Health & Place 18 (2012) 1206–1208

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Health & Place

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journal homepage: www.elsevier.com/locate/healthplace

Viewpoint

Being rural in rural health research

Jane Farmer a,n, Sarah-Anne Munoz b, Clare Daly b

a La Trobe Rural Health School, La Trobe University, Bendigo, Victoria 3550, Australiab Centre for Rural Health, Centre for Health Science, University of the Highlands and Islands, Inverness IV2 3JH, Scotland

a r t i c l e i n f o

Article history:

Received 17 December 2011

Received in revised form

10 May 2012

Accepted 17 May 2012Available online 26 May 2012

Keywords:

Rural health

Methodology

Positionality

Habitus

Health research

Health policy

92/$ - see front matter & 2012 Elsevier Ltd. A

x.doi.org/10.1016/j.healthplace.2012.05.002

esponding author. Tel.: þ61 354447671.

ail addresses: j.farmer@latrobe.edu.au (J. Farm

nne.munoz@uhi.ac.uk (S.-A. Munoz), 23366@

a b s t r a c t

This paper explores ways that being from a rural background might influence the health research

process and why this might occur. It draws on the research experiences of three ‘generations’ of rural

health researchers to suggest rural background affects how researchers approach and conduct study,

and how they interpret findings. Concepts of positionality, habitus, performance and ‘othering’ are

explored to suggest how existing sociological and philosophical ideas can explain why rural researchers

possess a particular worldview that may influence their research outputs.

& 2012 Elsevier Ltd. All rights reserved.

1. Being rural in rural health research

This paper considers how a researcher’s rural backgroundmight influence what happens when they conduct rural healthresearch. As rural health researchers, the authors of this paperhave sometimes reflected that ‘being rural’ adds a differentdimension to our study. We have reflected that it provides adifferent starting place with regard to rural health researchcompared with metropolitan based researchers (i.e. more attunedand richer in understanding of ‘rural life’) that allows us toachieve more informed or advanced study. We have also reflectedthat when involved in data collection with rural subjects, we havefelt able to ‘tune in’ to their expressed perspectives and experi-ences. Here we explore dimensions that being rural might add torural health studies and deploy existing theory to explore howconnections between being rural and dimensions in research canbe explained.

2. Rural identities

We are researchers at varying stages of rural health researchcareers. We all grew up in Northern Scotland in or near small ruraltowns; and we all now work at rural university campuses. Wepropose that our connection with rural areas, or our rural ‘identities’,

ll rights reserved.

er),

uhi.ac.uk (C. Daly).

interact in a particular way with our thoughts about exploring andaccessing rural communities and their health services.

Considering the selection of research questions and design,there may be an instinctual understanding of approaches thatmight be useful. As an example, Author 1 recalls a brainstormingsession about potential prevention studies at the UHI Centrefor Rural Health. A medical researcher suggested a study aimed atpreventing the tendency for youths to speed on narrow, dangerousrural roads, citing the sad toll of accidents involving young people.Remembering her youth, Author 1 cited this as a cultural hazard ofgrowing-up in rural areas, that this apparently thoughtless drivinghabit was actually a ‘mental outlet’ for (mainly) young rural men.She was able to add a dimension of understanding about why thebehaviour might occur (and its possible positive elements!) that themedical researcher had not considered. Such insights can informresearch question selection and study design.

Researcher’s rural positionality can be actively deployed toaccess study cases and participants. Commenting on her position-ality in an Australian sugar industry study, Pini (2004) recordsmultiple identities deployed to gain entry and rapport, including‘Italian–Australian’, ‘female’ and ‘nice country girl’. Similarly,Bhopal (2010) notes that her identity as an Asian womanfacilitated study participants’ trust, enabling them to reveal morepersonal information. In an English study of rurality and identity,Neal and Walters (2006) discuss how they alternated betweeninsider and outsider status, empathising with local issues as ruralinsiders, but applying reflexivity as researcher outsiders. Thesestudies support our belief that we apply our rural credentials toposition ourselves to gain entry to subjects and establish rapport.

J. Farmer et al. / Health & Place 18 (2012) 1206–1208 1207

However, we also think that our empathy with rural participantscan help to produce richer data; and that appears to reach beyondthe idea of positionality.

Author 2 thinks this empathy can be illustrated in interview-ing she conducted in a Scottish Highland village. The studyexplored older people’s aspirations about where and how theywanted to live as they became frailer. S-AM found that, in datacollection, she repeatedly compared and contrasted her ownexperiences of rural living, and those she had discussed withher older rural-dwelling family members, with those of inter-viewees. She thinks this allowed her to respond to and encourageextension of the articulations of research subjects. S-AM felt ableto empathise with fears of having to move and expressions ofneeding to remain in place, due to feelings of connection with theland, landscape and rural social life; and was able to identify withrespondents’ perceptions that connections, aesthetics and rela-tionships were more valued features than addressing technicalhealth or social care ‘needs’ assessed by external agencies.

