The purpose of this article was to review literature that pertains to women who provide informal care for an elder in a rural setting in Canada. Informal care provided in rural settings is more prevalent than in most urban areas1. This phenomenon of informal caregiving within rural settings is influenced by many factors, such as the growing population of people aged 65 years and older living in rural settings2, the restructuring of the Canadian healthcare system and subsequent regionalization of services3, and the preference of many rural elders to remain within their communities2.
The majority of caregivers within rural contexts in Canada are female2. Rural female caregivers provide care to elders within a rural context that presents many challenges. The challenges associated with providing care to an elder in a rural setting include: difficulties accessing necessary and adequate services4; transportation and distance from regionalized services5; and lack of awareness of available services2. Many rural women caregivers experience these challenges in providing care to an elder while balancing other responsibilities such as families, jobs, careers and household duties6. The unique challenges and multiple roles impacting rural women caregivers can ultimately lead to burnout2. Therefore, it is important to look at the specific context in which rural women are providing care and to develop strategies that provide support for these women. Nurses in rural settings in Canada are in key positions to offer support and assistance in order to promote the health of rural women caregivers and elders7,8. In this article we suggest implications and recommendations for rural women informal caregivers, as well as nurses practising in rural settings.
A review of the literature that pertains to rural women caregivers in Canada has not been done previously. The review in this paper found limited literature and research relevant to the topic of women providing care to an elder in rural Canada. The literature search included books, journal articles, reports, bulletins and government documents. The journal databases accessed include: CINAHL, MEDLINE, PubMed, and ProQuest. Three major guidelines were utilized in the selection of the literature: (i) the literature relates to women providing informal care or eldercare within rural settings; (ii) the literature is relevant to the Canadian context; and (iii) the literature was published between 1995 and 2005. A variety of pertinent keywords were selected to facilitate the search for relevant literature: rural, remote, northern, small town, women, female, gender, caregiving, eldercare and Canada. The database search activities recovered literature from the disciplines of nursing, medicine, psychology, education and social work, as well as government documents. Of the 30 literary works recovered in this search, 26 are Canadian publications. A limited amount of literature pertaining to the rural Canadian context was available; in light of this fact, relevant supplemental literature from the USA and Australia has also been included in this review. As a result, three works from the USA and one work from Australia were included in this review. Each work varied in methodological approach. Search results included four mixed methods studies utilizing an exploratory qualitative design and a descriptive quantitative design, three qualitative studies that utilized focus groups, one qualitative ethnography, one qualitative study that was based on the socialist constructionist paradigm, one descriptive phenomenology, two feminist grounded theory studies, three randomized quantitative studies, one quantitative comparison study, two secondary analysis studies, two policy analysis studies, five knowledge synthesis papers, one literature review and three articles that summarized Canadian statistics from the Canadian government.
The article begins with an overview of the rural Canadian context, followed by a summary of the literature that explores the nature of informal caregiving within rural settings. This is followed by a section that addresses female caregivers within rural settings, followed by implications and recommendations for rural women informal caregivers and nurses who practice in rural settings. The article concludes with a discussion of key findings.
The rural Canadian context
Clarity of the term 'rural' is important because differing definitions have the potential to encompass different groups of rural people, generating discrepancies in our understanding of rural census, characteristics, culture and needs9. Many articles have presented the debate of how and why rural should be defined and examine the dichotomy between defining 'rural' as a descriptive geographical location or as a social representation that reflects the socio-cultural aspects of living in rural communities9-11.
Statistics Canada9 offers six ways in which 'rural' can be defined: (i) census rural where individuals live in the countryside outside centers of 1000 or more people; (ii) rural and small town where individuals in communities live outside the commuting zone of an urban centre with 10 000 or more people; (iii) organization of economic co-operation and development (OECD) rural communities where individuals live in communities with less than 150 persons per square kilometer; (iv) OECD predominantly rural regions where individuals live in census divisions with more than 50% of the people living in OECD rural communities; (v) non-metropolitan regions where individuals live outside metropolitan regions with urban centers of 50 000 or more people; and (vi) rural postal codes where individuals have a zero as the second character in their postal code.
