Rural/urban differences in accounts of patients' initial decisions to consult primary care

In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions. This study, involving focus groups and interviews, examined rural/urban differences in accounts of patients' intentions around initial decisions to consult general practice. Findings suggest 'relationships' between doctors and patients and easier access to appointments could affect consulting in rural areas, while decision-making for urban patients tended to be more consumerist. Perceptions about access to different health services meant rural patients' decision-making in out-of-hours emergencies was complex. Rural/urban differences in demand could be affected by change in UK primary care provision.     

Rural, Urban and Suburban Comparisons of Preventive Services in Family Practice Clinics

Numerous studies have compared health services provided in rural and urban areas, and overall they have found that utilization is lower in rural areas. A significant factor in lower utilization is that rural residents have less access to health services. Much less is known about rural and urban utilization differences once a patient has access to a service provider. This paper focuses on preventive services received when a patient is already in a clinic. Using data from an in-depth qualitative study of 16 family practice clinics in Nebraska, comparisons of physician-specific preventive service rates are made across three geographic categories: rural, urban and suburban. Results from a one-way multivariate analysis of variance show that preventive services rates for nine services examined were as high or higher in rural areas, suggesting that rural health services do not lag for patients with access.     

Improving health care service provision by adapting to regional diversity: An efficiency analysis for the case of Germany

The provision of health care in Germany exhibits sizeable geographic variation with a heterogeneous allocation of medical services in rural and urban areas. Furthermore, distinct utilisation patterns and access barriers due to the socio-economic environment might cause inefficiencies in the provision of health care services. Accordingly, an improved understanding of factors governing inefficiencies in health care provision is likely to benefit an efficient spatial allocation of health care infrastructure. We analyse how socio-economic factors influence the regional distribution of (in)efficiencies in the provision of health care services by means of a stochastic frontier analysis. Our results highlight that regional deprivation relates to inefficient provision of health care services. As a consequence, policies should also consider socio-economic conditions to improve the allocation of medical services and overall health.     

Access to Care for Rural Medicare Beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.     

The influence of a "culture of referral" on access to care in rural settings after myocardial infarction

Access to care is an issue for rural people who require tertiary care following a myocardial infarction (MI). Access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers. Using a critical ethnographic approach, rural women, their nurses and physicians were interviewed to explore how rurality affected women's referral and access to care following a MI. Findings reflect that a previously undocumented culture of referral that was shaped by human factors influenced access to care. The culture of referral reflected an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. The findings extend conceptual understandings of access to health care in relation to rural populations.     

Adequate Access to Posthospital Home Health Services: Differences Between Urban and Rural Areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.     

Characteristics associated with use of dental services by dentate and edentulous elders: the SB Brazil Project

This study focused on the characteristics associated with use of dental services during the previous year by Brazilian elderly (with and without teeth) participating in the Brazilian oral health survey (Ministry of Health, 2002/2003). 345 were dentate and 669 edentulous. Prevalence of use was 32% and 11%, respectively. Multivariate logistic regression showed that for dentate elders, use of dental services was more frequent among those who perceived their voices as influenced by oral health. Less frequent use was associated with: residence in rural areas; low income; current oral problems; fewer than two teeth in at least one sextant of the arch; need for dentures; and worse self-perceived appearance. Among edentulous elders, more frequent use was associated with: 5 to 8 years of schooling; pain; and poor self-perceived appearance. Use was less frequent among elders with current oral problems and those who perceived that their personal relations were influenced by oral health. The analysis reviewed the differences between dentate and edentulous individuals. Use of dental services was less common among individuals who needed them the most, suggesting inequality in access to such services among the Brazilian elderly.     

Patterns of health service utilization and perceptions of needs and services in rural Orissa

Despite emphasis on strengthening local health care provision, concern remains regarding the rates of utilization of state-provided services within Orissa. The reported study examined patterns of service utilization across the rural population of four districts of Orissa, with special reference to perceptions of the availability and quality of state services at the primary care level. Within the selected districts, 219 interviews were conducted across 66 villages. Households reported utilizing a wide range of health care providers, although hospitals constituted the most frequently--and primary health care centres (PHCs) the least frequently--accessed services. Private practitioners (qualified and unqualified) represented a major sector of provision. This included high rates of access by scheduled tribes and castes (running at approximately twice the rate of access to both local and PHC provision). Key factors guiding patterns of utilization were reputation of the provider, cost and physical accessibility. Local health provision through assistant nurse midwives and male health workers was generally perceived of poor quality, with the lowest rates of resolution of health problems of all service providers. The location of a sub-centre base for assistant nurse midwives within a village had no demonstrable impact on access to services. Acknowledging constraints on broader generalization, the implications of the findings for informing health policy and programming within Orissa are noted. This includes support for current efforts to strengthen the capacity of PHC and sub-centre level provision within the state, and acknowledgement of the potentially growing role of effectively regulated private provision in meeting the needs of the rural poor.     

