Michael R. Daley, Ph.D., ACSW, University of South Alabama, and Michael O. Doughty, Ph.D., MSSW, Stephen F. Austin State University
A common theme in rural social work is that ethical concerns of confidentiality and dual relationships are greater than in urban communities. This study compared rural and urban social workers’ reported ethics violations and found complaint profiles for rural and urban social workers to be similar.
Ethics Complaints in Social Work Practice: A Rural–Urban Comparison
Michael R. Daley, Ph.D., ACSW
University of South Alabama
Michael O. Doughty, Ph.D., MSSW
Stephen F. Austin State University
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key Words: Professional Ethics, Rural Social Work, Ethics Complaints, Dual Relationships, Confidentiality, Licensing
A common theme in rural social work is that ethical concerns of confidentiality and dual relationships are greater than in urban communities. This study compared rural and urban social workers’ reported ethics violations and found complaint profiles for rural and urban social workers to be similar.
There has been much discussion about the special ethical challenges faced by social workers who practice in rural settings (Boisen and Bosh, 2005; Ginsberg, 1998; Gumpert and Black, 2005; Miller, 1998; Strom-Gottfried, 2005; Watkins, 2004). A recurrent theme is how rural social workers manage confidentiality and dual relationships given that they are integral members of their small communities. The National Association of Social Workers appropriately summarizes the key issues in their policy statement on Rural Social Work.
Small communities pose challenges to confidentiality, particularly when relatively few professional social workers interact with providers and community members who may have limited understanding of professional ethics. …Ethical practice in rural areas requires special attention to dual relationship issues. Few other settings expose social workers more to the risk of violating the NASW Code of Ethics’ admonition that social workers are to take steps to protect clients and are responsible for setting clear, appropriate and culturally sensitive boundaries (NASW, 2003).
Rural social workers must achieve a delicate ethical balance between two areas of the NASW Code of Ethics, specifically, “The Code is relevant to all social workers and social work students regardless of their professional functions, the settings in which they work, or the populations they serve” and “… setting clear and culturally sensitive boundaries” (NASW, 1999). This balance is so difficult to achieve because in rural practice “professional distance” can present a significant barrier to establishing trust and working with the community (NASW, 2003). Human behavior in small towns and rural communities is characterized by face-to-face relationships between individuals and with institutions (Ginsberg, 2005) and impersonal approaches are seen as culturally insensitive.
Yet, while we are well aware of the ethical challenges faced by social workers in rural settings, we know little about how well they are coping with these challenges. Given that rural social workers appear to be at greater ethical risk than their counterparts in other communities in the areas of confidentiality and dual relationships, we might expect to see more reports of violations in these areas. Analyzing these reports may be useful in understanding the extent of the risk and preparing rural social workers to practice more ethically.
Currently, there is a great deal of discussion of risk but little empirical evidence of social worker behavior relating to this risk (Croxton, Jayaratne, and Mattison, 2002; Miller, 1998). This study reports on data from the Texas State Board of Social Worker Examiners (TSBSWE) and examines the relationship between ethics complaints against social workers in rural communities and those against social workers from other types of communities.
2. Review of Literature
The rural social work environment has been compared to a “fish bowl” (Farley, Griffiths, Skidmore, and Thackeray, 1982) in which every action is subject to public observation and judgment. Rural communities operate on a highly personalized basis (Ginsberg, 1998) in which the closeness of people (NASW, 2003) is an important issue for social work practice. Social Workers become part of the community system and their actions and affiliations are important factors in how they are evaluated by the local community (Ginsberg, 2005). To be effective, social workers must take time to learn and adapt to the cultural norms of their communities, including becoming known by establishing personal relationships (Ginsberg, 1998).
In the close knit culture of the rural community social workers are challenged to adapt their practice in ways that are both effective and ethical. As professionals, social workers are usually educated in methods and models that are not well adapted to rural environments (Daley and Avant, 1999; Ginsberg, 1998; NASW, 2003). The emphasis on formal professional relationships conveyed through social work education and professional ethics are often viewed as inappropriate or distant. Rural communities, which value personal relationships, tend to see professional distance as either rude or culturally insensitive, and this presents a barrier to effective social work. Given the realities of rural life, social workers usually find themselves maintaining a delicate balance between the expectations of the profession and those of the community.
