Health researchers have paid scant attention to the role of place in health except as settings where interventions take place1,2. It is now widely recognized that characteristics of places beyond the physical environment affect the health of people living there3,6. The call now is for health promotion and population health to move research beyond methods that focus on individuals to methods that capture the influence of the social and physical environments in which people live2,7,8. Further, Young9 shows that gender affects experiences of space and experiences vary among women with different social characteristics.
In this article we are concerned with the influence of rural localities on health as described by mid-life women. It is part of an ongoing project on mid-life women's health10. The two most common explanations of the role of place in forming the health of populations, composition and context, emphasize different processes. One group of explanations (i.e. compositional) suggest that the characteristics of people who choose a place explain the relationship between place and health11. Contextual explanations suggest that features of the environment impact on health11. Past research on rural health has been limited to a narrow picture of rural life. While the definitions of 'rural' vary, they typically include considerations such as size of community, population density, isolation and agriculture12-14. While there is some acknowledgement that rural experiences are diverse12,15, much of the relevant research in health focuses on farming as central to rural living16,17. As a consequence, research focused on rural health and prevention typically describes the rural environment as a detriment to the health of individuals. For example, studies involving farm accidents, the dangers of chemicals and pesticides, and the perils of exposure to weather18-21 all point to challenges inherent in the rural environment.
Furthermore, the impact of isolated living on one hand22 and a lack of privacy regarding personal information on the other10,23-27 also speaks to a difficult environment. In fact, rurality has been referred to as a risk factor28. In other studies, rural is simply a setting (eg Bastani et al.29; Taylor30), rather than one of the social constructs (i.e. the range of social relationships and social processes associated with rural environments) that informs the results of the research.
Rural health research also tends to focus on physical function when defining health31-34. This may arise from an implicit and sometimes confusing emphasis on occupational health versus general health when one is studying farming (because the farm is both workplace and home). It is argued that rural people typically see their level of productivity and their ability to work as key indicators of health. Implicit within this tendency to define health in terms of the roles that a person is able to perform35 is a definition of health that places the body at its centre and that is supported by the Cartesian dualism (i.e. separation of mind and body) common in the health sector36-38.
Our attention was drawn to the notion of gender and rurality through Watson's discussion of gendering cities39. She demonstrates how urban planning has been based on and reinforced notions of appropriate and available roles for men and women, yet has ignored needs of women and children, such as safety. She raises the provocative question of distinguishing how social, cultural and physical environments influence men and women differently. Similarly, Krieger calls for improved understanding of how places we live and work influence the roles people play and how these roles influence health40.
This article explores the rural context as described by mid-life rural women from different parts of the province of Alberta in Canada. Our discussion focuses on rural environments and the ways in which women understand, talk about, and experience their health in rural settings. The qualitative research approach that guides this study is intended to place the perceptions and experiences of the women at the forefront of the analysis. Rural women's insight into the influence of their rural environment will add to our knowledge of place as a determining aspect of health41-43. This is relevant for future policy-making and research in the field of rural health studies.
This qualitative research used approaches from ethnography44, having women describe their lives and health and well being in their own words, and grounded theory45, looking for collective meaning in data collection and analysis. The study was funded by the Alberta Heritage Foundation for Medical Research, Canada and approved by the University of Calgary Conjoint Health Research Ethics Board. Written informed consent was received from all participants. All participants who left contact information received a brief summary of the results, with provisions for those who wished to receive notice of scientific publication to receive that information.
Four female rural community interviewers from three geographic regions in the province (excluding the most northerly and remote regions) were hired and trained for the purposes of this study. Rural was defined using Statistics Canada criteria as an area with a population of less than 10 000, therefore small towns were included. Suburbs included in the boundaries of large towns or cities were not included. Participants were recruited through convenience and snowball sampling (eg women who were interviewed identifying other women as potential participants)46 initiated by the community interviewers using personal contacts47. As data collection proceeded, interviewers were asked to identify women with certain characteristics that may have resulted in different perspectives or data, for example, being single or over 60 years. The participant was always known to the interviewer, but this ranged from having a mutual acquaintance to knowing each other very well. The decision to use local interviewers was based on the need to gain entré into communities that were unfamiliar to the researchers47. The advantages of local interviewers (eg access to and familiarity with the area, not being 'an outsider') were perceived by the researchers to offset the disadvantages (eg the potential for selection bias in sampling, participants not talking openly to someone lived within the area). These disadvantages were minimized through the interview training sessions that emphasized sampling strategies, interview techniques and ethics procedures and by regular communication between the interviewers and a research associate.
