Co-Occurring Conditions: Obstacles to Care in Rural Areas

One of the major objectives of national health systems worldwide is to provide equitable access to health care to every person. WHO has also termed easy access to health care as a human right’s issue meaning every person has a right to access to affordable health care despite their gender, ethnicity, sexual orientation, or nationality [1]. However, despite this fact people living in rural areas generally experience greater obstacles to accessing health care than the general population. For example, statistics shows that 20% of the American population lives in a rural area and the challenges that these communities face in accessing health care led to disparities and poor health outcomes. According to experts, obstacles to healthcare result in unmet health care needs including lack of preventive and screening services and treatment of serious diseases such as diabetes, chronic kidney disease and even cancer [2]. While access to health care does not always guarantee good health, access is important for the wellbeing of each individual and optimal health of the community. Some of the obstacles to health care in rural areas include geographical barriers, affordability, shortage of health practitioners and lack of physical resources such as transportation and healthcare facilities themselves.

One of the major obstacles for access to healthcare in rural areas is the geographical location and the distance. Many rural areas are farming communities and hence the area has vast expanses of land while having very few people living within the area. With very few people living within a county area it becomes difficult for investors to justify building large hospitals in such areas. Only the government tends to support and build health centers, but these are also strapped for resources [1]. Therefore, for serious illnesses the residents find that they have to travel long distances to receive the necessary health care. Furthermore, it becomes even more difficult for the elderly and patients with disabilities both physical and behavioral, who are more likely to need consistent and regular constant care and care management for chronic health conditions to have access. Telehealth did help bridge that barrier, but, with the end of the pandemic and the return to previous policies and regulations for service provisions for many insurance providers a wall has be rebuilt in many instances. The cost of traveling becomes excessive in many cases; this may hinder patients from seeking the much-needed treatment most of the time. In addition, the general lack of effective infrastructure and public transport may be a hindrance to the rural population especially in cases whereby the patients lack reliable access to personal or public transportation [1].

The lack of transportation leaves the patients with a general lack of options in case he/she needs care from a specific specialist provider who may be available only in hospitals that are far away or in urban areas. Some of the problems arising from lack of transportation include missed appointments, delayed treatment, and delayed or missed use of required medications. The consequences of these problems are that it leads to poor management of terminal disease and hence adverse outcomes such as mortality. People suffering from chronic conditions are more vulnerable because they need clinical visits, access to medication to manage the disease and changes to treatment plans in case the present one is ineffective. Several scholars have studied the relationship between lack of transport and health outcomes.

Jazowski et al.’s, [3] for example surveyed over 500 veterans who were cancer patients and found that an average of 50% of the patients from different ethnic backgrounds had poor access to transportation that resulted to missing of cancer treatment. He found transportation an important barrier to seeking care for veterans who lived a rural lifestyle. Salloum et al.’s, [2] studied over 400 patients suffering from cancer and found that those who had no access to efficient transportation due to demographics were less likely to receive first line chemotherapy due to their distance.

Affordability plays a key part in determining accessibility of necessary health care for the patients in rural areas. Most households in rural areas have a weak availability of inputs and affordability due to the costs associated. In addition, the rate of unemployment is very high in the rural areas, thus the residents are less likely to afford health insurance coverage. Paying for the health services out the pocket becomes expensive without proper insurance cover [4]. Residents rely on government supported health services such as Medicare and Medicaid which are not sufficient to cover some health problems such as long-term health care for chronic diseases and prescription medication. For these reasons many rural residents struggle to maintain a healthy quality of life if no chartable primary or behavioral healthcare facility is available in the area. The consequences are that patients in these areas often do not seek care or they may end up doing so only when there is availability of funds thus affecting the continuity of any care. Individuals in the rural areas lack support of outreach coordination to overcome some of the social determinants of health such as the access to housing, nutrition support and health insurance applications [1].

A recent survey shows that 9.1 percent of people living in rural areas lack insurance coverage as compared to only 8% of the general population. The same report also indicated that 40 % of uninsured residents in rural areas have no source of health care. The uninsured population in rural areas reported receiving delayed health care in the past due to the high cost and affordability issues. Kaiser Family Foundation issued a brief pointing out to the fact that the community as a whole in rural areas faced huge challenges while accessing health care due to limited health care facilities that offered low cost or charitable healthcare services. In addition to lack of insurance rural areas health facilities also suffer from limited funding and other constraints related to resources [5]. In rural areas there is considerable poverty, limited facilities, and available resources for health care. In rural areas there is habit of reducing funding for the construction of infrastructure to support health care services. This is happening because of the same argument that there is no large population to warrant the building of huge facilities. The economic activity in the rural areas of the United States is based on agriculture, fishing and mining causing a considerable disadvantages and rural economic decline. At the same time, policy makers have contributed to reduced decline of infrastructure in rural communities because of the failure of enacting favorable laws that can support rural development. Thus, many of the rural communities bear the cost of neglect and lack of proper planning from the policy makers [5].