Ethical vulnerability for rural social workers appears most pronounced in the areas of confidentiality and dual relationships. Strom-Gottfried (2005) highlights several areas in which social workers in rural communities may be at ethical risk. These include confidentiality, dual relationships and conflicts of interest, competence, and anonymity and self disclosure. Confidentiality issues present potential risk based on the community having common knowledge of the problem, overlapping relationships causing confusion about who knows what, community and family pressure to share information, and receiving confidential information from informal sources. Dual relationships present a difficult issue because of the lack of social distance and intersecting or overlapping relationships. Davenport and Davenport (1995) also identify the ethical dilemmas of confidentiality and dual relationships as issues for rural social workers. Specifically, they discuss the importance of maintaining confidentiality while enlisting natural helpers and potential business relationships with clients as challenges for rural social workers.
NASW (2003) highlights the ethical concerns related to confidentiality and dual relationships that confront rural social workers and calls for research to better inform the social work profession on these issues. Ginsberg (1998) states that the challenges of confidentiality and dual relationships in rural communities are such that social workers must adapt what they have learned to adjust successfully to the rural community.
Burkemper (2005) raises a number of ethical challenges that may confront rural social work practitioners. These include boundary dilemmas (dual relationships), confidentiality, fees and bartering, and cultural and practice competence. Among the confidentiality issues she raises are informed consent, sharing information with other professional and agencies, visibility of the office location and procedures. Watkins (2004) indicates that confidentiality may generate a potential conflict of values, especially for rural social workers working with natural helping networks, where the exchange of information is an expected part of the helping process. Fenby (1980) and Riggs and Kugel (1980) both mention maintaining confidentiality as an important consideration for social work practitioners in rural communities.
An opposing viewpoint is presented by Croxton, Jayaratne, and Mattison (2002). They surveyed 3,062 members of NASW possessing the MSW and who were identified as being in direct practice. Their results indicate little difference between rural and urban social workers with respect to beliefs and behaviors about client confidentiality.
Boisen and Bosch (2005) believe that the social isolation of rural residents creates a need for interdependence and generates difficulty for social workers in making a clear demarcation between personal and professional relationships. They also indicate that dual relationships are seen as more acceptable in rural communities. Their research concludes that rural social workers require an increased awareness of dual relationships. They indicate that boundary maintenance is the social worker’s responsibility, and because social workers must be engaged in rural mores, dual relationships must be approached with caution. Rural social workers must have a plan for dealing with dual relationships, and training on dual relationships must be a part of formal education for social workers practicing in rural areas.
Miller (1998) believes that dual relationships are an ethical issue for rural social workers and adds that dual relationships are hard to avoid because social workers are quite involved in their communities and the options for service provision are limited. She suggests that engaging in dual relationships is a beneficial part of the helping process for rural social workers. Watkins (2004) indicates that dual relationships may also present a potential ethical problem based on preexisting relationships that the worker may have with community members. His position is that as social work professionalized and adapted to an urban model based on secondary relationships, it developed an emphasis on confidentiality and discouraged dual relations. Rural communities were less committed to the formalized service model and remained more strongly tied to traditional, informal helping networks, thus creating a potential source of ethical conflict for social workers in rural settings. Croxton, Jayaratne, and Mattison (2002) found significant differences between rural and urban social workers in both practice beliefs and behaviors in their survey. Their results with regard to dual relationships indicate that more rural social workers consider dual relationships appropriate and enter in them with greater frequency than urban social workers.
To examine the ethical challenges of rural social workers, data on ethics complaints that were filed with the Texas State Board of Social Work Examiners (TSBSWE) from 1995 to 2003 was collected. This data on alleged violations of the code of ethics and state law yielded broad based information on social worker behavior related to ethical practice.
The eight year reporting period yielded a total of 594 complaint cases against individual social workers. Frequently, each complaint alleged violations of multiple sections the ethical code and licensing law. Each of these alleged violations was identified and coded. The case data also specified the community of residence of each social worker. It should be noted that the data base only contained data relating to ethics complaints and not to the validity or disposition of those complaints.
