The meaning of health and well-being: voices from older rural women

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Introduction

The ageing population

Throughout the 1990s, empirical gerontological North American studies have provided evidence that the older rural person's homes, families, support systems and the geographical locations in which they have lived the majority of their lives play an important role in the maintenance of their health, independence, and positive attitudes, reducing their susceptibility to illness^1-13. While such studies support the importance of self-perceived factors in maintaining aged-people's health, few studies have specifically focused on why geographical location influences the health and well-being of older people.

The size of Australia's older population is increasing and steadily becoming feminised. There is a steady decline in the proportion of men in the population after the age 65 years and men are more likely to age with their spouse¹⁴. Beyond 85 years, women comprise more than two-thirds of the aged population¹⁵. Approximately 37% of these older Australians live outside capital cities. Of these, approximately half live in major regional centres and the other half live in more rural and remote areas^16,17. The age and sex of people over 60 years living in rural and remote areas are increasing in proportion to the total Australian ageing population (pp.28,9)¹⁷, so widowed women living in rural and remote areas form the majority of this population.

The influence of environment

While older rural persons have been found to have the characteristics of independence, self-reliance, hardiness, privacy, dignity and self-sufficiency^11,12,18,19, they are also defined by environment. The environment of living influences the way older rural dwellers perceive their own health - for example, their ability to work, function and perform daily tasks, despite physical illnesses^11,21-23. Studies that focused specifically on older rural women and the influence of environment (as geographic location), found that the rural environment produced a distinct set of values and way of life^24-27. Some studies found that 'health', for this group, appeared to have the more subjective, holistic and qualitative properties of well-being, rather than than the traditional objective biomedical properties often assigned to health^28-35. However, these studies did not seek the views of the older rural women as to why this should be so, nor did the studies seek to understand the influence of environment on the maintenance of health and well-being in these older women's lives.

Gubrium's socio-environmental theory of ageing lends support to the value in pursuing such meanings: it attests that environment does play a role in the older person's 'health'³⁶. Gubrium's theory argues that the interpretation of the content and events of the older person's everyday life (eg widowhood, retirement and poverty in old age), is a highly social process located in their geographic and social environment. From Gubrium's theoretical position, the environment is not a static backdrop but changes continually as the older person takes from it what he or she needs, controls what can be manipulated, and adjusts to conditions that cannot be changed.

Rationale for researching the influence of environment

The impetus for research into the critical factors affecting health and well-being in the lives of rural Australian older women, and seeking their views about this, is supported by the goals for healthy ageing as set out in the National Strategy for an Ageing Australia³⁷. Furthermore, the 1995 Australian Health Minister's Advisory Council identified that older residents of rural and remote areas who share characteristics of living such as geographic isolation and inaccessibility, and special circumstances associated with what are often harsh environments, are predisposed to poorer health than are their urban counterpart¹⁷. For those planning services for this group of older women, the influence of the rural and remote social and physical context on health and well-being must be understood and considered.

This article, as part of a larger thesis³⁷, describes a qualitative study that explored the meaning of 'health' and 'well-being' from the perspective of the older rural woman, and the influence of geographic location on the way these factors are perceived.

Informants

Following ethics approval from the University of New England (New South Wales, Australia) Human Research Ethics Committee, five women aged 78-88 years, who had been widowed for at least 2 years and were not suffering from any major illness or disability, were voluntarily recruited. To eliminate bias, homogenous sampling strategy was employed: the informants had to meet the selected criteria of being an older widowed woman of 65-85 years, either living on a rural property or had done so for most of their lives. Meeting this selection criteria qualified the informants to be 'information rich' for the purposes of the study, and so able to provide an 'information rich' case history of their life in the required context^38,39. Because widowed women living in rural and remote areas are increasing in proportion to the total Australian ageing population, the importance of seeking their views was demonstrated¹⁷. A profile 'snapshot' of each woman is depicted (Table 1).

Table 1: Demographic and characteristic data of informants



Contextualising the study

The profile emerges from the snapshots (Table 1) of an older woman who lives away from any township in isolation on the land. Therefore, for the purposes of this study, 'living on the land' means living on a property away from any rural town or large regional centre. It is also inter-changeable with 'rural'. In keeping within the philosophical boundaries of this study as is consistent with Gubrium's socio-environmental theory³⁵, this concept conjures up a dynamic socio-cultural transaction and physical participation with the surrounding geographical milieu. It provides cognition of space and emotional attachment to place, which, in turn, has the potential to determine the way people live, manage and maintain their lives through reciprocal interaction.

