illustrate regularities in the elderly person's lifestyle. Such regularities, in the main, permit

xiii




appropriate and purposeful social interaction between the older person and some nearby relatives. In general, it can be said that the more knowledge that the aged person has of the routine activities of close friends and relatives, the more stability the elderly person will have in his or her life.
Lastly, health care seeking behavior is shown as an
integral part of the routine activities of the rural elderly individual. Moreover, the roles of close friends, relatives, just friends, and the more formal institutions of health care are presented. It is suggested that the elderly person takes care of or "treats" many of the illnesses or diseases which he or she considers as "less serious." This self-treatment includes over-the-counter drugs, some herbs and roots, advice from close friends or relatives, and advice from the local pharmacist. Although the evidence is not conclusive, the implication is that for more serious
illnesses and diseases, formal health care practitioners are consulted. The study concludes with suggestions of how this kind of research can be useful in implementing preventive health care education programs and better local health care services.

xiv




CHAPTER I
INTRODUCTION
Most, if not all, elderly persons who live in rural communities are affected, to some degree, by the presence of ill health and disease. Moreover each aged person in a rural area has adopted some practice which will assist him or her toward maintaining a functioning state of health. Collectively, these individual health care practices constitute the "healing systems" found in each rural community. As healing systems, they represent a culturally unique adaptation to the rural environment.
Anthropologists, since the time period when anthropology was nothing more than a hobby for some wealthy individuals, have made attempts to study the various healing arts and healing actors in different cultural areas. Disappointingly, however, this fascination with illness and disease behavior has meant an almost total absence of studies which have as their major focus the study of health care maintenance behavior.
Still, it is the mundane, almost routine, daily
activities of rural elderly individuals which determine the direction and the consequences of their health. In fact, the sum total of the rural elderly health care




seeking behavior can no longer be attributed to root doctors or herbal medications. Many of the rural aged individuals choose to treat themselves with over-the-counter drugs for some medical problems, and may travel many miles to see a physician for other diseases and illnesses.
Furthermore, while it is important to study the mechanisms of the rural elderly person's individual health care treatment system and his or her healing personnel, it is equally important to examine the everyday behaviors of the elderly individuals in a rural community. To be sure, it is almost impossible to have a full understanding of "why" and "how" individuals seek health care from the more formal health care institutions, if one does not understand their lifestyles. Moreover, the health care maintenance system of individuals consists of the habits of the persons in their neighborhoods, their household living situations, the kinds of employment they engage in, what they eat every day, as well as their health care seeking activities.
Rural Elderly Social Behavior
Clearly, studies of neighborhoods, household structures and living arrangements, as well as rural elderly employment constitute the morphology of an aged person's lifestyle. These variables, when studied, indicate the-organizational constraints in the elderly person's life but do not determine the motive or method of the elderly individual's personal activity. Therefore, studies which focus on the




health care maintenance and health care seeking behavior of rural elderly individuals must also examine their routine habits.
We expect to find that regardless of level of income, the rural elderly seek to live in a stable environment. Most of them will also attempt to surround themselves with family, neighbors who can be trusted, and close friends
within close reach. While not necessarily professing to do so, rural aged people link life in an environment of low stress with a high level of supportive friends. Extensive knowledge of their neighbors' ways of thinking and doing and of their community as a whole gives them a sense of security, and a stability of expectation in their surroundings.
The Nature and Scop~e of Studies in Medical Anthropology
The area of interest in the discipline of anthropology which encompasses, mainly, the study of illness and disease behavior in individuals and populations, has been given the label "Medical Anthropology." Recently, must discussion has been generated over the "scope of medical anthropology" as a subdiscipline of anthropology and the role or place of
medical anthropologists as practitioners of this subdiscipline. Unfortunately, some have attempted to define medical anthropology by contrasting it with medical sociology (Foster 1978; Olesen 1978; Polgar 1962); in fact, this comparison is not




necessary to define the activities of' medical anthropologists. Hasan (1978:17) most cogently put it this way: "The roots of' contemporary medical anthropology, in fact, are traceable to the development of anthropology itself." In the much broader sense, medical anthropology can best be defined through a presentation of the central concerns of' the parent discipline of anthropology.
Schwartz and Ewald (1968:4-5) best define the concerns of anthropology this way:
1) First, anthropology has been characterized by an
orientation toward non-Western peoples; it has been concerned with groups of' people not commonly studied
(until recently), by . other disciplines.
(However), many anthropologists are engaged in intensive studies of contemporary nations.
2) Second, the field research--collecting information
through intimate, firsthand experience among the
people being studied--is a necessary part of anthropological investigations.
3) Third, specific information and generalizations
derived from such information are essential to
anthropology.
Using the above concerns as general guidelines, the
following can be stated about the scope of medical anthropology:
1) First, medical anthropology can be viewed as the
study of health, healing, illness, and disease
behavior among contemporary, non-western, traditional and industrialized nations.
2) Second, the collecting of information through
participant/observation and through intimate, first-hand experience, combined with the more




recent techniques of' survey research and computer
technology, are part of' the methodology in medical
anthropology.
3) Third, the presentation of' the information gathered
through research to other scholars as new or
added-on information; the offering of' feedback, on
health issues, to institutions, communities, and
individuals being studied; and the presentation of' alternative ways of' viewing health care maintenance
and health delivery systems of' a given group of' people, constitute the nature of' medical anthropo logy.
In summary, medical anthropology is concerned with the healing and health maintenance systems of' all peoples in the morphological sense--the structure that each system takes in a given culture, the functional sense--the methodologies used by the different individuals in a culture to participate in a health system or to devise their own health system, and in the cognitive sense--the way each system is conceived and verbalized by the different individuals in a given culture. It is through the offering of' a tentative definition f'or medical anthropology, in comparison with the parent discipline of' anthropology, that one can begin to obtain a feeling f'or the holistic and comparative nature of' the subdiscipline and one can begin to see its roots in anthropology.




The above definition being offered is by no means the only way of viewing the subdiscipline of medical anthropology. It does, however, delineate the role and scope of the studies and activities of medical anthropologists. In addition, the definition offers a handle with which medical anthropologists as practitioners can develop new theories on the nature of healing systems and health care maintenance
systems in different cultures.
Purpose of This Study
This research project is a field exploration of the idea that the general health status of an individual is a measure of his or her ability to adapt to a given environment. The elderly in a rural, Northern Florida community called Citrusville (fictive name) constitute the research population. An examination is made of the environment in which the elderly person lives, as well as his or her daily activities and specific health care seeking activities.
There is a clear and undeniable linkage between disease, medicine, and human cultural activity (Landy 1977). Moreover, illnesss, illness behavior, and reactions to the ill are aspects of an adaptive social process in which participants are often actively striving to meet their social roles and responsibilities, to control their environment, and to make their everyday circumstances less uncertain, and
therefore, more tolerable and predictable." (mechanic 1978:1; Von Mering and Kasdan 1970).




However, medical anthropology, for the most part, while professing to offer the holistic approach to health and illness behavior, in actual practice has focused on disease behavior. A regrettable by-product of studies which focus only on disease behavior to the almost total exclusion of studies on wellbeing care behavior, is that health planning agencies measure the health status of a given population by
the presence or absence of particular life-threatening diseases, i.e., the idea that populations represent a "diseased herd" (Otto Von Mering, personal communication). Very rarely, if ever, is the health or "wellness status" of a population measured by determining the number of ageappropriate functioning individuals.
It is entirely possible that medical anthropologists can offer, from an epidemiological point of view, the concept of "wellness status" as a function of the individual's ability to adapt to his or her total environment (Dubos 1976)i thus, offering a reasonable alternative concept to the "diseased herd" idea. It seems feasible that the wellness status of a population may simply be a measure of the abiity of different individuals in a given environment to function in spite of their physical ailments. Thus, the traditional concept of health status can continue to serve as a particular measure of the number of individuals with particular diseases.
In the final analysis, the focus of studies on medical
anthropology is formulated through the activities of the




practitioners, and the research they perform. As a corollary, it should be pointed out that the research that is not performed will also characterize medical anthropologists. As one individual has been noted to say: "Oft-times, the research that should be performed is not performed because
the parameters surrounding it do not offer a strong stimulus (Gordon Streib, personal communication). In other words, most medical anthropologists, and other social scientists, have studied illness and disease behaviors, mainly, because these variables offer the researcher something that he or she can see, measure, chart, survey, and record in a tangible fashion. On the other hand, the techniques and methodologies employed to maintain health by various individuals, and not merely combat disease, are part of their daily, mundane,
routine behavior. Quite often, this behavior is neither the focal point of a study or a major segment of the final data analysis.
Moreover, when these routine behaviors are eventually brought forth in ethnographic studies, quite often they are missed as part of the health maintenance system of a given population. Many times, these behaviors are viewed merely
as day-to-day living activities of a given population with no connection to health care maintenance behavior. Why Study the Rural Aged
Older persons who live in rural communities present the researcher with a singular opportunity to fully explore the
idea that "wellness status" is a measure of individual




adaptation to a given environment, rather than a measure of the specific illnesses or diseases which individuals may have; rural communities are noted for having very few, if any, local primary care personnel or facililies. This means that individuals have to devise alternative ways of' maintaining their health status (Luft 1976; Salber et al. 1976; Barrett 1975; Murphee and Barrow 1970). Moreover, elderly persons can be characterized as afflicted by many chronic illnesses arnd diseases; therefore it is not too meaningful from a behavioral perspective to measure their health status primarily by indicating the amount and kinds of pathological states present or absent in their bodies. In effect, rural aged individuals have already invented ways of maintaining their wellness status quite apart from consulting formal primary care institutions for their health status; what means
they use to assure for themselves the highest feasible wellness status can only be ascertained through a thorough examination of their environment and their activities. Basic Assumptions Which Structure This Research Inqiuiry
There are three basic assumptions which will guide this research and which will determine the areas of the rural aged
person's life that will be investigated. The first assumption is that in order to fully understand and to be able to determine the health and wellness status of individuals in a given population, one must examine the surroundings or environmental constraints out of which health care and wellbeing maintenance behaviors develop. Considered to be most




critical are the housing situation, the individual living arrangements, economic survivorship activities, and neighborhood stability. This assumption is a way of' operationalizing the concept of' man adapting to his or her environment as put forth by Dubos (1976). Also, it is a logical extension of' the idea previously presented by various researchers which states that the environment in which an individual lives will affect his or her wellness maintenance activities, i.e., culture affects health and wellbeing care habits (Mechanic 1978; Von Mering and Kasden 1970).
The second assumption is that the specific routine or daily habits of' the aged person in a rural community are a result of' years of' living in an area in which the survival process transcends the more salient features of' ethnic group affiliation and sex, i.e., most rural elderly persons have
adopted similar wellness maintenance habits. In order to determine which strategies are being used to maintain the highest possible wellness level, an examination must be made of' what individuals do each day of' their lives. Moreover, this assumption represents an effort to relate findings from this research to a series of' studies which describe elderly leisure-time activities apart from elderly social interaction habits or social network activities. In ef'fectq
specific health care behavior and general wellness maintenance activity should not be viewed as exceptional behavior, but should be viewed as part of' routine behavior.
The third assumption being made is that rural aged
persons have to monitor their health status much more




closely than their urban/suburban counterparts, since they live in an environment which is largely deprived of specialized health care services. Also, it can be assumed that these elderly persons will take actions which they deem appropriate and necessary in order to maintain a functioning state of essential wellness rather than a state of essential health or freedom from disease. Specific to determining how older people maintain their essential wellness is to determine their health care seeking decision making process, and to elucidate their concurrent or subsequent wellness
maintenance seeking activities.
A critical question to be answered relates to the rural elderly person's ability to function in an environment which
is balanced precariously. Of special interest here is the question of whether or not the rural elderly person has enough stress-compensating power to carry him or her from the age of 60 through the time period of the mid-70s, at which time there occurs a statistically significant, rapid quickening in the number and severity of activity-limiting conditions (Gamm. and Eisele 1977; Ellenbogen 1967).
Restated, an area of particular research interest is to determine the capacity of the more formal medical systems to increase the extent and degree of essential self-care of the elderly through the utilization of elderly friendship and kinship ties within the local community. It is therefore hoped that this study will provide more reliable benchmark information on the particulars of rural elderly health




care and wellness seeking behavior. It will shed light on the nature of its occurrence, both within and apart from accessible public health agencies or programs, and on the question of how this behavior is furthered or blocked within prevailing networks of symbolic or kin linkages of care giving and wellness support to family, friend, neighbor, "club," and church.
Furthermore, aside from an examination of the questions raised by the above three assumptions, it is the purpose of this research to determine the features within the environment which promote or impede the health care wellness maintenance process. Once these variables have been more clearly identified as important to the process of growing old in a rural community, testable hypotheses can be generated so that more focused research can be done. Of course, it is hoped that this research project will add much-needed
data to the slowly-growing body of literature related to rural health care and its differential effects on different ethnic groups. In addition, it is believed that this research will contribute to future studies encompassing health education issues community self-awareness, and participation of residents in local health services. These and related implications of the research will be dealt with in the body of reported findings.




CHAPTER II
RESEARCH SITE: CITRUSVILLE, FLORIDA
Citrusville, Florida, not the town's real name, is a
small town located in the Northeastern portion of the State of Florida. It is, by its own definition, small and rural. Less than 4,000 people live in the entire Citrusville District which covers, excluding two large lakes, approximately 130 square miles; there are almost 31 people per square mile. Less than 2,000 people live within the city limits of Citrusville. Also, Citrusville is nearly 15 to 20 miles, in an east or west direction, from larger, more populated areas.
Reason for Choosing Citrusville as Town to Study
The Citrusville Census District was chosen to be the
research site because it offers three advantages over other small towns in the Northern Florida area. First, it is sufficiently close enough to the University so that transportation to and from the research site does not present a major obstacle to conducting the study. Second, it is the only small town, within a sufficiently close radius, that has a public health clinic, a dentist, a semi-retired physician, a pharmacist, and a fire department rescue unit.




Having these medical facilities locally allowed the investigators the opportunities to fully explore the relationships between the elderly individuals and the local institutions of health care. Third, and last, Citrusville has a large elderly population which is sufficiently scattered throughout its district area so that the different elderly living environments could be sampled.
Reaction of the Citrusville
Residents to the Research
Initially, no one in the town of Citrusville was consulted about whether or not the research could be carried out in their community. In fact, the researchers simply "showed up" in the community and began to talk with the townspeople. In addition, various individuals who live in the Citrusville District were consulted for information about the town and assistance in locating aged persons to be interviewed for the study. The Citrusville residents did not provide any funds for this research but did offer the facilities of the high school library and the public library. Also, the local pharmacist, and part-time mayor, granted the investigators permission to use his store to collect our notes, if desired.
A Brief Historical Sketch of Citrusville
According to the local "Citrusville Reporter" newspaper, Citrusville began in 1834 as the union of a road which came from a small town north of Citrusville, and a road which




came from a larger city west of Citrusville. Few individuals lived there, less than 500, and the population consisted of small land holding farmers and their slaves. The community was, basically, organized around a Baptist Church and many of the individuals who settled here came from England and Ireland.
During the mid- to late 1800s, Sea Island Cotton was grown in Citrusville, as well as orange trees and rabbits. Citrusville was thought to have one of the largest rabbit hatcheries in the state. Moreover, there were about five or six stores, two small hotels, two cotton gins, one blacksmith, a livery and feed stable, a sawmill, an academy for men and a newspaper--"The Citrusville Graphic."
After the turn of the century, according to the local librarian and a local service station owner, turpentine production and green beans became important products in Citrusville. It is believed that a freeze in the late 1800s killed much of the orange crop and also, much of that business. Also, around this time period, the railroads which came through Citrusville had given it a vital link to the world.
Because many, if not all, businesses in Citrusville
were segregated, until the late 1950s and 1960s, the Blacks who lived in town and who worked for the various businesses had to have their own stores. Most of the Blacks were workers in the cotton fields, green bean patches, and orange groves. However, it has been stated by many of the older




residents of Citrusville that Blacks owned land, and some were skilled craftsmen.
The Citrusville of the 1920s through 1950s lost many of its businesses, and therefore its population, due to the increased competition by many larger companies. One large paper manufacturer acquired much of the land formerly used for large-scale farming, and planted trees. All of the various stores have faded from the Citrusville streets, not only because they are no longer useful, but also because the present population cannot afford to support them.
The Citrusville of today, and the past thirty years, has seen a small increase in population but no tremendous increase in businesses. Although most individuals say that Blacks can live anywhere in Citrusville, there is a sharp and very distinct division of housing location for Blacks and Whites. Many Blacks still inhabit small, poorly constructed housing "across the railroad tracks" and on the west side and south side of town. The Whites live to the north,
northeast section of Citrusville.
There are few businesses in town: one small grocery store, two convenience stores, two or three family-owned restaurants, one or two small shops, one pharmacist, and several service stations. The majority, 95%, are owned by Whites. No significant other racial group lives in Citrusville. Most of the individuals who work in Citrusville either own their business, have been with the owner for many years or they are friends and relatives of the owner.




17
The others who do work, have to travel 20 miles east or west to the nearest larger city. The elderly, however, comprise 12% of the population and because most are retired, they form a major segment of the consumer population.




CHAPTER III
METHODOLOGY
Introduction: Descriptive vs. Quantitative Data
On every hand we hear the admonition, the study of
society must be made objective. When one asks what is
meant by this, Lhe or sheJ is referred to the Lresearch techniques used] in the natural and biological
sciences. But, while the average [social scientist] has little difficulty in comprehending what is meant by the objective study of a naturally occurring phenomena, he Lor she] is at a loss, as a Lcollectivity, trying to visualize the objects of a study in a social
inquiry (Lynd and Lynd 1956 v).
The study of human behavior in a customary setting
presents research design problems which are immense. The problems are immense because people do not necessarily behave in predictable, patterned ways. This lack of predictability in human behavior often means that the circumstances under which data are collected change in such a fashion that situations described in one report are history before they ever make print. As Gale (197431) stated: ". . man is a short-lived animal who is sociologically speaking, in a rapid phase of development. The Lproposed] laws which control his social actions and interactions are themselves subject to rapid change." Moreover, any major social event which may affect an entire community, such as a quick change in government, indeed, any event affecting a person's lifestyle, like failing health or a change in social status,




can almost immediately change the opinions, attitudes, and ultimately the behavior of each person affected.
Anthropologists studying human behavior do contribute much with a detailed synchronic and diachronic description of human activity under various circumstances. Furthermore,
detailed descriptive data, usually defined as the cataloguing and classifying of a range of elements seen as comprising a given subject matter, are basic to all scientific inquiry (Black and Champion 1976). In fact, for the anthropologists,
descriptive data are used to clearly illustrate how and why there is a relationship between the many "subsystems of' interaction" found in each group under study (StuddertKennedy 1975).
As a rule, moreover, the collection of descriptive data
is linked with performing qualitative research. Hence, collecting descriptive data involves the social scientist both in the firsthand, face-to-face participation and in the delineation of events or activities of' a naturally occurring social setting (Orenstein and Phillips 1978). To the extent that the social scientist is attempting to collect data in a natural social setting, he cannot, like the natural scientist, readily manipulate the variables of' his research to fully assess their causal significance.
This lack of planned overt and covert manipulation and interference with the research variables of a social inquiry by social scientists signifies to many non-social scientists that qualitative research is the least rigorous and least




difficult of all scientific inquiry. But, the differences found in the research strategies of the natural scientist and those of the social scientist do not necessarily mean inferiority of one research technique over the other one (Orenstein and Phillips 1978). Similarly, it has been asserted that the objective performance of research is automatically linked with being able to quantify all research data. Yet, for the anthropologist in particular and the social scientist in general, objectivity is not exclusively or necessarily linked with quantifiability of the observed (Studdert-Kennedy 1975). Scientific rigor is also attainable by alternative means.
Research Technique
The research methodology of anthropology involves the observation of human behavior in habitual settings for social events. All observations involve the participation of the anthropologist whenever possible. As a special data generating strategy, this technique has been called "participant observation." In most descriptions of anthropological research, it is commonly expected that the readership will understand what is meant by "participant observation."
Unfortunately, a great many anthropologists and social scientists differ in their understanding of this term.




Participant-Observations A Definition
Historically, participant observation has been viewed
as a role to be taken on by the researcher in order to gain easy entry into an unknown community (Kolaja 1956; Babchuck 1962; Bruyn 1963). Participant observation, according to Kluckhohn (19400331) is conscious and systematic sharing, insofar as circumstances permit, in the life-activities and on occasion, in the interests and affects of a group of persons. Its purpose is to obtain data about behavior through direct contact situations in which the distinction
that results from the investigators being an outside agent is reduced to a minimum.
Participant Observation as a Research Task-Oriented Role
When participant observation is viewed as a research
task-oriented social role, the assumption is being made that in order to gain access to data, certain inevitable social barriers much be crossed. In most research studies performed in non-western, traditional societies, taking on a role may be necessary in order to generate data. However, in many present-day western communities, as a result of individuals being affected by the mass media system, individuals have gained a superficial knowledge about social research. Consequently, the taking on of a special data collector role is often not necessary for the social scientist.




Partici-Pant Observation as a Research Technique
On the contrary, some Communities and individuals welcome social scientists who are concerned with their community affairs. In this case, participant observation
becomes a research technique rather than the performance of a social role to gather data. As a research technique,
participant observation becomes a direct observation
method which allows the researcher to record behavior as it occurs. Other data gathering methods
include: questionnaires, interviews, paper and pencil
tests, and case records that are available on the
research population. (Fry 1973:274)
In gathering data for a social inquiry, whatever the
method, the issue of the inability of social scientists to produce what is considered high quality data using the participant observation technique has been raised. The issue is not that participant observation produces low Caliber data, but that the data produced do not lend themselves to quantification. Hence, even a most carefully assembled
body of descriptive data may not be viewed as having the same truth values as quantitative data when both are treating the same social phenomenon.
However, Fry (1973) offers a way of looking at the
place of participant observation in research methodology. Many anthropologists may not agree with his statement that participant observation produces a "low order measurement" (1973:274). However, it is easier to support his idea of three levels of research measurement. His description states:
The first level of measurement is concerned with the value a recipient group places on an activity to be
evaluated; the second [measurement] represents the




appraisal of a group of' experts based on examinations
and comparison with similar [research findings];
the final level is concerned with effectiveness
Las] determined by standardized scientific procedure
including proper L or appropriate] research design and
instruments of determined reliability and validity.
(1973:t274)
Further suggestions have been put forth by Fry that
participant observation "is an appropriate methodology with which to approach the first level of measurement" (1973: 274). It is important that he should suggest using participant observation as a method to understand how individuals
feel toward a particular activity. The interpretation of human behavior is the "stuff" which forms the basis of all anthropological inquiry. Moreover, the present research has been conducted with the idea that participant observation can be used as a research technique to gain understanding about the values or priorities that the rural elderly place on various health care activities.
The practice of participant observation as the only
direct means of gaining access to information not otherwise obtainable Was not needed for this study; no reason existed to keep secret the motives of the investigator. The individuals who participated in this research were made fully aware that:
1) The researcher is affiliated with the Anthropology
Department at the University of Florida.
2) The research project was concerned with both black
and white individuals in Citrusville who were 60
years of age and older.
3) The results of the research would not necessarily
mean an increase in health care facilities or
access to health care.




L) The results of' the research would be made available
to them as well as to other health care agencies
concerned with the aged.
Research Sampling Proced-ure
In general, where research has been conducted in small, rural southern communities, the issue of obtaining a representative sample of' the population has been a technical, rather than a major research problem. For example, it has been observed by Ensminger (1949: 55) that "the rural community is the geographic area with which most of' the community's members identify themselves. To ask a rural dweller about his community in a given section of the country is almost
certain to bring forth a fairly uniform response." This view has been echoed recently by Ford (1978:8-9):
Virtually all comparative studies of the values and
belief's of rural and urban people have shown similar
patterns of difference. Rural people are generally
more traditional, [in the sense of clinging longer to
older views and resisting new ideals . . [and being]
more likely to share bonds with their neighbors or at
least to know their neighbors ...
Therefore, the fundamental methodological problem which has been a concern of' this study is to insure that different sections within the community are represented in the research sample. In addition, there is no real need to use a stratified random sampling procedure to obtain a research sample population. As Orenstein and Phillips (1978:357) assert: "If [one] studies a homogeneous social group in which most people think and behave alike, data on a few people may adequately represent them all." For the purpose




of sampling the different community areas, the snowball or key informant research technique was used. Key Informant Research Technique
The snowball research technique for defining a research sample population, in the main, involves using individuals who reside within the community as key informants. These
key inf ormants can be used by the investigator to obtain names of other individuals who might be willing to participate in a study. In this present study of the Citrusville
elderly, members of the community were asked by the investigators to reveal the names of individuals 60 years and older who would be willing to be questioned about their customary daily living habits. The major intent of this technique is to obtain a list of names from the key informants, and still more names from those individuals revealed by the key informants, until a research sample population is established.
The snowball technique, or key informant technique, for defining a research sample is one major method of conducting community research. Liebow (1967t246) in his book, Tally's Corner, describes how his relationship with "Tally, a key informant," enabled him to study ghetto street corner life. His description is as follows:
By the middle of March, Tally and I were close friends
("uptight") and I was to let him know if I wanted or
needed anything, anytime. By April, the number of men whom I had come to know fairly well (through Tally) and their acceptance of me had reached the point at which I
was free to go to the rooms, or apartments where they lived or hung out, at almost anytime, needing neither
an excuse nor an explanation for doing so.




The anthropologist, in effect, attempts to develop
within the research community, a "referral grid" upon which he or she is able to move about the community with the least amount of' interference. The informants within the community become reference points and essentially act as
referral sources through which the anthropologist is able to develop future contacts with others in the community (Von Mering, personal communication).
Carol Stack (1974t8-9), in her book entitled, All Our
Kin, was able to develop such a referral grid of individuals in a Black urban community, through which she studied their social networks. She describes her entry into one family and thus to the community, as follows:
During my first visit Viola told me that she and her
husband Leo have kept their family together for
twenty-three years. Leo, she said, is a good man, a
man who works and brings his money home. After several weekday visits, Viola asked me to come over on a Sunday
afternoon when the family would be home 0 When I
arrived, Viola called me back to the kitchen where the
women were cooking a Sunday dinner. Verna, Viola's
nine teen-ye ar- old daughter, and It both six months pregnant, talked about names and nicknames for our
babies, and eventually almost everyone in the household
joined the conversation. 0 0 The conversation among
Verna, Viola and myself was long, warm, and lively, and
eased the strain. our visits continued for months.
In all research, as Glazer (1972:11) says, it is essential for the investigator to spend an initial period of time preparing the kinds of questions he or she wants to ask, developing the tools of-data collection, and then venturing out and determining the extent to which the research design will be appropriate for the actual field situation. Gaining




acceptance from informants and respondents is a crucial component of this process.
other Uses for the Key Informant-Technique
Aside from providing an entry mechanism into the community of study, Orenstein and Phillips (1978:321) have put forth other positive reasons for using key informants. They say essentially that the field worker meets people who help him or her gain entry into the community, who direct the investigator's attention toward certain events, who point out patterns that the researcher might otherwise miss and who keep the investigator up-to-date on new happenings that he or she might not attend. The key informant also suggests explanations of events and when appropriate, comments on the final research project. Whether the field worker develops a key informant, or several informants who each make a more limited contribution, the active role that informants play in all phases of the research cannot be overemphasized.
Determination of Research Population Sample
one major component of the key informant technique is
that it serves the purpose of making the researcher known to
the community. Initially, the researcher is in contact with individuals who are familiar to the community residents instead of' initially confronting the residents. As illustrated in the studies by Stack (19741) and Liebow (1967),




the key informants may be chosen from amongst the various: school teachers, guidance counselors, principals and viceprincipals, local ministers, prominent church members and the public librarian. It is through contact with these key informants that a core group or "first generation research population" study group is established. Subsequently, after interviewing these first community residents and determining their close friends, a "second generation research population" study group is established. Likewise, upon completion of the interviews with this second generation research study groups, alternative, additional referrals are determined (see Figure 1).
My first contact with Citrusville residents involved my talking with the guidance counselor and vice principal of the local high school. These individuals allowed me to use the school library as a place to write up reports and they also gave me the names of several community residents. My second entry into the community involved myself and my
research assistant speaking with the ministers of all nine of the predominantly Black and predominantly White churches in Citrusville. Each minister was asked to give us the names of three individuals in his church who might be contacted to participate in this study. For the most parts all the ministers were very cooperative after they understood the nature and purpose of the study. once entry had been made into the community through the guidance counselor, the vice principal and the ministers, the local public




Key informants or
Initial referral Sources

Churches, Black" School Librarian
and White Related
Persons
(N=9) 9 (N=5) (N=I)

1st Generation Research Study Population
t4
2nd Generation Research Study Population

N=15 N=25 N=39

Alternative Additional Referrals (Unused)

Trusted Friends
of 2nd Generation Research Population

N=45

Figure 1. Research Population Determination (Schematic)
t ,R arrows indicate direction of referral

m

- "4*A




librarian and three school teachers were further contacted for names of individuals for the study. Overall, it can be stated that these key informants were enthusiastic and very
cooperative. Figure 1 reveals the numbers of individuals obtained through this procedure.
Composition and Size of Research Population
According to the 1970 census of population, there are approximately 3628 persons residing in the Citrusville District. Of that total, 12.5% or 450 residents are 60 years of age or older. Blacks number 211 or 47% of those over 60, while Whites number 2239 or 53%. Black females are represented by 118 or 26% of those over 60 and Black males account for 93 or 21%. On the other hand, White females make up 141 persons or 31% and White males number 98 or 22% (see Table 1) .
In the Citrusville research population, there are a
total of 64 persons or 14.2% of those individuals over 60. Fifty-three percent or 34 of the research population group is White, while the remaining 47% or 30 individuals are Black. In terms of the number of White females and White males in the group, the females number 24 or 38% of the total number of individuals in the research population and the males number 10 or 16%. Black females number 22 or 34% of the total study population and the Black males number
8 or 12% (see Table 2).




Table 1. Population Data for Citrusville Population Sixty and Older

1970 Population for Citrusville

Number of persons Over 60

Number of Whites

Number of Blacks

3628 450 239 211
100% 12.4%a 53%b 47%b
Number of Number of Number of Number of
White Females White Males Black Females Black Males
141 98 118 93
31% b 22%P 26% b 21%b
a Percentage representation of total Citrusville Population. b Percentage representation of Citrusville Population 60 and older.

Source: U. S. Census of Population for 1970.

Total % of Total
Total % of Total




Table 2. Population Data for Research Study Population Group

Total Research Study Population

Number of Whites

Number of Blacks

64 34 30
14.3%a ~ 53%b47b
Number of Number of Number of Number of
White Females White Males Black Females Black Males
24 10 20 8
38% b 16%b 3 Wb 1%
aPercentage representation of total Citrusville Population over 60. b Percentage representation of total research study population.

Total % of
Total
Total % of'
Total




Before conducting the research, it was determined that between 10% and 20% of those individuals 60 and over would be sampled since Citrusville represented a fairly homuogeneous area. Further, it was decided that the ratio of Blacks to Whites would be the same in the study population as those in the total population of those 60 and over. Although an attempt was made to maintain similar malefemale ratios in the research population as those in the
total over-60 group, it was not accomplished for several reasons. First, and most importantly, the men in Citrusville were elusive and difficult to detain for an interview.
Second, when men were interviewed, they usually named few individuals, on average one or none, as their close friends.
Third, and last, women, for the most part, named other women as their close friends and men named other men as their close friends. In very few instances, less than three, was there an overlap.
Interview Guide
An Interview Guide has been used to gather the essential data on the research population in Citrusville. The conceptual organization of the Guide's contents is based, mainly, on the areas of concern previously formulated in a study of Black family social networks by Carol Stack (1974, see Appendix A). In addition, a number of questions are based on a questionnaire which was used in 1976 by this




researcher to gather health care data on migrant workers in a Northern Florida rural community (see Appendix B). Precision and Accuracy of the Interview Guide
Repeatedly, to the social scientist conducting research in a natural setting, the question arises as to whether or not the data-gathering instrument is appropriate for obtaining the requisite information. Furthermore, once the data are collected, the question arises as to whether or not it truly reflects the information that one seeks. In fact, what these two questions do is raise two issues (1) what is the "precision" of the data-gathering instrument, and
(2) is the information collected "accurate" information.
The "precision" of a data-gathering instrument refers to the efficacy with which it is able to obtain the needed data. In fact, the precision of a data-collection instrument can be statistically measured through testing it in several places and comparing the results. The closer the results are to each other, after having used similar sampling procedures to choose the subjects, the more precise an instrument is said to be (Wax 1970; Chou 1975).
In this study, an Interview Guide was used instead of a questionnaire. The Interview Guide is an attempt to ask the study population all open-ended questions. However, although the questions were open-ended, each person in the study was asked the same questions. The only difference in interviewing one person over the next, was their responses to the questions. Because the Interview Guide




covers many aspects of' the elderly person's life, it is able to obtain the information needed relative to rural
elderly survivorship.
On the other hand, it is difficult to determine the true accuracy of the Interview Guide. For some sections, such as the section related to health care information, the data collected were easily verifiable because many of the elderly would show the investigators their prescriptions, bottles of pills, and in some instances, their cards for their next doctors' appointments. Moreover, the close friends of the individuals were easily determined because they are known to other persons in the community who would frequently refer to "Person A as a close friend of Person B."I Also, during the interviews, Person A would, most often, name Person B as a close friend. There was almost 95% mutual agreement between individuals who called each other close friends.
Yet, the age and personal data had to be accepted at face value, unless the researchers were willing to violate the privacy of the interviewees. Furthermore, the information on the economics, and household bills, was not easily checked because individuals were reluctant to discuss those issues at length. Finally, the data related to daily
activities in many instances, were checked and verified because the investigators visited many of the activities in which the elderly stated that they participated.




Components of Interview Guide
The research Interview Guide is divided into six components. They are: (1) General Information; (2) Life Habits; (3) Information on Household Structure; (4) Information on Social Network Structure; (5) Health Care Information; and (6) Health Care Problems. The overall Guide is designed to elicit detailed information on an individual's daily customary habits as well as gather specific data on the health care habits and health seeking behaviors (see Appendix C).
Interview Technique
As a rule, each individual whose name was given by a key informant was contacted for an interview within a week of the initial referral. Those individuals who consented
to being interviewed gave a time that would be most convenient to them. Each person was told that the interview would consume between 45 minutes and an hour of their time. However, many interviews lasted longer than the scheduled time because many persons wanted to discuss matters not specifically related to the primary purpose of the interview.
In the maino the two interviewers involved in this
research found the interviewees very pleasant, and willing to fully answer all questions to the best of their ability (see Figure 2). Many interviewees expressed thanks for




Number of Interviews per week
10
9
8
7
6
5

I
8th week

I
4th week

2
1
0
lst
week
Jan. 1
1979

16th week

12th week

20 th week

Number of weeks

June 1, 1979

Figure 2.

