Back Ground and Significance 13 STRENGTHENING AND SUSTAINING SOCIAL SUPPORTS FOR RURAL ELDERS Kristie J. Clark, MScN(c), RN1 Beverly D. Leipert, PhD, RN2 1 Regional Geriatric Program, St. Joseph’s Health Care, London, ON, kclark44@uwo.ca 2 Associate Professor, School of Nursing, University of Western Ontario, bleipert@uwo.ca Keywords: Social Support, Rural Elders, Rural Nursing, Rural Health, Canada ABSTRACT Rural elders face unique challenges in maintaining and strengthening their social supports. The purpose of this paper is to examine factors that influence social supports for rural elders as well as to identify implications for nursing practice and research. An extensive review of the literature revealed that rural elder social support is affected by factors related to outmigration of youth, geographical distance, transportation, decreased income, as well as rural culture, values, and norms. The literature also reviewed strategies that can facilitate social support in rural areas, including multiple use of one site, use of technology, mobile and outreach services, community development initiatives, and transportation projects. Rural nurses have a professional responsibility to share their knowledge of ways to sustain social supports for rural seniors, and to advocate for better funding and programs for this population. However, in order to prepare nurses to effectively advocate on behalf of rural seniors, education for nurses that encompasses the context of rural health is needed. INTRODUCTION The fastest growing population group in Canada consists of individuals over the age of 65 (Health Canada, 2002). In 2001, one in eight Canadians was part of this group (Health Canada) and as the “baby boomers” (individuals born between 1946 – 1965) age, the number of elderly is quickly increasing. The senior population is expected to reach 6.7 million in 2021 and one in four of these seniors will live in a rural setting (Health Canada). Furthermore, seniors in Canada greatly contribute to society by volunteering and in 1992 contributed 5.5 billion dollars worth of unpaid labor to our social programs (Health Canada). Therefore, promoting the health of this population will allow seniors to continue contributing to society in a meaningful and much needed way. As a result of the increase in our population’s age and the recognition of the economic impact this will have on our health care and social systems, a greater social interest in promoting health for older adults is evolving (Chapman, 2005; Nolan, 2001). Health promotion is the process of enabling people to improve and increase control over their health (World Health Organization (WHO), 1986). Since individuals living in rural and remote Canadian communities have diverse social, physical, and economic characteristics that have an impact on their health, it is important to look at the context of the rural setting when promoting health for older populations (Health Canada, 2003). In fact, rural people have higher rates of chronic illness, shorter life expectancies, higher unemployment rates, lower incomes, and fewer years of education (Health Canada). Thus, in order to promote the health of rural populations, it is important to examine social factors as well as environmental and economic factors and conventional health services (Troughton, 1999). Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 mailto:kclark44@uwo.ca http://www.uwo.ca/fhs/nursing/index.htm mailto:bleipert@uwo.ca 14 Strengthening social supports (SS) for elderly individuals is one method that can lead to improved health status and decreased use of health care services (Forbes, 1998). Hence, strengthening SS is an excellent strategy to promote health for rural seniors. The purpose of this paper is to look at factors influencing SS for rural elders. First, social support will be defined and factors influencing SS for this population will be examined. Then the authors will discuss strategies used to increase SS for rural seniors and identify implications for nursing practice and for nursing research. Defining Social Support Social support is a broad term and many definitions for it appear in the literature (Chappell, Gee, McDonald, & Stones, 2003). However, all the definitions for SS have a common underlying theme of relationships that contribute to individuals’ self worth and ability to function in society. For the purpose of this paper, social support will be defined as: Formal and informal activities and relationships that provide for the needs of people in their effort to live in society. These needs include education, income security, health care; and especially a network of other individuals and groups who offer encouragement, access, empathy, role models, and social identity (Barker, 1995, p. 357). Social support may include informal sources such as family, friends, neighbors, and community members, as well as more formal SS that encompass outside agencies such as support groups, housekeeping services, health care professionals, and volunteer organizations. Lack of SS is a mitigating factor in the deterioration of health for individuals so strengthening SS