Another very significant obstacle to access to health care in the rural areas is the shortage of work force. The shortage of workforce can impact the access of health care in rural communities in a negative way. One characteristic of a sufficient health care system is having a regular source of care, which highly depends on having enough healthcare staff. Scholars have argued that the best way to determine proper access to health care is not necessarily dependent on the adequate availability of the care providers. Rather, they suggest that the best way is to determine the number of residents who cannot find an appropriate care provider or specialist. In rural areas there is a shortage of professional health care providers which limits the supply of required services [3]. The problem becomes serious when there’s a severe shortage of providers, nurses, and other specialized health services in rural areas. Rural areas require sufficient number of skilled health providers who can work effectively and comfortably in such a rural setting, many times leaning on those with dual certification in family practice and behavioral health to help bridges and prevent gaps in care. Likewise, sustainability of these specialists and their services highly depend on adequate health service infrastructure which is also a problem in the rural areas. Courtemanche, [4] notes that although there is a general shortage of health care workers who are highly skilled across the United States, the problem become magnified three-fold in the rural communities as the people here tend to lack access to specialized health education system that is available in urban areas. The phenomenon is not only present in the United States only but globally whereby projections indicate a shortage of 12 million health workers by the year 2020. Currently the figure stands at 7 million and the WHO has warned that if not addressed the shortage will have a serious implication on the health of billions of people across the globe [4]. The problem is even more serious since more than 35 % of global populations reside in rural areas whereby only 20 % of the nurses and doctors work in these remote areas [4].

The other very significant obstacles to health care in the rural areas are the privacy issues and social stigma related to seeking health care. This is one of the most significant points in individuals who need services in the behavioral health care arena. Many people tend to ignore that privacy is key in access to behavioral health care and the fear of community knowledge and the stigma that can be related. For example, people in rural areas live as a close-knit community and everybody knows their neighbors. Thus, privacy and social stigma concerns are likely to arise as a barrier to health care access [4]. The residents may have a problem especially when seeking services such as mental health, sexual transmitted diseases, pregnancy, substance abuse or even common chronic diseases. The patient may harbor fears or concerns due to the people who are friends, coworkers or family members who may find out that the individual is seeking health services for conditions that are a taboo to talk about in the community such as HIV testing and mental health disorders [4]. The health services provider may also come from the area and the patient may be fearful due to the relationship that they may have with the service provider. There is a lot of stigma related to mental health in the rural areas and a patient suffering from a mental health disorder may think twice before seeking help with any service provider.

In conclusion, this information has presented the major factors that lead to the obstacles of access to proper health care in the rural areas. The article has identified multiple layers of social determinants of health from geographical barriers, affordability, workforce shortages, privacy, and social stigma as the most common lack of transportation in rural areas. Commonly identified is the fact that access to general and specialized care is a significant problem in the rural areas. The lack of easy access has a direct implication to people’s health because it leads to delay in seeking health care leading to adverse health outcomes and mortality. In view of these adverse effects the authors want to emphasize the need for a change in health policies that should aim at addressing the problem of access to health care in the rural areas. With the May 11, 2023, end of The COVID 19 pandemic and telehealth requirements and provisions drastically changing what infrastructure that had been built over the past three years was crumbled.

The recommendation is for policy makers in this state and country to make more of an investment on infrastructure and streamline the ability to obtain insurance coverage to ensure that it caters to the needs of the patients. In the absence of affordable insurance coverage, the government should ensure that it enables greater access to health care services by building the capacity of health facilities and encouraging health workers to target service provision for the uninsured as they are indeed regardless of disorder or condition one of the most vulnerable groups of people. Additionally, legislators should aim to reduce the barriers to access of health care by ensuring affordability and equality of care to all citizens.

None.

No conflict of interest.

1. Andrade LH (2019) Barriers to Mental Health Treatment: Results from the WHO World Mental Health (WMH) Surveys. Psychol Med, pp. 1-9.
2. Salloum RG, Smith TJ, Jensen GA, Lafata JE (2012) Factors Associated with Adherence to Chemotherapy Guidelines in Patients with Non-Small Cell Lung Cancer. Lung Cancer, pp. 255–260.
3. Jazowski SA, Sico IP, Lindquist JH, Smith VA (2021) Transportation as a barrier to colorectal cancer care. BMC Health Services Research 21(1): 332.
4. Courtemanche C (2018) Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health After 3 Years. Inquiry 55: 46958018796361.
5. Nielsen M, D Agostino D, Gregory P (2017) Addressing Rural Health Challenges Head On. Mo Med, pp. 363–366.