Williams and Cutchin11 determined that the categorical definitions of 'rural' were according to land use (occupation/economic activity), population density (number of people per area squared), demographic structure (villages/towns/hamlets), environmental characteristics (open countryside), population characteristics (degree of homogeneity), non-metropolitan areas, and commuting patterns. Stewart et al.12 suggested that the term 'rural' could also be used to describe the extent of a community's access to healthcare services. These authors also highlight challenges and barriers that rural women face when accessing healthcare services; therefore, their definition adds further richness to defining rural in this article.
Based on the lack of an encompassing definition for 'rural', a holistic approach that conceptualizes the social representation of living in a rural context, as well as the geographic context, may best define the term. For the purposes of this article, 'rural' is defined in terms of geographical locations that pose difficulties in accessing adequate and appropriate healthcare services due to distance from regionalized centers, where the small population size of 10 000 or less promotes challenges in providing anonymous and confidential care, and where much of the formal healthcare services are reliant on informal care providers. This definition is used to set the context and to provide a lens with which to view the article. This lens provides an understanding of both the social representation of rural women and the geographical context in which they provide eldercare.
The rural Canadian context
The Canadian context provides a unique view when examining rural settings. This uniqueness is rooted in the fact that over 90% of Canada's land mass is considered geographically rural10 and just over 20% of Canadians live in rural and small towns with populations of less than 10 000 people7,13. Geographic isolation is a major determinant of health among rural populations and has been recognized as such by the 2002 Romanow report on the health of Canadians5. Geographic remoteness poses different challenges to rural dwellers compared with the experience of persons residing in urban settings.
Regarding the Canadian population, there is a current phenomenon of out-migration of the rural young for educational and job opportunities within larger urbanized areas7. Out-migration in combination with the aging population in Canada is contributing to the steady increase of elders (greater than 65 years of age) in rural settings1,6. In many rural settings, larger percentages of the residents are elderly, compared with smaller percentages in urban populations1,6,14. Therefore, the health care of rural elders is of concern among rural populations and healthcare providers.
It is widely known that the health status of rural women is the poorest of all women in Canada12,15. Rural women have a lower life expectancy and are also known to access medical services less than the rest of the Canadian population12. Rural women seek health care less frequently for issues involving poor vision, dental problems, taking medications, and getting health services that require extra payment or insurance12. Rural women also face multiple role strain from their multiple workloads. Many rural women live on farms where they work up to 105 hours per week in paid and unpaid jobs that include household duties, tending to children, and employment on and off the farm12,16. Furthermore, rural women also experience increased poverty and unemployment rates12. Rural caregiving places an additional burden on rural women who are already compromised.
Several authors argue that the health beliefs of rural dwellers differ from their urban counterparts6,13,16. Thomlinson et al. conducted an ethnographic study that looked at the health beliefs of rural people in southern Alberta and northern Manitoba13. They found that health was viewed holistically, as a relationship between the physical, mental, social, and spiritual aspects of one's life, and many participants reported that 'rural' was a part of who they are13. This holistic understanding of health differs from traditional biomedical beliefs13.
The dominant cultural beliefs and attitudes within the rural context also shape the gendered positions of rural women. Within this context, women are seen as caregivers with the expectation that they will provide care for an elderly relative or ill spouse6. In addition, rural people may subscribe to the belief that seeking formal support such as in-home and respite care means that the caregiver is unable to manage without help2. Therefore, rural cultural beliefs greatly determine when, why, and how rural women should provide care. It is thus evident that any recommendations to support rural women and caregivers must incorporate an approach that is culturally competent with respect to rural cultural beliefs, and that is sensitive to rural gender and healthcare issues.