Rural identity can be actively applied by researchers to gainauthenticity. We have found rural credentials to be transferableacross rural settings, and have variously applied ours (e.g., ‘I grewup in a village north of Inverness in the Scottish Highlands’) togain entry and rapport in several Scottish settings, but also inCanada and Australia. This ‘crafty’ application of rural credentialsmay be interpreted as a part of researchers’ skills; although it canescalate into a rural authenticity ‘arms race’. For example, the ruralexperience of regional Victorians in Australia is regarded withdisdain by researchers based in Australian states with greaterremoteness. Similarly in Scottish research, islanders reflected thatmainlanders would not comprehend the difference made byseparation by sea. Degrees of rurality can be used by rural peopleagainst other rural people to characterise themselves as the ‘trulyauthentic’.

3. Rural interpretations

We three authors agree with each other that ‘being rural’ seemslinked to feelings of understanding what is being observed orrecorded in our rural studies. Crudely analysing this, our proposalis embedded in suggestions that the researcher from a rural areaconsciously or unconsciously: understands social system nuances;‘checklists’ for expected social or service dimensions; understandsand ‘speaks the language’ of rural communities; and is attuned torural activities and patterns.

For example, in Author 1’s study comparing rural and urbanhealth professionals’ work, it was observed that district nurses inremote settings were visiting individual patients up to five timesper day. Urban-based data analysts complained of inaccuraterecording by the nurses. The nurses explained that they might visita frail patient to get them out of bed, prepare meals, delivermedicines and put patients to bed. The philosophy was to keepfrail people living at home in their community plus there were fewspecialised staff members for specific tasks. The observed situationwas revelatory to the urban analysts who insisted on travelling tothe area and verifying the nurses’ work and data recording. As ruralresearchers, we found the nurses’ practice explicable. The followingexample of rural understanding was captured by Author 3’sdoctoral fieldwork in the Scottish Highlands:

‘‘As soon as the discussion gets under way, I quickly realisethat none of the participants are from the local area, they are allfrom other placesy It comes as a surprise that this observation isnoted from the start—was this a conscious observation or some-thing that occurs naturally within any exchange? Pondering thisalso leads me to consider what the impact of this is? Does myaccent signal to them that I am from the Highlands? Does that

knowledge impact in any way on the discussion and on theopinions that are expressed by the group? Such questions alsomake me consider my own role in the process. Does my gender,ethnicity, dialect or age ‘signal’ something to the participants?Does it make them more comfortable that I am from the High-lands? Either way, it certainly helps me to understand the culturalnorms that the participants speak of and, as a consequence, itseems to generate a discussion that is heavily nuanced and richwith meaning.’’ (Daly, 2010).

Interestingly, Australian Aboriginal researchers begin theirresearch reports by describing their positionality and relationshipwith ‘country’, considering this essential knowledge for the readerto comprehend the socio-cultural context within which findingshave been collected and interpreted (Reid and Taylor, 2011).

4. Theorising the impacts

Our feelings of empathy are likely linked with our lived experi-ence of rural cultural norms. Connell (2007) highlights that theprevailing sociological canon is Northern European metropolitan. Itthus ignores or ‘others’, different socio-cultural perspectives, includ-ing Southern, subaltern and non-Christian viewpoints. Healthcaresystems, policy and research in English-speaking cultures handlerural health similarly as the other. A consequence is that rural mustbe defined when submitting work to mainstream health journals,sometimes in ways that are not meaningful to the study conducted.Rural settings are diverse and those who study the relationshipbetween health and place are aware of the relevance of context inaffecting process and outcomes. Massey (2005, pp. 130–142) depictsplaces as permanences where influences overlap in space and time;for example, history, economics, politics, natural assets, weather.For Anderson et al. (2010), making the geographical dimensionexplicit, or the ‘where of method’, can fundamentally affect knowl-edge production. While rural places differ due to combinationsof interconnections, they share small population size and distancefrom population concentrations and related opportunities. As well asunderstanding links between health and place, rural health research-ers are aware of the relational dimension of service provision andreceipt; i.e. there are impacts on service uptake and demand whenpeople are known to each other. Rural health researchers have anin-built radar to the effects of place and relationships.

We explained that we were born, grew up, live, work and studyrural. Given our proposed special empathy, this might derive from‘rural belonging’; i.e. being born and growing up rural and/or beingbased in a rural area. But it may be that empathy can derive frombeing a rural health expert, having done much research and/orreading. There may be different ways of gaining empathy. This isan unexplored topic.

