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Although approximately 60% of Alabama's population resides in rural areas, less than 20% of the state’s physicians practice in these areas. In fact, some 38% of Alabamians reside in federally designated “professional primary health care shortage” areas. This discrepancy is just one of many rural health care issues facing Alabama; however, collaborative research is providing much needed insights into Alabama’s rural health care issues that may someday provide all Alabamians better access to quality health care. This study was conducted at the request of the University of Alabama’s School of Medicine in Tuscaloosa, which offers programs for training health care professionals to practice in rural Alabama. Their initiatives, such as the Rural Health Scholars Program and the Medical Scholars Program for undergraduate pre-medical and medical students, respectively, recruit rural students for the health care field and facilitate their pursuit of medical degrees. A major focus of these UA educational programs is on understanding of the conditions, culture, and social patterns of rural areas and rural residents. Being aware of these differences, understanding problems rural residents face while accessing healthcare, and gaining sensitivity to the structural obstacles that prevent access to care is vital if novice, rural health care providers are to gain the trust and confidence of their patients and are to be happy practicing in rural areas. To identify some of these issues, AAES researchers tapped into local knowledge bases. One such base is the Alabama Cooperative Extension System (ACES). ACES agents often have an intimate knowledge of local health care issues and rural health risks. Some long-standing rural health issues include limited access to medical and health care services, low Medicare and Medicaid reimbursements, and a lack of incentives for health professionals to practice in rural areas. Other issues can complicate rural patterns of access to health care, such as lack of personal transportation; low education levels; no or limited facilities; no or inadequate insurance; a decreasing number of primary care providers; poor availability of care to women, children, and minorities; and a lack of care for transient populations, such as migrant and seasonal workers.
To learn more about the health care needs of citizens in individual
counties and across the state, a mail survey was sent to 279 ACES agents
in all 67 Alabama counties. Useable returns were received from 175 agents
(a response rate of 62.7%) and came from 60 of the 67 counties (see For analysis, responses were broken into three primary areas of the state. These include (see Table 2 for county listings): urban, the 21 counties that comprise Alabama’s Metropolitan Statistical Areas (MSA); rural north, 21 non-MSA (urban) counties located in the Appalachian Region (northern portion of Alabama); and rural south, 25 non-MSA (urban) counties located in the southern portion of Alabama. Agents in every rural county identified some conditions that presented a level of risk for rural people in obtaining health care. Their service areas were identified by county and county type [urban (MSA), rural north, and rural south; see Table 2]. Agents responded from 18 of the urban counties, 18 rural north counties, and 24 rural south counties. In the survey, the dependent variable (health risk) was defined as the perceived risk for 16 potential constraints to accessing health care ranging from spiritual and cultural beliefs to lack of knowledge and high cost. A five-point rating scale (1 = no risk; 5 = extreme risk) was applied to each constraint (Table 3). Individual constraint risk scores were summed to form a composite risk index with possible scores ranging from 16 to 80. The factor analysis produced three clusters relating to infrastructure, poverty, and cultural beliefs. Infrastructure relates to the basic facilities and services, poverty correlates with cost factors to the individual, and cultural beliefs are attitudes derived from a group’s way of life. A considerable proportion of ACES agents offered no opinion on cultural risk barriers, such as the use of faith healers (22.2%), stoic or fatalistic attitudes and fundamental religious beliefs (21% each), and use of alternative medicines (15.4%). Some also expressed no opinion concerning distrust of the medical profession (11.7%) and communication barriers between patient and provider (11.1%), as shown in Table 3. The average (mean) of each of the 16 health risks was calculated in descending order according to their perceived risk. The greatest risk constraints were seen as health insurance costs (4.13), the lack of health insurance (3.95), and cost of treatment or care (3.92). All are economic in nature, involving either insufficient household or community resources. An index was formed adding all responses to the 16 perceived risks and barriers to health care. The total score of all responses was divided by the number of agents who responded in that county resulting in an average score for each county (see Table 4). With a possible high score of 80 and 16 being the lowest possible score, the scores were then sorted by county classification. The overall highest score of 60 was for Sumter County, located in the Black Belt region of rural south Alabama. Furthermore, the greatest range of scores was greatest for the rural south– 26.5 to the high of 60 (Table 4). The average scores for urban and rural north counties were similar, 42.1 and 41.3, respectively. Both were lower than the rural south counties average score of 44.9 and a greater health care risk that characterizes that region of the state. As hypothesized, Extension agents serving rural south counties perceive health care risks to be greater than those risks perceived by agents in other parts of the state. The study then evaluated the degree of variation among the three sectors–urban, rural north, and rural south counties (Table 5). Comparison of each of the 16 risk barriers reveal only four barriers that differ significantly. Lack of transportation, lack of health care providers, poor quality health care facilities, and failure to recognize a serious health problem all produced a patterned progression from the lowest average risk score for urban counties, intermediate risk in the rural north, and highest risk in the rural south counties. Common problems among all these areas also were identified. Infrastructure problems, such as a lack of facilities and providers and poor quality of facilities, were highest throughout the survey results. Cost or poverty factored second. The third factor grouped cultural beliefs, such as distrust of the medical profession, use of folk or alternative medicine, fundamental religious beliefs, and use of faith healers. Only one variable, communication barrier between patient and provider, showed some connection in two of the groupings. This problem could logically fit in either category. For a clearer portrayal of rural/urban variance as well as rural north and rural south distinctions, the responses were separated further and tested for significant (mean) differences. Rural counties are perceived to have greater risk in the lack of health insurance, lack of transportation, and poor quality health care facilities. Rural south counties have a higher perceived risk than rural North counties in the areas of cost of treatment or care, lack of healthcare facilities, poor quality of healthcare facilities, and lack of transportation. The rural North counties show higher risk in the use of folk and alternative medicine. The results also showed that variables relating to cost coincide with high poverty counties, except in counties where recent health care improvement efforts have been made. Both Wilcox and Dallas counties have been the focus of many recent health care studies and extensive healthcare investments have been made in both counties. These developments may contribute to lower overall scale numbers in these traditionally poor counties. Even with the low overall numbers, Wilcox County continues to be ranked high for the lack of transportation variable, so improvement is still needed. The data already collected and analyzed serve as a guide to areas where more investigation is needed, show where some improvements have been realized, and give preliminary information on what obstacles are present for doctors in rural areas. This data analysis will continue with the addition of new data from a survey of Alabama nurse practitioners conducted in 1999. Zaworski
is former Graduate Research Assistant of Agricultural Economics and Rural
Sociology, now Resource Coordinator with the Alabama Coalition Against
Domestic Violence and Adjunct |
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