Violence against women is understood to be any gendered-based action or conduct that causes physical, sexual, or psychological damage to women and occurs in both public and private settings1. Violence against women takes on several forms, with intimate partner violence being identified as one of the most commonly examined types of violence2. Intimate partner violence is defined as a pattern of physical, sexual, and/or emotional violence by an intimate partner within the context of coercive control3. Global estimates of the impact of intimate partner violence on women range from 15% to 71% with Canadian estimates of 25% to 30%3-5. Although leaving the abusive relationship is the dominant proposed solution to violence6, women who leave an abusive relationship often experience restricted socioeconomic mobility, loss of social and community networks, and ongoing interpersonal violence from the abuser, which can be greater than was anticipated at the time of leaving7-10. Given its prevalence and context, intimate partner violence has, not surprisingly, been identified as a significant public health concern11.
Research underscores the significant, detrimental, and often long-term impact of intimate partner violence on women's mental and physical health both during and after leaving a relationship4,12-14. Recently, long-term abuse has been linked to physiological and epigenetic changes15,16 as well as chronic psychological stress, with depression and post-traumatic stress disorder identified as the most common mental health sequelae associated with intimate partner violence4,15,17. Among the associated detrimental health effects, research demonstrated a compounding effect in rural settings18. This compounding effect on health is especially important as emerging research has demonstrated poorer mental health as a significant predictor of women's inability to maintain separation from an abusive partner19. Given the well-documented health effects of intimate partner violence, it is concerning that women who have experienced it face barriers in accessing health care and other social supports, and report significant unmet needs and/or poor fit of services when services are accessed, an experience further exasperated when living in rural areas18,20,21.
Rural settings can be understood based on the unique set of values embedded within the context such as rural pride, privacy, and sense of community22,23. The sociocultural context of rural settings increases women's vulnerability to intimate partner violence which in turn negatively impacts help seeking and resource availability24,25. However, these values are inherently problematic for women who have experienced intimate partner violence as it results in a context that sanctions intimate partner violence through cultural beliefs such as permanence of marriage, importance of privacy, preservation of intergenerational property transfer, and dominance of patriarchal attitudes26,27. Also, it fosters stigma, as close-knit community networks not only prevent anonymity during help seeking for health and social services, but also negatively impact willingness to seek help through the overlapping nature of relationships within social networks22,28. The negative aspects of the rural context are further compounded by the most obvious barrier women face when seeking health and social services: geographic distance29. Not only does distance adversely impact help-seeking behaviors but it also restricts access to appropriate health care and resources30,31.
A common social response to intimate partner violence is the use of shelters. The mandate of shelters in Canada includes the provision of a safe place for women during a time of crisis32,33, as well as safety and protection planning services, advocacy, transportation services, short-term counseling, and housing referrals32,34. Shelters remain the primary entry point for health and social services such as emergency and transitional housing, counseling/support groups, advocacy for the attainment of health and social resources, and legal advocacy35,36. However, the needs of women who have experienced violence are changing. Specifically, recent research highlighted that women are shifting to utilize shelter resources but are not necessarily staying in the shelter37 and the services within shelters are shifting to an integrated set of health and social services for women and children that extends beyond the current mandate of shelters34. Given the woman-centered feminist approach that prevails in the shelter community, shelters have evolved to be responsive to women's changing needs34,35,38. This changing role of the shelter merits further investigation, and as such the purpose of this case study was two-fold: to (1) explore how one rural Ontario women's shelter role was changing, and (2) examine how the shelter has adapted to address the changing role.
A qualitative case study was used based on a feminist, intersectional framework to ground findings in the lived experiences of participants and provide a basis for the pursuit of social justice39,40. Participants were recruited via posters at the rural Ontario shelter. The community where this study took place has a population size of 20 33541. The community is 35 km from a large urban center. The percentage of the working population (aged 15-64 years) is 64.2% and the average income per individual was $35,211 and per family was $80,973. Participants interested in the study responded by email or phone to the principal investigator. Participants were screened for eligibility over the telephone (see Table 1 for eligibility criteria) with all eligible participants enrolling in the study. Subsequently, a mutually convenient interview time was set up at the rural shelter where the principal investigator obtained written informed consent and provided an honorarium (of C$25 cash to all participants (service providers and women)) prior to the interview in appreciation and recognition of the participant's time. Data were collected from two subgroups: service provider (n=6) and women utilizing the shelter (n=4).
