The health status, health services utilization, and support networks of the rural elderly: a decade review.

Research from the 1980s on several dimensions of health and health care among the rural elderly is reviewed. Following a brief discussion of the demographic patterns and life conditions of the rural elderly, the current state of knowledge regarding health status, health services utilization, and the potential for informal and familial care of the elderly is examined. The review concentrates on studies that include comparisons between rural and urban populations and/or control for additional variables that are known to covary with residence. Such analyses permit the documentation of the effects of residential location on health indicators net of other factors. The review concludes that the rural elderly are relatively disadvantaged in terms of both health status and access to health care services, and have little if any advantage over the urban elderly in their access to informal sources of care. Following the review, an agenda for future research is identified.     

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.     

Technological access barriers,telehealth use and health care visits in the early pandemic period

ObjectiveThis study sought to characterize the role of technological barriers in limiting access to telehealth services.MethodsThe study used data obtained from the 2020 Nebraska Annual Social Indicators Survey (NASIS). A total of 2,213 out of 8,000 respondents returned a completed survey. Multivariate models were developed to estimate the relationship between demographic characteristics, technological barriers and overall telehealth utilization. An additional model was used to estimate the relationship between telehealth use and health care visits in the past year, controlling for the available demographic characteristics. Ordinal logistic regression was used.ResultsApproximately 27.9 percent of respondents had ever used telehealth services. Individuals who had used telehealth services were significantly more likely to have seen a health care provider for reproductive health or for a specific health need in the past year. Approximately 7.2 percent of survey respondents reported access to reliable internet as a barrier to telehealth use, 9 percent reported cost of internet services as a barrier and 7.1 percent reported access to electronic devices as a barrier. Respondents over 65 and those with lower education attainment were more likely to experience barriers to accessing technology. Holding technological access constant, telehealth use was significantly lower among males, individuals over 65 and rural residents.ConclusionsFactors other than cost and access to technology may be driving lower rates of telehealth use among these populations. The findings can help policymakers and health systems strategize approaches to increase access to telehealth among underserved populations.Public abstractLimitations in technology access may limit the usefulness of telehealth in connecting underserved patients to care. This study sought to understand the role of technological barriers in limiting access to telehealth services. Using data obtained from the 2020 Nebraska Annual Social Indicators Survey (NASIS), this study summarizes telehealth use among a random sample of individuals in rural and urban Nebraska. The study then assesses whether lower access to technology is associated with reduced use of telehealth services. Approximately 7.2 percent of survey respondents reported access to reliable internet as a barrier to telehealth use, 9 percent reported cost of internet services as a barrier and 7.1 percent reported access to electronic devices as a barrier. Holding technological access constant, telehealth use was lower among males, individuals over 65 and rural residents. Factors other than access to technology may be driving lower rates of telehealth use among these populations.     

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.     

Characterization of Rural Mental Health Service Systems

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.     

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.     

Cognitive appraisals of specialty mental health services and their relation to mental health service utilization in the rural population

Abstract Purpose: Rural individuals utilize specialty mental health services (eg, psychiatrists, psychologists, counselors, and social workers) at lower rates than their urban counterparts. This study explores whether cognitive appraisals (ie, individual perceptions of need for services, outcome expectancies, and value of a positive therapeutic outcome) of help‐seeking for depression symptoms are related to the utilization of specialty mental health services in a rural sample. Methods: Demographic and environmental characteristics, cultural barriers, cognitive appraisals, and depression symptoms were assessed in one model predicting specialty mental health service utilization (MHSU) in a rural sample. Three hypotheses were proposed: (1) a higher number of environmental barriers (eg, lack of insurance or transportation) would predict lower specialty mental health service utilization; (2) an increase in cultural barriers (stigma, stoicism, and lack of anonymity) would predict lower specialty mental health utilization; and (3) higher cognitive appraisals of mental health services would predict specialty mental health care utilization beyond the predictive capacities of psychiatric symptoms, demographic variables, environmental barriers, and cultural barriers. Findings: Current depression symptoms significantly predicted lifetime specialty mental health service utilization. Hypotheses 1 and 2 were not supported: more environmental barriers predicted higher levels of specialty MHSU while cultural barriers did not predict specialty mental health service utilization. Hypothesis 3 was supported: cognitive appraisals significantly predicted specialty mental health service utilization. Conclusions: It will be important to target perceptions and attitudes about mental health services to reduce disparities in specialty MHSU for the rural population.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Health, mental health, substance use, and service utilization among rural and urban incarcerated women.

