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The impact of urbanization on health needs to be studied in order to inform health policies and programmes. Rapid urbanization is taking place in developing countries, with both detrimental and beneficial effects on health and quality of life. Some baseline data are available on the impact of urbanization on physical health (e.g., decline in infectious diseases but increase of chronic diseases of lifestyle), and some on mental illness, but very little on psychosocial well-being, notwithstanding the fact that this facet of health is intricately linked to total health and well-being, as described by the World Health Organization (1986). Gudmundsdottir (2010) indicated the similarities in ideology between mental health promotion and positive psychology, which also imply that more should be known about mental well-being in all social contexts in order to facilitate psychosocial well-being from a public health perspective. Very little information is available on psychological well-being in urban versus rural areas—especially in South Africa, where large numbers of African people are currently in the process of urbanization. In this chapter we report on four cross-sectional snapshots of rural and urban psychosocial well-being in an African group in the North West Province of South Africa, as found in studies from 1998 to 2010.

Terminology

In this study urbanization refers to the rural–urban migration that is taking place within a country (Seager, 1992), and especially in the South African context. Rural areas are those designated as deep rural villages (some still under tribal heads) and farming communities. Urban areas include informal and formal townships, and upper urban areas. The construct psychosocial well-being refers to manifestations of well-being on the upper end of the mental health continuum. For purposes of this study, the constructs psychosocial health and psychosocial well-being are used as synonyms. Facets of non- well-being or ill-being (e.g., depression and symptoms of pathology) are included in this study together with characteristics of psychosocial well-being, or optimal functioning, with a stronger focus on the latter, as described in various theoretical perspectives in positive psychology (e.g., Antonovsky, 1987, 1993; Diener, Emmons, Larson, & Griffen, 1985; Fredrickson, 2000; Keyes, 2002, 2005, 2007; Pavot & Diener, 2008). According to Haybron (2003), a complete theory of well-being needs to take into account both positive and negative feelings and functioning. Inclusion of both symptoms of pathology and characteristics of well-­being in the current study are also in line with the two-continua model (Keyes, 2002, 2005; Westerhof & Keyes, 2010) in which it is postulated that pathology (mental illness) and well-being (mental health) are manifested on two separate continua. Although these two continua are moderately negatively correlated, mental health needs to be explored and described taking both into account.

Rapid Urbanization in Developing Countries

Rapid urbanization is taking place in developing countries, particularly in South Africa (Szabo, 2002), and especially in the case of the black South African population (Higgs, 2007). In South Africa, approximately 54 % of the population was urbanized in 1996, with Gauteng (97 %) and the Western Cape (89 %) as the most urbanized, and the Northern Province (11 %) and North West (34 %) as the least (Szabo, 2002). The current study focuses primarily on findings from the North West Province of South Africa, where urbanization is rapidly taking place from large rural areas to fast developing cities. Many African people are leaving the underdeveloped rural areas in search of a better life in urban contexts. However, urbanization is not necessarily accompanied by a better life and better economic circumstances (cf. Van Donk, 2002). Urban poverty is widespread, and many highly stressful situations are experienced (e.g., high levels of crime) that also impact mental health (Malan et al., 1992).

Physical Health in Rural Versus Urban Areas: Positive and Negative Consequences

Pampalon, Hamel, De Koninck, and Disant (2007) noted that people’s perceptions of place, such as where they live, are significantly related to their health. In particular, rural areas were in need of more attention as their characteristics differed from those of urban areas. Ek, Koiranen, Raatikka, Järvelin, and Taanila (2008) found in a Finish study more self-reported poor health in rural areas, but Lu (2010) could not detect a change in physical health from rural to urban areas in Indonesia over the medium term. Dye (2008) concluded from a worldwide comparison that death rates are lower with urbanization, that there is a shift in the burden of illness from acute childhood infections to chronic, non-communicable diseases of life style in adults, and that urban inhabitants generally have better health than their rural counterparts, with more benefits for the rich than the poor. In South Africa, Vorster, Venter, Wissing, and Margetts (2005) reported that urban Africans had a better micronutrition intake and status than rural participants, but also increased problems with obesity and other risk factors for life-style diseases. Thus on a physical level, urbanization is accompanied by both positive and negative consequences. A higher blood pressure is also found for urban African men and women in the North West Province of South Africa, in comparison to that of people from rural areas (Malan et al., 2006). L. Malan, Malan, Wissing, and Seedat (2008) indicated that urban men showed more symptoms of metabolic syndrome than their rural counterparts. South African studies thus provided a mixed positive and negative impact of urbanization on physical health.

Differential association of physical health with urban and rural areas may depend on the degree of development of countries, specific areas selected, socioeconomic and sociodemographic variables, or many other variables which are still not very well understood.

Mental Health in Rural Versus Urban Areas

More is known on mental health, defined as symptoms of pathology, than what is known about psychosocial well-being—on the upper end of the mental health continuum—and its association with rural versus urban areas.