Each participant completed a semi-structured interview lasting between 30 and 90 minutes (averaging 60 minutes). During the interview, data trustworthiness steps42 were undertaken including member checking, paraphrasing, and synopses to help ensure data was an accurate reflection of participants' experiences. In addition to the interviews, field notes were taken throughout the interview process by the interviewer to provide context and contribute to the rich descriptions and contextualization of the findings. The interviews were audio recorded and subsequently transcribed verbatim.
Table 1: Study inclusion criteria by subgroup
The interview content was divided into four sections: demographics, current status of services, barriers/challenges, and strengths/success. A short questionnaire was used to gain demographic information: highest level of education achieved, marital status, current housing situation, primary work status, personal income, dependent children, and ethnicity. Current status of health and social services use was determined with two open-ended questions: (1) 'What is the current status of services being offered/utilized at the shelter?' and (2) 'What is the history of service use with the rural shelter?' (probe: 'What services have you provided in the past?' or 'What services have you used in the past?'). Barriers and challenges were addressed through three open-ended questions: (1) 'What are the greatest challenges you face?' (probe: 'In delivering or accessing services?'), (2) 'What are the greatest programming/staffing needs?', and (3) 'Where is the greatest gap in health and social service and care provision?' Strengths and successes were asked using three open-ended questions: (1) 'How does the rural shelter encourage or support women to access care?', (2) 'What are the strengths of the rural shelter?', and (3) 'How does the rural shelter address the greatest gap in health and social services?'
Two researchers (principal investigator and co-investigator) conducted thematic inductive content analysis of all transcripts and field notes independently43,44. In addition to transcriptions and field notes, data triangulation was achieved through examination of website and social media materials, organization pamphlets, and interviewer participation in site programs. Emergent themes were identified and subsequently compared to examine consistency in findings. Arising discrepancies in analysis were discussed until a consensus was achieved in the emergent themes43.
Ethics approval was obtained from Western University prior to any communication with participants (REB106335).
The results of this study can be split into two sections: the changing needs - and subsequent role change - of the rural Canadian shelter, and the adaptation strategies being utilized by the shelter to fulfil those changing roles (Fig1). In the first section, the historical role of the shelter was examined and subsequently compared to the current role of the shelter as described by participants. This process highlighted the emergence of three unique changing roles within the rural shelter: filling gaps, case management, and system navigation. In the second section, three adaptation strategies emerged that the rural shelter was using to fulfil the change roles, including relationship building, community mobilization, and redesigning delivery. Ultimately the goal of the adaptation strategies was to not only fulfil the new role of the shelter but to also create larger social change by transforming the cultural and structural norms surrounding violence against women. Each of these themes will be discussed in turn.
Figure 1: Changing roles and adaptation strategies of one rural shelter.
The changing role of the shelter centered around three specific themes: filling gaps, case management, and system navigation. All three of these additions to the historical role of the shelter were based on either the shifting needs of the women utilizing the shelter or the shifting population utilizing the shelter.
Filling gaps: One of the changing roles of the shelter stemmed from an increased necessity to fill gaps left by other community and health services such that women's needs were not left unaddressed by the current systems. Part of the need to fill gaps was due to the rural context and the continuous erosion of health and social services and funding, with service providers saying 'I think it is partly that we're in a rural place and that we need to do things different because our environment necessitates that' (provider (P)2) and 'I think we try to cover as much as we can 'cause we're rural' (P3). This highlighted the notion that there were gaps left in health and social services due to geography and the rural shelter aspired to address those gaps. This addition to the role of the shelter to fill the gaps was recognized by service providers as essential: 'What it means to me is kind of the no wrong door philosophy. So I would hate for a woman to come in and for us to say, well we don't do that so find somebody who does. My hope is when she indicates a need or an area that she wants further exploration, growth or to get needs met that we would help her connect with that' (P2).