Methods

Data collection

The study was conducted in 2001. Information concerning the format, aims, purpose, assurance of anonymity and confidentiality, and benefits of the study was provided to each of the informants at a mutually agreed meeting in the informant's home. Each potential informant was asked to show the researcher photographs of their property and autobiographical material so that their life on the land could be visualized. The purpose of the preliminary interview was to begin to develop a relationship of mutual trust between researcher and informant, and to discuss the logistics of the data collection. In addition, the preliminary interview was the groundwork for the next data-collection strategy (the in-depth interview focusing on the informant's life history) in that it allowed it an openness and fluidity to '...grasp the native's point of view, his relation to life, to realize his vision of the world...' (pp.94-95)³⁹.

After informed consent was obtained, data were collected from each informant, in a unilateral fashion, by preliminary and repeated in-depth interviews, which included discussion of photographs and auto-biographical material. The researcher maintained a personal, reflective diary. It was also mutually agreed that each informant would be referred to by their forename, and the name of their property would be replaced with a pseudonym.

At the first in-depth interview, informants were asked about their property. This provided a background conducive to the social constructionist paradigm and placed the interview in the informant's context and environment. The interview opened with a broad statement such as: 'Tell me about your life here on this property'. In keeping with tactics for the collection of life histories suggested by Plummer (p.97)³⁹, the first in-depth interviews were transcribed verbatim and analyzed for issues that arose and needed clarification in subsequent interviews.

To ensure adherence to ethical principles, the typed verbatim transcripts, audio-tapes, photos and autobiographies of each of the informants were placed in a locked filing cabinet when not being analyzed. The researcher's personal reflective diary and information about the informants and codes were kept separately in a locked draw to ensure confidentiality of data.

Analysis

This inquiry was analyzed using qualitative methods and strategies that illuminated the meaning and motives of the informants. The choice of method was determined by the researcher's desire to gather descriptive data from the informants, delivered in their own words. The life history research approach was chosen to guide data collection and analysis³⁹. Social constructionism^40,41 and socio-environmental theory of gerontology^35,42 provided the philosophical boundaries to the central research question: how the rural geographic location influences health and well-being of the rural older widowed woman.

Validation of data

The data collected from each informant were analyzed to isolate and describe emergent themes. Following this, each informant's total life history was compared and contrasted with the other's. This thematic analysis avoided the life-history research approach of examining life themes in isolation³⁹. Each informant read the thematic analysis from her own life history and validated the emergent themes. The process, they said, gave them a feeling of pride and self-achievement, which in turn increased their feelings of self-worth and esteem. In addition, their validation of the process added to the rigor of the analysis.

Results and Discussion

While each informant's life history was unique, it was found that the informants' health and well-being were profoundly influenced by the geographical location of living on the land. Hence, 'living on the land' was identified as the major theme. This was identified as enmeshed with a sub-theme: the presence of an emotional connectedness to or intimacy with living on the land. As a result of the inclusion of these profound influences in informant' data, each informant self-identified the meaning of health and well-being.

Excerpts of interviews offer insight into the process of the research, where the informants' own words best reflected and articulated a particular concept.

Living on the land

Analysis of the data revealed that living on the land had a profound influence on the women. Their own particular environment reflected their sense of wholeness as transaction and interaction with the land provided a spiritual underpinning to life. All the informants loved the land to the extent that they developed an intimate relationship with it, as one develops a deep affection and love for another person. This interpretation concurs with Gubrium's socio-environmental approach to ageing in the sense that being healthy can be located in the context and environment of the older person, much as is the aged person's body: '...persons may act in response to the state of congruency in their environments' (p.133)³⁵.

These women derived congruency in a spiritual sense, and because of this had a dynamic and transactional association with the surrounding nature and environment, hence, living with and in the land - the bush:

I think, the very quietness of the bush and the very healthy lifestyle was what I valued...I felt it was a part of my life...it was my 'shield'...you become more aware of that 'other life' that is there around you...it was my 'shield'..a power...each person has their own interpretation as to what that 'power' is...for me, it was a sense of 'some one' watching all the time...and helping me.

In addition, the women saw living on the land, and their past work with their husbands, as a life-long career and way of life - this was the meaning of living as a woman of the land.

I came from the land...on both sides of the family...and that's why, I think, I could devote my whole life to it...it's a life that you never get bored, and you never get tired of it...something is always happening all the time...whether it's good or bad....we (my husband and I) just bred sheep.... that was our life...the whole of 'Sheep Acres'...we had been doing things together...we were joint owners.

I can't put into words how much getting out on my four-wheeler motor-bike around the place helps me...it's very peaceful and quiet out there...I look at the water in the dam, the cattle, the plovers, the wallabies.

