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Amplifier on Instagram: "Everyone, regardless of wealth should have access to healthcare. Right now, as we are in the midst of a global health crisis, please take the time to advocate for healthcare for all by contacting your representatives, researching which candidates for local and federal government are working toward providing healthcare for all Americans. 🎨 by @msheastudio"

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URL: https://www.instagram.com/p/B-SCo1alnkn/?utm_source=ig_web_copy_link
TITLE:  "Everyone, regardless of wealth should have access to healthcare. Right now, as we are in the midst of a global health crisis, please take the time to advocate for healthcare for all by contacting your representatives, researching which candidates for local and federal government are working toward providing healthcare for all Americans. 🎨 by @msheastudio"
AUTHOR: Amplifier on Instagram
DATE PUBLISHED: March 28, 2020
KEY INFO: It emphasizes the fundamental principle that healthcare should be accessible to all individuals, irrespective of their financial means, underscoring the importance of healthcare equity. It recognizes the current global health crisis, highlighting the urgent need to address healthcare issues in the midst of this crisis, making it clear that healthcare access is a pressing concern. It calls for proactive civic engagement that urges individuals to advocate for healthcare for all by reaching out to their elected representatives. In essence, this caption not only underscores the significance of universal healthcare access but also encourages active involvement in the political process as a means to overcome healthcare barriers.

-Maguad, Angela

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Amplifier on Instagram: "Everyone, regardless of wealth should have access to healthcare. Right now, as we are in the midst of a global health crisis, please take the time to advocate for healthcare for all by contacting your representatives, researching which candidates for local and federal government are working toward providing healthcare for all Americans. 🎨 by @msheastudio"

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3,766 likes, 24 comments - amplifierart on March 28, 2020: "Everyone, regardless of wealth should have access to healthcare. Right now, as we are in the mids..."

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Health services still beyond reach of remote communities

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URL:https://newsinfo.inquirer.net/1144382/health-services-still-beyond-reach-of-remote-communities-tribal-villages

TITLE: “Health services still beyond reach of remote communities”

AUTHOR: Delfin T. Mallari Jr., Joey Gabieta, Nestor Burgos Jr.

DATE PUBLISHED: July 22,2019
KEY INFO: A lot of rural areas face significant challenges when it comes to accessing medical services, often due to the absence of proper medical institutions. This forces people to travel farther than they should, exhausting them of their resources and financial state. Furthermore, since most people who reside in rural areas do not have enough money to spend for the expenses, they rely on traditional doctors and sometime even 'quack doctors' or shamans for aid, which are less effective than actual medicine, or may even be scams. Although, there are some readily available medical treatments in rural areas, they still lack the essential medicine in case of a full blown operation or treatment. This highlights the need of financial support and investment for healthcare in rural areas to ensure a steady supply of medicine and to maintain enough properly trained personnel for administering aid.

-Divino, Marko

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TACLOBAN CITY, Leyte, Philippines - Almost two years ago, Dr. Maria Socorro Kristina Medina left Metro Manila to serve in the island-town of Almagro in Samar province - one of the poorest areas in Eastern Visayas region.

While she finds fulfillment in her job, the 26-year-old Medina, a resident of Quezon City, feels a pinch in her heart whenever a child dies of a disease that could have been treated if only medical services are accessible to rural areas.

"We have deaths related to lack of access to medical services, especially children who are suffering ordinary ailments like pneumonia or gastroenteritis - diseases which can really lead to death but are still treatable," she said.

"In an ideal setup, dapat walang namamatay sa ganun (no one should die of such diseases)," Medina added.

Although she didn't give any figures, she said the impact of the Universal Health Care law signed by President Rodrigo Duterte on Feb. 20 had not been felt in remote towns like Almagro.

Almagro, four hours away by sea travel to Calbayog City on mainland Samar, is a fifth-class municipality with an annual income of not less than P15 million and with a population of 10,600.

It is composed of 23 barangays but only five villages have direct access to services rendered by its rural health unit. The remaining 17 villages are far from the town center or classified as island-barangays, and residents here do not get services from the government due to their location.
Medicine supply
Medina, who has been in Almagro for a year and eight months now under the Doctor to the Barrios program of the Department of Health (DOH), said medicines in rural health centers readily run out.

"We have medicine supply in our rural health center but it is not enough. Sometimes, we can outsource from the DOH and the provincial government but they don't have commitments that they will replenish our supplies every quarter," Medina said.

Sometimes, she would use her own money to buy medicines needed by the rural health unit.

The Almagro municipal government allocates only P500,000 a year for medical supplies and related items, an amount that she considers low since they are servicing 10,000 people. Medina said a majority of residents could barely buy food, much less medicines.

Parents living in remote island-barangays could not send their children for checkups at their health center due to lack of money and difficulty in transportation.

"We don't have a circumferential road here in Almagro and there are barangays that are also located on the islands. Traveling to our rural health center means additional expense for them," Medina said.

In extreme cases, she said, patients have to be taken to Calbayog City for treatment - an expense of at least P2,000 for boat rental.

"We have a motorboat procured by the local government but is managed by the rural health unit. But it's not available 24/7 due to a number of reasons," she said.

The town's rural health unit is being served by Medina, six nurses and a birth attendant.
Serving rural areas
Almagro's experience is shared by Panay Island, where many rural villages still lack adequate health services and resources.

"We can only provide basic and primary health services. Only a few can provide minor surgery service," said a municipal health officer on Panay Island, who asked not to be named in this report due to the source's employment in the government.

One of the main problems of rural health workers on the island, according to the source, is the low salary received by municipal health employees.

Many government doctors receive between P30,000 and P40,000 a month or about the same amount that the lowest ranking member of the Philippine National Police gets. Nurses in rural health units have an entry-level salary of P15,000 month, according to the municipal health officer.

"This affects the morale of our personnel amid our heavy load," the source said.

With their budget dependent on the priorities of the local government, many municipal health offices suffer from shortage of personnel, including midwives whose services are mostly needed in remote villages.

"A midwife is assigned [to cover] eight to 12 barangays each and the frequency of their visits to each village is weekly at most and up to every other month in some areas," the health officer said.

A village official in Igbaras town, Iloilo province, said government doctors were only available in the town center.

"We have to travel to the town center if we need [to see] a doctor. Only midwives in health centers are available weekly," the official told the Inquirer.

Midwives, apart from assisting pregnant women, give only basic health services, among these immunization and deworming for children.

"There has been no significant improvement in health services through the years," the source said.

But medicines are lacking, even in areas where village and municipal health centers operate.

"We can get free paracetamol, mefenamic acid and medicines for common ailments but we have to buy the medicines prescribed by doctors, like antibiotics," the village official said.
Traditional healers
In Quezon province, a leader of the Agta-Dumagat tribe said tribe members suffering from severe illnesses usually died while being transported to the "nearest" government health facility.

Ramcy Astoveza, a tribe leader and commissioner of the National Commission on Indigenous Peoples (NCIP), said trekking mountain trails in the Sierra Madre mountain ranges in northern Quezon to bring the sick to a hospital or clinic often took a day or two.

"The hardship of long transport is too risky, especially for those who are very sick," he said.

Astoveza said with government health centers and doctors too far away, tribe members would rely on traditional healers.

He said the NCIP, through the assistance of the DOH and the Department of Social Welfare and Development, had been training qualified indigenous peoples (IP) across the country so they could become certified health workers. These villages are also being equipped with emergency medical equipment and stocks of basic medicines.

"But the Agta tribe in the Sierra Madre in northern Quezon has yet to have one government-trained health worker from among our tribe," Astoveza said.

Dr. Grace Santiago, Quezon provincial health officer, said the task of training IPs to be certified health workers lay on the DOH.

"But they can go directly to our office so that we can train them," Santiago said. She said the provincial government would also provide emergency medical kits and medicines for tribe members.

Santiago said the problem of providing emergency medical care to sick patients in remote areas were now being addressed by the provincial government.

She said her office had three "telemedicine" units, bought from a supplier in the United States for P1.3 million each. The provincial government, she said, plans to buy 15 more units this year.

The portable unit is equipped with cameras, computer screens and other viewing devices to monitor a patient's vital signs, blood pressure and electrocardiogram, and ultrasound results, among others. It provides chat and video consultations with doctors so patients in remote areas no longer have to travel for consultations, Santiago said.

Subscribe to INQUIRER PLUS to get access to The Philippine Daily Inquirer & other 70+ titles, share up to 5 gadgets, listen to the news, download as early as 4am & share articles on social media. Call 896 6000.

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Delfin T. Mallari Jr., Joey Gabieta, Nestor Burgos Jr.

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Health services still beyond reach of remote communities

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TACLOBAN CITY-Almost two years ago, Dr. Maria Socorro Kristina Medina left Metro Manila to serve in the island-town of Almagro in Samar province-one of the poorest areas in Eastern Visayas region.

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Read "Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop" at NAP.edu

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URL:https://nap.nationalacademies.org/read/24967/chapter/1
TITLE: “Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop”
AUTHOR: The National Academics of SCIENCES, ENGINEERING, MEDICINE
DATE PUBLISHED: 2018
KEY INFO: It is a significant resource focused on addressing rural healthcare disparities. It delves into various aspects of rural health equity, examining challenges and potential solutions. The National Academies are renowned for their rigorous research and evidence-based recommendations, implying that the book likely provides authoritative insights. While specific content details would be found within the book, it is expected to cover topics such as healthcare access, disparities, and strategies for improving the well-being of rural communities. The book serves as a vital resource for healthcare professionals, policymakers, researchers, and anyone concerned with reducing healthcare inequalities in rural areas, highlighting the importance of equitable healthcare access for all, regardless of where they reside.