Rural health care providers
The restructuring of the Canadian healthcare system and the regionalization of many services have significantly impacted rural people's access to healthcare services5. Morton and Loos revealed that universal coverage does not indicate universal accessibility to healthcare services despite the underlying principles promoted nationally as foundational to the Canadian health care system: universality, accessibility, portability, comprehensiveness and public administration4. These principles are not uniformly evident in rural locations where geographical distances to healthcare services6, affordability of services and transportation challenges11, limited availability and presence of healthcare providers3, and the acceptability of services for women12 are factors that affect access to adequate and appropriate healthcare services. In addition, current reforms within the Canadian healthcare system assume women will provide care for the elderly17. This assumption is exemplified by the fact that healthcare reforms have shifted the provision of elder health care from formal caregiving sectors to more informal community sectors17.
The lack of availability of healthcare providers and services is a widely studied problem that shapes the lives of rural women. The availability of healthcare providers is affected by issues such as distances to travel to a healthcare provider, scarce amounts of healthcare providers located in rural areas, and lack of access to healthcare providers that offer appropriate care to rural women3-5,18,19. Healthcare providers are scarce among rural populations and many studies report problems with recruiting and retaining health care providers20. There has been a major focus on the recruitment of healthcare providers in rural settings, but many have failed to look at the recruitment of healthcare providers while they are still engaged in their initial education, for example, by offering theory courses and practicum experiences in rural locations20,21.
Although the recruitment of health care providers is an issue, a greater problem is retaining healthcare providers in rural settings11. Many healthcare services, such as geriatricians, gerontological nurses, home services and long-term care facilities are non-existent or under funded in rural settings6. Due to these factors and because of the lack of other healthcare providers to provide professional support in rural settings, many healthcare providers do not remain in rural settings for long periods of time6. This results in limited, inconsistent, or no access to much needed services for rural caregivers and their care recipients. In addition, retention and recruitment efforts in rural areas have focused mainly on physicians. Williams and Cutchin suggest that, although the availability of a physician may be an essential element in accessing health care services in Canada, nurses are often more effective than physicians in treating minor illnesses, and nurse practitioners, public health nurses and home care nurses are essential to rural hospitals, home care, health promotion, illness prevention and other rural care11,18. Therefore, the recruitment and retention of nurses is key to the provision of accessible, comprehensive, appropriate and cost-effective health care within rural settings18.
Although accessing a healthcare professional is essential for rural people, this does not always mean that available rural services are appropriate for rural women4,18,19. Many women in rural areas have found services to be inadequate in meeting their needs, for example services related to sexuality, violence and counseling12,18,19. In addition, rural women often do not receive appropriate, sensitive care from rural physicians due to physician attitudes, lack of awareness of rural women's needs, and limited time to discuss concerns with women19. Other barriers women face in rural settings are associated with culture and socioeconomic status, where the specific needs and concerns of women from ethnic minority groups or of low socioeconomic status are not addressed4,18,19. The Canadian healthcare system must further explore gender, culture and financial factors and their effects on client and provider needs within rural contexts. In addition, more research is needed regarding services needed by rural women in order to adequately promote their health.
This discussion of the rural Canadian context will provide readers with a lens with which to view the remainder of this article. This is the rural context in Canada that shapes the everyday lives of women who provide care to an elder in rural settings. Rural women are routinely challenged to surmount rural challenges to care for rural elders.
Informal caregiving within rural settings
Informal rural caregiving is rooted in the reality that elders need care, especially in under-funded and underserved rural areas3. Statistics Canada reports that over 18% of the Canadian population over 15 years of age provides one to more then 10 hours a week of care for an elderly person22. It has been argued that this prevalence is greater in rural settings. The increased prevalence of caregiving in rural settings is due in part to the lack of formal health care services23, to changes within the healthcare system, such as the restructuring and regionalization of services in distant locations24, and the increasing population of elders located in rural settings2,6.