In addition to the intimacy of living on the land, all the informants demonstrated the presence of a connectedness in living on the land in their own unique way. They referred to how the reminiscences and memories of living on the land helped with their ageing experiences, and the management of their health and well-being. Analysis of data revealed a feeling of deep belonging to, and intimate relationship with the land that remained forever as 'individuation - an inner process of transference whereby the archetypical self strives toward totality and wholeness' (p.13)³⁴. This individuation spoke of deep integration of the women's inner past experience of living on the land, while this was also expressed overtly as connectedness to and intimacy with living on the land. This process of integration and connectedness provided comfort for the informants during their transition to widowhood and in the variety of rural crises over their lives:

I can't say I was consciously thinking of it, but looking back on my thoughts, I realize how tangible it is...when you stop to think about it...that extra beauty of the world itself...which is more visible when you are in the bush..it is there, that feeling that there is a better world than what would have you believe...and nothing can distract me from that feeling of...well, inner peace...it is always there...I think the peacefulness...the serenity of the bush...really helped me a lot....

...it's there all the time, and you can't forget it, put it that way...I feel myself going back to 'Sheep Pastures' at times...I even dream about it...just little things come to my mind: 'Oh Yes! That happened at "Sheep pastures"!'...it's still most foremost in mind....

...there was never any thought of living anywhere else [after becoming a widow]...it's home...it's mine...that's where I'm happy...when I'm home I sit back in my chair in the shed, and I look out across the paddocks...it's very peaceful out there...I like to get out on my bike...that helps me a lot...

Health for the informants was seen as the assumption of not being ill, having any aches or pains, or having 'sick complaints'. In total, the informants equated health with the biomedical model, which emphasizes illness and treatment of existing conditions⁴³. The reverse, 'sickness', was seen as the person having a condition that must be treated by a doctor and/or taking medication. Furthermore, to have health was a definite and conscious state of being.

These women considered that if they did not maintain their health in the face of advancing age, this in itself would prevent them from living on the land:

...towards the end [just before re-locating to a retirement village], I started to feel that my health was getting a bit 'dicey'...I felt that I had passed that 'corner in my life'...K [older son] was out in the paddocks all day and I was alone in the house...

All the women expressed similar views of self-perceived health. A pathological condition that made them sick meant they were not healthy. Being healthy was 'when you haven't got bad thoughts', when you could be 'still be active, busy and happy'. Being healthy also was the maintenance of safety and being free of injury:

...I find the 4-wheeler safer...I don't ride the other [2-wheeler] as it's easy to fall off...I do need someone to keep the grass short around the bush bike tracks because of the snakes...

...there were times, when we were shearing and mustering, when my back would hurt...well, I had to learn to live with that...so, I just went on...you just cope with things!'

To each of the informants, well-being was not a conscious state that they instantly recognized within themselves, such as knowing about their health or what they saw as important to maintaining their health. Rather, well-being was found to be a state of being that unconsciously produced a positive mental approach to life: a sense of self-esteem, of being able to cope and being fully occupied and busy, all attributes of a rural person's persona^11,24,32. Well-being was seen as reliant on but different from health; however, in the end, self-perceptions of well-being were, as for health, enmeshed with the influences of living on the land.

Each of the informants recognized states of being which produced a general sense of well-being:

...I think the peacefulness...serenity...of the bush helped me in my general health...my 'mental' health, anyway...

...totally your own make-up, just a positive attitude and you can always turn a negative into a positive, providing you have that attitude.

Geographical location was not only a static back-drop for these women, but also played an active and intimate part in their process of ageing, and their maintenance of health and well-being. This is consistent with Gubrium's theory that the aged person's body and sense of being is included in their context and environment³⁶. The study also showed that spirituality, and participants' connectedness to and intimacy with the land were strong influences, representing unique findings among other, similar studies^{1,2,7,8,10,11,44,45}.

Many studies confirm the findings of the present study in relation to self-perceived health in the older person^27-34. However, no other study identified that health was consciously associated with the biomedical model and considered the only component of health status, as was found in the present study.

Conversely, well-being was identified in the present study to be reliant on health, yet different from it, in that well-being was not seen as such a definite and conscious state as health.

Conclusion

The main objective of this present study was to explore, from the perspective of the older woman who live on the land, the meaning of health and well-being, and the influence that geographical location has on that meaning. The present study supports other studies in the finding that the geographic location of the elderly plays an important role in the maintenance of their health and well-being. However the unique contribution of the present study is the finding that the informants' health and well-being was influenced by a connection to and intimate relationship with living on the land.

Although this study was limited to a small group of older widowed women who live on the land, the findings indicate the importance of and value in the older person's understanding of their own lives, health and well-being to the researcher. The study also highlights the influence of the older person's unique geographic location on their health and well-being.

By understanding this small group of older women's perspectives on the maintenance of health and well-being, a professional health-care worker can assist a similar population to maintaining a high quality of life. With this in mind, the authors recommend that this work be extended by a larger study, and that the present study and its larger work³⁷ be seen as a beginning step in defining health promotional activities, policy development and service programs for older rural women that are both person-centered and sensitive to their unique lifestyle.

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