Incarcerated women commonly report health, mental health, and substance use problems, yet there is limited research on service utilization before incarceration, particularly among women from urban and rural areas. This study includes a stratified random sample of 100 rural and urban incarcerated women to profile the health, mental health, substance use, and service utilization; examine the relationship between the number of self-reported problems and service utilization; and examine self-reported health and mental health problems in prison as associated with preincarceration health-related problems and community service utilization. Study findings suggest that health and mental health problems and substance use do not differ significantly among rural and urban women prisoners. However, there are differences in service utilization -- particularly behavioral health services including mental health and substance abuse services; urban women report more service utilization. In addition, rural women who reported using needed community services before prison also reported fewer health problems in prison. Implications for correctional and community treatment opportunities in rural and urban areas are discussed.     

医改前后重庆市城乡老年人住院服务利用状况分析

目的 比较医改前后重庆市城乡老年人的住院服务利用变化情况,评价医改政策在此方面的实施效果,为进一步完善相关卫生政策提供依据。 方法 利用第四次和第五次中国西部地区卫生服务调查资料,对重庆市2008年和2013年的城乡老年人住院服务利用数据进行分析。 结果 2008-2013年重庆市城市老年人的整体住院率从14.91%上升到19.18%,其中低收入人群的住院率从12.30%上升到20.29%,慢性病患者的住院率从17.96%上升到26.05%;城市老年人的应住院而未住院率从40.10%下降到17.35%。农村老年人的整体住院率从13.73%上升到18.02%,其中低收入人群的住院率从10.95%上升到18.59%,慢性病患者的住院率从18.40%上升到25.57%;农村老年人的应住院而未住院率从52.19%下降到27.00%。 结论 与2008年相比,2013年重庆市城乡老年人整体住院率上升,尤其是低收入人群和慢性病患者的住院率增加显著,应住院而未住院率大幅下降,但是城乡老年人在住院服务利用上仍然存在明显差距,说明医改政策对于提高重庆市城乡老年人整体住院服务利用的效果明显,但是仍有局限性。     

The Role of Federally Funded Health Centers in Serving the Rural Population

CONTEXT: Federally funded health centers attempt to improve rural health by reducing and eliminating access barriers to primary care services. PURPOSE: This study compares rural health center patients with people in the general rural population for indicators of access to preventive services and health outcomes. METHODS: Data from the annual reporting system for federally funded health centers, the 1999 Uniform Data System, and published national census data were used to provide sociodemographic comparisons. Selected health status indicators, preventive services utilization, and health outcomes were obtained from a survey of health center patients, and the results were compared with the National Health Interview Survey and National Vital Statistics. FINDINGS: Unlike the nation's rural population, the majority of rural health center patients are of minority race/ethnicity, live at or below poverty, and are either uninsured or on Medicaid. Despite having higher prevalence of traditional access barriers than the general rural population, rural health center patients are significantly more likely to receive certain preventive services and also to experience lower rates of low birthweight, particularly for African American infants. However, rural health center patients are not more likely to have received influenza vaccination or up-to-date mammogram screening. CONCLUSIONS: Health centers provide access to essential preventive care for many of the most vulnerable rural residents. A national strategy to expand the rural health center network will likely help to ensure improved health for the considerable proportion of rural residents who still lack access to appropriate services.     