Number of Interviews Accomplished, on average, by Both Investigators per week (schematic)

[Notes No particular significance may be attached to the frequency
of interviews conducted during any given week, except that variation in interviewee and interviewer time played a role
in the above pattern.]




having participated in the study because they felt that the questions raised made them think about their amount of self-sufficiency. Further while many persons had health care limitations# i~e., frequent heart attacks or almost total confinement to their homes, they nevertheless agreed to the interview. When others were to be contacted, quite often the individual being interviewed would call the next interviewee. This help given to the researchers saved many hours of trying to call individuals or trying to locate them.
While both interviewers in this study were able to
develop close relationships with some of the residents in Citrusvilleq a few residents were resistant to being interviewed and others were reluctant to discuss the relationships they had with close friends. In the main, the types of contacts that will be made in a research setting and the
kinds of interaction patterns that will be permitted, will depend upon the background of the researcher and the initial contacts made in the community (Orenstein and Phillips 1978). In fact, Glazer (1972:12) states it quite cogently with: "when the fieldworker attempts to gain entrance into a relatively closed community, . trust is the crucial ingredient and may often be more important than the various
forms of reciprocity."
Other Data Resources
The investigators were able to obtain information from many documentary resources. For instance, a city plan had




been completed on Citrusville and provided data on housing, living arrangements and economics. Comparative data were also obtained from the U. S. Census of Population for the years 1900 through 1970. Finally, the local residents and the Citrusville Library and high school library provided much of the information on the history of Citrusville and the Citrusville of today.
Summary Review
A description of the Key Informant research technique has been presented as a method used to develop a research sample in the Citrusville Community amongst those persons 60 and older. Also, it has been shown that the Interview Guide presents a way of ascertaining information from the population sample through open-ended questions. Although not specifically stated, it has been implied in this report that having open-ended questions allowed the investigators to obtain much more information about routine habits of the elderly than a pre-coded questionnaire may have allowed. In subsequent chapters, the data collected in the above fashion will be presented in relationship to the elderly community structure, daily activity, and health seeking behavior.




CHAPTER IV
DEFINING AN EILERIJY COMMlVUNITY STRUCTURE: CITRUS VILLE
In Chapter III the Key Informant Research Technique,
which defines the referral grid, was described as the method used in this research project to gain entry into a rural community and to obtain a representative research population sample. The Interview Guide is put forth as a data collection device which was used to ascertain: the morphology of the elderly person's environment, the individual behavior patterns and the individual's perception of his or her environment. In Chapters V-VIII, however, only the variables which define the structure of the rural aged
person's living environment will be discussed.
The environmental structural "regularities" under consideration for the Citrusville elderly individuals number four in all. They are: (1) the neighborhood conditions which define its stability; (2) the living arrangements of each household; (3) the local housing situation; and (4i) the economic conditions which determine survivorship. Whereas
these regularities, which may also be referred to as "environmental constraints," do not always determine the specific activity of individual behavior, they do influence in a major way the aged person's lifestyle. In addition, an examination of these regularities, in the sense of
4o




environmental constraints, together with routine behavior is
expected to reveal the overall survivorship mechanisms for rural aged persons.
Data Resources for Chapters V-VIII
The organization of these chapters will be centered
around the four environmental constraints listed above for the Citrusville Elderly Study Population sample. The data presented in each section of these chapters are derived from different sections of the Interview Guide (see Appendix C). Below are the pertinent sections, and particular information on the data resources. Stability of Neighborhoods in Citrusville
The data presented in this section come from the
following resources: (1) general notes taken after having
conversation with the elderly person being interviewed. For instance, female interviewee may be describing her children who live outside of Citrusville, but may comment on the fact that skilled young persons rarely come back or stay in Citrusville; (2) questions from the Interview Guide, Section C, "Information on Household Structure," Part I, questions A through E; and (3) observations of the neighborhoods by the investigators while driving to the interviews. Living Arrangements of the Citrusville Aged
Information for this section comes from two different sections of the Interview Guide. Data on individuals who




live alone or with spouse were collected in Section A, "General Information," Parts I, II and III. Data on those
persons who live with other relatives and friends were collected in Section C, "Information on Household Structure," Part II, questions B and G.
Housing and the Citrusville Elderly Individual
The information presented in this section is data
gathered in the Interview Guide, Section C, "Information on Household Structure," Part I, question F, "A Better Place to Live?" Most persons responding to this question usually discussed: their feelings toward their present location, the problems they are experiencing with their homes, and why they would or would not stay in their present homes.
Also, datawere collected for persons living with other relatives and friends, in Section C, Part II, questions A, F, and G.
Economic Survivorship of Citrusville Elderly
The data for this section were collected in one section of the Interview Guide and from the local Social Security Administration. The information from the Interview Guide was gathered in Section A, "General Information," Parts III and IV. Data from the local Social Security Administration came from a survey conducted on Citrusville elderly residents who receive Social Security benefits.




Presentation of Comparative Data
Where possible, throughout this report, the data
gathered on the Citrusville elderly will be compared to similar national studies of particular trends in rural communities amongst the elderly, or to local studies conducted on a larger rural population group. This comparing of local data to other data collected elsewhere is to demonstrate that in many instances, activities reported to occur on the national level may or may not occur at the local level.
Definition of Terms to be Used in This Report
Before presenting and discussing the information on the elderly community structure, the major terms which will be used throughout the remainder of the report will be explained. It is important to do this, because terms have different meanings depending on the context in which they are used. For this report, the following concepts are important, namely: social network, close friends, just
friends, and strangers.
Social Network
Quite simply defined, a social network is the sum total of an individual's social relationships, both the personal ones and the formal ones. In most instances, these relationships begin with the individual and the immediate family,




then eventually radiate Out to other relatives and the society at large (Fischer 1977). In this study, the concept of' an individual's social network will be used to provide an overall framework for discussing the various relationships
the Citrusville elderly have with relatives, friends, and institutions of health care.
Close Friends
In the main, close friends of the rural aged person are those individuals who will not reveal the contents of their discussions to others who are not part of their friendship group. When the elderly in this study group were asked, "What kind of person they considered a close friend," they stated that: "A close friend is an individual that you could count on when you needed them." Also, it was expressed that trust was a result of being friends for years. Almost 100%
of the people in the study gave this response when asked this question.
optimum number of close friends. In general, the number and kinds of close friends that a person has in a rural or urban setting depends upon his or her socio-economic status and sex (Clark and Anderson 1967). Individuals in the Citrusville Study who were self-sufficient economically were inclined to trust mainly their wives or husbands if they were married. If they were single, many stated that they would trust a minister, their doctor, or maybe one other
person outside of their family.
Those individuals who suffer economically were inclined to have many more persons that they would trust who were not




part of their immediate family. It is possible that the
discrepancy in "trusting behavior" between those who have and the have nots is directly related to the satisfaction of basic needs.
The poor individuals in Citrusville have to rely upon individuals within and outside of their immediate families in order to increase their chances for survival. By virtue of being poor, they do not have the basic necessities for living. Also, the monies received from government resources do not cover all of their living expenses. Therefore, these poor persons have to request both spiritual (mental) and in some instances, economic support from friends.
Relatives as close friends. For many elderly persons
in Citrusville, the relative may or may not occupy a central position in their lives. Indications are that unless a relative communicates on a frequent basis, whether far away or nearby, with the elderly person, he or she may be thought of with no special significance other than that of being a member of the family. For example, there are individuals with relatives who live on the same block and who seldom speak to each other. Also, there are individuals who live far apart but communicate on a regular basis; one lady in Citrusville has a son who calls her every day at 9:00 a.m. from 1100 miles away.
In this study, many individuals considered some relatives as "relatives," and other relatives as "close friends." For instance, on three of four occasions when I interviewed




an elderly person and a relative was present, usually a
sister,, the elderly person named that individual as a close friend.* On one occasion, the individual did not indicate that the relative present was a close friend; she
said, "I have no close friends."
Close friends of elderly individual and relative or
spouse,. Also, it is important to note that on almost all occasions where an individual lived with a spouse or another
relative, both of the individuals had their separate set of close friends. In less than 10% of the husband and wife cases were there occasions where the wife and husband shared the same group of close friends. In addition, most men had men as close friends, while most women had women as close friends. Only on two occasions did a man have a woman as a close friend and a woman had a man as a close friend. In both instances, the individuals were married and their close friends were married.
Problem of having only one close friend. One more
interesting note. Most individuals indicated a great sorrow and appeared to feel a great loss when one of their close friends died. In almost all instances, particularly those where an individual really only had one close friend, the individuals failed to develop other close relationships. Many simply stated that they did not have a close friend and felt very lonesome. others called a relative and asked him or her to come and live with them. After which, the individual and the relative became close friends. This




failure to develop new close friends is particularly noticeable in individuals where the husband and wife were close and one or the other died. Those who failed to develop new relationships appeared to live in constant sorrow, i.e., constant feelings of loneliness, nothing to do, boredom, etc. Just Friends
If one were to ask the general question, "Who are your friends?" to an aged person in Citrusville, the response would be, "Everyone is my friend." Indeed, most older persons in Citrusville believe that because they speak to each other on the streets, or occasionally participate in some community activity together, such as club meetings, church functions and community holidays, that they are friends. However, in reality, these individuals never really play a major role in the day to day activities of the aged person and, for the most part, can be classified as "just friends."
Strangers
Those individuals who come from outside of the Citrusville District and are not known to many people in the local communities can be called "strangers." The researchers, salesmen, etc., would fit into this category. While the Citrusville elderly person may "pass the time of day" with a stranger,i.e., discuss the weather or fishing conditions, most strangers are viewed with skepticism.




Social Networks and Community Structure
In general, the elderly persons in Citrusville communicate on the telephone or associate with individuals who are their close friends. The persons who are "just friends" or strangers enter into the social network of the aged individual only under specific circumstances. For most of
the elderly individuals, their social network is comprised of close friends, some relatives and, possibly, a formal institution such as a club or church.
The patterns and places of interaction for the elderly person and his close friends depends upon the organization of his environmental constraints. For some mobile elderly
persons, interaction can take place within the limits of their transportation, e.g., walking, bicycling or car. For those individuals who have to depend on some other person for transportation, most of the interaction may take place in their homes, the residences of relatives or close friends, or at a social gathering such as club meeting or church.
Therefore, while the organizational structural constraints in the Citrusville aged individual's life may dictate the framework for behavior, they do not necessarily control behavior. However, it is possible that older persons do respond to close friends based on the distance between them and the amount of contact they have each day.
For instance, an individual who has three close friends in Citrusville, one in the same neighborhood and the other two




one mile and two miles away respectively, may be more inclined to go across the street for a visit than to travel a mile away. Consequently, although the individual has
three close friends# in terms of who may be in "touch," the person who is closer may know more about the elderly person than the others further away. Moreover, the cognitive ranking of individuals within a social network by the
aged person may consist of that elderly person simply determining who he or she has the most contact with and/or who he or she talks with most often.




CHAPTER V
THE STABILITY OF NEIGHBORHOODS IN CITRUSVILLE
"For half a century of more, scholars have proclaimed
the extinction of Rural America or at least any meaningful distinction between urban and rural society in the United States" (Ford 1978:3, quoting Bender 1975). However, at least for the rural elderly population, this claim of extinction is not well founded in terms of population trends at both the local and national levels, migration patterns of the elderly, and length of time elderly individuals have lived in their present residences.
Population Trends in Citrusville
The elderly population in Citrusville has two basic characteristics which indicate its stability. The first characteristic is the slow growth in population. The second characteristic is the in-migration of older persons and the lack of out-migration by aged persons presently living there. These two traits, when coupled with the length of time in residence in one location, indicate that the Citrusville elderly individuals have a consistent
neighborhood environment.
From 1910 to 1970, with the exception of the time
period from 1930 to 1940, the Citrusville population has 50




shown steady, but slow growth. In fact, as Table 3 shows, there has only been an overall increase in population of
35%, whereas Citrusville County has had a 205% increase in population during that same time period. Much of the
increase for the entire Citrusville County can be attributed to the growth of the largest urban city.
The rural population trends for Florida and the United States have been steady over the last sixty years (see Appendices D and E for totals). The farm areas, moreover, indicate a rapid decrease in population both in terms of the actual number of persons who live on farms and the
percentage representation of farm areas in the overall rural population (see Appendix F for totals).
The data on Florida illustrate an overall increase in the rural population from 420,000 in 1900 to over 1,300,000 in 1970. These figures account for an increase of over 209% in seventy years. National, the rural population has grown from 46,800,000 in 1900 to 53,900,000 in 1970. The percentage change is only 17%. On the other hand, the farm population in the United States, which represents less than 15% of the total population, decreased from 29,900,000 in 1900 to 8,900,000 in 1970; this decrease in population is approximately 70%. Also, it should be noted that in 1900, the farm population was close to 64% of the rural population. In 1970, the farm population represents only 16% of the total United States rural population. Population data alone may have very little




Table 3. Population for Citrusville District and Citrusville County 1910-1970

Citrusville County Total Population
104,764
74,074 57,026 38,607

34,365 31,689 34,305

Percent Change From Previous Census
41.4 29.9 47.7 12.3

-8.2
6.4

Citrusville District Population
3628
3150 2980 2706 2726 2686
00. 0 a

Percentage Change from
Previous Census
15.1
5.7
10.1
-.7
1.4 6.8
....

Sources U.S. Census of Population, 1900-1970, U.S. Department of Commerce,
Bureau of Census

Year
1970
1960 1950 1940 1930 1920 1910




significance until it is coupled with the migration trends noted occurring in the rural elderly population.
While talking with the older persons in Citrusville, it was observed by both investigators on this research project that many of the elderly individuals complained of the community not being able to keep many of the "good/ intelligent" young persons around. They said that when most of the younger persons achieve a higher education, they leave town and never return. However, as will be fully explained in the section on "Economic Survivorship," there are few places for young people to earn a living in Citrusville. Furthermore, there is little, if any, major entertainment activity which would appeal to individuals between the ages of 18 and 45; Citrusville has no movie theatre or club which caters to younger individuals. For those young persons who have to stay, they may travel 10 to 20 miles to find entertainment.
Sanders (1977:64) has found that: ". . rural migrants to the cities in the United States come from areas of low economic opportunity, that they are relatively young (in their twenties), and that they number more females than males." Furthermore, he notes that ". . there is a tendency for many people over 65 years of age to leave the city and return to the rural areas where they originated" (1977:64). In the Citrusville Study Population Group at least 5 of the 64 individuals, who originated in Citrusville but lived elsewhere for most of their lives, have returned to Citrusville within the last 10 to 15 years.




In fact, it can be stated that the slow population
growth, the tendency for individuals 65 and over to return to the rural community, and the fact that many individuals
remain in the rural community until they are 60 and older, means that the local community can reflect the "pervasive influence of the elderly population" (Rose 1967). In concrete terms, this influence of older individuals can be illustrated not only in that things change slowly in the rural community, but their influence can be measured by: the numbers of items in the local drug stores and grocery
stores which appeal specifically to the elderly; whether or not merchants attempt to provide seating, probably
benches, in front of their stores for the elderly; and in some instances, there may be an absence of monies set aside in local government budgets for children's playgrounds and such, because taxes spent in this way may upset the elderly who comprise a major segment of the land holding taxpayers (Rose 1967).
Length of Time in Present Residence
An examination of the residential living patterns for the Citrusville elderly person reveals further information about the stability they give to a community. In fact, data gathered on the Citrusville Study Population Group indicate that more than 80% of the 64 persons had lived in their present location between 1965 and 1970 (see Table 4). In the Citrusville District population, more




Table 4. Place of Residence Between 1965-1970

Population
Citrusville Study Population
Citrusville County Citrusville Residents Florida

Same House
80% 38%
55%
440

Different House Same County
15% 21% 19% 22%

Different County
5%
18% 10%
7%

Percent Accounted For
100%
84%a 77%a 73%a

Source: Data taken from Comprehensive Plan for Citrusville 1977-2000. a Individuals not accounted for were in a different state.




than 50% of the residents had lived in their 1970 locations between 1965 and 1970. These figures are in contrast to those for the Citrusville County, which indicate that only 38% of the population lived in their 1970 homes between 1965 and 1970. For the State of Florida, 44% of the population had lived in the same house during the 1965-1970 period.
Furthermore, of the 64 individuals in the Citrusville Study Population Group, at least 50% have indicated living in their present residences for more than 20 years. At least three individuals stated that they have lived in their present homes for over 40 years. One individual has
lived in her present location for more than 50 years.
It can be postulated that the length of time that a rural elderly person spends in a neighborhood means that he or she can influence the character of the neighborhood,
i.e., who moves in and where they live. This power of rural elderly residents to determine the destiny of their neighborhoods is in direct contrast to the influence the urban elderly have on their neighborhoods. For the most part, the urban elderly individual is usually left behind in neighborhoods and communities that are, or have already, deteriorated and are highly unsupportive (Regnier 1975). In effect, it is possible for the rural elderly person to create for himself or herself a stable community through personal longevity and through the continued survivorship
of his or her neighbors who are quite frequently relatives and friends.




CHAPTER VI
THE LIVING ARRANGEMENTS OF CITRUSVILLE AGED
The living arrangements for the rural aged person can reflect his or her ability to maintain a household, as well as his or her desire for continued companionship throughout a lifespan. In the Citrusville Study Population Group, there are a wide variety of living arrangements which reflect the variety in rural elderly lifestyles. Moreover, much of this variety found amongst these rural elderly individuals can be attributed to many reasons. Among the more prominent ones mentioned in this study are: a simple desire not to live alone; the need to have another share the economic burdens of running a house; the loss of an older relative-usually much older mother or father--and the subsequent coming together of relatives to take care of the home; and, simply, returning to their place of origin ("coming back home").
Typical Household Size for the Citrusville Elderly Person
The average number of persons in the study population is smaller than the 1978 estimated number of individuals for the Citrusville County and the State of Florida. The Citrusville Study Population shows an average of 1.71 persons




per household. The 1978 estimated number of individuals per household is 2.6 for Citrusville County and 2.5 for the State of Florida (see Table 5).
Nationally, the number of persons per household has
dropped from 3.5 in 1950 to 3.1 in 1970. Zuiches and Brown (1978s60) have associated this decline in household size with several factors. They believe that there is an increased proportion of persons who live alone or with just one other person. Furthermore, they say that there is a growth in the households of young singles and the elderly. Particularly, they state that many of the elderly individuals maintain their residences after their children have left home and/or after the loss of a spouse.
Household Types Found Amongst Citrusville Aged
There are seven different household living arrangements in the Citrusville Study Population Group. Five were initially identified in a study of "Old People in Three Industrial Societies," by Shanas et al. (1968:218). The other two were developed from the findings in this research. Table 6, in illustrating the percentages of individuals who fit the various categories, readily shows that the data are in keeping with the idea that the Citrusville elderly have small households. Over 80% of the individuals are in the categories of. "married couple only," "widow, divorced, or separated parent living alone," and "elderly person who lives alone but never married."




Table 5.

Average Household Size for Citrusville Study Population, Citrusville District, Citrusville County, and Florida.

Population Group
Citrusville
Study Populationa Citrusville District Citrusville County

1960

N/A

N/A
3. 41b

N/A 3.58b
3.36b 3.11 b

Persons per Household
Estimated
1970 for 1978

N/A
3.30b

Florida

Citrusville 1979 Study

N/A
N/A
2.6c 2.5c

N/A = not available
a Figures for Study Population reflect 1979 research findings.
b
b Household size data taken from Comprehensive Plan for Citrusville 1977-2000. c Household size data taken from Population Studies, by Stanley K. Smith, Bureau
of Economic and Business Research, University of Florida, Gainesville, Florida.

1.71a




Table 6. Seven Household Types
Percentages
Shanas et al. Citrusville Seven Household Types Study Study
1) Elderly individual
lives alone, never 4-8% 1%
married
2) Widowed individual,
divorced or separated 22-28% 25%
parent
3) Married couple only 35-45% 55%
4) Married couple, and
married or single 7-14% 5%
children
5) Widowed, divorced or
separated parent and 9-20% 5%
married or unmarried
children
6) Widowed or divorced
individual and N/A 4%
relative other than
children
7) Married couple and
relative other than N/A 4%
children




These seven different household types describe approximately 99% of the living arrangements of the 64 individuals who participated in this study. However, there is one other category which might possibly be added, and which represents less than 1% of the research study population; it is: "Those Households consisting of the Elderly Individual and Unrelated Friend."
Purpose for Various Living Arrangements
The explanations for the various living arrangements found amongst the Citrusville Study Population Group can truly vary on an individual-by-individual basis; nevertheless, there are general themes which can be formulated. In general, many older people prefer to live alone or with spouse (Woodward 1974). In the rural Citrusville Elderly Population, it appears that over 82% of the individuals live alone or with spouse.
The tremendous desire by the elderly persons in
Citrusville to live alone or with spouse in spite of any health problems is demonstrated in many ways. For instance, on the one hand there are the aged individuals, particularly females, who expressed that they have frequent "heart attacks" or other acute medical problems, and who prefer to live alone than with a relative. However, many of these people stated that they live near or that they are only a phone call away from close friends and relatives in the event of an emergency which does not render them




incapacitated. Furthermore, close friends often call each other before going to bed each night. This calling, in effect, serves as a check-in system to see who is or is not okay. Should the caller not receive an answer, he or she may go by or call someone who is near and ask them to "check up" on their friend.
On the other hand, there are the elderly persons who
are not frequently ill and who have trouble with the upkeep of their homes, but still prefer to live alone. These individuals have been known to sell their furnishings,
obtain money from relatives and call on close friends to help them with the chore of keeping their homes. In Citrusville, most in this position, approximately six persons, stated that they would rather lose everything in their homes and live alone or with spouse before they go to the home of one of their children or brothers and sisters. They spoke of being able to control the operations of their houses: who visits, the noise level, the cleaning chores, etc. Living alone or with spouse means being able to control the household environment.
Still, while many of the aged persons in Citrusville
prefer to live alone or with spouse, 17% or 11 do not. For these individuals, who must share their living quarters with others, the reasons for the different arrangements offer five possibilities which encompass the following themes: Health Problems, Economical Reasons, Performance of Service, Natural or Man-made Disaster, and Emotional Attachment.




Below are presented these themes in the order of the most commonly occurring reason for living with persons other than spouse to the least commonly occurring reason. Health Problems
The elderly person who can no longer take care of
himself or herself because of an illness or debilitating disease is usually cared for by a son or daughter. Most of these people expressed happiness for their living
arrangements. In fact, they all would prefer "imposing" on a relative to being put into a nursing home. In one case, one elderly person in her late sixties was caring for
her mother who was in her late nineties. She had been doing so for several years.
Economic Reasons
The elderly individual without financial resources to
maintain a household and who does not suffer from an illness or disease which restricts activities, may suffer a dual loss when the decision is made to move in with another relative or with children. On the one hand, for these individuals the realization that their homes and furnishings
must be sold means a loss of independence and flexibility. In a sense, it is the harsh recognition of the fact that "I can no longer take care of myself."
On the other hand, losing the home can mean entering into an environment where, for the most part, the elderly person's needs are usually secondary. In this case, the




elderly individual suffers from isolation from close friends. Isolation is particularly acute if the elderly person has to move away from his or her "old" neighborhood or community, to another town or city. The ability of the elderly person to cope with this new situation will be directly related to the amount of time and support he or she receives from the family.
Performance of Service
In the Citrusville Study Population Group, 2 out of the 64 individuals interviewed stated that they, along with at least one other relative, had returned to Citrusville to help take care of a home left by an older relative. In this situation, both of the parties said that they came back because they were retired and really enjoyed living in the Citrusville environment. Moreover, they had grown up in Citrusville and had "kept in touch" with the family. In addition, it was made known that they "knew" Citrusville and knew basically what to expect. Natural or Man-made Disaster
This living arrangement is brought about in most instances because someone has been displaced as a result of a fire to a home. In a few instances, it can be the result of a natural weather occurrence, e.g., tornado or high wind damage. Only one person in this study fit this category. A fire had destroyed his home and he was living with two friends (married) until he could find a place to stay. This




individual did not appear to be in a hurry to find a new place because he stated that the individuals with whom he
lived were his only friends. However, in a rural poor area such as this one, fire to the home of an elderly person is
a common occurrence. Therefore, in such an event, it is necessary for them to have relatives or close friends who can temporarily offer them shelter.
Emotional Attachment
only one elderly person lived with her daughter and
son-in-law because she enjoyed being with them. At least, according to this elderly person, the living arrangement-she, daughter, son-in-law, and child--is satisfactory because she has her own place above the garage. Furthermore, she performs a useful service for them, acting as a live-in babysitter. However, it is my estimation that, because of the independent spirit of most of these rural aged persons, this kind of a living arrangement based solely on "emotional
attachment" is rare.
Duration of Living Arrangements
In order that this discussion of the elderly household living arrangements be complete, mention must be made of the duration of these relationships. Analysis of the data from this Citrusville Study indicates that there are six possible household living arrangements and durations. Four of these household structures had already been identified in the Shanas et al. (1968) study. Below, in Table 7, are




the arrangements and indications as to whether or not they
are independent or dependent and whether or not they are temporary or permanent.
Table 7. Six Types of Household Living Arrangements for the Elderly Adult Person in Citrusville.

Planned Duration of Household Structure
Aged Parent:
Need for Care Temporary Permanent
Parent living with Extended family of
children waiting for more than one
own dwelling, generation.
Inepndnt Elderly individuals Elderly individual
Indpenentliving with relatives who lives with other
or friends while friend or relative
awaiting repairs to to insure protection
home after fire or or to increase finatural disaster. nancial security.

Permanent

Widowed or disabled
parent, waiting to be institutionalized.

Widowed or divorced parent living with child while incapacitated.

Sources Adopted from Shanas et al. (1968:219)
In the main, these living situations and durations
apply to individuals who do not live alone or with spouse. For the Citrusville Study Population Group, the information presented in Table 7 will fit only 17% of the 64 persons in the study. Moreover, it is possible to state that the duration of any of the various relationships thus described will have an effect on and possibly determine the rural elderly person's behavior and perceptions about his or her environment.




CHAPTER VII
HOUSING AND THE CITRUSVILLE AGED
For most individuals, the house or apartment in which they live provides them with several physical comforts, such as physical space, light, heat, sanitary facilities and cooking facilities. In addition, the dwelling unit provides mental comforts, which include- a feeling of warmth, access to a particular neighborhood, a sense of safety, and pleasing surroundings (Struyk 1977). Although the typical individual in America strives to achieve a certain standard of living which will allow him or her to maximize his or her comfort level, it can be stated that as one gets older, the physical as well as the mental satisfaction which is derived from a dwelling becomes more important.
Thus, for instance, when the elderly person in Citrusville says that he or she derives satisfaction from his or her home, the aged individual is also describing feelings and perceptions of the surroundings in which one lives. More than that, the elderly person is taking his or her total environment and making some judgments about how one fits into it. That is, the older person is making a subjective statement about the degree to which an adaptation to the environment has been made.




Quality of Housing as Measured by
Physical Condition of Facility
In the Citrusville Study Population Group, 60 or 94% of the individuals live in a house which they own. The other 4 persons live with relatives or friends who own the house or rent the apartment. Most of these homes have a well-kept appearance on the outsides the yards are free of debris, the hedges (when present) are neatly trimmed, most do not need painting, and the lawns are cut. However, many individuals complain about the need for internal repairs: leaky roofs, poor plumbing and sewage, deteriorating floorboards and cracks or holes in the walls.
Quite in evidence in many homes was the need for a
better heating system. For some elderly in this study, the main source of heating was a space heater which occupied
the center of the "living room." While these heaters provided the appropriate amount of heat such that the elderly person did not get cold, many were next to mounds of discarded newspapers or kerosene cans.
The housing for most of the elderly persons in Citrusville appears to be structurally sound. Approximately 60% of the elderly in the study live within the Citrusville city limits where a survey was conducted to determine the worthiness of the homes there (see Table 8). None of the homes of
the elderly persons who live in these areas is either deteriorated or delapidated. Although in Quadrant III over 55% of the homes are in poor shape, the elderly individuals in this




Table 8. Structural Conditions of Citrusville Housing

Quadrant of City

Percent of Study Group in Quadrant

I
II III IV
V

5%
70%
5% 15%

Condition of Housing in the Area
(percentage representation)

Sound

88% 89%
45%
43% 91%

Deteriorating

10%
33%

Dilapidated

2% 22%
16%

Sources Adopted from City of Citrusville Comprehensive Plan, 1977-2000.




study did not live in poorly constructed homes. Of the remaining 26 persons who live outside the city limits, only
5 complained about their homes needing repairs.
A national survey of elderly persons who own homes and who live in rural areas describes them as living in larger older dwellings. Overall, Struyk (1977t132, see Table 9 for summary). states that "8% do not have complete kitchen facilities and about 15% lack complete plumbing. Heating equipment and services are below standards; over half do not have central heat and 10% obtain most of their heat from stoves, fireplaces, or portable heaters."
Quality of Housing as Measured by the Elderly
Persons' Feelings about Their Homes
If one were to examine the physical structures of many of the elderly homes, one may find some agreement with the study of rural older persons' homes on the national level. However, while it may be true that many of the elderly persons' homes need repairs, most of the individuals are pleased with their living quarters. In fact, over 95% or 61 of the persons interviewed expressed satisfaction with the condition of their homes, despite the problems they may harbor. In addition, persons who expressed dissatisfaction with their present homes did not have a desire to leave the
area in which they live.
In other words, the elderly person usually recognizes the physical problems he or she is experiencing living in




Table 9. Selected Housing Characteristics of the Elderly, 1973
Selected Physical Rural Areas (percentage figures)
Characteristics of
Elderly Household Farm Area Non-Farm Area
1) Fully equipped kitchen
for private use 92 93
2) Complete plumbing 85 86
3) Heating Equipments
Central heat 41 52
Room heaters 48 39
Fireplace 9 stove 11 9
None 0 0
4) Electrical wiring
concealed 94 94
5) Roof has leakage 15 11
6) Cracks or holes in wall 5 6
7) Broken plaster/paint
peeling 10 10
8) Evidence of rodents 25 18
9) Number of rooms
1 or 2 1 3
3 or 4 17 36
5 or 6 53 44
7 Plus 29 16
Conditions of
Neighborhood
1) Street noise 8 16
2) Airplane noise 5 4
3) Heavy street traffic 8 12
4) Odors, smoke, gas 1 1
5) Trash 3 5
6) Boarded/abandoned structures 4 6
7) Inadequate lighting 2 6
8) Crime 3 3

Source: Adopted from Struyk (1977:133-134).




72
his or her present home but, in terms of' his or her perception of the living environment, he or she does not desire any changes. In fact, many persons would rather live with a leady roof in their own homes than to live with
other relatives and experience no problems.




CHAPTER VIII
ECONOMIC SURVIVORSHIP OF CITRUSVILLE ELDERLY
The measurement of' the economic survivorship for the
rural aged person involves much more than an examination of gross income or an examination of' the amount of' social
security benefits. In fact, for most rural elderly, a simple survey of' wages would more than likely reveal that over half of them are living at or below the designated
povertylevels (Tissue 1972). However, in spite of the local and national statistics which indicate that, according to overall gross income half' the rural elderly are poor, many still manage to maintain a household, pay for their medical bills, buy groceries, and achieve some acceptable level of mobility.
In the main, an adequate discussion of' the economic
survivorship for the rural elderly individual must include an examination of' gross income, as well as an examination of' participation in state and federal programs. Quite often, the rural aged person has no choice but to participate in state and federal social programs, such as food stamps, welfare, meals on wheels, and supplemental social security, to prevent joining the ranks of' the rural poor.
Yet, even the elderly person's participation in social welfare programs is not enough to help achieve a respectable
73




level of living. Therefore, the rural aged person must count on relatives, friends, and neighbors for money, goods, and services. In effect, the aged poor have to "juggle" these different income resources to maintain a standard of living which will enable them to survive.
In this discussion of the economic survivorship of the rural aged in Citrusville, the major attempt will be to provide an overall perspective on the sources of gross income for the Citrusville elderly. Moreover, employment opportunities as well as the elderly participation in state social welfare programs will be discussed. Aid received from relatives, friends, and neighbors is often referred to as "Inkind Services." The role of close friends, relatives and just friends will be presented in terms of the "Inkind Services" they provide.
Citrusville Elderly Income
Income for Older Persons: National Picture
According to income data on individuals by age group reported in 1972, overall, the mean income showed a steady decrease as the age of the individual increased. Table 10 reflects this trend. It shows that individuals 65 to 69 had a mean income of $7432. Those individuals 70 to 74 had mean incomes of $5895. Persons 75 to 79 presented mean incomes of $5237. Finally, persons 80 to 99 had mean incomes of $4566, or almost half the income of those individuals 62 to 64.




Table 10. Components of Income by Age of Head of Household for 1972
(As a Percentage of Total)

Earnings

76.64 49.95 31.56 26.30 22.85

Property Income

7.65 12.78 18.35 17.65 22.70

Social Security

7.65 24.01 35.76 40.03 39.06

Welfare/ Public Assistance

.77 1.11
1.63
1.83 2.88

Source: Taken from Moon (1977:6), The Measurement of Economic Welfare: Its
Application to the Aged Poor.

Age of Family Head
62-64
65-69 70-74
75-79 80-99

Me an Income
9841.29 7432.93
5895.25 5237.44 4566.42

Other Income
7.35 12.54 13.34 14.31

12.53




Table 10 also reflects the source of the income as a
percentage of the mean income. When viewed in this fashion, the elderly individuals 62 to 64 show over 64% of their income from their earnings. Persons who are between the ages of 65 and 69 have almost 50% of their income from their earnings. Those individuals 70 to 74 obtain approximately one-third of their income from earnings. The two remaining groups, persons 75 to 79 and individuals 80 to 99, receive approximately one-fourth and one-fifth, respectively, of their income from earnings.
Income for Older Persons: Local Picture
In the Citrusville Study Population Group, there is no breakdown by age group of the mean earnings. Quite frankly, individuals would not give out their gross yearly income (Lawton et al. 1978). Possibly, individuals were reluctant to disclose their incomes for fear of being penalized by federal programs which use annual income as a basis for determining eligibility for program participation. However, persons were asked to rank their sources of income from major to minor. Table 11 shows the results of this ranking process.
It can clearly be seen from Table 11 that most individuals ranked Social Security as their number one source of income.* For the Blacks, SalaryApJages ranked as the number two income source, while Whites ranked Pension as their number two income source. Number three for Blacks was Pension, and number three for Whites was Salary/Wages.




Table 11.

Ranking of Major Income Sources by Percent of Individuals Responding to that Category

Black Elderly

White Elderly

Rank Income Source
1 Social Security
2 Salary/wages
3 Pension 4 Property
5 Public Assistance/
Welfare, SSI
6 Other Income/Stocks,
Bonds, Investments
Totals

(Figures are rounded to nearest whole number percentage total is not 100%)

and therefore

Number

Number

99%

99%




Property, Public Assistance, and Other Income, ranked four, five, and six, respectively, for both Blacks and Whites.
Although data are not available to illustrate the mean income by age for the Citrusville elderly person, it is possible to postulate that the individuals' major sources of income will change, as already demonstrated by the national survey, as the individuals become older. Further, for the Citrusville resident who has to depend solely on social security as a major source of income, the amounts and kinds of help that the individual receives from relatives, friends and neighbors will become more important with age. In an area such as Citrusville, where the mean income per capita for 1969 was $2,078 and the 1972 figure only rose to $2,785, the amount of support the elderly person can gather through inkind services will ultimately determine
his amount of independence as well as his dependence (Source: Comprehensive Plan for Citrusville, 1977-2000).
Sources of Income for the Citrusville Resident
Table 12 illustrates the income of the Citrusville
residents by income type. It can readily be seen that wages are low. Of particular importance is the fact that the median income from social security, where most of the elderly receive their annual income, is only $1,376. Welfare adds very little to the income, showing only a median amount of $609 annually.