This filling of gaps was salient for women who had received services, as they were able to recount many instances where service providers at the shelter went above and beyond the defined role of the shelter. Particularly, one woman noted that a service provider walked with her to a healthcare appointment and waited while she was in the appointment as ' they knew I wouldn't walk there by myself because I wasn't ready to do that one on my own' (woman (W) 1). Another woman identified myriad support she had received that she knew was a clear extension of what shelters normally do, such as '... microloans, food, through the Circles program [about social boundary creation] ... I actually got a used vehicle through the program for free' (W4). This filling of gaps was recognized by women and much appreciated.
Case management: Service providers and women alike highlighted the changing role of the shelter in terms of case management. The need for case management was seen as the result of the ever-increasing complexity of women's lives and healthcare needs alongside the increased barriers for health and social service: 'we see the complexity increase for the women that we experience [at our service] and the barriers to good service, we don't see that decreasing' (P2). As such, service providers were increasingly taking on a case management role whereby they supported women in seeking and accessing health and social services: 'we give women some supports and help them find resources in the community' (P3). Women highlighted this support, saying service providers were 'very supportive and helpful, you know printing off applications and just, you know making things as easy as possible so I didn't have to do a lot of the footwork to get what I needed' (W3) and 'the staff here is terrific, they help me take care of everything like find a place to live, buying food, making friends. Everything' (W2).
Additionally, the changing needs of women were also the results of the changing population the shelter was serving, with one service provider identifying 'we're not serving as many families as we used to be. We're serving single women who are more transient in nature. They may have intersectionality with addictions, trauma, mental health, that kind of thing' (P2). This shift in population increased the complexity of the health and social services needs for women. In order to facilitate the successful intersection of the system with the women, service providers were adopting a case management role to bridge existing gaps.
System navigation: A final important new role of the rural shelter was system navigation. Supportive system navigation was understood in two ways: identifying providers who understood the context of violence, and preparing women to interact with systems that did not understand the context of violence. For the former, service providers were working to help women effectively navigate the system by helping to identify service providers who would provide care and understand the violence context, which was difficult in the rural setting. One service provider highlighted this by examining the difference between knowing what a service provider was like versus not: 'I can give you a phone number and say, call these people, right. It's a whole different feel if I say, you know I know those people and this is some of the service. I think you might benefit. Do you want to invite them here? Or I can go there with you. Or something like that. A warm transfer I think is much more effective than here, cold call this number and see how that goes' (P1). This informal system navigation to 'preferred' service providers was important given the rural context, as one service provider highlighted that within the rural context 'doctors don't know about trauma, and have an old fashioned idea about who is using the [shelter]' (P1). As such, utilizing informal system navigation has the potential to increase the success of the interaction of the system with the women. Informal system navigation was identified as a key to success by women as their access to health and social services was expedited, with one woman saying 'I had made an appointment [with a counselor] within the first week of being here for that same week' (W3). This expedited service was particularly salient for this woman as she had been trying independently to access the healthcare service prior to the shelter for months with no success.
In the rural context, when a service provider could not be found who understood the context of violence, shelter service providers would help women to navigate the system by preparing them for the interaction, with one service provider identifying 'I always try to warn them ahead of time, like even though you're going [to the hospital] because you're feeling suicidal they're still going to take all your vitals. So they're going to be hands on with you. Sometimes they'll ask, sometimes they just kind of do it. Just make sure you're ready for that ..., and try to prepare them for those things if I can't go with them as well' (P1). Another woman identified this system navigation piece as paramount in her finding a family doctor. There was a lack of family doctors in the rural region and so the service provider highlighted the need to continually follow up in order to get rostered. The woman recalled 'it was taking so long so we got together and called them again and again, and we kept on them to get me a doctor because it was important' (W1).
To fulfil the shelter's changing roles (ie filling gaps, case management, and system navigation) several adaptation strategies were utilized, namely relationship building, community mobilization, and redesigning delivery. By adopting these new strategies not only was the rural shelter able to address the changing needs of the women but also to advance the larger mission of transforming cultural and structural norms as a means of contributing to the end of violence against women45-47.