Pathology. Conflicting findings are reported on the association of rural versus urban areas with psychopathology. On the one hand, K. Sundquist, Frank, and Sundquist (2004) report a higher incidence of psychopathology in urban areas in Sweden (a highly developed first world country) in comparison to areas with a low density, and this was unrelated to age, marital status, or education. Schoevers, Peen, and Dekker (2007) also indicated in a nationwide epidemiological study in the Netherlands (a first world country) that urbanization is linked to a higher prevalence of psychiatric disorders in urban areas (twice as high), which was also reiterated by Peen and colleagues (2007). Lu (2010) also reported in a longitudinal study that migration from rural to urban areas in Indonesia has had a negative impact on psychological health, as manifested in more symptoms of depression in urban participants. This effect is explained as attributable to the separation from the family and support provided by them, and the possible gain from a better economic situation in urban areas that might have been hindered by many physical and psychological stressors. However, Oguzturk (2008) reported that people in rural areas in Turkey experience more psychological distress than their urban counterparts. Peen et al. (2007) noted that inconsistencies in reports on the association between pathology and rural–urban links in the United States and United Kingdom may be attributable to differences in the organization of mental health care, and differences in migration patterns that may affect vulnerability status in some contexts.

Psychosocial well-being. Few studies directly explored psychosocial well-being as measured on the upper end of the mental health continuum in rural versus urban areas, and some seemingly contradictory findings are reported. Tsuno and Yamazaki (2007) showed that urban participants in Japan had a significantly higher level of sense of coherence than rural participants, and suggested that this may be due to more social support, self-efficacy, and higher economic status found among urban participants. Along the same line, Oguzturk (2008) reports that people in rural areas in Turkey experienced a lower quality of life than those in urban areas. In Finland (which is a highly developed European country), Ek et al. (2008) also found more dissatisfaction with life in rural areas in comparison to urban areas. This was explained as mostly being the result of poorer education, high unemployment, lack of social support, passive coping strategies, and more negative affect or pessimism in rural areas. On the contrary, exploring coping strategies and psychological sense of community in urban and rural areas in Greece, Roussi, Rapti, and Kiosseoglou (2006) found that coping strategies clustered differently in the two areas, and that psychological sense of community was stronger in the rural area, where it was positively related to social joining as a coping strategy. It is thus noteworthy that the same variable (i.e., social support) is used to explain higher quality of well-being in urban (cf. Tsuno & Yamazaki, 2007) and in rural (cf. Roussi et al., 2006) areas. This indicates that there probably exists a complex relation between urbanization and well-being, and the interaction among various variables needs to be taken into account in order to understand the relation between urbanization and rural–urban environments. Eckersley (2006) contended that there is evidence to link cultural factors via psychosocial mechanisms to psychological well-being, and that well-­being then influences physical health via behavioural and physiological pathways—at least in western societies. This needs to be explored in an African context.

In the South African context, Higgs (2007) estimated with his Everyday Quality of Life index, taking various facets into account, that the mean South African score is 57 as measured in 2005 (scale range from 0–100; higher is better). For black people in urban areas it is 56, whereas it is only 45 for black people in rural areas—thus indicating the disparity in quality of life between rural and urban areas. The major contributors to the estimated quality of life were basic infrastructure (e.g., water, sanitation, and transport), a varied life with many activities, health, networks, optimism, self-esteem, and employment. Money only played a major role below R3000 per month income (approximately US$340). Disparities in psychosocial health are not only related to race/ethnicity and socioeconomic factors, but also to geographic location, and it is necessary to establish the mechanisms by which social disadvantage affects biological processes resulting in disease (Adler & Rehkopf, 2008); for example, high blood pressure and obesity as part of the metabolic syndrome (Botha, Wissing, Ellis, & Vorster, 2007). From a developmental perspective, Clark (2003) concluded that we need to know much more in South Africa about human capabilities and the psychology of human well-being. The development of well-being over time also needs to be monitored. Although gender differences were noted in psychosocial well-being in relatively more westernized groups (e.g., Roothman, Kirsten, & Wissing, 2003), very little is known about gender differences in well-being in African groups, and especially within urban and rural areas.

Possible value for health policy and interventions. Findings on psychosocial well-being and health in rural versus urban areas may inform health policies and provide information for specifically targeted interventions. Diener, Kesebir, and Lucas (2008) argued that accounts of well-being may help governments to identify groups in the greatest need for interventions in a given society. They indicate that accounts of well-being are highly useful for policymakers because it may add value beyond existing social and economic indicators. Previous research has indicated that psychological well-being and life satisfaction are associated with many positive outcomes on individual and societal levels (e.g., Keyes, 2005, 2007; Pressman & Cohen, 2005; Seligman, 2008). Currently no national or regional systematically collected data on levels of psychological health in rural versus urban areas exist for South Africa. Some epidemiological data can be found on symptoms and syndromes of psychopathology, but very little on levels of psychological well-being, and this study aims to fill this gap to some extent.