Table 12. Income of Citrusville Residents by Income Type
1) Salaries $ 7,920.00
2) Non-Farm Self-Employment 3,421.00
3) Farm Self-Employment 3,893.00
4) Social Security 1,376.00
5) Welfare or Public Assistance 609.00
6) Other Income 2,020.00
Source: Data taken from "Income Characteristics of
the population for Florida SMA's, 1970."
In fact, the national average of social security benefits for each person eligible was only $207 per month in 1975 (Social Security Bulletin 1975, Annual Statistical Supplement: 156). If multiplied by 12 to achieve an approximate annual amount, the figure would be $2434. In the State of Florida, the average amount of social security was $209 in 1975. On an annual basis, that amount would be approximately $2508. In Citrusville, the average amount of social security was $165 a month in 1975. Annually, that amount would be about $1980. Compared to the 1970 figure of median social security income for Citrusville of $1376, the 1975 amount of $1980 represents a $604 overall increase.
Employment Opportunities for Citrusville Elderly
According to the Citrusville elderly Blacks in the research study population, employment ranked as the second most important source of income. For the Whites in the




study, employment ranked third as a major source of income. Below are the major employers in the Citrusville area:
Citrus ville Employers 1) A dealer in poultry supplies
2) A jobber of dairy products
3) Citrusville Concrete and Supply Manufacturers
4) Bank of Citrusville
5) Pharmaceutical Manufacturer
6) Elementary, Junior High and High Schools
(one each)
Other employment sources, such as small shops, stores, etc., include the following:
1) Pharmacy
2) Truck Stop/Restaurant
3) Convenience Stores
4) Package Store
5) Breakfast/Fast Food Shop
6) Two Insurance Agencies
7) Law Office
8) Several Used Furniture Stores
9) Public Health Service Office
10) Dental Office
11) Physician's Office
While at first glance there appears to be a wide
variety of employment sources in the Citrusville community, in reality, most of these shops tend to be family owned and family operated. In fact, most of the businesses are operated by Whites who employ very few older Blacks. For most Citrusville residents, employment must be obtained in the major city located in the Citrusville County approximately twenty miles away.
Therefore, except for a few elderly who have worked in one or two of the businesses for a long period of time, most of the elderly have to own their business, as is the




case for many of the White elderly, or they must work for the school system or other White individuals in the community as maids and yard men, as is the case for most of the Black elderly.
Occupations of Citrusville Residents and Citrusville Elderly
Study Population
The overall distribution by occupation for the Citrusville residents can be seen in Table 13. For the most part, individuals in Citrusville work in Service Occupations, Professional Occupations, Craftsman Trades, and Clerical Professions. In the Citrusville County area, the top four occupations are: (1) Professional, (2) Clerical, (3) Service Workers, and (4) Operations Workers.
Table 14 shows the present and former occupations of the Citrusville elderly by percentage distribution. It should be apparent that the Blacks have occupied a larger percentage of the service worker occupations than the Whites. Also, it should be noted that more Whites than Blacks stated that they had never worked. Only 14 individuals admitted to working at the time of this study.
Elderly Participation in Other Federal Programs
Outside of the 100% participation of the Citrusville elderly in the social security programs, the distribution of elderly who stated that they take part in the Food Stamps Program, Meals on Wheels Program, or the Medicaid/ Medicare Programs varied. About 80% reported participating




Table 13. Percentage Distribution by Occupation
for Citrusville and Citrusville County
Percentage Distribution Occupation Citrusville Citrusville County
1) Professional, Technical and Kindred 15.9% 24.9%
Workers
2) Ivanagers, Officials
and Proprietors, 7.6% 7.3%
Except Farm
3) Clerical, and Kindred
Workers 13.2% 22.4%
4) Sales Workers 2.0% 7.0%
5) Craftsmen and Foremen and Kindred Workers 14.7% 7.6%
6) Operators and Kindred
Workers 10.1% 7.9%
7) Service Workers, including Private 18.6% 17.6%
Households
8) Farm Laborers and
Foremen 8.6% 1.1%
9) Laborers, except farm
and mine 9.3% 3.3%
10) Farmers and Managers 0.0% 2.4%
Source: Data adapted from Citrusville Comprehensive
Plan, 1977-2000, p. 30.




83
Table 14. Percentage Distribution by Occupation for
Citrusville Elderly Study Population
Percentage Distribution
Present Occupation Former Occupation (N=14) (N=64)
Occupation Black White Black White
1) Professional,
Technical and 0% 0% 8% 9%
Kindred Workers
2) Managers, Officials
and Proprietors,
except farm 7% 21% 3% 8%
3) Clerical, and
Kindred Workers 0% 0% 0% 6%
4) Sales Workers 0% 0% 0% 2%
5) Craftsmen, Foremen, and Kindred 0% 7% 3% 2%
Workers
6) Operators and
Kindred Workers 0% 0% 0% 5%
7) Service Workers,
including Private 21% 0% 20% 0%
Households
8) Farm Laborers and
Foremen 0% 0% 2% 0%
9) Laborers, except
farm and mine 22% 0% 9% 0%
10) Farmers and Farm
Managers 7% 15% 3% 6%
11) Never Worked 0% 0% 0% 14%

57% 43%

48% 52%

Totals




in the Medicaid/Medicare Programs. Approximately 30% of the Blacks and less than 5% of the Whites admitted to receiving Food Stamps. Many cited the detailed applications and seemingly unnecessary questions asked about their personal habits as deterrents to their making application for food stamps (see Appendix G, especially the sections
covering "Other Income and Utilities"). Another reason cited for the non-participation in this program is the small amount of money for the large amount of information given.
Many elderly residents stated that even with help from these many different social welfare programs, they still have to put bills off for future months in order to make their income last the entire month. Table 15 below is a breakdown of expenses for a typical month. It reveals some further information about the problems and expenses of elderly economic survivorship.
Table 15. Composite Typical Expenses
for Elderly Person
Ave rage Monthly
Expense Amount
Low High
1) Medical bills $4o $90
2) Medication 5 50
3) Utilities 20 100
4) Gas winter months 15 50
5) Food 80 150
6) Yard work 5 25
7) Miscellaneous 20 150




Inkind Services for the Elderly
Individual in Citrusville
It has been demonstrated that the Citrusville elderly person suffers from the lack of a steady income as well as few employment opportunities. To increase their chances for economic survival, the elderly persons in Citrusville rely on help from relatives, close friends and just friends. The help received from these people is mainly in the form of the exchange of goods and services, the cooking of foodstuffs on occasion, and the providing of free transportation when necessary. In the economic sense, for those elderly persons who live at or below the poverty level, the inkind services can ofttimes mean the difference between purposeful survival and mere existence. Exchange of Goods and Services
The older individuals in Citrusville normally extend a helping hand to any person who has become the victim of economic disaster, such as a medical bill which cleans out the savings or a household repair which costs more than expected. Usually, the impetus to ask the community for aid is initiated by a close friend who may tell the minister of the church. The minister will make an appeal to the Sunday congregation. By word of mouth, the news is quickly spread throughout the community.
However, the help given by the community acts as an initial stabilizing source of aid. For a short period,




possibly two or three weeks, the close friends can help the person, along with any local relatives* Any support which will be for a long period of time, a month or more, will usually be the responsibility of the individual's family. In the case where the person has no family, the person may receive intermittant help from close friends, and just friends in the community.
For instance, Mrs. A had been in a nursing home for two
years. Upon her return home, she found that her home had been ransacked and a stove, some clothes, and a sofa were missing. Mrs. A did not have any money, but a close friend helped her, through an appeal within the church, to obtain a stove as well as some articles of clothing. Moreover, someone bought her a chair. Although Mrs. A was happy to have received the various forms of help from the church-money, furniture and clothing--she remembers best the individuals who spent time with her and who still communicate with her. Furthermore, she feels that she owes them and periodically sends them inexpensive gifts: hats that she
knits or baked goods.
Cooking of Foodstuffs
Most persons who were interviewed stated that it was difficult for them to, on any regular basis, invite close friends over for a meal. Persons who are just friends are not usually considered when food is cooked. on occasion, the elderly individual will cook some "sweets" when he or




Full Text

PAGE 1

RURAL MEDICAL SELF-HELP LINKAGES BY TYSON LEE GIBBS A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1979

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ACKNOWLEDGMENTS The writer wishes to thank the members of the Citrus ville Community for giving him the opportunity to enter into their private lives while conducting this research. I wish to acknowledge the particular assistance given to me by the Assistant Principal of the local high school, the teacher in charge of special education at the high school, the high school librarian, the librarian of the local public library, the local pharmacist, the local Citrusville Fire Department, the local public health clinic, and the Older Americans Council for Citrusville County. Their attention to my many probing questions helped me to gain a better understanding of the community. My advisor, Dr. Otto Von Mering, has been my mentor and guide throughout my graduate career. It is because of him that I have learned the value of asking the questions which have no sharp features but which often give a better insight into the problem being considered. His tireless efforts on my behalf cannot easily be summed because I have learned much from him both inside and outside the classroom. The other members of my dissertation committee have each contributed to my development. Dr. Leslie Lieberman has given me many opportunities to "test" my ideas and has ii

PAGE 3

suggested alternative ways of examining and measuring phenomena in the social world. Dr. Carol Taylor counseled me throughout my graduate education and has helped me to sort out and understand the more formal institutions of health care delivery. Dr. Charles Mahan has given me a vehicle to research some of my ideas and has offered me advice on the formulation of my research projects. Finally, I wish to thank Dr. Paul Magnarella for reading the final draft of my dissertation. There are others who have been instrumental in my career development. Dr. Angelo O'Rand helped me to formu late my dissertation research project. Dr. Elizabeth Eddy encouraged me to stay in anthropology and complete the Ph.D. Dr. Jerry Melanich frequently gave me a push so that I would not slow down. Mrs. Lydia Deakin and Mrs. Idella Bivens always gave me a sympathetic and understanding ear. Finally, I wish to thank Mrs. Theresa Bridges who was my research assistant on this project. She was instrumental in helping me develop a research sample and in gathering the necessary data for the project. Without her assistance, this project would have taken much longer to reach completion. iii

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TABLE OF CONTENTS PAGE ACKNO W LEDGMENTS ii LIST OF TABLES , ix LIST OF FIGURES xi AB S TRACT CHAPTER ONE TWO THREE xii 1 Rural Elderly Social 2 The Nature and S cope of Studies in M edical 3 Purpose of This 6 W hy Study the Rural Aged 8 Basic Assumptions Which Structure This Research 9 RESEARCH SITE: CITRUSVILLE, FLORIDA 13 Reason for Choosing Citrusville as Town to Study 13 Reaction of the Citrusville Residents to the 14 A Brief Historical Sketch of Citrusville. 14 M ETHODOLOGY Introduction: tati ve Data Descriptive vs. QuantiResearch Technique Participant Observations A Definition. Participant Observation as a Research Task-Oriented Role Participant Observation as a Research Technique Research S ampling Procedure Key Informant Research Technique Other Uses for the Key Informant Technique iv 18 18 20 21 21 22 24 25 27

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FOUR FIVE SIX Determination of Research Population Sample . . . . 27 Composition and Size of Research Population 30 Interview Guide 33 Precision and Accuracy of the Interview Guide 34 Components of Interview Guide 36 Interview Technique 36 Other Data 38 Summacy Review 39 DEFINING AN ELDERLY COMMUNITY STRUCTURE: CITRUS VILLE Data Resources for Chapters V-VIII Stability of Neighborhoods in Citrusville Living Arrangements of the Citrusville Housing and the Citrusville Elderly Individual Economic Survivorship of Citrusville Elderly ........... .......... Presentation of Comparative Definition of Terms to be Used in This Report ........... Social Network Close Friends Just Strange rs Social Networks and Community S tructure THE STABILITY OF NEIGHBORHOODS IN CITRUS VILLE 40 41 41 41 42 42 43 43 43 44 47 47 48 50 Population Trends in Citrusville 50 Length of Time in Present Residence 54 THE LIVING ARRANGEMENTS OF CITRUSVILLE AGED 57 Typical Household Size for the Citrusville Elderly 57 Household Types Found Amongst Citrusville Aged 58 Purpose for Various Living Arrangements 61 Health 63 Economic Reasons 63 Performance of S ervice 64 Natural or M an-made Disaster 64 Emotional 65 Duration of Living Arrangements 65 V

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SEVEN EIGHT NINE HOUSING AND THE CITRUSVILLE AGED 67 Quality of Housing as Measured by Physical Condition of 68 Quality of Housing as Measured by the Elderly Persons' Feelings about Their Homes 70 ECONOMIC SURVIVORSHIP OF CITRUSVILLE ELDERLY Citrusville Elderly Income for Older Persons: National Picture .......................... Income for Older Persons: Local Pie ture .......................... Sources of Income for the Citrusville 73 74 74 76 Resident 78 Employment Opportunities for Citrusville 79 Occupations of Citrusville Residents and Citrusville Elderly Study Population 81 Elderly Participation in Other Federal Programs . . . . . 81 Inkind Services for the Elderly Individual in Citrusville 85 Exchange of Goods and Services 85 Cooking of Foodstuffs 86 Providing 87 Summary Review 88 CUSTOMARY BEHAVIOR OF THE CITRUS VILLE AGED POPULATION 90 Social Networks and Routine Behaviors 91 Daily Activities 92 Ni o rning . . . . . . . 9 3 House Cleaning 93 Cleaning the Dishes 94 Cleaning the Yard 94 Gardening 95 Reading Behavior 95 W riting Letters 95 Talking on the Telephone 96 Afternoon . . . . . 97 W atching 97 Sewing, Knitting and 98 Shopping 98 Club Acti vi ties 99 Visiting 101 Number of Close Friends of the Elderly 102 vi

PAGE 7

Age of Close Friends Who Receive Visits from 102 Number of Visits to Home of Close Friend . . . . . 10 3 "Just Friends" and the Elderly Visiting Practices 104 Visiting Behavior: Offering 105 Role of Social Network of Close Friends and Relatives During an Illness Episode 105 Evening . . . . . . 108 Weekend Activities 108 Holiday 110 Discussion and 111 TEN THE ELDERLY AND LOCAL HEALTH CARE ELEVEN RESOURCES 115 Social Networks and Health Seeking Behavior . . . . . . . 116 General State of Health: Male and Female Subjective Differences 117 General State of Health: Age Differences 120 Toward a Definition of Illness: The Decision to Seek Health Care 121 Resources for Health Care Advice 125 Health Care Activities of Citrusville Aged 126 Elderly Usage of Herbal Remedies and Over-the-Counter 127 Elderly Persons and the Local Pharmacist. 128 Reasons for Visiting or Not Visiting a Doctor's Office 132 Number of Individuals Per Physician... 133 Distance Traveled to a Doctor's Office 133 Number of Visits to a Doctor's Office 134 Local Public Health Clinic 134 Citrusville Fire 135 An Overview of Findings 137 CONCLUSIONS 139 Adaptation to a Rural Environment: VJellness Behavior and Heal th Care Seeking 139 Rural Self Help Linkages and the Individual Aging Experience 142 Growing Old in Citrusville ~......... 143 The Utility of Studies on the Health Care Maintenance Behavior of Rural Aged Persons 145 Health Education Programs 146 Social Network System and Upgrading Elderly Health Care Services 149 vii

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Social and Health Care Programs for the Rural 150 Improving Ruture Research into Rural Elderly Health Care Seeking Habits: Some Suggestions 152 Health Care Policy and Research on the Rural Aged 153 APPENDICES A B C D E OUTLINE OF INTERVIE W TOPICS M IGRANT W ORKER HEALTH CARE QUESTIONNAIRE QUESTIONNAIRE FOR S TUDY OF SOCIAL HEALTH CARE NET W ORKS IN CITRUS VILLE, FLORIDA POPULATION TRENDS FOR RURAL AREA S OF FLORIDA RURAL POPULATION OF UNITED STATE S 1900-1970 F FAR M POPULATION OF THE UNITED STATES 154 167 173 193 195 1900-1975 197 G APPLICATION FOR FOOD STAMPS 199 LIST OF REFERENCES 204 BIOGRAPHICAL SKETCH 211 viii

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LIST OF TABLES TABLE PAGE 1 Population Data for Citrusville Population Sixty and 31 2 Population Data for Research Study Population Group 32 3 Population for Citrusville District and Citrusville County 1910-1970 52 4 Place of Residence Between 1965-1970 55 5 Average Household Size for Citrusville Study Populationt Citrusville Districtt Citrusville Countyt and 59 6 Seven Household Types 60 7 Six Types of Household Living Arrangements for the Elderly Adult Person in Citrusville 66 8 Structural Conditions of Citrusville Housing.. 69 9 Selected Housing Characteristics of the Elderlyt 1973 71 10 Components of Income by Age of Head of Household for 1972 (As a Percentage of Total) 75 11 Ranking of Major Income Sources by Percent of Individuals Responding to that Category. 77 12 Income of Citrusville Residents by Income Type , 79 13 Percentage Distribution by Occupation for Citrusville and Citrusville 82 14 Percentage Distribution by Occupation for Citrusville Elderly Study 83 ix

PAGE 10

15 Composite Typical Expenses for Elderly Person ............................ 16 Age Group of Friend and Percentage of Individuals Who Reported having Close Friends in Those Age Groups 17 Responses to the Question About Feeling "Sick" .............................. 18 Distribution of Answers to Question: "How Often Do You Feel Sick?" 19 Schematic Outline of Rural Elderly Health Care Seeking 20 S elf-treatment Remedies 21 Over-the-counter Drugs and their Uses 22 Rescues of Citrusville Fire Department, 1978-1979 ............................... X 84 103 118 120 124 129 131 136

PAGE 11

FIGURE 1 2 LIST OF FIGURES Research Population Determination (Schematic) Number of Interviews Accomplished, on average, by Both Investigators per week {schematic) xi PAGE 29 J?

PAGE 12

Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy RURAL ~EDICAL SELF-HELP LINKAGES By Tyson Lee Gibbs December, 1979 Chairman, Dr. Otto Von Mering Major Department, Anthropology Rural elderly individuals, both Black and White, live in an environment which compels them to be economically self-sufficient if possible and alternatively to rely on the assistance from close friends and nearby relatives. Little research has been done to determine how rural older people are able to survive in spite of the many social and health care problems which plague them. This dissertation examines the health care networks in which the elderly participate and examines the relationship of these net works to environmental constraints, routine behavior, and health care seeking behavior. The data gathering method ology includes participant observation, an Interview Guide, the analysis of local community studies, and the collection of information from local health care resource institutions. xii

PAGE 13

The study proceeds from the premise that research into health care maintenance behavior and health care seeking behavior of rural aged people must examine much more than the availability of health care resources or illness and disease behavior. In fact, to limit a research study to only the more salient features of health care seeking behavior would belittle the effect of personal routine habits on the overall state of health. Furthermore, for the rural aged poor, the relations they have with each other in a given social network, including their continued moni toring of each other's health status, assure them of help and sometimes ample time to seek treatment. Therefore, this research first examines the environ mental constraints out of which social networks develop and within which routine behaviors take place. The most impor tant are the housing situation, the stability of the rural neighborhoods and communities, the living arrangements and the mechanisms of economic survival. These, along with the perceptions that the elderly have of their surroundings, are presented as the major factors which support or impede the rural aged individual's activities. Next, the routine activities are presented as the prac tical survival techniques which not only describe elderly daily behavior but also serve to solidify the structure of the various social networks. In effect, these routine behaviors illustrate regularities in the elderly person's lifestyle. Such regularities, in the main, permit xiii

PAGE 14

appropriate and purposeful social interaction between the older person and some nearby relatives. In general, it can be said that the more knowledge that the aged person has of the routine activities of close friends and relatives, the more stability the elderly person will have in his or her life. Lastly, health care seeking behavior is shown as an integral part of the routine activities of the rural elderly individual. Moreover, the roles of close friends, rela tives, just friends, and the more formal institutions of health care are presented. It is suggested that the elderly person takes care of or "treats" many of the illnesses or diseases which he or she considers as "less serious." This self-treatment includes over-the-counter drugs, some herbs and roots, advice from close friends or relatives, and advice from the local pharmacist. Although the evidence is not conclusive, the implication is that for more serious illnesses and diseases, formal health care practitioners are consulted. The study concludes with suggestions of how this kind of research can be useful in implementing preven tive health care education programs and better local health care services. xiv

PAGE 15

CHAPTER I INTRODUCTION Most, if not all, elderly persons who live in rural communities are affected, to some degree, by the presence of ill health and disease. Moreover, each aged person in a rural area has adopted some practice which will assist him or her toward maintaining a functioning state of health. Collectively, these individual health care practices con stitute the "healing systems" found in each rural community. As healing systems, they represent a culturally unique adaptation to the rural environment. Anthropologists, since the time period when anthropology was nothing more than a hobby for some wealthy individuals, have made attempts to study the various healing arts and healing actors in different cultural areas. Disappoint ingly, however, this fascination with illness and disease behavior has meant an almost total absence of studies which have as their major focus the study of health care maintenance behavior. Still, it is the mundane, almost routine, daily activities of rural elderly individuals which determine the direction and the consequences of their health. In fact, the sum total of the rural elderly health care 1

PAGE 16

2 seeking behavior can no longer be attributed to root doctors or herbal medications. Many of the rural aged individuals choose to treat themselves with over-the-counter drugs for some medical problems, and may travel many miles to see a physician for other diseases and illnesses. Furthermore, while it is important to study the mech anisms of the rural elderly person's individual health care treatment system and his or her healing personnel, it is equally important to examine the everyday behaviors of the elderly individuals in a rural community. To be sure, it is almost impossible to have a full understanding of "why" and "how" individuals seek heal th care from the more formal health care institutions, if one does not understand their lifestyles. Moreover, the health care maintenance system of individuals consists of the habits of the persons in their neighborhoods, their household living situations, the kinds of employment they engage in, what they eat every day, as well as their health care seeking activities. Rural Elderly Social Behavior Clearly, studies of neighborhoods, household structures and living arrangements, as well as rural elderly employment constitute the morphology of an aged person's lifestyle. These variables, when studied, indicate the organizational constraints in the elderly person's life but do not deter mine the motive or method of the elderly individual's personal activity. Therefore, studies which focus on the

PAGE 17

3 health care maintenance and health care seeking behavior of rural elderly individuals must also examine their routine habits. We expect to find that regardless of level of income, the rural elderly seek to live in a stable environment. Most of them will also attempt to surro1.md themselves with family, neighbors who can be trusted, and close friends within close reach. While not necessarily professing to do so, rural aged people link life in an environment of low stress with a high level of supportive friends. Exten sive knowledge of their neighbors' ways of thinking and doing and of their comm1.mity as a whole gives them a sense of security, and a stability of expectation in their sur roundings. The Nature and Scope of Studies in Medical Anthropology The area of interest in the discipline of anthropology which encompasses, mainly, the study of illness and disease behavior in individuals and populations, has been given the label "Medical Anthropology." Recently, must discussion has been generated over the "scope of medical anthropology" as a subdiscipline of anthropology and the role or place of medical anthropologists as practitioners of this subdisci pline. Unfort1.mately, some have attempted to define medical anthropology by contrasting it with medical sociology (Foster 1978; Olesen 1978; Folgar 1962); in fact, this comparison is not

PAGE 18

4 necessary to define the activities of medical anthropologists. Hasan (1978:17) most cogently put it this way: "The roots of contemporary medical anthropology, in fact, are traceable to the development of anthropology itself." In the much broader sense, medical anthropology can best be defined through a presentation of the central concerns of the parent discipline of anthropology. Schwartz and Ewald (1968:4-5) best define the concerns of anthropology this way: 1) First, anthropology has been characterized by an orientation toward non-Western peoples; it has been concerned with groups of people not commonly studied (until recently), by other disciplines. (However), many anthropologists are engaged in in tensive studies of contemporary nations. 2) Second, the field research--collecting information through intimate, firsthand experience among the people being studied--is a necessary part of anthro pological investigations. J) Third, specific information and generalizations derived from such information are essential to anthropology. Using the above concerns as general guidelines, the following can be stated about the scope of medical anthro pology: 1) First, medical anthropology can be viewed as the study of health, healing, illness, and disease behavior among contemporary, non-western, tradi tional and industrialized nations. 2) Second, the collecting of information through participant/observation and through intimate, first-hand experience, combined with the more

PAGE 19

5 recent techniques of survey research and computer technology, are part of the methodology in medical anthropology. J) Third, the presentation of the information gathered through research to other scholars as new or added-on information; the offering of feedback, on health issues, to institutions, communities, and individuals being studied; and the presentation of alternative ways of viewing health care maintenance and health delivery systems of a given group of people, constitute the nature of medical anthro pology. In summary, medical anthropology is concerned with the healing and health maintenance systems of all peoples in the morphological sense--the structure that each system takes in a given culture, the functional sense--the methodol ogies used by the different individuals in a culture to participate in a health system or to devise their own health system, and in the cognitive sense--the way each system is conceived and verbalized by the different individuals in a given culture. It is through the offering of a tentative definition for medical anthropology, in comparison with the parent discipline of anthropology, that one can begin to obtain a feeling for the holistic and comparative nature of the subdiscipline and one can begin to see its roots in anthropology.

PAGE 20

6 The above definition being offered is by no means the only way of viewing the subdiscipline of medical anthro pology. It does, however, delineate the role and scope of the studies and activities of medical anthropologists. In addition, the definition offers a handle with which medical anthropologists as practitioners can develop new theories on the nature of healing systems and health care maintenance systems in different cultures. Purpose of This Study This research project is a field exploration of the idea that the general health status of an individual is a measure of his or her ability to adapt to a given environ ment. The elderly in a rural, Northern Florida community called Citrusville (fictive name) constitute the research population. An examination is made of the environment in which the elderly person lives, as well as his or her daily activities and specific health care seeking activities. There is a clear and undeniable linkage between disease, medicine, and human cultural activity (Landy 1977). More over, "illness, illness behavior, and reactions to the ill are aspects of an adaptive social process in which partici pants are often actively striving to meet their social roles and responsibilities, to control their environment, and to make their everyday circumstances less uncertain, and therefore, more tolerable and predictable." (Mechanic 197811; Von Mering and Kasdan 1970).

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7 However, medical anthropology, for the most part, while professing to offer the holistic approach to health and illness behavior, in actual practice has focused on disease behavior. A regrettable by-product of studies which focus only on disease behavior to the almost total exclusion of studies on wellbeing care behavior, is that health planning agencies measure the health status of a given population by the presence or absence of particular life-threatening diseases, i.e., the idea that populations represent a "diseased herd" (Otto Von Mering, personal communication). Very rarely, if ever, is the health or "wellness status" of a population measured by determining the number of age appropriate functioning individuals. It is entirely possible that medical anthropologists can offer, from an epidemiological point of view, the con cept of "wellness status" as a function of the individual's ability to adapt to his or her total environment (Dubos 1976); thus offering a reasonable alternative concept to the "diseased herd" idea. It seems feasible that the wellness status of a population may simply be a measure of the ability of different individuals in a given environment to function in spite of their physical ailments. Thus, the traditional concept of health status can continue to serve as a partic ular measure of the number of individuals with particular diseases. In the final analysis, the focus of studies on medical anthropology is formulated through the activities of the

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8 practitioners, and the research they perform. As a corol lary, it should be pointed out that the research that is not performed will also characterize medical anthropologists. As one individual has been noted to says "Oft-times, the research that should be performed is not performed because the parameters surroimding it do not offer a strong stimulus (Gordon Streib, personal commimication). In other words, most medical anthropologists, and other social scientists, have studied illness and disease behaviors, mainly, because these variables offer the researcher something that he or she can see, measure, chart, survey, and record in a tangible fashion. On the other hand, the techniques and methodologies employed to maintain health by various individuals, and not merely combat disease, are part of their daily, mundane, routine behavior. Quite often, this behavior is neither the focal point of a study or a major segment of the final data analysis. Moreover, when these routine behaviors are eve ntually brought forth in ethnographic studies, quite often they are missed as part of the health maintenance system of a given population. Many times, these behaviors are viewed merely as day-to-day living activities of a given population with no connection to health care maintenance behavior. Why Study the Rural Aged Older persons who live in rural commimities present the researcher with a singular opportunity to fully explore the idea that "wellness status" is a measure of individual

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9 adaptation to a given environment, rather than a measure of the specific illnesses or diseases which individuals may have; rural communities are noted for having very few, if any, local primary care personnel or faciliues. This means that individuals have to devise alternative ways of main taining their health status (Luft 1976; Salber et al. 1976; Barrett 1975; Murphee and Barrow 1970). Moreover, elderly persons can be characterized as afflicted by many chronic illnesses and diseases; therefore it is not too meaningful from a behavioral perspective to measure their health status primarily by indicating the amount and kinds of pathological states present or absent in their bodies. In effect, rural aged individuals have already invented ways of maintaining their wellness status quite apart from consulting formal primary care institutions for their health status; what means they use to assure for themselves the highest feasible well ness status can only be ascertained through a thorough exam ination of their environment and their activities. Basic Assumptions Which Structure This Research Inquiry There are three basic assumptions which will guide this research and which will determine the areas of the rural aged person's life that will be investigated. The first assump tion is that in order to fully understand and to be able to determine the health and wellness status of individuals in a given population, one must examine the surroundings or environmental constraints out of which health care and well being maintenance behaviors develop. Considered to be most

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10 critical are the housing situation, the individual living arrangements, economic survivorship activities, and neigh borhood stability. This assumption is a way of operation alizing the concept of man adapting to his or her environ ment as put forth by Dubos (1976). Also, it is a logical extension of the idea previously presented by various re searchers which states that the environment in which an individual lives will affect his or her wellness maintenance activities, i.e., culture affects health and wellbeing care habits (Mechanic 1978r Von Mering and Kasden 1970). The second assumption is that the specific routine or daily habits of the aged person in a rural community are a result of years of living in an area in which the survival process transcends the more salient features of ethnic group affiliation and sex, i.e., most rural elderly persons have adopted similar wellness maintenance habits. In order to determine which strategies are being used to maintain the highest possible wellness level, an examination must be made of what individuals do each day of their lives. Moreover, this assumption represents an effort to relate findings from this research to a series of studies which describe elderly leisure-time activities apart from elderly social inter action habits or social network activities. In effect, specific health care behavior and general wellness mainte nance activity should not be viewed as exceptional behavior, but should be viewed as part of routine behavior. The third assumption being made is that rural aged persons have to monitor their health status much more

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11 closely than their urban/suburban counterparts, since they live in an environment which is largely deprived of special ized health care services. Also, it can be assumed that these elderly persons will take actions which they deem appropriate and necessary in order to maintain a functioning state of essential wellness rather than a state of essential health or freedom from disease. Specific to determining how older people maintain their essential wellness is to determine their health care seeking decision making process, and to elucidate their concurrent or subsequent wellness maintenance seeking activities. A critical question to be answered relates to the rural elderly person's ability to function in an environment which is balanced precariously. Of special interest here is the question of whether or not the rural elderly person has enough stress-compensating power to carry him or her from the age of 60 through the time period of the mid-70s, at which time there occurs a statistically significant, rapid quickening in the number and severity of activity-limiting conditions (Gamm and Eisele 1977; Ellenbogen 1967). Restated, an area of particular research interest is to determine the capacity of the more formal medical systems to increase the extent and degree of essential self-care of the elderly through the utilization of elderly friendship and kinship ties within the local community. It is there fore hoped that this study will provide more reliable bench mark information on the particulars of rural elderly health

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12 care and wellness seeking behavior. It will shed light on the nature of its occurrence, both within and apart from accessible public health agencies or programs, and on the question of how this behavior is furthered or blocked within prevailing networks of symbolic or kin linkages of care giving and wellness support to family, friend, neighbor, "club," and church. Furthermore, aside from an examination of the questions raised by the above three assumptions, it is the purpose of this research to determine the features within the environ ment which promote or impede the health care wellness maintenance process. Once these variables have been more clearly identified as important to the process of growing old in a rural community, testable hypotheses can be gener ated so that more focused research can be done. Of course, it is hoped that this research project will add much-needed data to the slowly-growing body of literature related to rural health care and its differential effects on different ethnic groups. In addition, it is believe d that this re search will contribute to future studies encompassing health education issues, community self-awareness, and participa tion of residents in local health services. These and related implications of the research will be dealt with in the body of reported findings.

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CHAPTER II RESEARCH SITEz CITRUSVILLE, FLORIDA Citrusville, Florida, not the town's real name, is a small town located in the Northeastern portion of the State of Florida. It is, by its own definition, small and rural. Less than 4,000 people live in the entire Citrusville Dis trict which covers, excluding two large lakes, approximately 130 square miles; there are almost 31 people per square mile. Less than 2,000 people live within the city limits of Citrusville. Also, Citrusville is nearly 15 to 20 miles, in an east or west direction, from larger, more populated areas. Reason for Choosing Citrusville as Town to Study The Citrusville Census District was chosen to be the research site because it offers three advantages over other small towns in the Northern Florida area. First, it is sufficiently close enough to the University so that trans portation to and from the research site does not present a major obstacle to conducting the study. Second, it is the only small town, within a sufficiently close radius, that has a public health clinic, a dentist, a semi-retired physician, a pharmacist, and a fire department rescue unit. 13

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14 Having these medical facilities locally allowed the investi gators the opportunities to fully explore the relationships between the elderly individuals and the local institutions of health care. Third, and last, Citrusville has a large elderly population which is sufficiently scattered through out its district area so that the different elderly living environments could be sampled. Reaction of the Citrusville Residents to the Research Initially, no one in the town of Citrusville was con sulted about whether or not the research could be carried out in their community. In fact, the researchers simply "showed up" in the community and began to talk with the townspeople. In addition, various individuals who live in the Citrusville District were consulted for information about the town and assistance in locating aged persons to be interviewed for the study. The Citrusville residents did not provide any funds for this research but did offer the facilities of the high school library and the public library. Also, the local pharmacist, and part-time mayor, granted the investigators permission to use his store to collect our notes, if desired. A Brief Historical Sketch of Citrusville According to the local "Citrusville Reporter" newspaper, Citrusville began in 1834 as the union of a road which came from a small town north of Citrusville, and a road which

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15 came from a larger city west of Citrusville. Few individuals lived there, less than 500, and the population consisted of small land holding farmers and their slaves. The community was, basically, organized around a Baptist Church and many of the individuals who settled here came from England and Ireland. During the midto late 1800s, Sea Island Cotton was grown in Citrusville, as well as orange trees and rabbits. Citrusville was thought to have one of the largest rabbit hatcheries in the state. Moreover, there were about five or six stores, two small hotels, two cotton gins, one black smith, a livery and feed stable, a sawmill, an academy for men and a newspaper--"The Citrusville Graphic." After the turn of the century, according to the local librarian and a local service station owner, turpentine production and green beans became important products in Citrusville. It is believed that a freeze in the late 1800s killed much of the orange crop and also, much of that busi ness. Also, around this time period, the railroads which came through Citrusville had given it a vital link to the world. Because many, if not all, businesses in Citrusville were segregated, until the late 1950s and 1960s, the Blacks who lived in town and who worked for the various businesses had to have their own stores. Most of the Blacks were workers in the cotton fields, green bean patches, and orange groves. However, it has been stated by many of the older

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16 residents of Citrusville that Blacks owned land, and some were skilled craftsmen. The Citrusville of the 1920s through 1950s lost many of its businesses, and therefore its population, due to the increased competition by many larger companies. One large paper manufacturer acquired much of the land formerly used for large-scale farming, and planted trees. All of the various stores have faded from the Citrusville streets, not only because they are no longer useful, but also because the present population cannot afford to support them. The Citrusville of today, and the past thirty years, has seen a small increase in population but no tremendous increase in businesses. Although most individuals say that Blacks can live anywhere in Citrusville, there is a sharp and very distinct division of housing location for Blacks and Whites. Many Blacks still inhabit small, poorly constructed housing "across the railroad tracks" and on the west side and south side of town. The Whites live to the north, northeast section of Citrusville. There are few businesses in town: one small grocery store, two convenience stores, two or three family-owned restaurants, one or two small shops, one pharmacist, and several service stations. The majority, 95%, are owned by Whites. No significant other racial group lives in Citrus ville. Most of the individuals who work in Citrusville either own their business, have been with the owner for many years or they are friends and relatives of the owner.