Cancer in Rural Versus Urban Populations: A Review

Rural-urban comparisons have identified higher age-, race-, and sex-adjusted cancer incidence and mortality rates in urban populations for most anatomic sites, suggesting that rural populations are at lower risk from cancer. Conversely, findings that rural cancer patients are diagnosed at later stages of disease, that higher proportions of rural cancer cases are unstaged at diagnosis, and that rural cancer patients are at a more advanced stage of illness when referred to home health care agencies, suggest that rural cancer patients are disadvantaged when compared to their urban counterparts. This paper summarizes rural-urban patterns of cancer mortality, incidence, and survivorship since 1950; outlines rural-urban differences in utilization of health care services; questions the appropriateness of using rural-urban comparisons of cancer mortality and incidence to evaluate access to cancer care; and suggests potential approaches to the question of whether rural residents have access to cancer care comparable to that available to urban residents.     

Preventive services for rural and urban African American adults

BACKGROUND: Studies have shown that African Americans and rural patients receive fewer preventive services than other patients. OBJECTIVE: To compare the use of preventive services by African Americans in urban and rural settings to determine if race and rural residence were additive risks for not obtaining preventive services. METHODS: Three hundred African American patients seeking care in family practices in South Carolina were surveyed about preventive health care. RESULTS: Rural and urban African Americans were equally likely to know about preventive services and be up-to-date on receiving these services. In both practices, those with lower incomes were less likely to be up-to-date. Patients seen in the urban setting were more likely to receive counseling regarding exercise and smoking than those in the rural practice (87% vs 71%, P = .003). CONCLUSIONS: For both urban and rural African American patients with access to primary care physicians, preventive service use is high. The best predictor of poor compliance with preventive service recommendations was low income, suggesting that a lack of access to care is the primary reason why rural and African American populations do not receive adequate preventive health care.     

Rural health care: a British success or a tale of unmet need?

Discussion over health needs and health care in the U.K. has mainly centered on the urban area. The countryside has not been included in this debate because it is assumed that rural people are healthier than their urban counterparts and that health and social services are more effective. This paper questions these two premises and shows higher than expected levels of illness in the rural area and the health services to be largely dependent on general practice which, like all rural services, is becoming increasingly centralised and inaccessible. What is needed, it is argued, is the construction of a case for more localised care. Not that this should necessarily lead to a singularly rural type of health service, rather that patterns of provision should be adapted to local needs wherever they are situated.     

Financing rural health and medical services.

The provision and utilization of health care services in rural areas are tied directly to the structure of financing. The model of rural health care shaped by federal policies over three decades was significantly altered by changes during the 1980s. With reactions of third-party payers to health care costs rising faster than inflation, the difficulty of accommodating access to care and cost efficiency in provision became evident. This review begins with the literature on patient services and capital financing of rural hospitals, then continues with the financing of clinics, community centers, and other supply forms. Research during the 1980s provides insight into the effects of various financing policies on the supply of services. The demand for health care in rural areas is characterized by less generous third-party coverage, leaving residents paying a larger share of their incomes for care than do urban residents. As a consequence, access to care is especially difficult for low-income and elderly people, heavily dependent upon government financing. Third-party payers have severely reduced cost shifting as a mechanism for taking care of the health care needs of a sizable share of the population, thereby placing providers in an uncomfortable position. Several potential and more formalized financing options for replacing cost shifting are discussed. Several important changes will take place with rural-focused legislation enacted in the late 1980s. These are used to present a rural financing research agenda for the 1990s.     

Access to and use of health services by rural elderly, Brazil, 1998 and 2003

We analyzed access to health services and the utilization of such services by elderly rural residents in Brazil in 2003, comparing the patterns to those of the urban elderly and the equivalent rural pattern in 1998, using data from the National Household Sample Survey. Access barriers were greater in rural as compared to urban areas. Health services utilization was less than in the urban elderly, even for rural elders who reported health problems. There was no difference in hospitalization rates among rural and urban elderly. Analysis of the health services that were used showed that there was limited access to services with intermediate complexity. The results suggest that access barriers increase even further with advancing age. Gender differences in utilization, generally favoring women, are more marked in the rural elderly. Financial barriers are also more evident. The health services supply should be expanded and adapted to the territorial, cultural, and social characteristics of the rural elderly.     

Primary Care Practice Management in Rural and Urban Veterans Health Administration Settings

Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.     

Rural Psychiatry

The commonly occurring psychiatric disorders, anxiety and depression, have a combined community prevalence rate of 15–30% and are associated with significant clinical and economic cost. Although a number of effective pharmacological and psychological treatments are available for the management of these disorders, many people do not have access to, or do not receive, these treatments. An important factor associated with the lower rates of use of specialist services is rural, particularly remote, residence.This review discusses the problems of delivery of services to rural areas in countries with formal mental health services, and where the availability of psychiatrists and specialist mental health practitioners approximates that recommended by the World Health Organization. Relevant data were collected via a literature search using Medline and PsychLit and supplemented by material from key textbooks and by articles recommended by local experts in the field.A variety of special issues in rural areas, which make mental health service provision problematic, were identified. These relate to the characteristics of the rural location and community, demands upon and availability of mental health clinicians, and the changing role and focus of mental health services.These features, together with limited access to services by patients, necessitate models of service delivery different from those provided in urban areas. Important features include a shift from the ‘specialist as direct provider of care’ role to one of consultation, education, and indirect service provision and the use of a variety of outreach arrangements to enable patient access to essential specialist services.     