The main aim of this study was to compare psychosocial well-being of African people in rural and urban areas in the increasingly urbanizing North West Province of South Africa. To achieve this broad aim, a number of specific steps were undertaken, including (a) an exploration of the differences in psychosocial well-being of people in rural and urban areas, as evaluated with various measures in four different studies, (b) a description of possible changes over time, as noted in cross-sectional studies including the same measures at different points in time from 1998 to 2010, and (c) an exploration of possible gender differences within rural and urban areas.

Method

Design and Participants

Data were collected in four cross-sectional multidisciplinary studies from 1998 to 2010, including randomly selected samples of African adults from various strata in the North West Province of South Africa (total N = 3,617). These multidisciplinary studies also examined other research questions, and included the measures used for purposes of the current study. All measures were validated in the original studies, and those implemented in this study all showed acceptable to good psychometric properties. Within the randomly selected samples, participation was voluntary, as is ethically required. In the case of identification of physical illnesses, participants were referred to the nearest clinic. Participants received a small food package after the relatively extensive multidisciplinary data-collection procedures, in the case of the first sample. Although some measures implemented in the various studies were the same, others varied among samples. Participants were predominantly Setswana speaking. Sample 2 and Sample 4 included mainly the same participants, as the 2010 data collection was a follow-up on the 2005 evaluation, whereas samples 1 and 3 may include some of the same participants, but not necessarily.

Sample 1 (N = 814). The THUSA study (THUSA = Transition and Health during Urbanization of South Africans; Vorster (1996); ‘thusa’ means ‘help’ in Setswana, which is the mother tongue of the participants) was a multidisciplinary project, and data used in this study (814 participants completed the psychological questionnaires) were collected in 1998. Setswana-speaking participants were recruited in ten randomly selected health sites in the North West Province of South Africa. Participants were stratified for gender (males n = 362, females n = 452), age (15–24 years: n = 184; 25–34 years: n = 206; 35–44 years: n = 126; 45–54 years: n = 100; 55–64 years: n = 73; 65 years + n = 48), and level of urbanization (deep rural tribal respondents: n = 196; farm workers: n = 113; informal settlements: n = 168; urban township dwellers: n = 250; professional people: n = 11). Disparities in numbers are due to missing data. For purposes of comparison within urban and rural contexts, participants from deep rural and farming areas were combined (rural n = 310), as were those from urban townships and the professionals (urban n = 316), thus excluding the informal settlements around towns as an in-between group.

Sample 2 (N = 1,050). The PURE-FORT2 study (PURE = Prospective Urban and Rural Epidemiology; Kruger, 2005; forte = strength; FORT2 = Understanding and promoting psychosocial health, resilience, and strength in an African context; Wissing, 2005). This study was conducted during 2005 in an African sample, of which most participants were Setswana speaking. Participants were randomly selected following instructions of the overarching international PURE–project, and included 1,050 participants from rural (n = 599) and urban (n = 451) areas, 392 males and 648 females, and as far as age is concerned, 228 were between 30 and 40 years, 416 between 41 and 50 years, 248 between 51 and 60 years, 106 between 61 and 70 years, 29 between 71 and 80 years, and 2 above 80 years. Disparity in numbers is due to missing data.

Sample 3 (N = 477). The FORT3 study was conducted during 2008 (FORT 3 = The prevalence of levels of psychosocial health: Dynamics and relationships with biomarkers of (ill)health in South African social contexts; Wissing, 2008). The sample included 225 participants from rural areas and 252 from urban areas, of which 143 were males and 326 were females (with 11 cases of missing data for gender). Ages ranged between 20 and 70 years, with most being between 30–40 years. All participants were Setswana-speaking and resided in the North West Province of South Africa. Urban participants were selected in the Potchefstroom area using the ESRI Arch-View software to identify houses. Rural participants were selected by identifying every 10th house in the deep rural area of Ganyesa.

Sample 4 (N = 1,275). In the PURE-FORT3 study, a stratified, randomly selected community sample of urban (n = 581) and rural (n = 694) Setswana-speaking adults completed questionnaires as part of the multidisciplinary PURE-SA (PURE = Prospective Urban and rural Epidemiology; Kruger, 2005) project and the FORT3 during 2010. The mean age was 54.7 (SD = 10.1), with a range from 30 to 97 years. The group included 407 men and 836 women. Disparities in numbers are due to missing data. This study was a follow-up study on participants from Sample 2, and includes only a few new participants.

