Top Patient Engagement Challenges Affecting Rural Healthcare

February 29, 2024 - In a challenging industry landscape like medicine, the topic of rural healthcare stands out for its complexity. Those complexities can affect patient engagement efforts, in particular, and can stymie provider efforts to support care management.

What’s resulted is a rural-urban divide in healthcare outcomes.

Indeed, a July 2023 analysis from The Commonwealth Fund found that the United States is home to the worst geographic health disparities in the developed world. Disparities are particularly steep in the US for having multiple chronic conditions, having mental health conditions, and experiencing material hardship.

That data confirmed what has long rung true about rural healthcare: it can be harder to achieve better health and well-being in rural America than in other parts of the country. This is due to a complex web of limitations, ranging from the remoteness of healthcare providers to the financial pressures faced by rural healthcare providers.

In the case of patient care and experience, specifically, rurality is tied to poorer healthcare access, a higher occurrence of chronic illness and social determinants of health, and limitations in accessing the digital tools that have come to define patient engagement.

Long travel distances

One of the leading patient engagement barriers in rural healthcare is poor patient access to care, caused in part by the long travel distances most people in rural America face.

According to 2018 numbers from the Pew Research Center, rural patients live an average of 10.5 miles from the nearest hospital, compared to suburban patients who live an average of 5.6 miles away and urban patients who live 4.4 miles from the nearest hospital. That shakes out to a 17-minute drive for those in rural areas, compared to 12 minutes in suburban areas and 10 minutes in urban areas.

Moreover, these lengthy travel distances have gotten worse over time. A 2023 analysis from Texas A&M Health showed that the number of rural residents traveling 30 minutes or more for medical or dental care increased by around a third between 2001 and 2017.

This increase in travel distance doesn’t necessarily equate to a decrease in patient access to care or the quality of care, the Texas A&M Health researchers noted, but most experts agree that these longer travel distances can make it harder for patients to manage their care, especially when they have greater healthcare needs.

Long travel distances represent a perennial patient engagement challenge, keeping patients from accessing the providers who help guide engagement and self-management activities. Although solutions like transportation assistance, community-based care, and virtual care delivered via telehealth have emerged to fill in gaps, overcoming the logistical hurdles to actually delivering on care access can be complicated.

Provider & workforce shortage

Even when patients do manage to visit a healthcare center, it is not a given that there is enough staff to meet patient demand.

While the entire nation faces healthcare workforce shortages—in October 2023, workforce woes surpassed financial pressure as healthcare’s top threat—those problems are exacerbated in rural areas. Per December 2023 figures from the Bureau of Health Workforce under the Health Resources and Services Administration (HRSA), there were 8,544 total health professional shortage designations in the United States; of those, 5,598 were in rural areas.

Separate data from the National Rural Health Association (NRHA) outlined the unfavorable patient-to-PCP ratio in rural America, with only 39.8 primary care providers available to treat every 100,000 people. That’s compared to 53.3 PCPs per 100,000 people in urban settings, NRHA says on its website.

With so few providers, it is difficult to meet patient demand. In turn, patient care access—and, with that, care management and patient engagement efforts—falter.

And it’s not just a primary care provider shortage that affects rural patients. There’s also a shortage of specialty care providers, the Rural Health Information Hub contends. While there are some efforts to bolster primary care access by way of community health centers in rural regions, most specialty care is offered in centralized hubs like academic medical centers, making it less accessible.

This is the case across a number of specialties, but a look into maternity care provides a solid case study in rural specialty care access. Right now, the US is grappling with a maternal care crisis nationwide; in rural areas, which tend to see poorer maternal health outcomes than rural areas, this is stressed by a lack of obstetric providers.

A January 2024 Center for Healthcare Quality & Payment Reform (CHQPR) report showed that 55 percent of rural hospitals in the US do not offer labor and delivery services. While a physician shortage is at play, CHQPR indicated that financial pressures have also led more hospitals to shutter their obstetric wards. In the past ten years, more than 200 rural hospitals have closed their labor and delivery services, the report noted.