The Code of Ethics and administrative rules employed by the Texas State Board of Social Worker Examiners (Texas Administrative Code, 2005) is similar to, but not identical to the NASW Code of Ethics (NASW, 1999) Standard 1 which addresses social workers’ ethical responsibility to clients. Because the primary purpose of social work licensing is protection of the public, the Texas regulations and rules do not cover social worker conduct beyond that relating to clients. Ethics complaints may be filed by anyone who believes that social workers have violated either the TSBSWE Code of Ethics or any specific administrative rule related to conduct.
Once the case data was collected some recoding of data was necessary to put it into a format for analysis. First, the information on the specific complaints that were alleged had to be coded. Violations identified in the data base were specific to sections of the TSBSWE Code of Ethics and administrative rules. Reclassification of these complaints into categories that were more general in nature and more commonly used in the literature was necessary to facilitate analysis, interpretation of the data, and general understanding of the findings. Second, to determine the context of practice for the social workers, their communities of residence had to be identified as rural or urban. This required recoding of address data.
Data regarding alleged ethics violations were reclassified into categories adapted from Strom-Gottfried’s (2000) study of NASW ethics violations. This classification was useful in that it included categories that contained commonalities and were more generally applicable than the specifics of the Texas Code. The classification used had nine categories: Boundary Violations, Poor Practice, Competence, Record Keeping, Honesty, Confidentiality, Informed Consent, Reimbursement, and Conflicts of Interest. Some of the alleged ethics violations in this data did not match any of these categories, as they related to very specific aspects of the Texas law such as the requirement for licensure, and were excluded from the study. After reclassification of the data, a total of 1389 alleged violations were identified from the 594 cases.
Social workers’ community of residence was determined by using zip code data. Using the individual social workers’ zip codes, the population of their community was determined using data from the Texas Almanac (County - ZIP Code Database, 2005; Dallas Morning News, 1997). Based on population data and the United States Department of Agriculture’s listing of rural counties (National Association of Counties, 2005) the community of residence was classified as rural or urban. This method of classification is based on that of the US Census Bureau and is suggested by the work of Olaveson, Conway, and Shaver (2004) and Daley and Avant (2004). The resultant data were analyzed using an SPSS statistical program and descriptive statistics for the data were computed.
In 2003, the Texas State Board of Social Worker Examiners licensed approximately 23,500 social workers, and during the reporting period complaints were received only about 2.5 percent of this number. Annually this is only about 3.2 per thousand social workers who are alleged to have ethical violations per year. The 594 individuals who were reported for violations were alleged to have violated 1,389 sections of the State Code of Ethics or Administrative Code that corresponded with the NASW Code of Ethics. Thus, on average, each report identified 2.3 areas of violation.
Based on the large number of complaints retrieved from the data base, the number of ethics complaints filed against social workers in rural communities was remarkably low. Of the 1,389 alleged violations, only 118 (8.5%) were filed against rural social workers, while 1,271 (91.5%) were filed against urban social workers. The rate for ethics complaints did not appear to differ for rural and urban social workers, as 9.3% of the social workers licensed in Texas lived in rural and 90.7% lived in urban areas.
As indicated by this data there was a relative scarcity of social workers in rural communities. There are 254 counties in Texas, 196 of which are classified as rural (Dallas Morning News, 1997; National Association of Counties, 2005). The rural counties contain approximately 15% of the state’s 21 million plus population (Texas State Data Center, 2005). However, in 36 counties, there were no resident social workers, and 68 counties had five or less social workers. In the rural counties that did have social workers 54.3% were licensed at the BSW or pre-professional level (Social Work Associate).
The data were broken down by community of residence to make a rural-urban comparison across the alleged category of violations. The bar graph in Figure1 illustrates the rural-urban comparison in ethics complaints by category and Table1 summarizes these results in terms of specific percentages.
It is interesting to find that the ethics category poor practice was the most frequently cited category of complaint for rural social workers. Poor practice refers to failure to meet accepted standards for client care such as evaluation of clients’ progress, appropriate use of supervision, and making appropriate referrals. Poor practice was listed in 27.1% of rural complaints versus only 21.9% of those for urban social workers. The difference in percentages of the total reports for each group of 5.2% in this category was the largest in the study.
| Category of Ethics Violation by Residence|
| || Rural|| Urban|
| || %||N |
|Poor practice |
|Boundary Violations |
|Conflicts of Interest |
|Record Keeping |
|Informed Consent |
The literature review had led us to expect that citations for confidentiality and dual relationships would be higher for rural social workers. Boundary violations include inappropriate and potentially harmful personal, social, and/or business relationships with clients. This category has two subgroups, dual relationships and sexual relationships.