Data collection, using an interview guide, continued until saturation48 was reached. Twenty-four women were interviewed. The interview guide was designed to capture rural issues and was pilot tested before full data collection was undertaken. Questions addressed during the interview included definitions of health and current health issues, use of health services10, responsibilities, family roles and health behaviours. Women were asked to rate their health status from 1 to 10 (1 = poor health; 10 = excellent health). Women were also asked about their geographical environment and its role in their lives. A sub-sample of 14 of the same women additionally participated in a telephone follow-up interview concerning their views specifically on how rural living affected their health.
All interviews were transcribed verbatim and imported into the software program QSR N4 Classic (formerly NUDIS*T 4; Sage Software, USA) for summary and analysis and to aid in interpretation49. One member of the research team performed the initial coding for this project. Thematic analysis was undertaken using memoing and coding45 and immersion and crystallization50,51 on 12 of the interviews. At this point the primary author returned to the literature to seek categories suggested by other authors. The remaining 12 transcripts were then coded to confirm or modify the previous findings. Connecting and legitimating52 through reviewing of the texts and identified themes was also done by the research team in conjunction with revisiting the relevant literature.
We used several techniques common to qualitative research to ensure that standards of rigor were met. Situating the study in the literature, bracketing, and methodological cohesion46,48 were used as strategies to ensure validity. Within-project validation was addressed through using multiple research team members to develop codes and interpret the data, searching for disconfirming evidence and thick description48,53-55.
Twenty-four women ranging in age from 40 to 65 years were interviewed. The majority was married and a minority had children still living at home. Women outside of towns or villages lived anywhere from a few kilometres away from the nearest town to within close proximity of a sizeable city; all were connected by road to other houses and other towns or cities. Women's length of residence in non-urban settings ranged from their entire lives to relatively recent moves away from the city. Some women had occupations outside of the home, and some were retired from the paid labour force.
Women held a holistic view of health (i.e. incorporating physical, mental, spiritual and social aspects) and firmly rejected a notion of separate minds and bodies, unless they were speaking of medical matters56. They were knowledgeable about health issues, some more so than others, and had many sources of information. They valued healthcare services and healthcare professionals, but they also utilized complementary and alternative health care10. Some had serious chronic illnesses (eg chronic viruses, arthritis) and others considered themselves health-problem free, with the majority rating their health as good or better which is typical of Canadian reports of health rating57.
Through analysis and interpretation four important aspects of rurality were revealed for these women: (i) the meaning and symbols of rurality; (ii) change and the understanding of rurality; (iii) getting away and getting around; and (iv) diversity in rurality. We represent the perspectives of these women by summarizing their statements under thematic headings based on our interpretations of the data58. Direct quotations from the participants are occasionally used to illustrate linkages between the data and our interpretive statements.
The meaning and symbols of rurality
Rural life is symbolized by: clean air; no 'hustle and bustle'; the presence of wild life; the freedom, if one wishes, to have domestic animals; the beauty of nature; open space; and knowing the people around you. All of these symbols have importance in terms of health for mid-life women.
The city 'smells differently'. The importance of the symbol of clean fresh air is evidenced by the capacity of the women to dismiss the importance of bad smells (eg from horse processing plants or chicken farms) as occasionally linked to shifts in the wind. These bad smells were not discussed as health threatening. The air in general was considered to be smog-free, health enhancing, clear and linked to peace and quiet.
Rural living is quiet, laid back, peaceful and relaxing. Several women echoed the phrases used by this woman to distinguish rural from city living.
I think the laid back pace and the lack of stress, you know, from the hustle and bustle around you. Because it seems like, I'm not sure if the word is contagious, or if it rubs off, but when people are just like frantic all the time, you sort of start feeling that and become that too, yeah. 
