Healthcare Access Barriers in Low-Income Rural Southern Communities of Color

Study Objectives and Research Parameters

• The primary objective of this study, authored by Christine Crudo Blackburn, PhD (Texas A&M University), is to examine perceived and experienced barriers to healthcare access specifically for low-income, rural communities of color within the Southern United States.

• The study adopts a qualitative design, utilizing focus groups to investigate these barriers across four distinct communities.

• Transcripts were analyzed using thematic analysis and description-focused coding via MAXQDA $2022\copyright$ software.

• The research was supported by the USA Center for Rural Public Health Preparedness and the Scowcroft Institute for International Affairs at the Bush School of Government and Public Service.

• The institutional approval was granted by the Texas A&M University Institutional Review Board (IRB ID: IRB2018-0886).

Profile of Rural Health in the United States

• Approximately $15\%$ of Americans live in rural areas, which are defined by the U.S. Office of Management and Budget as "micro areas" (population cores of $10,000$ to $49,999$) and counties outside of metropolitan or micro areas.

• Economic Status: The majority of individuals in these areas live near or below the poverty line. Rural residents typically possess lower per capita incomes and higher poverty rates than urban residents.

• Demographics: Rural populations are generally older, more likely to be uninsured, and have lower overall education levels.

• Health Disparities: There is a widening gap in health outcomes between rural and urban communities. Rural residents experience higher rates of chronic conditions, including:

  • Heart disease

  • Diabetes

  • Chronic Obstructive Pulmonary Disease (COPD)

• Behavioral Risks: Rural areas see higher rates of smoking and obesity compared to urban counterparts.

• The "Rural Mortality Penalty":

  • Rural residents have higher mortality rates across the $10$ leading causes of death.

  • By $2004$, rural counties experienced more than $35,000$ additional deaths annually compared to urban areas.

  • The difference in excess deaths grew from $6.2$ per $100,000$ population in the $1980\text{s}$ to $71.7$ per $100,000$ by $2004$.

  • Notably, $88\%$ of high mortality counties are located in the South, particularly in the Mississippi Delta and Appalachia.

Infrastructure Deficits: Healthcare and Ambulance Deserts

• Resource Scarcity: Rural areas have fewer hospital beds, physicians, and nurses per capita. Approximately $60\%$ of the nation’s primary care shortages occur in rural communities.

• Hospital Closures: Between $2005$ and $2020$, a total of $171$ rural hospitals closed in the U.S.

• Impact of Closures: Rural hospital closures increase mean emergency medical service (EMS) transport times by up to $76\%$.

• Specialty Care Access:

  • $4.4\text{ million}$ rural residents live in a county without a hospital.

  • $61\%$ of rural counties lack an OB-GYN.

  • $58\%$ of rural counties lack a pediatrician, forcing children to rely on emergency departments for standard care.

• Ambulance Deserts:

  • $4.5\text{ million}$ people in the U.S. live in an ambulance desert, with $52\%$ of them residing in rural counties.

  • In the states studied, the percentage of counties with ambulance deserts is as follows:

    • Louisiana: $98.4\%$

    • Mississippi: $97.6\%$

    • Alabama: $95.5\%$

    • South Carolina: $95.7\%$

Social Determinants and Structural Racism

• Predictive Mortality: Medical care is estimated to be responsible for only $10-15\%$ of preventable mortality in the U.S.; the remainder is tied to social conditions like education and social support.

• Maternal Education: Infant mortality rates are $7.7$ per $100,000$ live births for mothers with less than a high school education, compared to $3.7$ per $100,000$ for college graduates.

• Unmet Social Needs: Factors such as food insecurity, financial insecurity, chronic stress, neighborhood safety, and residential instability predict lower access to and quality of care.

• Structural Racism: Historical policies and institutional biases (including legacy Jim Crow laws that segregated hospitals) continue to impact resource allocation and lead to substandard care for people of color.

• Insurance Disparities: Uninsured rates among Black and Hispanic individuals remain significantly higher than among white individuals across all income levels.

Study Methodology and Participants

• Focus Group Settings (Total Participants: $N=37$):

  • Alabama: Black Belt region; Population $1,832$; Poverty rate $24.7\%$.

  • Louisiana: Delta region; Population $3,759$; Poverty rate $56.1\%$

  • Mississippi: Delta region; Population $1,437$; Poverty rate $44.3\%$

  • South Carolina: Low country; Population $2,682$; Poverty rate $37.7\%$

• Recruitment and Sampling:

  • Methodology: Purposive sampling and network sampling (snowball sampling).