In urban settings, elderly patients may be referred to specialized clinics earlier and caregivers may receive more in home support long term, compared with rural settings23. In rural settings, services related to respite care, home health care, health promotion and illness prevention, rehabilitation, transportation, and elder care facilities may not be available and, therefore, not an option for rural caregivers21,23. Several studies also suggest that rural caregivers receive more help from informal networks than from formal resources23,25, and that rural elders in Canada depend more on these informal care networks than on formal services25. This is due in part to healthcare reform, where many healthcare services are no longer available or in close proximity to rural elderly people25. Fast et al. found that informal caregivers in rural settings in Canada provide 80-90% of care for people greater than 65 years of age, and that although these elders have a network of family and friends working together, it is usually one individual who assumes the bulk of caring25. This informal care is usually provided by a female family member5,25 and most often by daughters23. Fast et al. also found that caregiving provided by women is more frequent and involves more traditional roles, such as personal care, housekeeping and emotional support; where the care provided by men is less frequent and associated with maintenance and repair of property25.
Many elderly only access formal healthcare services when their health needs exceed the abilities of their informal caregivers2. However, rural elders have been reported to seek all assistance exclusively from their informal caregiver2. This type of care seeking may be because rural elders prefer care from known and trusted care providers and because many healthcare services for rural elders are less accessible, limited in variety, and fewer in number compared with urban elders2. In addition, the ability of elders to independently access healthcare services in rural settings may be limited due to the physical location of the service site. Barriers associated with distance are further exacerbated due to limited accessible and affordable transportation, winter travel, and limited availability of in-home assessments that are required for service by a health professional, due to travel, time, distance and weather26. Relocation to acquire access to healthcare services may not be a viable option because rural elders often want to remain in their home environments. Indeed, the ability to 'age in place' was found to facilitate a healthy sense of wellbeing among aging rural women in Australia27. Morgan et al. found that Canadian rural informal caregivers had a desire to keep the elders they cared for in their home environment for as long as possible2.
Female caregiving within rural settings
It has been estimated that women represent 70% of all caregivers in Canada23. This proportion of female caregivers is even greater among rural populations due to the expectation that women should and will assume traditional caring gender roles16. Studies have also revealed that some women feel that being a caregiver is part of being a woman28 and that rural women may assume caregiving roles due to the belief that it is repayment to their parents for raising and caring for them as children29. Women may also provide care for an elder as a result of women's increased life expectancy6. Because women live approximately 6 years longer than men in Canada, rural women may be providing the majority of care to elderly people by default6. In rural settings, women may care for a spouse because rural cultural values place an expectation on women to provide care for an ill or ageing husband2. Rural cultural values also influence decision-making regarding placement of an elder in a nursing home. Rural women caregivers may equate nursing home placement of their elder negatively, even in situations where such care is available29. These beliefs and values place additional burdens on rural women, especially those who cannot or do not wish to provide eldercare.
Rural women often provide care for an elder while also participating in the paid workforce2,30. Keefe found that in 1996 approximately 60% of rural women caregivers in Canada were also employed outside the home30. This percentage has likely increased in recent years due to further health care restructuring and downsizing, and the deepening farm crisis in Canada. The large percentage of rural women who are both employed and providing informal care is worrying, considering that many women also assume roles related to family, child care, household duties and community2,6,29. These multiple roles further add to the role strain and burnout many rural women caregivers experience6. Since many women who live in rural settings are located on farms and are not officially employed or paid as such16, these rural women may be providing care with limited financial resources. Additionally, many women assume the caregiver role unexpectedly, with minimal training and no compensation6.
