How Rurality, Social Determinants of Health Affect Care Access

March 11, 2020 - Having an address in a rural area could mean a patient needs more than just better access to care. According to new research out of the Mayo Clinic, it could also mean that patient experiences the social determinants of health at a higher rate, all of which could impact cancer screening and preventive care rates.

The study, published in JAMA Network Open, specifically found that those living in the most deprived areas of rural states were also less likely to follow through on recommended breast, cervical, and colorectal cancer screenings.

It is widely accepted that access to care is a bigger burden for individuals living in rural regions. Conventional wisdom dictates that hospitals and clinics are few and far between in these areas, and rural areas are known to be staring down a serious provider shortage. Those issues combined make it harder for patients to access care.

But the issue might be broader than that, researchers reported in JAMA Network Open. Patients living in rural area might be disenfranchised, experiencing a slate of social determinants of health that affect their ability to obtain care, regardless of geographic provider and clinic density.

The Mayo Clinic researchers used preventive care access – specifically cancer screenings – to test that theory. Cancer has seen overall lower cancer mortality rates nationwide in recent years, but care disparities persist, nonetheless. The researchers posited that this might have something to do with geographic location and social determinants of health.

READ MORE: Travel Times Still a Challenge for Rural Health, Access Disparities

“Although cancer-related mortality has declined over the past few decades, substantial racial/ethnic, rural, educational attainment, and socioeconomic disparities remain,” the researchers wrote.

“The morbidity and mortality associated with these cancers can be reduced with timely guideline-recommended screening, diagnosis, and treatment. Therefore, lower rates of preventive screening for cancer may contribute to and exacerbate the disparities in cancer-related health outcomes in minority, rural, and low-income individuals.”

Looking at medical records from 75 primary care providers in Minnesota, Iowa, and Wisconsin – three states which have substantial rural populations — the researchers aimed to understand the rates of recommended cancer screenings. This included over 78,000 patients qualifying for breast cancer screenings, nearly 127,000 patients eligible for cervical cancer screenings, and 145,500 for colorectal cancer screenings.

The researchers also used the area deprivation index (ADI), a measure from the Census Bureau, to look at key social determinants of health in certain parts of the three rural states in the study. The team used the ADI to identify the 20 percent most deprived areas within each state, and then looked at the cancer screening rates in those areas.

In other words, the researchers looked at how rurality affected social risk factors, and whether the social determinants of health limited patients from receiving their recommended cancer screenings.

On the whole, this turned out to be the case, the team found. Patients living in the areas with the highest ADI scores – meaning they experience more social determinants of health – were about half as likely to receive recommended cancer screenings. Odds ratios ranged from 0.51 for breast cancer screenings, 0.58 for cervical cancer screenings, and 0.57 for colorectal screenings.

At the same time, the chances of completing a recommended cancer screening were lower in rural than in urban settings. For breast cancer, the odds ratio was 0.76, for cervical cancer it was 0.81, and for colorectal cancer it was 0.93.

These findings suggest that rurality and social risk factors are intrinsically linked. Patients living in rural areas overlapped with the patients living in the highest deprivation areas, the researchers indicated.

These findings have implications for healthcare professionals working to improve preventive care access.

“Overall, the results of the present study suggest that implementing area-based measures, such as the ADI, into practice and understanding differential cancer screening practices based on rural status may help inform and guide tailored interventions to meaningfully address disparities based on social determinants of health,” the researchers said.

Specifically, this research makes the case for better community-based health partnerships and support systems.

“In the case of cancer screening, community-based factors may intensify or supersede individual risk factors, including inadequate access to health care resources, poor community engagement with or distrust of the health care system, misperceptions about cancer screening, and other factors,” the team explained.

“Therefore, identifying disparities in cancer screening and other preventive health behaviors that stem from area-level deprivation and rurality signals the need for health care systems to form partnerships with local communities to enhance awareness, increase access, and improve overall health.”

In other words, providers need to look at a more complete picture of patient care access when screening for social determinants of health. Rurality is not a one-dimensional care access barrier; improving care access in those areas will require more than just getting more clinics and providers in those areas.

Instead, healthcare professionals need to look at the other social risk factors that beleaguer these patients at higher rates than their urban-dwelling peers.

“Area-level deprivation likely alters all aspects of health care use and health behaviors and, as a result, should be considered in addition to rurality when developing interventions aimed at improving cancer screening rates,” the study authors concluded.

“Further research is needed to examine how the ADI correlates with chronic disease management, receipt of other preventive services, and potentially preventable acute care use. Using the ADI has the potential to support and advance practice, public health, and policy by empowering health systems and community organizations to provide more patient-centered and equitable care.”