  • Community Partners: Initial contacts were made with religious leaders, hospital administrators, or university extension office staff.

• Conceptual Framework: The study employed "Naturalistic Inquiry," a framework by Lincoln and Guba ($1985$) designed to examine behaviors in context without preconceived expectations.

• Data Analysis: Audio recordings were transcribed verbatim. Three rounds of semantic coding were conducted to develop the codebook and identify themes present across all four communities.

Theme 1: Physical Distance and the Acceptability of Care

• Findings: Most participants identified long travel distances as a primary barrier to both routine and emergency care.

• Perception vs. Reality: Interestingly, $3$ of the $4$ communities had critical access hospitals or clinics within the town limits. Despite this, participants still perceived a need to travel.

• Lack of Acceptability: The distance barrier often stems from a lack of "acceptability" regarding local services rather than a literal lack of "availability." This perceived lack of quality leads residents to seek care elsewhere.

• Verbatim Testimonies:

  • A Louisiana participant: "I travel… to Jackson [Mississippi]. That's a whole day trip."

  • An Alabama participant on emergency care: "If the airplane in Greenville is gone and the one in Thomasville is gone, no ambulance service here, what [are] you going to do?"

  • Concerns for the Elderly: One Mississippi participant noted that the elderly often cannot drive and do not know the location of distant hospitals.

  • Compounding Effects: Distances create additional financial burdens, such as paying for gas, feeding children during travel, and paying someone for transportation.

Theme 2: Psychological Barriers and Fear of Illness

• Findings: A pervasive culture of health care avoidance exists, based on the fear of finding out one is sick.

• Cultural Context: Avoidance was described as a "tradition" or "custom."

• Emotional and Financial Intersection: Fear is not just about the diagnosis but the subsequent emotional and financial burden of treatment. Participants avoided the "fixation" of a diagnosis because they knew they could not afford the remedy.

• Verbatim Testimonies:

  • Alabama participant: "It's like we don't want to go to the doctor because we don't want to find out."

  • Louisiana participant on the difficulty of persuasion: "You tell these people [to go to the doctor], but if they got a fixation in their minds, there is nothing you can do."

  • Financial Stress: "They [are] working trying to pay a bill… they just don't take the time to get it examined… because they are scared."

Theme 3: Financial Detriments Post-Insurance

• Findings: Even with health insurance, the out-of-pocket costs for procedures and medications (copays and deductibles) act as a severe deterrent.

• Medication Adherence: High prescription costs lead individuals to skip treatments or avoid the doctor entirely, reasoning that if they cannot afford the medicine, the visit is useless.

• Verbatim Testimonies:

  • Cost of Procedures: "If I have to go and have procedures done, I have to come out of my pocket with $5$, $6$, $700$ dollars, which will make someone go, 'nah, I'll put it off.'"

  • Medication Costs: A South Carolina participant noted, "Your copay could be like $\$10$, but your medicine could be like $\$100$."

  • Alabama participant conclusion: "Healthcare is just another bill."

Discussion and Academic Implications

• The study confirms existing research on distance and costs but adds nuance regarding "acceptability." A local facility does not equate to access if the community does not trust or accept its services.

• Emergency Implications: Lack of trust in local emergency departments leads residents to travel upwards of $2$ hours in life-threatening situations (e.g., strokes or heart attacks).

• Safety Net Hospitals: Previous research (Hanchate et al.) shows that patients of color are more likely to be transported to "safety net hospitals" rather than the nearest facility, which aligns with the study's findings on perceived access.

• Expansion of Financial Barrier Theory: The deterring effect of prescription costs suggests that financial access must be redefined to include the entire treatment cycle (diagnosis, consultation, and pharmacological treatment).

• Intersectionality: Though the study did not explicitly use intersectionality theory in its design, the results highlight the compounded effects of being in subordinate categories of race, class, and geographic location.

Conclusion and Limitations

• Limitations: The findings are qualitative and cannot be generalized to all rural communities. The study focused specifically on communities of color and did not investigate the perceptions of white residents in those same areas.

• Policy Recommendations: Policymakers must reassess the assumption that the presence of a medical facility and insurance coverage equates to actual healthcare access. Future interventions should address the psychological barriers (fear) and ensure that rural health services are culturally and economically acceptable to the populations they serve.