Measures

Measures of psychosocial well-being overlap, to some extent, among the various samples. The following measures were implemented in the various samples:

Sample 1. The THUSA–study included a core battery consisting of the following measures: The Sense of Coherence Scale (SOC; Antonovsky, 1987, 1993), consisting of 29 items and measuring an individual’s way of experiencing life in the world. Core components evaluated are comprehensibility, manageability, and meaningfulness. The 20-item Affectometer 2 (AFM; short version; Kammann & Flett, 1983) measures general happiness or sense of well-being as experienced on an affective/emotional level, and evaluates both Positive Affect (PA) and Negative Affect (NA) with 10 items each. The 5-item Satisfaction with Life Scale (SWLS) (Diener et al., 1985) measures individuals’ assessment of their quality of life as experienced on a cognitive-judgmental level. The General Health Questionnaire (GHQ-28; Goldberg & Hillier, 1979) measures the opposite of well-being, namely the degree of somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. The THUSA-study additionally included the Neuroticism subscale (NEO-N) of the NEO-Personality Inventory–Revised (Costa & McCrae, 1992) that measures facets of emotional instability, and the 21-item JAREL Spiritual Well-Being Scale (SWS-­H; Hungelmann, Kenkel-Rossi, Klassen, & Stollenwerk, 1996) that measures broad dimensions of spiritual well-being, including the harmonious interconnectedness of all individual components.

Sample 2. The PURE-FORT 2 dataset also included, apart from the above mentioned core battery (SOC, AFM, and SWLS), the 14-item Mental Health Continuum Short Form (MHC-SF; Keyes, 2005, 2006; Keyes et al., 2008) that measures emotional well-being (EWB), social well-being (SWB), and psychological well-being (PWB); the 8-item New General Self-Efficacy Scale (NGSE; Chen, Gully, & Eden, 2001) that measures an individual’s perception of the self as capable of meeting demands in various contexts; and the Community Collective Efficacy Scale (revised) (CCES; Carrol, Rosson, & Zhou, 2005) that measures the perception of the community’s ability to succeed in joint activities.

Sample 3. The FORT3-study also included—apart from the core battery—the MHC-SF, and additionally the 20-item General Psychological Well-being Scale (GPWS; Khumalo, Temane, & Wissing, 2010) that measures general psychological well-being; the 26-item Coping Self-Efficacy Scale (CSE; Chesney, Neilands, Chambers, Taylor, & Folkman, 2006) that measures a person’s confidence or perceived self-efficacy in performing coping behaviours when facing life challenges or threats; the 20-item Fortitude Questionnaire (FORQ; Pretorius, 1998) that measures the strength to manage stress and stay well (fortitude) in terms of appraisal of one’s own problem-solving efficacy and mastery, perceived support from family, and perceived support from friends; and lastly the 9-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) that measures depressive symptoms, as described in the DSM-IV criteria.

Sample 4. The PURE-FORT3 included the 20-item GPWS, the MHC-SF, the SWLS the CSE, the PHQ-9, and the GHQ-28, as described above. Additionally, the 14-item Warwick-Edinburgh Mental Well-being Scale (WEMWBS; Tennant et al., 2007) was included. This measure was developed from the AFM, and measures positive health in adults.

Procedure

The specific procedures for the abovementioned four studies are described by Vorster et al. (2000; Sample 1), Kruger (2005), Teo, Chow, Vaz, Rangarajan, and Yusuf (2009) and Keyes et al. (2008; Sample 2), Khumalo et al. (2010; Sample 3), and Wissing et al. (2011) and Wissing and Temane (2013; Sample 4). All studies were granted ethical approval by the North-West University and comply with the Helsinki Declaration, as revised in 2000. Permission was obtained from all relevant health authorities and departments, authorities of towns involved, and tribal chiefs in deep rural areas. Entrance to communities was negotiated by project leaders and all relevant authorities gave permission. Participants provided informed consent and were assured of confidentiality. Illiterate participants signed informed consent with an “X”. Translated and validated psychosocial questionnaires were administered in a structured interview format by extensively trained fieldworkers in Setswana, which was the mother tongue of the participants.

Data Analyses

Analysis of variance and t-tests for uncorrelated groups were conducted. For the purposes of this study, differences were regarded as statistically significant when the p-value was smaller than 0.05 (cf. Ellis & Steyn, 2003), and practical significance was determined according to Cohen’s (1988) guidelines for the interpretation of the effect size of differences between means: d = 0.2 (small effect), d = 0.5 (medium effect), and d = 0.8 (large effect), and taking into account his caution that these guideline values are only a basis and should not be used in an absolute sense. Typical effect size magnitudes may vary greatly across different research areas, and in the case of the social sciences where there is a large variation among human beings, it is generally expected that effect sizes would fall in the medium range. As the data collection in the four time periods used in this chapter were specific to the objectives of the various studies, differences in psychosocial well-being is reported as a cross-sectional snapshot of that time period.

