Health & Place 18 (2012) 1231–1239

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Health & Place

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The reality of rurality: Rural parents’ experiences of early years services

Kerri Graham, Kathryn Underwood n

Ryerson University, Canada

a r t i c l e i n f o

Article history:

Received 31 May 2012

Received in revised form

28 August 2012

Accepted 3 September 2012Available online 14 September 2012

Keywords:

Rural services

Children

Early years

Family supports

Critical ecological systems perspective

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

x.doi.org/10.1016/j.healthplace.2012.09.006

espondence to: Ryerson University, School of

Street, Toronto, ON Canada M5B 2K3. T

416 979 5239.

ail addresses: kerri.graham@ryerson.ca (K. Gr

ood@ryerson.ca (K. Underwood).

a b s t r a c t

This study examined the experiences of rural parents accessing early years support services through a

specific service delivery strategy in Ontario, Canada. Nine focus groups and five interviews were

conducted in two rural communities as part of a larger research project exploring parent experiences in

both urban and rural communities. Thematic analysis, informed by a critical ecological systems

perspective, revealed that certain factors related to rural life and location affected parents’ experiences.

Services must be accessible in terms of location and social and psychological dimensions for parents to

attend and make use of supports. These supports, in turn, foster healthy child development and healthy

communities.

& 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Rural and urban parents cite small towns as ideal places toraise children, based on perceptions about safety, communityvalues, and connexion to nature (Bonner, 1997; Struthers andBokemeier, 2000). Yet, this singular image of rural life as ‘‘happy,healthy and problem-free’’ (Cloke and Milbourne, 1992, p. 359)can mask the various differences between rural communities andoverlook the unique challenges of living in small towns andremote areas (Struthers and Bokemeier, 2000). Rural communitiescan face difficulties in ensuring residents have access to neededsupports and services. Certain models of service delivery functionbetter in urban areas than in rural, and as Romanow (2002) noted inhis review of healthcare in Canada, ‘‘many health care adminis-trators, planners and providers rely on urban-focused approachesinstead of developing alternative models to suit the unique circum-stances of [rural] communities’’ (p. 164). These questions of effectiverural service delivery and accessibility are relevant to most humanservices, including health and social supports for children, parents,and families.

Best Start is a specific model of integrated service delivery thathas been implemented in rural and urban communities acrossOntario, Canada. It is a ‘‘comprehensive, evidence-based earlylearning and care strategy designed to help give Ontario’s childrenthe best possible start in life and help them achieve success in

ll rights reserved.

Early Childhood Studies, 350

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school’’ (Ministry of Children and Youth Services (MCYS), 2005, p. 4).It focuses on integrating and strengthening existing programmesand services and requires collaboration at all levels of governmentand service delivery. It was implemented in 2004, and was designedto have a phased-in implementation over a 10-year period; how-ever, the government of Ontario selected three demonstrationcommunities to receive funding for accelerated implementation.These three communities served as models for other communitiesand as research sites.

The present study analysed data from the two rural sites, aspart of a larger research project funded through an external callfor proposals to evaluate parents’ experiences of early childhoodservices at all three demonstration sites. Throughout this paper,early years services including childcare, family support pro-grammes, early assessment and intervention, family literacyprogrammes, child protection programmes, and children’s publichealth, are referred to collectively as Best Start programmes. Theseprogrammes are delivered through regional agencies, meaning theymay differ considerably between the two communities.

1.1. Rural context of the research

The geography of rural Ontario is diverse, and includes variousrural communities that often have little in common, apart fromtheir population counts. Multiple official definitions of ‘rural’ areavailable, each resulting in quantifiably different ways of seg-menting the landscape and population (Douglas, 2010; du Plessiset al., 2001).

The families in this study live in two different areas of theprovince (one southern and one northern), and represent some ofthe varying realities of rural life. The southern communities have

K. Graham, K. Underwood / Health & Place 18 (2012) 1231–12391232

small populations, but are heavily influenced by their closeproximity to large urban centres and multiple border crossingswith the United States. Agriculture plays an important role in thisarea, but manufacturing is the key industry. The northern com-munities, with large Francophone and Aboriginal populations, arewidely dispersed over a large geographic area and the nearestlarge urban centres are located more than 150 km away. The mainindustries in this region are resource-based, and include agricul-ture, mining, mineral aggregate extraction, and forestry (OntarioMinistry of Northern Development and Mining (MNDM), 2007;ServiceOntario, 2010). These areas share certain rural character-istics, but belong to very different regions within Ontario andhave their own unique sets of opportunities and challenges.

This research was intended to clarify how rural parentsperceive early childhood services and supports, and to investigatewhether parents’ experiences with Best Start were affected bytheir rural context. The research was based on a philosophicalframework that takes a critical approach to Bronfenbrenner’s(1992) ecological systems theory and combines assumptionsabout the importance of place with an analysis of the ways inwhich ‘place’ shapes meaning and experience for rural parents.