The stress and caregiver burnout that rural women experience have also been associated with rural women's need to seek services such as respite care. However, rural women and their families may not accept respite care for a variety of reasons. Protection of family image from the potential stigma related to having a family member with dementia or Alzheimers disease may be a delaying factor in accessing support in a rural setting2. Close knit rural families may not accept the reality that they are unable to provide continuous care for an elder, and thus deny themselves the additional support of formal caregiving services2. Rural caregivers may hold the impression that receiving formal care services is an indication that they cannot adequately perform the role of providing care to an elder2. In addition, informal caregivers may refuse respite care because they perceive that they may place a burden on the healthcare system, taking services from those with greater need2.
Combined emotional and physical stress and resulting burn out have the potential to put women caregivers at risk of ill health. Cueller and Butts reported that rural women caregivers in the USA are more likely to be self-reliant, tend to refuse additional help and, depending on the dependency of the elder, may be required to employ significant physical strength and exertion while providing care6. Activities such as independently lifting and moving elders can place an extreme physical burden on caregivers6. As a result, rural women caregivers may report having poorer health than the elder for whom they are caring6. Cuellar and Butts found that rural women reported a rapid deterioration of their own physical health related to symptoms of persistently interrupted sleep, chronic fatigue, irregular eating habits, and numerous muscle aches6. Also, in addition to these symptoms, geographical remoteness prevents many rural women from obtaining their own health care6. Furthermore, because of geographic remoteness, many rural women caregivers may become immersed in the care they are providing to an elder, and ignore their own health problems, further contributing to their stress and ill health6. Stress can result in chronically elevated hormone levels, chronic fatigue and poorer diets, factors that constrain the immune system and enhance women's susceptibility to a variety of acute and chronic illnesses23. Browder's study explored how rural women caregivers make decisions about caring for an elder29. It was found that stress and mindset affected the decision-making process of rural women, and that stress affected women's ability to problem solve and seek second opinions29. Thus, although rural women may require care themselves, stress combined with inadequate, inappropriate and inaccessible healthcare services often means that rural women are less likely to seek needed healthcare attention10.
Implications and recommendations
This review of the literature revealed several implications and recommendations for rural women informal caregivers, as well as nurses who practice within rural settings. It is important to offer implications and recommendations for caregivers because healthy caregivers are able to provide better care for themselves and for elders in rural settings. Nursing implications and recommendations are also important to suggest because, in many rural communities, nurses may be the only or the most appropriate healthcare providers available18.
Implications and recommendations we suggest to support rural women who are informal caregivers focus mainly on education, building partnerships with formal care providers and with each other, and the need for enriched services and resources for women caregivers in rural settings. It has been suggested that the main reasons rural women refrain from utilizing formal support services are a lack of information on the availability of services and on the importance of using these services to prevent burnout2. Thus, informal caregivers may benefit from learning about support services and resources that are available in their own or a neighbouring rural setting, such as transportation services, in-home care and support, local respite care, and public policies and programs that support caregivers in rural settings. As well as providing direct support, these resources may provide ideas for rural communities about ways they can develop enriched resources.
Rural women caregivers may want to develop partnerships with formal care providers, such as nurses. Nurses within rural settings can offer caregivers information and assistance and can act as advocates for rural women informal caregivers. For example, nurses and informal caregivers in rural and remote settings could lobby municipal, provincial and federal governments for enriched support resources in home care, health promotion and illness prevention, respite services and long-term care facilities. Healthcare providers and policymakers need to seek the participation of rural women when planning programs, policies and research. In addition, rural women caregivers may find that, through their relationships with each other, informal supports can be developed. For example, a rural woman may be able to shop in a nearby town for both herself and her neighbour, while the neighbour temporarily assumes caregiving for both women. Through their knowledge of the location and needs of care providers and care recipients, formal care providers such as nurses may be able to facilitate these types of informal relationships in rural settings.
Although many of these implications could assist rural women caregivers in providing care for an elder, it is unrealistic to assume that all rural women caregivers are able to do so. Many rural communities pose challenges in accessing resources, and many rural women caregivers are already consumed with their multiple role demands and may not have the time or energy to participate in and to acquire additional resources. Thus a further recommendation is that government at all levels and policymakers need to better appreciate and support women's caregiving in rural and remote communities. The need for enriched services and resources for women caregivers in rural settings is critical, and governments have a responsibility to attend to these rural needs. To ensure relevance and effectiveness, rural women care providers should be directly involved in advising governments about how best to meet their needs in rural settings.