for elderly people can contribute to their well-being (Choi & Wodarski, 1996). In fact, increases in SS can lead to increases in: a) quality of life (Chappell et al., 2003; Graydon & Ross, 1995); b) morale (Edmunds, 2003; Wilson, Calsyn, & Orlofsky, 1994); c) activity (Chogahara, Cousin, & Wankel, 1998); d) medication and health care regime compliance (Kitchie, 2003); and e) self care abilities (Wang & Laffrey, 2001). As well, SS can lower levels of depression (Bothell, Fischer, & Hayashida, 1999) and feelings of isolation for those living in rural and remote areas (Mullins, Elston, & Gutkowski, 1996; Saito, Sagawa, & Kanagawa, 2005). For these reasons, it is important that nurses explore the impact that SS has on rural elders and factors that influence SS for this population. Factors Influencing Social Support Rural elders face unique challenges in maintaining and strengthening their SS due to their geographical location. Developing an understanding of the unique factors influencing SS for rural elders will help nurses plan care and create programs that meet the specific needs of this population. While there are no studies that look directly at factors influencing SS for rural elders, the literature identifies specific factors that contribute to promoting and maintaining SS. Issues such as outmigration of youth, geographical distance, transportation, decreased income, and rural culture, values, and norms are recognized as factors influencing SS for the rural elderly. Outmigration of Youth. Individuals growing up in rural environments often face limited opportunities and therefore leave their rural homes for urban centres where educational and Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 15 employment prospects are more abundant (Bushy, 2000; Gerrard, Kulig, & Nowatzki, 2004; McLaughlin & Jensen, 1998; Stoller, 1998; Troughton, 1999). Additionally, adult children who are gay or lesbian often move away because they prefer the invisibility and increased SS that urban areas can offer (Stoller, 1998). Since rural elders have a strong preference for informal SS, especially from family members and friends (Magilvy & Congdon, 2000; Weinert & Long, 1993), this outmigration of youth from rural areas has a significant impact on their informal SS. As well, formal supports may be affected by this outmigration of youth because fewer youth will be available to deliver more formal services either as paid professionals or as volunteers. Furthermore, outmigration of youth may result in smaller communities having higher proportions of elders. These rural communities of elders have greater health needs compared to other younger and less isolated communities, but may be, by virtue of their needs and demographic characteristics, too small to sustain geriatric social and health services (McLaughlin & Jensen, 1998). Geographical Distance. Geographical distance has a negative impact on SS and can lead to social isolation (Anderson, 2003). In fact, the further the distance between individuals and their SS, the less contact and access they have with these support systems (Anderson, 2003). In addition, weather can further limit SS for rural elders living in geographically distant locations because it can lead to unsafe driving conditions such as poor visibility, mudslides, icy roads, and even road closures (Johnson, 1998, Kihl, 1993). These unsafe driving conditions limit the ability of rural elders to maintain or access their SS networks. Moreover, in geographically isolated areas there are fewer educated or trained individuals to deliver social services thereby limiting the number of formal SS available to those elders living in geographically distant areas (Nagarajan, 2005; Romanow, 2002). Transportation. For elders living in isolated, rural areas, the ability to drive has a positive impact on their quality of life and mobility because the ability to drive results in being able to access social services and support networks independently (Kihl, 1993). For some rural seniors, functional declines related to aging, such as reduced vision, reflexes, and reaction time, may lead to losing their driver’s licenses, thereby limiting their access to SS (Johnson, 1998; Rashba & Pavelock, 2006). Disturbingly, older rural adults may continue to drive even after they have lost their licenses because no alternative transportation is available (Johnson, 1998; Rashba & Pavelock, 2006). In fact, most rural areas do not have reliable public transportation systems such as buses or taxis, and seniors from these areas are dependent on themselves, neighbours, and family members to provide transportation (Kihl, 1993). Consequently, a lack of reliable transportation is a major barrier when setting up satellite clinics or formal support programs in rural areas (Choi & Gonzalez, 2005; Kihl, 1993). Likewise, rural elders who still have their licenses face unsafe driving conditions prevalent in rural areas, such as inclement weather, gravel roads, unlit roads at night, and mountainous or monotonous terrain (Johnson, 1998, Kihl, 1993; Leipert, 2006). Decreased Income. Lower levels of socio-economic status are linked to