2. Literature review

2.1. Accessibility and rural service delivery

Rural areas and small communities present different chal-lenges for service delivery than densely populated urban areas,due to geographic and demographic characteristics (Rice andSmith, 2001). Discrete local delivery of specialised services isfrequently not economically viable because of population size(Archie et al., 2008; Wakerman et al., 2008); when services arelocated at a distance, clients and/or professionals are required totravel. Accessibility is sacrificed in this process and many of thecosts are born by clients with ‘‘consequent equity issues, parti-cularly for ‘transport-poor’ groups such as elderly people, youngpeople and many women’’ (Asthana and Halliday, 2004, p. 458).

These accessibility issues are a common theme that permeatesmuch of the literature on human services in rural communities.Proximity-based definitions dominate rural accessibility statistics,but Sutherns and Bourgeault (2008) challenged this practice,claiming that ‘‘recent operational definitions of access to ruralhealth care are inadequate because they too narrowly focus onthe proximity of available services’’ (p. 863). They argued thatwhile it is important to ensure services are close to people, theseservices will not be accessible if they are not appropriatelydesigned to meet the needs of the local community. Distance isoften a barrier to access, but it is not the sole barrier for ruralfamilies. Halliday and Little (2001) reported similar findings withregard to rural childcare in England; they found that multiplefactors affected the child-care decisions of rural parents, includingproximity of services, rural gender relations, and cultural con-structions of what it meant to be rural.

2.2. Services for rural families and children

In both Canada and the United States, rural families are morelikely to use home-based and informal care options because theyare the only options available in the community (Bushnik, 2006;Gordon and Chase-Lansdale, 2001; Smith, 2006; Wright, 2011).Parents often commute long distances to work, restricting child-care options even further and requiring parents to find careduring non-standard hours or to coordinate a mixture of formaland informal care (De Marco et al., 2009; Fletcher et al., 2010).Albanese (2006) found that opening and closing hours were an

important factor for mothers in a small Quebec town, who werejuggling shift work and/or commuting as well as selecting a child-care centre. These mothers often needed to organise complexnetworks of formal and informal care to meet their families’needs, but they considered the availability of affordable childcareto be a key component of their ability to work outside the home(Albanese, 2007).

Further research has demonstrated that rural children aremore likely to enter school with no previous participation informal early learning and care programmes (Temple, 2009).Children from low-income families in rural areas were even lesslikely to have attended formal programmes before school(Temple, 2009). Scottish research by Shucksmith et al. (2006)found similar results. In a statistical mapping exercise, theauthors found a significant gap between the number of eligiblepreschool-aged children and the available preschool places thatgrew systematically larger with increasing remoteness. Inter-views with parents led the researchers to conclude that ‘‘accessto this basic educational service is frustrated or diluted bydistance, transport costs, the high costs of providing for small,dispersed populations, and concerns about quality of provision’’(Shucksmith et al., 2006, p. 689).

Research has also found accessibility difficulties for earlyintervention and specialised healthcare services for young chil-dren in rural communities, such as mental health and speechpathology services (National Center for Rural Early ChildhoodLearning Initiatives, 2005; O’Callaghan et al., 2005; Wilson et al.,2002). In an attempt to clarify the underlying causes of differ-ences in access between rural and urban families, Skinner andSlifkin (2007) found that rural families were more likely to haveunmet needs because of transportation difficulties or needingcare that was unavailable in the area. Urban families were morelikely to report unmet needs because of barriers from serviceproviders (such as waitlists).

2.3. Integrated rural service delivery

Considerable research has documented evidence of accessibil-ity barriers and lack of service in rural areas. With regard toprimary healthcare, Humphreys et al. (2008) reported:

The problem of how to provide accessible, sustainable, appro-priate health care services is most acute in small rural andremote communities, where the increased costs and difficul-ties of workforce recruitment and retention are compoundedby the lack of economies of scale associated with servicingsmall populations dispersed over vast distances. (p. S77)

However, some evidence indicates that innovative and suc-cessful service delivery models are possible in rural communities.As population size/density decreases and remoteness increases,integration across disciplines and between providers, and com-prehensive (instead of specialised) services, become more neces-sary (Wakerman et al., 2008).

Canadian research focusing on early learning and care hubs intwo different areas of British Columbia (Ball, 2005; Rutherfordet al., 2007) revealed themes of positive outcomes for parents,children, and communities associated with integrated early learn-ing and care hubs. As Ball (2005) wrote:

[W]hen a community begins a development process with thewell-being of its children as the starting point, the focus onchildren can work as a hook to attract and secure communitycommitment and action and the ECCD [early childhood careand development] program can become a hub of community-serving programs and activities. (p. 48).