Growing old before growing rich: inequality in health service utilization among the mid-aged and elderly in Gansu and Zhejiang Provinces, China

ABSTRACT: BACKGROUND: China's recent growth in income has been unequally distributed, resulting in an unusually rapid retreat from relative income equality, which has impacted negatively on health services access. There exists a significant gap between health care utilization in rural and urban areas and inequality in health care access due to differences in socioeconomic status is increasing. We investigate inequality in service utilization among the mid-aged and elderly, with a special attention of health insurance. METHODS: This paper measures the income-related inequality and horizontal inequity in inpatient and outpatient health care utilization among the mid-aged and elderly in two provinces of China. The data for this study come from the pilot survey of the China Health and Retirement Longitudinal Study in Gansu and Zhejiang. Concentration Index (CI) and its decomposition approach were deployed to reflect inequality degree and explore the source of these inequalities. RESULTS: There is a pro-rich inequality in the probability of receiving health service utilization in Gansu (CI outpatient = 0.067; CI inpatient = 0.011) and outpatient for Zhejiang (CI = 0.016), but a pro-poor inequality in inpatient utilization in Zhejiang (CI = -0.090). All the Horizontal Inequity Indices (HI) are positive. Income was the dominant factor in health care utilization for out-patient in Gansu (40.3 percent) and Zhejiang (55.5 percent). The non-need factors' contribution to inequity in Gansu and Zhejiang outpatient care had the same pattern across the two provinces, with the factors evenly split between pro-rich and pro-poor biases. The insurance schemes were strongly pro-rich, except New Cooperative Medical Scheme (NCMS) in Zhejiang. CONCLUSIONS: For the middle-aged and elderly, there is a strong pro-rich inequality of health care utilization in both provinces. Income was the most important factor in outpatient care in both provinces, but access to inpatient care was driven by a mix of income, need and non-need factors that significantly differed across and within the two provinces. These differences were the result of different levels of health care provision, different out-of-pocket expenses for health care and different access to and coverage of health insurance for rural and urban families. To address health care utilization inequality, China will need to reduce the unequal distribution of income and expand the coverage of its health insurance schemes.     

Rural-Urban Home Health Care Differences Before the Balanced Budget Act of 1997

This study arose from concerns that home health care may be more difficult to provide to rural than urban elderly patients (because of geographic barriers, personnel shortages, and other factors) and may therefore be less effective in terms of patient outcomes. Case mix, home health care service use, and outcomes (primarily discharge status) were analyzed for a national random sample of 3,869 rural and urban elderly home health patients. Longitudinal data covered the period from home health admission to discharge or 120 days (whichever occurred first). Primary data collection instruments were designed to obtain longitudinal patient-level health status data; agency records and Medicare data provided service use information. (The study did not address access but focused on services and outcomes after admission to home health care.) Two-group statistical tests and multivariate analyses were employed to assess rural-urban differences. The major findings were that, after adjustment for rural-urban case mix and agency differences, rural compared to urban patients received fewer home health services and attained less favorable discharge outcomes. For example, the rural patients had a higher case mix adjusted hospitalization rate. Because the study data pertain to 1995 through 1996, the results provide a baseline for future analyses of possibly different rural compared to urban effects of the Balanced Budget Act of 1997, which resulted in major changes in Medicare payment for home health care.     

Health services access and use among older adults in North Carolina: urban vs rural residents.

OBJECTIVES. This study compared health service use and satisfaction with health care among older adults living in urban vs rural counties in North Carolina. METHODS. A stratified random sample of 4162 residents of one urban and four rural counties of North Carolina was surveyed to determine urban/rural variation in inpatient and outpatient health service use, continuity of care and satisfaction with care, and barriers (transportation, cost) to care. RESULTS. Inpatient and outpatient service use did not vary by residence in controlled analyses. Continuity of care was more frequent in rural counties. Transportation was not perceived as a barrier to health care more frequently in rural than in urban counties, but cost was a greater barrier to care among rural elderly people. CONCLUSIONS. In this sample, older persons living in rural counties within reasonable driving distance of urban counties with major medical centers used health services as frequently and were as satisfied with their health care as persons in urban counties. Cost of care, however, was a significant and persistent barrier among rural elderly people, despite Medicare coverage.     