Wild birds and animals around the home were linked to the natural beauty of the surroundings, which contributed to a sense of wellbeing. One woman suggested that she did not value nature as much when she was younger, but that in mid-life it has become more important. Domestic animals were also important as companions and sources of pleasure. Pets, especially dogs, were seen to benefit from the space and to provide pleasurable opportunities for the women to be physically active and outside. Other domestic animals (eg cattle, calves, sheep) were valued not just for the economic role they played, but also as symbols of nature, reasons to be outside, and sources of involvement for women in the economic life of the family.
Open space is a symbol of freedom and linked to nature. While one knows everybody, there are also spaces between homes, so that, unlike in the city, the neighbour is not monitoring your yard. Open spaces allow one to walk freely, without following roads or pathways. They also provide places to take an impromptu commune with nature, either during a lunch break, or while commuting between work sites or work and home.
Knowing the people in your area was an important symbol of rural living. In the city, it was believed people often do not know their neighbours even though people are perceived to live very close to each other. In rural areas neighbours homes may not be visible but one knows personally the shopkeepers and the healthcare providers. Knowing everyone and having everything about you known was sometimes perceived to be negative.
These aspects of rural life were powerful symbols3 of rurality and almost everyone interviewed considered them important to their health and wellbeing even when the facts (eg pollution) might contradict their symbolic value.
Change and the understanding of rurality
Women talked about how their views of rural living changed at different stages of their lives. They also talked about how rural places changed over time. One of the big changes perceived by the women was in the role of farming in rural life. Age-related change and re-evaluating priorities were common themes associated with mid-life by these women, and we have discussed this elsewhere56. Women who still had children at home and women who had raised their children saw rural settings as, for the most part, places that benefit child development. The perception of benefits was offset for some by physical isolation and increased travel associated with visiting friends, participation in sports or other extra-curricular activities.
I had young children, my husband was gone for long hours and the areas that we were in, most of the people were of my in-law's age group, not mine. So at the time seems to me it was very lonely, it seemed like I was always on the road running the kids to town for, you know, skating and music and that. 
Rural settings were perceived by some to offer much more support for both last minute and planned childcare unlike in cities where neighbours were perceived as strangers.
As one ages, caring for properties becomes a bigger challenge. Although most women lived in homes that they owned (or co-owned), even those in rental properties were responsible for upkeep and yards. Some women had moved because maintenance had become too much for them to handle, especially after the loss of their husband or other family. Other women spoke of the likelihood that they would move to town if their husband died or if ill-health for either of them required closer proximity to health services. Although some had children living in cities, only one woman spoke of moving to a city to be with them.
Finally, changing lifestyle also meant that the lack of hustle and bustle that is so symbolic of rural life was not always a reality. In fact, the stress of complex lives filled with jobs, homes, families, churches, and volunteer activities was discussed by several of the women in discussing their health.
Places also changed over the course of women's lives through shifting demographics. One place was described as having a populace that went from middle-aged to seniors to younger people. Another woman talked about many of her friends having died or moved away. Another place was changing in nature because younger people were commuting from both cities and farms to work with one of two large employers, opposite to the assumption that people commute into cities to work. They were not moving to the town, however, and the town, therefore, maintained a large senior population.
Rurality used to be synonymous with farming but the changes in agribusiness have meant that many rural people work off the farm, and some farming is, as one woman said, 'more like a factory'. Two women had husbands who were employed on farms that were not owned by relatives. In one case, the couple was considering a move and different employment because of the time demands of being the farm manager.
Well its changed a lot...well actually most of them work out, the young people all work out...its like an exodus in the morning here. They either go to the city or, you know, so its changed a lot and they're not really rural people in the same sense that we were. 
Despite the changes in farming, however, it still influences the meaning of rural. Some people, for instance, do not consider small town living rural - rural is being out of town, and to many, out of town means being on a farm. One woman emphasized the link between her health and the closeness to the land and nature that is associated with farming.
Well it is yeah, um, physical being on a farm...it's important for me to be able to connect with nature, and so I think with the animals and with the land that I own and the land that I rent,...I take advantage of that, and it helps a lot and releases tension and you know to go find a place where you can just be there or, I find that helpful. 