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The current research project is intended to add to this growingbody of evidence examining integrated services for youngchildren in rural areas, but rather than an overall examination,this paper specifically focuses on parents’ experiences of inte-grated service delivery in rural communities.

2.4. Experiences of rural parents

The specific experiences of rural parents are largely absentfrom research exploring early learning and care services. A broadexamination of parental involvement research reveals that ruralparents are sometimes included as participants in an effort toensure a more representative sample or as a matter of conve-nience (Crossnoe et al., 2002; Hoover-Dempsey et al., 2001).However, unlike the substantial body of literature about urbanparents, few studies have explored the strengths, weaknesses, orconcerns that might be unique to rural parents. Researchers havespecifically explored the distribution and use of childcare in ruralcommunities (Albanese, 2006; De Marco et al., 2009; Fletcheret al., 2010; Son and Bauer, 2010) and have demonstrateddifferences in the culture, demographics, and service deliverybetween urban and rural communities (see Martinez-Brawley,2000 and Pugh, 2007 for examples from social work; Rice andSmith, 2001 and Wakerman et al., 2008 for examples fromhealthcare). However, little research has explored parents’ experi-ences with early learning and care services in rural communities,or addressed whether aspects of rural life and location influencethese experiences.

McBrid et al. (2003) investigated barriers to establishingfamily–school–community partnerships in several rural preschoolprogrammes in the United States. They found that while reportedbarriers seemed similar to those in urban programmes, geo-graphic isolation and rural poverty magnified their effects. Addi-tional research in rural communities has revealed that a flexibleservice delivery model informed by family-centred practices canalleviate some of these geographic barriers in delivering servicesto rural and remote families (Brown and Remine, 2008; Checkeret al., 2009). Family-centred practices encompass a certain set ofbeliefs and values that work from a strengths-based perspectiveto empower parents and strengthen family capacity (Dunst,2002). Checker et al. (2009) proposed that by focusing on thefamily’s needs and strengths, organizations will be more likely todevelop service delivery models that adapt to the context of thefamily.

Family-centred practices are also characterized by ‘‘parent/professional collaborations and partnerships as the context forfamily-program relations’’ (Dunst et al., 2008, p. 370). Previousresearch about both the culture of rural life and service delivery inrural communities has suggested that these parent–professionalpartnerships may be of great importance to rural families. Thesocial climate of rural areas often does not allow for distant,detached professionals (Pugh, 2007). People are likely to live andwork in the same community, and effective service delivery oftenrequires that professionals ‘place’ themselves in relation to otherindividuals in the community:

Workers may be expected to answer questions or provideinformation themselves that would rarely be sought in anurban setting. This might include information about local links,previous experience, family background and local knowledge.This may then be used to ‘check out’ the worker, to establishwhat other people think of the worker and, crucially, to decidewhether, and to what degree, to engage with the worker.(Pugh, 2007, p. 1406)

Moules et al. (2010) referred to this process as ‘knowing andbeing known’ and highlighted the necessity of developing reci-procal relationships to provide effective services for families insmall northern communities. Reciprocal partnerships betweenparents and professionals may be generally recommended andencouraged in early learning and care services, but they may benecessary in rural early learning and care services.

Literature in multiple disciplines points to a need for researchexamining parents’ experiences of early learning and care servicesin rural communities. A body of research suggests that ruralcommunities differ from urban communities in many ways, butthis research has not specifically investigated whether aspects ofrural life and location influence parents’ experiences of earlylearning and care services. To address this gap, we completed arural-specific analysis, guided by the following questions: whatare the experiences of rural parents accessing services throughBest Start networks in two rural communities? What factorsrelated to service delivery and rural location affected parents’experiences of and satisfaction with these services?

3. Methodology

A qualitative approach, specifically thematic analysis, wasselected for this project. Qualitative research allows for richdescriptions of data and includes an important focus on context,an essential element of the theoretical framework informing theresearch (Braun and Clarke, 2006; Marshall and Rossman, 2011).Ecological systems theory assumes that people must be under-stood in relation to their environmental context (Bronfenbrenner,1992); in other words, place matters. A critical ecological systemsperspective retains this importance of place, but requires morefocus on inequities and marginalizing processes (Keating, 2008).Researchers using a critical perspective must continually questiontheir actions and interpretations, asking, ‘‘how what is has cometo be, whose interests are served by particular institutionalarrangements, and where our own frames of reference comefrom’’ (Kincheloe and McLaren, 2002, p. 124).

The data for this study were collected as part of the Have a

Voice Project (Underwood et al., 2010), a larger study exploringthe experiences of parents accessing Best Start services in threedemonstration communities in Ontario. The original project wasinformed by an ‘appreciative inquiry’ methodology and employeda consecutive mixed methods approach, using a survey, focusgroups, and interviews. The current analysis, based on criticalecological theory, was conducted specifically to address theexperiences of rural parents. It uses qualitative data collectedfrom focus groups and interviews in the two rural demonstrationcommunities. The methodology and results of the original projectare described elsewhere (Underwood et al., 2010; Underwood andKilloran, submitted for publication).