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17 The others who do work, have to travel 20 miles east or west to the nearest larger city. The elderly, however, comprise 12% of the population and because most are retired, they form a major segment of the consumer population.

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CHAPTER III METHODOLOGY Introduction: Descriptive vs. Quantitative Data On every hand we hear the admonition, the study of societ must be made obective. When one asks what is meant by this, he or she is referred to the Lre search techniques used] in the natural and biological sciences. But, while the average [social scientist] has little difficulty in comprehending what is meant by the objective study of a naturally oocurring phe nomena, he Lor she] is at a loss, as a Lcollectivity], trying to visualize the objects of a study in a social inquiry (Lynd and Lynd 1956:v). The study of human behavior in a customary setting presents research design problems which are immense. The problems are immense because people do not necessarily be have in predictable, patterned ways. This lack of predic tability in human behavior often means that the circumstances under which data are collected change in such a fashion that situations described in one report are history before they ever make print. As Gale (1974:31) stated: man is a short-lived animal who is sociologically speaking, in a rapid phase of development. The [proposed] laws which con trol his social actions and interactions are themselves subject to rapid change." Moreover, any major social event which may affect an entire community, such as a quick change in government, indeed, any event affecting a person's lifestyle, like failing health or a change in social status,

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1~ can almost immediately change the opinions, attitudes, and ultimately the behavior of each person affected. Anthropologists studying human behavior do contribute much with a detailed synchronic and diachronic description of human activity under various circumstances. Furthermore, detailed descriptive data, usually defined as the cataloguing and classifying of a range of elements seen as comprising a given subject matter,a~e basic to all scientific inquiry (Black and Champion 1976). In fact, for the anthropologists, descriptive data are used to clearly illustrate how and why there is a relationship between the many "subsystems of interaction" found in each group under study (Studdert Kennedy 1975). As a rule, moreover, the collection of descriptive data is linked with performing qualitative research. Hence, col lecting descriptive data involves the social scientist both in the firsthand, face-to-face participation and in the delineation of events or activities of a naturally occurring social setting (Orenstein and Phillips 1978). To the extent that the social scientist is attempting to collect data in a natural social setting, he cannot, like the natural scientist, readily manipulate the variables of his research to fully assess their causal significance. This lack of planned overt and covert manipulation and interference with the research variables of a social inquiry by social scientists signifies to many non-social scientists that qualitative research is the least rigorous and least

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20 difficult of all scientific inquiry. But, the differences found in the research strategies of the natural scientist and those of the social scientist do not necessarily mean inferiority of one research technique over the other one (Orenstein and Phillips 1978). Similarly, it has been asserted that the objective performance of research is automatically linked with being able to quantify all re search data. Yet, for the anthropologist in particular and the social scientist in general, objectivity is not exclu sively or necessarily linked with quantifiability of the observed (Studdert-Kennedy 1975). Scientific rigor is also attainable by alternative means. Research Technique The research methodology of anthropology involves the observation of human behavior in habitual settings for social events. All observations involve the participation of the anthropologist whenever possible. As a special data generating strategy, this technique has been called "partici pant observation." In most descriptions of anthropological research, it is commonly expected that the readership will understand what is meant by "participant observation." Unfortunately, a great many anthropologists and social scientists differ in their understanding of this term.

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Participant Observations A Definition Historically, participant observation has been viewed as a role to be taken on by the researcher in order to gain easy entry into an unknown community (Kolaja 1956; Babchuck 1962; Bruyn 1963). Participant observation, according to Kluckhohn (194OsJJl) is conscious and systematic sharing, insofar as circumstances permit, in the life-activities and on occasion, in the interests and affects of a group of persons. Its purpose is to obtain data about behavior through direct contact situations in which the distinction that results from the investigators being an outside agent is reduced to a minimum. Participant Observation as a Research Task-Oriented Role When participant observation is viewed as a research task-oriented social role, the assumption is being made that in order to gain access to data, certain inevitable social barriers much be crossed. In most research studies per formed in non-western, traditional societies, taking on a role may be necessary in order to generate data. However, in many present-day western communities, as a result of individuals being affected by the mass media system, indi viduals have gained a superficial knowledge about social research. Consequently, the taking on of a special data collector role is often not necessary for the social scien tist.

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22 Participant Observation as a Research Technique On the contrary, some communities and individuals welcome social scientists who are concerned with their community affairs. In this case, participant observation becomes a research technique rather than the performance of a social role to gather data. As a research technique, participant observation becomes a direct observation method which allows the researcher to record be ~avior as it oc?urs Othe~ data gathering methods include: questionnaires, interviews, paper and pencil tests, and case records that are available on the research population. {Fry 1973:274) In gathering data for a social inquiry, whatever the method, the issue of the inability of social scientists to produce what is considered high quality data using the participant observation technique has been raised. The issue is not that participant observation produces low cali ber data, but that the data produced do not lend themselves to quantification. Hence, even a most carefully assembled body of descriptive data may not be viewed as having the same truth values as quantitative data when both are treat ing the same social phenomenon. However, Fry (1973) offers a way of looking at the place of participant observation in research methodology. Many anthropologists may not agree with his statement that participant observation produces a "low order measurement" (1973:274). However, it is easier to support his idea of three levels of research measurement. His description states: The first level of measurement is concerned with the value a recipient group places on an activity to be evaluated; the second Lmeasurement] represents the

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23 appraisal of a group of experts based on examinations and comparison with similar [research findings]; the final level is concerned with effectiveness [asJ determined by standardized scientific procedure including proper Lor appropriate] research design and instruments of determined reliability and validity. (19731274) Further suggestions have been put forth by Fry that participant observation "is an appropriate methodology with which to approach the first level of measurement" (1973: 274). It is important that he should suggest using partici pant observation as a method to understand how individuals feel toward a particular activity. The interpretation of human behavior is the "stuff" which forms the basis of all anthropological inquiry. Moreover, the present research has been conducted with the idea that participant observation can be used as a research technique to gain understanding about the values or priorities that the rural elderly place on various health care activities. The practice of participant observation as the only direct means of gaining access to information not otherwise obtainable was not needed for this study; no reason existed to keep secret the motives of the investigator. The indi viduals who participated in this research were made fully aware thats 1) 2) 3) The researcher is affiliated with the Anthropology Department at the University of Florida. The research project was concerned with both black and white individuals in Citrusville who were 60 years of age and older. The results of the research would not necessarily mean an increase in health care facilities or access to health care.

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24 4) The results of the research would be made available to them as well as to other health care agencies concerned with the aged, Research Sampling Procedure In general, where research has been conducted in small, rural southern communities, the issue of obtaining a repre sentative sample of the population has been a technical, rather than a major research problem, For example, it has been observed by Ensminger (1949: 55) that "the rural community is the geographic area with which most of the community's members identify themselves, To ask a rural dweller about his community in a given section of the country is almost certain to bring forth a fairly uniform response." This view has been echoed recently by Ford (1978:8-9): Virtually all comparative studies of the values and beliefs of rural and urban people have shown similar patterns of difference, Rural peo~le are generally more traditional, [in the sense ofj clinging longer to older views and resisting new ideals [and being] more likely to share bonds with their neighbors or at least to know their neighbors Therefore, the fundamental methodological problem which has been a concern of this study is to insure that different sections within the community are represented in the re search sample, In addition, there is no real need to use a stratified random sampling procedure to obtain a research sample population. As orenstein and Phillips (1978:357) assert, "If [ one] studies a homogeneous social group in which most people think and behave alike, data on a few people may adequately represent them all, 11 For the purpose

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of sampling the different community areas, the snowball or key informant research technique was used. Key Informant Research Technique The snowball research technique for defining a research sample population, in the main, involves using individuals who reside within the community as key informants. These key informants can be used by the investigator to obtain names of other individuals who might be willing to partici pate in a study. In this present study of the Citrusville elderly, members of the community were asked by the investi gators to reveal the names of individuals 60 years and older who would be willing to be questioned about their customary daily living habits. The major intent of this technique is to obtain a list of names from the key informants, and still more names from those individuals revealed by the key in formants, until a research sample population is estab:lished. The snowball technique, or key informant technique, for defining a research sample is one major method of conducting community research. Liebow (19671246) in his book, Tally's Corner, describes how his relationship with "Tally, a key informant," enabled him to study ghetto street corner life. His description is as followss By the middle of March, Tally and I were close friends ("uptight") and I was to let him know if I wanted or needed anything, anytime. By April, the number of men whom I had come to know fairly well (through Tally) and their acceptance of me had reached the point at which I was free to go to the rooms, or apartments where they lived or hung out, at almost anytime, needing neither an excuse nor an explanation for doing so.

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26 The anthropologist, in effect, attempts to develop within the research community, a "referral grid" upon which he or she is able to move about the community with the least amount of interference. The informants within the community become reference points and essentially act as referral sources through which the anthropologist is able to develop future contacts with others in the community (Von Mering, personal communication). Carol Stack (1974: 8-9), in her book entitled, All Our Kin, was able to develop such a referral grid of individuals in a Black urban community, through which she studied their social networks. She describes her entry into one family and thus to the community, as follows: During my first visit Viola told me that she and her husband Leo have kept their family together for twenty-three years. Leo, she said, is a good man, a man who works and brings his money home. After several weekday visits, Viola asked me to come over on a Sunday afternoon when the family would be home When I arrived, Viola called me back to the kitchen where the women were cooking a Sunday dinner. Verna, Viola's nineteen-year-old daughter, and I, both six months pregnant, talked about names and nicknames for our babies, and eventually almost everyone in the household joined the conversation The conversation among Verna, Viola and myself was long, warm, and lively, and eased the strain. Our visits continued for months. In all research, as Glazer (1972:11) says, it is essen tial for the investigator to spend an initial period of time preparing the kinds of questions he or she wants to ask, developing the tools of data collection, and then venturing out and determining the extent to which the research design will be appropriate for the actual field situation. Gaining

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27 acceptance from informants and respondents is a crucial component of this process. Other Uses for the Key Informant Technique Aside from providing an entry mechanism into the com munity of study, Orenstein and Phillips (1978:321) have put forth other positive reasons for using key informants. They say essentially that the field worker meets people who help him or her gain entry into the community, who direct the investigator's attention toward certain events, who point out patterns that the researcher might otherwise miss and who keep the investigator up-to-date on new happenings that he or she might not attend. The key informant also suggests explanations of events and when appropriate, comments on the final research project. Whether the field worker develops a key informant, or several informants who each make a more limited contribution, the active role that informants play in all phases of the research cannot be overemphasized. Determination of Research Population Sample One major component of the key informant technique is that it serves the purpose of making the researcher known to the community. Initially, the researcher is in contact with individuals who are familiar to the community residents instead of initially confronting the residents. As illus trated in the studies by Stack (1974) and Liebow (1967),

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28 the key informants may be chosen from amongst the various: school teachers, guidance counselors, principals and vice principals, local ministers, prominent church members and the public librarian. It is through contact with these key informants that a core group or "first generation research population" study group is established. Subsequently, after interviewing these first community residents and determining their close friends, a "second generation research popula tion" study group is established. Likewise, upon completion of the interviews with this second generation research study group, alternative, additional referrals are determined (see Figure 1). My first contact with Citrusville residents involved my talking with the guidance counselor and vice principal of the local high school. These individuals allowed me to use the school library as a place to write up reports and they also gave me the names of several community residents. My second entry into the community involved myself and my research assistant speaking with the ministers of all nine of the predominantly Black and predominantly White churches in Citrusville. Each minister was asked to give us the names of three individuals in his church who might be con tacted to participate in this study. For the most part, all the ministers were very cooperative after they under stood the nature and purpose of the study. Once entry had been made into the community through the guidance counselor, the vice principal and the ministers, the local public

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Key informants or Initial referral Sources Alternative Additional Referrals (Unused) Churches, Black ... School Librarian and W hite Related Persons (N=9) '\a (N=5) .t (N=l) J 1st Generation Research Study Population t~ 2nd Generation Research Study Population t Trusted Friends of 2nd Generation Research Population Figure 1. Research Population Determination (Schematic) f i arrows indicate direction of referral N=l5 N=25 N=J9 I\) "' N=45

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39 librarian and three school teachers were further contacted for names of individuals for the study. Overall, it can be stated that these key informants were enthusiastic and very cooperative. Figure 1 reveals the numbers of individuals obtained through this procedure. Composition and Size of Research Population According to the 1970 census of population, there are approximately J628 persons residing in the Citrusville District. Of that total, 12,5% or 450 residents are 60 years of age or older. Blacks number 211 or 47% of those over 60, while Whites number 239 or 5J%. Black females are represented by 118 or 26% of those over 60 and Black males account for 93 or 21%. On the other hand, White females make up 141 persons or Jl% and White males number 98 or 22% (see Table 1). In the Citrusville research population, there are a total of 64 persons or 14.2% of those individuals over 60. Fifty-three percent or J4 of the research population group is White, while the remaining 47% or JO individuals are Black. In terms of the number of White females and White males in the group, the females number 24 or J8% of the total number of individuals in the research population and the males number 10 or 16%. Black females number 22 or J4% of the total study population and the Black males number 8 or 12% (see Table 2).

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Total % of Total Total % of Total Table 1. Population Data for Citrusville Population Sixty and Older 1970 Population for Citrusville 3628 100% Number of persons Over 60 450 12.4%a Number of Whites 239 53%b Number of Blacks 211 47%b Number of White Females Number of White Males Number of Black Females Number of Black Males 141 98 118 93 31%b 22%b 26%b 21%b a Percentage representation of total Citrusville Population. b Percentage representation of Citrusville Population 60 and older. Sources U. s. Census of Population for 1970.

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Total % of Total Total % of Total Table 2. Population Data for Research Study Population Group Total Research Study Population 64 14.J%a Number of White Females 24 38%b Number of Whites Number of Blacks 34 53%b Number of White Males 10 16%b Number of Black Females 20 34%b 30 47%b Number of Black Males 8 12%b a Percentage representation of total Citrusville Population over 60. b Percentage representation of total research study population.

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33 Before conducting the research, it was determined that between 10% and 20% of those individuals 60 and over would be sampled since Citrusville represented a fairly homo geneous area. Further, it was decided that the ratio of Blacks to Whites would be the same in the study population as those in the total population of those 60 and over. Although an attempt was made to maintain similar malefemale ratios in the research population as those in the total over-60 group, it was not accomplished for several reasons. First, and most importantly, the men in Citrus ville were elusive and difficult to detain for an interview. S econd, when men were interviewed, they usually named few individuals, on average one or none, as their close friends. Third, and last, women, for the most part, named other women as their close friends and men named other men as their close friends. In very few instances, less than three, was there an overlap. Interview Guide An Interview Guide has been used to gather the essen tial data on the research population in Citrusville. The conceptual organization of the Guide's contents is based, mainly, on the areas of concern previously formulated in a study of Black family social networks by Carol Stack (1974, see Appendix A). In addition, a number of questions are based on a questionnaire which was used in 1976 by this

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34 researcher to gather health care data on migrant workers in a Northern Florida rural community (see Appendix B). Precision and Accuracy of the Interview Guide Repeatedly, to the social scientist conducting research in a natural setting, the question arises as to whether or not the data-gathering instrument is appropriate for ob taining the requisite information. Furthermore, once the data are collected, the question arises as to whether or not it truly reflects the information that one seeks. In fact, what these two questions do is raise two issues: (1) what is the "precision" of the data-gathering instrument, and (2) is the information collected "accurate" information. The "precision" of a data-gathering instrument refers to the efficacy with which it is able to obtain the needed data. In fact, the precision of a data-collection instrument can be statistically measured through testing it in several places and comparing the results. The closer the results are to each other, after having used similar sampling pro cedures to choose the subjects, the more precise an instru ment is said to be (Wax 1970; Chou 1975). In this study, an Interview Guide was used instead of a questionnaire. The Interview Guide is an attempt to ask the study population all open-ended questions. However, although the questions were open-ended, each person in the study was asked the same questions. The only difference in interviewing one person over the next, was their re sponses to the questions. Because the Interview Guide

PAGE 49

35 covers many aspects of the elderly person's life, it is able to obtain the information needed relative to rural elderly survivorship. On the other hand, it is difficult to determine the true accuracy of the Interview Guide. For some sections, such as the section related to health care information, the data collected we re easily verifiable because many of the elderly would show the investigators their prescriptions, bottles of pills, and in some instances, their cards for their next doctors' appointments. Moreover, the close friends of the individuals were easily determined because they are known to other persons in the community who would frequently refer to "Person A as a close friend of Person B." Also, during the interviews, Person A would, most often, name Person Bas a close friend. There was almost 95% mutual agreement between individuals who called each other close friends. Yet, the age and personal data had to be accepted at face value, unless the researchers were willing to violate the privacy of the interviewees. Furthermore, the informa tion on the economics, and household bills, was not easily checked because individuals were reluctant to discuss those issues at length. Finally, the data related to daily activities in many instances, were checked and verified because the investigators visited many of the activities in which the elderly stated that they participated.

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Components of Interview Guide The research Interview Guide is divided into six com ponents. They ares (1) General Information; (2) Life Habits; (J) Information on Household Structure; (4) Infor mation on Social Network Structure; (5) Health Care Infor mation: and (6) Health Care Problems. The overall Guide is designed to elicit detailed information on an individual's daily customary habits as well as gather specific data on the health care habits and health seeking behaviors (see Appendix C). Interview Technique As a rule, each individual whose name was given by a key informant was contacted for an interview within a week of the initial referral. Those individuals who consented to being interviewed gave a time that would be most con venient to them. Each person was told that the interview would consume between 45 minutes and an hour of their time. However, many interviews lasted longer than the scheduled time because many persons wanted to discuss matters not specifically related to the primary purpose of the inter view. In the main, the two interviewers involved in this research found the interviewees very pleasant, and willing to fully answer all questions to the best of their ability (see Figure 2). Many interviewees expressed thanks for

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Number of per week 10 9 8 7 6 5 4 3 2 I 1 0 1st week Jan. 1979 Interviews I 4th 8th week week 1, 12th 16th week week 20th week June 1, 1979 Number of weeks Figure 2. Number of Interviews Accomplished, on average, by Both Investigators per week (schematic) [Note: No particular significance may be attached to the frequency of interviews conducted during any given week, except that variation in interviewee and interviewer time played a role in the above pattern.]

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38 having participated in the study because they felt that the questions raised made them think about their amount of self-sufficiency. Further, while many persons had health care limitations, i.e., frequent heart attacks or almost total confinement to their homes, they nevertheless agreed to the interview. When others were to be contacted, quite often the individual being interviewed would call the next interviewee. This help given to the researchers saved many hours of trying to call individuals or trying to locate them. While both interviewers in this study were able to develop close relationships with some of the residents in Citrusville, a few residents were resistant to being inter viewed and others were reluctant to discuss the relationships they had with close friends. In the main, the types of contacts that will be made in a research setting and the kinds of interaction patterns that will be permitted, will depend upon the background of the researcher and the initial contacts made in the community (Orenstein and Phillips 1978). In fact, Glazer (1972:12) states it quite cogently with: "when the fieldworker attempts to gain entrance into a relatively closed community, trust is the crucial ingredient and may often be more important than the various forms of reciprocity." Other Data Resources The investigators were able to obtain information from many documentary resources. For instance, a city plan had

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39 been completed on Citrusville and provided data on housing, living arrangements and economics. Comparative data were also obtained from the u. S. Census of Population for the years 1900 through 1970. Finally, the local residents and the Citrusville Library and high school library provided much of the information on the history of Citrusville and the Citrusville of today. Summary Review A description of the Key Informant research technique has been presented as a method used to develop a research sample in the Citrusville Community amongst those persons 60 and older. Also, it has been shown that the Interview Guide presents a way of ascertaining information from the population sample through open-ended questions. Although not specifically stated, it has been implied in this report that having open-ended questions allowed the investigators to obtain much more information about routine habits of the elderly than a pre-coded questionnaire may have allowed. In subsequent chapters, the data collected in the above fashion will be presented in relationship to the elderly community structure, daily activity, and health seeking behavior.

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CHAPTER IV DEFINING AN EIDERLY COMMUNITY S TRUCTURE: CITRUSVILLE In Chapter III the Key Informant Research Technique, which defines the referral grid, was described as the method used in this research project to gain entry into a rural community and to obtain a representative research population sample. The Interview Guide is put forth as a data collection device which was used to ascertain: the morphology of the elderly person's environment, the individ ual behavior patterns and the individual's perception of his or her environment. In Chapters V-VIII, however, only the variables which define the structure of the rural aged person's living environment will be discussed. The environmental structural "regularities" under con sideration for the Citrusville elderly individuals number four in all. They are: (1) the neighborhood conditions which define its stability; (2) the living arrangements of each household; (3) the local housing situation; and (4) the economic conditions which determine survivorship. Whereas these regularities, which may also be referred to as "envi ronmental constraints," do not always determine the specific activity of individual behavior, they do influence in a major way the aged person's lifestyle. In addition, an examination of these regularities, in the sense of 40

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41 environmental constraints, together with routine behavior is expected to reveal the overall survivorship mechanisms for rural aged persons. Data Resources for Chapters V-VIII The organization of these chapters will be centered around the four environmental constraints listed above for the Citrusville Elderly Study Population sample. The data presented in each section of these chapters are derived from different sections of the Interview Guide (see Appendix C). Below are the pertinent sections, and particular information on the data resources. Stability of Neighborhoods in Citrusville The data presented in this section come from the following resources, (1) general notes taken after having conversation with the elderly person being interviewed. For instance, female interviewee may be describing her children who live outside of Citrusville, but may comment on the fact that skilled young persons rarely come back or stay in Citrusville; (2) questions from the Interview Guide, Section C, "Information on Household Structure," Part I, questions A through E; and (J) observations of the neigh borhoods by the investigators while driving to the interviews. Living Arrangements of the Citrusville Aged Information for this section comes from two different sections of the Interview Guide. Data on individuals who

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42 live alone or with spouse we re collected in Section A, "General Information," Parts I, II and III. Data on those persons who live with other relatives and friends were collected in Section C, "Information on Household Structure," Part II, questions Band G. Housing and the Citrusville Elderly Individual The information presented in this section is data gathered in the Interview Guide, Section C, "Information on Household Structure," Part I, question F, "A Better Place to Live?" Most persons responding to this question usually discussed, their feelings toward their present location, the problems they are experiencing with their homes, and why they would or would not stay in their present homes. Also, datawere collected for persons living with other relatives and friends, in Section C, Part II, questions A, F, and G. Economic Survivorship of Citrusville Elderly The data for this section were collected in one section of the Interview Guide and from the local Social Security Administration. The information from the Interview Guide was gathered in Section A, "General Information," Parts III and IV. Data from the local Social Security Administration came from a survey conducted on Citrusville elderly resi dents who receive Social Security benefits.

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43 Presentation of Comparative Data Where possible, throughout this report, the data gathered on the Citrusville elderly will be compared to similar national studies of particular trends in rural communities amongst the elderly, or to local studies con ducted on a larger rural population group. This comparing of local data to other data collected elsewhere is to demonstrate that in many instances, activities reported to occur on the national level may or may not occur at the local level. Definition of Terms to be Used in This Report Before presenting and discussing the information on the elderly community structure, the major terms which will be used throughout the remainder of the report will be ex plained. It is important to do this, because terms have different meanings depending on the context in which they are used. For this report, the following concepts are important, namely: social network, close friends, just friends, and strangers. Social Network Quite simply defined, a social network is the sum total of an individual's social relationships, both the personal ones and the formal ones. In most instances, these rela tionships begin with the individual and the immediate family,

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44 then eventually radiate out to other relatives and the society at large (Fischer 1977). In this study, the concept of an individual's social network will be used to provide an overall framework for discussing the various relationships the Citrusville elderly have with relatives, friends, and institutions of health care. Close Friends In the main, close friends of the rural aged person are those individuals who will not reveal the contents of their discussions to others who are not part of their friendship group. When the elderly in this study group were asked, "What kind of person they considered a close friend, ti they stated thats "A close friend is an individual that you could count on when you needed them. ti Also, it was expressed that trust was a result of being friends for years. Almost 100% of the people in the study gave this response when asked this question. Optimum number of close friends. In general, the number and kinds of close friends that a person has in a rural or urban setting depends upon his or her socio-economic status and sex (Clark and Anderson 1967). Individuals in the Citrusville Study who were self-sufficient economically were inclined to trust mainly their wives or husbands if they were married. If they were single, many stated that they would trust a minister, their doctor, or maybe one other person outside of their family. Those individuals who suffer economically were inclined to have many more persons that they would trust who were not

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45 part of their immediate family. It is possible that the discrepancy in "trusting behavior" between those who have and the have nots is directly related to the satisfaction of basic needs. The poor individuals in Citrusville have to rely upon individuals within and outside of their immediate families in order to increase their chances for survival. By virtue of being poor, they do not have the basic necessities for living. Also, the monies received from government resources do not cover all of their living expenses. Therefore, these poor persons have to request both spiritual (mental) and in some instances, economic support from friends. Relatives as close friends. For many elderly persons in Citrusville, the relative may or may not occupy a central position in their lives. Indications are that unless a relative communicates on a frequent basis, whether far away or nearby, with the elderly person, he or she may be thought of with no special significance other than that of being a member of the family. For example, there are individuals with relatives who live on the same block and who seldom speak to each other. Also, there are individuals who live far apart but communicate on a regular basis; one lady in Citrusville has a son who calls her every day at 9:00 a.m. from 1100 miles away. In this study, many individuals considered some rela tives as "relatives," and other relatives as "close friends." For instance, on three of four occasions when I interviewed

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46 an elderly person and a relative was present, usually a sister, the elderly person named that individual as a close friend~ On one occasion, the individual did not indicate that the relative present was a close friend; she said, "I have no close friends." Close friends of elderly individual and relative or spouse. Also, it is important to note that on almost all occasions where an individual lived with a spouse or another relative, both of the individuals had their separate set of close friends. In less than 10% of the husband and wife cases were there occasions where the wife and husband shared the same group of close friends. In addition, most men had men as close friends, while most women had women as close friends. Only on two occasions did a man have a woman as a close friend and a woman had a man as a close friend. In both instances, the individuals were married and their close friends were married. Problem of having only one close friend. One more interesting note. Most individuals indicated a great sorrow and appeared to feel a great loss when one of their close friends died. In almost all instances, particularly those where an individual really only had one close friend, the individuals failed to develop other close relationships. Many simply stated that they did not have a close friend and felt very lonesome. Others called a relative and asked him or her to come and live with them. After which, the individual and the relative became close friends. This

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47 failure to develop new close friends is particularly notice able in individuals where the husband and wife were close and one or the other died. Those who failed to develop new relationships appeared to live in constant sorrow, i.e., constant feelings of loneliness, nothing to do, boredom, etc. Just Friends If one were to ask the general question, "Who are your friends?" to an aged person in Citrusville, the response would be, "Everyone is my friend." Indeed, most older persons in Citrusville believe that because they speak to each other on the streets, or occasionally participate in some community activity together, such as club meetings, church functions and community holidays, that they are friends. However, in reality, these individuals never really play a major role in the day to day activities of the aged person and, for the most part, can be classified as "just friends." Strangers Those individuals who come from outside of the Citrus ville District and are not known to many people in the local communities can be called "strangers." The researchers, salesmen, etc., would fit into this category. While the Ci trusville elderly person may "pass the time of day" with a stranger,i.e., discuss the weather or fishing conditions, most strangers are viewed with skepticism.

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48 Social Networks and Community Structure In general, the elderly persons in Citrusville commun icate on the telephone or associate with individuals who are their close friends. The persons who are "just friends" or strangers enter into the social network of the aged individual only under specific circumstances. For most of the elderly individuals, their social network is comprised of close friends, some relatives and, possibly, a formal institution such as a club or church. The patterns and places of interaction for the elderly person and his close friends depends upon the organization of his environmental constraints. For some mobile elderly persons, interaction can take place within the limits of their transportation, e.g., walking, bicycling or car. For those individuals who have to depend on some other person for transportation, most of the interaction may take place in their homes, the residences of relatives or close friends, or at a social gathering such as club meeting or church. Therefore, while the organizational structural con straints in the Citrusville aged individual's life may dictate the framework for behavior, they do not necessarily control behavior. However, it is possible that older persons do respond to close friends based on the distance between them and the amount of contact they have each day. For instance, an individual who has three close friends in Citrusville, one in the same neighborhood and the other two

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49 one mile and two miles away respectively, may be more in clined to go across the street for a visit than to travel a mile away. Consequently, although the individual has three close friends, in terms of who may be in II touch, 11 the person who is closer may know more about the elderly person than the others further away. Moreover, the cogni tive ranking of individuals within a social network by the aged person may consist of that elderly person simply determining who he or she has the most contact with and/or who he or she talks with most often.

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CHAPTER V THE STABILITY OF NEIGHBORHOODS IN CITRUSVILLE "For half a century of more, scholars have proclaimed the extinction of Rural America or at least any meaningful distinction between urban and rural society in the United States" (Ford 1978:J, quoting Bender 1975). However, at least for the rural elderly population, this claim of ex tinction is not well founded in terms of population trends at both the local and national levels, migration patterns of the elderly, and length of time elderly individuals have lived in their present residences. Population Trends in Citrusville The elderly population in Citrusville has two basic characteristics which indicate its stability. The first characteristic is the slow growth in population. The second characteristic is the in-migration of older persons and the lack of out-migration by aged persons presently living there. These two traits, when coupled with the length of time in residence in one location, indicate that the Citrusville elderly individuals have a consistent neighborhood environment. From 1910 to 1970, with the exception of the time period from 1930 to 194o, the Citrusville population has 50

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51 shown steady, but slow growth. In fact, as Table 3 shows, there has only been an overall increase in population of 35%, whereas Citrusville County has had a 205% increase in population during that same time period. Much of the increase for the entire Citrusville County can be attri buted to the growth of the largest urban city. The rural population trends for Florida and the United States have been steady over the last sixty years (see Appendices D and E for totals). The farm areas, moreover, indicate a rapid decrease in population both in terms of the actual number of persons who live on farms and the percentage representation of farm areas in the overall rural population (see Appendix F for totals). The data on Florida illustrate an overall increase in the rural population from 420,000 in 1900 to over 1,300,000 in 1970. These figures account for an increase of over 209% in seventy years. National]y, the rural popu lation has grown from 46,800,000 in 1900 to 53,900,000 in 1970. The percentage change is only 17%. On the other hand, the farm population in the United States, which represents less than 15% of the total population, decreased from 29,900,000 in 1900 to 8,900,000 in 1970; this decrease in population is approximately 70%. Also, it should be noted that in 1900, the farm population was close to 64% of the rural population. In 1970, the farm population represents only 16% of the total United States rural popu lation. Population data alone may have very little

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Table J. Population for Citrusville District and Citrusville County 1910-1970 Citrusville Percent Change Citrusville Percentage County Total From Previous District Change from Year Population Census Population Previous Census 1970 104,764 41.4 3628 15.1 1960 74,074 29.9 3150 5.7 1950 57,026 47.7 2980 10.1 1940 38,607 12.3 2706 -.? 1930 J4,J65 8.4 2726 1.4 1920 Jl,689 -8.2 2686 6.8 1910 34,305 6.4 Source, U.S. Census of Population, 1900-1970, U.S. Department of Commerce, Bureau of Census V\ N

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53 significance until it is coupled with the migration trends noted occurring in the rural elderly population. While talking with the older persons in Citrusville, it was observed by both investigators on this research project that many of the elderly individuals complained of the community not being able to keep many of the "good/ intelligent" young persons around. They said that when most of the younger persons achieve a higher education, they leave town and never return. However, as will be fully explained in the section on "Economic Survivorship," there are few places for young people to earn a living in Citrusville. Furthermore, there is little, if any, major entertainment activity which would appeal to individuals between the ages of 18 and 45; Citrusville has no movie theatre or club which caters to younger individuals. For those young persons who have to stay, they may travel 10 to 20 miles to find entertainment. Sanders (1977:64) has found that: rural mi grants to the cities in the United States come from areas of low economic opportunity, that they are relatively young (in their twenties), and that they number more females than males." Furthermore, he notes that ". there is a tend ency for many people over 65 years of age to leave the city and return to the rural areas where they originated" (1977:64). In the Citrusville Study Population Group at least 5 of the 64 individuals, who originated in Citrusville but lived elsewhere for most of their lives, have returned to Citrusville within the last 10 to 15 years.

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54 In fact, it can be stated that the slow population growth, the tendency for individuals 65 and over to return to the rural community, and the fact that many individuals remain in the rural community until they are 60 and older, means that the local community can reflect the "pervasive influence of the elderly population" (Rose 1967). In concrete terms, this influence of older individuals can be illustrated not only in that things change slowly in the rural community, but their influence can be measured by: the numbers of items in the local drug stores and grocery stores which appeal specifically to the elderly; whether or not merchants attempt to provide seating, probably benches, in front of their stores for the elderly; ahd in some instances, there may be an absence of monies set aside in local government budgets for children's playgrounds and such, because truces spent in this way may upset the elderly who comprise a major segment of the land holding taxpayers (Rose 1967). Length of Time in Present Residence An examination of the residential living patterns for the Citrusville elderly person reveals further information about the stability they give to a community. In fact, data gathered on the Citrusville Study Population Group indicate that more than 80% of the 64 persons had lived in their present location between 1965 and 1970 (see Table 4). In the Citrusville District population, more

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Table 4. Place of Residence Between 1965-1970 Same Different House Different Percent Population House Same County County Accounted For Ci trusville Study Population 80% 15% 5% 100% Ci trusville County 38% 21% 18% 84%a Ci trusville Residents 55% 19% 10% 77%a Florida 44% 22% 7% 73%a I.ft \,J't Source: Data taken from Comprehensive Plan for Citrusville 1977-2000. a Individuals not accounted for were in a different state.

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than 50% of the residents had lived in their 1970 locations between 1965 and 1970. These figures are in contrast to those for the Citrusville County, which indicate that only 38% of the population lived in their 1970 homes between 1965 and 1970. For the State of Florida, 44% of the popu lation had lived in the same house during the 1965-1970 period. Furthermore, of the 64 individuals in the Citrusville Study Population Group, at least 50% have indicated living in their present residences for more than 20 years. At least three individuals stated that they have lived in their present homes for over 40 years. One individual has lived in her present location for more than 50 years. It can be postulated that the length of time that a rural elderly person spends in a neighborhood means that he or she can influence the character of the neighborhood, i.e., who moves in and where they live. This power of rural elderly residents to determine the destiny of their neigh borhoods is in direct contrast to the influence the urban elderly have on their neighborhoods. For the most part, the urban elderly individual is usually left behind in neighborhoods and communities that are, or have already, deteriorated and are highly unsupportive (Regnier 1975). In effect, it is possible for the rural elderly person to create for himself or herself a stable community through personal longevity and through the continued survivorship of his or her neighbors who are quite frequently relatives and friends.