Relationship building: A key adaptation strategy utilized by the rural shelter was relationship building. One service provider highlighted this focused endeavor, saying 'I would say that over the past couple [of] years we've been working at developing deeper relationships with organization like Children's Aid, Community Mental Health, addictions services, and sexual assault center, the family health team and with the local hospital. We're recognizing that there's barriers there and perhaps those other organizations aren't aware of the barriers in the same way we are. And so just building relationship to have more difficult conversations' (P2). The importance of building relationships was underscored as it had a positive impact on the work being done both in the shelter and within the community, with one service provider saying, 'the relationships, nurturing the relationships are so important so I'm seeing this theme you know it's good work, good relationships follows good work' (P1). Furthermore, all the service providers identified that system navigation was best achieved through relationship building, saying 'building those relationships still needs to kind of happen, and makes, the referral process easier, knowing what you are referring to' (P1).
It is through this specific focused strategy that change started to emerge both in an attitude of the community and in women's ability to partner with agencies. The attitude change was evident as the rural shelter was able to facilitate a conversation with several local agencies that work with women who have experienced violence, with one service provider saying 'we had police, children's aid manager and frontline, mental health, family counseling, sexual assault center, victim's services, our agency [rural shelter], our First Nation community - really a gamut of people ... we developed a coordinating committee' (P1). The purpose of this committee was to examine options to improve service delivery to meet the changing needs of women who access services. It was through this collaboration and relationship building between service providers and community partners that the perception of violence against women was starting to change within the community both for the women utilizing the shelter and the community partners alike. Specifically, the ameliorated relationships increased comfort for women in accessing various services, particularly services that were typically difficult for women to work with: 'It is hard to have good relationships with some of the people who are supposed to help you like [children's aid], but at least when someone here says yeah so and so is good, it makes it a bit easier to trust them' (W3).
Community mobilization: Another adaptation strategy was facilitating community mobilization through education and engagement. Community education was an important gap the rural shelter was trying to overcome. This included a general lack of knowledge around violence or the impacts of violence for community members, with one service provider saying 'there is a gap in our community about violence and we are trying to fill that gap' (P1). This was further underscored when a lack of knowledge about the impacts of violence, such as homelessness, by community service providers was highlighted: 'We were at a community event where the psychiatrist, the only psychiatrist at the hospital said there was no homelessness in rural [settings]' (P1).
It is through this education piece that the rural shelter was able to foster community engagement, as highlighted by one service provider who noted the emerging change within the culture of the community, saying ' so we see a community sort of mobilizing around a shared understanding of what the problems are' (P1). The importance of community engagement was identified as foundational in promoting community ownership of violence within the community and the need to facilitate change. One service provider described this, saying 'so I think the community engagement piece [is] really asking our community like putting it out there and making them take ownership that violence is not just our agency's work' (P3). Another service provider said 'so I love that we're engaging community and I think that the fact that we, when we see a need we try our best either to provide it or talk to other agencies and say ... these are the trends we're seeing, ... what are we going to do as community agencies to address this' (P3). It was through education and engagement that the rural shelter was able to mobilize a community around the need to change responses to violence.
Moreover, filling gaps in service was partially achieved through community education specifically utilizing outreach strategies. A service provider noted that she was only able to engage children of women who were actually in the shelter or referred for the shelter, and had little ability to connect with other children whose families had been in contact with police for violence issues (but had yet to be referred). To address the lack of service for other children who could benefit from her services, she would often reach out, '... introduce myself, our role and say, this is what we do here. This is something you might be interested and come on and meet me for an hour and let's have a coffee and talk about what's going on' (P4). This informal strategy was used to generate knowledge about the shelter's services. Another service provider noted the lack of preventative work with young girls in the community and filled through additional programing, '... so we're doing kind of self-esteem building, advocacy stuff, education with school boards around how to support teens' (P5). Both of these initiatives underscored a need to be proactive in the rural context as there were gaps in services resulting in women's needs not being met, and the rural shelter was working to overcome these gaps.
Redesigning delivery - 'hub' model: The third adaptation strategy identified by the rural shelter was the emerging change in service delivery that was naturally occurring. The service providers highlighted there was a switch from an inpatient to an outpatient care model, saying 'it seems to be less and less accessing shelter, but wanting the same services while still remaining in the community' (P5). The shift in delivery was an important adaptation as it better aligned with the mission of the shelter of 'prevention, education, and support' (P1) as this service provider highlighted, noting that historically prevention and education were being neglected. Moreover, by switching to this 'hub' model the rural shelter was better able to 'serve this whole community and understand and respond to this issue [of violence], beyond picking up the pieces' (P3).
