Distance and health care utilization among the rural elderly

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Abstract

This paper explores the relationship between distance and the utilization of health care by a group of elderly residents in rural Vermont. By drawing on recent work on the geography of health we frame the decision to visit a primary care physician in the context of the experience of place. The paper devises a test of this broader reading of the role of distance for utilization, and operationalizes this test using a custom designed survey. Using a randomized mail survey of elderly residents of Vermont’s North East Kingdom we explore how grocery shopping, travel to work, home location relative to local services, access to private transportation, and living arrangements are associated with the number of doctor visits made to primary health care providers. Although the results confirm the idea that increased distance from provider does reduce utilization, they strongly suggest that distance to provider is a surrogate for location in a richer web of relations between residents and their local communities. We conclude by calling for further research that establishes links between place and the use of health facilities.

Introduction

Increased distance between residents and health care providers is commonly thought to decrease the utilization of health care (see, for example, Bosanac and Parkinson et al., 1976, Joseph and Bantock, 1982, Bentham and Haynes, 1985, Bronstein and Morrissey, 1990). This barrier effect of distance is assumed to be greater for those with reduced access to transportation (for example, the elderly), and for those living in sparsely populated areas where distances between residences and facilities are large (for example, rural residents). Indeed, Fiedler (1981) confirmed that, along with fees for services and the availability of a regular physician, distance to provider is the major correlate of utilization for rural residents. However, not all analyses of the use of health care facilities report negative distance decay relationships. In a study of travel for primary care in western Maine, Shannon et al. (1979) found that relying on distance as the only spatial determinant of utilization resulted in inaccurate designations of access and underserved areas. This suggests that distance may play a complex role in mediating behavior.

Recent theoretical developments in the geography of health set the stage to discuss a more nuanced relationship between distance and health care utilization (Park and Wood, 1992, Kearns and Joseph, 1993, Philo, 1995). Gesler (1992) argues that “fields of care”, rooted in place, can be perceived as therapeutic and comforting. Such fields of care help structure the ongoing relationships between the individual and place. Is it possible, then, that fields of care shape attitudes toward, and use of, health care resources?

The implication that human behavior is recursively bound up with how individuals use places and derive meaning from these interactions resonates with the arguments of those inclined to view concepts like location, distance, and health as socially constructed (for example Jackson, 1989, Jones and Moon, 1993). Distance, then, may take on different meanings for different individuals. Models which summarize the population-level association between distance and utilization with one (mostly negative) parameter may mask important differences between individuals and across groups. How, for example, will an elderly population ‘construct’ the barrier effect of distance in relationship to their experiences of rural life?

To date, few studies empirically validate the recursive, constructivist view of the distance-utilization nexus. This paper extends the theoretical conversation about the role of distance in health care utilization in two ways. First, we draw on prior research to devise an empirical test of the supposition that distance can be read as a surrogate for what we term experience of place. In this part of the research we aim to see if arguments made (and currently supported) at the individual, ethnographic scale can be generalized to small populations.

Second, we apply this position to the analysis of healthcare utilization of elderly residents in a rural region of Vermont. Our research thus contributes a timely analysis to an increasingly important public policy challenge: the situation of the rural elderly. Recent demographic trends in the United States make the general question of elder health care in rural areas a compelling one. Increased demographic demand coupled with impoverishment is making elder health care delivery fragile in many rural areas (Wennberg et al., 1996). Increased distance between parents and their children implies greater separation between the elderly and potential in-family sources of care (Joseph and Hallman, 1998). Such demographic trends also increasingly coincide with the selective impoverishment of some rural areas. McLaughlin and Jensen (1993) report higher rates of poverty among older Americans who live in non-metropolitan areas than among older Americans who live in metropolitan areas, while Lichter and McLaughlin (1995) noticed increases in rural poverty outside the rural south and in non-black counties.

Section snippets

Theoretical context

Location theorists bequeathed medical geographers a rich set of analytic concepts for understanding variations in individual behavior over space. Demographers of the past century provided empirical support for the notion that, as distance increased, human interaction decreased. The logic of regular hierarchies of settlements that lies at the heart of central place theory also turns on the notion that demand for goods and services decreases with increasing distance (i.e. the concept of range,

Study site

The analysis focuses on the rural elderly in Orleans County, Vermont (see Fig. 1 for its relative location on the US–Canadian border). Selecting Orleans County, Vermont enables us to speak to the more general debate on rural health care issues among the elderly in several ways. First, Vermont has the highest percentage of residents living in rural areas of any state, 67.8% (US Census, 1993). Within Vermont, 81.6% of the residents of Orleans County live in rural areas. The proportion of

Elderly health care utilization in Orleans County

Our study sample exhibited rates of utilization in line with those reported elsewhere (Table 1; see also Cromley and Shannon, 1986). Relatively few persons never saw their physicians, with most making between one and four visits over the preceding 12 months.

These visits were made to a total of 22 different providers located in three states and two countries (Table 2). Under one third of the providers were located in Orleans County. Although the choice set of providers is widely dispersed, 69%

Discussion

Our analysis confirms the broad slate of factors associated with health care utilization among the sample of rural residents in Vermont (Thouez et al., 1988). Descriptive statistics and multivariate analysis point to health status and the designation of having a regular physician as markers strongly associated with utilization behavior.

However, the most important contribution of this study is the statistically significant association between utilization and physician location relative to

Acknowledgements

We thank the Rockefeller Center for Social Sciences at Dartmouth College for providing financial support for the research. Laura Conkey, David Goodman, Francis Magilligan, Jim Sargent and Richard Wright provided comments on an earlier draft of this research. We are very grateful for feedback from the editor and three anonymous reviewers. The authors remain responsible for the findings.

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