The broader project explores parent perspectives in both urbanand rural communities; but the rural specific human services andservice delivery literature reveal a need for analyses that speci-fically examine place, particularly rural location. Rural parents asa group are bounded by certain geographic and communitycontexts that are important to consider in relation to theirresponses. A strict operational definition of rural was not neededfor this research, as the communities were specifically identifiedas rural and northern demonstration sites for Best Start before theresearch began (Ministry of Children and Youth Services (MCYS),2005). However, additional clarification was needed to frame theanalysis. For this purpose, we applied the Metropolitan InfluencedZone (MIZ) classification system developed by Statistics Canada(2003); this system allows not only differentiation between urbanand rural areas, but also between rural areas. All rural census

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subdivisions in Canada (population of less than 10,000) areassigned an MIZ category based on the number of residentswho commute to a nearby urban centre for work. The variouscategories allow for differentiation between rural areas based onproximity to, and influence of, nearby urban centres. The southerncommunity in this study received a strong MIZ rating, indicatingthat it is heavily influenced by its urban neighbours. The northerncommunity received low to moderate ratings, indicating littleinfluence from urban areas.

The rural dataset included all focus groups and interviewsfrom two of the three communities included in the originalproject. Data from the urban centre were not included, and thefinal rural dataset included nine focus groups and five interviews.All of these discussions were facilitated by a member of theresearch team. Eleven were conducted at a site within thecommunity, while three were conducted via teleconference. Atotal of 36 participants were involved: 10 from southern Ontarioand 26 from northern Ontario. Each focus group or interviewlasted between 60 and 120 min, and with the exception of one, allwere audio recorded. Two focus groups were conducted entirelyin French, but notes were recorded in both French and English. Intotal, this dataset consists of audio recordings, index cards fromfocus group discussions, parent worksheets, and researcher notes.All types of data were used in the analysis process.

3.1. Data analysis

Data were organized, coded, and analysed using the thematicanalysis process described by Braun and Clarke (2006). Analysisbegan with the ideas generated in focus groups being recordedand then clarified by cross-checking with memos from theoriginal research and audio recordings of focus groups/interviews.This iterative process included navigating back and forth betweenaudio recordings, memos, and spreadsheets to clarify the contextof the data. Once the researchers were familiar with the data,codes were generated. Boyatzis (1998) defined a code as ‘‘themost basic segment, or element, of the raw data or informationthat can be assessed in a meaningful way regarding the phenom-enon’’ (p. 63). Initial codes were generated for the entire dataset, andconsisted of a combination of inductive codes (which emerged fromthe dataset itself) and ‘theory-driven’ codes (which were derived byapproaching the data within the context of a specific question; seeBraun and Clarke, 2006, pp. 88–89). The critical ecological systemsapproach provided an analytical structure for the theory-drivencoding process, because it required the research to focus on labellingthe data in meaningful ways that related to the participants’ rurallocation and ecological context.

Three rural specific themes emerged after the dataset was coded:(a) Accessibility of Services; (b) Impact of Personal Relationships;and (c) Opportunities for Social Interaction. These themes werecarefully reviewed for internal homogeneity (data within themes fittogether meaningfully) and external heterogeneity (clear distinc-tions between themes; see Braun and Clarke, 2006; Guba, 1978).Given space constraints, this article presents the findings for thefirst two themes, which generated the greatest number of codedstatements.

3.2. Trustworthiness and limitations

The trustworthiness of the data for this study was derivedfrom the focus group methodology employed by the researchteam (Underwood et al., 2010). Multiple sources of data weregathered and triangulated with each other and with the literature,adding to the credibility of the analysis (Creswell, 2009). Memberchecks were built into the methodology via explicit checks byfocus group facilitators. Additionally, the participatory nominal

group process (where participants created and labelled cate-gories), increased the trustworthiness of the data as participantscould confirm the accuracy of statements. Theoretical saturationand data adequacy were also observed. The three major themescontain data from all focus groups and interviews and the sub-themes contain data from focus groups and interviews conductedin both northern and southern communities. The researchersnoted repetition and redundancy in the data, and often encoun-tered similar stories during analyses. This repetition has beenidentified as one index of saturation; Margaret Mead purportedlyreferred to it as ‘‘the boredom that occurred when investigatorshad ‘heard it all’’’ (Morse, 1995, p. 147).

This research makes an important contribution to the body ofliterature on service delivery for rural families with youngchildren, but it is not without limitations. The sample size of 36participants makes large scale generalisations difficult. Cautionmust be exercised when using the conclusions drawn in thisstudy to inform policy and practice in other locations. The voicesof these participants can serve as a resource for other rural areas,but their stories are intricately linked with the specific contexts ofthe two communities.

