Microsoft Word - Eisenhauer_397-2396-1-ED.docx Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 195 Partnering with Rural Farm Women for Community-Based Participatory Action and Ethnography Christine Marie Eisenhauer, PhD, CNE, APRN-CNS 1 Carol H. Pullen, EdD, RN 2 Terry Nelson, PhD 3 Sarah A. Kumm 4 Jennifer L. Hunter, PhD, RN 5 1 Assistant Professor of Nursing and Clinical Researcher, University of Nebraska Medical Center-Northern Division, ceisenhauer@unmc.edu 2 Professor, College of Nursing, University of Nebraska Medical Center, Omaha, chpullen@unmc.edu 3 Professor, Division of Social Sciences, Mount Marty College, Yankton, SD, tnelson@mtmc.edu 4 Rural community stakeholder, sarahannekumm@gmail.com 5Associate Professor, School of Nursing, University of Missouri-Kansas City, hunterj@umkc.edu Abstract Background: U.S. farm women experience poor access to health care and high rates of health disparities. Demographic shifts are increasing isolation and decreasing social capital for these women. Providing locally meaningful health care requires cultural-historical understanding gained through community partnership. Yet, rural farming communities present challenges to establish local-buy-in and participation for research collaboration. Purpose: This article describes the steps taken to establish an action partnership between rural, farm women and a Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 196 local researcher, and outlines lessons learned from using participatory approaches to inform ethnographic research. Sample: Based in an agrarian county in the Northern Great Plains, a partnership between two farm women developed into a research study inclusive of 24 female informants (ages 22-92). Methods: Ethnographic data (key informant interviews, focus groups, participant observation, artifact review, analytic memos, and reflective field notes) was analyzed thematically and the findings were examined reflexively to discern partnership building and participatory approaches that supported local community engagement with research. Findings: Promoters of relationship building included: 1) identifying the community gatekeepers, 2) using locally familiar language, 3) using a culturally congruent approach to recruitment, 4) accommodating seasonal farm demands, and 5) capitalizing on enthusiasm and community resolve to build partnerships for action planning. Conclusion: Local knowledge and sustained community presence are essential for rural nurses to engage in participatory action partnerships with rural farm women. Keywords: Partnership, engagement, rural farm women, participatory action, ethnography Partnering with Rural Farm Women for Community-Based Participatory Action and Ethnography Rural older farm women experience a high degree of health disparities when compared with their urban counterparts (Florence, Southerland, Pack, & Wykoff, 2012). The health conditions of these individuals is exacerbated by recent demographic shifts, which include the movement of increasing numbers of aging baby-boomers to rural farming states upon retirement, and the mass exoduses of young people who are moving out of the rural counties toward more urban settings (Beyer, Comstock, Seagren, & Rushton, 2011; Jack, 2012; Ramos, Fullerton, Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 197 Sapien, Greenberg, & Bauer-Creegan, 2014). As the Northern Great Plains states experience an influx of retirees, additional burdens are placed on an already over-taxed health care system. This exodus of young families results in school consolidations and school closings (Tieken, 2014), increasing farm size (Adamopoulus & Restuccia, 2014; Nelson, Arwood, Meendering, & Sanner, 2004), and decreasing social capital for the remaining and returning older adults (Eisenhauer, Pullen, Hunter, & Nelson, 2015). The population that resides the longest in the rural Northern Great Plains states are older women (Congdon & Magilvy, 2001). Much can be learned from rural older women, including what they consider to be health priority and what actions they consider key to addressing them. Community-based participatory research (CBPR) is an approach where the researcher engages as a facilitator with community members to collaboratively identify issues of local concern and apply socially acceptable solutions to alleviate those issues (Reason & Bradbury, 2006). This article describes the relationship stages between a local researcher and farm women residing in a rural county before and during an ethnographic study. Our lessons learned exemplify the strengths of using ethnographic and participatory action approaches simultaneously to build capacity for CBPR. Building the Community Partnership The stages of partnership building and research that are described were partially planned as part of an a-priori research design, but also unfolded naturalistically (Lincoln & Guba, 1985). Much of the “naturalism” had much to do with the first author’s (hereby referred to as “the researcher”) “insider” status in the community as a 20-year resident in the county. She was known to most residents as a farmwife and home health nurse. While not every researcher has this insider connection, the challenges that persisted, despite being an insider, highlight the trust Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 198 and local understanding that must be gained in order to obtain deep entrée for a rural-based study. Time and physical presence were fundamental for partnership initiation. Community Partnership Building over Time Neighbor to Neighbor. The first stage began with an “individual partnership” that occurred weekly between two neighbors over coffee. An 83 year-old farm woman and the researcher (although not functioning in a research role during these visits) began an informal, yet ongoing conversation. Research opportunities started to unfold when this older woman said she wanted to change the way rural healthcare was provided to farm women because “they don’t understand