Results

Sample 1

Differences among levels of urbanization and between rural and urban groups, as found in the THUSA study on indices of psychosocial well-being, are indicated in Tables 20.1, 20.2, and 20.3.

Table 20.1 Analysis of variance across five levels of urbanization for measurements in the THUSA-study (1998) (Sample 1)
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Table 20.2 Means across levels of urbanization for measures of well-being in the THUSA-study (N = 814) (Sample 1)
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Table 20.3 Significance of differences between rural (n = 310) and urban (n = 316) groups on measures of psychosocial well-being in the THUSA-study (Sample 1, 1998)
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As shown in Table 20.1, participants from the various strata differed significantly on all indices except Positive Affect. Table 20.2 indicates the mean scores on the various scales, as manifested for participants from the various strata. It can be seen that with increase in urbanization, participants showed generally lower symptoms and negative affect, as measured by the GHQ, AFM-NA, and NEO-N, and increased well-being, as measured with the SOC, AFM-PA, and SWLS. With urbanization, spiritual well-being—as measured with the SWH—decreased. It is noteworthy that on the whole, participants from the farming community showed the lowest levels of well-being, and the highest levels of symptoms of pathology.

Table 20.3 shows significant differences between rural and urban groups, as manifested on all measures in the THUSA study (excluding the in-between group of informal settlements). Participants from rural areas manifested statistically significantly more symptoms and negative affect, but also higher spiritual well-being, whereas participants from urban areas showed higher levels of positive emotion, sense of coherence, and satisfaction with life. However, these differences approach only practical significance (small effect) in the case of more symptoms and spirituality in the rural group, and higher satisfaction with life in the case of the urban group.

Sample 2

The significance of differences between rural and urban groups is indicated in Table 20.4 for all measures. Rural participants showed statistically significantly more negative affect and symptoms of stress, but also more general self-efficacy—the latter two with a small practical significance. The urban group had higher levels of positive affect, more satisfaction with life, and better emotional well-being, as well as significantly higher levels of collective community efficacy and social well-­being, which is traditionally more associated with rural areas. These differences were varied from medium to large possible, practical significance, as shown by Cohen’s d-values.

Table 20.4 Significance of differences between urban (n = 451) and rural (n = 599) groups on measures of psychosocial well-being in the PURE-FORT2-study (Sample 2, 2005)
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Sample 3

Table 20.5 shows the significance of differences between urban and rural groups on measures implemented in Sample 3 (FORT3). In this sample, with data collection in 2008, the differences between rural and urban psychosocial well-being were very stark. The rural group had statistically significantly more symptoms of depression, more negative affect, and more symptoms of stress and physical problems. The urban group manifested higher levels of psychosocial health on all indices of positive health. These differences were all from medium to large practical significance.

Table 20.5 Significance of differences between urban (n = 252) and rural (n = 225) groups on psychosocial measures in the FORT 3-study (Sample 3, 2008)
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Sample 4

Table 20.6 indicates the differences between rural and urban groups as established in 2010. The picture changed in some respects: Compared to previous studies, now the rural group had significantly higher psychological well-being, as measured with the MHC-PWB, and no longer had higher levels of depression (PHQ), as measures with the GHQ and scored with the GHQ-method (0-0-1-1). However, when the Likert-method of scoring was implemented (1-2-3-4), the rural group still showed more somatic and anxiety symptoms. No differences between the groups were found for emotional well-being, as measured with the MHC, but the urban group still had higher levels of satisfaction with life (SWLS) and higher scores on general psychological well-being (GPWS), social well-being (MHC-SWB), coping self-­efficacy strategies (PFC, SUE, and SFF), and positive health, as measured with the WEMWBS. Some of these differences were of practical significance (medium to large effect), especially in the case of the urban group experiencing more self-­efficacy in their efforts to cope with problems and to suppress negative thoughts.

Table 20.6 Significance of differences between rural (n = 694 ) and urban (n = 582) groups on psychosocial measures in the PURE-FORT3-project (Sample 4, 2010)
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A comparison of psychosocial well-being of urban and rural participants at various cross-sectional data collection points in time on similar measures is shown in Table 20.7. Levels of well-being and satisfaction with life dropped for both groups, as shown in measures taken in 2005 and 2008, but especially for the rural participants. During 2010, satisfaction with life was again on approximately the same levels as during 1998 for both groups, with the urban group being more satisfied. However, scores on the GHQ showed that somatic symptoms of stress increased for both the urban and rural groups, as measured in 2010 and compared to previous years.