-Maguad, Angela

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Rural counties make up about 80 percent of the land area of the United States, but they contain less than 20 percent of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well-being of rural Americans. Rural areas have histories, economies, and cultures that differ from those of cities and from one rural area to another. Understanding these differences is critical to taking steps to improve health and well-being in rural areas and to reduce health disparities among rural populations. To explore the impacts of economic, demographic, and social issues in rural communities and to learn about asset-based approaches to addressing the associated challenges, the National Academies of Sciences, Engineering, and Medicine held a workshop on June 13, 2017. This publication summarizes the presentations and discussions from the workshop.

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Read "Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop" at NAP.edu

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Read chapter Front Matter: Rural counties make up about 80 percent of the land area of the United States, but they contain less than 20 percent of the U.S...

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WHO: Universal health coverage - the best investment for a safer, fairer and healthier world

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URL: https://www.youtube.com/watch?v=C1bIjISMlTo&ab_channel=WorldHealthOrganization%28WHO%29
TITLE: “Universal health coverage - the best investment for a safer, fairer and healthier world”
AUTHOR: World Health Organization (WHO)

DATE PUBLISHED: Dec 13, 2017
KEY INFO: It is a production of the World Health Organization (WHO), a globally respected authority on public health. The video is centered around the crucial topic of universal health coverage (UHC) and its transformative potential. It likely emphasizes that UHC is not only a fundamental right but also the most effective investment for creating a safer, fairer, and healthier world. The intended audience for this video includes policymakers, healthcare professionals, researchers, and anyone interested in global health issues.

-Divino, Marko
-Dela Cruz, Marc

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WHO: Universal health coverage - the best investment for a safer, fairer and healthier world

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Kakulangan sa health services, paano nakaaapekto sa ilang pamilya sa Northern Samar?

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URL: https://youtu.be/CIkPdv2e9QM?si=oTVFd45O7PPvvn7G
TITLE: “Kakulangan sa health service, paano nakaaapekto sa ilang pamilya sa Northern Samar?”
AUTHOR: GMA Public Affairs
DATE PUBLISHED: August 10, 2018
KEY INFO: It delves into the critical issue of healthcare shortages in Northern Samar, a province in the Philippines. Produced by GMA Public Affairs, a division of GMA Network, it is likely to provide in-depth coverage and insights into how the lack of healthcare services impacts local families in this region. The video's importance lies in its potential to shed light on the challenges faced by these families, including delayed medical treatment, heightened health risks, and economic hardships. It serves as a call to action, highlighting the pressing need for policy changes and investments to improve healthcare access in underserved areas like Northern Samar.

-Maguad,Angela

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Kakulangan sa health services, paano nakaaapekto sa ilang pamilya sa Northern Samar?

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Health Disparities: Gaps in Access, Quality and Affordability of Medical Care

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URL:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540621/
TITLE: “Health Disparities: Gaps in Access, Quality and Affordability of Medical Care. “
AUTHOR: Wayne J. Riley
DATE PUBLISHED: 2012
KEY INFO: This blog talks about the difficulties of citizens getting the access they need, to afford the medical care, and the quality of the services they receive. These difficulties also known as 'disparities' range from financial dilemmas to discrimination. Furthermore, despite making progress in combating these challenges or 'health disparities', some issues still remain untouched. If such issues remain untouched and continue to exist, it will only lead to worsening the state of the current, pre-existing disparities that plague healthcare.

-Fajardo, Sammer
-Divino, Marko

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Abstract

Health disparities, which are sometimes referred to as health inequities, have garnered an increasing amount of attention from physicians and health policy experts, as well as a renewed focus from federal health agencies. As a complex and multi-factorial construct, differential access to medical care, treatment modalities, and disparate outcomes among various racial and ethnic groups has been validated in numerous studies. The antecedents of such differences involve such "drivers" as cost and access to the healthcare system, primary care physicians, and preventive health services. In addition, the subtle role of bias in creating and/or exacerbating health disparities is well documented in the literature. This article highlights the dimensions and extent of health inequities and emphasizes the challenges facing physicians and others in addressing them.

THE SIGNIFICANCE OF RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE

Racial and ethnic disparities in healthcare are important for a number of reasons. They pose significant moral and ethical dilemmas for the US healthcare system. As a nation, we have an abundance of healthcare facilities, cutting edge technologies, and pharmacotherapeutics and other assets that are the envy of the world, but which are not accessible for a myriad of reasons to all segments of the population. Also, healthcare as a resource is tied to various notions of social justice, opportunity, and quality of life for our patients, our communities, and the nation at large. A closely allied concern is the nation's economic well-being, which is both directly and indirectly tied to the health status of our population in general, and of specific population groups in particular. As a result, inadequate, inaccessible, and/or poor medical care further exacerbates increasing healthcare costs that have broad implications for the overall quality of care experienced by all Americans.

Evidence garnered over the past 3 to 4 decades is compelling. Health and disease states are unevenly visited upon various population groups. A few examples are illustrative: infant mortality for black babies remains nearly 2.5 times higher than for white babies; the life expectancy for black men and women remains at nearly 1 decade fewer years of life compared with their white counterparts; diabetes rates are more than 30% higher among Native Americans and Latinos than among whites; rates of death attributable to heart disease, stroke, and prostate and breast cancers remain much higher in black populations, and minorities remain grossly under-represented in the health profession's workforce relative to their proportions in the population.

HEALTH DISPARITIES DEFINED

Health disparities are differences and/or gaps in the quality of health and healthcare across racial, ethnic, and socio-economic groups. It can also be understood as population-specific differences in the presence of disease, health outcomes, or access to healthcare. Another useful definition has been provided by the Institute of Medicine that suggests that health disparities are racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention. Despite the usefulness of these definitions, it is important to understand that health disparities are not just based on race, ethnic, and cultural differences within the population. Lifestyle choices, age, sexual orientation, lack of access, and personal, socio-economic, and environmental characteristics are also to be included.

THE LANDMARK MALONE-HECKLER REPORT

The emergence of greater awareness and focus on health disparities has its genesis in the 1985 landmark Report of the Secretary's Task Force on Black & Minority Health issued by then US Health and Human Services Secretary, Margaret M. Heckler ( 1). The poor health status, poor outcomes, and constricted access to medical care for more than 300 years, anecdotally well known by many African Americans, and in some cases by a small cohort of academicians and public health officials, gained greater awareness with the "Heckler Report." The report objectively detailed the wide disparity in the excess burden of death and illness experienced by blacks and other minority Americans as compared with the nation's population as a whole. It also put forth that such disparities had been in existence for as long as federal health statistics were routinely collected. The report further emphasized the fact that six medical conditions between blacks and whites accounted for 86% of excess black mortality and the fact that close to 45% of deaths up to the age of 70 years (58,000 of 138,000) in the black population would have been avoidable if better evaluation, detection, and treatment had been available. The six conditions were: cancer (3.8%), heart disease and stroke (14.4%), diabetes (1.0%), infant mortality (26.9%), cirrhosis (4.9%), and homicide and accidents (35.1%).

UNEQUAL TREATMENT: CONFRONTING RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE

Although generally well received, the impressive work and initial analysis detailed in the Heckler-Malone Report was not followed up until 2003 when the Institute of Medicine published its groundbreaking report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare" (2). This IOM analysis began with a simple approach to rigorously review the 600 or so articles published in the medical literature over the prior 3 decades that addressed racial and ethnic disparities in healthcare. As part of this analysis, there was a specific focus on the 100 highest-quality studies covering cancer, cerebrovascular disease, renal transplantation, HIV/AIDS, asthma, diabetes, analgesia, and cardiovascular care. The IOM analysis revealed even more objective evidence of major differences and raised the specter of the role of bias and discrimination with regard to populations with equal access to healthcare. Underscoring the resultant discrepant quality of care experienced by populations as manifested in the appropriateness of clinical care and patient preferences, and the often confusing and challenging nature of the healthcare system and its legal and regulatory environment, are the roles of bias, discrimination, and uncertainty. The IOM report contributed further to a more robust dialogue on health disparities by offering an integrated model of health disparities that places in context the complex and multifactorial etiology for disparate treatment decisions and outcomes ( Figure 1 ).

DISPARITIES IN CARDIOVASCULAR CARE

Subsequent to the release of "Unequal Treatment," there was understandable skepticism by many in the House of Medicine that such disparities existed at all-and that, in part, they could be caused by disparate treatment decisions based on ethnic, racial, and/or cultural differences. The American College of Cardiology and the Henry J. Kaiser Family Foundation jointly undertook an analysis of the cardiology services. After an extensive review ( 3) of 81 of 158 studies on the topic, they that affirmed that there was credible evidence that African Americans were less likely than whites to receive diagnostic and revascularization procedures and thrombolytic therapy even when patient characteristics were similar. Among the key studies included was the work of Whittle et al ( 4). In a retrospective study of cardiovascular procedures among black and white veterans, Whittle et al found that there was a clear discrepancy in cardiac catheterization rates, angioplasty, and coronary artery colon bypass grafting absent financial barriers: Blacks were less likely to undergo invasive cardiac procedures in the Veterans healthcare system. Another study by Schulman et al ( 5) also found racial and sex differences in recommendations for cardiac catherization, and Chen et al ( 6) showed similar differences in the utilization of catherization after acute myocardial infarction.

DISPARITIES IN COST AND AFFORDABILITY

A plethora of data further emphasizes a major contributor to the problem of health disparities: the cost and access to many Americans for obtaining the medical care they require. Clear disparities exist in rates of health insurance coverage among black and Latino population groups. The consequences of being uninsured are significant and include use of fewer preventive services, poorer health outcomes, higher mortality and disability rates, lower annual earnings because of sickness and disease, and the advanced stage of illness (i.e., many are "sicker" when diagnosed). Thus, the uninsured tend to be disproportionately poor, young, and from racial and/or ethnic minority groups. An analysis by the Joint Center for Political and Economic Studies and Johns Hopkins University explored the economic burden of health inequalities in the United States and revealed that there is a significant financial burden ( 7). The elimination of health inequalies for minorities would have reduced total costs by approximately $1.5 trillion over a 3-year period.