Access of rural AFDC Medicaid beneficiaries to mental health services

This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas.     

Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban‐rural inequality in health service utilization among the elderly. Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference‐in‐differences model was employed and estimated by the random‐effect probit method. Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.     

Access and Issues of Equity in Remote/Rural Areas

This article reports on a workshop in which the major focus was a review of the barriers that prevent access to the array of community-based services available to the rural elderly. The demographics of the elderly were outlined and key components of the service system described. Attention was given to access hospital-based care, the closing of hospitals and the reasons for bypassing rural hospitals for those in large towns or cities. Special emphasis also was given to mental health services and their uneven accessibility. A review of the policy implications closed the workshop.     

Ancillary Community Pharmacy Services Provided to Older People in A Largely Rural and Ethnically Diverse Region: A Survey of Consumers in West Texas

Little is known about the quality of pharmacy services provided to the rural elderly population. This exploratory study examines rural/urban and ethnic differences in perceived access to ancillary pharmacy services among elderly people. Two telephone surveys were conducted using directory listings in West Texas to generate a longitudinal sample. Persons aged 65 years and older who were not cognitively impaired were asked to complete the survey. The number of participants in both rounds of the survey was 3,689. Seven ancillary pharmacy services were examined: delivery of medications, medication counseling, written medication information, blood pressure monitoring, blood glucose monitoring, osteoporosis screening, and immunization. The sample was stratified by county of residence (urban, rural, or frontier) and racial/ethnic background. Chi-square tests were performed to detect rural/urban and racial/ethnic differences in access to the seven ancillary services. The association between proficiency in English and access to the services was also examined. Rural residents were more likely than urban residents to report that their pharmacies provide delivery of medications, medication counseling, and immunization services, but they were less likely than their urban counterparts to report that their pharmacies provide blood pressure monitoring. Access to ancillary pharmacy services was reported as poorer by older Hispanic people compared with non-Hispanics. Deficiency in English was significantly related to inequality in reported access to ancillary pharmacy services. It is essential to consider the special needs of rural and Hispanic elderly people to ensure equitable access to ancillary pharmacy services.     

Access and utilisation of social and health services as a social determinant of health: the case of undocumented Latin American immigrant women working in Lleida (Catalonia,Spain)

Although Spain has social and healthcare systems based on universal coverage, little is known about how undocumented immigrant women access and utilise them. This is particularly true in the case of Latin Americans who are overrepresented in the informal labour market, taking on traditionally female roles of caregivers and cleaners in private homes. This study describes access and utilisation of social and healthcare services by undocumented Latin American women working and living in rural and urban areas, and the barriers these women may face. An exploratory qualitative study was designed with 12 in‐depth interviews with Latin American women living and working in three different settings: an urban city, a rural city and rural villages in the Pyrenees. Interviews were recorded, transcribed and analysed, yielding four key themes: health is a tool for work which worsens due to precarious working conditions; lack of legal status traps Latin American women in precarious jobs; lack of access to and use of social services; and limited access to and use of healthcare services. While residing and working in different areas of the province impacted the utilisation of services, working conditions was the main barrier experienced by the participants. In conclusion, decent working conditions are the key to ensuring undocumented immigrant women's right to social and healthcare. To create a pathway to immigrant women's health promotion, the ‘trap of illegality’ should be challenged and the impact of being considered ‘illegal’ should be considered as a social determinant of health, even where the right to access services is legal.     

Developing Policies Responsive to Barriers to Health Care Among Rural Residents: WhatDo We Need to Know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies hove grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.