Getting away and getting around
These women did not lament a lack of services or feel burdened by the necessity of going to town for goods and services. If one ran out of something, one ran out, and it was not 'that far' to go. In their view, small towns have most of the services that people need - shops, gas stations, libraries, schools and so on. Cities were places to shop, but mainly to increase variety or to find lower prices. The only services that women consistently identified as lacking were medical services, particularly emergency and specialist services10. If health appointments necessitated regular visits to cities, however, one could optimize the effort, 'make a day of it' and do errands for other people as well.
The privacy of not being near neighbours and the ability to get away from society56 was an important way of maintaining mind and body balance:
I think that, that that's what keeps me healthy, is that I have that ability to go and get away some place, uh it may not be for very long, it may just be like for a half hour or, out of the day or something, but at least I have that opportunity whereas if I were in a city, uh and I couldn't go some place, to kind of unwind, I think I would feel really trapped. 
Driving is an important aspect of literal movement for rural women and movement in general was captured in many figures of speech associated with health and wellbeing for these women (eg bouncing back, coasting along, moving on, slowing down)56. Women drove to town to shop but also for health appointments. Some also drove to cities to visit children, or to attend special medical appointments, and some did a lot of driving for their jobs. It is not surprising, therefore, that having cars was also important, as was having family and friends who would help keep the cars operational.
Rural roads were contrasted to city streets where 'fighting with traffic' was considered intolerable. Roads were also, however, places where one might encounter strangers in an area where knowing everyone was the norm. Strangers 'on the roads' were a reason for one woman not to go walking by herself, though in general women felt safe walking in the country. Strangers, as well as winter conditions, made getting to towns or cities a problem for some and placed limits on their freedom of movement:
No I don't drive in the city anymore, no. I just drive out in the smaller areas. Yeah, and that's, and that is a bit of a problem out here because there's a lot of people that don't, you know, you just don't drive where it's that busy because you're not used to it, and you know, it's quite a challenge. 
Diversity in rurality
It became clear from analyzing these interviews that if a simple notion of rurality was ever useful, it is now obsolete. The women talked about many forces that shaped the rural towns and villages in which they lived, including the economic and demographic changes that happen as a result of external and internal policies, history and geography. Some towns in Alberta were described as centres of seasonal tourism and that issue was a focus for policies, such as where highways should be located, and the types of employment opportunities available. Sometimes tourists are drawn to visit historic sites, other times 'outsiders' construct homes or cottages to take advantage of the symbols of rural life. These outside people were rarely considered rural, but they may have become friends or neighbours. Some of the respondents' discourse challenged whether towns can even be considered rural, for instance:
We still own land rurally [emphasis added] which we have rented out to neighbours um, but that's the extent. You know once in a while you know we reminisce on how much we enjoyed the cattle and you know but you know I felt lonely out in the country [emphasis added] and I do not feel lonely living in town...the connection is still there and the possibility, you know like if they ever wanted to go back out rural, outside of town [emphasis added], we could do it, it's just I don't think we ever would. We're happy here. 
These women's narratives revealed facets of their lives and environments that seemed to be markers for their own personal status of being rural, and together inform a new understanding of what it is to be rural in our contemporary world.
This study contributes to the call by Rosenberg and Wilson59 for new theories of geography that take into account the differences among places and meanings. They suggest that such theories should reflect the political and physical properties of place. Differences among rural places was evident in the women's discussions, including their descriptions of what it was like to inhabit a rural place7. The data challenge assumptions about the detrimental relationship between place and health in rural contexts and point to the need for further investigation in rural populations.
Our analysis suggests that there are important differences in rurality and to ignore this may perpetuate what Rosenberg and Wilson refer to as making generalizations that are too simple to be useful59. The finding of heterogeneity or difference is not new; other researchers who have done qualitative research12,60 with rural women have remarked on the heterogeneity of the populations. These differences have important implications for researchers and program planners.
It is common to see comparisons made between 'urban' and 'rural' people. The evidence presented here suggests that some rural people have more in common with their urban counterparts than with their rural 'neighbours'. In fact the concept of neighbour and neighbourhood varies for those living in small towns, on small farms versus large farms and so on. Researchers may be encouraged by other demands to collect and code data on rural people in a way that obscures our understanding of the relationship between place and health59,61. The necessity of statistical power, for instance, can push researchers to incorporate people from a large area into one group, thus combining people from both inside and outside of towns in a single analytic category and calling the group rural, potentially obscuring important features of place.