THE CHALLENGES AHEAD

In the 27 years since the release of the Heckler Report, significant strides have been made in addressing health disparities. The report served as a catalyst for the coordination of federal and state responses to address disparities and the establishment of the Office of Minority Health within the US Department of Health and Human Services. However, despite such progress, it is clear that much work remains to be done to fully address health inequities. As documented by Benz et al ( 8), overall awareness of ethnic and health disparities remains somewhat disappointing, particularly in racial and ethnic groups, about certain disease conditions such as HIV/AIDS. In addition, although medical education has made perceptible progress in what is commonly referred to as cultural competency training for students, trainees, and physicians in general, recent evidence emphasized by Haider et al ( 9) reveal worrisome implicit preferences for whites and upper-class patients in implicit association testing instruments. Furthermore, in the emerging era of health reform, cost-conscious care and pay-for-performance reimbursement schemes for hospitals and physicians, recent evidence by Jha et al ( 10) emphasizes the challenge in even more stark terms: Lower performing hospitals, as manifested by quality performance data and metrics, tend to treat higher percentages of minority patients and have higher overall costs. Failure to address these disparities will only serve to worsen pre-existing disparities in access, quality, and costs of medical care for the most our most vulnerable populations. Indeed, much work remains.

Footnotes

Potential Conflicts of Interest: Director, Vertex Pharmaceuticals, Inc.

DISCUSSION

M. Gershon, New York: To what extent in the data that you've shown have the studies controlled for poverty? I think it was George Bernard Shaw who said that poverty is the greatest sin that humans can commit because no other sin is punished as severely. The point being that racial minorities tend to have a low socio-economic status, and, as you've shown in the Johns Hopkins report, those students had a preference not just for not dealing with racial minorities but low socio-economic minorities. Is it poverty that's the problem?

Riley, Nashville: Absolutely, a significant contributor. We know that low socio-economic status is a huge social determinant of health. We see it in many communities in terms of simple things, in terms of just access to fresh fruits and vegetables - so, it has a tremendous collateral benefit to overall health over time. Obviously, the economic aspects of this country, particularly in light of what we are going through now, exacerbates that, as I think you are pointing out, disparities are going to be with us for a long while. So I think you're dead on target.

M. Gershon, New York: It's not just nutritional point of view, if you compare education, and I'm talking about early education, not Johns Hopkins. I'm talking now about earlier education. Very few people in low socio-economic groups have access to the kind of enrichment that the higher socio-economic groups do that are routine. Training kids, pushing kids, pre-K, it's just not coming and so these kids go to class 2 to 3 years behind, and when they get into kindergarten, they don't know how to go to class. They are not socialized yet and that disparity carries with them throughout the educational system. So, the country needs to address it, but not just changing attitudes in medical school. This is a major problem that requires massive political action, which is not coming at the moment.

Riley, Nashville: I agree with you 100%, and Jordy Cohen and I were just at NIH last week. We were both appointed by Frances Collins to the Blue Ribbon panel looking at the disparity in RO-1 grants among investigators, and Jordy will tell you, we've had 2-hour, vigorous debates about where do we look first. You know the educational system is a problem, and we know that that contributes to the downstream lack of enough healthcare professionals for minority communities. So, it is a complex "nubby" problem that has many dimensions, which you've nicely articulated.

Alexander, Atlanta: I congratulate you on an absolutely terrific presentation. You are addressing one of the most important issues that we have as a nation. My questions were in the same context as were just asked and I think all of us realize that whatever our deficiencies are in the healthcare system and the way people are treated, that the saying that we kick around, I guess everyone is, "Tell me something about your zip code and I'll tell you something about your health... " Are there data on US populations comparing the kinds of outcomes that you've suggested that are based on socio-economic status (SES) or some measure of SES, and how do you teach?

Riley, Nashville: Yes. Actually, Rand has done some great work in looking at zip codes and analyses and looking at health indices. Excellent work. I can't remember the investigator with Rand who's done that, Dr. Alexander, but again, that punctuates that socio-economics is a huge contributor to health disparities, and we would never minimize that. You know my counter to that is that as physicians and as medical educators that is a situation we are going to be ill-equipped to change in of itself, and again, I have a slightly more polemical version of this talk, which I dub the "Pox in the House of Medicine," where I think it's really incumbent upon those of us who are in the medical institutions to do really as much as we can while we work towards getting more rigorous data, more expansive data on many of these aspects. I think Henry Bodenheimer gave a great talk yesterday about transplantation and we had an offline conversation about wouldn't it be great to compare his New York data to the Atlanta data and to see what happens in terms of the differences just geographically and culturally, South versus North or West versus East. So, I think you're dead on target.

Ludmerer, St. Louis: A comment that might be pertinent: Certainly these issues, as I believe Dr. Gershon pointed out, are very broad and complex. It was Rudolph Virchow who pointed out that the health of the nation is a reflection of how healthy that nation is as a society. So, there are many factors that go into those issues of health disparities, but I think the message that I hear you saying, and I would concur with, is that it does not excuse us as physicians from doing what we can and what we are capable of and what is within our own house. This is a difficult message for many physicians to receive, I believe, because most physicians have big caring hearts and they want to do the right thing and take care of people and help people. And the idea that they may not be fully helping people kind of goes against the core. And I think what this points out too, in my mind, is the importance of the subtle disparities that come out. It's not the overt decisions that are made but many of the subtle decisions that are made by prejudice, by ignorance, by just not having the right cultural understanding. There is a wonderful historical example that illustrates this in the early days of anesthesia: Anesthesia was demonstrated at the Massachusetts General Hospital in 1846, but it took a generation or so for anesthesia to come into accepted common standard use in surgery because there were many legitimate concerns in the signs of the time as to what the anesthesia might be doing to the physiology of the body, and if there was some late price to pay for the benefit of having painless surgery. But what's interesting is studying who received and who did not receive anesthesia during those 20 or 30 years. And this has been thoroughly studied in a quantitative fashion in a book by Martin Pernick at Michigan. What he found was that the African Americans, the Native Americans, and so forth received anesthesia much less commonly than did Caucasians. And the wealthier you were, the more likely you were to get it. And this was rationalized because, after all, we don't know what this anesthesia is doing to the physiology of the body, but the slaves, they're tough. You know, we don't need to worry about them, but these fragile Caucasian ladies, you know, they are very labile and very emotional and their physiology really might be messed up by the pain, so we'll give it to them - but it's this type of subtle disparity, I think, that we have a great deal of control over physicians if we are educated about it and we look internally.

Riley, Nashville: Absolutely. Ken you are right. The modern day manifestation of that is that I could have presented strong data that shows that African Americans that present to emergency rooms are not given analgesia at the same rates as other populations because of the hunch or the fear or the unconscious bias that they may be drug-seeking or not worthy of expensive analgesia. So, that's the modern day manifestation of what you have just articulated, Ken, and you are the world's most foremost medical historian, so I appreciate your point. Thank you.

Wilson, Baltimore: I think that the comments that have been made about poverty, education are absolutely correct, but I want to remind you that there are multiple studies that show that when poverty is controlled for and education is controlled for they show gross disparities in healthcare based along ethnic and racial groups.

Riley, Nashville: Point well-taken. Dean Wilson has reminded us again, which is one of my basic contentions when I give this talk, is we have work to do, colleagues, as physicians in the "house of medicine," and I think Don has articulated it very well.

REFERENCES

1. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health, Vol. 1, Executive Summary, August 1985 [ Google Scholar]

2. Smedley BD, Stith AY, Nelson AR, editors. National Research Council. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (full printed version) Washington, DC: The National Academies Press; 2003. [ Google Scholar]

3. Henry J. Kaiser Family Foundation and the American College of Cardiology. Report on Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence, October 2002 [ Google Scholar]

7. LaVeist T, Gaskin DJ, Richard P. The Economic Burden of Health Inequalities in the United States, Joint Center for Political and Economic Studies, Fact Sheet, September 2011 [ Google Scholar]

9. Haider A, Sexton J, Sriram N, Cooper LA, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306:9. [[ PMC free article] [ PubMed] Google Scholar]

Articles from Transactions of the American Clinical and Climatological Association are provided here courtesy of American Clinical and Climatological Association

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Health Disparities: Gaps in Access, Quality and Affordability of Medical Care

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Health disparities, which are sometimes referred to as health inequities, have garnered an increasing amount of attention from physicians and health policy experts, as well as a renewed focus from federal health agencies. As a complex and multi-factorial ...

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Accessible health services for women pushed | Davao Today

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URL:https://davaotoday.com/economy/health/accessible-health-services-for-women-pushed/
TITLE: “Accessible health services for women pushed”
AUTHOR: Zea Io Ming C. Capistrano
DATE PUBLISHED: May 29, 2015
KEY INFO: The article highlights the difficulties and challenges faced by women when accessing healthcare services in Davao city, due to financial issues and limited resources. The article has mentioned various women from low-income backgrounds seeking free health services. Overall, the article sheds light on the importance of health related fairs and events like these for those incapable of paying the expenses of overpriced medicine as well as the value and further need of government involvement in matters such as these.

-Montelibano, Althia
-Divino, Marko

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DAVAO CITY - Fe Francisco, 56, is among those who lined up for free services during the women's health fair sponsored by various organizations on Thursday.

Francisco, a resident of Lasang, said she wanted to have her eyes checked by doctors for blurred vision. She has no eyeglasses.