4. Findings

4.1. Accessibility of services

Accessibility of services was a common theme across all focusgroups and interviews. Parents discussed their level of satisfac-tion with accessing services through Best Start, as well asaccessibility difficulties related to rural location.

4.1.1. Culturally relevant services

The ability to access culturally relevant services was importantfor parents. Francophone parents spoke of the necessity ofaccessing services in French for both their children and them-selves. One parent noted the importance of having bilingual andFrancophone staff: ‘‘When you have preoccupations and ques-tions, and it’s not in your language, it is more difficult to seekhelp.’’ Having access to culturally and linguistically relevantservices was a great support for these families, but Francophoneparents also raised concerns about where these services weremissing in their communities. One mother, who was pregnant atthe time of the interview, noted the difficulties she had encoun-tered in accessing health services in French. She worried that shewould be unable to communicate clearly with an Anglophonedoctor. This idea was echoed in another French focus group whereparticipants stated:

It is crucial to be able to explain things in your language toyour nurse or doctor. It would be very difficult trying toexplain or asking about complicated medical questions to anEnglish-speaking health professional.

Culturally relevant services were also of paramount impor-tance to Aboriginal parents, grandparents, and elders, who allspoke of the importance of Aboriginal early learning programmesand childcare services for their community. They said it wasimportant for children to have opportunities to learn theirancestral language and be engaged in culturally relevant pro-grammes. Aboriginal early years programmes that included bothAboriginal and non-Aboriginal children were thought to ‘‘makethe racism go away’’ and benefit children, families, and commu-nities now and in the future. One participant observed that:

Aboriginal daycares, they need to be here for the children.They need to know. They need self esteem from their own

K. Graham, K. Underwood / Health & Place 18 (2012) 1231–1239 1235

daycares, and their own stories, and their own elders - thatthey’re worthwhile so that when they go to school and hearnegative commentsyand like I said if you integrate with non-native kids they’ll already know, they’re already buddies withall their little Aboriginal friends so you can’t isolate either.

While they were proud of the early learning services that wereavailable, Aboriginal parents were very aware of absences ofculturally relevant services. They considered support for Abori-ginal students and Aboriginal culture in the school system to belimited or non-existent. They identified a disconnect between theschool board and the Aboriginal Best Start early years services,and noted the need for more Aboriginal programmes and servicesin general. Parents wanted services and programmes that wentbeyond the cultural education available for their children at thechildcare centre and early learning programmes. They spokeparticularly of the need for Aboriginal parenting groups, playgroups, and programmes for parents who are not working.

4.1.2. Services close to home

In every focus group and interview, parents shared theimportance of being able to access both everyday and specialisedservices within their communities and close to home. Satelliteprogrammes provided added convenience, and parents in thesouthern rural community were particularly happy with theirability to access many services through drop-in programmes. Onemother talked about the convenience of being able to accessinfant hearing tests through her local health centre. A drop-incentre for parents to weigh their infants was identified ascritically important by another mother who had encountereddifficulties breastfeeding and whose daughter was not gainingweight. For her, it was vital to have a regular drop-in centre in hercommunity with consistent staff and equipment.

Parents were aware of what services were not available intheir communities. One group noted that formal literacy/numer-acy programmes were only available in the nearest city, whichwas too far to drive. They commented that ‘‘[in] rural commu-nities y the scheduled type workshops don’t always happen aseasily.’’ Parents also noted certain difficulties in accessing high-quality childcare. In the northern rural community, parents notedthe lack of childcare near the local college, resulting in extendedtravel for students with children. Satellite play-group pro-grammes had been implemented in several small communities,but one mother noted, ‘‘it’s great, but it’s not child care.’’

Parents also said they had trouble accessing needed healthcareservices close to home. Obstetric services were no longer avail-able at one local hospital and women were not always able toaccess appropriate maternity services. A Francophone mothershared an experience of preparing to deliver her second child ata hospital outside her community. None of the hospitals availableoffered the quality of care she wanted as well as service in French.Parents were conscious that not all families had a car and mighthave difficulty getting to a hospital during labour or an emer-gency. They were also concerned about accessing critical health-care for their children, some of whom had complex medicalneeds. The proximity of these services was a particularly impor-tant issue for parents in the north: the nearest children’s hospitalsare in Toronto or Ottawa, both more than 500 km from thecommunity.

4.1.3. Barriers to access

Several barriers to accessing services in small communitiesemerged in focus group discussions. Gaining knowledge of whatprogrammes and services are available was identified as a barrier toaccess. One mother, drawing from her experience both as a parentand a social services professional, commented that ‘‘getting that

information out there about how to get those services is friggintoughy A lot of times there’s tons of services out there it’s justnobody knows how to get to them and getting that information topeople is just an ongoing struggle.’’ Parents in the southern ruralcommunity, where physical hubs were often located in schools, feltthat parents who already had school-age children had a significantadvantage. One mother said that the only time she saw advertisingwas when she physically went to the Best Start hub. This was seen asa disadvantage for first-time parents, or newcomers to the commu-nity. In other focus groups parents spoke of poorly advertised satelliteand evening programmes.