While existing research has shown that the divisions that governments create, such as census groupings, are often useful for examining compositional effects of geographical areas because they are usually designed to minimise compositional variations within the areas, our data suggest that the practice of using these units for studying contextual effects is problematic. Indeed because attributes emerge from local patterns of social relations and resources, a definition of local environments must include how people define their local environment. Units that make sense to people in terms of resources for various aspects of their life and significant relationships are more likely to produce results that will illuminate the relationship between context and health, than geographical areas defined solely in terms of administrative relevance or data availability. A nearby town may provide services for some rural women, services and a workplace for others. The town is likely to be more significant to the latter woman, but she may not consider herself to be a 'towny'. All women in the geographical area may be assumed to have access to the services provided in the town, but women who have to drive for half an hour have a greater barrier to access then those living in the town, especially with variable road conditions.
What it is like to live in rural places
Many assumptions persist about rural life and the meaning of living in rural areas. Our data reveal that mid-life rural women imbue rural places with health enhancing properties and their everyday experiences support both compositional and contextual explanations for the relationship between rurality and health. Respondents believe that there are rural folk and city folk (i.e. people with similar characteristics choose rural living) and they also believe that many characteristics of the rural setting are health enhancing. What is true, however, about the role of place for mid-life rural women will not necessarily be true for younger women with children, nor for older women who, for instance, can no longer drive. The characteristic of rurality that mid-life women criticized most in terms of health was lack of access to health services10; however, this is far more salient for those women who no longer drive in cities than for those who can 'make a day of it' when an appointment in the city is required.
It was clear that mid-life rural women did not see rurality overall as a threat to their health. Macintyre et al. define the reputation of a neighbourhood as 'how areas are perceived by their residents, outsiders, and service or amenity planners and providers' (p. 221)7. If health promotion practitioners characterize rural areas as 'high risk', focus on the occupational health threats of farming, or otherwise suggest that their view of an area is negative, this may be at odds with the views held by residents and create communication problems. Moreover, if believing your area has a good reputation is good for the residents' health, this deficit model of program justification may be damaging in the long run.
The data here suggest that assumptions about the relationships between place and health need to be re-examined in rural settings. In fact, the large role of movement, including the need to commute for social, employment and recreational purposes, means that place in a rural context is often fluid and multifaceted. Contrasts among rural settings and between these and urban settings may help clarify the composition and context arguments. It is difficult, for instance, to situate rural women in any one locale or community, even individually. Many mid-life rural women did try to contribute to community health and wellbeing through their jobs, and others through volunteer activity.
Some women described current political issues that were impacting on the wellbeing of their communities. They knew where to go for health information, and used personal networks extensively to share information. Their social networks and the people they care about, however, may live within a large geographic radius. Children may live in a nearby city. Services from specialists are certainly sought in larger urban areas that are also visited for some entertainment and consumption needs.
Engaging mid-life rural women in community empowerment and of monitoring long-term outcomes raises special challenges for researchers. Simple notions of geography may over-simplify community relations59 and notions of where women might be found at any given time. If the opportunity to participate in community activities is indeed key to health62 this is not a minor concern.
Our study supports the assertion that there is no one rurality, but that rural living is understood by mid-life women to be very important to their health. Where geographical or conceptual boundaries between 'urban' and 'rural' are drawn will have important effects on studies of compositional and contextual influence of rural living. Furthermore, the role of context changes with the age of women, largely due to changes in their roles. Speaking of 'rural women' does immediately alert us to their exclusion from the category 'urban', but beyond that, the phrase combines two complex context (rural) and compositional (women) variables63 that require further elaboration. Providing rural women with an opportunity to articulate their views on rural living and health has contributed important insights upon which to build.
We would like to thank Cathie Scott for her assistance in training community researchers and the final preparation of the manuscript, Carol Berenson for completing the follow-up interviews and Kathy Dirk for copy editing. We would also like to thank the editor and reviewers for their helpful comments, and in particular Jennifer Richmond for her feedback. This project was funded by a Health Research Grant from the Alberta Heritage Foundation for Medical Research.
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