Table 20.7 Comparison of results between rural and urban contexts on similar measures across time
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In all four samples, gender differences were found specifically for women showing significantly more symptoms of distress and depression, or negative affect, as shown on the GHQ, NEO-N, and PHQ (results not shown). In Sample 1 (THUSA; 1998), rural women manifested significantly higher levels than men of neuroticism (NEO-N), but also higher levels of satisfaction with life, whereas women in urban areas had significantly higher symptoms of distress, as shown on all sub-scales of the GHQ, and urban men had significantly higher levels of positive affect (AFM-PA), sense of coherence (SOC), and perceived social support from friends (for the latter cf. M. P. Wissing, Wissing, Temane, Khumalo, & Van Eeden, 2004). In Sample 2 (PURE-FORT; 2005), women from both rural and urban areas showed more symptoms of distress (GHQ) in comparison to men. In the case of Sample 3 (FORT 3–2008), only urban women showed more symptoms of distress and depression (GHQ and PHQ), whereas no significant gender differences were shown for rural participants. During 2010, Sample 4 (PURE-FORT 3) rural women showed significantly more somatic symptoms (GHQ-SS), whereas urban women manifested significantly more satisfaction with life in comparison to men. However, urban men experienced significantly more self-efficacy in seeking social support in comparison to women.

Discussion

This study aimed to compare psychosocial well-being of African people in rural and urban areas in the increasingly urbanized North West Province of South Africa, within specific data collection points. The main finding of this study is that psychosocial well-being is significantly lower in rural areas, but apart from the seemingly beneficial effects of urbanization for psychosocial health, some facets of psychosocial well-being are higher in rural areas. Well-being decreased for urban and rural groups from 1998 to 2008, but increased again, as shown in 2010. However, high levels of distress still existed for both groups in 2010. Some gender differences are noted.

Rural Versus Urban Well-Being

The finding that urban participants in this study had better psychosocial well-being than rural participants (as manifested on most measures) and a variety of facets of well-being (as shown over time in various studies in the same area) is contrary to the finding reported by Amato and Zuo (1992) that urban African Americans—the poor in particular—have lower levels of psychological well-being than in rural areas (note: they measured well-being with a single item dealing with happiness). The current findings are in line with those of Tsuno and Yamazaki (2007), who reported a higher sense of coherence for urban people in Japan, and with the finding of Higgs (2007) in South Africa, who found that people in rural areas experience a lower quality of life than those in urban areas. The latter study did not focus on psychological well-being per se and included infrastructural and other indices, too, which may be part of an explanation for the differences in well-being. Findings from Sample 1, in which participants were also stratified for various levels of urbanization, showed that with an increase in urbanization, participants manifested generally lower symptoms of distress and negative affect, and an increase in well-being, as determined with various measures. Urbanization in itself may not be the causal determinant of better urban well-being, but other variables that are associated with urban environments, such as better infrastructure and health facilities, more employment opportunities, better educational facilities, better nutrition, and other resources, in contrast to what is available in the compared rural areas (Higgs, 2007; Vorster et al., 2000). Rural communities often experience greater poverty and have fewer resources (Temane, 2001) than urban communities, and the lack of proper educational facilities may be a drawback for realization of many other aspirations.

Urban participants from the four samples showed higher well-being than rural participants in many facets of psychosocial health; for example, sense of coherence, satisfaction with life, emotional well-being, and general psychological well-being. Surprisingly, urban groups also scored higher on facets related to social well-being (i.e., experienced support from friends and family, community collective efficacy, and general social well-being), which would be expected to be higher in rural, more traditional areas, where collective values are supposed to be upheld to a greater extent than in urban areas, where acculturation towards more individualist values might take place. This finding is also contrary to that of Roussi et al. (2006) in Greece, where rural participants had a greater sense of community and use of social joining as a coping strategy. Urban African participants may experience higher well-being in this particular South African context, as cities are still developing (one of them in the North West Province is considered to be developing the fastest in Southern Africa) and the migration out of cities had not yet started, as in many developed countries. However, the reasons for the better psychosocial well-being of urban participants need to be explored further, as well as whether the pattern is the same for the various population groups.

Contrary to previous literature indicating more symptoms of pathology, especially depression in urban areas—for example, in Sweden (K. Sunquist et al., 2004), the Netherlands (Schoevers et al., 2007), Indonesia (Lu, 2010), and South Africa (Szabo, 2002)—the African samples in the current study manifested significantly more symptoms of pathology (i.e., symptoms of distress, negative affect, and depression) in rural areas. This may be associated with high poverty and lack of resources in rural areas, as well as other socioeconomic and sociodemographic factors that need to be explored further. Li, Nussbaum, and Richards (2007) established that poverty, hassles, and exposure to violence predicted pathology in urban African American youth. This may, however, be the case for both urban and rural areas in South Africa, and needs to be further understood.

The current findings underscore Keyes’ (2002, 2005) contention that well-being and pathology are two different, but correlated dimensions of mental health, and not only the endpoints of a continuum, as shown by the fact that urban participants had relatively high well-being, as measured with various indices, but simultaneously also relatively high levels of symptoms of distress. It is therefore important to include measures of both facets in an evaluation of mental health. Well-being and pathology may be differentially correlated with sociodemographic and other variables, such as gender and geographical context, pointing to different foci for interventions.