Scheduling was also identified as a barrier to access. Farmingfamilies and parents employed in shift work in manufacturingjobs were concerned about being able to access childcare pro-grammes that fit their need for longer or non-standard hours andschedules, and specifically noted the difficulty that could arise inaccessing half-day early learning programmes. Parents in bothnorthern and southern communities suggested that a full-dayprogramme would meet their families’ needs better than a half-day programme. One father said that he had to change thefamily’s daily routine drastically to pick up his son from a half-day preschool programme and transport him to another childcareprogramme.

Transportation issues were raised as a particularly relevantbarrier to access in rural communities. One parent said, ‘‘it’s aproblem with living in a remote place where everything is spreadout. It’s a lot of area to cover; it’s different than the cities.’’Another parent said, ‘‘transportation is an issue. If you are in ruralareas, even if you have a free program, how do you get to it?’’Parents spoke positively about the available transportation pro-grammes (a shuttle van), but were conscious that these transpor-tation services were only available for some programmes andtransportation remained a barrier to accessing other services.They suggested that early learning programmes should have morepick-up and drop-off services for children, because ‘‘many missout on the service because they can’t get to the centres.’’

4.2. Impact of personal relationships

The quality and nature of relationships with other people, bothparents and staff, played a role in parents’ experiences of BestStart services.

4.2.1. Cliques

In some groups, parents explicitly stated that small commu-nities can be socially unwelcoming, or cliquey. The presence ofcliques, or tight-knit exclusive groups, in programmes acted as adeterrent for some parents and affected other parents’ satisfactionwith the services offered. Some parents simply chose to accessdifferent programmes, or stay at home. Other parents did nothave these options because the service was necessary and onlyone local option was available. A mother who needed to use drop-in services to weigh her infant said:

I can be honest, I didn’t find this room all that welcoming. Ifound it very very cliquey. I was also new to [this community].So I mean the staff was friendly but the people here grew uphere and knew each other their whole livesyI didn’t findanyone really talked to me if I wasn’t instigating it. It was a lotof ‘oh, didya go to John’s birthday party?’ You know, it wasthey all just automatically knew each other and I don’t thinkthey were being rude on purpose it was just they’d knowneach other for so many years that it was like ‘‘we don’t reallyneed anyone else.

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This feeling of being an outsider was echoed by other motherswho had moved into small communities as adults and did nothave local networks of friends and family. When discussing drop-in programmes, one mother commented: ‘‘with me, you know,I’ve no relatives here. It’s like complete dropped in the middle ofthe province kind of thing.’’ The insider–outsider dynamic ofsome programmes, especially feelings of not belonging or notbeing welcome, affected parents’ satisfaction with the servicesand their future choices. Some parents chose to attend otherprogrammes or services where they felt more welcome; othersdid not have that choice, and were forced to choose between notaccessing needed services and continuing to access services inenvironments where they felt unwelcome.

4.2.2. Relationships with staff

In addition to relationships with other parents (or lackthereof), experiences in early years programmes were affectedby personal relationships with staff. The experience of havinghome visits from public health nurses, midwives, and otherprofessionals resonated with rural parents. They noted that closerelationships with staff were one of the benefits of living in smallcommunities where ‘‘everybody knows everybody.’’ Parents alsorecognised when staff went above and beyond what was requiredof them because they were more than just professionals—theywere also friends and neighbours. One group discussed hownurses working in the maternity ward would do things they werenot required to do, like taking the infants so that new motherscould rest, because ‘‘everybody knows everybody’’ and this‘‘makes a difference in the manner the services are provided.’’

Negative experiences also played a significant role in parents’use of and satisfaction with services. One mother had lost trust inthe staff at her daughter’s childcare programme and felt sheneeded to deal with ‘‘the attitudes of strangers and staff inprograms.’’ Her daughter was extremely shy and a staff personhad discussed the child’s need for services from a children’streatment centre with another parent, who was also an employeeof this treatment centre. Some parents saw the reality that‘‘everybody knows everybody’’ as an incredibly positive elementof living in a small community, but the lack of anonymity andtendency to exclude outsiders also created situations that wereunwelcoming, exclusionary, and painful for some parents.

4.2.3. Parents’ expectations of staff

Parents expected staff members to help build relationshipsbetween parents and to work against the exclusionary tendencieswithin small communities. Parents who had experienced cliquesin services and programmes wanted staff members to workagainst that kind of atmosphere by introducing parents to eachother and helping to build relationships. One mother directlylinked her use of a programme with the actions of the staffmembers who introduced her to the other parents: ‘‘I didn’t knowa soul and the staff was so great about showing me around thewhole centreythey really did make an effort to introduce me.’’