Indeed, boundary violations, which include dual relationships, were the second most commonly identified ethics report for rural social workers at 19.5% of the total citations. Boundary violations also ranked as the second most frequent report for urban social workers with 21.1% of the reports. Further examination of the boundary violation category revealed that there was an approximately even split in this category for rural social workers, with 11 (47.8%) citations for dual relationships and 12 (52.2%) citations for sexual relationships. For urban social workers there was a greater difference, with 170 (63.4%) reports for dual relationships and 98 (36.6%) reports of sexual relationships.
Therefore, the data would suggest that dual relationship related issues represent a greater concern for urban social workers than they do for rural social workers. This is the opposite of what the literature would lead us to expect. Yet, almost two-thirds of the reports of boundary violations for urban social workers are for dual relationships versus a little less than one-half for rural social workers.
Reports of confidentiality violations were less than expected given the attention paid to this issue in the literature. These complaints represented only 10.2% total citations for rural social workers. Confidentiality violations were only the fifth most frequently reported type of ethics citation for both rural and urban social workers. The percentage of complaints for confidentiality violations by urban social workers was very close to that for rural social workers at 9.4%. Thus, the rate for confidentiality complaints was only minimally higher for rural social workers and appears very consistent with that for urban social workers.
The category of ethics complaint that ranked third in frequency for rural social workers was conflict of interest, with 16.4% the citations. This category ranked fourth for urban social workers at 10.9% of the total complaints. Two types of behavior were evident in this category: exploitation, or placing the interest of others (including the social worker) over the interest of the client, and discrimination in the form of a prejudicial denial of service.
The complaint category that ranked fourth in frequency for rural and third for urban social workers was honesty. This category accounted for 11.0% of the citations for rural and 14.6% of the citations for urban social workers. This category included reports for allegedly engaging fraudulent, deceitful, or misleading acts affecting a client.
The five highest ranked categories of complaints account for 83.9% of the total citations for rural and 77.9% of the total citations for urban social workers. Given the small numbers of complaints about rural social workers in the remaining four categories, the percentages and rankings for those complaints may be a little less reliable and informative. Competency citations ranked sixth overall at 5.1% for rural social workers versus 7.9% for urban social workers. This category included practicing within the limits of the social workers’ knowledge and skill, and issues related to impairment of the practitioner due to physical or mental health, the use of medication, drugs or alcohol. The remaining three categories record keeping, informed consent, and reimbursement accounted for very small percentages of the reports. Citations in this area require social workers to maintain accurate up-to-date service records, fully inform clients of all aspects of the services offered, and to seek reimbursement only for services actually rendered. The report rate for each of these categories for both rural and urban social workers ranged from 3.4% to 4.8%.
The licensing profile of the social workers alleged to have committed ethics violations differed markedly between rural and urban communities. In rural communities, social workers licensed at the BSW level had the highest percentage of complaints at 44.7%, while social workers licensed for independent practice accounted for 30.3% and MSW licensed social workers for 15.7%. Reports for urban social workers reflected complaints against those licensed for independent practice at 52.6%, MSW licensees at 23.3%, and BSW licensees at 15.4%. This data may simply reflect the differing compositions of the social work community in rural and urban areas in which rural communities tend to have larger proportions of BSW social workers and urban communities greater proportions of MSWs and those licensed for independent practice (Daley and Avant, 1999).
It is important, for several reasons, to be cautious in making broad generalizations based on the results of this study. First, the data used in this study was retrieved from the social work licensing entity of only one state and the ethics violations reported may be idiosyncratic to that state. Second, the data reflect reports of alleged violations not adjudicated findings of violations. Thus, the extent to which these allegations are valid is not known. Third, the citations recorded for a complaint involve interpretation and assessment both when received by TSBSWE and when classified into categories for analysis by the researchers. Fourth, the small number of alleged violations for rural social workers in some categories makes interpretation of the percentages and rankings of those violation categories difficult. For example, the variation just of one or two reports in some categories could make a large difference in the percentages for rural social workers. Fifth, the data does not lend itself for tests of statistical significance to assess differences between rural and urban social workers, since many individuals had multiple reports, affecting the independence of the complaints. Thus, the results reported are descriptive and should be evaluated in that context.