how things are for us.” The researcher had previously noted that this was a recurring concern expressed by other older farm women during her home health visits and conversations in the community (Eisenhauer, Hunter, & Pullen, 2010). These two neighbors decided to see if other local farm women shared the same concerns. The older woman telephoned other friends and neighbors, and eight farm women (ages 70-91) willingly responded to a group meeting. Thus, the next stage, an exploratory partnership with a small group of community stakeholders began with the aim of improving rural health. Neighbor to Neighborhood. The first decision of this small group was to identify which health problem(s) would be the focus of the discussion. The group began this process by exploring each woman’s experiences through their telling of health-illness stories. Story telling around the kitchen table, created a shared understanding among the partners, and began to affirm and clarify perceived clashes between the health care system and rural norms. The group decided to query other women through a similar process of comparing and contrasting health-illness stories in order to document a broader range of experiences. This action moved the women’s discussion from a small-neighborhood group partnership to a broader county level scope. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 199 Neighborhood to University. As a part of this larger venture, the researcher, who was just beginning her doctor of philosophy studies, asked the women if she could help advance their issue by using their aim as the focus for her research. However, the aim would need to be specified to select a health issue pertinent to them. The farm women agreed. They identified cognitive decline, or fear of “losing my mind” as they defined it culturally, as their priority problem. Thus, cognitive decline became the topic of the researcher’s doctoral dissertation. Usual to ethnographic research, the socially constructed meaning of cognitive decline as interpreted through the rural farming context was sought. The perspective of community- dwelling farm women with self-identified intact memory was sought because they could articulate how the co-construction of fear surrounding cognitive decline was reinforced within the local context. Engaging the Community and Examining Relationship Development through Ethnography Applying a constructivist paradigm (Schwandt, 1994), the researcher sought to determine how the meaning of cognitive decline was co-created over time and across social interactions with the local community to create fear among mentally intact, older farm women (age 65 and older). Ethnography uses multiple data collection approaches to holistically identify the elements and internal processes of social organization. Analysis of ethnographic data reveals patterns of behavior, which distinguish unique cultural norms such as life customs, the meanings created from shared knowledge and social relationships, and the challenges experienced while living in the cultural context (Agar, 1996; Emerson, Fretz, & Shaw, 1995). Institutional review board (IRB) approval (protocol #SS10-95e) was obtained for this study. In-depth life history interviews, focus groups, participant observation, and review of local artifacts and documents were collected over one year by the researcher to obtain detailed Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 200 contextual data surrounding the day-to-day interactions of the older women. This provided a contextual background and understanding of the local constructions of reality within which to situate the women’s views, particularly their fears, of cognitive decline. Interviews were held in either the women’s homes or the researcher’s farm house at a time and hour that was convenient for them. A total sample of 24 women, ranging from 22-92 years of age, participated in the study. The study was set in a U.S. county with a designated Rural-Urban Community Area Code (RUCA) of 10- a rural area whose primary flow was outside an urban area Health Resources and Service Administration, Federal Office of Rural Health Policy (ORHP), and U.S. Department of Agriculture, Economic Research Service (n.d.). The sample was recruited through reputational case selection by community leaders and neighborhood partners. Reputational case selection is a common sampling technique in ethnography that seeks out participants based upon desired case characteristics that are reported by community leaders (LeCompte, 1982). Key Informants Four women were recruited to serve as key informants to share their detailed life history. Inclusion criteria included being a resident of farming based county, aged 65 or older, self- identified as having an intact memory. In-depth life history interviews were conducted over a series of 3-5 consecutive visits, until a richly detailed life history was obtained. The goal of these interviews was to elicit a pattern of learned behaviors and social interactions that persisted across their life course. The life course patterns were then compared using focus groups with four cross- generational cohorts of younger women to examine how the rural, farm context had changed over time, and how this change may influence the older women’s beliefs and behaviors surrounding cognitive decline. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 201 Focus Groups Twenty women were recruited to participate in one of four focus groups, each representing a separate generational cohort. Inclusion criteria for the focus group included: 1) resident of the county under study, 2) at least 18 years of age and representative of one of four different historical cohorts: generation Y (born 1983-2001), generation X (born 1965-1982), baby boomers (1946-1964), and the greatest generation (born 1926-1945) (Carlson, 2009). The women were interviewed about their health and illness behaviors and the social-cultural practices they employed to deal with them. The women were asked detailed questions about their views of cognitive decline, specifically its cultural impact and the outcomes they saw result for older farm women who developed it. Observation Participant observation was conducted across the entire year, during morning, afternoon, and evening hours, across different communities, and amid the context of formal/informal events. Some of these included ladies aid meetings, Cattlemen’s Ball, home canning-preserving, farm chores, birthday parties, baking, and hunting wild animals. Observational and interactional notes were recorded in the field using Emerson and colleagues’ (1995) approach. Cultural Artifacts Local artifacts that were valued and displayed by the women were noted to richly detail the farm context. Such items included polka music, extension club cookbooks and manuals, community centennial books, pictures of severe weather from years past, farm animals, family albums, church directories, and cemetery registries. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 202 Reflexive Journaling The researcher kept a detailed, typed journal, which was documented across each day of the study, which noted changing reflexive stances. Reflexivity, often used synonymously with reflection, is defined as the “constant movement between being in the phenomenon and stepping outside of it” (p. 578). Items documented pertained to the: 1) perceived/observed changing social stance as an insider-outsider with the participants across the study, 2) self-conscious reflections of communication, recruitment, engagement, and retention issues, and 3) perceptions regarding what was evolving across each stage of the study (Enosh & Ben-Ari, 2016). Analysis The reflexive notes made throughout the study detailed the researcher’s initial analysis of effects of interactive and contextual influences, including her changing positions between an “insider” (farmwife) and “outsider” (researcher) among the women (Naples, 1996). Analytic memos of methodologic-analytic decisions surrounding changes in coding schemes and conceptual reasoning were made at the close of each day (Saldana, 2009). All interviews were audio recorded, transcribed verbatim, and checked against the digital file for accuracy. Data was iteratively coded and analyzed until themes were discerned that were “internally coherent, consistent, and distinctive” (Braun & Clark, 2006, p.36). The local artifacts and observations enriched interpretation during thematic analysis by detailing material aspects of the women’s lives that shape their beliefs and behaviors (Sandelowski, 2002). A second researcher audited research procedures weekly and the research team’s discussion surrounding the findings, interpretations and consensus was documented ongoing. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 203 Neighborhood Involvement in the Research Process The neighborhood partners were involved in select aspects of the research process. While these women did not serve as participants in the actual study, they influenced the iterative design and implementation of the study by: (a) guiding the selection of the research questions, (b) offering recruitment and retention strategies, (c) suggesting data collection sites, (d) developing and testing interview guides, (e) offering their interpretation of the findings presented during community dissemination, and (f) identifying a plan for subsequent action. During the year of the study, three of these neighborhood women were lost, due to death or worsening health. Analysis of the challenges and lessons learned in performing a community-based ethnography provide insight into approaches for engaging farm women into community-based participatory action research. Lessons Learned Building trusting relationships that were required to recruit farm women into the study was not easy, despite the early local involvement of the neighborhood partners and the insider status of the researcher. Cultural clashes between the social norms of farm women and IRB restraints were immediately evident. Agrarian work seasons also challenged local engagement. Reflections below, on these challenges, provide lessons for development of novel strategies needed in researching with rural farm communities. Lesson 1: Identify the Gate Keepers Initial attempts to recruit the farm women for the ethnographic interviews were through females who were active leaders in their community, as determined by reviewing local newspapers, community flyers, and by word-of-mouth. These women were leaders in their ladies’ aid groups at church, business owners, or members of community-interest groups. As Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 204 they were socially “visible”, it was assumed (wrongly) that these women would best represent the interests of the other women. However, many of these individuals were not willing to join the partnership nor willing to recommend other women who might be interested in the study. The polite indifference left the researcher and neighborhood partners baffled and frustrated. While it was understood that establishing trust in the community was important in the identification of potential participants, merely having a shared history with other women who are active in community affairs did not guarantee study engagement. In contrast to the indifference that was expressed by some of the females of the community, when the researcher stopped at local businesses to run daily errands, men would initiate conversations and ask eagerly about the upcoming study. As time went by, the researcher observed a recurring pattern of men’s versus women’s willingness to engage in conversation about the research and to recommend potential study participants. That is, after the men of the community became engaged in the study, they were able to bring women aboard. This indicated that males were acting as “gatekeepers”, or those who are able to encourage women to take part in the study. Once recruitment targeted the males as referral agents, a list of over 50 farm women was generated in less than a month, as these men “volunteered” their wives, mothers and neighbors. As the research unfolded, it became clear that the building of trust was also a process which was often dependent upon the males of the community. In fact, several study participants cited the approval of their sons and husbands as pivotal in their decision-making process when it came to health care. This insight then, led the researcher to seek out conversations with the men. Trust regarding the research study was built directly with the men and indirectly with the women, following the norms and expectations around social connections and personal interactions within the farming community. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 205 Lesson 2: Keep the Conversation Local Entrée into this county was largely due to the researcher’s trusted position as a local home health nurse and farmwife. However, increased social distance between the researcher and the local women was observed once recruitment commenced. Negotiating trust with the farm women was a continual process. In the farmwife role, talking about health concerns or personal ailments among the partners was as common as discussing the weather. However, when the researcher spoke of the finer points of research or of political advocacy during study recruitment, social distance increased. Once the study was underway, recurring questions and phone calls from local women wanting to know who was in the study became problematic. The inquiries were consistent with the local cultural norms for communication and information, a finding that had been documented in the field notes. When the researcher explained she could not divulge the names of other study participants, this also increased social distance between herself and her research subjects. The ever changing social position between farmwife and researcher during the study was specifically differentiated by the “language” being spoken. The norms for “farmwife” conversation included use of local slang and discussion of agrarian seasonal work related issues such as crop yields, grain market prices, and farm cooking. Conversations which took place in the “researcher role” addressed the research goals through the use of farm-normed language and relevant farm-related topics the women were willing to discuss as part of the partnership. Using too much “research language” would result in puzzled looks on the faces of the women, or would result in their changing the topic of conversation. Continually maintaining a workable social distance in both roles required constant attention and fluent translation and negotiation across the “academic and farm culture divide”. As a farmwife, the researcher had the advantage of knowing Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 206 the local language, yet she was viewed as an “outsider” as a researcher. Mastering the skills which were required to negotiate the ever changing social positioning with the women took time and experience, but doing so promoted trusting interactions with them. Another innovative approach that successfully decreased social distancing from partners and research participants was holding the focus groups at the researcher’s farmhouse. The farmhouse setting enhanced the women’s comfort and confidentiality by providing a private, yet culturally familiar space. The women’s mannerisms, conversation style, and body language relaxed once the informed consent was obtained, coffee was served, and the interview proceeded around the kitchen table. An unplanned interruption happened during one of the focus groups, when a set of baby calves walked up to the kitchen window and peered in at the participants, then darted across the lawn with their tails in the air. While considered an interview interruption by most researchers and participants, in this situation, it served to further familiarity, relaxation, and increased participation in discussion. After the focus group interview was complete, pie was served to the women. Many of the women expressed their level of comfort by walking into the kitchen and staying after the conclusion of the focus group discussion to visit informally with other participants. Upon leaving, two of the women expressed they were glad the focus group was held in the country as opposed to in town at the community hall. “I felt like this was a more private setting where I didn’t have to worry about who saw my vehicle, and was going to ask what I was doing there and why.” Holding discussions around the kitchen table, over a cup of coffee, decreased social distancing and strengthened the women’s bonds with the researcher by creating a “locally familiar” context, within which they could discuss what for many of them was an unfamiliar topic- the research study. The procedures used in rural research are thus kept culturally congruent with local norms. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 207 Lesson 3: Emphasize the Importance of Cultural Congruity The University Institutional Review Board (IRB) prohibited the researcher from directly recruiting study participants because of the risk for coercion due to her close relationship with the locals in the county. To comply with this directive, a female research assistant was hired to contact potential participants using a pre-approved recruitment script. The research assistant was trained in the recruitment protocol by the researcher and she recited the recruitment script during the calls. The research assistant also took detailed notes regarding the women’s replies, as well as their tone to the call, and she documented each call attempt and conversation duration in a time log. Rather than being a help, the IRB-mandated script became a hindrance. The indirect approach, being contacted by the research assistant versus researcher, created a sense of suspicion among many of the women contacted. Although the research assistant was