Most of the stories about staff facilitating relationshipsbetween parents were positive, but one parent spoke about anegative experience. She said that staff members had encouragedher to attend only certain programmes, and felt that they hadsteered her toward groups of parents with whom they thoughtshe would be more likely to develop friendships. Upon reflection,she considered their actions to be prejudicial—while she did endup making friends within these groups, she felt it should havehappened in a different way:

Now that I look back on it though, I realise that’s probably nothow it should have gone–it was more biased like it was theiropinion stuck in therey when I say cliquey, that’s what I

mean. They’ve already right away said ‘‘okay you’re kind of inthis part of your life and these people are this and you mightnot fit there.’’

Parents acknowledged that staff may know some familiesbetter than others for a myriad of reasons, but that ‘‘in ruralcommunities it can be alienating if not from there’’ and staffshould work to build relationships with all families.

5. Discussion

Accessibility emerged as the most relevant theme for ruralparents in this research. Proximity of services was important, andhaving services close to home was identified in all focus groupsand interviews as a significant supportive factor of Best Start.Other rural research has supported this finding; in most cases,having basic care close to an individual is better than moresophisticated care that is inaccessible because of distance (Baird,1997; Martinez-Brawley, 2000). Halseth and Ryser (2006) wrote:‘‘services provide stability and quality of life in rural and smalltown places, something which in return provides a strong base forattracting economic activity, retaining residents, and maintainingcommunities’’ (p. 86). However, they also identified a generaltrend in service reduction in rural communities across Canada(Halseth and Ryser, 2006). The two communities in this studyappear to be in direct opposition to this trend; parents in thesecommunities believed that more services were being offered intheir communities than in others, rural or urban. Locating theseservices in rural areas is an important step in improving acces-sibility for rural families.

The ability to access services locally is beneficial for allfamilies, but may be a necessity for families who do not havethe resources to travel. Consolidation and regionalisation ofservices can improve cost efficiency for service providers, butgenerally places more economic burden on families who mustcover the costs of travel in terms of both money and time(Asthana and Halliday, 2004). For some families, increased costsand distances may restrict their access to services (Martinez-Brawley, 2000; Sutherns and Bourgeault, 2008). The Best Startnetworks in this study have implemented innovative ways ofproviding services in local communities and addressing the needsof widely dispersed populations, including drop-in assessmentsand baby weigh-ins, mobile play groups, and transportationprogrammes. Overall, parents were extremely satisfied withhaving services available close to home, but they also acknowl-edged that other factors affected accessibility, apart from locationand proximity of services.

The appropriateness of available services was an importantconcern for parents, especially Francophone and Aboriginalfamilies who wanted services that were culturally and linguisti-cally relevant. Pence et al. (2007) identified ‘‘culture, context, andcommunity’’ (p. 2) as essential elements of quality early learningand care programmes. Some parents in this study expressed greatsatisfaction that some available programmes and servicesaddressed their cultural and contextual needs. Accessibility inthis circumstance is not only about the availability of services, butrather the intersection of availability and appropriateness. Ball(2005), referring to Aboriginal early childhood care and develop-ment centres, noted, ‘‘When the centre is located in their owncommunity and it is culturally safe, the services available are bothgeographically and culturally accessible’’ (p. 48). Parents identi-fied these services as important for personal, family, and com-munity identity. An understanding of accessibility that relies onlyon measures of distance and proximity does not incorporate the

K. Graham, K. Underwood / Health & Place 18 (2012) 1231–1239 1237

multi-faceted aspects of appropriateness that play importantroles in facilitating access and outcomes for these families.

Culturally relevant and appropriate services were particularlyrelevant for Aboriginal and Francophone families, but the experi-ences of other parents also illustrate the importance of appro-priate services. Sutherns and Bourgeault (2008) wrote: ‘‘if theservices are available, but are not a good fit with the client’sexpectations or culture, then accessibility is compromised’’ (p.873). Effective and appropriate services are especially relevant inrural communities where choice may be limited. The differencebetween simply having services available in the community, andhaving services that are perceived as effective and appropriate,can be illustrated by parents’ experiences with childcare.

Parents in this study were concerned about access to childcare.They tended to feel that centre-based childcare was of betterquality than home-based childcare, because it offered morelearning opportunities for children. Best Start provided a sub-stantial increase in licensed childcare spots in these communities,but in some areas licensed home childcare was much moreprevalent than licensed centre-based care. This prevalence ofhome-based care over centre-based care is common in rural areasthroughout Canada and the United States, as small populationsmake centre-based care prohibitively expensive (Bushnik, 2006;Wright, 2011). In some communities, the prime concern is theavailability of any type of childcare; in others, parents are mostconcerned about the perceived quality and appropriateness of thecare that is available. For families in many rural, remote, andnorthern communities in Ontario, including some of the familiesin this study, home childcare is the only option available locally(Ontario Municipal Social Services Association (OMSSA), 2011).Parents may perceive centre-based childcare to be of betterquality, but research has demonstrated some notable benefits ofhome-based care, including greater flexibility in scheduling(Bromer and Henly, 2004), and increased potential for strongand stable relationships with families and communities (Freeman,2011).

