Women's Perspectives
Health Concerns in Rural Frontier Wyoming
by Alan Barstow • photos Paula Wilson-Caziér
Picture the iconic Wyoming scene: a rancher in a barn jacket, cowboy boots, and Stetson hat, with a stubbly chin and tired eyes, tending a newborn calf.
Now picture a woman, maybe the rancher's wife, mother, or daughter, who photographs this scene, and hear her comment: "It's a hard but good life."
Or picture a gravel road bordered by barbed-wire fence, a pale green field of sagebrush stretching to grey mountains with white peaks, and a pristine blue sky—and hear this woman, a life-long resident of rural Wyoming, as she reflects on her photo of the scene: "There's nothing here, and no one to notice when you are in trouble."
Independence, natural beauty, peace, and privacy are hallmarks of living in Wyoming, but they aren't virtues when women like these live in places where the nearest health-care provider is an hour or more away.
"When it comes to health, these women are straddling
the line," says Susan McCabe, an associate professor at the University of
Wyoming's Fay W. Whitney School of Nursing, who recently completed a study
of rural frontier health by recording the experiences of women in photos and
words. "This means these women—and their families—constantly have one foot
in health and the other
in illness."
The weak December sun colors the books and artifacts on the shelves in McCabe's office in the Natural Sciences Center at the University of Wyoming, and it catches on the reading glasses hanging from her neck. McCabe's phone rings often, and former and current students stop by her office.
McCabe doesn't talk as if she's busy. She takes time with people, often hearing what they're not saying. These skills helped her carry out a study commissioned in 2007 by the private, non-profit Wyoming Health Council (WHC), which works to ensure that Wyomingites have access to quality health care. The project also earned in-kind support from the School of Nursing.
McCabe joined the School of Nursing in 2004 after working as a registered nurse and health educator across the U.S. and in Micronesia. Her background in mental health and work with underserved and rural populations made her the ideal researcher to lead a study for which the data would be real women with real frontier perspectives.
"Who did you turn to when you were sick or ill as a child?" asks Lucy Williamson, executive director of the WHC, from her office in Cheyenne. "Often, it was your mother, grandmother, or aunt. Women take the initiative to address health concerns for the entire family. It was your mother who said you had to go to the hospital or doctor when you were ill, rather than your father. This is why we said, ‘Let's talk with women.'"
For this program, the WHC was not interested in statistics-based research. "We already know that there are X-number of doctors in Wyoming," Williamson says. "We want to know more about why people aren't using health services because of issues like the environment, transportation, health insurance, and work. We want to know more about why these people aren't taking advantage of these services because of issues like the environment, transportation, and work."
McCabe says, "People cannot relate to numbers as well as they relate to the graphic picture, and the words of the women resonate in ways that numbers don't."
For this study, McCabe worked with secondary researchers Corrinna Seeley, a UW graduate student on contract with the Wyoming Health Council; Carol Peterson, the director of the WHC's Wyoming Women's Health Coordinating Center; and Norman Peterson, a WHC-contracted employee and former UW professor.
The team intentionally chose six Wyoming communities that represent the agricultural, mineral, gas and oil, and mining economic base of the state, as well as Wyoming's ethnically diverse population of Caucasians, Hispanics, and Native Americans. Because of the confidentiality requirements of the research, the women cannot be identified.
The next step was identifying a key person in each community. "This is someone everybody knows," McCabe says. "Could be a person in health care, could be the owner of a store, or a librarian." That person found other women willing to talk about their experiences with health and health care. McCabe and her team interviewed 45 women, asking each to complete a health survey. They collected data on the communities by visiting the chambers of commerce or visitor's centers and flipping through local newspapers and phone books.
About half of the women interviewed agreed to participate in and additional photo-voice study, in which the women photographed images relating to health. McCabe recorded conversations with the women, who explained why these pictures were important.
"The pictures are actually fairly boring,"
McCabe says, leaning back in her office chair. "They're of common, everyday
sorts of things. It's only when you get words associated with them that you
realize how we understand things through the common aspects of our lives."
They tell a powerful story of their health experiences in rural, frontier Wyoming.