lower levels of SS and increased incidences of social isolation (Health Canada, 2005). Since both seniors (Ahn & Kim, 2004; Health Canada, 2002) and individuals living in rural areas (Health Canada, 2003; Troughton, 1999) are more likely to experience decreased incomes, rural seniors are at an increased risk for living in poverty. While income and SS are not the major focus of the literature analyzed for this paper, the link between poverty for rural elders and decreased SS is repeatedly mentioned in the literature (Ahn & Kim, 2004; Comerford, Henson-Stroud, Sionainn, & Wheeler, 2004; Magilvy & Congdon, 2000; Wang & Laffrey, 2001). Rural seniors with limited Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 16 incomes may not have enough money to pay for transportation and other expenses associated with social programs or to pay for more formal supports such as house cleaning and homecare services (Ahn & Kim, 2004; Gerrard et al., 2004; Keating, Keefe, & Dobbs, 2001). Furthermore, individuals living in lower income rural areas may need two incomes to support their families and therefore more adult children may need to work outside of the home, thus decreasing the amount of informal support available for rural elders (Magilvy & Congdon, 2000). The limited amount of research addressing the link between SS and poverty is from a quantitative focus. While statistical data is important, it does not tell us about the impact poverty has on SS and the lives of rural elders. Therefore, more qualitative research addressing poverty and SS is needed in order to gain an understanding of these issues from the perspective of rural dwelling elders. Since women, immigrant, and Aboriginal populations in rural areas experience limited job opportunities, lower paying employment, and increased incidences of poverty (Black, Cook, Murry, & Cutrona, 2005; Gerrard et al., 2004; Health Canada, 2005; Leipert, 2006; McCracken et al, 2005; McCulloch & Kivett, 1998; Ship, 2004; Wang & Laffrey, 2001), specific attention should be given to these groups. Rural Values, Culture, and Gender Differences. Prevalent in the literature on rural health are the strong values of independence and self-reliance (Bushy, 1990; Gerrard et al. 2004; Lee & McDonagh, 2006; Long & Weinert, 2006; Shenk, 1998; Thomlinson, McDonagh, Crooks, & Lees, 2004; Weinert & Long, 1993). As already mentioned, if help is needed, rural elders prefer informal supports such as family, friends, and neighbours (Bushy, 1990; Lee & McDonagh, 2006; Shenk, 1998; Weinert & Long, 1993). In fact, one study finds that rural individuals are less likely to use formal services even if they were available (Weinert & Long, 1993). Thus, for rural elders, assistance from family and friends buffers against poor health and loss of independence (Keating et al. 2001). Moreover, volunteerism is a strong part of rural culture (Keating et al. 2001; Keefe & Side, 2003; Little, 2002; Rowles, 1998; Sutherns, McPhedran, & Haworth-Brockman, 2004) and this can enhance SS for rural elders. However, it is important to recognize that women are primarily responsible for providing voluntary care to rural elders, even if they work or have young children for whom they care for at home (Little, 2002). As rural populations age, continuing to expect women to provide these supports to rural elders when they may already be juggling multiple roles may have detrimental effects on the health of both the rural woman caregiver, as well as the rural recipient of care. Regrettably, there is no research that explores these issues or that identifies supports rural women caregivers may need in order to maintain their well being. Since rural women are a strong source of support for the rural elderly, research that focuses on rural women and caregiving is desperately needed. Rural cultures also tend to prefer and enact gender differences in how SS are maintained and accessed. For instance, women are predominantly responsible for maintaining social relationships and SS (Krout, McCulloch, & Kivett, 1997; Little, 2002; Shenk, 1998). As well, rural women are more likely to receive SS from family and friends, whereas rural men rely more heavily on their wives for support because they have fewer resources to turn to and find it harder to ask for help (Krout et al. 1997; Weinert & Long, 1993). Thus, there is a risk for rural men, especially those who are single or widowed, to have poorer SS than women. Furthermore, it is important to recognize that rural communities are heterogeneous and that subpopulations within communities will have their own values and traditions. In the literature on SS, there is a paucity of information regarding SS and minority populations. One study found that rural older lesbians receive help and support from their neighbours but these women still need to leave town on a regular basis to seek emotional support that respects their Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 17 lesbian social identity (Comerford et al. 2004). Additionally, in rural areas informal support networks are commonly church-based and not well utilized by lesbians because of the historic disapproval