Parents’ access to and experiences with Best Start serviceswere heavily influenced by their relationships with other people.Research has demonstrated the positive role that strong socialcapital and informal support networks can play in rural commu-nities (Falk and Kilpatrick, 2000; Katras et al., 2004; Moseley andPahl, 2007), and some parents in this study said they weresupported by the close-knit relationships in their community.However, often only ‘insiders’ benefit from these strong social ties(Edwards and Cheers, 2007; Martinez-Brawley, 2000). Parentsnoted that it was difficult to move into communities where strongrelationships were already established, and that this processaffected more than friendships and informal support networks.The strong social capital in rural communities is not evenlydistributed; ‘outsiders’ can face exclusion and other negativeconsequences (Edwards and Cheers, 2007). This kind of exclusioncan prevent individuals from building their own informal supportnetwork, making it even more difficult for them to tap into thepositive potential of close-knit communities (Martinez-Brawley,2000). Of even greater concern is how cliques can affect parents’use of formal services that should be accessible to all families.

Informal support networks are important for families in ruralcommunities (Albanese, 2007; Katras et al., 2004; Swanson et al.,2008), but for families without these networks, formal pro-grammes and services are vital sources of support. Some parentsin this study said that formal programmes with obvious cliquescould compromise accessibility for those who felt like outsiders.In cases where cliques were present and parents reported positiveexperiences, responsive staff members were the common factor.These staff members were able to bridge the gap between parentsand facilitate inclusion for the ‘outsider’ parent. Staff members

need to be aware of the insider–outsider dynamics withinprogrammes and how some parents may feel excluded. Theymust also act on this information to prevent further margin-alisation of parents positioned as ‘outsiders’. As one parent in thisstudy stated, ‘‘in rural communities it can be alienating if notfrom there–the hubs should work against that, staff shoulddevelop relationships with everybody.’’

The complexity of social relationships is compounded whenparents’ access to services rests on the strength of their relationshipwith a single professional. For many parents in this study, their useof Best Start programmes and services was facilitated by a singlestaff person. Many parents said they had been successfully con-nected to the network of services through their relationship withone person, demonstrating the great potential of this model for ruralcommunities. Staff members who develop a strong relationship withparents and families can access the strengths of rural areas andnavigate the challenges of dual roles and professional boundaries.Moules et al. (2010) described this working relationship as theability to ‘‘build on the opportunities of context–to share what itmeans to live in rural, often isolated communities, where locationplays a large role in every day interaction’’ (p. 332). However,difficulties may arise if the single staff person is not well trained,or well supported, or able to navigate the multiple relationshipsinvolved in rural practice. When accessibility to, and navigation of,the system of services and supports rests on a single staff person, itis essential to treat that position as critically important and providethe necessary training and system of support to ensure families donot fall through the cracks and staff do not burn out (Halliday andAsthana, 2004)

6. Conclusions

Rural parents’ experiences with Best Start services are affected bya complex interplay of factors related to rural life and location.Accessibility is a fundamentally important issue in rural commu-nities, but it is a complex and multi-faceted concept that involvesmore than the distance to a given programme or service. Availabilitymust be considered in relation to the social, cultural, and psycho-logical dimensions of living in rural areas. The proximity of servicesis an important starting point, especially in consideration of servicereduction trends, but the answer is not as simple as providingservices close to home. Outcomes are connected to the design ofservice delivery, and appropriate services are as important asavailable services. Threaded through all service delivery is the factthat personal relationships have a substantial influence on theexperiences of parents and staff. Many of the initial themes andcodes from the rural-specific dataset supported the findings of theoriginal Have a Voice Project (Underwood et al., 2010). Together,these findings highlight the need for community-driven strategies inrural communities and a broader conception of what it means tohave accessible services. As Sutherns and Bourgeault (2008) wrote,‘‘employing an expanded understanding of access that reflects thecomplexity of how lives are lived opens possibilities for achieving[access] in more creative, cost-effective ways’’ (p. 878).

Acknowledgements

This study was funded by a Grant from the Ontario Ministry ofChildren and Youth Services. The opinions expressed in this report aresolely the opinions of the authors/researchers and are not necessarilythe views of the Ministry of Children and Youth Services. From theHave a Voice project, we appreciate the contributions of IsabelKilloran, co-investigator, and Nina Webster, project coordinator.

K. Graham, K. Underwood / Health & Place 18 (2012) 1231–12391238

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