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CHAPTER VI THE LIVING ARRANGEMENTS OF CITRUSVILLE AGED The living arrangements for the rural aged person can reflect his or her ability to maintain a household, as well as his or her desire for continued companionship throughout a lifespan. In the Citrusville Study Population Group, there are a wide variety of living arrangements which reflect the variety in rural elderly lifestyles. Moreover, much of this variety found amongst these rural elderly individuals can be attributed to many reasons. Among the more prominent ones mentioned in this study are: a simple desire not to live alone; the need to have another share the economic burdens of running a house; the loss of an older relativeusually much older mother or father--and the subsequent coming together of relatives to take care of the home; and, simply, returning to their place of origin ("coming back home"). Typical Household Size for the Citrusville Elderly Person The average number of persons in the study population is smaller than the 1978 estimated number of individuals for the Citrusville County and the State of Florida. The Citrusville Study Population shows an average of 1.71 persons

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per household. The 1978 estimated number of individuals per household is 2.6 for Citrusville County and 2.5 for the State of Florida (see Table 5). Nationally, the number of persons per household has dropped from 3.5 in 1950 to J.l in 1970. Zuiches and Brown (1978:60) have associated this decline in household size with several factors. They believe that there is an in creased proportion of persons who live alone or with just one other person. Furthermore, they say that there is a growth in the households of young singles and the elderly. Particularly, they state that many of the elderly individuals maintain their residences after their children have left home and/or after the loss of a spouse. Household Types Found Amongst Citrusville Aged There are seven different household living arrangements in the Citrusville Study Population Group. Five were initially identified in a study of "Old People in Three Industrial Societies," by Shanas et al. (1968:218). The other two were developed from the findings in this research. Table 6, in illustrating the percentages of individuals who fit the various categories, readily shows that the data ar.e in keeping with the idea that the Citrusville elderly have small households. Over 80% of the individuals are in the categories of "married couple only," "widow, divorced, or separated parent living alone," and "elderly person who lives alone but never married."

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Table 5. Average Household Size for Citrusville Study Population, Citrusville District, Citrusville County, and Florida. Persons per Household Estimated Citrusville Population Group 122Q. 1960 121.Q for 1978 1979 Study Citrusville Study Populationa N/A N/A N/A N/A 1.71a Citrusville District N/A J.58b J.JOb N/A Citrusville County J.4lb J.J6b J.06b 2.6c Florida J.22b J.llb 2.90b 2.5c N/A = not available a Figures for Study Population reflect 1979 research findings. b Household size data taken from Comprehensive Plan for Citrusville 1977-2000. c Household size data taken from Population Studies, by Stanley K. Smith, Bureau of Economic and Business Research, University of Florida, Gainesville, Florida. V\

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_ 60 Table 6. Seven Household Types Percentages Seven Household Types 1) Elderly individual lives alone, never married 2) Widowed individual, divorced or separated parent 3) Married couple only 4) Married couple, and married or single children 5) Widowed, divorced or separated parent and married or unmarried children 6) Widowed or divorced individual and relative other than children 7) Married couple and relative other than children Shanas et al. Study 4-8% 22-28% 35-45% 7-14% 9-20% N/A N/A Citrusville Study 1% 25% 55% 5% 5% 4% 4%

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61 These seven different household types describe approxi mately 99% of the living arrangements of the 64 individuals who participated in this study. However, there is one other category which might possibly be added, and which represents less than 1% of the research study population; it is: "Those Households consisting of the Elderly Individual and Unre lated Friend." Purpose for Various Living Arrangements The explanations for the various living arrangements found amongst the Citrusville Study Population Group can truly vary on an individual-by-individual basis; neverthe less, there are general themes which can be formulated. In general, many older people prefer to live alone or with spouse (Woodward 1974). In the rural Citrusville Elderly Population, it appears that over 82% of the individuals live alone or with spouse. The tremendous desire by the elderly persons in Citrusville to live alone or with spouse in spite of any health problems is demonstrated in many ways. For instance, on the one hand there are the aged individuals, particularly females, who expressed that they have frequent "heart attacks" or other acute medical problems, and who prefer to live alone than with a relative. However, many of these people stated that they live near or that they are only a phone call away from close friends and relatives in the event of an emergency which does not render them

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62 incapacitated. Furthermore, close friends often call each other before going to bed each night. This calling, in effect, serves as a check-in system to see who is or is not okay. Should the caller not receive an answer, he or she may go by or call someone who is near and ask them to "check up" on their friend. On the other hand, there are the elderly persons who are not frequently ill and who have trouble with the upkeep of their homes, but still prefer to live alone. These individuals have been known to sell their furnishings, obtain money from relatives and call on close friends to help them with the chore of keeping their homes. In Citrus ville, most in this position, approximately six persons, stated that they would rather lose everything in their homes and live alone or with spouse before they go to the home of one of their children or brothers and sisters. They spoke of being able to control the operations of their houses, who visits, the noise level, the cleaning chores, etc. Living alone or with spouse means being able to con trol the household environment. Still, while many of the aged persons in Citrusville prefer to live alone or with spouse, 17% or 11 do not. For these individuals, who must share their living quarters with others, the reasons for the different arrangements offer five possibilities which encompass the following themes: Health Problems, Economical Reasons, Performance of Service, Natural or Man-made Disaster, and Emotional Attachment.

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63 Below are presented these themes in the order of the most commonly occurring reason for living with persons other than spouse to the least commonly occurring reason. Heal th Problems The elderly person who can no longer take care of himself or herself because of an illness or debilitating disease is usually cared for by a son or daughter. Most of these people expressed happiness for their living arrangements. In fact, they all would prefer "imposing" on a relative to being put into a nursing home. In one case, one elderly person in her late sixties was caring for her mother who was in her late nineties. She had been doing so for several years. Economic Reasons The elderly individual without financial resources to maintain a household and who does not suffer from an illness or disease which restricts activities, may suffer a dual loss when the decision is made to move in with another relative or with children. On the one hand, for these individuals the realization that their homes and furnishings must be sold means a loss of independence and flexibility. In a sense, it is the harsh recognition of the fact that "I can no longer take care of myself." On the other hand, losing the home can mean entering into an environment where, for the most part, the elderly person's needs are usually secondary. In this case, the

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64 elderly individual suffers from isolation from close friends. Isolation is particularly acute if the elderly person has to move away from his or her "old" neighborhood or com munity, to another town or city. The ability of the elderly person to cope with this new situation will be directly related to the amount of time and support he or she receives from the family. Performance of Service In the Citrusville Study Population Group, 2 out of the 64 individuals interviewed stated that they, along with at least one other relative, had returned to Citrusville to help take care of a home left by an older relative. In this situation, both of the parties said that they came back because they were retired and really enjoyed living in the Citrusville environment. Moreover, they had grown up in Citrusville and had "kept in touch" with the family. In addition, it was made known that they "knew" Citrusville and knew basically what to expect. Natural or Man-made Disaster This living arrangement is brought about in most in stances because someone has been displaced as a result of a fire to a home. In a few instances, it can be the result of a natural weather occurrence, e.g., tornado or high wind damage. Only one person in this study fit this category. A fire had destroyed his home and he was living with two friends (married) until he could find a place to stay. This

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individual did not appear to be in a hurry to find a new place because he stated that the individuals with whom he lived were his only friends. However, in a rural poor area such as this one, fire to the home of an elderly person is a common occurrence. Therefore, in such an event, it is necessary for them to have relatives or close friends who can temporarily offer them shelter. Emotional Attachment Only one elderly person lived with her daughter and son-in-law because she enjoyed being with them. At least, according to this elderly person, the living arrangementshe, daughter, son-in-law, and child--is satisfactory because she has her own place above the garage. Furthermore, she performs a useful service for them, acting as a live-in babysitter. However, it is my estimation that, because of the independent spirit of most of these rural aged persons, this kind of a living arrangement based solely on "emotional attachment'' is rare. Duration of Living Arrangements In order that this discussion of the elderly household living arrangements be complete, mention must be made of the duration of these relationships. Analysis of the data from this Citrusville Study indicates that there are six possible household living arrangements and durations. Four of these household structures had already been identified in the Shanas et al. (1968) study. Below, in Table 7, are

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66 the arrangements and indications as to whether or not they are independent or dependent and whether or not they are temporary or permanent. Table 7. Six Types of Household Living Arrangements for the Elderly Adult Person in Citrusville. Aged Parent: Need for Care Independent Permanent Planned Duration of Household Structure Temporary Parent living with children waiting for own dwelling. Elderly individuals living with relatives or friends while awaiting repairs to home after fire or natural disaster. Widowed or disabled parent, waiting to be institutionalized. Permanent Extended family of more than one generation. Elderly individual who lives with other friend or relative to insure protection or to increase fi nancial security. Widowed or divorced parent living with child while incapac itated. Sources Adopted from Shanas et al. (1968:219) In the main, these living situations and durations apply to individuals who do not live alone or with spouse. For the Citrusville Study Population Group, the information presented in Table 7 will fit only 17% of the 64 persons in the study. Moreover, it is possible to state that the duration of any of the various relationships thus described will have an effect on and possibly determine the rural eld erly person's behavior and perceptions about his or her environment.

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CHAPTER VII HOUSING AND THE CITRUSVILLE AGED For most individuals, the house or apartment in which they live provides them with several physical comforts, such as physical space, light, heat, sanitary facilities and cooking facilities. In addition, the dwelling unit pro vides mental comforts, which include a feeling of warmth, access to a particular neighborhood, a sense of safety, and pleasing surroundings (Struyk 1977). Although the typical individual in America strives to achieve a certain standard of living which will allow him or her to maximize his or her comfort level, it can be stated that as one gets older, the physical as well as the mental satisfaction which is derived from a dwelling becomes more important. Thus, for instance, when the elderly person in Citrus ville says that he or she derives satisfaction from his or her home, the aged individual is also describing feelings and perceptions of the surroundings in which one lives. More than that, the elderly person is taking his or her total environment and making some judgments about how one fits into it. That is, the older person is making a subjec tive statement about the degree to which an adaptation to the environment has been made. 67

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68 Quality of Housing as Measured by Physical Condition of Facility In the Citrusville Study Population Group, 60 or 94 % of the individuals live in a house which they own. The other 4 persons live with relatives or friends who own the house or rent the apartment. Most of these homes have a well-kept appearance on the outside1 the yards are free of debris, the hedges (when present) are neatly trimmed, most do not need painting, and the lawns are cut. However, many individuals complain about the need for internal repairs: leaky roofs, poor plumbing and sewage, deteriorating floor boards and cracks or holes in the walls. Quite in evidence in many homes was the need for a better heating system. For some elderly in this study, the main source of heating was a space heater which occupied the center of the "living room." While these heaters pro vided the appropriate amount of heat such that the elderly person did not get cold, many were next to mounds of dis carded newspapers or kerosene cans. The housing for mbst of the elderly persons in Citrus ville appears to be structurally sound. Approximately 60% of the elderly in the study live within the Citrusville city limits where a survey was conducted to determine the worthi ness of the homes there (see Table 8). None of the homes of the elderly persons who live in these areas is either deteri orated or delapidated. Although in Quadrant III over 55% of the homes are in poor shape, the elderly individuals in this

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Table 8. Structural Conditions of Citrusville Housing Condition of Housing in the Area Percent of {Eercentage reresentation} Quadrant Study Group of City in Quadrant Sound Deteriorating Dilapidated I 5% 88% 9% 3% II 5% 89% 10% 2% III 70% 45% 33% 22% IV 5% 43% 41% 16% V 15% 91% 9% 0% Source, Adopted from City of Citrusville Comprehensive Plan, 1977-2000.

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70 study did not live in poorly constructed homes. Of the remaining 26 persons who live outside the city limits, only 5 complained about their homes needing repairs. A national survey of elderly persons who own homes and who live in rural areas describes them as living in larger older dwellings. Overall, Struyk (1977:132, see Table 9 for summary) states thats 11 8% do not have complete kitchen facilities and about 15% lack complete plumbing. Heating equipment and services are below standards; over half do not have central heat and 10% obtain most of their heat from stoves, fireplaces, or portable heaters." Quality of Housing as Measured by the Elderly Persons' Feelings about Their Homes If one were to examine the physical structures of many of the elderly homes, one may find some agreement with the study of rural older persons' homes on the national level. However, while it may be true that many of the elderly persons' homes need repairs, most of the individuals are pleased with their living quarters. In fact, over 95% or 61 of the persons interviewed expressed satisfaction with the condition of their homes, despite the problems they may harbor. In addition, persons who expressed dissatisfaction with their present homes did not have a desire to leave the area in which they live. In other words, the elderly person usually recognizes the physical problems he or she is experiencing living in

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71 Table 9, Selected Housing Characteristics of the Elderly, 1973 Selected Physical Rural Areas (percentage figures) Characteristics of Elderly Household Farm Area Non-Farm Area 1) Fully equipped kitchen for private use 92 93 2) Complete plumbing 85 86 3) Heating Equipment: Central heat 41 52 Room heaters 48 39 Fireplace, stove 11 9 None 0 0 4) Electrical wiring concealed 94 94 5) Roof has leakage 15 11 6) Cracks or holes in wall 5 6 7) Broken plaster/paint peeling 10 10 8) Evidence of rodents 25 18 9) Number of rooms 1 or 2 1 3 3 or 4 17 36 5 or 6 53 44 7 plus 29 16 Conditions of Neighborhood 1) Street noise 8 16 2) Airplane noise 5 4 3) Heavy street traffic 8 12 4) Odors, smoke, gas 1 1 5) Trash 3 5 6) Boarded/abandoned structures 4 6 7) Inadequate lighting 2 6 8) Crime 3 3 Source: Adopted from Struyk (1977:133-134).

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72 his or her present home but, in terms of his or her per ception of the living environment, he or she does not desire any changes. In fact, many persons would rather live with a leady roof in their own homes than to live with other relatives and experience no problems.

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CHAPTER VIII ECONOMIC S URVIVORSHIP OF CITRU S VILLE ELDERLY The measurement of the economic survivorship for the rural aged person involves much more than an examination of gross income or an examination of the amount of social security benefits. In fact, for most rural elderly, a simple survey of wages would more than likely reveal that over half of them are living at or below the designated poverwlevels (Tissue 1972). However, in spite of the local and national statistics which indicate that, according to overall gross income half the rural elderly are poor, many still manage to maintain a household, pay for their medical bills, buy groceries, and achieve some acceptable level of mobility. In the main, an adequate discussion of the economic survivorship for the rural elderly individual must include an examination of gross income, as well as an examination of participation in state and federal programs. Quite often, the rural aged person has no choice but to participate in state and federal social programs, such as food stamps, welfare, meals on wheels, and supplemental social security, to prevent joining the ranks of the rural poor. Yet, even the elderly person's participation in social welfare programs is not enough to help achieve a respectable 73

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74 level of living. Therefore, the rural aged person must count on relatives, friends, and neighbors for money, goods, and services. In effect, the aged poor have to "juggle" these different income resources to maintain a standard of living which will enable them to survive. In this discussion of the economic survivorship of the rural aged in Citrusville, the major attempt will be to provide an overall perspective on the sources of gross in come for the Citrusville elderly. Moreover, employment opportunities as well as the elderly participation in state social welfare programs will be discussed. Aid received from relatives, friends, and neighbors is often referred to as "Inkind Services." The role of close friends re la ti ves and just friends will be presented in terms of the "Inkind Services" they provide. Citrusville Elderly Income Income for Older Persons: National Picture According to income data on individuals by age group reported in 1972, overall, the mean income showed a steady decrease as the age of the individual increased. Table 10 reflects this trend. It shows that individuals 65 to 69 had a mean income of $7432. Those individuals 70 to 74 had mean incomes of $5895. Persons 75 to 79 presented mean incomes of $5237. Finally, persons 80 to 99 had mean incomes of $4566, or almost half the income of those individuals 62 to 64.

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Age of Family Head 62-64 65-69 70-74 75-79 80-99 Table 10. Components of Income by Age of Head of Household for 1972 (As a Percentage of Total) Welfare/ Mean Property Social Public Income Earnings Income Security Assistance 9841.29 76.64 7.65 7.65 .77 7432.93 49.95 12.78 24.01 1.11 5895.25 31.56 18.35 35.76 1.63 5237.44 26 .30 17.65 40.0J 1.83 4566.42 22.85 22.70 .39.06 2.88 Sources Taken from Moon (1977:6), The Measurement of Economic Welfare: Its Application to the Aged Poor. Other Income 7.35 12.54 1.3 .34 14.Jl 12.53 '"'1 \..n

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76 Table 10 also reflects the source of the income as a percentage of the mean income. When viewed in this fashion, the elderly individuals 62 to 64 show over 64% of their income from their earnings. Persons who are between the ages of 65 and 69 have almost 50% of their income from their earnings. Those individuals 70 to 74 obtain approximately one-third of their income from earnings. The two remaining groups, persons 75 to 79 and individuals 80 to 99, receive approximately one-fourth and one-fifth, respectively, of their income from earnings. Income for Older Persons: Local Picture In the Citrusville Study Population Group, there is no breakdown by age group of the mean earnings. Quite frankly, individuals would not give out their gross yearly income (Lawton et al. 1978). Possibly, individuals were reluctant to disclose their incomes for fear of being penalized by federal programs which use annual income as a basis for determining eligibility for program participation. However, persons were asked to rank their sources of income from major to minor. Table 11 shows the results of this ranking process. It can clearly be seen from Table 11 that most indi viduals ranked Social Security as their number one source of income. For the Blacks, Salary/wages ranked as the number two income source, while Whites ranked Pension as their number two income source. Number three for Blacks was Pension, and number three for Whites was Salaa/Wages.

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77 Table 11. Ranking of Major Income Sources by Percent of Individuals Responding to that Category Black Elderll White Elderll Income Source Number ill Number w 1 Social Security 11 38 12 35 2 Salary/wages 8 27 6 18 3 Pension 6 20 10 30 4 Property 3 9 2 6 5 Public Assistance/ Welfare, SSI 2 5 2 5 6 Other Income/Stocks, Bonds, Investments 0 0 2 5 Totals 30 99% 34 99% (Figures are rounded to nearest whole number and therefore percentage total is not 100%)

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78 Property, Public Assistance, and Other Income, ranked four, five, and six, respectively, for both Blacks and Whites. Although data a re not available to illustrate the mean income by age for the Citrusville elderly person, it is possible to postulate that the individuals' major sources of income will change, as already demonstrated by the national survey, as the individuals become older. Further, for the Citrusville resident who has to depend solely on social security as a major source of income, the amounts and kinds of help that the individual receives from rela tives, friends and neighbors will become more important with age. In an area such as Citrusville, where the mean income per capita for 1969 was $2,078 and the 1972 figure only rose to $2,785, the amount of support the elderly person can gather through inkind services will ultimately determine his amount of independence as well as his dependence (Source: Comprehensive Plan for Citrusville, 1977-2000). Sources of Income for the Citrusville Resident Table 12 illustrates the income of the Citrusville residents by income type. It can readily be seen that wages are low. Of particular importance is the fact that the median income from social security, where most of the elderly receive their annual income, is only $1,376. Welfare adds very little to the income, showing only a median amount of $609 annually.

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79 Table 12. Income of Citrusville Residents by Income Type 1) Salaries 2) Non-Farm Self-Employment 3) Farm Self-Employment 4) Social Security 5) Welfare or Public Assistance 6) Other Income $ 7,920.00 3,421.00 3,893.00 1,376.00 609.00 2,020.00 Source, Data taken from "Income Characteristics of the population for Florida SM3A's, 1970." In fact, the national average of social security benefits for each person eligible was only $207 per month in 1975 (Social Security Bulletin 1975, Annual Statistical Supplement: 156). If multiplied by 12 to achieve an approximate annual amount, the figure would be $2434. In the State of Florida, the average amount of social security was $209 in 1975. On an annual basis, that amount would be approximately $2508. In Citrusville, the average amount of social security was $165 a month in 1975. Annually, that amount would be about $1980. Compared to the 1970 figure of median social security income for Citrusville of $1376, the 1975 amount of $1980 represents a $604 overall increase. Employment Opportunities for Citrusville Elderly According to the Citrusville elderly Blacks in the re search study population, employment ranked as the second most important source of income. For the Whites in the

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80 study, employment ranked third as a major source of income. Below are the major employers in the Citrusville area: Citrusville Employers 1) A dealer in poultry supplies 2) A jobber of dairy products 3) Citrusville Concrete and Supply Manufacturers 4) Bank of Citrusville 5) Pharmaceutical Manufacturer 6) Elementary, Junior High and High Schools (one each) Other employment sources, such as small shops, stores, etc., include the following: 1) Pharmacy 2) Truck Stop/Restaurant 3) Convenience Stores 4) Package Store 5) Breakfast/Fast Food Shop 6) Two Insurance Agencies 7) Law Office 8) Several Used Furniture Stores 9) Public Health Service Office 10) Dental Office 11) Physician's Office While at first glance there appears to be a wide variety of employment sources in the Citrusville community, in reality, most of these shops tend to be family owned and family operated. In fact, most of the businesses are oper ated by Whites who employ very few older Blacks. For most Citrusville residents, employment must be obtained in the major city located in the Citrusville County approximately twenty miles away. Therefore, except for a few elderly who have worked in one or two of the businesses for a long period of time, most of the elderly have to own their business, as is the

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81 case for many of the White elderly, or they must work for the school system or other White individuals in the community as maids and yard men, as is the case for most of the Black elderly. Occupations of Citrusville Residents and Citrusville Elderly Study Population The overall distribution by occupation for the Citrus ville residents can be seen in Table 13. For the most part, individuals in Citrusville work in Service Occupations, Professional Occupations, Craftsman Trades, and Clerical Professions. In the Citrusville County area, the top four occupations are, (1) Professional, (2) Clerical, (3) Serv ice Workers, and (4) Operations Workers. Table 14 shows the present and former occupations of the Citrusville elderly by percentage distribution. It should be apparent that the Blacks have occupied a larger percentage of the service worker occupations than the Whites. Also, it should be noted that more Whites than Blacks stated that they had never worked. Only 14 individuals admitted to working at the time of this study. Elderly Participation in Other Federal Programs Outside of the 100% participation of the Citrusville elderly in the social security programs, the distribution of elderly who stated that they take part in the Food S tamps Program, Meals on Wheels Program, or the Medicaid/ Medicare Programs varied. About 80% reported participating

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82 Table lJ. Percentage Distribution by Occupation for Citrusville and Citrusville County Percentage Distribution Occupation Citrusville 1) Professional, Technical and Kindred 15.9% W orkers 2) Managers, Officials and Proprietors, 7 .6% Except Farm J) Clerical, and Kindred W orkers lJ.2 % 4) S ales Workers 2.0% 5) Craftsmen and Foremen and Kindred Workers 14.7% 6) Operators and Kindred Workers 10.1 % 7) Service Workers, in cluding Private Households 8) Farm Laborers and Foremen 9) Laborers, except farm and mine 10) Farmers and f'/I anagers 18.6 % 8.6 % 9.3% 0.0 % Citrusville County 24.9 % 22.4 % 17.6 % 1.1 % J.J % 2.4 % Source: Data adapted from Citrusville Comprehensive Plan, 1977-2000, P JO.

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83 Table 14. Percentage Distribution by Occupation for Citrusville Elderly Study Population Percentage Distribution Present Occupation (N=l4} Former Occupation {N=64} Occupation Black White Black White 1) Professional, Technical and 0% 0% 8% 9% Kindred Workers 2) Managers, Officials and Proprietors, except farm 7% 21% 3% 8% J) Clerical, and Kindred Workers 0% 0% 0% 6% 4) Sales Workers 0% 0% 0% 2% 5) Craftsmen, Foremen, and Kindred 0% 7% 3% 2% Workers 6) Operators and Kindred Workers 0% 0% 0% 5% 7) Service Workers, 0% including Private 21% 0% 20% Households 8) Farm Laborers and Foremen 0% 0% 2% 0% 9) Laborers, except 9% 0% farm and mine 22% 0% 10) Farmers and Farm Managers 7% 15% 3% 6% 11) Never Worked 0% 0% 0% 14% Totals 57% 43% 48% 52%

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84 in the Medicaid/Medicare Programs. Approximately JO% of the Blacks and less than 5% of the Whites admitted to re ceiving Food Stamps. Many cited the detailed applications and seemingly unnecessary questions asked about their personal habits as deterrants to their making application for food stamps (see Appendix G, especially the sections covering "Other Income and Utilities"). Another reason cited for the non-participation in this program is the small amount of money for the large amount of information given. Many elderly residents stated that even with help from these many different social welfare programs, they still have to put bills off for future months in order to make their income last the entire month. Table 15 below is a breakdown of expenses for a typical month. It reveals some further information about the problems and expenses of elderly economic survivorship. Table 15. Expense 1) Medical bills 2) Medication 3) Utilities Composite Typical Expenses for Elderly Person Average Monthly Amount Low High $40 5 20 4) Gas winter months 15 80 $90 50 100 50 150 25 150 5) Food 6) Yard work 7) Miscellaneous 5 20

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85 Inkind Services for the Elderly Individual in Citrusville It has been demonstrated that the Citrusville elderly person suffers from the lack of a steady income as well as few employment opportunities. To increase their chances for economic survival, the elderly persons in Citrusville rely on help from relatives, close friends and just friends. The help received from these people is mainly in the form of the exchange of goods and services, the cooking of foodstuffs on occasion, and the providing of free trans portation when necessary. In the economic sense, for those elderly persons who live at or below the poverty level, the inkind services can ofttimes mean the difference between purposeful survival and mere existence. Exchange of Goods and Services The older individuals in Citrusville normally extend a helping hand to any person who has become the victim of economic disaster, such as a medical bill which cleans out the savings or a household repair which costs more than expected. Usually, the impetus to ask the community for aid is initiated by a close friend who may tell the minister of the church. The minister will make an appeal to the Sunday congregation. By word of mouth, the news is quickly spread throughout the community. However, the help given by the community acts as an initial stabilizing source of aid. For a short period,

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86 possibly two or three weeks, the close friends can help the person, along with any local relatives. Any support which will be for a long period of time, a month or more, will usually be the responsibility of the individual's family. In the case where the person has no family, the person may receive intermittant help from close friends, and just friends in the community. For instance, IVIrs. A had been in a nursing home for two years. Upon her return home, she found that her home had been ransacked and a stove, some clothes, and a sofa were missing. Mrs. A did not have any money, but a close friend helped her, through an appeal within the church, to obtain a stove as well as some articles of clothing. Moreover, someone bought her a chair. Although Mrs. A was happy to have received the various forms of help from the churchmoney, furniture and clothing--she remembers best the indi viduals who spent time with her and who still communicate with her. Furthermore, she feels that she owes them and periodically sends them inexpensive gifts: hats that she knits or baked goods. Cooking of Foodstuffs Most persons who were interviewed stated that it was difficult for them to, on any regular basis, invite close friends over for a meal. Persons who are just friends are not usually considered when food is cooked. On occasion, the elderly individual will cook some "sweets" when he or

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87 she expects a close friend or well-liked relative will drop by. Some persons will exchange meals on Sundays as a way of insuring that they will see each other at least once a week when they live far apart without adequate transporta tion. Finally, if a close friend is confined in his home due to a chronic or acute illness episode, the elderly person may bring him food as a way of helping extend his budget and as a way of socializing with that person. Providing Transportation The elderly person who has a vehicle for transportation and is allowed by the state to drive, is an elderly person who has freedom. In this study, approximately 55% of the people had transportation and were driving, while three individuals had cars but could not drive due to illness or unrenewable drivers' licenses. Those people who have to depend on others, no matter how easy it is for them to obtain the transport, are forever having to rearrange their schedules to meet the other person's schedule. Close friends and relativeswho do not work during the day and who live within five miles of Citrusville are usually the first source of transportation. Without the inquiry of the investigators, most people interviewed readily admitted that they usually pay for the gas. There were the elderly who could obtain transportation from a relative or close friend who lived further away but most stated that the inconvenience to the person would not be worth the trouble.

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88 For those individuals who did not have a close friend or a relative that lived nearby, and who did not have a close friend with a car, they had to either pay just friends in the neighborhood or use public transportation. M ost in dividuals are aware of the various persons in the community who will transport them for a fee. Many of these individ uals supplement their incomes this way. Just friends and the public transportation system are the transportation resources of last resort, frankly, because just friends can cost a great deal and public transportation provides a long and trucing ride for the elderly person. Summary Review Chapters IV-VIII detailed findings on four basic structural regularities or environmental constraints affect ing every elderly citizen of Citrusville. Discussed in turn were: neighborhood, living arrangements, housing situa tion, and the items of economic survivorship. It has been demonstrated, for instance, that the elderly people in Citrusville live in stable, slow growth communities which, for the most part, they enjoy. The most telling evidence in this regard is that the quantitative and factual listing of structural or internal problems with housing shows very little about the older person's perception of his or her surroundings. Thus, for example, the majority of the elderly individuals interviewed, 61 of the 64, did seem to agree

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89 that given their point in the life cycle, even if their daily life was no bed of roses, they did not feel unduly short changed. In addition, it has been pointed out in Chapter IV that these environmental regularities broadly define the context in which the elderly routine activities occur. They also signify, moreover, the restraints under which the older person must attempt to carve out an existence. But, in a real sense, these restraints serve to demonstrate the proba ble directions which routine behaviors will take. The next chapter presents both the facts and a discussion of these routine behaviors as they occur within the context of neighborhood existence.

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CHAPTER IX CUSTOMARY BEHAVIOR OF THE CITRUSVILLE AGED POPULATION Presented in Chapters IV-VIII is a discussion of the major parameters which shape and determine the boundaries of the older person's living habits in Citrusville. It is little news, however, that individuals function under and manage to operate through various self-imposed or culturally determined constraints. What is important in this instance is whether or not the different parameters within the older person's surroundings represent overwhelming barriers such that he or she cannot advance beyond merely existing. More important is the question of whether the aged person can develop practical survival techniques in order to overcome unnecessary limitations in his or her neighborhood, living arrangements, income, and housing. This chapter describes routine behaviors, that is to say, practical survival techniques, of the elderly person during a typical day. Morning, Afternoon and Evening routines are discussed in turn. Taken as a whole, they illustrate both what older people do each day and how they manage to survive when the routine schedule is interrupted by illness. Whom the aged person calls, the reasons for calling, and how the individual called responds, are some of the critical 90

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91 issues explored in this chapter. The daily routine schedule is contrasted with the weekend and holiday schedule in order to examine variation in the elderly person's behavior and interaction patterns with friends and relatives. The data for this chapter were collected in the Interview Guide, Section B, "Life Habits." Social Networks and Routine Behaviors For almost all the elderly individuals in this study, the relationships that they experience with relatives, close friends and just friends have been developed and nurtured over many years. The patterns of interaction with different people within their social network, also, have been established over time. For instance, Mrs, C. will not call Mrs. M. before 10:00 a.m. unless there is an emergency. Such behavior on the part of Mrs. C. is not there at the request of Mrs. M,, but it is there as a result of a mutual understanding that these two women have for each other's behavior patterns. Therefore, the older person's environmental constraints, as described in previous chapters, can determine the general circumstances out of which social networks must develop. The routine activities, however, will determine the behavior patterns adopted toward each person within a given social network. That is, routine behavior determines the amount of time one elderly person will devote to participating in any given social network.

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92 Daily Activities During any given day, at any time period during the day, the older individuals in Citrusville will be found participating in a variety of activities. In general, many of these activities, such as cleaning the house or washing dishes, are performed more frequently during certain time periods. This regularity in behavior gives the aged person a sense of control over his or her day. For instance, I made several mistakes when trying to interview elderly per sons during the morning; many of the elderly did not wish to be interviewed during the early morning hours because they had scheduled chores to be completed before receiving visitors. An elderly person's close friend or relative would not have made that mistake. On the other hand, there are other activities in which the aged person participates which have no time boundaries; watching television and telephoning friends are two of these activities. What one will find amongst the older people in Citrusville, therefore, is that close friends and relatives keep track of one another's routine schedules and tailor their interaction patterns to meet these schedules. In effect, elderly individuals can insure that they know where and how to reach a close friend or relative in the event of an unforeseen emergency by knowing the various routine activities. Quite often, individuals will notify each other in the event of a major change in routine behavior.

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93 Morning In the Citrusville Study Population Group, the usual activities which are performed in the morning are: house cleaning activities, cleaning the dishes, cleaning the yard, gardening activities, reading, writing letters, and talking on the telephone. In the main, these habits usually involve only the elderly person, except when talking on the telephone. House Cleaning Activities Approximately 70% of the females in this study stated that they spend some portion of the morning cleaning their homes. The other 30% were able to hire someone else to clean their houses; worked and cleaned up after they returned home; were too sick to clean their homes and had to rely on close friends and relatives; or did not clean the house every day. Less than 5% of the men admitted to participating in this activity and did not state that they would do so for friends. Most individuals said that housecleaning did not re quire much effort, or much of their time because they tried to "do a little bit of cleaning" each day. Those persons who had to rely on close friends and relatives to help them with their housecleaning chores usually had that individual to live with them, while they were sick, until the crisis was over, i.e., they could move around their place of resi dence. In general, most of the homes observed by the

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94 investigators were essentially clean, A few were crowded with furniture and cluttered with paper items. Cleaning the Dishes Cleaning up after meals is known to be time consuming, particularly if an individual eats two or three meals a day at home. Over 75% of the elderly claim they eat two or three meals a day. The majority eat their meals at home. Only 10% of those who eat two or three meals a day stated that they use paper plates to avoid having to clean dishes. Most also said that they attempt to clean the dishes after each usage to avoid having them "pile up." It should be stated, however, that approximately 20% of the elderly do occasionally eat out. This appears to be a social event accomplished with a spouse, relative or close friend. Cleaning the Yard Unless a Citrusville elderly person happens to live in a neighborhood where children throw trash in their yards, or tree limbs and other debris end up in their yards as a result of stormy weather, constant yard maintenance is not needed. Nevertheless, 100% of the men, except where they were not physically able, said that they spend at least one morning or afternoon a week cleaning their yards. Approxi mately 50% of the women who live alone admitted that they clean their yards. Of those women who do not clean their yards, the majority said that they either hire someone to do it (many times an older man in the neighborhood) or that a relative cleans the yard for them.

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95 Gardening Activity Gardening is an activity reported by only 40 % of the individuals questioned. In the main, gardening is done in the morning hours or the late afternoon. Almost 90 % of the individuals engaged in this activity reported that they wanted to supplement their incomes by growing their food for personal consumption. The other 10 % enjoyed growing food as a hobby. Less than 5% of the individuals raised live stock for either their personal usage or for purposes of marketing the animals. Reading Behavior Almost all the females and some of the males reported reading as an activity which consumed a portion of their day. Those persons of a higher socio-economic status re ported reading the local newspaper, as well as many subscrip tion magazines and out-of-town newspapers. Individuals of a lower socio-economic status more often reported reading the local newspaper, an occasional magazine bought from the store newsstand, and the Bible. In the main, most individu als considered reading "something" an important part of their morning. W riting Letters Individuals who stated that they wrote letters, whether to the sick and shut-in or to personal friends and family, numbered only 20% of the study population. W hether or not this lack of writing signaled an inability to write, a desire

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96 not to write, or a heavy dependence on the telephone needs to be explored further. At any rate, for those individuals who did write, it was not considered a very rewarding activity. Most letter writing appeared to be done in the morning or evening hours. Talking on the Telephone Talking on the telephone is an activity which 100 % of the females and 75% of the males do at least once a day. In many cases, individuals stated that they talk on the phone on the average of two to six times a day depending on whether or not they or a friend is sick. Surprisingly, only one person stated that she did not have a phone. This indi vidual is quite worried about the real possibility of needing someone in an emergency situation and not being able to locate them. Furthermore, most of the other elderly in this study stated that a phone was not a luxury item but a necessity. Almost always, when an elderly person calls a close friend in the morning, the call means much more than a simple "Howdy Neighbor or Howdy Friend." Older persons are check ing up on one another to see who "made it through the night." M ost persons say that they talk only a few minutes in the morning, but it is a way of saying that "I care about you and wanted to see if you were okay." If an individual calls a close friend or relative and that person is not home, that individual may make other inquiries to find out the where abouts of a close friend or relative. On rare occasions,

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97 after having made several inquiries, and no immediate answer having been found, the original caller, if physically able, will drop by to see if he or she can find his or her close friend or relative. On several occasions, I was told that individuals have found their friends sick and unable to use the phone. Afternoon The time period from after lunch until supper time is considered by most persons in Citrusville to be the after noon. During this time, both indoor and outdoor activities are carried out by the Citrusville elderly. These are: watching television, sewing, knitting, crocheting, shopping, club meetings and visiting close friends and relatives. Watching Television Only 70% of the Citrusville Study Population Group admitted to watching the television at some point every day. However, observations of the households when interviewing indicated that over 85% of the 64 individuals had tele vision sets that were visible to the interviewers. Only three individuals stated that they did not own a television set. In the main, watching television was an activity which had no real time boundary, but most stated the after noon and evenings as favored watching times. Individuals also stated that they had special programs that they watched and these programs were: sports, game shows, soap operas, family shows and talk shows.