To respond to the changing needs of women and successfully adapt to this role there was a marked transition to a 'hub' model of service. One service provider highlighted this change saying there was a 'real commitment to this model - pushing towards the hub model' (P1). This 'hub' model would allow women to access services through a centralized location although all the services would not necessarily be housed at the shelter. The 'hub' model was identified as innovative and a response to the changing needs of women, with one service provider saying 'I think we're pretty innovative. I think we recognize that things are changing. So thinking we're looking at how we can change and better serve all the women' (P2). Moreover, one woman highlighted the strength of this model: 'You don't have to retell your story here, you just tell it once and work with the other people so you don't have to do it again' (W4). This 'hub' models offered an alternative to the inpatient approach.
The purpose of this article was to explore the changing role and the adaptation strategies of one rural Ontario shelter utilizing a qualitative case study approach from a feminist intersectional framework. The inductive content analysis of the in-depth interviews with service providers and women revealed the role of the rural shelter was changing to include not only historic roles (safe place, protection planning, advocacy, transportation services, short-term counseling, and housing referrals) but also filling gaps left by existing community supports and health/social services, case management for the evolving complex health and social needs of women accessing the shelter, and system navigation to improve access and outcomes for health and social services. In order to accomplish the changing role, the rural shelter was utilizing three adaptation strategies: relationship building, community mobilization, and redesigning delivery. Relationship building through purposeful connection with existing health and social services facilitated community mobilization through education and engagement which fostered community ownership over solutions to violence against women. Both relationship building and community mobilization dovetailed with the redesign of service delivery wherein the shelter was shifting to act as a 'hub' for health and social services.
The principal findings of this study regarding the expansion of the role of the shelter and the adaptation strategies utilized align with the current discourse of extending scopes of practice and shifting the design of services to a model of integration48. Specifically the need to coordinate health and social services across sectors was highlighted as a necessity to improve the system's response to violence against women49, a finding that was reiterated with the case management and systems navigation role along with the relationship building and community engagement adaptation strategies. Community mobilization through education, awareness, and actions has been highlighted as foundational in addressing intimate partner violence50 and was a strategy being utilized by this rural shelter. In addition to confirming previously published knowledge in the area, this study highlighted the specific ways in which one rural shelter was changing its role, and adapting to address the shift in needs of women and the community. This case study underscores an important insight into how one Ontario shelter was evolving from the original shelter mandate to an integrated and women-centered service driven largely by second-wave feminism35,36,48.
This study is not without limitations. Specifically, the case study methodology resulted in a relatively small population to draw on for this research. Despite interviewing a cross-section of shelter service providers and all women who were staying at the shelter, and one woman utilizing the shelter on an outpatient basis during the time of the study, the research methodology along with the sample size resulted in decreased generalizability of findings, a common criticism of case study methodology51. Future studies should attempt to verify the changing role and adaptation strategies of shelters with additional rural agencies and women.
The principal implication of this study is the specific knowledge of the changing role of the rural shelter and how the shelter is achieving that change. This changing role is being shaped by a decrease in traditional service use7,20 in favor of an outpatient approach. This shift has important implications for policy makers; namely, the current metrics being utilized to assess the health and social services provided by shelters and determine the amount of funding are not capturing the full picture of what rural shelters are doing and providing52,53. Moreover, this has implications for service providers as it underscores the need to have an openness to education and a need to create a culture that fosters attitude changes that support knowledge attainment alongside collaboration across services. Given that people who live in rural contexts are less supportive of government involvement in intimate partner violence, this creates an atmosphere that both supports grassroots initiatives for collaboration but also undermines formal supports18.
The changing role of the shelter and the adaptation strategies being utilized have very real implications for the health of women. Specifically, given the increased use of healthcare services for women who have experienced violence7 the changing role of the shelter has the potential to decrease healthcare service use while increasing the potential fit of services54. With the shift in role to include filling the gaps presented by the current system, case management, and system navigation, the rural shelter is essentially taking on the role of helping women to manage healthcare and social services access, which has been demonstrated to improve health outcomes55. The changing role of the rural shelter alongside the new adaptation strategies has the potential to have real positive implications in terms of acceptability of health and social service use for women who have experienced violence. Further research is required to ascertain the potential and extent of this change.