She said she would also like to have a free shot of pneumococcal vaccine after her eye checkup.

Francisco said because of limited resources, she only avails free health services.

"Wala gyud koy ika-afford mao nang naningkamot ko nga maka-avail aning medical mission (I have no money so i have to avail of the medical mission)," Francisco said.

Francisco worked as a lady guard for 20 years but now she and her husband are jobless.

Emelyn Sanchez, 25, also lined up to get free cervical cancer screening. She brought along her two kids, aged one and three.

Sanchez narrates that she has been experiencing pain on her waistline and suffers from constipation.

Her husband earns P10,000 a month but is "only enough for their most basic needs."

"Una gyud namong paliton ang bugas, dayon de-lata ug biskwit sa mga bata (We prioritize buying rice, canned goods and biscuits for the kids)," Sanchez said adding that she is worrying now because her eldest will be going to school soon.

Sanchez said she does not include her medical check-ups in the list of budget priorities.

"Kung naa ray libre sa barangay moadto mi (If there are free services in the barangays we avail them)," she said.

Single parent of four kids Marivic Egot, 46 years old, also brought her children to avail free haircuts. She said she hopes to also avail free school supplies for them during the fair.

Egot, who works as a manicurist, said she earns P300 a day by going from house to house. On rare occasions she earns P500.

"Pero pangkaon ra gyud na namo (But that will only be spent for our food)," Egot told Davao Today.

Egot said she only avails free medical check-ups and would only self-medicate when she is ill.

She said she suffers from high blood sugar and high blood pressure.

Hundreds of women availed free health services including pap-smear, IUD insertion and removal, pre-natal check-ups, optical and bone screening, and dental services held at the Davao Medical School Foundation compound. Lectures on alternative and herbal medicine and HIV-AIDS awareness were also held.

Dr. Darlene Estuart, chairperson of the Reproductive Health (RH) Network here, said free services happens only "once or twice" a year and many women avail them.

Estuart said privatized health services entails cost.

"If you go to the public sector, it's supposed to be free, it's available in the health center. Maybe for some reason they cannot go there," Estuart said, adding that it is a common experience that women do not usually prioritize their health care because "health centers might be far from them and they are busy in their homes".

"But on a daily basis, these services should always be available," she said.

Lyda Canson, chairperson emeritus of Gabriela Davao, said the influx of women from poor communities like Fe and Marivic during the health fair shows that a lot of women "wants free health services".

"They came as early as 7:00 am to line up," Canson said adding that it shows that there is lack of health services for women.

Canson explains that this year's commemoration of the International Day of Action for Women's Health focuses on "institutional violence".

"It refers to not giving services, health services to women," Canson said.

Canson said the Philippine government is signatory to International Conference on Population and Development and Belgium Platform Action for Women which commits to focus on women's health.

"Although ang gobyerno kasama namin dito to give services, we engage them (Although we have government agencies here, we engage them to give services)," Canson said. However, she said that the state is still "the leading violator of the women's right to health."

"First, they cannot fully implement the RH Law which was passed on 2012. Because their people lack knowledge and they need to be trained. But the government has no funding for their trainings so they are looking for civil-society organizations to train their people on reproductive health," she said.

Canson said, because of privatized health services, patients are forced to pay hospital bills "from their own pocket."

Canson said if the government will spend for health "they can be efficient and effective".

Gabriela Women's Partylist Representative Luzviminda Ilagan said women's health is very important.

"We are the mothers, we give birth," she said adding that the Philippines has a very high mortality rate.

Ilagan cited a survey released by the Food and Nutrition Research Institute (FNRI) that reveals that one of every four pregnant Filipino mothers are nutritionally at risk.

The same survey also reveals that the incidence of malnutrition increases among the younger mothers and especially among those in the lowest income brackets.

Almost four out of ten or 37.2% of young pregnant women aged 20 years old and below are nutritionally at risk. The prevalence of malnutrition among women in the lower income bracket is at 30% and 14.4% among women in the higher income brackets.

"Amid such malnutrition and poverty exacerbated by the inaccessibility of healthcare services, it is not surprising that maternal mortality rate in the Philippines is now at 221 for every 100,000 live births," said Ilagan.

Ilagan said the government's failure to address the increases in the price of rice and other food items has reduced staple food for a majority of Filipino women and their children to instant noodles and canned goods.

"We should continuously bring attention to the lack of services and bring attention to government policies that are detrimental to women like privatization," she said. (davaotoday.com)

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Accessible health services for women pushed | Davao Today

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Fe Francisco, 56, is among those who lined up for free services during the women's health fair sponsored by various organizations on Thursday.

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The Coming Collapse of the U.S. Health Care System

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URL:https://time.com/6246045/collapse-us-health-care-system/
TITLE: “The Coming Collapse of the U.S Health Care System”
AUTHOR: Time Magazine
DATE PUBLISHED: January 10, 2023
KEY INFO: This magazine article talks about the downfall of the healthcare in the U.S. How it went from hospitals having a stable operation to hospitals closing because of the lack of finances. This event led to citizens having to suffer because they could not access a facility for their needs, especially during an emergency.

-Maguad, Angela

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The Coming Collapse of the U.S. Health Care System

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The nursing strike in New York is emblematic of the huge stresses the U.S. health care faces coming out of the pandemic

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EXPLAINER: Universal health care – ano pa ang kulang?

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URL: https://www.youtube.com/watch?v=RlO9Z9YF3yM
TITLE: “EXPLAINER: Universal health care – ano pa ang kulang?”
AUTHOR: Rappler
DATE PUBLISHED: March 27, 2019
KEY INFO: After the signing of the Universal Health Care Act by President Rodrigo Duterte, it promised to provide extensive healthcare services, including free consultations and lab tests, to all Filipinos, regardless of whether they live in urban or rural areas, by making each Filipino a member of PhilHealth. However, does it truly cover all medical expenses? What happens if a medical treatment is expensive? Is it still covered? If not, how can it be considered 'universal,' especially when the target demographic is the minority, the poor, and those in rural and isolated areas?

-Divino, Marko

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EXPLAINER: Universal health care – ano pa ang kulang?

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Why Health Care Is Harder to Access in Rural America

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URL: https://www.gao.gov/blog/why-health-care-harder-access-rural-america
TITLE: Why Health Care Is Harder to Access in Rural America
AUTHOR: Alyssa M. Hundrup of the U.S. Government Accountability Office
DATE PUBLISHED: May 16, 2023
KEY INFO: Ease of access to health care is important, especially when presented with dire and critical situations where medical treatment should be administered as soon as possible. However, with the abrupt closure of many rural hospitals and clinics all around the world, especially in Western countries like the United States, rural residents have to travel farther to get healthcare services. Just imagine, someone had a stroke or a heart attack, and the nearest hospital is 20 or so miles away.

-Divino, Marko

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More than 60 million Americans-about one-fifth of the U.S. population-live in rural areas. On average, rural residents are older and generally have worse health conditions than urban residents. But while they may require more medical attention and care, they also might have more limited access to health care.

Today's WatchBlog post looks at both changes and challenges in rural health care access, as highlighted in our latest Health Care Capsule.
Hospital closures and higher risks
Having a local hospital or access to care is critical in an emergency situation where minutes can make a big difference. But we've found that many rural residents are seeing their local hospital close. More than 100 (or 4% of) rural hospitals closed from 2013 through 2020. As a result, residents had to travel about 20 miles farther for common services like inpatient care, and 40 miles farther for less common services, such as alcohol or drug misuse treatment.

We also found, as you might expect, that rural areas without hospitals also generally had fewer health care providers overall compared to those without closures.
People had to travel farther to get health care services after rural hospitals closed in their areas
In addition to losing their hospitals, rural residents might also face additional health risks.

Often rural residents lack insurance coverage, which is associated with less access to care and increased risk of poor health outcomes.

Many rural residents may turn to telehealth services-health care services delivered via phone or video-when care isn't available locally.Telehealth can be an option to address limited provider availability in rural areas. However, we found that, as of 2019, at least 17% of people living in rural areas lacked broadband internet access, compared to 1% of people in urban areas.
Certain populations are disproportionately affected
While rural communities face access and quality of care issues-we've found that some populations face unique challenges. Pregnant people, American Indians and Alaska Natives, and veterans may struggle to access the care they need in rural areas.

For example, we found that more than half of rural counties lacked hospital-based obstetric services in 2018. By 2030, the anticipated supply of OB/GYNs is expected to meet only about 50% of the demand in rural areas. In rural counties, the loss of hospital-based obstetric care is associated with increases in pre-term births and distance traveled for obstetric care, which may contribute to poor maternal and adverse infant health outcomes. These poor outcomes have been more prevalent in rural areas and for non-White racial and ethnic groups, particularly for Black and American Indian or Alaska Native populations.

About one third of veterans enrolled in the Veterans Health Administration (VHA) live in rural areas. However, in our review of VHA data, we found that rural veterans use intensive mental health care services, such as residential care or intensive case management, less than urban veterans, raising questions about access.

VHA's Office of Rural Health has a mission to improve the health and well-being of rural veterans. In FY 2022, the office allocated approximately $245 million for 35 separate initiatives, such as transportation for veterans to VA facilities. However, we found that the office does not communicate all of its funding opportunities across VA. As a result, VHA may be missing chances to fund research at VA facilities serving rural veterans with unique access issues.
What should the federal government do?
There are a number of federal agencies involved with ensuring rural communities have access to health care. But more action by these entities is needed. In our work, we've made important recommendations that would improve the information available to federal agencies and help them understand and address the health care needs of rural populations. Considering health care challenges faced by rural populations and the availability of financial incentives is also important when developing programs for rural populations. Learn more about these recommendations and policy options by reading our new Health Care Capsule.