Many implications and recommendations are evident for public health nurses, nurse practitioners, home care nurses and acute care nurses who practice in rural contexts. First and foremost, it is essential for rural nurses to be able to locate rural women caregivers so that they can assist them. Although locating rural women caregivers has been found to be a challenge because rural women may not always obtain health care for themselves6, rural women caregivers may be identified through home-health visits with patients in the community, and by asking elderly patients in acute and long-term care settings about the support they receive from family and friends. In addition, nurses living in rural and remote communities may recognize caregivers during various social and community events.
Second, nurses in rural settings must become aware of resources, such as transportation services, health promotion and illness prevention resources, in home care, long term care and respite care that may be available to rural women caregivers. Nurses can then assist rural women caregivers in learning about and accessing available resources. Because of their intimate knowledge of rural care providers, recipients and contexts, rural nurses must also act as leaders and advocates for needed services and resources in rural settings18. Rural nurses can become effective leaders and advocates with various informal rural groups and associations such as churches, community groups, special interest groups and rural associations such as the Women's Institutes and the Canadian Farm Women's Network, as well as within formal nursing groups and associations. Rural nursing leadership and advocacy advance the development of policies, programs, practices, and resources for rural women caregivers and care recipients13,18.
Third, nurses need to promote the education of informal caregivers and others about caregiving in rural communities. Through education, nurses are able to offer support to informal caregivers, assisting with the many decisions they are faced with and helping them to define boundaries and limits. Supporting rural women caregivers' problem solving abilities helps to decrease the likelihood of burn out and enhances women's health and quality of life18.
Nurses need to be active leaders in the recruitment and retention of nurses for rural practice. Nursing curriculums can foster recruitment and retention of nurses in rural areas by enriching rural theory and practicum opportunities so that students gain an understanding of the rural context and how this affects rural women's health and nursing practice21. Rural nurses can act as preceptors and mentors to nursing students and they can support nurse colleagues who are new to the rural setting. These strategies may assist with recruiting nursing students to rural practices, as well as retaining nurses who currently practice in rural settings. As a result, the availability of appropriate healthcare services for rural women caregivers and other rural residents may be enhanced.
Nursing research must focus on women's issues and health within rural contexts with a specific emphasis on the informal caregiving roles of women. Qualitative nursing research in particular would assist with developing an understanding of rural women's caregiving experiences and needs and the rural context in which they are enacted. Nurses in rural settings are in key locations to participate in and conduct research on rural women's caregiving experiences and needs. Increasing this knowledge base could prove beneficial by highlighting rural women caregivers' needs so that they are evident to government and policy makers; therefore, potentially influencing future government and policy decisions to enhance rural health care.
In conclusion, this literature review has determined that there is limited research that examines issues of rural women caregivers who reside within rural contexts in Canada. Nevertheless, the available literature revealed that rural women caregivers are faced with several challenges when providing care to an elder. Many of these challenges are associated with accessing adequate and appropriate healthcare services, geographical distances from regionalized centers and health services, culturally incongruent health care, social/geographical isolation and transportation challenges. This review offers important implications and recommendations for rural women caregivers as well as nurses practising within rural settings. Educational opportunities must be made more available and accessible to both rural women informal caregivers and to nursing students. Nurses and rural women care providers need to work collaboratively in order to provide truly accessible supportive services. In addition, government and policymakers need to ensure that rural contexts and rural women caregivers are included and valued in healthcare planning, policies, programs, research, activities and services. Rural women caregivers are often the link between rural people who need care and the healthcare system. Therefore, supports need to be in place so that women truly have the option to choose whether and how to provide care within rural settings.
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