Analysis of ethics complaints submitted to the Texas State Board of Social Worker Examiners suggests that while the ethical issues of confidentiality and dual relationships may represent significant challenges for rural social workers, the challenges are handled at least as well as those faced by their urban counterparts. Clearly the “fishbowl” environment of rural life creates a greater potential for ethical risk for rural social workers in both of these categories. But heightened risk does not equate to ethical violations, the critical piece is how the risk is managed. Ethical challenges are confronted and overcome every day by all social workers, and it appears that despite the heightened risk, rural social workers are measuring up to the challenge. Our data offers no insight into how they are doing this, but it is an interesting question for future research.
The data from our study indicates a similarity in profile between ethics citations for rural and urban social workers that is greater than is normally acknowledged in the literature. Rural and urban social workers demonstrated no statistically significant differences on the categories of ethics citation reported. In addition, the rank order for each of these categories were parallel in most respects, and the percentages of the total complaints for each category were comparable for both groups, further indicating rural and urban consistency.
It might be argued that our findings are an artifact of the rural tendency to handle things informally within the community, thus reducing reports of ethical violations. This does not appear to be the case because the rates of reporting for alleged ethics violations, both rural and urban, are in direct proportion to their membership among licensed social workers.
While the study did not find great differences between rural and urban social workers in reported ethics violations, we should not lose sight of the practical fact that almost 30% of the ethics complaints alleged against rural social workers related to either boundary or confidentiality violations. Thus, the rural social work literature appropriately these raises these key issues for practice and education. Perhaps it is the attention to the ethical risks of rural practice that makes social workers better prepared to recognize and attend to these issues in their practice.
Ethics complaints regarding poor practice were the most common ethics allegations against rural social workers and represented over one fourth of the reports. This finding represents another substantial area of concern regarding ethical practice. The poor practice category contains allegations that social workers did not meet accepted standards for client care such as: making proper assessments, using supervision appropriately, and making suitable referrals. While the issue of poor practice is not as keenly highlighted in the literature, it is not entirely surprising either. The poor practice category that was used in our study appears to correspond more closely to a concept identified as competency in the rural social work literature. While our study did include a competence category, it was less focused on to competent practice behaviors than upon worker impairment and practicing within the formal preparation the social worker.
Behavioral aspects of social worker practice and competence are identified as a source of ethical risk to rural social workers by a number of authors. Strom-Gottfried (2005) believes that rural social workers may be presented with responsibilities and situations exceeding their level or area of competence and these situations would traditionally indicate making a referral in densely populated communities. However, referrals might not be a viable option in a rural community either because of availability or distance. The rural social worker must then confront the decision of whether the client may benefit more from marginally competent service than no service at all. Croxton, Jayaratne, and Mattison (2002) also indicate that the broadened responsibilities of rural social workers put them in situations where they must provide service despite limitations or leave clients to receive no services. Burkemper (2005) cites the difficulties rural social workers face in obtaining supervision and in accessing continuing professional education. Ginsberg (1998) suggests that rural social workers function with more independence from supervision because of the scarcity of social workers available to provide ready supervision.
Each of these factors may lead to poor practice allegations being the most frequent for rural social workers. Geographic distance and communication issues may create a self reliance that may ultimately result in barriers to using supervision either appropriately or effectively. The desire to help in a rural community where appropriate referral sources are not practical options may also lead social workers to delve into areas where their preparation is limited. One might also postulate that these circumstances, the likelihood of successful outcomes would be lower. Croxton, Jayaratne, and Mattison (2002) do report that rural social workers were more likely to report unsuccessfully outcomes with recently terminated clients. Perhaps frustrations over unsuccessful outcomes led to more reports of poor practice in our study.
Conflict of interest allegations for rural social workers were also notably higher than those for urban social workers. Reports in this category consisted of behaviors related to discriminatory treatment of the client and placing the interests of others over those of the client. There was a strong relationship conflict of interest and boundary violation complaints, as in 43.7% of the cases both allegations were reported. In these cases, conflict of interest and boundary violation allegations likely refer to different aspects of the same behavior. In instances where discriminatory treatment was alleged, the closeness of the rural community may play an important role. The close knit atmosphere of rural life may make it more likely that the social worker knows or knows of the client and/or the client’s family. Given this preexisting knowledge, it may be more likely for the social worker to prejudge a client, or for the client to believe that he or she is being prejudged.