of homosexuality that is prevalent in many religions (Comerford et al. 2004). Studies that examine rural, minority and ethnic populations demonstrate a common theme: increased SS from family and friends coupled with decreased uses of formal SS due to racism and cultural insensitivity (Adelson, 2005; Black et al. 2005; Ship, 2004; Radina, Longo, & Armer, 2005; Weiner, Burhansstipanov, Krebs, & Restivo, 2005). In order for rural nurses to deliver care that is culturally sensitive, more research that explores SS and rural minorities is needed. Significantly, in Canada, a large portion of Aboriginals live in rural and remote areas (Health Canada, 2003) and yet there is very limited information on SS for this group; consequently, this is one area that researchers need to concentrate on in order to promote better health for this population. As identified, there are many factors influencing the SS of rural elder. In addition to having a better understanding of what these factors are and how they affect SS, nurses need to use innovative and creative strategies to strengthen and sustain SS for older individuals living in rural settings. Strategies to Strengthen SS for Rural Elders Since rural elders have unique determinants of health, it is important to establish creative ways to address the challenges these individuals face in maintaining their health. Unfortunately, there is only a small amount of literature looking at innovative ways already implemented to strengthen SS of individuals living in rural areas. Through the literature review, common themes were revealed regarding ways to increase the SS of rural people include multiple uses of one site, use of technology, mobile and outreach services, community development initiatives, and transportation projects. While some of these strategies are not specific to strengthening SS for older rural residents, these strategies could be utilized to increase SS for this population. Multiple Uses of One Site. Creating multi-use centres that house more than one social support service or agency can increase access to SS for rural seniors. In Quincy, Illinois a rural senior centre that houses 14 different service agencies and provides meeting and activity space to 182 groups was built in 1992 (Rowley, 2004). Within this centre there is assisted living housing for up to 14 individuals; social support programs such as art classes, support groups, and adult day care; support for informal care givers; and care provided by a nurse practitioner. Although centralizing SS in one centre is an ideal way to increase SS for elderly rural people, not all communities can afford the cost of building and operating major centres. Therefore, it is important to look at services already existing in the community that can be utilized to house multiple SS. In the video Fear on the Farm (Birdsong Communications, 1993), a rural community was portrayed that utilized the local church to centralize information about the SS and health programs available to its community. Since most rural individuals have strong ties to the local church (Little, 2002), this is an excellent solution that is relatively inexpensive. On the other hand, it is important to keep in mind that not all rural community members will access church-based services as identified earlier when addressing the SS needs of older lesbian women (Comerford et al. 2004). An alternative to help address the special needs of populations not comfortable with accessing church-based services is to use other common meeting areas within the community, such as local libraries or post offices, to distribute information about SS for the area. Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 18 Additionally, in order to meet the need for more long-term care beds in rural areas and the accompanying SS needs of rural elders who require this type of care, Magilvy & Congdon (2000) advocate for using acute care beds that can be converted to long-term care beds when needed in rural hospitals. Such an adaptation prevents the need to send elderly individuals to centres that may be hours away from their informal SS. This is an excellent idea because it makes good use of hospital resources, while at the same time sustaining smaller rural hospitals. To this end, the multi-use of rural beds could be broadened to include multi-use of rural hospital space that provides low cost or free areas for local social support programs such as Meals on Wheels, social clubs, volunteer transportation services, and other geriatric services. Even with such an innovative plan, providing reliable, affordable transportation for rural elders to the multi- use centres remains a priority. Use of Technology. Recently the uses of the Internet, web-based programs, and tele- technology have been used as ways to increase SS for rural residents. Using the Internet to form support groups is one way to address the issues of anonymity and access for people who are geographically isolated and who have limited mobility (Cudney, Butler, Weinert, & Sullivan, 2002; Hill & Weinert, 2004; Weinert & Hill, 2005). One example of a successful Internet support program is