Community-level disadvantage and access to health care in the rural South

Communities in the rural South face serious barriers to accessing health care services, including high rates of uninsurance and high population percentages in physician shortage areas. Most research, primarily urban, has focused on individual determinants of access and not contextual factors, including community economic indices and workforce density, which strengthens the external validity of results and provides a more comprehensive picture of rural settings. We consider the impact of community disadvantage on whether rural residents obtained needed care, beyond individual-level characteristics. Methods: We used individual-level data from the Southern Rural Access Project, a study that sought to improve access to health care in 150 Southern rural counties (n=4879). The outcome variable was whether individuals obtained needed health care. The community-level variables, such as poverty rate and percent minority, were derived from data maintained by HRSA at the Primary Care Service Areas (PCSAs) level. To examine community-level influences, multilevel logistic regression was used to model the relationship between access and individual and community levels. Results: Over 12% of residents did not obtain needed care. Demonstrating the challenges of rural living, distance to care providers was positively related to missed care. Other community indices did not predict whether rural residents obtained health care once individual characteristics were controlled. Conclusions: Individual characteristics may be more important than community factors for determining which individuals access care. More research is needed to determine whether positive neighborhood characteristics, like social capital, play a role in access to care; variables not available in the datasets used here.