The WatchBlog was recently named No. 20 on FeedSpot's list of the "Top 50 U.S. Federal Government Blogs and Websites." Blogs and websites were ranked based on their traffic, social media followers, and freshness.

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Why Health Care Is Harder to Access in Rural America

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More than 60 million Americans-about one-fifth of the U.S. population-live in rural areas. On average, rural residents are older and generally have worse health conditions than urban residents. But while they may require more medical attention and care, they also might have more limited access to health care.

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A qualitative study of rural healthcare providers' views of social, cultural, and programmatic barriers to healthcare access - BMC Health Services Research

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URL:https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07829-2
TITLE: “A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access”
AUTHOR:BMC Health Services Research
DATE PUBLISHED: April 2, 2022
KEY INFO: According to the research paper, healthcare services are not just about availability or accessibility, but for a patient, acceptability and appropriateness of healthcare services are just as equally important, as they should also tend to the needs and necessities of the people. Furthermore, we need to understand that providing and ensuring equal access to healthcare for everyone can be a daunting task since healthcare itself is complex, which is why we have to factor in different aspects when providing universal healthcare. According to the text, these problems are prominent and evident among rural places which often have 'barriers' that could be a lack of healthcare services or the geographical remoteness that may hinder these amenities. We can come up with a solution for these issues if we dig deeper into the underlying reasons.

-Divino, Marko
-Dela Cruz, Marc

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BMC Health Services Research 22, Article number: 438 (2022) Cite this article

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Abstract

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient's acceptance of services that they are to receive and ensuring appropriate fit between services and a patient's specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients' treatment plans. Semi-structured interviews and content analysis were used to explore barriers-appropriateness and acceptability-to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients' rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems' ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Background

Unequal access to healthcare services is an important element of health disparities in the United States [ 1], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3, 4, 5]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully 'access' healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.'s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one's capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient's specific healthcare needs [ 2]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7, 8, 9]. Findings like these emphasized a fragility in the financial security of the American population [ 10]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11]. Indeed, employer-sponsored insurance covers close to half of Americans' total cost of illness [ 12]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural-urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15, 16]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19, 20, 21].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans' access to healthcare [ 23]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient's ability to seek healthcare, particularly linked to one's professional values, norms and culture [ 2]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24]. According to the Centers for Disease Control and Prevention, health literacy or a high 'health IQ' is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26, 27, 28]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29].

Stigma, an undesirable position of perceived diminished status in an individual's social position, is another challenge that influences healthcare acceptability [ 30]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31, 32]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34].

A provider's attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36, 37]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman's decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman's likelihood to access care [ 38].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient's ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2]. The ability to engage in healthcare is influenced by a patient's level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider's goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40, 41, 42]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43, 44]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient's experience than a provider's degree of medical knowledge or use of modern equipment [ 46]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47, 48].

Rationale

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: 'If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?' [ 49]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as 'Is there a place that you usually go to when you are sick or need advice about your health?' or 'Have you ever delayed getting medical care because you couldn't get through on the telephone?' In contrast, the remaining two dimensions-acceptability and appropriateness-require a qualitative approach, as the social and cultural factors that determine a patient's likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient's specific healthcare needs (appropriateness) can be more abstract [ 50, 51]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52, 53]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers' experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54, 55]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Methods

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana's rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined 'provider' as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients' treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom's audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university's main campus.

Procedure

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque's framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms 'culture' and 'communication' were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, 'culture' is included in the definition of acceptability and 'communication' is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52, 59]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63]. Member checks consisted of contacting each study participant to explain the study's findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors' institution's Institutional Review Board.

Definitions of Analytic Domains

Cultural Considerations

Western health systems often fail to consider aspects of patients' cultural perspectives and histories. This can manifest in the form of a providers' lack of cultural humility. Cultural humility is a process of preventing imposition of one's worldview and cultural beliefs on others and recognizing that everyone's conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66, 67]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68, 69]. Since cultural identities and humility have been marked as factors that can heavily influence patients' access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71, 72]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73, 74]. Any miscommunication between a patient and provider can affect one's access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75].

Provider-Provider Communication

A patient's journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68, 77]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient's hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Results

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2-15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients' rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients' challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of 'rugged individualism' among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

Another participant echoed this finding by stating:

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one's concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient's perceived stigma from healthcare providers may also impact a patient's willingness to receive services. One participant put it best by stating

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient's perceptions of neglect or disorganization. This 'honest miss' may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79, 80]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

Curiosity was another reaction noted by a handful of participants. One participant said:

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Table 1 Facilitating factors to react to cultural attitude/behavior that does not align with treatment path

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through "on the job training" or "off the cuff learning." The general way of medicine, one participant remarked, was to "throw you to the fire." This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider's job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients' treatment is rarely overseen by a single provider [ 82]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient's primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient's health information, there may be increased risk of medical error. One participant in a specialty field stated:

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they're sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis. I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy... He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process 'rounds' when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient's experience. In contrast, ineffective communication can result in poor clarity regarding providers' responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient's specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000's [ 84]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

Participants reported an "astronomic" number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a "chore" so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15]. Rural areas, in particular, are subject to resource limitations [ 16]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to "do more with less." This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician's assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient's ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider's time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It's not that they don't have the capacity to think beyond that, but that's what their role is, making sure we're profitable. That's part of why our healthcare system in the US is as broken as it is. It's accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a "cherry-picking" process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

Discussion

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients' rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque's framework, specifically regarding healthcare providers' poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67, 70]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures' beliefs and values but induces risk of stereotyping and stigmatizing a patient's views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient's culture [ 88].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients' negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92, 93, 94]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95, 96]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98, 99, 100]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons' negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with 'rugged individualism' to squelch rural residents' engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients' experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers' perceptions of barriers to healthcare access for their patients may differ from patients' specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers' views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors' roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

Conclusion

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers' views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients' rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider's approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186-20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

References

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Acknowledgements

This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, and not-for-profit sectors.

Author information

Authors and Affiliations

1. School of Public & Community Health Sciences, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Nicholas C. Coombs & James Caringi

2. Department of Psychology, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Duncan G. Campbell

Contributions

The authors confirm contribution to the paper as follows: study conception and design: NC and JC; data collection: NC; analysis and interpretation of results: NC and JC; draft manuscript preparation: NC, DC and JC; and manuscript editing: NC, DC and JC. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to Nicholas C. Coombs.

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Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers' views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22, 438 (2022). https://doi.org/10.1186/s12913-022-07829-2
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Keywords

Access to healthcare

Rural health

Qualitative methods

# data[].attributes.attachment_link.title
A qualitative study of rural healthcare providers' views of social, cultural, and programmatic barriers to healthcare access - BMC Health Services Research

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Background Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate.

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‎Life Matters - Full program podcast: Healthcare outside the city on Apple Podcasts

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URL:https://podcasts.apple.com/ph/podcast/healthcare-outside-the-city/id73330343?i=1000616743973
TITLE: “Healthcare outside the city”
AUTHOR: Hilary Harper and Michael Mackenzie of Life Matters
PUBLISHED: June 13, 2023 at 6:45am
KEY INFO: The podcast "Healthcare Access Outside the City" delves into a critical narrative shift as we move from urban to rural, regional, and remote Australia. In the city, access to a wide array of healthcare services, including specialists, hospitals, GPs, and allied health professionals, is typically within reach, even if it's not always cost-effective, immediate, or geographically convenient. However, as we venture into the rural, regional, and remote areas of Australia, this narrative undergoes a profound transformation. The podcast aims to shed light on how healthcare access changes in these less densely populated regions. It explores the challenges, disparities, and unique solutions that arise when healthcare becomes a different story outside the city limits.

-Maguad, Angela

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If you're in the city, you usually have access to specialists, hospitals, GPs, and allied health. It may not always be cheap, or immediate, or local, but it is available. When you head out to rural, regional, and remote Australia, how does that story change?

# data[].attributes.attachment_link.title
‎Life Matters - Full program podcast: Healthcare outside the city on Apple Podcasts

# data[].attributes.attachment_link.description
If you're in the city, you usually have access to specialists, hospitals, GPs, and allied health. It may not always be cheap, or immediate, or local, but it is available. When you head out to rural, regional, and remote Australia, how does that story change?

# data[].attributes.body
URL:https:https://publichealth.tulane.edu/blog/how-to-improve-health-care-in-rural-areas/
TITLE: How to Improve Health Care in Rural Areas
AUTHOR: Tulane University - School of Public Health And Tropical Medicine
DATE PUBLISHED: January 17, 2023
KEY INFO: According to a report from February 2020, a total of over 400 hospitals in the U.S. were at a risk of shutting down because of financial reasons, which is the reason as to why rural areas often lack healthcare services. Consequently, this is also why rural areas have less medical attention than their urban counterparts. In addition, rural communities often suffer in chronic illnesses as well as lack of funding, therefore, rural areas are at a risk of having limited access to various medical services. Furthermore, since most medical institutions have closed, people who live in rural areas have no form of immediate medicinal treatment, which is important especially when it comes to life threatening illnesses or diseases. Fortunately, the article has given some suggestions on how to healthcare in rural communities. These include the usage of 'mobile-health clinics' and implementing telehealth for long-range communication where people can get advice from doctors without having to travel a dozen kilometers. Lastly, another solution is to collaborate with larger healthcare networks to procure valuable resources for rural areas.

-Divino, Marko

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URL:https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport
TITLE: “Designated Health Professional Shortage Areas Statistics”
AUTHOR: Bureau of Health Workforce
Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services
DATE PUBLISHED: June 30, 2023
KEY INFO: This data shows the shortage and differences of healthcare access, like mental health treatments or dentistry in different areas.