also a life- long resident (she worked at the farmer’s Co-op), women vocalized concerns for their privacy, when she requested that they take part in the study. Some of the women’s replies were: “Why didn’t she (the researcher) contact me herself?” “What is she selling?” or “What’s the catch?” Some community women even responded, “I doubt my name was really brought up by the men.” In total, five women declined to participate. Whether the women’s replies were in part to the indirect nature of the recruitment call by research assistant is unclear. However, the experience informs critical discussion surrounding the best way to recruit rural farm women for research. Researchers need to explain the cultural significance of direct recruitment and retention strategies to IRBs, especially when it is imperative that they be congruent with rural norms for communication. Our experiences suggest that indirect recruitment approaches, meant to protect rural participants from coercion, instead may have evoked suspicion and fears over possible violation of privacy. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 208 Lesson 4: Accommodate Seasonal Farm Demands The livelihood of the farm is dependent upon seasonal fluctuations that affect the growth of crops and livestock. Farm women have adapted coping mechanisms for dealing with seasonal uncertainty, both short-term and long-term, including weather-related storms, farm equipment malfunctions, predator animal invasions, and livestock illness and loss. These seasonal demands require close attention and flexibility during research activities. One woman phoned the researcher the day after missing her focus group to report that her absence was because “the cattle were out (of pasture and on the road) and I had to drop everything to put them back in”. Another of the key informants refused to start the interview at her home until she had removed a predator raccoon who was menacing her canning cellar. Work-intensive seasons (planting, harvesting, canning, calving) nearly halted the research activities due to heightened demands on the research participant’s time. Twelve to eighteen hour work days aren’t unusual for rural women as they extend their presence in the fields and become couriers of farm supplies that are needed to maintain seasonal farm operations. Communicating with actual and potential participants via their home land-lines became difficult because they were rarely near their phones. Cell phone contact with potential participants was also difficult due to poor reception and the fact that cell phone numbers are not published for public access. In strategizing a successful partnership development and research design, one must be cognizant of heavy work seasons, their related demands and risks, and plan activities respectfully around them. In this study, the majority of the recruitment and interview process took place during times which least interfered with planting and harvest. The interviews that occurred after the women had completed peak-season activities yielded the richest data. It is surmised that the Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 209 women were more recently in touch with these farm experiences and better able to relate them. They were also eager for socialization after their hectic work seasons had ended. Lesson 5: Capitalize on Enthusiasm and Resolve to Build Participatory Action Plans While there were several challenges when engaging research participants, there were also many positive outcomes. The study generated a great degree of local interest and trust. In fact, two women bypassed the male gatekeepers and joined the research on their own. Also, since the study concluded, there has been a growing number of community members expressing a desire to partner in future research studies, which has resulted from a broader and deeper discussion regarding other local problems. At the conclusion of the study, a celebratory event was sponsored by the researcher as a way to gather the local residents, research participants, and the neighborhood partners. The goals of this event were twofold: to share the findings with the community and to learn what sorts of actions community members wanted to see take place in response to the findings. The event was held at a local bar/café and was attended by over 56 community members and partners. Gourmet cupcakes were displayed throughout the room along with a summary sheet of study results to encourage informal mingling and discussion. In addition, the researcher’s bound copy of her dissertation was displayed to allow the community to see the impact they had on the education of one of their own. Discussion lasted for over five hours, a testament to the engagement of the community. Since the ethnographic study has ended, there has been a growing number of community members expressing a desire to partner in future research studies, which has resulted from a broader and deeper discussion regarding other local problems. For instance, the problem of farm specific barriers to maintaining a heart healthy diet and physical activity, specifically among Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 210 men, was identified as a local concern. Because farm-raised food, activity, and well water were believed to prevent cognitive decline (Eisenhauer et al., 2015), culturally-tailored weight loss and weight maintenance strategies were identified as a new priority action area for intervention. Women and men discussed environmental and social barriers for maintaining or losing weight across peak farm seasons, and expressed a new found trust in the power of a community- researcher partnership to meaningfully address their problems. Discussion Farm-specific recruitment and partnership-building lessons based on this study provide valuable insight for future action partnerships between farming communities and rural nurse researchers. The neighborhood women identified as a clear concern the problem of cognitive decline, which