One rural shelter in Ontario is adapting to and changing its role to meet the needs of women who have experienced violence. Through the changing role and adaptation strategies the rural shelter was challenging prevailing social norms and fostering an atmosphere that was promoting collaboration and system redesign. This is in line with the cultural context of rural settings in Ontario and provides valuable learning opportunities for other shelters, rural context, and agencies who provide services for women who have experienced violence.
This study was funded by the Women's Xchange (from Women's College Hospital (Toronto) 15K Challenge).
1. Ribeiro M, Sacramento O. Violence against prostitutes: findings of research in the Spanish-Portuguese frontier region. European Journal of Women's Studies 2005; 12(1): 61-81. https://doi.org/10.1177/1350506805048856
2. World Health Organization. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Report by the Secretariat to the 130th session of the executive board. Geneva: World Health Organization, 2011.
3. Tjaden P, Thoennes N. Full report of the prevalence, incidence,and consequences of violence against women. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice, 2000. https://doi.org/10.1037/e514172006-001
4. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet 2008; 371(9619): 1165. https://doi.org/10.1016/S0140-6736(08)60522-X
5. Johnson H. Assessing the prevalence of violence against women in Canada. Presented at UN Division for the Advancement of Women Expert Meeting, 'Violence against women: A statistical overview, challenges and gaps in data collection and methodology and approaches for overcoming them'. (Internet) 2005. Available : http://www.un.org/womenwatch/daw/egm/vaw-stat-2005/docs/expert-papers/johnson.pdf (Accessed 8 March 2016).
6. Anderson DK, Saunders DG. Leaving an abusive partner. Trauma, Violence and Abuse 2003; 4(2): 163-191. https://doi.org/10.1177/1524838002250769
7. Ford-Gilboe M, Varcoe C, Wuest J, Merritt-Gray M. Intimate partner violence and nursing practice. Family Violence and Nursing Practice 2011; 2: 115-154.
8. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359(9314): 1331-1336. https://doi.org/10.1016/S0140-6736(02)08336-8
9. Tolman RM, Rosen D. Domestic violence in the lives of women receiving welfare: Mental health, substance dependence and economic wellbeing. Violence Against Women 2001; 7(2): 141-158. https://doi.org/10.1177/1077801201007002003
10. Walker R, Logan TK, Jorda C, Campbell J. An integrative review of separation in the context of victimization. Trauma, Violence and Abuse 2004; 5(2): 143-193. https://doi.org/10.1177/1524838003262333
11. Rosen G, Imperato PJ, Fee E. A history of public health. Johns Hopkins University Press, 2015.
12. Du Mont J, Forte T, Cohen MM, Hyman I, Romans S. Changing help-seeking rates for intimate partner violence in Canada. Women and Health 2005; 41(1): 1-19. https://doi.org/10.1300/J013v41n01_01
13. Afifi TO, MacMillan H, Cox BJ, Asmundson GJG, Stein MB, Sareen J. Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females. Journal of Interpersonal Violence 2009; 24(8): 1398-1417. https://doi.org/10.1177/0886260508322192
14. Woods S, Grill J. Family violence: long-term health consequences of trauma. In: J. Humphreys, JC Campbell (Eds). Family violence and nursing practice. New York: Springer, 2010; 29-50.