-Maguad, Angela
-Fajardo, Sammer

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FIVE BARRIERS TO RURAL HEALTHCARE ACCESS

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URL:https://myabmed.com/five-barriers-to-rural-healthcare-access/
TITLE: “Healthcare access in rural areas”
AUTHOR: ruralhealthinfo.org
DATE PUBLISHED: March 2019
KEY INFO: This article talks about the barriers that are stopping citizens from getting the healthcare they need. It states in this article that rural residents must also have financial means to pay for services, means to reach and use services, Confidence in their ability to communicate with healthcare providers, Trust that they can use services without compromising privacy And Confidence that they will receive quality care.

-Fajardo, Sammer

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FIVE BARRIERS TO RURAL HEALTHCARE ACCESS

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However, rural residents, who account for almost 19.3% of the US Population, are facing inequalities when it comes to both access and quality of healthcare

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Less staff, longer delays and fewer options: Rural America confronts a health care crisis

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URL:https://abcnews.go.com/amp/Health/staff-longer-delays-fewer-options-rural-america-confronts/story?id=97911613

TITLE: “LESS STAFF, longer delays and fewer options: Rural America confronts a health care crisis”

AUTHOR: Peter Charalambous

DATE PUBLISHED: March 18, 2023

KEY INFO: Many of the graduating students will be on the front lines of the nation's healthcare shortage as the country struggles with a primary care physician shortage and a rural health care crisis at the same time. New medical professionals beginning their residency have no control on the state of the failing health systems, especially those joining rural system.

-Maguad, Angela

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More than 40,000 graduating medical students learned Friday where they will spend the next three to seven years of their medical training.

With the United States grappling with a simultaneous shortage of primary care physicians and a rural health care crisis, many of the graduating students are set to enter the front lines of the country's health care shortage.

At least 136 rural hospitals and health systems closed between 2010 and 2021, and over 40% of rural hospitals operate with negative profit margins. Despite billions of dollars in investment in health care, hospitals throughout the United States face the possibility of shutting down.

"I would say it is probably the worst time for health care that we ever experienced," Joanne Conroy, the chief executive officer and president of Dartmouth Health, told ABC News. She noted that increased costs, inflation, limited housing, and workforce shortages have made running rural hospitals more challenging.

"We know what to do if we face another pandemic," Conroy said. "The question is whether or not we have the financial resilience in order to survive it."

Many hospitals that remain open have cut costs to survive, offering fewer services and beds.

In 2020, 47% of rural community hospitals did not provide obstetric services, with 89 obstetric units closing between 2015 and 2019. Seven million women reside in counties with limited or no access to maternity care, impacting half a million newborns annually.

According to Conroy, patients can already feel the impact of the crisis, noting that some women in New Hampshire need to drive two hours to deliver their babies. Other effects include fewer available beds in emergency rooms, delays for elective surgery and longer wait times for prescriptions or ambulance pickups.

For new medical professionals entering their residency, especially those joining rural systems, the circumstances of the struggling health systems are out of their control.

"It is not my job to fix all of the problems for an entire community, that's impossible. When you feel like that's your responsibility, burnout is basically inevitable," said Katie Stevenson, a Tufts medical student. "When you feel like your goal is to do the best you can with the resources you have, you are able to right-size your expectations a bit."

An increasing number of students are entering medical school programs that focus on rural medicine. In 2019, the Health Resources and Services Administration issued grants to create 32 newly accredited rural residency programs, supplementing the preexisting programs.

This year, Tufts School of Medicine will graduate its tenth class of students from its Maine Track MD program - a partnership with Maine Medical Center that allows students to pursue a community-based curriculum and gain financial incentives to encourage primary-care specialties.

Graduating roughly 40 students annually, 27% of Maine Track students have been matched to programs in Maine and 47% have been matched into primary care programs, according to Dena Whitesell, an assistant dean for students at Tufts and psychiatrist at Maine Medical Center.

"We know that students and residents who live in an area [and] who train in an area are more likely to practice in that area in the future," Whitesell said.

Liv Fauver, a Tufts student who matched with a University of Vermont residency program, grew up in rural New Hampshire and said she felt motivated to work in a similar community where she could positively impact the local residents.

"I think for me, my goal is to live and work in the community that I serve," she said. "So I'm really in a place where I go home or go to the grocery store and see my patients all the time, because that's the world that I live in and work in."

While rural hospitals have closed in record numbers, PCPs - medical professionals who patients regularly use for checkups and other routine care - face additional challenges, especially in rural areas, according to experts.

Greg Sawin, a PCP who has practiced in Massachusetts and North Carolina as well as Duke University School of Medicine professor, said he worries that the goals of primary and long-term preventative care can sometimes be at odds with larger health care systems.

"We get paid to do things to people. We don't get paid to keep populations healthy," he said.

Moreover, he believes the costs associated with medical schools - including the high cost, the likelihood of incurring debt and substantially higher pay to pursue competitive specialties like orthopedic surgery or dermatology, for example - disincentivize primary care options like family or internal medicine.

"It can be very appealing to want to go into a specialty where you're guaranteed to make more money and pay that debt off more easily," Stevenson said.

Owen Foster lives in rural Vermont and has felt the impact of the decreased number of available PCPs, spending six months to book an appointment with a doctor. Living in a rural area, Foster shares his dilemma with millions of Americans in rural areas impacted by the shortage of PCPs.

"You need basic things at certain intervals in your life," he told ABC News. "If you don't have a primary care provider, you can't get that and you can't get the referrals you need, so it's really, really difficult."

What makes Foster's experience unique is his position as the state of Vermont's top health care regulator. As chair of Vermont's Green Mountain Care Board, he oversees the quality and cost of the state's health care system.

Learning about the shortage of primary-care physicians in Vermont, Foster decided to use the opportunity to find a PCP as a chance to examine the market as a "secret shopper."

"What I found was I was completely incapable of getting a doctor," he said. "I called eight places and the best I got was on an indefinite wait list, which never came to fruition."

Rural areas comprise about two-thirds of the primary care health professional shortage areas nationwide, even though only 20% of Americans live in rural areas.

The problem is also likely to worsen over time. Projections indicate that the United States will likely suffer a shortage of between 17,800 and 48,000 PCPs by 2034.

Moreover, health care professionals believe that the shortage of PCPs can make other elements of health care more expensive and worsen overall patient outcomes. Sawin gave the example of a person getting strep throat. Without a PCP, the person might go to a local hospital emergency room, which is significantly more expensive than other treatment options.

"In terms of mismatch of resources, you know, a kid with strep throat showing up in the ER is like cutting butter with a chainsaw," Sawin said.

Foster added that primary care providers are "critical to controlling the costs of a health care system" due to their role in the early identification of issues, their ability to diagnose mental health issues, and their approach to preventative medicine.

According to Foster, PCPs in rural areas, however, struggle to find and retain staff, negotiate with insurance companies and prevent burnout. The shortage of PCPs, combined with the increased health care needs of the older population in rural areas, creates a concerning combination.

Despite these issues, Foster said he was optimistic about some approaches to make primary care more financially feasible, including adding a floor for PCP spending within health plans and government involvement in rate setting.

A new generation of students graduating from rural track programs also has the potential to reverse the tide of the PCP shortage in rural areas, with 571 additional primary care matches this year. Stevenson, for example, matched with the Swedish Cherry Hill rural program in Washington state.

"I think we have an opportunity in this country to do a much better job of taking care of our patients if we do a better job of funding primary care and preventative care and creating healthy environments," Stevenson said.

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The United States is grappling with a simultaneous shortage of primary care physicians and a rural health care crisis.

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UNICEF - Every day, over 1000 children die from diseases...

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TITLE: Every day, over 1000 children die from diseases linked to unsafe water, sanitation and hygiene.A new UNICEF- World Health Organization (WHO)  report found that 2 billion people lacked basic hygiene services in 2022.
UNICEF calls on governments to invest in improving access to hygiene facilities to protect families.

AUTHOR: UNICEF

DATE PUBLISHED: July 9, 2023
KEY INFO: Lack of hygiene is evident in urban and rural places, however, poor hygiene is more prominent in poor and rural areas. We all know that some diseases stem from bad practices of hygiene, therefore, UNICEF has taken action in creating hygiene facilities for ensuring the health of families.

-Guising Madale, Ashbelle
-Divino, Marko

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UNICEF - Every day, over 1000 children die from diseases...

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Every day, over 1000 children die from diseases linked to unsafe water, sanitation and hygiene.

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Rural Healthcare's Workforce Shortage: Designing an Innovative Solution | Trudie Milner | TEDxAWC

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URL: https://youtu.be/yH3tuScZOy8?si=984DGxsjiUuKjUnF
TITLE: “Rural Healthcare’s Workforce Shortage: Designing an Innovative Solution | Trudie Milner | TEDxAWC”
AUTHOR: Trudie Milner of TEDx Talks
DATE PUBLISHED: May 9, 2023
KEY INFO: It addresses the pressing issue of workforce shortages in rural healthcare. Presented at TEDxAWC, this talk likely explores innovative solutions to address this challenge in rural areas, aiming to improve healthcare access and outcomes. Trudie Milner, the speaker, is expected to provide insights, strategies, or examples of how innovative approaches can bridge the gap in rural healthcare staffing. This video underscores the importance of finding creative solutions to ensure that rural communities receive quality medical care despite workforce shortages.