Deep understanding maybe about ‘habitus’ (Bourdieu, 1990).An extensive rural health literature explores factors associatedwith working as a rural health professional. Evidence suggests thatgrowing up, schooling or university education, in a rural place, areassociated with a rural career (Brooks et al., 2002). Bourdieu’sdescription of ‘habitus’ provides an explanation. Habitus is definedas ‘‘an individually operationalised set of expectations and under-standings based on the collection of experiences one encountersthat shape one’s sense of ‘rules of the game’’ (Bourdieu, 1990, p.13). It explains how people’s social influences from childhood andgrowing-up allow them to feel comfortable with certain socialcustoms and ways of living. Due to this ‘social conditioning’,individuals can understand, empathise and live with these cus-toms at other times in their lives. Habitus appears a usefulexplanation for why being rural in rural health research helpsresearchers to fit in and comprehend findings about places, peopleand services.

J. Farmer et al. / Health & Place 18 (2012) 1206–12081208

Associated with conforming to cultural norms is Woods’(2010) discussion of the ‘performance’ of rural; explaining that,when in rural places, people adapt their practices to fit with localculture. Social interaction is the process through which peopleinterpret and reconfirm their rural situation by ‘the productionand reproduction of discourses of rurality’; as such ‘the repeatedperformance of everyday practices becomes instinctive and intuitive’.Knowledge of, acceptance or assimilation of rural social practicesprovides a source for researchers gaining entry and rapport. FromWoods’ descriptions, performance is possible both by those withgenuine rural provenance and by those who have rural knowledge;thus performance might not necessarily be linked with belonging,but the quality of the performance and therefore the acceptabilityof ‘the performer’ might vary depending on the degree of localauthenticity.

5. Conclusions

This paper reflects on the difference that being rural mightmake, but not form a position of denying a role for urbanresearchers. Indeed the simple insider–outsider dichotomy, withimplied advantages for the former, is challenged by some (Herod,1999). What it does suggest is that those doing rural researchshould get to know the locality so that the methods are attunedand findings interpreted with awareness of context.

A persistent gripe of rural health researchers is the challenge ofconveying rural life to metropolitan policymakers. Researchersoften have to begin discussions by justifying how processes andoutcomes may be place-related, but there is often an uncomfortablefeeling of leaving a room having been written-off as a naive ruraladvocate rather than insightful, expert observer. This leads to thethought that it may only be possible to effectively communicateabout rural health and health services with those who are them-selves rural or who have experienced rural living.

In this paper, we air some ideas about our place in our researchthat have been bothering us. We propose that being rural makes adifference to rural research, but we maybe deluding ourselves.

We cannot more precisely define the difference made than tosuggest greater underpinning cultural knowledge to informresearch choices and interpretations and empathy that lubri-cates the process perhaps producing richer data. An unresolvedquestion is whether or to what extent being rural might affectthe nature of findings produced, published and disseminated?We seek to highlight the potential significance of the researcherin research production and suggest that increased attentionshould be given to researchers’ biographies and values inevidence production (Gewirtz and Cribb, 2006). In relation tothis, insights may be gained from indigenous peoples’ researchperspectives, internationally.

References

Anderson, J., Adey, P., Bevan, P., 2010. Positioning place: polylogic approaches toresearch methodology. Qualitative Research 10, 589–604.

Bhopal, K., 2010. Gender, identity and experience: researching marginalisedgroups. Women’s Studies International Forum 33, 188–195.

Brooks, R., Walsh, M., Mardon, R., Lewis, M., Clawson, A., 2002. The roles of natureand nurture in the recruitment and retention of primary care physicians inrural areas: a review of the literature. Academic Medicine 77 (8), 790–796.

Bourdieu, P., 1990. In Other Words: Essays Towards a Reflexive Sociology. StanfordUniversity Press, Stanford, CA.

Connell, R., 2007. Southern Theory: the Global Dynamics of Knowledge in SocialScience. Allen & Unwin, Crows Nest, NSW.

Daly, C., 2010. Researcher Diary. Unpublished.Gewirtz, S., Cribb, A., 2006. What to do about values in social research: the case for

ethical reflexivity in the sociology of education. British Journal of Sociology ofEducation 27 (2), 141–155.

Herod, A., 1999. Reflections on interviewing foreign elites: praxis, positionality,validity, and the cult of the insider. Geoforum 30, 313–327.

Massey, D., 2005. For Space. SAGE, London.Neal, S., Walters, S., 2006. Strangers asking strange questions? A methodological

narrative of researching belonging and identity in English rural communities.Journal of Rural Studies 22, 177–189.

Pini, B., 2004. On being a nice country girl and an academic feminist: usingreflexivity in rural social research. Journal of Rural Studies 20, 169–179.

Reid, J.B., Taylor, K., 2011. Indigenous mind: a framework for culturally safeindigenous health research and practice. Aboriginal and Islander HealthWorker Journal 35, 4–6.

Woods, M., 2010. Performing rurality and practising rural geography. Progress inHuman Geography 34 (6), 835–846.