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98 Sewing, Knitting and Crocheting S ewing, knitting and crocheting can all be put in the same category of activity. While each activity is differ ent and requires a different skill, they all can be accomplished while sitting. In fact, they can be accom plished in concert with other activities such as watching television, and talking on the telephone. Approximately 20 % of the females admitted to participating in this activity. S hopping Behavior Most of the elderly in the Citrusville study completed their food shopping locally. Only 45 % said that they go away from the local community to shop on a regular basis. Lack of consistent transportation, lack of close friends or relatives who might be able to take them, and the expense of hiring a driver are the most frequently cited reasons for not shopping away from Citrusville. M any individuals stated that for a fee ranging between $3.00 and $ 10.00 per trip, they could obtain a ride to a store located in the next largest city. M ost agreed, of course, that they could not afford to add this amount to their already dwindling purchasing power. For that 45% who either had their own mode of trans portation or the usage of a close friend or relative's car, shopping is a way of leaving Citrusville. In fact, shopping can be performed along with other duties, particularly when

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99 it is accomplished with a close friend or a relative. Almost all those who receive rides with close friends said that they offer to pay for gas on these trips. Many of the individuals who claimed that they took their friends to the store also claimed that they refuse the money offered most of the time. Club Activities For many of the aged persons in Citrusville, the clubs provide both a time period for gathering together with friends, close and just, as well as a time to discover how other individuals are doing. In the main, club meetings range from once every two weeks to once a month. The activ ities include, playing card games, having special dinners, going on mini-trips, taking care of the graveyards of the deceased, sending flowers to the sick, and organizing ways of taking care of the infirmed when they need temporary support. There is usually a small fee paid which covers most of the cost of the various activities and new members are nominated and selected by individuals already in the club. Clubs usually meet during the afternoon or early evening hours. Quite interestingly, there has been a parallel and separate development of Black and White clubs in Citrus ville. Very few Blacks or Whites admitted to belonging to the same clubs. Some of the clubs to which the Whites belong mirror long time established clubs: American Legion and Knights of Columbus. In both the Black and White

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100 communities, there has also been a parallel development of social clubs which serve the same functions in each com munity but have a predominant membership of one race or the other. Only the activities of the Older Americans Council, which in some ways resembles the socializing aspects of a club, had both Black and White older participants. The activities of the various other clubs, however, appear to be restricted to either Blacks or Whites only. No one told the investigators that a Black or a White person could not join any club in Citrusville; but no one stated that a Black or a White person had ever tried or had a desire to join a club which had a single racial membership different from his or her race. The Blacks mentioned five names of clubs which they have joined. Most of these clubs are social clubs. The names and percentages of individuals who stated that they partici pate are given as follows: Silver Leaf Club (17%), Pall bearers Club (13%), Lilly White Club (10%), Labelle Club (3%), and the Eastern Star Lodge (3%). All of these clubs appeared to have a majority membership of females over the age of 55. Most persons participate in only one club. The White elderly in this study stated that they be longed to the following clubs: Women's Club (29%), Women's Guild (15%), American Legion (12%), Eastern Star (12%), Circle Club (12%), Hunt Club (3%), Armchair Travel Club (3%), Knights of Columbus (3%), and the Homemakers Club (3%). The

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101 Women's Club, the Women's Guild, Circle Club, and the Home makers Club all appear to be social clubs which entertain the various members at each other's homes and at tim83they play bridge. The Armchair Travel Club is just as its name implies, a club where members share the still and moving pictures from their vacations. Visiting Behavior One of the major forces which help initially form and eventually maintain social networks in Citrusville is the visiting activities of the members who comprise a network of close friends and relatives. In the main, moreover, the aged person in Citrusville limits most of his or her visiting activities to close friends and relatives because the elderly say that "they do not like to be in the streets all the time." The elderly also say that anyone is welcome to drop by for a chat as long as they are familiar with the person, i.e., just friends would fit that category of indi vidual. Quite obviously, the subject matter discussed be tween the older person, close friends and relatives will be much different than that between the older person and just friends. Reasons for Visiting. Visiting a close friend or rela tive can serve two basic purposes. The first purpose is simply that of a friend visiting another friend. The second purpose is that of a friend who is coming to the aid of another friend. Most importantly for the older person,

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102 however, is that frequent social visits from close friends and relatives almost insures that someone will come in the time of greatest need. In many instances, frequent visits also mean that a close friend or relative may already be there when a crisis situation arises. In Chapter IV, the number of close friends of the elderly person has already been discussed. In this dis cussion of the visiting habits, the following subjects will be presented, Age of Close Friends, Number of Visits to Home of a Close Friend, Just Friends and the Elderly Visiting Practices, Role of Close Friends in the Health Care Network, and Just Friends and Elderly Health Care Behavior. Number of Close Friends of the Elderly Person The Citrusville elderly seem to have an optimal number of close friends. The range in number of close friends for the elderly starts at '0' where the individual says that he or she does not need any friends, and ends at 1 4 1 where one person had the largest number of close friends. The overall mean number of close friends per individual is approximately 2.4 persons, with a mode of 3 persons. Over 55% of the elderly individuals stated that they had only three close friends, Age of Close Friends Who Receive Visits from Elderly The Citrusville elderly appear to have close friends who are, mainly, over the age of 60. Although there is no

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103 clear-cut boundary which would show that individuals of a certain age group have more friends in that particular group, the data do reflect a trend toward individuals over 60 having more of their friends over 60. Table 16 below gives the breakdown of the age groups of the friends and percentage of individuals in the Citrusville study who stated that their close friends were in that age group. Table 16. Age Group of Friend and Percentage of Individuals Who Reported having Close Friends in Those Age Groups. Age Group % of Individuals with Close of Friends Friends in this Age Grou~ 1) Less than 50 5 % 2) 50 to 59 9% 3) 60 to 69 55% 4) 70 to 79 33% 5) Greater than 80 11% Number of Visits to Home of Close Friend The individuals in the Citrusville study showed an overall trend of visiting their close friends approximately once a day if they were between the ages of 60 and 70, and approximately .6 times a day if they were between 71 and 80. For those individuals who are 81 and older, they visited their friends .2 times per day. These figures simply indicate that in this study population, individuals are more active,

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104 in terms of visiting friends, when they are closer to 60 than when they get closer to 80. As with any statistic, the above figures represent an overall average visiting rate per day per age group. There were those elderly in all age categories who made as many as three or four visits per day, and then there are those who did not visiting. "Just Friends" and the Elderly Visiting Practices Persons in Citrusville who are classified in this study as "just friends" appeared to be visited only when indi viduals were in their neighborhoods. For instance, person X is visiting close friend Y, W hile discussing the affairs of the community, person X discovers that another individual A, known to both X and Y, is sick. Person X on the way home will more than likely drop by to see how individual A is managing or to find out if individual A needs something from the store. Although no special attempt was initially made by individual X to visit person A, upon finding out that A was sick, X usually makes an effort to see A. Furthermore, in this study, while the Black and W hite elderly often know each other, communication and visiting are usually limited to a chance meeting on the street. Very few Blacks, three out of JO, and almost no Whites say that they visit with each other on any regular basis, although both Blacks and W hites have been known to come to the aid of each other in times of crisis. For instance, one Black elderly female stated that she had her house bum down, and

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105 the Blacks and Whites in Citrusville contributed to helping her rebuild and refurnish her new place of residence. Visiting Behavior: Offering Aid There are many times when the elderly person visits a close friend in order to lend that person a helping hand. If a friend has been displaced as a result of a fire or natural disaster, the elderly person who is a close friend or the nearby relative will most assuredly offer assistance. In reality, these kinds of disasters do not happen with a frequency which is great enough to demonstrate the strength within a given social network. In general, however, what does happen to the Citrus ville elderly people is that they get sick or ill with enough frequency that the true relationships that exist within a personal network are tested many times. Moreover, the many visits to individuals during the time periods when the elderly person is doing the best, insures that during medical crisis, a close friend or relative will be there to continue much of the routine schedule for the sick person which affects the way he or she lives. Role of Social Network of Close Friends and Relatives During an Illness Episode It has already been stated that close friends and rela tives who are physically able visit one another regularly in Citrusville, according to the demands of their schedules.

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106 Those individuals who cannot visit, telephone each other and receive visits from close friends and relatives routine ly; they receive calls or visits from just friends occa sionally. During an illness episode, however, these routine visits may increase, becoming "check-up" visits, depending on the needs of the person stricken. In Citrusville, the behaviors of the close friend or relative do not change during a medical crisis or a chronic illness. A close friend or relative continues to give ad vice and offer moral support. Aside from the advice they receive from close friends, the Citrusville elderly say that close friends may also cook food or perform some minor services. Most of the food preparation involves serving soup, or tea, to the sick person. The minor services include going to the store, bathing the person, and, at times, cleaning up the house for him or her. At least 65% of the 64 elderly persons in the study state that they would carry out this kind of helping hand work. Approximately 35% state that they would not or physically could not perform the above services. Transportation in a rural area is important to all. It is particularly noteworthy for the elderly since many of them do not drive or cannot afford a car. Therefore, when an elderly person has a close friend or relative who can on demand provide transportation for him or her, he or she is indeed above the norm. While many individuals have close friends and relatives who would usually do anything for them,

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107 these close friends or relatives may or may not possess transportation. Approximately 45 % of the elderly have close friends who can provide free transportation. Finally, only 8 % of the elderly told the researchers that they would share their medical prescriptions with a close friend. One individual stated that she once shared a "heart pill" with a friend. Another stated that she shared her valium with a friend when her friend was "out." However, most individuals said that they would be afraid to share a prescription with a friend. The routine behaviors of the Citrusville elderly have been discussed in terms of the knowledge they impart to close friends and relatives about the elderly person's behavior patterns and the control that they give to an elderly individual who must manipulate many variables within the environment in order to survive. The different activi ties themselves really only illustrate the variety in the older person's lifestyle. W hat is important to remember is that the interaction patterns within a social network are based on the numbers and time periods of routine behaviors, most of which are usually common knowled g e to close friend s and frequently visiting relatives. As a result of this knowledge, moreover, individuals within a given network solidify their relationships through appropriate and regular interaction: telephoning, visiting, mini-trips, and social activities.

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108 The evenings, for the Citrusville elderly person, are spent pursuing some of the activities mentioned earlier: reading, writing letters, watching television, and occa sionally attending a club meeting or church meeting. Tele phoning in the evening hours serves two purposes: (1) it is another check system to alert relatives and close friends to the fact that things are or are not going well; and (2) the elderly person can catch up on any news that was acquired during the day but had not been earlier transmitted. Most of the 64 elderly persons said that they like to spend most of their time indoors when the sun goes down. Many cited the problem of having no transportation and having to walk home alone down unlighted streets as deter rents which curb their nighttime activities. In view of the fact that the elderly are easy prey for purse snatchers and their homes vulnerable to break-ins when they are not there, their fears about leaving their dwellings at night are well founded in reality. Weekend Activities Saturdays, for the elderly who do not work, are like the weekdays; many of the same routine activities are per formed. However, some of the elderly did state that they use Saturdays for mini-trips to the local flea market, to the grocery stores (outside of Citrusville) or to visit

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109 relatives who live in nearby towns. In general, the major reason put forth for waiting until the weekend to travel is that their ability to obtain rides from close friends and younger relatives is greater. M oreover, when a mini-trip is planned for the elderly person for the weekend, it gives him or her something to look forward to as a change in routine activities. Sunday, on the other hand, is a special day for most of the aged persons in this Citrusville study. Almost 100 % of both Black and White females stated that they attend some church on a Sunday morning if they are physically able to do so. Approximately 90 % of the White males and 60 % of the Black males said that they go to a church on Sunday. M any of the Black and White churches have a minister who rotates giving sermons in different communities either on the first and third Sundays or the second and fourth Sundays of each month. Thus, quite often, individuals will go to a different church when their minister is not in town. In the main, Blacks and Whites go to churches which have traditionally been attended by only Blacks or Whites. Only one White minister stated that he had a Black male come to his services on Sunday. Both Blacks and W hites claim that there are individuals they see on S undays whom they do not see during the week, mainly because that persons lives outside of the immediate Citrusville community. Thus, the church serves the dual purpose of reuniting close friends and functioning as a

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110 gathering place so that individuals can check on the physical wellbeing of various other persons in the community who are just friends. In fact, in many instances, close friends who live apart from each other may spend the entire day together: taking turns eating at each other's homes; visiting mutual close friends who could not come to church; and visiting sick individuals who are just friends; and, on occasion, taking mini-trips with relatives to visit other relatives. Holiday Pursuits The schedule of the elderly person in Citrusville on holidays varies from that of either a weekday or weekend. Over 38 of the 64 persons interviewed state that on Christmas and Thanksgiving they spend time with a relative. Most individuals spend this time with their sons or daughters and their grandchildren. The other persons who do not spend these holidays with relatives spend them alone or with close friends. At least two persons assert that they did not spend these holidays with anyone because these holidays brought memories of tragic occurrences. The other major holidays, Fourth of July, Easter, Memorial Day, Labor Day, etc., seemed to be pretty much like most weekdays or simply long weekends. The Blacks in the study stated that they did celebrate a special day called "Homecoming day." This is a day in which the relatives of individuals who live in Citrusville return to Citrusville

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111 for a two or three day celebration. This event happens on the last day of June every year. Discussion and Review The presentation of routine activities in terms of whether or not they are performed during the week, on the weekend or on special holidays, serves more than the simplistic purpose of demonstrating that there is variety in the life of older people. Routine behavior is the life blood of a social network because it enables individuals to predict in a relatively accurate fashion the activity patterns of close friends and relatives. Knowledge of the routine activities of their friends further enables older individuals to modify their behavior such that when social interaction does take place, it is wanted and not disruptive. Of course, any purposeful interaction or visit to close friends, relatives, or just friends does not require knowl edge of routine behaviors, nor does it require that the activity pattern be respected. For example, if Mrs. G. is sick and needs the assistance of her close friend, Mrs. M ., she will not concern herself with the fact that M rs. M may be washing dishes or taking a nap at the house she decides to call. Furthermore, in this chapter, it has been shown that when essential routine behaviors are interrupted by a disaster or illness, close friends can act to initially

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112 stabilize the home situation for the elderly person, i.e., cook, run important errands, or clean the house; but rela tives must take on the responsibility, or at least see to it that measures are worked out, if long term care is needed. It is essential, therefore, for the older person, that friendship ties be solidified through time and constant social interaction. Those individuals who do not have a close friend or a relative living nearby are at the mercy of just friends, whose schedules they are not familiar with, and the local institutions of health care, which are not always available. Shanas and M addox (1976) report that studies conducted in the United States, Denmark, and Britain reveal that the family is the actual as well as the potential long term caretaker of the sick older person. Further, they report that the older adult children are the major social support of the elderly sick. They state that when there are no children present or no children at all, other relatives and close friends arrange for medical care and indeed, like children, serve as nurses, housekeepers, chauffeurs, and heal th worker "surrogates." Shanas (1962) postulates that women play a major role in helping the elderly sick person. However, with the increased rise of women in the labor force along with the decrease in family size and rapid rise in efforts toward urbanization, there is an increasing problem in maintaining the older sick person within the limits of family social and financial resources.

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113 Data from Rosencranz, Pihlblad, and McNevin (1968) indicates that the rural elderly receive more visits when they are sick, from children and other relatives, than they return those visits. Lowenthal and Robinson (1976:437) believe that: "Ill health may function to strengthen the [social] kinship network in terms of frequency of interaction." In terms of the quality of the relationship between ill older persons and their children, however, data from Citrusville suggests that older persons are closest to those children who visit them or call them frequently on all occasions. Lastly, Blau (1973) suggests that illness behavior in the elderly person, after a time, tends to isolate those family members close to them, and who are responsible for attending to the elderly person's needs and demands. M ore over, the relationship with kin is usually emotional, thus creating a kind of traditionally recognized social obliga tion burden with relatives, regardless of the severity and intensity of the older person's illness. Friendship ties with neighbors and close friends are based on reciprocity. In times of ill health and disease, relatives may be the first to be consulted only if they are usually consulted first about other issues; and, in this instance, friends and neighbors would serve to give relatives "relief." Finally, the obvious must be pointed out, and that is, that not all activities are carried out within the time framework of a morning, afternoon or evening. Many

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114 activities in which the elderly participate, such as fishing, entertainment seeking, or long distance travel, are performed all day or over a period of several days. In general, these activities represent variations of the routine schedule, and most of the people discuss variations in their routine schedules with close friends and relatives to let them know that: (1) if an emergency should arise, he or she will not be available; and (2) if one had planned to simply stop by for a social visit, that person should call first to find out if the older person has returned.

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CHAPTER X THE ELDERLY AND LOCAL HEALTH CARE RESOURCES The previous discussion of the routine behavior of the older people in Citrusville demonstrates the means by which constant social and purposeful interaction talces place within the context of a given social network. The idea is presented, moreover, that routine behavior is much more than a variety of activities in which the aged rural person is involved. In general, routine behavior also means that the elderly Citrusville resident follows a regular pattern of activity to the extent that close friends and relatives, within a social network, can predict his or her whereabouts during the day. It is evident that individual survival is keyed to detailed knowledge of the routine habits of a large number of age mates and relatives; the widespread readiness to respond to an older person's call for aid and comfort has a direct effect on his or her ability to maintain a functioning state of health. As a rule, close friends provide the necessary aid in the short run; relatives are expected to be or find adequate long term sources of support for the older person in need. 115

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116 This chapter discusses the decision-making process by which the elderly individual chooses to consult close friends and relatives on some occasions, and more formal health care persons or institutions at other times. Nearly all the raw data have been collected with the help of two sections of the Interview Guide labelled: "Information on Social Network Structure," parts III and IV, and "Heal th Care Information." Data related to local heal th care re sources were obtained from the following places: the Citrusville Public Health Clinic, the Citrusville Drugstore, and the Citrusville Fire Department. Social Networks and Health Seeking Behavior In Chapter IX, it was established that close friends and relatives become rather quickly aware of an illness that has overtaken a close friend within a given social network. In fact, in the Citrusville Study Population Group, over 91% of the 64 individuals stated that either a friend would call them when he or she was sick, or through being in constant contact with each other, they would already know about the illness. Only 9% or 6 persons said that they would receive news of a close friend's sickness from a neighbor or someone else in the community. From time to time, individuals who are "just friends" of the elderly enter into the aged person's personal net work when they are "sick." If necessary, an elderly

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117 individual in Citrusville will sometimes answer a call for aid from someone who is thought of as "just a friend" and provide transportation if needed. This response to a call for help from someone who is outside the older person's social network creates a situation whereby that so-called "outsider" may be more responsive in the future to a recip rocal call for help. The findings suggest that the elderly person's response to calls for aid from persons who are "just friends" does not automatically assure them of a similar response in their time of need. This outcome is quite likely because the elderly person does not usually know the routine schedules of "just friends" and vice versa. Furthermore, this circumstance tends to make locating "just friends" a "hit" or "miss" affair in his or her time of need. In fact, the category of people labeled as "just friends" may not be as willing to stop their activities to accom modate the needs of the elderly person. General State of Healths Male and Female Subjective Differences In general, the Citrusville elderly men and women are different in terms of their subjective view of their state of health and wellbeing. The men report that they are seldom bothered by many health problems, and the women present a picture of health which shows that they are more often "sick" than well. The term "sick" is here defined as that state of being which severely reduces physical activity.

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118 Thus, the following reaction, in Table 17, to the question, "How often do you feel sick," is not surprising: Table 17. Responses to the Question About Feeling "Sick" Men {N=l8) Women (N=46) Seldom (less than one day a week) 44% 48% Sometimes (between two and three days a week) 39% 15% Often {greater than four days a week) 17% 28% Never 0% 9% The data show that 8)% of the 18 men interviewed report that they either seldom or only sometimes feel "sick," while 6)% of the women state that they seldom or sometimes feel "sick." Only 17% of the men and 28% of the women say that they feel "sick" often. Not one of the interviewed men re ported never feeling "sick, 11 while 9% of the women stated that they never feel "sick." These results illustrate a 20% difference in the way that men and women subjectively report their feelings of "sickness" as seldom or sometimes. Also, these data show an 11% difference between men and women reporting that they "often" feel sick. These findings conform to the findings on male-female subjective reports of wellbeing. Campbell (1978) reports on a study which involved the data collected on older people

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119 from "senior citizens centers" in 25 selected cities across the country. His study indicates that only J4.6% of the women polled but over 50% of the men rate their health as excellent. The remainder, 61.1% of the women and 44.4% of the men, feel that their health is fair-poor. Verbrugge (1976sJ98) relates similar findings. She examined the data from the "Heal th Interview Survey for 1957-72" and found that, on the whole, women subjectively report their heal th as "poor" more often than do men. She attributes her findings to the following possibilities: (1) that females are generally more cooperative during health interviews, have a higher recall of their physical symptoms, and health activities or can better verbalize their physical ailments; (2) that females may more often be sensitive to body discomforts and more willing to report these symptoms to others; and (J) that both sexes are actually exposed to different physical risks of disease and injury; thus, the female may report more of one kind of health prob lem than another. However, in rural areas, other possibilities do exist for male-female differences in reporting health problems. Men, in rural areas, may wish to appear strong, productive and independent and therefore will not report every ache or pain, while the women are "expected" to report all health problems. In fact, in many instances, the acceptance of an illness or sickness, which often implies dependency on others, may be extremely difficult for both rural men and

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120 women. As Estes (1977 :109) writes: "A questionable symptom or sign may be ignored until pain or other symptoms force a medical consultation, or until concern by other family members Land close friends] leads to the same results." General State of Healths Age Differences Campbell (1978s50) believes that the subjective rating or assessment of one's state of health changes over the life span. He states that "a pronounced decline, (in terms of the subjective rating of health as 'excellent,' occurs] in the 25 through J4 age group and a further decline [occurs] through middle age to the 60's." In addition, he demon strates that as many as 55% to 75% of the elderly in their "later years" rate their heal th as excellent, i.e., seldom having any health problems or seldom being sick. A re-examination of the question discussed earlier, "How often do you feel sick," by age group within the Citrus ville Study Population Group, yields the results in Table 18. Table 18. Distribution of Answers to Questions "How Often Do You Feel Sick?" 60-70 (N=42) 71-80 (N=l3) 81 and older Seldom 47% 31% 55% Sometimes 24% 31% 0% Often 20% J8% 45% Never 9% 0% 0% (N=9)

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121 When viewed in this fashion, the results in Table 18 show that, overall, most individuals feel that they are in good health. The results do not show that individuals who are older necessarily feel sick more often because of their age. However, these results could also illustrate that as individuals get older, they expect to feel a certain way and become accustomed to particular aches and pains. There fore, when asked the question, "How often do you feel sick," the reply, for the most part, is II seldom. 11 Toward a Definition of Illness: The Decision to Seek Health Care The reasons which govern whether or not rural older people in Citrusville choose to consult health care prac. titioners, close friends and relatives, or simply choose to take care of health care matters themselves, are intricately related to their perception of change in their own health status. In a general way, each person has a "he al th status warning system" which simply defines an illness episode in terms of whether or not it can be taken care of at the dwelling unit. A subjective evaluation of this kind includes a ranking of the condition as "a not too serious illness," or whether or not it "requires outside advice" and/or attention from a more formal health care facility, and hence constitutes a "serious" heal th problem. In both instances, "whether or not an illness can be treated at home," or "whether or not it must be treated at

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122 a formal health care facility," the threat of the illness or disease to whatever mobility the older individual has is of major importance. In the main, the elderly person in Citrusville considers serious health problems those which slow down or stop physical activity. The following are common examples provided by the interviewees, problems with the heart, stomach, or joints; and problems which affect vision, skin or feet. Health problems perceived as less serious mainly encompass, small cuts, bruises, burns, headaches, sleeplessness, some colds or fevers, "gas" in the stomach, "nature problems or problems with sexual im potency," and stabilized chronic diseases. On the basis of classifying an illness or disease epi sode as serious or not serious, the rural aged person in Citrusville may or may not consider himself or herself sick, and may or may not immediately seek out health care advice. In fact, the older person's response to the question of "Who does he or she call if he or she is sick," confirms the above positions. Most of the elderly state that if the illness were serious, they would call someone at a formal institution of health care. Some of the older people also said that their doctors had asked them to call when their health had deteriorated to a point at which they felt the need for his advice. To prove their point, many showed the investigators phone numbers which they stated were the home phone numbers of their personal physicians.

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123 On the other hand, if the illness or disease episode was not incapacitating, 44% of the 64 persons said that they would initially call "no one." Almost 28% or 18 people stated that they may call their physician anyway. Only 14% stated that they would initially call a close friend or relative. Only 7% and 6% said that they would call the local clinic nurse or their pastor. It is difficult to determine precisely whether or not an individual first calls a close friend or relative, or his or her personal physician. This is so because illness episodes are being discussed in the abstract sense: the individual is presented with a hypothetical "what if" situation since the investigator is not there at the imme diate onset of a health problem (Weaver 1970). This means that for the investigator not only the process of how the elderly define a change in health status as a health problem which needs immediate self-treatment or the attention of a nurse or physician, but also their actual decision path taken to secure health care treatment are more a matter of conjecture than of hard facts. However, enough information on the past health care seeking habits of the Citrusville elderly has been obtained to propose a schematic outline of health care seeking behavior. Below, in Table 19, is the proposed outline of the health care seeking decision process.

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124 Table 19. Schematic Outline of Rural Elderly Health Care Seeking Behavior Phase One Self-Address Phase: Phase Two Advice Seeking Phase: Phase Three Re-Definition Phase: Phase Four Action Phase: Phase Five Re-Definition Phase: Self-perception of change in health status as health problem: problem defined as serious or not serious. Depending on decision made in Phase One, elderly person will either treat problem if defined as not serious, and may or may not ask the advice of a pharmacist, close friend, or relative; if health problem perceived as serious, the older person may call: a personal physician, the local clinic nurse, a close friend or a relative; on some occasions, the local pharmacist may be consulted. All advice is re-evaluated to determine the next step in the health care seek ing process or to develop a plan of action. In this phase, the illness is redefined. Based on outcome of re-evaluation proc ess, individual will do one of the fol lowing: consult his or her "medicine cabinet," or that of a close friend or relative, or go to the local pharmacist for self-treatment medication; for more serious problems, transportation may be sought from close friends, relatives or just friends, the Citrusville Fire De partment Rescue Unit may be called, or a private ambulance company may be contacted. After illness or disease episode has either been stabilized by older person at home or been treated by more formal health care practitioners, the indi vidual will re-evaluate his or her progress and re-define the state of his or her health status change. In this fashion, the older person con tinually monitors his or her state of health. Source: Modelled after Weaver (1970): "Phases of Illness."

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125 The schematic outline presented in Table 19 has been constructed to account for the decision making process which occurs with both chronic and acute illness episodes. In the main, many individuals do not consider illnesses that they have lived with for many years as health problems unless there is a sudden change in the status of the illness or disease (Brearley et al. 1978). Therefore, in most instances, the process or need to define a change in health as "serious" or "not serious" is relevant only to situations which are sudden, such as the onset of colds, fevers, rashes, heart problems, etc., and situations in which a chronic illness or disease changes to further impair the older person's activi ties or cause considerable discomfort. Moreover, it is proposed that this schematic outline can be used in future studies to examine rural elderly health care habits. Resources for Health Care Advice V~ hen the aged individual in Ci trusville was asked the question, "Who gives you advice when you are not feeling well," the following results were obtained. Most, 55% of 64, say that they receive advice from a close friend. Nearly 27% say that no one can give them advice. Again, the re maining interviewees, 18% or 12, receive advice from the local clinic nurse or their pastor. It must be stressed here that almost all the interviewees state that they only offer advice on illnesses which should not require a doctor's

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126 care--colds, cuts, small burns, rashes, etc. When "serious" health problems arise, most persons indicated that they would tell their friend to see a doctor. Also, it should be stated that while the elderly indi viduals receive and listen to advice from close friends and relatives, most report that that may or may not follow such advice. However, it is very clear from the manner in which they discuss the advice they receive from their close friends and relatives that they truly welcome it. In a sense, these elderly individuals are saying that this advice shows that a close friend or relative is concerned about their wellbeing. Health Care Activities of Citrusville Aged Many more rural elderly persons than their cohorts in the city have to make extra special efforts to maintain a functioning state of health. This is so because of the scarcity of local health care facilities and transportation. Most people living in rural areas are often caught up in the technological and service transitions occurring in modern medicine. They have little choice but to provide for their own health care needs (Murp~ and Barrow 1970). However, the question of what the rural elderly actually do to provide for their health care treatment is subject to debate. On the one hand, the rural elderly are depicted as frequent users of herbal medications and root doctors. Many individuals believe that health care in rural America is based on some of "Granny s potions and cure-alls." While

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127 it may be true that in some rural areas, herbal medications abound, it is not always the case in all rural communities. On the other hand, there are those health care prac titioners who take the view that rural people, regardless of age, do not behave differently in their health care seek ing behavior than do individuals from urban areas. These health professionals believe that rural persons have "moved" into the 20th century. In fact, some health practitioners believe that individuals in rural areas demand and desire the same modern health care facilities usually associated with urban communities. The health care seeking behavior of the rural elderly is, however, actually somewhere in between these extremes. The background and experience of the individual in a rural community influence the extent to which behavior leans toward one or the other. The direction of the health care practices followed by the elderly is clearly related to their level of education and/or their previous exposure to a given health care delivery system. Previous exposure is probably the more important factor because a habit fully formed earlier in life is not easily broken after 20 or JO years. Elderly Usage of Herbal Remedies and Over-the-Counter Drugs In the Citrusville Study Population Group, the health care practices of the elderly encompass some usage of herbal medication and over-the-counter drugs, along with their usage of an established health care practitioner. For the

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128 most part, the data on the Citrusville Study Population Group show that the aged use herbal remedies and over-the counter drugs for illnesses which they believe will not re quire a physician. For instance, colds, cuts, burns, rashes, etc. are usually described by most individuals as problems requiring self-treatment when they occur in a mild form. Table 20 below presents a breakdown of the various problem areas, their possible treatments and the percentage of indi viduals interviewed who stated that they used a particular treatment method. The remedies used in Table 20 represent a broad spectrum for cuts, burns, and colds. Few individuals indicated that they changed their treatments with each occurrence of the same health problem. Most interviewees stated that they do not like to take pills or drugs unless it is necessary. For instance, only 11% of the females, and no males, indicated that they take valium or librium when they worry and cannot get to sleep. However, over 75% of the Citrusville Study Population Group reported that they pray, read or do nothing when they worry, or have headaches or sleepless nights. Elderly Persons and the Local Pharmacist Information provided by the local pharmacist reveals that almost all the elderly who have frequented his store, over half of the total population of elderly people in town, seek his advice on matters related to chronic health problems

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129 Table 20. Self-treatment Remedies Health Problem Areas Cut Burn Colds Fever Rashes Sores/soreness Possible Treatment Kerosene Vaseline Iodine Alcohol Merthiolate Soap and water Peroxide Turpentine Mercurochrome Black ink Baking soda Ice Mayonnaise Aloe plant Epsom salts Vaseline Mercurochrome Ointment Butter Aspirin Contac Coricidin Tylenol Quinine tablets Sassafras Cod liver oil Camphophenique Aspirin Tylenol Estrogen Calamine lotion Alcohol Baking soda Aloe plant Dial soap soak Camphophenique Alcohol Methods 2 % 2% 1% 3% 9% 5% 2% 2% 2% 2% 5 % 9% 2 % 14% 2% 3% 2% 6% 2% 13% 3% 3% 3% 2% 2% 2 % 2% 14% 3% 2% 6% 2% 2% 3% 3% 2% 2% CNote: The majority of the individuals in the Citrusville Study Population Group did not say that they used any remedies for the above health problem areas. Moreover, most indicated that they did not use multiple treatments for any one problem.]

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lJO and less life-threatening illnesses or diseases. He also states that they use a wide range of over-the-counter drugs to treat their minor ailments. Table 21 summarizes these findings. The pharmacist also indicated that while he often gives advice to the elderly on a wide range of health care prob lems, most individuals ask him for advice concerning colds, skin rashes, and backaches or muscle strains. According to his own admission, he refers individuals to a qualified physician when health care issues arise which are beyond the scope of his expected duties In effect, the pharmacist acts as a "Health Advisor" by actually screening the various health care problems brought before him. It is suggested that the pharmacist is a potentially valuable person in community health education programs be cause of his important position as a direct authoritative source of health care information for consumers. The follow ing case vignettes cited by the Citrusville pharmacist are typical of the kinds of health problems he was expected to deal with: Example #1 A man is worried about his "nature" and wishes to have a pill to help him along. Pharmacist gives him sugar-coated placebo. The man returns, satisfied with the results from this pill, and he requests a refill. Example #2 A grandmother is babysitting children over the weekend. One of the children begins to run a temperature; and she calls the pharmacist for advice. Example #J A woman wishes medication to help cure her "hot flashes"; the matter is objectively discussed by the pharmacist.

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131 Table 21. Over-the-counter Drugs and their Uses Health Problem Areas Colds Headaches M uscle Pains Laxative S leeping Aids Upset Stomach Vitamins Over-the-counter Drugs Used Robitussin Father John's Medicine (Blacks mainly) Vicks Formula 44 Nyquil Creomulsion Tylenol (does not upset stomach) Anacin (arthritis strength) Bufferin Ben Gay (lotion or jel) Infra-Rub Heet Rexall Vicks Mentholatum Camphorated oil Witch hazel Mineral oil Correctol (mainly used by females) Feen-a-Mint (mainly used by males) Ex-Lax Cardui (mainly Black females, for hot flashes) Tincture of A s afetida Castor oil Phillips M ilk of Magnesia Epsom salts Sominex (used by few, sleeping Sleep-eze aids not a big seller to elderly) Di-Gel Alka-Seltzer Rolaids Pepto-Bismol Maalox Mylanta Rexall One a Day Unicap M Theragran M

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132 Example #4 A somewhat agitated person comes in and wishes to rid herself and her home of lice, and requests the "most effective" over-the-counter drug. While the investigator was sitting in the local drug store, an elderly gentleman, approximately 65 years of age, entered complaining about a "flax" seed under his eyelid. He wanted the pharmacist to give him some eye drops. W hen the pharmacist asked the gentleman how long the flax seed had been in his eye, the man replied, "About six weeks, but I was afraid to go to the doctor. You can never tell what they will do to your eyes." The pharmacist did not attempt to remove the flax seed, nor did he sell the gentleman eye drops. He did persist in telling the man to consult a physician. The pharmacist further indicated that both men and women, Blacks and Whites, appear to come into his store with the same frequency and kinds of questions. Reasons for Visiting or Not Visiting a Doctor's Office The Citrusville elderly go to a physician for treatment of the health care problems which are classified as more serious. These include heart problems, broken bones of any kind, eye or dental problems and any problems involving the internal organs. In the Citrusville Study Population Group, only ten individuals stated that they did not have a personal physician. One female stated that she was made sterile by a physician some 20 years ago, and she has not been to a doctor since that time. Another person indicated that phy sicians love to give pills, and she did not wish to receive pills.

