1. Rethinking the rural health deficit:
Does sense of belonging have an influence?
Peter Kitchen and Allison Williams
School of Geography & Earth Sciences
McMaster University
James Chowhan
DeGroote School of Business
McMaster University
Rural Research Workshop
Ottawa. May 5, 2011
What is Sense of Belonging?
Sense of belonging is a psychological construct
based on a person’s attachment to and social
comfort with their community, friends, family,
workplace, or personal interests (e.g. activities or
hobbies).
Research has shown that there is an association
between sense of belonging and physical and
mental health

2. Research Questions
1) What are the major health, social and geographic
determinants of sense of community belonging?
2) How does this sentiment vary across the urban
to rural continuum and among settlements of
different size?
3) Does the rural health deficit need to be re-
examined in the context of a broader view of
health?
Literature
• Maslov (1954): belonging as an important human
need
• Anant (1966): belonging as a link to mental health
and mental illness
• Hagerty and colleagues (1990s and 2000s):
belonging correlated with stress and depression

3. Literature
Statistics Canada:
• Ross (2002): sense of community belonging
associated with self-perceived health
• Turcotte (2005): community belonging
improved across the urban to rural gradient
• Shields (2008): sense of community belonging
lower in urban areas and strong association
with self-perceived health and mental health
Data
• Statistics Canada’s 2007/08 Canadian Community
Health Survey (CCHS) Master File
• Sample: Adults aged 18 or over (n=116,258)
• Dependent variable: Sense of belonging to local
Community
• Question: How would you describe your sense of
belonging to your local community? Would you
say it is: (very strong, somewhat strong, somewhat
weak, or very weak)?

4. Data: Independent Variables
Health Geography Socio-Economic
(control)
Self-perceived Census rural Age, Sex
health
Self-perceived Metro. Influence Aboriginal and
mental health Zone immigrant status
Perceived life Province Household income
stress
Perceived work Education
stress
Physical activity Dwelling type
Household type
Housing tenure
Defining Rural
The Metropolitan Area (CMA) and Census
Agglomeration (CA) Influenced Zones (MIZ) were
used.
A Metropolitan Influence Zone (MIZ) refers to
the population living outside the commuting
zones of larger urban centres (CMAs and CAs).
Four zones:
CMA/CA Strong MIZ Moderate MIZ Weak/No MIZ

5. Vancouver CMA
Fort Nelson, BC
Weak/No MIZ

6. Methods of Analysis
• Descriptive statistics: contingency tables
• Ordered logit regression modeling (dependent
variable: sense of community belonging – 4
point Likert scale)
• Analysis conducted using Stata 11
• Individual sample weights employed
• Bootstrap techniques applied
Results
Overall and Mental Health
Sense of belonging to local community by health status
% Very strong/somewhat
70
60 66.0 66.5
strong belonging
61.5
50 54.5 57.0
40
43.7
30
20
10
0
Self-perceived health Perceived mental health
Excellent/very good Good Fair/poor
(Canadian Community Health Survey 2007-08
respondent aged 18+)

7. Life and Work Stress
Sense of belonging to local community by level of stress
% Very strong/somewhat
80
70
strong belonging
60 68.5 66.3
50 62.6 62.7
56.7 58.6
40
30
20
10
0
Perceived life stress Perceived work stress
Not at all/not very A bit Quite a bit/extremely
(Canadian Community Health Survey 2007/08
respondents aged 18+)
Geography: Province
Sense of belonging to local community by province of residence
% Very strong/somewhat strong belonging
Canada 68.0
Territories 73.7
BC 68.6
Alberta 64.1
Saskatchewan 73.2
Manitoba 71.5
Ontario 68.5
Quebec 59.7
New Brunswick 68.8
Nova Scotia 72.1
PEI 74.0
NFLD/Labrador 81.8
0 20 40 60 80 100
(Canadian Community Health Survey 2007/08
respondents aged 18+)

8. Geography: Metro. Influence Zone
Sense of belonging to local community by place of
residence
% Very strong/somewhat
100
strong belonging
80
75.6
60 69.8
61.8 63.7
40
20
0
Metropolitan Influence Zone (MIZ)
CMA/CA Strong MIZ Moderate MIZ Weak or no MIZ
(Canadian Community Health Survey 2007/08
respondents aged 18+)
Ordinal Logit Regression
Model 1: Health variables only
Model 2: Health plus geography variables
Model 3: Health, geography plus SES
(control) variables