Beneficial and Detrimental Effects of Urbanization

Despite the clear association of better psychosocial health with urban living, some facets of well-being were significantly higher in rural areas; namely, spiritual well-­being (Sample 1), general self-efficacy (Sample 2), and psychological well-being, as measured on a subscale of Keyes’ Mental Health Continuum scale (MHC-PWB). This is, to some extent, in line with findings on a physical level that showed both beneficial and detrimental effects of urbanization (Dye, 2008). The established higher levels of spiritual well-being in rural areas is in line with findings from Temane and Wissing (2006) and may be associated with greater maintenance of traditional cultural, religious, and spiritual practices in rural areas, which are known to often suffer a breakdown with urbanization. The higher level of general self-­efficacy noted in rural areas may be explained by the fact that most participants make a living from farming activities in which they are relatively isolated and dependent on themselves. The significantly higher psychological well-being as measured with the MHC-PWB in the 2010 rural group is surprising, as this subscale measures more intrapsychological facets that are typically high in relatively more individualist contexts. The African groups included in this study are from a relatively collectivist cultural background (cf. Allik & McCrae, 2004; Wissing & Temane, 2008), and it could be expected that more collectivist values would be still more important in rural areas than in urban areas. However, possible explanations can be that attention paid to the rural areas by government since 2008 gave hope and a future directedness as well as a feeling of being affirmed. The latter linked with the positive vibe before the soccer World Cup in South Africa could perhaps contributed to a spike in the experience of well-being, especially in rural areas. However, these dynamics need to be explored in future research. The findings that urban and rural groups differ in facets of well-being that are stronger than in the other area indicate the importance of the use of various measures of psychosocial well-being, covering a broad range of facets of well-being. All facets of well-being are not similarly affected by urbanization or other sociodemographic variables.

Psychosocial Well-Being Over Time

From 1998 to 2008, psychosocial well-being decreased for both the urban and rural groups, especially in the case of rural areas, but increased again in 2010. However, both groups still manifested high levels of distress symptoms in 2010. This may be in line with Watson’s (2006) conclusion—after a qualitative study on stress and social change in Poland—that stress is a major factor affecting health in times of transition, especially when it is linked to a lack of security of employment, low income, changing social relations, and when a political context exists where the enrichment of some could be seen as taking place at the expense of society. The initial decrease in well-being from 1998 to 2008 for both urban and rural groups may be related to unfulfilled expectations after the democratic transitional process of South Africa in 1994 that created high expectations in the previously disadvantaged and deprived black population. As the government could not provide the services and infrastructures hoped for immediately, dissatisfaction arose, and together with an increase in crime rates in South Africa (that is typical after major political changes), corruption, and droughts in rural areas, the well-being of the target population suffered. Then the government developed a strategic plan from 2008 to 2013 (South Africa. National Department of Health, 2008, 2010) to enhance health services in rural and other areas, and consequently an upgrading of infrastructure became visible in rural areas. The ministry of rural development and land reform may have given more hope to people in rural areas in terms of agrarian transformation, land reform, and consequent development (Parliamentary Monitoring Group, 2009). This may partly explain the increase in well-being noticed in 2010. Another contributing factor may be positive feelings related to the build-up towards the soccer World Cup taking place in South Africa during July 2010. Data gathering took place in the first half of 2010 during the excitement of preparations for the soccer World Cup, which generated a lot of positive emotions and optimism, as reported in the media by Harris as part of her follow-up study of 2007 (Harris, 2007). These observations suggest change in well-being and symptoms, as found across different time points of cross-sectional data collection. Further studies with longitudinal designs are necessary.

Gender Differences

The position of women seemed to have changed between 1998 and 2010. Whereas rural women experienced more satisfaction with life than men in 1998, it was urban women who experienced more satisfaction with life in 2010. It may be because urban women experienced more autonomy than in rural, more traditional areas, and had more educational and employment opportunities in urban areas than before. As far as symptoms of distress and pathology are concerned, both rural and urban women experienced more symptoms of distress and pathology than men in 1998 and 2005, whereas it was only rural women who experienced more distress than men in 2010. This may indicate a shift on the mental health continuum towards higher well-being for urban women, but may of course also reflect a higher incidence of stress for urban men. However, in general, men manifested higher well-­being than women, especially in urban communities. For example, in 1998 urban men had higher positive affect, sense of coherence, and experienced more support from friends than did women, and in 2010 they reported higher levels of experienced self-efficacy in seeking social support than did women. It is noteworthy that in these studies men enjoyed greater well-being in social contexts than did women, whereas previous literature in relatively individualist groups in South Africa showed that women experienced more well-being in social contexts did than men (Roothman et al., 2003). These differences may be explained by the possibility that women function more optimally in close interpersonal and family relationships, and men experience more well-being and satisfaction in larger social groups, as shown by Wissing et al. (2004). This needs to be explored further.