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133 .lli:!filber of Individuals Per Physician The average age of the ten individuals who said that they do not have a physician is 69 years. There were three individuals, aged 74, 82, and 91, without physicians. The other seven persons were 69 years and younger. The sex ratio was one to one, five females and five males. Eight individuals were White and two were Black. Of the remaining 54 aged persons in the Citrusville Study Population Group, 16 of 54 have a minimum of two pri vate physicians they consult for medical advice. As a rule, this includes an internist or chiropractor, and a dentist or opthamologist. Approximately 34 different persons share the same private physicians. The average number of people who share a particular physician is 5.0 people, with a mode of 2.0 people. However, the average is inflated because 26 people go to one dentist in Citrusville. A total of 55 different physicians were named, by 54 persons, with 38 individuals naming only one physician. Distance Traveled to a Doctor's Office The average number of miles traveled to a physician's practice is 34 miles. The mode for miles traveled, however, is 20 miles, with 90% or 58 people traveling that distance. One individual travels to Miami, approximately 350 miles away, and another to North Carolina, approximately 500 miles away. Both individuals use visiting their families as

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134 opportunities to obtain health checkups. Most persons have been with the same doctor an average of ten years or more and they expressed a strong desire to remain with their physician as long as possible. They appeared quite willing to travel a considerable distance to see their chosen doctor (Von Mering et al. 1976; Williams et al. 1960). Number of Visits to a Doctor's Office Approximately 38% of the 64 elderly people in this study stated that they see their physicians only "when necessary." Over 17% or 11 said that they go to the doctor three or four times a year. About seven of the elderly go once a year. Almost 8% of the elderly indicate going to the doctor two or three times a year, while 7% say that they have no regular check-up time and 5% of the individuals indicate once a month or once or twice a year. Less than 3% of the individuals indicate four times, once a week, and every six weeks. Local Public Health Clinic The Citrusville elderly use the local public health clinic mainly to obtain advice over the phone and to have their blood pressures checked. However, blood pressure checks for the elderly are also provided by the Older Ameri cans Council every Tuesday and by the fire department on occasion. Therefore, the elderly do not necessarily need to utilize that particular service of the public health

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135 clinic. Only one elderly individual in the study stated that she uses the clinic on a regular basis. Besides, by the clinic staff's own admission, they only see about five individuals a month over the age of 60. Most of the elderly individuals in the Citrusville Study Population Group be rated the clinic staff for changing personnel so frequently. Th~stated that they found no continuity in the care they received with doctors changing once every two or three years. Moreover, the public health clinic is only open two days a week and sometimes it does not open its doors even on those scheduled days. Citrusville Fire Department The Citrusville Fire Department, in conjunction with the Citrusville County Rescue Program, provides immediate life support and definitive care until the ambulance can arrive from either of the two counties nearest Citrusville (Report of Citrusville Fire Department). During the year just prior to the start of this research project, the rescue unit answered J42 calls. Approximately 18% or 62 of these calls concerned individuals 60 and older. Table 22 below covers the "rescue" work performed for the elderly Citrus ville residents during one calendar year. It is evident from the report that the Cit ru s vi lle F ire Department plays a major role in meeting the e m e rg e ncy health care needs of the elderly residents. Their list of

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136 rescue calls runs the gamut from accidents to life-threat ening illnesses. The Fire Department also offers CPR classes and first aid classes to the public. No data are kept on the age of the individuals who attend these classes. Table 22. Rescues of Citrusville Fire Department, 1978-1979 Conditions, Emphysema Alcoholism Cardiac Problems Cardiac Arrest Cancer Signal 7 (Death) Natural Causes Signal 7 (Death) Trailer Fire Falls Signal 4 (Auto Accident) Strokes Miscellaneous (diabetes, internal problems, respiratory, etc.) Cases: 2 males 1 male 12 males, 3 females 1 female 1 male, 2 females 1 male, 3 females 1 male 1 male, 2 females 3 males, 4 females 3 males, 2 females 10 males, 10 females [Note, These 62 cases represented 14% of the approximately 450 individuals over the age of 60 in Citrusville. It should be noted that 56% are males and 44% are females. J

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137 An Overview of Findings Taken as a whole, the findings presented in this chapter show that the elderly define a change in health status as "serious" or "not serious" on the basis of whether or not the illness or disease impairs, or stops their present range of mobility. It has also been suggested that the decision to define an illness episode as serious or not serious is not dependent upon whether or not it is a "new" health problem or a "chronic" health problem. In the main, most of the Citrusville elderly do not consider stabilized chronic illnesses or diseases as health problems which make them "sick." Furthermore, many would say that they were not "sick," even though they were taking quite a number of medications. In effect, the elderly define a sickness as an "immediate" health problem or a "long term" health prob lem in light of their ability to continue their present level of mobility in their surroundings. Similar findings are reported by Brearley et al. (1978, 14-15); they state that, [a] chronic condition [will] not be thought of as illness because it [is] not interfering with the established routine of normal activi ties." They also say that the illness of a person is defined not only by him or her, but also by the family members. Their findings agree with those of Parsons (1964), Knapp (1966), and Litman (1974), all of whom say that the family is the context and the major force in determining the "seriousness" of a given illness or disease episode.

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138 It has also been pointed out in this chapter that both men and women subjectively view their state of health in different ways. This conforms with findings from the literature that social mores and perceptions about male female susceptibility to disease as well as "biological block" differences, may well incline women to view their health status as "poorer" than a male of the same age with similar problems. Analogous arguments have also been presented to explain complaint reporting and health service utilization differences among the elderly. These arguments usually suggest that the older person would "naturally" rate his or her health as poorer simply because of his or her age. The Citrusville data do not confirm this finding.

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CHAPTER XI CONCLUSIONS The purpose of this research project was to explore the idea that the "general health status" of an individual is a measure of an individual's ability to adapt to a given environment. Three assumptions were put forth to structure the research inquiry; they ares (1) the assumption that the environment in which one lives determines adaptational mechanisms of survival; (2) the assumption that an examina tion of daily habits and routine behaviors will bring forth significant wellbeing care techniques; and (3) the assump tion that rural elderly individuals will devise specific health care seeking habits. The question to be raised at this point is, "What did the research show about adapta tional strategies and the process of growing old in a rural community? Adaptation to a Rural Environment, Wellness Behavior and Health Care Seeking Activities The environmental constraints for most rural elderly individuals in Citrusville showed certain similar charac teristics, most persons lived in stable neighborhoods; over 80% of the individuals lived in their own homes, either alone, with a relative, or with spouse; most persons had to 139

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140 juggle several economic resources in order to be able to feed themselves; and almost half of. the persons had to depend on others for transportation. There is a public health de partment operated clinic. However, very few older people use it since it is only open on a restricted time basis each week. Instead, they travel over 20 miles to their private physicians, and almost all consult the local pharma cist for health care advice. In the main, these environmental conditions or "constraints" also hold for the Citrusville Study Population Group. The ability of the rural older person to survive on a daily basis is a direct function of his or her ability to have some measure of control over the various elements which influence his or her living environment. Moreover, the ability to control routine activities, as well as the ability to generate support at a time of greatest need from nearby relatives, close friends, and II just friends" constitutes the "general wellness" maintenance activity of the rural elderly person. Thus, it is the aged person in Citrusville, without close friends, or nearby relatives, without a spouse, that has very little room for error in terms of trying to survive each day. The specific activities of elderly individuals in trying to resolve the demands placed on them by an illness or disease episode, determines their health care and mainte nance behavior. In fact, an elderly individual's involvement with a particular illness or disease will determine his or

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141 her "health status." Therefore, in attempting to discover how rural aged persons survive to live beyond the age of 60, it is not only important to understand their health care seeking behavior, but one must also understand their "wellness" maintenance activities. In effect, understanding what individuals in rural areas do to maintain themselves under conditions of a particular state of "wellness" involves much more than the simple collection of data related to the usage of roots or herbal medications, over-the-counter drugs, health care practitioners, and health care facilities. A concentration on these variables, and to the exclusion of environmental factors, such as housing, economics, and living arrangements, or social interaction factors embodied in the idea of social networks, is to limit the amount of information that would be gained from a more holistic approach to studies in health care (Foster and Anderson 1978; Landy 1977; Wood 1979). This dissertation research examined the health care seeking behavior as well as the health care maintenance be havior of the Black and White elderly in a rural community. Using an interview guide as a major data-gathering tool, along with the participant observation research technique, as described in Chapter II, information was collected and analyzed concerning the overall environment and the social relationships of the elderly. The attempt has been to demonstrate the interrelationships between environmental constraints, routine behavior, health care maintenance be havior, and elderly survivorship.

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142 Rural Self Help Linkages and the Individual Aging Experience The idea is not a new one that the rural aged poor need the economic and social assistance from relatives and friends in order to survive. In 1925, before the introduc tion of the Social Security system in this country, indi viduals were discussing the importance of the family and close friends to the aged person. Epstein (1925:Jl) presents these concerns clearly: "The utter dependency of [the aged] is brought out by the fact that [most] of [them say] that aside from what help Lthey] receive from children and relatives, they have no other means of support What is new, and demonstrated in this re search project, is that rural older persons can control many variables which affect their survival through the inter action patterns which they have established between them selves and close friends and/or relatives. Most studies of the activities of older people have focused on either the social networks and support systems, or they have concentrated on leisure time activities and routine behaviors of the older person. However, social networks and routine activities are closely interrelated, and not separate activities and events. The routine activ ities of the various individuals within the social network give the elderly person a sense of security found in trust ing and knowing the elements within his or her environment. As Cavan (1949:71) states: "When people live continuously

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143 in one type of home [environment], they learn to manipulate the situation for maximum satisfaction and to respond to its stimuli. Thus, life tends to fall into a pattern, comfortable and secure. 11 In effect, the elderly person, having lived in his or her neighborhood for many years, develops a support system whose members interact with one another in a regular, patterned fashion. Thus, the impor tance of the concept of social network in this instance is that it gives meaning to the routinized interaction patterns of close friends and relatives. In the Citrusville Study Population Group, individuals outside the network do not have a true, day-to-day effect on the membership inside the network. Therefore, the most successful aspect to the rural elderly aging experience is the fact that most individuals fit into a defined category in the community (Simmons 1960). That is, they know their neighbors, and understand not only their own relationships, but also the relationships of persons who are "just friends. 11 In fact, the boundaries of their advice giving, and the individuals whom they can give support to and expect support from, are defined by the various positions which individuals occupy within a given social network, within a community. Growing Old in Citrusville The process of growing old in Citrusville is a similar experience regardless of the person's age, socio-economic

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144 status, marital status, sex, race, and social support system. In fact, in many cases, the above variables simply determine the degree to which the older person will partici pate in a given activity. To be sure, the most striking variable which determines whether or not a person will participate in a given activity is the income of that person. In the main, regardless of ethnic group affiliation or sex, individual members of the study population had their private physicians, many owned their homes, and most persons had a support system which consisted of one or more of the follow ing: a spouse, a relative, or a close friend. Therefore, a quick examination of Citrusville would reveal some surface features which appear to make the process of growing old in Citrusville different because of an individual's demographic features. We find that Blacks and Whites rarely participate in activities which involve both groups together. Churches, clubs, and housing are separate for both ethnic groups. In the Citrusville Study Population Group, only two individ uals indicated having a person from the opposite ethnic group as a close friend. However, it is worth noting that many individuals, both Blacks and Whites, have "just friends" which are from the opposite ethnic group. It must be pointed out also that ethnic group affiliation and sex are artificial separation points. Both Blacks and Whites have adopted similar adaptation strategies by dependency on close friends and/or relatives, little usage of local health

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145 care facilities, and frequent consulting with the local pharmacist for over-the-counter drugs. W ithin the two major ethnic groups, however, the economic status of the individual sets him or her apart from other members of their group. M ost individuals in Citrusville who did not have to manipulate many variables in their immediate environment to make a living, usually have very few, if any, close friends, do not rely too heavily on friends or relatives for support and generally do not have or belong to a particular social network. In many instances, the day-to-day concerns of these individuals focus mainly on maintaining their present income level. It is more important to them than trying to maintain certain friendship ties. Indeed, as many grow older, and their income level drops substantially, they are compelled to develop close friends and keep open lines of communication with nearby relatives. The ultimate consequence for them, should they fail to gather a minimum of close friends, or should they sever ties with relatives, is growing old alone. At this point, of course, they face a situation without the wherewithal to withstand both sudden changes in their en vironment and in their health status. The Utility of S tudies on the Health Care M aintenance Behavior of Rural Aged Persons Aside from the obvious fact that research on the rural elderly increases the level of knowledge about how such

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146 people manage to survive in spite of their circumstances, the collection of data on the habits of the rural elderly also serves the purpose of demonstrating three important issues: (1) how health education programs can be offered as preventive health care strategies; (2) how the social network system may be used to deliver health care services; and (3) how the local social and health care programs do not fulfill their intended goals. The contributions that research in the rural community can make to the above issues means that in the long run, better programs of health care delivery can be designed to "fit" the needs and aspirations of the people who will ultimately benefit from them. Health Education Programs M ost of the persons in the Citrusville study claimed that they do not try to treat "serious" medical problems but instead seek out the advice of their personal physician. For the most part, the elderly may contact more formal health care practitioners. However, the crucial questions to be raised are: (1) at what point do they consider an illness or sickness serious enough to seek the advice of a physician; and (2) what are they willing to learn about health care and how should they be taught? On the first question concerning the point at which the elderly consider an illness or disease serious enough to warrant the attention of a nurse or physician, this study has shed some light. It has been shown that the elderly rate the occurrence of a change in health status as serious

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147 when the change stops their routine activities. However, if this is true, then it may at times also be true that the older person is waiting beyond the point when medical atten tion is effective. Furthermore, while some older people may have learned to live with pain, pain oftentimes signals the need for medical treatment. Surely, if the pain is in the chest, it can signal "heartburn" as well as trouble with the heart itself. Therefore, it would be important that the elderly understand which kinds of health problems offer the most promising response to treatment and which ones do not. For many of the elderly, they may be unneces sarily living with illnesses and diseases, which if caught in the early stages, can be successfully treated. The second question related to the willingness of the elderly to learn, and what would be important for them to learn, raises more issues than there are answers available. On the one hand, the Citrusville study, and other studies of the routine activities of the elderly, have demonstrated the fact that many elderly have free time in which they can do whatever is physically possible for them to do. These same studies, however, show that the elderly indicate that they are also "busy" and have very little free time. In other words, there is a discrepancy between what researchers have observed in elderly behavior and what the elderly person reports as routine activities. The issue that this question raises is "would the elderly person be willing to give time to learn new information?" The chances are good that they would because the information to be learned is related to

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148 their health, a subject with which most older people are truly concerned. On the other hand, the best method by which they could learn is debatable. One obvious way would be to use the local pharmacist, and expand his or her role as a health educator. For many pharmacists who practice in neighborhoods which are poor and have clientele who have frequent health problems, the role of health advisor has been thrust upon them (Linn 1973). In the Citrusville community, the phar macist functions as one of the local health consultants. The elderly continually seek his advice for various health problems. The problem to be solved first is to find out the willingness of the pharmacist to expand his or her role as health advisor and secondly, to determine what information he or she should dispense. Other methods by which health care information can be given to the rural elderly include: (1) using the health educators at the local high schools to speak in various churches on Sundays or (2) asking the rescue unit at the local fire station to conduct seminars on issues which relate to better health care for the elderly. For such seminars, the topics might include: "How to use the telephone to obtain medical information, 11 "How to rid the homeof hidden health hazards," and W hat to do, until the ambulance arrives, for specific medical emergencies, and also, what not to do."

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149 Social Network System and Upgrading Elderly Health Care Services The older people in Citrusville already keep in touch with each other and attempt to aid and comfort one another in the event of a medical crisis or an illness episode. Therefore, in one sense, it can be stated that the elderly use the social network system to deliver medical attention. However, on the practical level, the question of whether or not the social network system can be used to augment formal medical services, remains an interesting one. Since there is no possible way to maintain quality control in a system whereby various individuals within a community serve to "extend" the arm of the physician, it is unrealistic to consider using the social network system to deliver formal medical care. But, it is possible to "up grade" the quality of the medical information which is being passed from friend to friend, through educating the elderly person about health care. Also, many of the older people perform services such as giving insulin shots or checking on one another to see that each person continues to take the appropriate medication. It should be possible that these individuals who are performing these services could be taught to also recognize the signs and symptoms of a "pill gone sour," i.e., what should one do in the event the person has a reaction to the medication. In the main, since little research has been done in these areas, new approaches need to be considered and ex plored to determine the "information load" and "carrying

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150 capacity" of a given social network. It could be possible that any new requirements on a social network may seriously overload the system, or cause a complete breakdown in com munications because of the demands which are already placed on close friends and relatives as participants in a given network. Social and Health Care Programs for the Rural Elderly The number of social and health care programs in the Citrusville community are many. To name a few, there are the Older Americans Council, Public Health Care Center, M eals on W heels, Rescue Unit in Citrusville Fire Department and Summer S chool Lunch Program. These programs do in fact increase the survival chances for older people who take part in their activities. Yet, there are those elderly who, for one reason or another, refuse to participate. It is these elderly who have stated that the programs do not ful fill their promises and offer more red tape than the elderly are willing to deal with. While for many older people these programs offer some measure of protection against starvation, there are others who would rather struggle, ofttimes unsuccessfully, than be a participant. In many instances, their fears are justified. Programs get cut as often as the political climate changes. Others fade away, when county governments who administer them must make a choice between social programs for the

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151 rural areas or increased services for the largest city in the county seat. In most instances, the programs for the elderly are cut completely or diminished in their scope. For instance, in Citrusville the Public Health Clinic cut its days of operation from four to two, and does not have a stable medical staff. Rather than use the clinic which is local, many elderly travel over 20 miles to see a private physician, thus increasing their medical bills and trans portation costs. The question of how the "help" to the elderly can be more stable is one which requires much careful consideration by health care policy makers. This is very important since it is projected that by the year 2000, more than one-fourth of the population will be over the age of 50. This pro jected increase in the older population may signal the increased demands for more specialized health care services and may signal the need for more localized social programs. A related policy research issue is the determination of whether or not the introduction of a health care mainte nance facility into a rural community could destroy the beneficial interaction patterns that elderly persons have with each other. The research showed that rural older people depend on one another for various well-being enhancing "favors," and that they developed particular routine behavior habits and social relationships based on the frequency of their interactions. The information gathered in this study demonstrates the health maintenance

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152 significance of social networks for the elderly. Moreover, it is suggested that the impact of a new health facility or social service agency in a rural community such as Citrusville would tend to decrease the present level of self-sufficient interdependence among the Black and White social networks. That is to say, such an agency might well lead to a breakup of essential, routine interaction patterns by becoming a substitute support system for the individual older person. Improving Future Research into Rural Elderly Health Care Seeking Habits: Some Suggestions This research project collected data on health care maintenance activities from individuals 60 and over using an interview guide, instead of an interview survey ques tionnaire. The research sample population, moreover, was determined by using the "key informant" research technique. For the purposes of gathering data on a small, homogeneous, rural community both of the above research tools are ex tremely useful. However, in order to re-test the various assumptions about growing old put forth in this project, the following are suggested: (1) a larger sample population should be used and the interview guide should be used to examine health care maintenance activities of those indi viduals over the age of 21, i.e., a lifespan study of health care; (2) a stratified random sampling procedure should be used to determine the population sample, and the sample

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153 should consist of individuals from different rural environ ments, within different county areas; (J) the investigators should be given nine months to a year to observe and parti cipate, where possible, in community activities; and (4) the men 60 and over should be "over-sampled" since the women may outnumber them and since most older men are reluc tant to discuss their health care maintenance strategies. Health Care Policy and Research on the Rural Aged For too long, health care planners and health agencies have designed health delivery systems which do not conform to the wellbeing behavior patterns of the individuals they were intended to serve. "Grassroots" research such as this, however, should be conducted before any new health delivery system is implemented. This is so, because the institutions of health care, along with health care policy, should be adapted to meet the needs of the residents in a given area and not vice versa. For example, two rural communities may share the same salient features of housing, individual living arrangements, and economic levels; however, the residents who inhabit the communities may have adapted to the environment differently. In effect, when developing a health care policy for people who live on the marginal fringes of society, the major determining component should be the individuals, and not the various diseases or ill nesses which they represent.

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APPENDIX A OUTLINE OF INTERVIEW TOPICS (Taken from Carol Stack's book, All Our Kin, Harper & Row, 1974.) A. SOCIAL AND DOMESTIC RELATIONS 1. Daily Lives Comment, This interview is hard to do unless you know the person really well. The aim is to learn how people spend their time from the moment they wake up in the morning until they go to bed at night. We are trying to learn who they visit, which relatives they see daily or weekly, what they do for each other, whether they exchange goods and services, and how these exchanges are arranged. a. Ask the person to describe a typical day in great detail. Help them along by asking detailed questions. b. Who does the person visit each day, each week? Which relatives (relationship), boyfriends, friends, fathers of their children, etc. c. Did they trade clothes, money, child care with any one this week? Did anyone help them out? d. What did they do for someone else this week? Did anyone help them out? 15~

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2. 155 e. What guys (girls) do they see each week (not names); for example, fathers, boyfriends, mothers of their children, sisters, etc. f. Do they give to any of the individuals listed in e? Do they receive money from any of the individ uals listed in e? The Acquisition of Goods Comments Ask the person to name all of the items (furniture, pictures, radios, etc.) in each room in their house. Give each item a number and ask the fol lowing questions about each item. a. Give a physical description of the item. b. How long has it been in the house? c. Was the item in anyone else's home before? Whose? d. Does it belong to anyone in the house? Who? e. Where did it come from? Was it bought at a store? f. g. h. i. j k. 1. Where? Was it bought for cash, credit? Was it bought new or used? Who bought it? Who made the decision to buy it? Was it a gift or a loan? Who loaned or gave it to you? Who will it be given to or loaned m. Is it home-made? Who made it? to? n. What else should we ask you about it?

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J. 1~ Finances Comments Everyone has a hard time making it on the money they get and so you have to get some help from others. The aim is to try to figure out how people make it financially, how their daily and weekly budget works. This gets very complicated because some people live together, others eat together, and others share their income. a. Learn who is living in the house of the person you are interviewing (list relationships) and how they contribute to the finances of the household (rent, utilities, food, etc.) b. Who eats in the household? Which meals? Who pays for the food? Who cooks? c. Try to learn the source of income of everyone in the household and how much they earn (you may have to guess.) d. Learn other ways people in the house get money and the amount; for example, from boyfriends, children's fathers, parents, etc. e. Try to write down a complete budget which includes how much money comes into the house and from where, expenses, who pays for what. 4. Leisure Time and Sex Roles Comments Men and women have leisure time to spend and finances to organize. We are trying to learn who people spend their free time with, and the differences between men's and women's buying habits.

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157 a. In whose name are the insurance policies? b. In whose name is the car, the house? c. Does your wife or girlfriend (husband, boyfriend) buy your clothes, or do you buy your own? d. Where do you sleep, keep your clothes, records? e. Where and with whom do you eat breakfast, lunch, dinner? f. How and with whom do you spend your day? g. Which bills do you pay? h. What housework do you do (shopping, scrubbing, cooking, dishes, etc.)? i. When and how much time do you spend with your own children? Your nieces and nephews? B. GOSSIP 1. How do you keep up on what's happening to people you don't see very often? 2. Who do you gossip with? J. How much time do people spend gossiping? How much time did you spend gossiping this week? Give an example. 4. What is the difference between gossip and when someone comes over to your house and says to you, "You man's creeping on you?" What do you call something that someone tells you to your face but is not true? 5. What do people gossip about? Give examples. 6. Do you learn anything about how people should act from gossiping?

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158 7. What is the difference between what people gossip about in front of a person or behind his back? 8. How much do people believe gossip? 9. How does gossip spread? If you tell a friend something, how long would it take for your mother to hear about it? 10. How many people gossip together at a time? Who, if anyone, is left out of the group? 11. What kind of people do people gossip about the most? What do they say? 12. What makes a person a good gossiper? How do these people get their information? lJ. Why do people gossip? C. KINSHIP AND RESIDENCE 1. lJ~ho Are Your Relatives? Comments The study of American kinship has left many unknowns. Students of black kinship do not have an agreed-upon American kinship model that they can compare to black kinship. Some of the unknowns in the study of American kinship that are of interest in the study of black kinship are the following, a. In the black community, who is considered to be a relative or kin? Who counts as kin? There are many possibilities, blood relatives on the mother's side, the father's side, or both; in-laws; friends. b. In order to get at this very basic question, you have to be very "open-ended." You can't make the

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159 mistake of giving people answers, or examples, because they catch on very quickly to the kind of answers you want. c. Begin by asking the question, "Do you have any relatives?" d. If the answer is yes, then ask, "Who are your relatives?" e. List the names the informant gives. Have him/her look at the list and decide whether he/she wants to add anyone to the list. At this point don't say, "Well, does Joe have a brother, a wife, kids?" You want to get their own view of who their relatives are without prompting them or helping out. f. After you have the list of names, then find out the relationship of each person to the informant. You will end up with a list of kin types (daughter, mother, father, etc.) and non-kin types, friends, etc. g. At this point you know how many relatives are listed, the order in which they were given, the kin types listed on the informant's mother's and father's side, which includes kin terms like step, great, grand, etc. When these terms appear, find out what they mean; for example, what is a grand nephew? h. For each person listed, find out what the informant calls the person.

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2. The Basic Genealogy Comment, In contrast to "Who are your relatives?'', when you gather the informant's genealogy, you want to push as far as you can to get the informant to list evecy blood relative and relative by marriage that he can possibly remember. Even if the informant can't remember names, if he is aware of a great-grandfather who had six brothers, put these down on the chart. The purpose of gathering this extensive list of kin is so that you can eventually gather all sorts of genealogical information (residence, employment, etc.) about the relative. The easiest way to start is to begin with the informant's (Ego) own generation and work down, because these people are freshest in his mind. Once he catches on, then you can work upwards to his parents generation and gradparents generation. (Ego refers to informant.) a. Ego's Generation, Write down the names of Ego's brothers and sisters. i. Write down the name of Ego's children and the names of his brothers' and sisters' children. ii. Write down the names of all of Ego's children's fathers/mothers. Elicit the relationship of Ego to the parent of each child. iii. Write down the names of Ego's siblings chil dren, the children's fathers/mothers, and the relationship of those parents to Ego's brothers and sisters.

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161 iv. Write down any additional spouses or consensual unions of Ego and Ego's siblings that are not alreaqy included. v. For each of Ego's partners (spouse, consensual union, parent to Ego's child), get their brothers, sisters, parents, grandparents, etc., and repeat ii-iv for each of them. b. Ego's Children's Generation, i. For each of Ego's children, and for Ego's siblings' children, repeat ii-v. To do this, consider each child as Ego when you are asking the questions. This way you can learn about half siblings. c. Ego's Parents Generation: i. Write down Ego's mother's and father's name, and the names of all the children born to each. ii. Write the relationship between Ego's parents and the parents of any children they had with another partner. iii. Write down any additional spouses or consensual unions of Ego's parents that are not already included. iv. For each of Ego's parents siblings (do one side at a time), repeat i-iii for all children born to them and to additional partnerships. d. Ego's Parents Parents, i. Repeat (c) i-iv for Ego's mother's mother, mother's father, father's mother, and father's father.

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J. Genealogical Information a. For each relative in the genealogy, gather the fol lowing information: age, sex, relationship to Ego, whether living or dead, place of birth, current place of residence, major occupation or source of income, total number of spouses, total number of consensual unions, total number of children, edu cation, whether rents or owns home, year and cause of death. 4. Residence Life Histories: Children Comment: The following data will evantually be gathered for everyone in the genealogy, but for now the emphasis is on children in the genealogy (informant's children's generation) because the informant's memory is best at this level. The focus of this data is where and with whom these children lived as they were growing up. Much of this information constitutes details in the life histories, but at this point the emphasis is on residence and the specific changes in the residence of children. For each child we are interested in straight forward data on residence changes and in rules about the decision-making process. Gather data for each child from birth to the present. a. Name of child. b. Relationship of child to informant: state rela tionships from informant's point of view; for

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163 example, the informant's sister's daughter. For comparison with the computer study, be sure and keep point of view clear. c. Age at time of move. d. For each change in residence since birth, get the following information, i. Relationship of child to adult male in new households state relationship from point of view of child. ii. Relationship of child to adult female in new household: state relationship from point of view of child. Note a For i and ii, take 11 adul t" to mean responsible adults in household. If a child moved to a household and the informant says he moved to "my sister's house, 11 write down that relationship for ii even if the sister's mother and others are also in the household. When in doubt, write down more than one response for i and ii. e. Other relatives in household. f. Location of household (city and state). g. Reason for move, Ask informant to describe the situation in which the change took place. (Eventu ally we will have this information from several points of view.) h. Who made the decision?

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164. i. What alternatives were open? What other relatives were considered? Non-kin? Residence Life Histories, Adults Comment, Begin with the adults in the informant's genealogies (Ego and his siblings) and work upwards in the genealogy to great-grandparents, etc., on both sides. Basically we want the same data that is gathered for children, but the adult residence charts might be more sketchy as -YOU get to older and more distant kin. For each adult, gather the following data from birth to the present, or to the death of the individual: a. Name of adult. b. Relationship to informant from informant's point of view. c. Age at time of move. Year of move. d. Location of household (city, state). This informa tion gives us a picture of migration, where they moved, when, who joined whom, etc. e. Relationship to adult male in new household: state relationship from point of view of person whose life you are detailing. f. Relationship of adult female in new household: state relationship from point of view of person whose life you are detailing. g. Other relatives in that specific household. h. Other relatives living in the general area near household (especially if this move is part of migration).

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165 i. Reason for the move. j. Who made the decision? k. What alternatives were open (other places to move, other relatives to join)? D. CHILD-KEEPING AND FOSTERAGE Comment: For each sample of extended child-keeping or fosterage (over six months) found in the Residence Life Histories of Children, get the following information wherever possible. 1. Decision Model a. Who was involved in making the decision? b. What is their relationship to the child? c. How was the decision made? d. Events surrounding the decision. e. What possible alternatives were considered? f. How long has the child lived in household? What were the original intentions? g. What rights have the male and female in the household acquired over the child? What rights do they not have? 2. The Mother a. Number of children she has living with her. b. Marital status, economic status. c. Social relationship of fathers of her children to children living with her. J. The Child a. Age, place in family he was born into (oldest, youngest).

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166 b. Residential history, Has the child been "kept" before? By whom? c. Social relationship to his biological father. d. Social relationship to his biological mother, siblings. e. Kin map, Which adults does the child consider to be his relatives? f. What does a child call adults in household and his biological parents? How does he refer to them?

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APPENDIX B MIGRANT WORKER HEALTH CARE QUESTIONNAIRE ________________ gave us your name and said they thought you would be willing to help us. My name is ____________ and I work with Happy Taylor and the ACORN clinic. I want to ask some questions that will help the people at the clinic and Miss Happy to help you better. Are you the head of this household? --How many people live here regularly? ___ How many are kids? --How many are related to you? How many adults share the --household expenses? __ Now I'd like you to tell me about yourself. 1. How old were you on your last birthday? 2. Do you read and write English? 3. Do you speak another language other than English? 4. Do you read ___________ ? Do you write it? 5. When did you leave school? 6. How long have you been married? 7. Do you own or rent your home? 8. Are you satisfied with your living conditions here? What would you change? 167

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168 9. What do you do for a living? How long have you been working at this? 10. Do you work year round on your job? 11. How far do you travel to work? 12. (If farmworker) Are you an hourly worker or a piece worker? lJ. How much do you normally make in a week? 14. Are there some times during the year when you do better than others? 15. Do you get any regular government benefits from Social Security? Veterans benefits? Or the Division of Social and Economic Services? 16. What special skills do you have for your work? 17. Have you ever thought of learning something new that would help you get a better job? 18. Do you have someone to take care of your kids while you work? Have you ever heard about credit unions? (Where you can put in 25 a week or every two weeks, then when you have put in $1.00 you own a share in the credit union and when you own 5 shares you can borrow money?) That way if you needed something you could get it even if you didn't have the cash right then. 19. Would you be interested in something like that here in (La Crosse) ?

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1~ What about a food co-op. Everyone could do a little work and put their money together so that everyone could get their food cheaper. 20. Would that interest you? You might even need a place to leave your kids while you did your share of the work. 21. If someone were to start a community center where you could leave the kids, would you like that? Or would you just as soon stay at home with the kids? 22. You might even be able to start a public laundromat like this, would you like to see that happen? 23. Is there anyone around here close that can tell you what to do when you get sick? 24. Have you ever had a check-up? When was it? 25. Do you think you feel good most of the time? 26. What about right now? 27. What's the matter? 28. Do you worry a lot? Would you mind telling me what you worry about? 29. Who helps you when you get worried? JO. Do you have any special problems with your kids? What do they give you trouble about? Jl. Have you ever had to be in the hospital (other than to have a baby)? 32. What for? JJ. After you went home, did you go back to see the doctor for a check-up? How long after?

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170 34. What do you know about the ACORN clinic? 35. Have you ever gone there? 36. Would you go there first when you get sick? Or do you go when other remedies have failed? 37. Is there some reason you don't go there? 38. Have you ever been to a mental health clinic? 39. How do you usually get to a clinic or doctor when you're sick? 40. Do you have to pay? Who do you pay? 41. Does this keep you from going to the clinic or doctor sometimes when you think you might need to go? 42. Does not having the cash to pay for the doctor ever keep you from getting help? 43. Do you have Medicare? Medicaid? Veterans medical care? Medical insurance through work? Retired mili tary privilege? Do you buy your own insurance? 44. Are you certified by the Dept. of Social Services for care at Alachua General? 45. Has anyone ever treated you badly when you went to see a doctor or went to a clinic? 46. When would you like for the ACORN clinic to be open? 47. Have you ever been to the clinic for a problem they couldn't help you with? What? 48. Are there any babies on the way in your family? 49. Is the mama seeing a doctor? 50. Is she having any trouble? What kind? 51. Where will she have her baby?

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l?l 52. Is this what ya'll usually do? 53. What about when the baby is born. Do ya'll usually take it f'or a check-up? Where? 54. Do you have all the children that you want? 55. Do you have a regular way to keep f'rom having babies? How well does it work, Can you tell me about it? 56. Would you like more inf'ormation in this area? 57. Have you ever been to the dentist? 58. Was that at a clinic? 59. Do you need to see a dentist now? 60. Do you think --(_La ___ C_r_o_s_s_e_) __ needs a dental clinic? 61. One last thing. We want to find out about nutritional intake. Would you tell us exactly what you ate yester day? Breakf'ast ------------Lunch _____________ Supper _____________ What about snacks? -------Do you take vitamins? ______ WOULD YOU TELL US TWO MORE PEOPLE WHO MIGHT HELP US WITH OUR SURVEY? Thanks.

