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Working Together for Healthier Rural Communities

I Introduction

This article is an overview of the process of and learnings from a rural health study in the Region of Waterloo, initiated by Region of Waterloo Public Health, Health Determinants, Planning and Evaluation Division. This large-scale qualitative research project has stretched our perspectives as health promoters and taught us some practical lessons about working with community partners.

II Rural Health Study Background

While there is some debate about what constitutes "rural," rural health has been receiving a great deal of attention of late. The terms "rural and remote" are often paired together. Although the rural population in the Region of Waterloo could not be defined as remote, we had reason (e.g., 1995 community assessment, experience working with rural communities) to believe that there were factors affecting the health of the rural population that were different from those affecting the urban population. This study was designed to help us understand more about the determinants of health in the four unique rural townships surrounding the three core cities in the Waterloo region and to ultimately give us ideas about how to improve and maintain rural health.

We approached the study by first conducting key informant interviews in the summer of 2001 with service providers and other community members in all four townships. The purpose of these interviews was to gauge the interest in a rural health study, gain an initial sense of rural health issues and learn what rural residents and service providers might hope to gain from such as study.

Everyone we spoke to supported the idea of a rural health study and were very clear that they wanted an action component to the research. Respondents identified a wide range of rural health issues including poverty, transportation, affordable housing, isolation, farm safety and environmental factors, and also a great deal of existing capacity (e.g., high responsiveness to local need, high citizen involvement, high level of collaboration between local agencies).

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III Involving Community

Participants in the initial interviews were invited to form a steering committee that would guide the Rural Health Study. While the first steering-committee meeting in the fall of 2001 was well attended, only a few local-agency staff (most of whom were also rural residents) maintained consistent, active involvement. For most rural service providers, lack of active involvement was not an indication of lack of interest but rather a lack of time. They, like most agency staff are stretched to the limit. To facilitate involvement we maintained connections through email updates and invited participation at key points along the way.

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IV The Research Framework & Process

The study was guided by a steering committee of rural community members and agency staff. Information was gathered from January to June of 2002. Qualitative data methods were chosen because of their potential to provide deep insight into which factors affect health and why. The study consisted of approximately seventy focus groups and interviews with a wide variety of rural residents from all four townships. Participants included seniors, youth, conservative Mennonites (Old Order, David Martin and Low German speaking Mennonites from Mexico), families and farmers. Although we reached a wide range of people, we had difficulty reaching some groups of rural residents, for example those who were isolated and those living on limited incomes.

Two community researchers were hired to help conduct the focus groups and interviews. Steering-committee members also became researchers, assisting with facilitation of focus groups and conducting telephone interviews.

Focus-group participants were provided with a very broad definition of health (including physical, emotional, social and spiritual health). They were then asked open-ended questions about the factors they believe affect their health (in both negative and positive ways), the resources they use and their beliefs about what is needed to improve health in their communities. Our intent was to identify the social, economic and environmental factors that have an effect on the health of rural individuals and communities.

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V Collaborating on the Research

The preliminary interviews led to links with other community organizations and groups working on rural health issues in Waterloo Region. For example, we discovered a group of citizens working to establish a Community Health Centre (CHC) in the Township of North Dumfries. As they were also planning to conduct a needs assessment, we decided to pool our resources and collaborate. The Rural Health Study interview guide was revised to include questions about the establishment of a CHC in North Dumfries.

This partnership, as well as other connections that we made through the Rural Health Study steering committee, facilitated access to a number of groups that otherwise might have been hard to reach, for example conservative Mennonites. Where trust and language barriers existed, local service providers either assisted us or conducted the focus groups without us. In this way, service providers obtained some data for their own use and contributed to our study.

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VI What Are We Learning?

Working with rural residents has kept us grounded. Our textbook knowledge of participatory action research, collaborative processes and rural health issues was greatly enhanced by the experiences and insights of the rural residents.