the Women to Women program in Montana (Rowley, 2004). This program used the Internet to link women with chronic illnesses living in remote areas to virtual support networks. To date, this project demonstrates that this type of intervention is successful for increasing SS to rural women with chronic illnesses (Rowley, 2004). Accordingly, the use of technology is one strategy practitioners should consider when looking at ways to increase SS for rural elders, as well as for their informal caregivers and other informal SS personnel such as family and friends. In addition to using the Internet, rural seniors are using the World Wide Web to access information related to health issues and resources (Thomlinson et al. 2004). Currently, in Missouri, a project using online communities that house health-related resources and information for specific rural areas is underway (Centner, 2006). Nurses could develop websites like the one mentioned as an inexpensive way to provide information about local SS resources to rural elders. Tele-technology and the use of videoconferencing have also increased access to health care and SS for rural elders. For example, The Interactive Home Health Care Program in Kansas links homebound, elderly, rural individuals to registered nurses through the telephone and specialized television sets with cameras (Lindberg, 1997). Nurses in this program provide physical assessment, care recommendations, and coordination of care services to these clients. While the focus of this program is heavily based on the physical aspects of care, this technique could be enhanced to focus on providing SS to rural elders and their informal caregivers. Also, other projects have successfully used telecommunications and videophones for nurses to provide support and resources to rural patients and their caregivers (Maxwell, 2006; Rowley, 2004). Although these other projects are not specifically targeted at older rural residents, they do provide evidence that these types of initiatives are successful at increasing SS and should be considered for use with rural seniors and their informal SS. While there is growing evidence to indicate that the use of technology can improve the health and access to services for rural dwelling individuals, it is important to recognize that not all individuals are computer literate. Furthermore, not all remote areas will have the technical infrastructure available to support internet and telecommunication services, so this option may not be available to all rural populations. Moreover, even though the use of technology can Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 19 increase some SS for rural elders, this type of technology does not address needed physical supports such as housekeeping, help with activities of daily living, or reliable transportation. Mobile and Outreach Services. Creating interdisciplinary, mobile health units is a resourceful solution with the potential to increase the quality of health care for rural elders (Alexy & Elnitsky, 1996; Hayward, 2005). For instance, there is the ISU Senior HealthMobile, a health service designed to deliver mobile health and wellness interventions to rural residents over the age of 60 in Idaho (Hayward, 2005). This program encompasses an interdisciplinary, community development approach that addresses the specific needs, both physical and social, identified by communities. Regrettably, Hayward provided little information about the issue of insider/outsider status that is prevalent in rural communities (Boland & Lee, 2006; Long & Weinert, 2006) and whether or not the outsider status of service providers presented any barriers to the program, given rural residents’ preference for care by known others (Bushy, 1990; Lee & McDonagh, 2006; Shenk, 1998; Weinert & Long, 1993). One way to increase the success of mobile outreach teams would be to include insiders, such as local health care professionals or community members, as part of the unit’s team. Alternatively, lay individuals or local professionals could be educated to deliver these services and the mobile team could act as a support resource. Community Development Initiatives. Using community members to identify, create, and run needed programs can lead to the sustainability and success of services because doing so increases community capacity, ownership, and utilization of programs (Averill, 2003; Gustafsson-Larsson & Hammarstrom, 2000). In Jamtland, Sweden, women’s networks were created to develop social networks for women living in rural areas (Gustafsson-Larsson & Hammarstrom, 2000). These networks address a community-identified need and women are involved in unpaid activities such as competence development, preservation of the local culture, community development, or caregiving for young children and the elderly. These networks lead to improved health and stronger SS for participants (Gustafsson-Larsson & Hammarstrom, 2000). A project like this one could be considered for rural elders in Canada to enhance their SS. Another community development initiative, The Promatoras Project, utilizes lay community educators to help strengthen the social