Analysis: Rural chronic-illness patients face four broad barriers to treatment that go beyond doctor shortages

Rural residents are more likely to have a chronic illness and more likely to die from it than their suburban and urban peers, in large part because of lack of access to health care. The longstanding shortage of doctors and nurses is partly to blame, but so are widespread barriers to access. A new analysis of 62 studies, recently published in the Annals of Family Medicine, identifies four broad barriers to access rural patients with chronic illnesses face:

• Navigating the rural environment. This includes the financial and physical costs of living far from medical care. Some patients found it difficult to stay in the car for long distances, and some said the cost of gas was prohibitive. Some patients said caregivers weren't able to drive them so far, or that they felt too guilty about the time and cost to ask for a ride. But patients and caregivers in nearly half the studies surveyed said they were willing to drive further away for care because locally available services weren't good enough.
• Navigating the health-care system. Some patients and caregivers described delays in obtaining care because there weren't enough local clinicians. Many also said it was difficult to maintain continuity of care with certain doctors or organizations because of high turnover. And many said they were frustrated with clinics' inflexible scheduling and long wait times while in the clinic (on top of the long drive there and back) that made it difficult to fit a visit into the patients' schedules.
• Financing chronic disease management. Half of the studies analyzed cited patient complaints that health-care was too expensive, when factoring in rural price hikes, the already high cost of health care, hotel and transportation costs, childcare, and time spent away from work. Participants in nearly half of studies citied competing financial priorities such as bills, childcare and other household expenses, and some patients simply accepted that they couldn't afford treatment because of the cost. Many patients who said they couldn't afford treatment said they lived in communities marked by "widespread poverty, a lack of employment opportunities, and a general sense of being 'forgotten' by policy makers." Some subgroups, especially Native Americans relying on the Indian Health Service, said lack of health-insurance coverage made treatment too expensive.
  
• Rural life. Many participants cited tight-knit rural communities as a positive aspect, but that can be a "double-edged sword" for those with highly stigmatized chronic illnesses such as HIV or mental-health disorders. Participants in 13 studies said worries about gossip and lack of privacy kept them from accessing care. Participants in about one-third of studies said that rural values of self-sufficiency and stoicism made them reluctant to seek treatment. And some patients said they felt belittled or stereotyped for being rural. Indigenous patients described western clinicians as often "paternalistic, condescending, and openly skeptical of tribal healing practices" and "inadequately versed in tribal health-related beliefs, communication preferences, and social norms"

The researchers undertook the analysis because these barriers to access haven't been well represented in studies. That's partly because it's harder to recruit and retain rural student participants, and partly because studies about rural health-care access sometimes overgeneralize about rural living, ignoring the wide variance in rural settings and lifestyles.