Implications of Findings

The current findings on psychosocial well-being in rural versus urban areas add to a body of knowledge that may help to inform health policies and provide information for specifically targeted interventions with regard to various facets of well-being. Diener et al. (2008) argued that accounts of well-being may help governments to identify groups in the greatest need for interventions in a given society, and that accounts of well-being are highly useful for policymakers because it may add value beyond existing social and economic indicators. Several previous studies had indicated that psychological well-being and life satisfaction are associated with many positive outcomes on individual and societal levels (e.g., Keyes, 2005, 2007; Pressman & Cohen, 2005; Seligman, 2008), and may affect heath outcomes as well as buffer decline in diseases (Howell, Kern, & Lyubomirsky, 2007). The implications for public health promotion are that health promotion should also include enhancing psychosocial well-being—not only for the sake of the individual’s quality of life and longevity, but also for the sake of society’s health care costs (cf. Gudmundsdottir, 2010; Keyes, Myers, & Kendler, 2010). However, the foci for interventions need to be specifically targeted for rural versus urban participants, and from a preventative perspective facilitation of psychosocial well-being should start in childhood to shift life trajectories towards a healthier, more flourishing direction.

Interventions should promote and enhance sustainable environmental and social conditions (cf. McMichael & Butler, 2007), especially in rural areas, but should also build capabilities, competencies, and constructive coping strategies on individual levels, as described by Wandersman and Nation (1998), Raeburn, Akerman, Chuengsatiansup, Mejia and Oladepo (2007), and others. Valuable frameworks for interventions may be the functional capabilities perspectives of Sen (1999) and Nussbaum (1995, 2000), who stressed that development should not only be about resources and utility, but should focus on people. These functional capabilities and essential inputs therefore include physical, emotional, cognitive, interpersonal, contextual, and cultural components. Such a framework should, however, also take into account that in poor communities in the South African context, some very basic capabilities not included in the above frameworks are shown to be important for a good life in people’s own experiences, as found by Clark (2003); for example, income, job opportunities, physical security, adequate housing, hygienic living conditions, food, and clothing. Therefore, psychosocial interventions and public health promotion and protection, as advocated by Keyes, Dhingra, and Simoes (2010), should go hand in hand.

Limitations of the Study

Only some samples included in this study (2 and 4) were part of longitudinal designs and, therefore, only limited deductions can be made of well-being patterns over time. A further limitation is that all studies did not include the same psychosocial measures. However, the tendencies for differences between rural and urban groups were similar across studies. A further limitation is that the role of sociocultural and other demographic variables, such as socioeconomic status, marital status, and religion, were not included in the current analyses, and might have acted as confounding variables. A further limitation is the lack of qualitative data that could have assisted in explaining quantitative findings. A mixed method approach is advised for further studies.

Contribution and Further Research

These are the first findings on regional and systematically collected data for rural and urban areas in South Africa, with implementation of validated measures on a variety of facets of psychosocial well-being. Disparities shown between urban and rural areas in psychosocial well-being indicate important foci for psychosocial health promotion in the next few decades in South Africa. An important next step in research is to determine the dynamics of psychosocial health in rural and urban areas, which may differ. Possible contributing factors may be disparities between income, services, and access to health care facilities, and the impact of environmental factors such as droughts, social resources, educational facilities, skills development, recreational facilities, etc. A combination of these factors in rural areas may contribute to chronic stress and the experience of a lack of control, and thus lower levels of psychosocial health, which in some instances may also be linked to lower levels of physical health. The relation between poverty and lower well-being in rural areas needs to be explored further, as suggested in findings elsewhere (Rojas, 2009; Tiliouine, 2009; Tiwari, 2009) and indicated by Neff (2007) in a South African context. Although Helliwell and Putnam (2004), among others, have shown the importance of social context for well-being, the differences in social contexts that are associated with differential well-being of men and women in both urban and rural areas also needs to be explored further.

Conclusion

The findings of this study indicate that urban participants manifested higher levels of psychosocial well-being on most facets of wellness. However, urbanization may be accompanied by some detrimental effects apart from its beneficial effects, as can be noted on some facets of psychosocial well-being that decreased with urbanization, and still very high levels of symptoms of distress in urban groups. From 1998 to 2008, a decrease in psychosocial well-being for both the urban and rural groups—especially in the case of rural areas—were noted, but again increased in 2010. These differences were, however, only descriptively compared, and further exploration and analyses are indicated. Findings underscore the distinction between pathology and well-being as two distinct, but correlated dimensions of psychosocial health, and indicate the importance of implementing measures of various facets of well-­being in order to comprehensively evaluate well-being in various contexts. Gender differences were also manifested for some facets of well-being and pathology. Findings may inform public health policy and development of specifically targeted interventions.