15. Humphreys JC, Epel ES, Copper B, Lin J, Blackburn EH, Lee KA. Telomere shortening in formerly abused and never abused women. Biological Research in Nursing 2012; 14(2): 115-123. https://doi.org/10.1177/1099800411398479
16. Wong JY-H, Fong DY-T, Lai V, Tiwari A. Bridging intimate partner violence and the human brain: a literature review. Trauma, Violence and Abuse 2014; 15(1): 22-33. https://doi.org/10.1177/1524838013496333
17. Woods S, Hall R, Campbell J, Angott D. Physical health and posttraumatic stress disorder symptoms in women experiencing intimate partner violence. Journal of Midwifery and Women's Health 2008; 53(6): 538-546. https://doi.org/10.1016/j.jmwh.2008.07.004
18. Edwards KM. Intimate partner violence and the rural-urban-suburban divide: myth or reality? A critical review of the literature. Trauma, Violence and Abuse 2014: 16(3): 359-373. https://doi.org/10.1177/1524838014557289
19. Abdulmohsen Alhalal E, Ford-Gilboe M, Kerr M, Davies L. Identifying factors that predict women's inability to maintain separation from an abusive partner. Issues in Mental Health Nursing 2012; 33(12): 838-850. https://doi.org/10.3109/01612840.2012.714054
20. Ford-Gilboe M, Varcoe C, Noh M, Wuest J, Hammerton J, Alhalal E, et al. Patterns and predictors of service use among women who have separated from an abusive partner. Journal of Family Violence 2015; 30(4): 419-431. https://doi.org/10.1007/s10896-015-9688-8
21. Bhandari M, Dosanjh S, Tornetta P, 3rd, Matthews D. Musculoskeletal manifestations of physical abuse after intimate partner violence. Journal of Trauma 2006; 61(6): 1473-1479. https://doi.org/10.1097/01.ta.0000196419.36019.5a
22. Tummala A, Roberts LW. Stigma and Illness 2009; 188-205.
23. Leipert BD, George JA. Determinants of rural women's health: a qualitative study in southwest Ontario. Journal of Rural Health 2008; 24(2): 210-218. https://doi.org/10.1111/j.1748-0361.2008.00160.x
24. Anderson KM, Renner LM, Bloom TS. Rural women's strategic responses to intimate partner violence. Health Care for Women International 2014; 35(4): 423-441. https://doi.org/10.1080/07399332.2013.815757
25. Shannon L, Logan TK, Cole J, Medley K. Help-seeking and coping strategies for intimate partner violence in rural and urban women. Violence and Victims 2006; 21(2): 167-181. https://doi.org/10.1891/vivi.21.2.167
26. Doherty D, Hornosty J. Abuse in a rural and farm context. In: ML Sterling, CA Cameron, N Nason-Clark, B Miedema (Eds). Understanding abuse: partnering for change. Toronto: University of Toronto Press, 2004; 55-82. https://doi.org/10.3138/9781442682870-007
27. Riddell T, Ford-Gilboe M, Leipert B. Strategies used by rural women to stop, avoid, or escape from intimate partner violence. Health Care Women International 2009; 30(1-2): 134-159. https://doi.org/10.1080/07399330802523774
28. Kitchen P, Williams A, Chowhan J. Sense of community belonging and health in Canada: a regional analysis. Social Indicators Research 2012; 107(1): 103-126. https://doi.org/10.1007/s11205-011-9830-9
29. Farmer J, Munoz SA, Threlkeld G. Theory in rural health. Australian Journal of Rural Health 2012; 20(4): 185-189. https://doi.org/10.1111/j.1440-1584.2012.01286.x
30. Bosch K, Walter RS. Accessibility to resources: helping rural women in abusive partner relationships become free from abuse. Journal of Sex and Marital Therapy 2004; 30(5): 357-370. https://doi.org/10.1080/00926230490465118
31. Eastman BJ, Bunch SG, Willams AH, Carawan LW. Exploring the perceptions of domestic violence service providers in rural localities. Violence against Women 2007; 13(7): 700-716. https://doi.org/10.1177/1077801207302047
32. Burnett C, Ford-Gilboe M, Berman H, Ward-Griffin C, Wathen N. A critical discourse analysis of provincial policies impacting shelter service delivery to women exposed to violence. Policy, Politics and Nursing Practice 2015; 16(1-2): 5-16. https://doi.org/10.1177/1527154415583123
33. Tutty LM. Addressing the safety and trauma issues of abused women: a cross-Canada study of YWCA shelters. Journal of International Women's Studies 2015; 16(3): 101.