and economic infrastructures of their own communities (Ramos, May, & Ramos, 2001). Using lay community educators could be a strategy used to strengthen SS for older rural individuals. Furthermore, since this approach is culturally based, it may be the optimal approach to use with rural immigrant and Aboriginal populations as a way of ensuring culturally sensitive care. On the other hand, it is important to note that, in order for these programs to be successful they need to be supported with sufficient funding and supportive policies and should not be viewed as a way to fill gaps within the health care system (Gustafsson-Larsson & Hammarstrom, 2000). Transportation Projects. Most of the literature looking at transportation issues for rural populations focuses on the barriers presented by having no reliable transportation. Little information is available about initiatives or programs addressing inadequate transportation systems for rural residents. In Iowa, a review of rural transit services for the elderly was conducted and this report found that due to inflexible scheduling and poor accessibility of rural transit systems, many rural elders preferred to pay others to drive them rather than use transit (Foster, Damiano, Momany, & McLearns, 1997). Since rural communities face unique needs for transportation, rural individuals may benefit more from informal, local, community-created transit options. For instance, the amount of money needed to sustain rural transit systems could be provided to rural communities to purchase a wheelchair accessible van that could be available Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 20 through centralized booking to transport community members. Alternatively, the funding for rural transit systems could be used to reimburse informal supports already transporting rural elders and to help ensure that these individuals have proper insurance for doing so. This manuscript provides the reader with some creative ways to strengthen and build SS for rural elders. The authors’ own experiences of living and working in rural areas, have revealed that there are very likely several other programs and initiatives occurring in rural areas, but that these have not been written about or otherwise publicly shared through publications and conferences. For example, during flu season, many public health nurses travel out to farms to immunize rural seniors who cannot travel to town to visit the health unit. These public health nurse visits provide excellent opportunities to also assess and provide SS to rural seniors. Another example is the informal network of rural seniors who shared their skills and expertise to help one another remain in their rural homes. For example, a farmer with a tractor would cut the grass and clear snow for those unable to do so, and a senior lady would make meals that could be frozen and deliver them to seniors who needed them. Ideally, a network of rural communities could be created that shares information about challenges and solutions rural residents have faced in implementing supports. This network could readily disseminate information important to the success of supporting health and resources for rural elders to health care professionals, policy makers, and rural residents themselves, thereby promoting the health of rural elders and rural communities. Implications for Nursing Practice First, when planning care or developing programs for rural elders, it is essential to assess existing supports and to include informal SS in the process. As a result, care and programs in situ that are sensitive to the unique needs of elderly rural individuals can be better supported and developed. Issues surrounding transportation and costs to participants should be key considerations when program planning occurs, and reliable and affordable transportation should be factored into program costs and needs. If formal rural transportation is not available, then appropriate monetary compensation should be made available to suitable rural individuals who are willing to transport rural elders. As well, due to the higher rates of lower incomes faced by many rural seniors, cost of programs should be kept to a minimum. If rural elders require funds for travel, these monies should be provided upfront, before travel commences, to avoid lack of participation due to not having enough funds a priori. Second, program planners should incorporate a community development approach when developing programs to promote health and strengthen SS with older rural community members. Since rural populations are heterogeneous, using this approach allows community members to identify needs specific to their areas. Additionally, taking a community development approach allows individuals in the community to take ownership of the initiatives and builds on the pre- existing strengths within the community, thereby contributing to the success of programs while building capacity within the community (Averill, 2003; Gustafsson-Larsson & Hammarstrom, 2000). Third, rural nurses need to advocate for programs based on needs, not on numbers or on how programs relate to costs of services. While