9. Results of Ordinal Logit Regression Analyses
Mode1 1 Model 2 Model 3
Independent Odds S.E. Odds S.E. Odds S.E.
Variables ratios ratios Ratios
Self-perceived
health
Excellent/Very Good Reference
Good 0.935*** 0.021 0.930*** 0.021 0.878*** 0.021
Fair/poor 0.888*** 0.033 0.851*** 0.032 0.714*** 0.028
Self-perceived
mental health
Excellent/Very Good Reference
Good 0.737*** 0.018 0.721*** 0.018 0.717*** 0.018
Fair/poor 0.472*** 0.027 0.455*** 0.025 0.493*** 0.027
Perceived life stress
Not at all/not very Reference
A bit 0.803*** 0.017 0.802*** 0.017 0.867*** 0.019
Quite a bit/extremely 0.708*** 0.020 0.740*** 0.022 0.814*** 0.025
Results of Ordinal Logit Regression Analyses
Geography Variables
Mode1 1 Model 2 Model 3
Independent Odds S.E. Odds S.E. Odds S.E.
Variables ratios ratios Ratios
Province
Quebec Reference
Nfld/Labrador 2.280*** 0.158 2.200*** 0.151
PEI 1.697*** 0.138 1.664*** 0.138
Ontario 1.452*** 0.051 1.427*** 0.053
Manitoba 1.401*** 0.078 1.379*** 0.079
Saskatchewan 1.524*** 0.069 1.515*** 0.070
Territories 2.417*** 0.240 2.719*** 0.256
Metropolitan
Influence Zone
CMA/CA Reference
Strongly MIZ 1.026 0.056 0.986 0.054
Moderate MIZ 1.414*** 0.052 1.343*** 0.052
Weak or no infl. 1.694*** 0.048 1.631*** 0.049

10. Selected Socio-Economic Variables
Mode1 1 Model 2 Model 3
Independent O.R. S.E. O.R. S.E. O.R. S.E.
Variables
Immigrant status
Immigrant 1.016 0.031
Non-immigrant Reference
Aboriginal status
Aboriginal 0.976 0.048
Non-Aboriginal Reference
Dwelling type
Single detached Reference
Double/row/duplex 0.925** 0.030
Low-rise 0.930 0.041
High-rise 0.778*** 0.058
Other 0.959 0.055
Household type
Unattached individual Reference
Couple living alone 1.054* 0.030
Couple with children 1.327*** 0.045
Lone parents 1.105** 0.044
Summary
• A very strong association between SoCB and health
(especially mental health) even when controlling for
geography and SES
• SoCB becomes stronger across the urban to rural
continuum (rural areas & small towns)
• Lower SoCB among lone-parent families (compared to
couples with children) and those living in high-rise apts
(compared to detached homes)

11. Sense of belonging and the rural health deficit
• Research shows a clear health deficit in rural/small
town Canada:
- health outcomes (self-rated health, life expectancy,
chronic conditions, disease, accidents, etc)
- access to health resources (acute care hospitals,
primary health care)
• Canadian Institute for Health Information (CIHI)
• Statistics Canada
• Numerous Canadian rural health researchers
Three-way contingency table:
the urban health advantage
Sense of belonging to local community by place of residence
and self-rated health
80
% Reporting Excellent/Very
70
Good Self-rated health
60 64 62
50 56 58
59 49 49
40
41
30
20
10
0
Very strong Somewhat Somewhat weak Very weak
Strong
Sene of belonging to local community
CMA/CA Strong MIZ Moderate MIZ Weak or no MIZ

12. Discussion
• Do the findings of this research suggest a type of
paradox?
• How can regions with lower health outcomes have higher
SoCB when health is found to be such a strong contributor
to SoCB?
• It appears that rural and small-town residents are able
to overcome this health deficit
• Social capital may be a factor
Conclusion
On-going research has pointed to the fact that SoCB is
much higher in rural and small-town Canada despite
the presence of a health deficit.
These communities are clearly benefiting from a
number of social and organizational factors leading to
enhanced SoCB.
However, our understanding of what exactly these
factors are and how they are related to health and
well-being is limited.

13. Further research
Quantitative research that directly measures both
SoCB and social capital in rural and urban areas.
Ethnographic study of a small-town to uncover
the social, cultural and political dynamics at play in
creating a strong SoCB as related to issues such as
trust and reciprocity.
Re-examine the notion of a health gap between urban
and rural residents by broadening the definition of
health to include sentiments such as belonging.
Questions
• Why is SoCB so low in Québec?
• With respect to SoCB and health is there a certain
resiliency in rural communities and small towns?
• Should the definition of health include a person’s
sense of belonging?