-Maguad,Angela

# data[].attributes.attachment_link.title
Rural Healthcare's Workforce Shortage: Designing an Innovative Solution | Trudie Milner | TEDxAWC

# data[].attributes.body
URL: https://youtu.be/SXN76-EZnsM?si=v3aysUxTESJC6mss
TITLE: “Bringing Healthcare to the People”
AUTHOR: Freethink
DATE PUBLISHED: September 9, 2019
KEY INFO: In Africa, millions of people face formidable barriers to accessing healthcare services, particularly in underserved rural communities. This video showcases how governments are taking proactive steps to overhaul their healthcare systems, ensuring that every child and family has a dedicated community health worker right in their neighborhood. The essence of this promotional video is to extend healthcare to people in the manner we envision in our research. It highlights community healthcare workers as the linchpin of a system that can deliver equal and dignified care to everyone.

-Maguad,Angela

# data[].attributes.body
Dela Cruz, Marc Angelo
Divino, Marko Amando
Fajardo, Sammer Grace S.
Madale, Ashbelle Guising
Maguad, Angela P.
Montelibano, Althia Marian E.

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Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial - BMC Medical Education

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URL:

https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-02386-w

TITLE: “Visual Art in the clinical clerkhip: a pilot cluster-randomized, controlled trial”

AUTHOR:

Garth W. Strohbehn, Stephanie J. K. Hoffman, Joel D. Howell

DATE PUBLISHED:

November 30, 2020

KEY INFO: Exposure to the arts is linked to beneficial psychological concepts. No randomized, controlled research have examined the integration of art into clinical medical education or examined how it affects either educational outcomes or positive psychological dimensions.

-Guising Madale, Ashbelle
-Montelibano, Althia

# data[].attributes.attachment_link.readable_text
Garth W. Strohbehn 1,2,

Stephanie J. K. Hoffman 1,3,

Molly Tokaz 1,

Nathan Houchens 1,2,3,4,

Ruth Slavin 5,6,7,

Suzanne Winter 3,4,

Martha Quinn 4,8,

David Ratz 4,9,

Sanjay Saint 2,3,4,9,

Vineet Chopra 2,3,4,9 &

...

Joel D. Howell orcid.org/0000-0002-0527-4700 7,10,11,12,13

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BMC Medical Education 20, Article number: 481 (2020) Cite this article

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Abstract

Background

Arts exposure is associated with positive psychological constructs. To date, no randomized, controlled studies have integrated art into clinical medical education or measured its effects on positive psychological constructs or educational outcomes. In this study, we assessed the possibility and potential benefits of integrating visual arts education into a required internal medicine (IM) clinical clerkship.

Methods

We conducted a controlled trial in an academic healthcare system with an affiliated art museum. IM students were assigned to one of three interventions: museum-based arts ( n = 11), hospital-based arts ( n = 10), or hospital-based conventional education ( n = 13). Arts groups explored empathy, resilience, and compassion in works of art during facilitator-guided discussions. We assessed pre- and post-intervention measures of empathy, mindfulness, tolerance of ambiguity, and grit and tracked National Board of Medical Examiners IM shelf exam performance to capture changes in educational outcomes. Focus group discussions with participants in the arts-based interventions were performed at the study's conclusion.

Results

Arts education was successfully integrated into a busy clinical clerkship in both hospital and art museum settings. Focus group participants reported increased implicit bias cognizance and time for reflection, but no significant differences in psychometric or educational outcomes were identified. While most students felt positively toward the experience; some experienced distress from missed clinical time.

Conclusions

This pilot study demonstrates the feasibility of integrating visual arts education into the clerkship. Although observable quantitative differences in measures of positive psychological constructs and educational outcomes were not found, qualitative assessment suggested benefits as well as the feasibility of bringing fine arts instruction into the clinical space. A larger, multi-center study is warranted.

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Background

Medical students increasingly grapple with burnout and loss of empathy [ 1, 2, 3, 4, 5, 6]. Once they enter clinical clerkships, learners face traumatic clinical events and an unfamiliar environment in which they perceive themselves to be constantly evaluated [ 7, 8]. Loss of empathy contributes to patient depersonalization and lower quality of care [ 9, 10, 11], while its preservation is associated with improved clinical performance reviews [ 12]. In prior studies, medical students who demonstrated higher empathy scores similarly obtained higher ratings of clinical competence in core clinical rotations [ 12].

Incorporating the visual arts into medical training may help address this struggle. One study in which 739 medical students were surveyed found that exposure to the humanities (e.g. visual arts, music, theater, literature) was significantly correlated with positive qualities, including empathy, tolerance for ambiguity, and emotional intelligence, that portend strong clinical practice skills in the future [ 13]. Notably, arts exposure was also inversely correlated with components of burnout, suggesting the arts improve sustainability of one's clinical practice [ 13]. Operating within this paradigm, educators have tried to mitigate burnout and loss of empathy using arts-based curricular strategies [ 14, 15, 16, 17, 18, 19, 20, 21, 22]. However, these prospectively conducted studies do not offer conclusive evidence of the arts' benefits due to their designs. Many offer opportunities only for self-selected students, others occur outside of core clinical rotations, the crucible of clinical training that is central to medical student development, and none include randomization or appropriate control groups. Prior studies have also not assessed whether introducing time for the arts will alter academic performance, an area of interest to both learners and medical schools. Moreover, many interventions are based on visits to art museums, an opportunity not readily available at all institutions. Rigorously evaluating the role of the arts in medical education would require a randomized, controlled-trial, but it is unclear whether this trial would be feasible.

In this context, we created a pilot study aimed to assess the possibility and potential benefits and drawbacks of integrating the visual arts into an intense, graded, core internal medicine (IM) clinical clerkship. The pilot study utilizes a systematic study design and incorporation of relevant population and treatment groups with both quantitative and qualitative outcome measures toward an objective of informing a larger, multi-center study.

Methods

Research design

The cluster-randomized, controlled pilot study using pre- and post-intervention assessments was conducted between February and May 2018 (Fig. 1). Eligible study participants included four groups of clinical medical students at the University of Michigan Medical School enrolled in the IM core clerkship at the Veterans Affairs Ann Arbor Healthcare System (hereafter "VA"). Two groups had been assigned a two-week clinical block (Fig. 1; Groups A and C) and the other two a three-week clinical block (Fig. 1; Groups B and D). All medical students rotate through the VA as part of the IM clerkship.

CONSORT diagram of study. Flow of participants through study. Sample sizes noted are cumulative for all 4 groups. Notes: * Session not performed for groups A and C due to shortened rotation duration per medical school academic schedule. **Each cycle of the flow diagram is represented by a Group--4 cycles, 4 groups (A-D)

Study participants provided written informed consent. After providing informed consent, an independent statistician using a random number generator cluster-randomized each group of medical students in 1:1:1 manner to one of three interventions (described in depth below): Museum Arts, Hospital Arts, or hospital-based, Case-Based Control ("control"). Using this randomization scheme, all members of a single clinical group were exposed to the same intervention. Participants and study team were not blinded to group assignment and there was no crossover. Institutional Review Boards from both the VA and the University of Michigan Medical School deemed the study exempt. As this was not a clinical trial utilizing educational endpoints, it was not registered in National Clinical Trials registry. Full trial protocol is available upon requerst from the corresponding author. All study reporting was adherent with CONSORT guidelines [ 23].

Interventions

Three interventions were utilized in this study: Museum Arts, Hospital Arts, or hospital-based, case-based control ("control"). Each study arm intended to include two to three weekly, one-hour afternoon sessions, for a total contact time of 3 hours per arm. Due to shortened clinical rotation, Session 3 was not completed for all participating students (Fig. 1). The timing of study activities was consistent across the arms and chosen to minimize impact on regularly scheduled clinical care and educational conferences. Groups received their interventions on the following dates: Group A, February 5 through February 16; Group B, February 19 through March 9; Group C, April 2 through April 13; and Group D, April 30 through March 18 (Fig. 1).

Museum Arts sessions were held at the University of Michigan Museum of Art (UMMA). Transportation was arranged to and from the museum. Sessions were facilitated by a trained academic art museum educator who had prior experience collaborating with medical professionals (RS). The one-hour sessions used visual art to explore themes of empathy, tolerance of ambiguity, mindfulness, and grit, as well as resilience and compassion. The Hospital Arts curriculum was identical to that of Museum Arts, except that a) it was held in a conference room at the VA, b) it was led by IM house officers (GS, SH, MT) with backgrounds in education and medical arts who were trained by the arts educator, and c) study participants interacted with printed and digital representations of the same works of art being discussed at UMMA (Supplemental Appendix A). The control arm consisted of case-based medical education sessions about common diseases encountered by IM physicians facilitated by the same house officers (GS, SH, MT) and were held in a conference room within the VA. (Supplemental Appendix B).

Psychometric and educational outcome measures

Before randomization, participants completed paper-and-pencil surveys assessing demographic and arts-related variables, including voluntary participation in a Medical Arts program [ 24], prior art museum visits, formal or educational exposure to the visual arts, undergraduate study in the humanities, and intended specialty choice [ 25]. Baseline psychometric studies (Supplemental Appendix C) included the Jefferson Scale of Physician Empathy for Students (JSPE-S) [ 26], Tolerance of Ambiguity Scale (TOAS) [ 27, 28], Mindful Attention Awareness Scale (MAAS) [ 29], and Short Grit Scale (SGS) [ 30, 31]. These psychometric studies, our primary outcome measure, were repeated 2 days after the final intervention exposure due to study participants leaving the VA clinical site for clinical clerkships at other hospitals.

To evaluate whether incorporating the arts into the clerkship curriculum negatively impacts learners' development of medical knowledge, we included an academic assessment as a secondary outcome measure. Post-intervention exam performance was assessed using the National Board of Medical Examiners (NBME) IM shelf exam, which was administered to all students at the conclusion of the clerkship. NBME shelf exams are standardized exams widely utilized in the United States to assess medical students' acquisition of medical knowledge. These exams are administered at participating medical schools at the completion of core clerkships, including internal medicine.