nurses have a responsibility to provide care that is cost effective, there are some communities that will never have high enough numbers of elderly individuals to make programs cost effective. Therefore, nurses need to find resourceful ways to deliver much needed services that contribute to strengthening the SS of rural elders. One Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 21 way this can be done is by utilizing lay service providers who could be supported by health professionals in other geographical areas. This approach would not only provide services needed by the elderly, but could also lead to potential employment opportunities in rural areas, potentially keeping rural youth in the community. Rural nurses also need to advocate for more resources for the elderly, specifically focusing on more funding and on the creation and support of knowledgeable resources, both formal and informal, to provide services to this population. Fourth, sensitivity to gender issues and cultural needs and differences is needed in order to provide SS that are holistic and valued by rural community clients. For instance, men have a harder time asking for help (Shenk, 1998); therefore, when working with rural men it may be more appropriate to offer help instead of waiting for them to request it. Likewise, women are mainly responsible for providing informal SS to rural seniors (Little, 2002) so it would be important to make sure that these women are well supported themselves and that resources are put in place so that these women are not overextended and exploited. Furthermore, rural seniors prefer informal SS to formal ones, and they receive more SS from informal networks than urban seniors (Forbes & Janzen, 2004). Consequently, nurses need to explore how caregiving affects the health of these informal SS care providers, and determine and advocate for supports that are needed to sustain these critical rural caregivers. Finally, in Canada there is a lack of rural health courses in nursing curricula, and those nurses already working in rural areas have limited opportunities to enhance their practice knowledge (Kenny & Duckett, 2003). Thus, in order for nurses to fully comprehend the complex factors influencing health and SS for rural communities, rural health courses need to be available to these nurses. Through increased knowledge about the health of rural Canadians, nurses will be better prepared to deliver care that is holistic and that meets the needs of rural communities. Future Research As already emphasized, more research is needed to better understand and address factors that influence SS for rural elders. Most of the literature that discusses SS for individuals living in rural areas focuses on how SS are related to the health of individuals from a quantitative perspective. Grounded theory, a methodology used to create meaning out of social interactions (Beck, 1999), would be an excellent approach for researchers to use in order to gain an understanding of factors that influence SS and of SS processes used to maintain and promote health from the perspectives of elderly individuals living in rural areas. In addition, the use of ground theory research can contribute to the development of much needed theories for rural health nursing (Beck, 1999). Furthermore, there is limited information about the health of rural Canadians, and although some of the research from Australia and the United States can be applied to rural communities in Canada, it is important, for relevance and utility that Canadian context-specific knowledge be identified and used to advance the health of rural elderly people within the Canadian rural setting and health care system. Specifically, in Canada additional research is needed to: a) gather more data regarding SS in Aboriginal populations; b) increase our understanding of gender differences and SS; c) explore the link between poverty and SS; and d) develop nursing theory about strengthening SS for rural communities. Online Journal of Rural Nursing and Health Care, vol. 7, no. 1, Spring 2007 22 Conclusion Social support can increase the health of rural elders. By examining the personal experiences of rural seniors and their SS, an appreciation for the day-to-day challenges these people face can be created. In this way, nurses can better plan care and develop programs that address specific factors that influence SS for elderly rural populations. In addition to creating innovative ways to sustain SS for rural individuals, nurses have a professional responsibility to share with policy makers and other health care professionals their knowledge about factors influencing SS for these individuals. As well, nurses need to advocate for services and funds to strengthen the SS for older rural people. In addition, information should be widely disseminated regarding what is being done and what needs to be done in order to foster SS for the rural elderly. In these and other yet-to-be determined ways, rural policies, programs, and funding for health initiatives can be strengthened and rural elders’ health promoted. 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