Equitable access to dental care for an at-risk group: a review of services for Australian refugees

OBJECTIVE: Despite the poor dental health of refugees, few specific services are available. This review maps public dental services for refugees across Australian jurisdictions, identifies gaps in provision, identifies barriers to accessing dental care, and provides recommendations for improving access and oral health promotion for this group. METHODS: Data were sought from the State and Territory services for: a) the survivors of torture; b) oral health care units; and c) auditors-general reports of dental services. Eligibility criteria and estimated waiting times for general dental services, criteria for access to emergency care and availability of interpreter services were reviewed. RESULTS: Marked variation exists across Australian jurisdictions in available dental services and criteria for access to public dental care for refugees. There is limited priority access to general dental services for refugees. Waiting times for public dental treatment in most, if not all, jurisdictions are unacceptably long (range 13-58 months). Few interpreter services exist for refugees seeking to access dental services. CONCLUSIONS: Access to dental services for refugees across Australia remains fragmented and limited, particularly in rural and regional areas. Refugees are not using services because of several barriers, including long waiting times, variation in assessment criteria, different eligibility criteria and limited interpreter services. Consequently, their pattern of service use does not accurately reflect their needs. IMPLICATIONS: Australia needs better co-ordinated, more extensive dental services that are easily accessible for this very high risk group. Identification of refugees as a special needs group and provision of targeted interventions addressing barriers to care are needed to establish adequate dental care.     

Cost of access to health services in Zambia

Equity is an important policy objective in the health care field. The importance of equity in health care provision can be argued from various points of view. As a result governments in all countries attempt to provide health care systems that enable equal access for everyone. Zambia is no exception. In the health care reforms the objective of the national health strategy is to provide Zambians with equity of access to health care. We focus on access defined as the costs (both monetary and time) an individual incurs when visiting a health care facility. Using a survey of 900 households, this article explores equality of access to health care among Zambians. Four areas are compared: urban high cost, urban low cost, townships and rural areas. The results of the analysis indicate that there are inequalities among residential areas, especially between rural and urban areas. In particular these differences exist because of differing distances to the nearest health facility. Large distances make it very costly for rural dwellers to seek medical care, especially during the high season for farming. The analysis suggests that obtaining equality of access to health care poses a challenge for the Zambian Government.     

The Role of Interorganizational Partnerships in Health Services Provision Among Rural,Suburban, and Urban Local Health Departments

Context: With limited resources and increased public health challenges facing the US, the Centers for Disease Control and Prevention and others have identified partnerships between local health departments (LHDs) and nongovernmental organizations (NGOs) as critical to the public health system. LHDs utilize financial, human, and informational resources and develop partnerships with local NGOs to provide public health services. Purpose: Our study had 2 primary goals: (1) compare resources and partnerships characterizing rural, suburban, and urban LHDs, and (2) determine whether partnerships play a mediating role between LHD resources and the services LHDs provide. Methods: We conducted secondary data analysis using the National Association of County and City Health Officials 2005 Profile Study. We used chi-squared and analysis of variance (ANOVA) to examine differences between rural, suburban, and urban LHDs. We used regression-based mediation methods to test whether partnerships mediated the relationship between resources and service provision. Findings: We found significant differences between LHDs. Urban LHDs serve larger jurisdictions, have larger budgets and more staff, cultivate more partnerships with local NGOs, and provide more health services than suburban or rural LHDs. We found that partnerships were a partial mediator between resources and service provision. In playing a mediating role, partnerships reduce differences in service provision between rural, suburban, and urban LHDs. Conclusions: Partnerships mediate the relationship between resources and service provision in LHDs. LHDs could place more emphasis on cultivating relationships with local NGOs in order to increase service provision. This strategy may be especially useful for rural LHDs facing limited resources and numerous health disparities.     

Consumer Perspectives on Medicaid Managed Care: A Comparison Between Rural and Urban Enrollees in One Selected Health Plan

This report presents the findings from a telephone survey of 313 respondents who have family members enrolled in Medicaid managed care in a multicounty region that encompasses both rural and urban counties in Wisconsin. Some demographic differences were noted between the rural and urban families that might affect their impressions of the health care system, their needs for services and their abilities to use those services appropriately. Families in the urban counties had poorer access to health care, as they were more likely to report at least one child not being assigned to a primary care provider. Inadequate preventive health behaviors were found among both rural and urban families, as evidenced by children being overdue for immunizations or health checkups. Yet respondents reported being happy with the care they received. Rural families in particular seemed to fare well in this managed care system.