Allegations related to honesty alleged social workers engaged in fraud or deceit with clients. Although this was the fourth most frequent ethics report for rural social workers, the rate of reporting was lower than that for urban social workers. Perhaps the informal networks and communication systems in rural communities served as a deterrent to dishonest behavior. In other words, a person’s reputation in rural America tends to be well known and be given great weight. Once the word got out that a social worker was not to be trusted, it would be hard to work with clients and colleagues, and it would be difficult to be effective. Four other categories of ethics complaint had so few reports, that the data is not of practical use.
Perhaps the most striking finding of difference between rural and urban social workers lies in the distribution and the composition of the labor force. Rural social workers comprise only 9.3% of the licensed social workers yet serve 15% of the population. Based on the number of rural counties in Texas, the geographic area that these rural social workers must serve is enormous and must be a viewed as significant factor in service delivery. Rural social workers are more likely to be licensed at the baccalaureate level (Daley and Avant, 1999), and are less likely to have the MSW or be licensed for independent practice. This is the case with our population as 54.3% of the rural social workers were licensed at the BSW or pre-professional level. Moreover, the percentage of rural social workers who are licensed as associates without a social work degree is twice that found in urban counties. Thus, based on the logistics of service delivery, the relative scarcity of social workers, and their preparation as baccalaureate generalists, it is not surprising that rural social workers are frequently thrust into situations in which advanced or specialized services are needed and resources for referral may be difficult, if not impractical to access. Practically speaking, in rural areas BSW social workers are often asked to perform the types of tasks usually assigned to MSWs in urban settings. In the environmental context of rural social work the ethical decision to serve clients, perhaps on the fringes of professional competence, or do nothing is a serious one that appears to confront rural social workers with some frequency and bears further exploration.
Discussions about the ethical challenges of rural social work have raised the question of whether there may be a rural code for social work practice (Boisen and Bosh, 2005). This study of alleged ethics complaints for rural and urban social workers strongly suggests that there is not such a rural code, as our data did not indicate great differences between the two groups. Rural social workers may, indeed face higher ethical risk in some areas than their urban colleagues, but they appear to have found a way to manage that risk within a common code of ethics. An important question for future research is to identify the strategies used by rural social workers in their risk management.
These findings do appear to raise questions concerning some widely held assumptions about the differences in rural and urban social work practice, particularly in the areas of confidentiality and dual relationships. While confidentiality and dual relationships have received the greatest emphasis in the rural literature, it was ethical allegations regarding poor practice that were reported with the greatest frequency in our study. It does appear that the scarcity of rural social workers and available supervision and referral resources may contribute to the greater frequency for reports of poor practice. However, ethical social work practice is an extremely complex matter and additional research is needed to further clarify more specifically how these issues play out in practice.
This study may indicate that we need to make revisions in ethics education and training for the social work profession in rural communities by focusing on the areas of greatest risk for complaints. The profession may need to strengthen its emphasis on ethical practice in rural settings, particularly with regard to the effective use of supervision and the use of referral. This may require discussing strategies for strengthening supervision and improving communication linkages, perhaps by using technology. It may focus on developing networks of referral sources external to the community that may be utilized when appropriate. Clearly ethics training for rural social work must also continue to address the challenges of confidentiality and dual relationships.
The shortage of social worker in rural communities is a challenge that the profession needs to address (Daley and Avant, 1999; NASW 2003). Otherwise, not only will rural social workers continue to be faced with the troubling ethical dilemmas about the services they provide, but many services might continue to be provided by non-professionals who may not subscribe to any ethical code.
In the final analysis, it seems that the differences between rural and urban social workers play out more subtly than our data could capture. We would be well served to remember Ginsberg’s (2005, p. 4-5) perspective that “Perhaps the first important principle is that social work with rural populations and in rural areas is, ideally, simply good social work that reflects and considers the environment in which practice takes place”. Our challenge for the future is to identify ways in which good social work can be adapted to the rural environment to strengthen practice.
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