Social determinants of health

In addition to carrying an outsized chronic disease burden, patients living in rural areas experience several social determinants of health (SDOH). While rurality in itself is a key SDOH, NRHA says that other determinants like income, food insecurity, and transportation access are more pressing in rural areas.

The Economic Research Service put the average per capita income for all Americans at $64,143 in 2021, the Rural Health Information Hub reported. By comparison, the average per capita income in rural states was $49,895, meaning people in rural areas are more likely to be impacted by income as an SDOH. What’s more, rural areas have an average poverty rate of 15.4 percent, compared with a national average of 12.8 percent.

Statistics from 2016 showed that 16 percent of households in rural areas participated in SNAP, a leading program for addressing food insecurity. By comparison, only 13 percent of households in metro areas participated in the program.

Feeding America says hunger is a bigger problem in rural areas. While rural areas are less than two-thirds of all US counties, nine in ten counties with the highest food insecurity rates are rural. This is likely due to poor transportation access, lower wages and income, and institutional racism and discrimination, the group says on its website.

Considering the role both income and food security play in an individual’s ability to be healthy, the higher occurrence of some SDOH in rural areas hamper patient engagement efforts.

For example, low income can be tied to less healthcare utilization, poorer medication adherence, and other SDOH that affect wellbeing. Meanwhile, food insecurity can seriously exacerbate certain chronic conditions, particularly diet-related illnesses, and can even lead to the development of those illnesses.

Limited broadband & infrastructure

Often considered another in a long list of SDOH affecting patient well-being and engagement, broadband and infrastructure support are outsized issues in rural America. This is problematic, considering the surge of digital health tools many in the industry tout as being critical to patient engagement and care management.

According to 2019 Federal Communications Commission (FCC) figures (the most recent year for which the FCC had data), there was a 16-percentage-point difference in the number of rural Americans with access to 25/3 Mbps fixed broadband compared to their urban counterparts.

Although broadband providers are making progress in closing the rural-urban infrastructure gap (since 2016, the number of people living in rural areas without access to 25/3 Mbps service has declined by more than 46 percent), this is still a big limitation for healthcare providers looking to use health IT to engage patients.

For example, a May 2023 report in Cureus showed that, despite similar health IT ownership rates, rural patients were less likely to use their digital devices to communicate with their providers than their urban peers. The researchers suggested that this was likely due to inferior broadband and internet access.

This is a bad sign, considering the increased role digital health is playing in care management. Telehealth and remote communication have overhauled the patient-provider relationship, with both parties looking to communicate more outside of the traditional clinic space.

Lack of health IT infrastructure is even getting in the way of patient care access. A January 2024 report in Nature Mental Health outlined a link between limited mental health resources and poor broadband internet access. The researchers indicated that poor broadband hampered efforts to deliver mental healthcare via telehealth. This comes even as virtual care has found a sweet spot in the mental and behavioral health space.

Lower health literacy levels

Adequate health literacy—the ability for patients to find, understand, and use health information—is essential to patient engagement and healthcare self-management. Patients with high health literacy are better equipped to understand the health information their providers give them and understand and apply care management treatments.

Personal health literacy is woefully low in the US, with some estimates saying nearly a third of adults have low health literacy.

But in rural regions, those figures are likely lower.

An October 2020 NIH-backed literature review showed that people living in rural regions tended to have lower health literacy levels. After adjusting for sociodemographics, the team asserted that rurality in itself was not a determinant of health literacy. Factors like educational attainment, sex, and race/ethnicity had stronger links with health literacy.

Still, lower health literacy levels among those living in rural areas can impact overall patient engagement levels.

“Rural communities often experience unique needs based on their geographic location and remoteness,” experts from the Rural Health Information Hub wrote on its website. “Additional needs may include a lack of healthcare providers within certain regions or limited access to culturally and linguistically adapted materials that meet the needs of residents.”

Healthcare providers treating a mostly rural patient population should consider the key strategies for overcoming health literacy challenges: ensuring all written and verbal communication is at a low reading level, ensuring understanding through patient teach-back, and cultural competency and humility.