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APPENDIX C QUESTIONNAIRE FOR STUDY OF SOCIAL HEALTH CARE NETWORKS IN CITRUSVILLE, FLORIDA

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NUMBER ---------CONSENT FORM PROJECT TITLE: Social Network Study NAME OF PERSON BEING INTERVIEWED: ------------NA ME OF INTERVIEWER: -------------------DATE OF INTERVIEW: --------------------ST ART ING TIME OF INTERVIEW, ---------------ENDING TIME OF INTERVIEW: ----------------PROJECT SUMMARY: This project is an attempt to determine the extend and kinds of social health networks which develop in rural com munities amongst the elderly. Through the usage of a focused interview questionnaire and open-ended questions, data will be gathered on: perceived income level, health seeking be havior and social health networks. All answers to questions on the questionnaire will be kept confidential and no names will be used at any time during the final write-up. The results of this study, written in the final report, will be made available to area agencies concerned with the health care of the elderly. INFOR~ED CONSENT STATEMENT: I, the undersigned, give the interviewer my permission to ask the questions on the focused interview questionnaire. The interviewer has fully explained the focus and nature of the study to my complete satisfaction. I fully understand that the information collected will be used responsibly. SIGNATURE OF INFORMANT: ________________ S IGNATURE OF INTERVIEWER: _______________ 173

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17~ Hello, my name is ( name of interviewer ). I am working on a project with the University of Florida. With your per mission, I would like to ask you a number of questions re lated to the way you take care of your health and take care of your health problems. Some of the questions will involve questions about your family financial resources. I can assure you that any answer given on any of the questions will be kept confidential. These questions are not a test; you are not obligated to answer any of the questions that are asked of you. However, I would appreciate your cooper ation.

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175 GENERAL INFORMATION A) This section is designed to obtain some general data about the individual, The questions below should be used as guides to elicit the information. 1) Ask the individual about their age, date of birth, and whether or not the individual is married, A) If the individual is married, try to determine the status of the marriage, Ask if the spouse lives with the individual or elsewhere. Find out if the spouse works and where the spouse works. Ask for the spouse's name. B) If the individual does not have a spouse at the present time, try to determine if there is a significant other male or female friend, C) If the individual has been married before, but presently lives alone, try to determine whether the marriage ended because of a separation, due to death, or because of a divorce. 2) Try to determine if there werewer any children. A) If there were children, find out their names, ages, and their present location. B) If there were never any children through birth, try to determine whether or not kids were raised by the individual. 3) Ask about the educational background of individual and spouse. A) How far along did they go in school? B) Where did or does the individual presently work? C) Find out if individual is retired, quit work or was fired. If possible, find out why they left work. 4) Explore the matter of individual finances. A) Determine whether the major source of household is from individual, or from spouse, or both. B) Check to see if individual and/or spouse is part of: Social Security, Pension Plan, Disa bility Income, Workman's Compensation, and Welfare.

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176 LIFE HABITS B) This section is designed to explore the individual be havior as it relates to daily living. 1) What does individual eat for breakfast? A) Ask if individual eats breakfast routinely. Try to determine the composition of breakfast. B) Try to ascertain whether or not the time of the breakfast is important. Ask if the indi vidual eats breakfast alone, with spouse, with relative, or with friend. 2) If individual does not eat breakfast routinely, what activities does individual engage in upon awakening each day? A) Does individual clean up the house? B) Is the visitation of friends, calling of friends, visitation or calling of relatives a morning activity? C) If the individual visits other persons, what do they do? Do they eat, talk, sew, or visit still others? J) Is individual responsible for the care and feeding of children? A) Whose child is the individual responsible for? Is the individual paid for this service? If the individual is paid, how much and how often is this service rendered1 B) If individual is not paid for this service of child watching, what does the individual re ceive? Is good, clothing, shelter, furniture, gifts, transportation given in return for baby sitting? Or, does the individual receive nothing for the services? 4) Who does the individual visit during the day? A) What is the relationship between the individual and the person the individual visits? B) Is the visit a social visit? Does the individ ual receive food, or drink during the visit? Does the individual discuss "community affairs"

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17? at this time? How does individual transport themselves to the other person's home? C) What does individual do when not visiting? Does the individual spend time in other activities: sewing, church activities, local community clubs, Older Americans Council, or home activities? 5) Where does individual eat each day? A) Is individual part of structured eating program: Older Americans Council, Meals on Wheels, School Luncheon Program or church eating program? B) If individual does not participate in structured program, does individual prepare personal meals? Do relatives or friends prepare the meals? If relatives or friends prepare meals, who are they and where do they live? Also, are they spouse's relatives or friends or individual's? 6) What does individual do on weekends and holidays? A) Does individual have a scheduled routine? What is the routine? B) Does individual participate in fishing, sewing, gardening, shopping, church, visiting friends, washing clothes, paying bills, visiting Gaines ville, visiting relatives on weekends? C) Which holidays does individual enjoy most? Why? How much time does individual spend on holidays with relatives, friends, and church group? 7) Besides caring for children, if that is an activity of the individual, does individual work for friends, relatives, or church on a routine basis? A) What kinds of duties are performed? B) Who provides transportation for work away from home? C) Are services paid services? D) If services are provided free by individual, why does individual perform service? E) How does individual feel about the work? Is it a chore?

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178 INFORlVIATION ON HOUSEHOLD STRUCTURE C) In order to understand individual behavior in the house hold context, the following questions are being raised. 1) Does individual live alone, with spouse, with friend or with relatives? A) If individual lives alone, what does individual pay for: rent, electricity, gas, water, sewage, yardwork, and household repairs? B) Does individual feel that income is adequate to pay for all bills? C) How did individual provide furnishings for home? Which were given? Rented? Bought on time? Still being paid for? D) Is individual part of any federal programs: Medicaid, Food Stamps, Foster Grandparents, or other? E) How often does individual entertain friends? Relatives? Who does individual invite over? What is the occasion? How often does individual invite people over? Who drops by? Who cannot drop by? F) If individual could wish for and receive any thing they wanted, what would individual ask for? More money? Friends? Better trans portation ? A better place to live? 2) If individual does not live alone, but lives with relatives, friends or spouse,where does individual II fit. II A) Does individual pay rent, babysit, clean house, cook, make groceries, watch house or sew in exchange for shelter? B) Does individual have a single room, alone, in the house? Does individual have to share, if so, with whom? C) Does individual entertain friends? If so, in which room? Are friends common friends of other members in household? Who invites the friends? Do they II drop over"?

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179 D) Does individual eat all meals in house? If so, does individual eat with others? Separate? If not all meals, which meals are eaten else where? E) Where does individual obtain income? Welfare, Foster Grandparents, etc.? F) Do any of the household furnishings belong to the individual? G) Does individual enjoy present situation? What would individual change?

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INFORMATION ON NETWORK STRUCTURE D) This section is designed to gather information on the function of and the structure of the individual social network. 1) Which relatives, friends, or members of the church live with or near the individual? (List their names, location, length of time known, and age.) 2) Which of the above does the individual see on a daily basis? Weekly? Every now and then? (List name, and frequency of contact.) What is the usual reason for seeing the person? 3) Which person does individual call, invite over, or visit when the individual wishes to know what is "going-on" in the church? Community? A) Which person can the individual rely on to tell them the truth? B) How does individual find out what friends are doing when individual does not see them? C) Which of the friends, or relatives, would the individual call who almost always know what is happening in the community? D) Which person does the individual call when the individual has "personal problems"? E) How does the individual know when friends are sick? F) Which friends does the individual speak with mainly on the phone? Which ones does the individual visit or visit the individual? 4) How often does individual visit friends or relatives? A) B) C) When is a person a friend? Is there a "primary friend"? Does individual and friends or relatives ex change gifts, "favors" or services? Give examples.

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181 HEALTH CARE INFORMATION E) The nature and function of the health care habits are the focus of this section. 1) How often does individual feel sick? A) Who does individual call for general sickness? B) Is there a friend or relative who gives advice to individual when individual is not feeling well? C) Does individual use the local clinic, nurse or doctor? How often does individual go to another city for treatment? D) Does individual treat self when an illness occurs? 2) What does individual do when a friend or relative is sick? A) Does individual provide direct treatment? B) Does individual share prescriptions? C) Does individual provide transportation? D) How does individual know when friend or relative is sick? 3) When does individual visit a doctor or nurse or health facility? A) Does individual obtain regular health check-ups? B) Which hospital or doctor or nurse does individual visit? Why? C) Does individual have private physician? Public? D) Does individual use other medical practitioners when individual is sick?

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!~hen I have a problern \~ith any of the following: Den ta 1Teeth, Gums, etc. I u s ually visit: Relationship to indiviclui!l beiriq i nterview : d: I-------------------I ______ __ j ____ ___ __ ----------------Last contact made: r-requen(:y of contact: Met.hod of contact: M~thod of treatment: ------------1-------+------------------------+-----------------+--------+---------r------1--------+-----

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When I have a I usually vis it: Relationship to Last contact Frequency of Method of ft, .:,t h o d 0 problem with any individual being made: contc1ct: contact: tre a t me n of the fol lowing: interviewed: --. Eyes -Glasses, Contacts, etc. -------~ -I I -----_ ___ ., _ ,-----

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\-/hen probl of th Ear, Back, Stoma l\rrns I have a I usually vis it: em with ar.y e following: Nose, Feet, Skin, Heart, ch, Legs, Relationship to Last contact Frequency of Method of I Me t h o individual being made: contact: contact : trr.at interviewed: ---------------+---II I

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\o/hen I have a I usually vis it: Relation s hip to Lnst contact FreqLJency of Method of Method oroblem with any individul being made: contact: contact: t rea trr of the following: interviewed: ------------\o/orryi ng, Headaches, Sleeplessness I I I---

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Hhen I have a problem l'li th any of the following: I u s ually visit: Reli:itionsh ip individual be interviewed: to ing ---------t------------------------. .. ---Burns, Cuts, Sores, Rashes, Fever, Colds ----------t-----------1--------------I -La st contact made: -----~ I _______ __ ------------' ------1 I Fre quen cy of Method of Metho d con tact: conta c t: tr eatme ---

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I My most pressing I us uu l ly visit: Relationship to Last contact rrequency of Method of Method o f hea 1th problems individual being made: contact : contact: tr eaim~rr t : are : interviewed: ------------------I -----1J

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M y most pres s ing hr->il 1th prob l e111s are: I usuall y visit: Relation s hip to individu;il being intervi01 ~ci d: L ast con ta ct mad e: rr eq u e ncy of c ont;ict: M rt hod of contact: M et hod of t r ea : men t : ---------1 ---------f -----------------------------------------1 ------------+----~ -----------------------------__ __ ______ ___, _____________ .. --------------------------------------------------------------------------~ ---_ ___ J __ _____ -__ ____.!.----I-' co co

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My most pres,;ing hr.alth problems itr e: r usually visit: P.eltionship to individu;il bP.ing i nterv i ewr.d: Last contact madr.: Fr eqnr.ncy of contact: M e thod of contact : Method o f tr r.il trw !nt : --------! ------+ --.. . .. ---- ----------------------------------------------! -----------. -----------_ __ ___ ____ _, -------------. -----------------------------------------------------' -------------------___ ___ .__ __ __

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My most pres s ing h ea lth problem s ;ire : I usually visit: n 0 li:itionship to individt1i1l lu;,ing i nter v I r. 1 -,ed : Lust contact milrle: rrequ e n c y of c ontact : Meth o d of c o ntact : Meth o d o f t re t1 tmr. n t: ---------------------------------------__ ___ ___ ,___ ___ .. -------4------------------------------------l-------+-------------1 ----------___ __ ___ ___ ----------------------------------. -----------_ _________ __,, ___ ---------------------------------------------------------_ __ ______ ___,_ ____ __

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My most p r essing h e alth problem s are : I usually visit: Relationship to individu;il br.ing int~rvir. wP. d : LiJ~t c onta c t 111ilde: rrequr.ncy o f c ontact: M et hod of co ntact: Me tho d o f t re;1 m~nt: -------------------.. -.. ---------------1-------..J---. ---------!-------'-~ ----------------------!-------1 ------------1 ------. ----------------+------------------. ------------------------------------------------------------~ ----'-----------------

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APPENDIX D POPULATION TREND S FOR RURAL AREA S OF FLORIDA

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I-' \D \.,J Percent Change Percent Change Total from Previous Rural from Previous Year Po12ulation Po12ulation Po12ulation Po12ulation 1970 6.7 (million) 37.1 1.3 (million) 2.4 1960 4.9 II 78.7 1.2 II 34.8 1950 2.8 II 46.1 9.6 (hundred 1940 1.9 II 29.2 thousand) 8.5 II 44.9 1930 1.5 II 51.6 7.1 II 15.2 1920 9.7 (hundred 28.7 6.1 II 15.3 thousand) 1910 7.5 II 42.4 5.3 II 26.6 1900 5.3 II 35.0 4.2 II 34.2 Sources u. s. Census of Population for 1970, u. S. Department of Commerce, Bureau of Census.

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APPENDIX E RURAL POPULATION OF UNITED S TATES 1900-1970

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Percent Change Percent Change Total From Previous Rural From Previous Year Population Census Po12ulation Census 1970 203.2 (million) 13.3 53,9 (million) -,3 1960 179.3 18.5 54.1 -.8 1950 151.3 II 14.4 54,5 II 1940 132.2 II 7.3 57,5 II 6.3 1930 123.2 II 16.2 54.o II 4.4 1920 106.0 It 15.0 51,8 II 3.2 I-' 1910 92.2 It 21.0 50.2 9.1 \0 \J\ 1900 76.2 21.0 46.o II 12.5 Sources Adapted from Ford (1978,38)

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APPENDIX F FARM POPULATION OF THE UNITED STATES 1900-1975

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Farm Percent of Percent of Year Population Total Population Rural Population 1975 8.9 million 4.2 N/A 1970 9.7 ti 4.8 18.o 1960 15.6 II 8.7 28.9 1950 23.0 II 15.3 42.3 1940 30.5 II 2.3.2 5.3.2 .... 1930 .30.5 II 24.9 56.5 \0 61.8 --:] 1920 .32.0 II .30.1 1910 .32.1 II J4.9 6.3.9 1900 29.9 II .39 .3 65.2 Source: Adapted from Ford (1978:.39)

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APPENDIX G APPLICATION FOR FOOD STAMPS

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STATE OF FLORIOA for Ofrice Use Only OEP !>. RTMENT OF HEALTH ANO REHABILITATIVE S ERVICES Case number _____ Application for Food Stamps-Part 1 Date received _____ Step 1. Complete Page 1 To begi n to apply for food s tamps you ca n complete t his first p age tea r it off a nd give it to us We are required to take action on yo ur a pplication within 30 days from the date yo u giv e us this first page So. the soo ner yo u give us the first page. the quicker yo u will know w hether you will receive food s tamps No w go to S tep 2. Yo ur name Mailing Address City II yo u don't have a street a ddress. tell us how to g et to yo ur home S ign here If You Need Food Stamps Right Away If yo ur household ( y o u and the people who live and ea t with yo uJ h as littl e o r no i ncome right now yo u may be ab le to r eceive food s tamps within a fe w days Answer t he following questions o nly ii yo ur house hold has l i ttle o r no income a nd needs food stamps right a w ay. Has a nyone in yo ur household received a ny income so far this m o nth 1 C Yes 0 N o 11 y es. how much '? S Did yo ur household s o nly income recentl y s t o p / 0 Y es 0 No Does anyone in y, >ur household expect to receive inc o me la ter 1his m o nth 1 0 Yes 0 No D Dont know II yes. how much '/ S H o w many people live in your home a nd eat with you '/ I include yo urselll Is anyone in your household 60 yea r s o r older'' D Yes 0 No Step 2. Complete Pages 2-5 Pages 2 5 must be co mpl eted beiore we ca n see ii yo u re digible for food sta mps Y o u can re tum pages 2 -5 to us a l o n g with th e first page or a t the time of the interview we wi ll schedule fo r yo u Try tu fill o ut as much as possible n ow Your case worker wi ll help you with the r e st duri n g the interview. Telephone number where yo u can be reached S t ate Zip Code Today 's elate When'/ How much do t he members of yo ur h ouse ho l d have in cash and sav in gs'! Give yo ur best estima1e of the total.) 5 ATmmON ..... # YOUR APPOINThlENT IS FOB..,;..;._. RfAO frlE NEXT P AG E CAREFULLY #_;,, ON,_______ l FAILURE T~ BW!G NECESS ~R'f PROOF ~"c!:J~ ,.. ENTRIES 0,' i o :.J R APPi 'C '" ; I MA OF APPUCA T.O .... ~S T BE COMP IL"1'l!ll 1N A LONG 0 1:u I Mio -A sEt:' y REsuLr ... ~'-,,.. ro BE SEEN AT w ABOVE TIME TH OFFICE BffQ,; 1 ~-~D TRIP TO ~,:s / SHOULD YOU BE MORE THAN HRS-SES FO RM 3000,iwa:~, iF.1! &1!Jf J fDiarc h 7 9 edition w,fl'be u se d ; obsoletes earlier e d1ttons & DFS-FS 35!11 ;,l:;J '.'T~S LH~ IN ARitV N G O:l CO/.f P~ET~tG 'liE Al'P ~i C AT:Otl THE APP0;:-1-.M~NT IS VOlO Page 1 199

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200 STATE OF FLOAIOA OEPAATMENT OF HEALTH ANO REHABILITATIVE SERVICES for Office U ,e Onl~ Case number ______ Application for Food Stamps-Part 2 Dale received ______ Answer the fllllowing questions honestly and completely. If you know but refuse on purpose 10 give any needed information. your house hold I you and the people who live and eat with youl won t be eligible for food stamps You may complete this form at home and mail it or bring it to the food stamp office Or. another member of your household or an adult who knows you may complete and return it to us Your name Mailing Address City If you dont have a street address. tell us how to get to your home. Household Members Fi!! in all blanks for each household member including yourself. People who live and eat with you texcept roomers or hoarders I should be listed as household members For each person who is not a citizen. y ou will need 10 show the food stamp office an alien registration card. s uch as INS Forms l-151. l-551. 1-94. or a Re-entry Permit. Name J 4 6 Resources Dl,c:s an\"unc in -, : uur h1,,,usc:huld o wn anv cars. t rucks. t,oa 1 s. ~ampers. motorc y clt:s ur otht!r v~hicles Q Yes O ; 'lo If yes. please describe. :vtake Model Does your household have any savings / 0 Yes 0 No If yes how much Year Cash on hand s Does vour household o wn anv real esrate other t han l'our home For e~ample. land or buildings. including buildings y~u rent to o rhers. C Yes O No Did you or a member o f your household sell. rrade or give away any thin~ of subsranrial value durin~ the lasr three monrhs' 1 0 Yes O No J lmportanl: When you are in1~rviewed. please hring proof nf a ll household income-for example pay stubs and award letters for government benefits 1such as SSI or Sncial Security I We may also need the following items: statements of all household savings and checking accounts: rent or mortgage receipts: and utility bills Having these items with you could speed up your applica1ion Telephone number where you can be reached State Zip Code We would like you 10 include the social security number o f each member of your household who has one. although you are not re4uired to do so. This will help us to identify y our household c orrectly These social securi1y numbc::rs may also be used in program r e views or audits 10 make sure your household is eligible ior food s tamps We are aurhorized to ask for 1his informarion under th~ Tu Reiorm Acr of 1976 Age Social security number ti/ known! ls this person a U.S citizen ? Yes No Yes No Yes No Yes No Yes No c;lYes No Yes No Attach a separate sheet ii y ou need more room Make "'1udel Year Make \1o
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2 J 29~ Income from Work Fill in all blanks for eac h household member wi1h a full or part-lime job. If a member has more 1han one job, lis1 each job separately Include members who receive income from CET A or WJN. Do no1 include self-employed household members Household member Is anyone in your household self-employed'/ Yes No If yes g ive 1heir names. Name of employer Please bring las1 year's Federal Tax forms (or self-employed members of your household. Or. if no such 1ax forms were filed last year. bring proof of self-employmen1 coslS and income. Has anyone in yo ur household quit a job in 1he las1 60 days Yes No Other Income Amounts Source of income AFDC tAi d to Families wi1h Oependen1 Children I Social Securi1y Blue i green checks SSI iS upplemen1al Securi1y Incomel-Gold checks GA (general assis1ancel VA (Vete rans benefits) Pensions or retirement income U nemployment or Workers Compensa1ion Child support and alimony Money from friends or re latives !other 1han loansl 01her1speci(y1 2 Household members who receive 1his income Amoun1 of each pay check b6fort deductions such as taxes. re1iremen1. or union dues are 1aken ou1 s s How o(len paid Amoun1 or each check or payment How o llen receive
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Roomers and Boarders Does anyone pay you for meals. a room, or both / D Yes No If yes. complete the following: Name Dependent Care Does anyone in your household pay for someone to babysit or care for a child or a disabled adult. so that a member can get work or training or look for a job '/ D Yes D No Who provides this care '/ Name Address Shelter Please list the amount our household is billed for each o f the following items Property taxes I if not included in mortgage! Utilities Amount How often is each payment due Check che box next to the utility costs you pay and list the amount you are billed. lf y o u don t list che amount you are billed we ll use a standard amount co compute your benefits. But, if your utilicy bills are higher chan our standard amount. listing chem below may help y ou receive more food stamps 202 Amount Te l ephone \ basic rate I Electricity Gas for heac, ; :g and co oking Oil Water and s ewerage Garbage and crash lnstallacion oi utilicies Other tcoal. wood) Does anyone outside your household pay o r help you pay any of che shelter or utility bills you ve listed above? D Yes D No 0 s s s s s How much do they pay you '/ How often / s s If yes how much do you pay'! How often / s Telephone number Amount Rent or How o hen is each payment due mortgage payment Insurance o n home ( if not included in mortgage) How often do yo u get a bill / If y es which bills do the y pa y > How much do t he y pay / Page 4

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201 Students Are there any srudenrs in yuur househ1.lld who rc:ct:i\'t: i:t.Jul.'a11onaJ ~ants. scholarships ur loans.' D Yes C Nu If y es. complete the r,,lluwin~: Name uf student Name ur Sc hool How much of the grants. scholarships or loan, are used 10 pay 1ui1ion or fees charged by the school"? I Do not include ewenses that are not charged by the school. such as 1exthooks or 1ransp,ma1iun 1<> school.) S Authorized Representative You can au1horize someone ou tside yuu r household 10 get your fow stamps for you or to use 1hem to buy food for you. If you would like to authorize someone. write the person s name belo w T urn l amount ,)i ~ rams schola~hips ,l r lo an'i ~unt h con!retl h:,,, this amount From Tu From To Are there any ~1udi.:nrs in yo ur household who are 18 or ovc!r an<.J a tlend collegt: or career training programs Yes No -----------------------------------------Name Address Telephone number Florida Fraud Law Information Any person who knowingly fails, by f alse statement, misrepresentation impersonation, or other fraudulent means, 10 disclost a material fact used in making a determination as to s uch person s qualification to receive aid or benefits under any state o r tederally-iunded assista nce program or who knowingly fails to disclose a change in c ircumstances in order to obtain or continue to receive under a ny such program aid or benefits to which he is not entitled or in an amount larger than that to which he is onutled, o r who knowingly aids and abets a nother person i n t he commission of any such act is guilty of a cri me, and shall be punished as provided i n c hapter 409 325. subsection (5). Additional i nformation on the Florida Fraud Statutes for Public Assistance Programs is available in the Food Sta mp Office. Penalty Warning II your household receives food sramps. it must follow the rules listed below. Any member of your household who hreaks any of these rules on purpose can be barred from the food stamp proi:ram for 3 months to 2 years: fined up to S 10.000. imprisoned up to 5 years, or both: and subject to prosecution under other applicable federal laws. DO NOT give false information. o r hide i nformation. 10 ge1 o r continue m get food s1amps. Your Signature I understand the questions on this application and the penalty for hiding or giving false info rmation or breaking any of the rules listed in t he Penalty Warning. My answers are co rrect and com plete 10 the be~t ,;,i my knowledge I understand that I may have t o provide documents to prove what I' v e said I ,gree to do this. Your signature __________________ Authorized Representative ______________ You or your representative may request a lair hearing either orally or in writing if you disagree with any action taken on your case. Your case may be presented at the hearing by any person you choose DO .'I/OT trade o r s ell food sta mps or authorizauon cards. DO NOT ailer au1horiza1ion cards 10 ge1 food s tamps youre nut entided to receive. DO NOT use food siamps to huy inelig1hle ite ms s uch as alcoh o lic drinks and tohacco. DO NOT use so meone else s iood stamps ,r authorization cards for you r household. If documents are not available I agree to give the name o f J person or organization the Food Stamp Office may co n1act to obtain the necessary proof. l ,uthorizc the Department of Health and Rehabilitative Serv i ce s and the Division o i Public As s istnce Fraud to verify any of the i nformation provided 1n 1 h1 s a pplica tion and to make inq uiry o f past o r present employers and cords. financial or otherwise. Today's date ____________________ Witness if signed with an X ______________ We will consider this application without regard to r:ice. color. sex, age, handicap, religion, national origin, or polidcal hellef. Page 5

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LIST OF REFERENCES Babchuck, Nicholas 1962 The Role of the Researcher as Participant Observer and Participant-as-observer in the Field Situation. Human Organization 211225-228. Barrett, Laurence 1975 The Need for a Regional Focus in Rural Health Services. Public Health Reports 90,349-356. Bender, Thomas 1975 Toward an Urpan Visions in Nineteenth Century America. of Kentucky Press. Black, James, and Dean Champion Ideas and Institutions Lexington: University 1976 Methods and Issues in Social Research. New York: John Wiley and Sons. Blau, Zena 1973 Old Age in a Changing Society. New York: Franklin Watts. Brearley, Paul, Jane Gibbons, Agnes Miles, Eda Topliss, and Graham Woods 1978 The Social Context of Health Care. London: The Chaucer Press. Bruyn, s. 1963 The Methodology of Participant Observation. Human Organization 22:224-235. Campbell, Richard M. 1978 Variable Differences Among Older Persons and Their Subjective Health. Texas Medicine 74:49-55. Cavan, Ruth W. 1949 Family Life and Family Substitutes in Old Age. American Sociological Review 14:71-83. Chou, Ya-Lun 1975 Statistical Analysis. New York: Holt, Rinehart and Winston. 204

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205 Clark, Margaret and Barbara Anderson 1967 Culture and Aging. Springfield: Charles c. Thomas Publisher. Dubos, Rene 1976 Man Adapting. New Haven: Yale University. Ellenbogen, Bert L. 1967 Health Status of the Rural Aged. Americans. E. Grant Youmans, ed. pp. ton: University of Kentucky Press. In Older Rural 195-220. LexingEnsminger, Douglas 1949 Rural Neighborhoods and Communities. Life in the United States. Carl C.Taylor, New York: Alfred A. Knopf. Epstein, Abraham In Rural ed. pp. 55-77 1925 A Sidelight on the Family Status of Aged Dependents. American Labor Review 15:30-31. Estes, E. H. 1977 Health Experience in the Elderly. In Behavior and Adaptation in Late Life. Ewald w. Busse and Eric Pfeiffer, eds. pp. 99-116. Boston: Little, Brown and Company. Fischer, Claude, Robert M. Jackson, c. Ann Stueve, Kathleen Gerson, Lynne Jones, and Mark Baldassare. 1977 Networks and Places. New York: The Free Press. Ford, Thomas R., ed. 1978 Rural U.S. A., Persistence and Change. Ames, Iowa, Iowa State University Press. Foster, George 1978 Medical Anthropology, Some Contrasts with Medical Sociology. In Health and the Human Condition. Michael Logan and Edward E. Hunt, eds. pp. 2-10. Massachusetts: Duxbury Press. Foster, George and Barbara G. Anderson 1978 Medical Anthropology. New York: John Wiley and Sons. Fry, Lincoln J. 1973 Participant Observation and Program Evaluation. Journal of Health and Social Behavior 14:274-278. Gale, Stephen 1974 Evolutionary Laws in the Social Sciences. In Developments in the Methodology of the Social Sciences. Werner Leinfellner and Eckehart Kohler, eds. pp. 309336. Boston: Reider Publishing Company.

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206 Gamm, Larry and Frederick Eisele 1977 The Aged and the Chronically Services: The Local Perspective. pp. 170-181. Montpelier: Capital Glazer, Myron Ill. In Health ArthurLevin, ed. City Press. 1972 The Research Adventure. New York: Random House. Hasan, Khwaja 1978 What is Medical Anthropology? In Health and the Human Conditin. Michael Logan and Edward E. Hunt, eds. pp. 17-22. Massachusetts: Duxbury Press. Kluckhohn, Florence 1940 The Participant-Observer Technique in Small Communities. The American Journal of Sociology 46: 331-343. Knapp, D. A., D. E. Knapp and J. Engle 1966 The Public, the Pharmacist, and Self Medication. Journal of the American Pharmacological Association 561 460. Kolaja, J. 1956 Contribution to the Theory of Participant Observation. Social Forces 35:159-163. Landy, David, ed. 1977 Culture, Disease, and Healing: Studies in Medical Anthropology. New York: MacMillan. Lawton, M. P., Elaine Brody, and Patricia Massey-Turner 1978 The Relationships of Environmental Factors to Changes in Wellbeing. Gerontologist 181133-137, Lie bow, Elliot 1967 Tally's Corner: A Study of Negro Streetcorner Men. Boston: Little, Brown, and Company. Linn, L. s. 1973 Indicated vs. Actual Behavior: the Pharmacist as Health Advisor. Social Science Medicine 7:191-197. Litman, T. 1974 The Family as a Basic Unit in Health and Medical Care: A Social-Behavioral Overview. Social Science and Medicine 8:495-519. Lowenthal, Marjorie Fiske and Betsy Robinson 1976 Social Networks and Isolation. In Handbook of Aging and Social Sciences. Robert H. Binstock and Ethel Shanas, eds. pp. 432-450. New York: Van Nostrand Reinhold Company.

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207 Luft, Harold S., J. C. Hershey, and J. Morrell 1976 Factors Affecting the Use of Physician Services in the Rural Community. American Journal of Public Health 66:865-871. Lynd, Robert S. and Helen M. Lynd 1956 Middletown: A S tudy in Modern American Culture. New York: Harcourt, Brace and World. Mechanic, David 1978 Medical Sociology. New York: The Free Press. Murphee, Alice and Mark Barrow 1970 Physician's Dependencies, Self-Treatment Practices, and Folk Remedies in a Rural Area. Southern Medical Journal 63:403-408. North Central Florida Planning Council 1977 Comprehensive Plan for Citrusville 1977-2000. Olesen, Virginia L. 1978 Convergences and Divergences: Anthropology and Sociology in Health. In Health and the Human Condition. Michael Logan and Edward E. Hunt, eds. pp. 11-16. Massachusetts: Duxbury Press. Orenstein, Alan and William R. Phillips 1978 Understanding Social Research: An Introduction. Boston: Allyn and Bacon. Parsons, T. 1964 Definitions of Health and Illness in the Light of American Values and Social Structure. In Social Structure and Personality. Talcott Parsons, ed. pp. 257-291. New York: Free Press. Folgar, Steven 1962 Health and Human Behavior: Areas of Interest Common to the Social and Medical Sciences. Current Anthropology 3:159-205. Regnier, Victor 1975 Neighborhood Planning for the Elderly. In Aging: Scientific Perspectives and Social Issues. Diana s. Woodruff and James E. Birrenn, eds. pp. 295-314. New York: D. Van Nostrand. Rose, Arnold M. 1967 Perspectives on the Rural Aged. In Older Rural Americans. E. Grant Youmans, ed. pp. 6-21. Lexington: University of Kentucky Press.

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208 Rosencranz, H., C. Pihlblad, and T. McNevin 1968 Social Participation of Older People in the Small Town. Missouri-Columbia: Department of Sociology, University of Missouri. Salber, E. J., W. L. Beery, and J. J. Feldman 1976 Access to Health Care in a Southern Rural Community. Medical Care 14:971-986. Sanders, Irwin T. 1977 Rural Society. Englewood Cliffs, N. J.: PrenticeHall. Schwartz, Barton and Robert H. Ewald 1968 Culture and Society: An Introduction to Cultural Anthropology. New York: The Ronald Press Company. Shanas, Ethel 1962 The Health of Older People: A Social Survey. Cambridge: Harvard University Press. Shanas, Ethel and George Maddox 1976 Aging, Health and the Organization of Health Resources. In Handbook of Aging and the Social Sciences. Robert H. Binstock and Ethel Shanas, eds. pp. 592-614. New York: Van Nostrand Reinhold. Shanas, Ethel, Peter Townsend, Dorothy Wedderburn, Henning Friis, Poul M.ilhpj, Jan Stehouwer 1968 Old People in Three Industrial Societies. New York: Atherton Press. Simmons, L. vJ. 1960 Aging in Pre-industrial Cultures. In Handbook of Social Gerontology. c. Tibbitts, ed. pp.b2-88. Chicago: University of Chicago Press. Social Security Bulletin 1975 Social Secutiry Bulletin, Annual Statistical Abstract 156. Washington: Social Security Administration. Stack, Carol 1974 All Our Kin: Strategies for Survival in a Black Community. New York: Harper and Row. Stewart, Frank H. 1977 Fundamentals of Age-Group Systems. New York: Academic Press. Struyk, R. J. 1977 Housing Situation of Elderly Americans. Gerontologist 17:130-139.

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209 Studdert-Kennedy, Gerald 1975 Evidence and Explanation in Social Sciences An Interdisciplinary Approach. London: Routledge and Keegan Paul. Tissue, Thomas 1972 Old Age and the Perception of Poverty. Sociology and Social Research 561331-346. U. s. Bureau of Census 1970 General Characteristics for County Subdivisions 1960 Characteristics of the Population, for Census County Divisions 1950 Population of Counties by Minor Civil Divisions: 1930-1950 1940 Population of Counties by Minor Civil Divisions: 1920-1940 1920 Population of Counties by Minor Civil Divisions: 1890-1920 Verbrugge, Lois M. 1976 Females and Illness: ences in the United States. Social Behavior 17:387-403. Recent Trends in Sex Differ Journal of Health and Von Mering, Otto and Leonard Kasdan, eds. 1970 Anthropology and the Behavioral and Health Sciences. Pittsburgh: University of Pittsburgh Press. Von Mering, Otto, Gary Shannon, William Deal, and Pamela Fischer 1976 A Long Day's Journey to Health Care. Human Organization 35:381-389. Wax, Murray L. 1970 Sociology. Health Sciences. eds. pp. 39-52. Press. Weaver, Thomas In Anthropology and the Behavioral and Otto Von Mering and Leonard Kasdan, Pittsburgh: University of Pittsburgh 1970 Use of Hypothetical Situations in the Study of Spanish American Illness Referral Systems. Human Organization 29:140-154. Williams, T. F., K. S. White, L. P. Andrews, E. Diamond, L. G. Greenbert, A. A. Hammrick, and E. A. Hunter 1960 Patient Referral to a University Clinic: Patterns in a Rural State. American Journal of Public Health 50:1493-1507.

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210 ~"J ood, Corinne S. 1979 Human Sickness and Health: A Biocultural View. Palo Alto: M ayfield. V Joodward, H. 1974 Loneliness and the Elderly as Related to Housing. Gerontologist 14:349-351. Zuiches, James J. and David L. Brown 1978 The Changing Character of the Nonmetropolitan Population: 1950-1975. In Rural USA: Persistence and Change. Thomas Ford,ed. pp. 55-74. Ames, Iowa: Iowa State University Press.

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BIOGRAPHICAL SKETCH Tyson Lee Gibbs was born in Knoxville, Tennessee, in 1951; he attended Maynard Elementary and Beardsley Junior High School. From 1967 to 1969, he attended Hanover High School in Hanover, New Hampshire. In 1973, he earned his B.A. degree from Dartmouth College. Starting at the University of Florida in 1975, he completed his M.A. in anthropology in 1977. Presently, he is completing his Ph.D. with a specialization in medical anthropology at the University of Florida. 211

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Leslie Lieberman Assistant Professor of Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate~ in scope and quality, as a dissertation for the degree of Doctor of Philosophy. .,J Charles Mahan ___________ Associate Professor of Obstetrics and Gynecology

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Paul Magnarella Professdr o f Ahth ology This dissertation was submitted to the Department of Anthropology in the College of Liberal Arts and Sciences and to the Graduate Council, and was accepted as partial ful fillment of the requirements for the degree of Doctor of Philosophy. December, 1979


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