We have also learned flexibility and creativity. Sometimes this meant altering our protocols to meet the goals and needs of our partners (yet without compromising the integrity of our work!). To facilitate involvement from important non-profit stakeholders that were already stretched to the limit, we also had to allow varying levels of involvement rather than expect full, ongoing participation. We communicated with people between meetings and encouraged participation at key points, such as when identifying potential participants, analyzing data, writing reports and disseminating information.

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VII What is Challenging?

One of the challenges, as expected, was the emerging issues that fell beyond the jurisdiction of public health, for example, housing, transportation and land-use planning. To inform and engage other regional departments, we provided regular briefings and invitations to meet with us to review findings and consider implications and actions.

Communication, in a world where there is so much information competing for our attention, was also a challenge. We have tried to use existing channels, such as newsletters of rural service providers to communicate findings and action possibilities in a way that community members could understand and use.

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VIII What is Encouraging?

For our public health team, this project has been an opportunity to meet people, learn about their work, build relationships and create opportunities for future partnerships. Our links with the community mean the findings are more relevant and therefore more likely to be used. It has been rewarding to see that people in the rural communities are fully engaged in the research process and have become ambassadors for the study.

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IX Data Analysis

The information was analysed using NVivo, a qualitative data analysis computer program. While it is possible to count the number of times a particular topic or issue was raised, we cannot correctly assume that the most frequently mentioned topics are the most important to the majority of rural residents. What we can do is look at trends--themes that appeared again and again. We can also look at issues that appear to have the greatest impact on health.

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X What Have We Learned About Rural Health?

Following are a few, extremely abbreviated, points about our findings.

a. Rural Culture

Rural residents described a rural culture characterized by self-reliance, resilience, pride and privacy. Social support and sense of community are valued, yet the sense of self-reliance and privacy means that people often prefer to handle difficulties themselves rather than seeking help from others.

b. Rural Life as Different

Participants value the sense of community and social support found in rural communities. They talked about the importance of being part of the community and contributing to the community. Churches, schools, festivals and events are very important contributors to their sense of community.

c. The Changing Face of Rural Life

Rural residents value the unique aspects of the rural lifestyle and want to preserve rural life as they know it. Rural residents expressed concerns about the impact of growth, land use, planning and development, as well as urban encroachment and the increase in "bedroom communities."

d. The Changing Nature of Farming

Farmers are facing major financial concerns as they find it increasingly difficult to compete with larger farms and farm commodity subsidies in the United States and other countries. More farmers are working off the farm to make ends meet. They are experiencing a high level of stress.

e. The Physical Environment

Rural residents have differing views about the environment. Some expressed no concerns and in fact believe they have cleaner air and water than their urban neighbours. Others expressed concerns about water quality and pollution from dust, noise, pesticides and industry.

f. Supports, Services & Access

Participants indicated that they need the same kinds of services in rural areas, but services need to be delivered in a different way--with more integration of health, social and community services and more outreach (i.e., strategies to bring services to where people are).

Lack of transportation was reported as a major barrier to accessing various services and resources, including medical and specialized medical services, legal assistance, social services and employment.

Participants expressed concerns about the lack of affordable housing, in particular decent, appropriate and affordable rental housing. Housing issues affect seniors, young people starting out, single-parent families and other people living on low incomes.

While there seem to be numerous supports available for families with young children, many participants said there is not much available for youth. Many believe that there is a relationship between lack of social, recreational and employment opportunities for youth and the rates of vandalism and drug and alcohol use among youth.

g. Rural Voices

Rural residents feel there is a risk that rural communities are forgotten and are concerned that their voices are not being heard. There is concern that decisions that affect rural residents are made by people with a limited understanding of rural issues.

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XI Next Steps

In April 2003, findings were shared at township meetings and next steps were discussed. We are currently meeting with potential partners and deciding which action steps will be taken and by whom. We are pleased to report that the findings are already being used by several groups.

For more information contact:

Barbara Zupko

Region of Waterloo Public Health

99 Regina Street South, Waterloo ON N2J 4V3

Phone: (519) 883-2004 ext. 5511

Fax: (519) 883-2241