34. Wathen CN, Harris RM, Ford-Gilboe M, Hansen M. What counts? A mixed-methods study to inform evaluation of shelters for abused women. Violence against Women 2014; 21(1): 125-146. https://doi.org/10.1177/1077801214564077
35. Messing JT, Ward-Lasher A, Thaller J, Bagwell-Gray ME. The state of intimate partner violence intervention: progress and continuing challenges. Social Work 2015; 60(4): 305-313. https://doi.org/10.1093/sw/swv027
36. Barner JR, Carney MM. Intimate partner violence, gender and lethality: a case analysis of two fatalities. Journal of Forensic Social Work 2015; 5(1-3): 150-166. https://doi.org/10.1080/1936928X.2015.1095140
37. Grossman SF, Lundy M. Characteristics of women who do and do not receive onsite shelter services from domestic violence programs. Violence against Women 2011; 17(8): 1024-1045. https://doi.org/10.1177/1077801211414169
38. Gutmanis I, Beynon C, Tutty L, Wathen CN, MacMillan HL. Factors influencing identification of and response to intimate partner violence: a survey of physicians and nurses. BMC Public Health 2007; 7: 12. https://doi.org/10.1186/1471-2458-7-12
39. Cho S, Crenshaw KW, McCall L. Toward a field of intersectionality studies: theory, applications, and praxis. Signs 2013; 38(4): 785-810. https://doi.org/10.1086/669608
40. Olesen V. Feminist qualitative research in the millennium's first decade. In: NK Denzin, YS Lincoln (Eds). The Sage handbook of qualitative research. London: Sage, 2011; 129-146.
41. Guba EC, Lincoln YS. Paradigmatic controversies, contradictions, and emerging confluences. In: NK Denzin, YS Lincoln (Eds). 2nd edn. The Sage handbook of qualitative research. London: Sage, 2000; 163-188.
42. Statistics Canada. NHS Profile, Strathroy-Caradoc, TP, Ontario. (Internet) 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/dp- d/prof/details/page.cfm?Lang=E&Geo1=CSD&Code1=3539015&Data=Count&SearchText=Strathroy-Caradoc&SearchType=Begins&SearchPR=01&A1=All&B1=All&GeoLevel=PR&GeoCode=3539015&TABID=143. (Accessed 27 March 2016).
43. Downe-Wamboldt B. Content analysis: Method, applications, and issues. Health Care for Women International 1992; 13(3): 313-321. https://doi.org/10.1080/07399339209516006
44. Morgan DL. Qualitative content analysis: a guide to paths not taken. Qualitative Health research 1993; 3(1): 112. https://doi.org/10.1177/104973239300300107
45. Mansour J, Snell L. Rising up to end violence against women - how far have we come in twenty years. Human Rights Defender 2013; 22: 14.
46. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013.
47. United Nations: Women. Effective approaches to addressing the intersection of violence against women and HIV/AIDS: findings from programs supported by the UN Trust Fund to end violence against women. (Internet) 2012. Available: http://www.unwomen.org/en/trust-funds/un-trust-fund-to-end-violence-against-women/publications (Accessed 27 February 2014).
48. Suter E, Oelke ND, Adair CE, Armitage GD. Ten key principles for successful health systems integration. Healthcare Quarterly (Toronto, Ont) 2009; 13(Spec No): 16.
49. García-Moreno C, Hegarty K, d'Oliveira AFL, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. The Lancet 2015; 385(9977): 1567-1579. https://doi.org/10.1016/S0140-6736(14)61837-7
50. Roberto KA, Brossoie N, McPherson MC, Pulsifer MB, Brown PN. Violence against rural older women: promoting community awareness and action. Australasian Journal on Ageing 2013; 32(1): 2-7. https://doi.org/10.1111/j.1741-6612.2012.00649.x
51. Anderson RA, Crabtree BF, Steele DJ, McDaniel Jr RR. Case study research: the view from complexity science. Qualitative Health Research 2005; 15(5): 669-685. https://doi.org/10.1177/1049732305275208
52. Harris R, Wathen N, Lynch R. Assessing performance in shelters for abused women: can 'caring citizenship' be measured in 'value for money' accountability regimes? International Journal of Public Administration 2014; 37(11): 737-746. https://doi.org/10.1080/01900692.2014.903273
53. Ontario Municipal Social Services Association. Emergency shelter services: more than just a bed. Emergency Hotel Taskforce, 2005.
54. Waldrop AE, Resick PA. Coping among adult female victims of domestic violence. Journal of Family Violence 2004; 19(5): 291-302. https://doi.org/10.1023/B:JOFV.0000042079.91846.68
55. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Affairs 2013; 32(2): 207-214. https://doi.org/10.1377/hlthaff.2012.1061