allowed them to partner with the researcher as consultants-stakeholders. The researcher also observed, documented and analyzed the relational aspects of her social positioning as an “insider-outsider” with the women and the local communities throughout the study, which allowed her to clarify the processes that encourage involvement in this sort of study. The findings of our study also hold significance for future research in both the process and content of rural engagement by demonstrating how trust with rural farm women may be achieved over time and through multiple interactions. In our study, the women’s trust in the researcher and research study was enhanced by first establishing a trusting relationship with the local men. Continual reflexive journaling across the study permitted examination of this otherwise “invisible” insider-outsider dynamic in terms of the meaning of the men’s relationship to engagement with larger local community of women. The researcher’s relationship with the men was not only influential on study recruitment, but also on sustained community engagement across time, including opportunities for future studies. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 211 The importance of the nurse researcher’s presence in the rural community before, during, and after initiating research partnerships led to a network of relationships and a strong degree of negotiated trust within the community. The findings illustrate that the optimum group structure for participatory action in this rural farming community was small, informal, and with researchers who have become locally familiar. Becoming locally familiar required a physical presence as well as a time commitment; though, the researcher can expedite the process by engaging in informal discussions during normal daily activities. These findings are consistent with participatory action studies reported on other rural populations (Averill, 2005; Bish, Kenny, & Nay, 2012; Richter, Hall, & Deere, 2007). Implications for Recruitment of Rural Women Rural nurses who are planning research with farm women can enhance study recruitment plans in several ways. First, writing flexibility into their study in such a way so that their work will occur around peak farm seasons. By doing so, partnership building, recruitment and data collection will be more easily managed. Second, rural nurses can identify community gatekeepers through repeated informal social interactions. Other research findings have mirrored the importance of involving men as community partners when locating the “contextual, cultural experts” in rural communities (Averill, 2005). Third, adhere to the local social norms when developing recruitment plans to enhance feasibility. Fourth, document reflexive notes of the ever changing social positioning that is observed as the researcher proceeds through the study, as it serves as an indicator of local norms and it indicates the researcher’s skill in negotiating her position as both “insider” and “outsider”. In addition, the findings from this study emphasize that direct correspondence with the researcher decreases concerns over encroachment on personal privacy and heightens study interest and participation. Nurse researchers who can share Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 212 personal histories connecting them to the rural region, rural occupation, or local ancestors can also provide cultural connections that enhance their social position as an “insider”, thus decreasing suspicion and fear on the part of the study participants. In the end it was found that establishing broad, trusting relationships inside and outside the community through a small initial partnership, and by conforming to local norms, recruitment, retention, and results were able to exceed study expectations. The ethnography produced outcomes that strengthened partnership-building efforts, which are critical for future participatory action aimed at informing rural health policy. The partnership process enhanced solidarity and ongoing local engagement among men and women in this farming county to promote actions which improve the health of rural adults. Conclusion This is a story that has moved through three stages, and it is one that continues to the present day. The first stage involved the development of a rather spontaneous researcher- community partnership, spawned among eight older farm women. These initial conversations led to a community assessment and a prioritization of health problems. This partnership was unique in that is did not originate from formal community structures (county extension, medical providers, or Centers for Rural Health) (Guin et al., 2012; May et al., 2003). Rather, the building blocks of this rural study were provided by neighborhood farm women who wanted to affect change for themselves and those like them. The commitment to this partnership ran deep, even to the point where a widower, along with his children and grandchildren, maintained their dedication to this study even after the neighborhood partner had died. This stage serves as an exemplar of initiating a community partnership with the most vulnerable rural residents- older farm women- to work toward common participatory action goals. Online Journal of Rural Nursing and Health Care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 213 The second stage involved the process of rolling an action priority into an extensive traditional ethnography, whose focus and progress was informed by the community-partners. Although the researcher was a farmwife in the community, the process of looking from a researcher’s perspective at rural life across generations provided far more insight and understanding than had her farmwife role, which involved far less questioning and scrutiny of rural culture. The third stage exemplifies how community-based participation motivates action in response to ethnographic findings for research. 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