One picture shows a broken machine in a clinic. McCabe says a woman took this picture after taking her daughter in for care. She reads the woman's quote, a motif on her experience with health care: "They don't give [my daughter] anything else. Not a Band-Aid, not anything. Just check her and taking the X-ray and $680 bill. [Health care] is all busted up like this machine; should run, but it don't."
McCabe says the women were primarily concerned with the cost of medical care, the unreliability of health insurance, and the consequences of seeking care. She reads another woman's quote: "They had a gal [hospital employee] who talked to me, and she [said], ‘We will work with you, we will try not to take your house.'" McCabe shakes her head and says, "It never occurred to this woman that she could lose her house because she received health care for her sick child."
Almost half of the sample, 45 percent, reported they did not have health insurance; those who had health insurance lived primarily in energy boomtowns and were constantly afraid of losing it.
"Poverty and bad health, they go together," McCabe says, reading another quote. Due to costs, 34 percent of women reported not seeing a health provider in the last year when ill, and 19 percent reported not taking prescription medicines. To make matters worse, McCabe witnessed reports of women watering down insulin and diluting high blood pressure medicine to save money.
McCabe found the women had an incredible system for making decisions on which providers to see about their health concerns. Due to issues like the breakdown of confidentiality and lack of trust, women often didn't see their local provider, but traveled long distances to visit other clinics.
"Across the board," McCabe says, "the women were concerned that no one gave them credit for knowing themselves. Nobody respected their ability to come in and say, ‘I think this is it, this is what I need.' They felt they knew their bodies and knew what they wanted, but they were usually dismissed and disregarded as experts of their own health."
This disenfranchisement may have been linked to gender and ethnic stereotypes the women encountered, especially with mental health. A shocking 45 percent of the women reported suffering from depression, but felt they were dismissed or had to prove they weren't going to hurt themselves or someone else to gain access to care, which often left them even more depressed.
Outside Wyoming, these problems may be avoided simply because of greater access to healthcare providers closer to where people live. But this is not the nature of rural Wyoming.
Yet, in their comments, the women said it was the nature of Wyoming that kept them healthy: less stress because of less traffic and fewer people, and the beautiful environment. Even so, these same factors, however, keep these women feeling vulnerable, which leaves them with the perception of not having good health.
"This is the paradox of rural," McCabe says. Experiences like this leave the women feeling as if they are on the brink of disaster, especially in inclement weather. Not only do the Wyoming winters make travel hard between September and May for people, they make trucking fresh produce to rural towns difficult. Without affordable produce, the women aren't able to eat as well as they should to treat their most common ailments—diabetes, cancer, and arthritis.
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The women unanimously agreed the environmental factors that most influenced their health were wind and elevation. McCabe says Wyoming has the highest sustained winds of any state, the greatest range of daily temperature, one of the highest elevations, as well as one of the nation's highest suicide rates. "But," McCabe says, "there is not one iota of discussion about wind affecting mental health. I presented these results in Washington, D.C., at a large federal conference, and a person in the very back row said, ‘Excuse me, but Little House on the Prairie defined that for years.'"
McCabe's team was hoping to capture perceptions like these, and that put the WHC in a better position to influence the health of Wyoming residents.
McCabe is now wondering what kind of connection exists between health, temperature, and elevation in Wyoming. She and Carol Macnee of the School of Nursing are applying for funding to research such a connection. McCabe believes that as more research is done and the concerns of women are addressed, families' concerns will be addressed as well, which, in turn, will increase the welfare of the state.
McCabe found these women eager to tell their stories and thirsty for more knowledge. During the focus group sessions, McCabe says, "The women asked us ‘Should I be taking this medicine?' Or, ‘Do I need a second opinion?' For the sake of the research, we couldn't answer those questions then."
"These communities put their faith in the researchers," Williamson, the WHC director, says, "and we don't want to just drop them. We plan to get back into the communities."
With the support of the School of Nursing, McCabe, Macnee, and School of Nursing professor Pamela Clarke will visit these communities for open sessions in which residents will be able to ask health professionals questions about their health and get some answers.
"Ethically, this is our way to say thank you to these communities," McCabe says.