NBME IM shelf exam performance allowed us to measure knowledge acquisition during the clerkship and assess if substituting art education for traditional didactic learning had an impact on academic achievement. If there were differences in NBME IM shelf exam performance between the groups, we could use each participant's Medical College Admission Test (MCAT) national percentile to suggest whether differences in NBME IM shelf exam performance were due to differences in underlying test-taking abilities.

Statistical analysis

We summarized the demographic characteristics and scores at baseline and post-intervention periods. We compared mean scores of JSPE-S, TOAS, MAAS, SGS, and educational outcome measures between arms of the study using analysis of variance (ANOVA). We compared the difference in differences between study arms from baseline and follow-up periods (i.e., to assess for whether there were differences between the three arms in the changes from pre-intervention to post-intervention) using repeated measures ANOVA. As this was a pilot study, we performed no formal power calculation; we utilized convenience sampling to arrive at sample size for the trial. Analysis was performed according to participants' assigned groups and there was no crossover. No interim analysis was performed and the trial was not stopped early.

Focus groups

Following completion of the post-intervention psychometric surveys, Museum Arts and Hospital Arts participants met for one-hour, semi-structured focus group discussions (Supplemental Appendix D) to gather participants' perceptions and opinions of the intervention. We focused on groups receiving arts-based interventions. This was independent from any medical arts teaching. Focus groups were audio-recorded and were conducted by a female Masters' degree-level research team member who was familiar with but did not have direct involvement in study interventions (SW) [ 32, 33]. Study participants were aware of the focus group facilitator's role in the study. No other observers were present. Digital recordings were transcribed verbatim. All identifying information was removed from written transcripts prior to qualitative analysis. Focus groups were performed within COREQ guidance [ 34].

Qualitative analysis

We conducted content analysis on focus group data using both deductive and inductive approaches. Two study team members with expertise in qualitative methods (SW, MQ), one of whom was blinded to the group's exposure (MQ), reviewed a sample of focus group transcripts and created a preliminary coding scheme that included pre-identified deductive codes based on the study's goals (e.g., participant reflections on art sessions, emotional impacts, and clinical applications) [ 35]. Additional inductive codes emerged from the transcripts. The same two study team members independently coded (line-by-line) the focus group transcripts. Coders discussed any discrepancies in coding until agreement and thematic saturation was reached. Data were aggregated, organized by code into table format, and synthesized to explicate findings. Study participants did not provide feedback on the findings. Qualitative analysis and data reporting were conducted under COREQ guidance [ 34].

Results

Study population

Participant flow is presented in Fig. 1. Forty-three students were approached; 39 provided consent and underwent randomization. Four individuals did not consent due to time commitment concerns. Of the 39 participants who consented, 35 completed all available interventions. One participant (control group) was unable to complete follow-up surveys, yielding data for 34 total participants. Due to the distribution of individuals who did not participate in the study, group A did not include a Hospital Arts arm and group C did not have a Museum Arts arm (Fig. 1).

Study arms did not differ significantly in terms of age, gender identity, race, undergraduate area of study, prior art museum exposure, prior attendance at a Medical Arts program event, or whether the decision of a future specialty had been made (Table 1). Among all groups, six (17.6%) participants had pursued non-natural science-based undergraduate degrees and one (2.9%) had pursued both non-natural science and natural science degree programs.

Table 1 Summary of study participants

Psychometric and educational outcomes

Comparison of baseline and post-intervention psychometric outcome surveys demonstrated no significant between-arm differences in JSPE-S, TOAS total score or sub-scores, MAAS, or SGS scores (Table 2, rows 1-8). Baseline measurements demonstrated no statistically significant between-arm differences in MCAT percentile (Table 2, row 9). Evaluation of NBME shelf exam performance after completion of the intervention revealed no between-groups differences (Museum Arts, 47.9 +/− 20.4; Hospital Arts, 66.6+/− 29.3; control, 7.5 +/− 22.8 percentile; p = 0.22 by ANOVA; Table 2, row 10).

Table 2 Quantitative outcome measures comparison

Focus groups

Six focus groups organized by individual, arts-based intervention teams were conducted (participants: n = 11 Museum Arts, n = 10 Hospital Arts). Key themes are summarized below.

Participant reflections on the study

Study participants had largely positive responses to involvement.

Clinical applications

Study participants thought the arts provided a space to practice empathy. They also thought the arts increased awareness and understanding of biases present in clinical care, especially in caring for patients with different backgrounds from themselves.

Study participants randomized to arts interventions generally reported an improvement in their ability to differentiate between subjective and objective information, a focus of one intervention.

Emotional and psychological impact

Many study participants found the interventions to be calming and relaxing. They appreciated the opportunity to reflect, to think in a different way, to escape from a perceived scrutiny of medical knowledge, and to acknowledge their own limitations.

However, reactions were not universally positive. Participants stressed over leaving the clinical environment. They worried about time away from direct patient care, not least because they feared that their absence would have a negative impact on their clinical evaluations.

Conversely, participants stated the arts-based intervention reminded them of the importance of self-care and mindfulness.

Suggestions for improvement

Some study participants recommended making it possible for students to opt out of the arts-based experience, or incorporating it into a non-core clinical clerkship (although it should be noted that one of the study's goals was to integrate the arts experience into a required part of clinical training).

Discussion

This pilot cluster-randomized, controlled study demonstrated that incorporating a visual arts curriculum into an IM clerkship is, in fact, possible and that it can be done both in art museum and acute care hospital settings. We did not observe significant between-groups differences in measured psychometric outcomes, an unsurprising finding given the short intervention and small sample size. Within the limitations of our study, a complementary arts curriculum does not negatively impact standardized educational metrics, a finding that could ameliorate medical students' concerns about lost time in the clinical environment.

The focus groups offered several conclusions that may not otherwise have been captured in a hypothesis-driven study. First, many participants reported that arts interventions offered a novel way of thinking and allowed for time to reflect on clinical experiences. They identified this time for reflection as a rare part of their education. Participants reported awareness of and changes in foundational clinical practice principles, such as developing increased empathic skills, recognizing personal implicit biases, and differentiating between subjective and objective information.

Second, while participants described the arts interventions as a welcome escape, many had a more negative response. Temporarily putting aside their clinical responsibilities led to feelings of stress and guilt. This effect seemed more pronounced for participants who physically left the hospital setting. It is possible, but unlikely, that the content of the arts interventions themselves contributed to this feeling of stress. It is more likely that the stress reflects the intense educational environment that characterizes medical school, one in which learners feel constant pressure to excel under the specter of constant evaluation [ 36]. In other words, by being physically removed from the hospital setting, students worried that their absence would reflect poorly on their clinical performance and subsequent evaluations, despite explicit assurances to the contrary by both medical educators and department administration. This stress of perceived absence may have negatively impacted participants' experience on-site at the museum or distracted participants from the intended lessons of the experience. Therefore, it was encouraging that under these conditions, participants thought the intervention fostered mindfulness and a recognition of the importance of self-care in their medical career. That an arts-based curriculum could promote self-care was a promising conclusion from this pilot study and could inform both interventions and outcomes of interest in future studies.

These results are consistent with previous studies of short-term arts-based curricula for medical students [ 14, 15, 19]. In one study, participants completed three 90-min sessions led by art museum educators at a local museum. Similar to our population, participants reported improvement in their appreciation of varying perspectives, listening skills, and recognition of assumptions [ 15, 19]. In that study, students were self-selected - a key difference from our trial's methodology. Our work suggests that arts-based curricula may be valuable for all medical students, not just those who choose to participate. Our data are also congruent with a study of surgical interns, which demonstrated that incorporating non-traditional educational efforts into the clinical space is personally and professionally beneficial [ 37].

Strengths of our study include use of a cluster-randomized design and outcome measures relevant to curricular stakeholders. Unlike some prior studies in the field, which struggled to garner faculty acceptance of incorporating less traditional concepts into medical training, we benefitted from strong institutional support for the central idea and purpose of the study [ 37]. The Hospital Arts arm of our study suggests that benefits of integrating arts into the curriculum may not be limited to institutions with ready access to an art museum or expert art museum educators. The museum environment is traditionally where the arts have been enfolded into medical education [ 38]. Trained arts educators can provide expert perspective and analysis, all the while enhancing an intervention as being "evaluation-free." However, not all clinical training sites have access to art museums or trained arts educators. Armed with appropriate techniques, training, and curricula, medical educators may represent a potential solution.

It is unsurprising that we did not find between-groups differences in psychometric outcomes. This was a small, short duration trial, although for some individuals a single arts session may be sufficient to fundamentally change worldviews [ 38]. We chose this two- to three-week period at the VA during the medical students' IM clerkship for both consistency and practical purposes. The VA IM clerkship is the only clerkship for medical students where all are simultaneously on the same rotation, have nearly equal clinical experiences, and are able to dedicate an additional hour weekly to the trial. Other hospital sites at University of Michigan provide varying internal medicine rotations (i.e., sub-specialty, outpatient internal medicine, and general inpatient internal medicine occur during the same time period). Moreover, our evaluations followed the interventions closely. After the passage of more time and the acquisition of more clinical experience, learners might look back on the arts experiences as being more valuable than they did immediately after the intervention.

More nuanced and robust conclusions will require larger studies, perhaps with longer duration of intervention, longer-term follow-up, or multiple sites. The nature of the arts stimuli may also have played a role in the observed outcomes. While prior studies of visual thinking strategies with similar duration of exposure have been reported as positive, these were not controlled, randomized, or tested in an exclusively clinical medical student population.

Logistical barriers included transportation, scheduling, and facility and personnel availability. As mentioned previously, many students were concerned that absences of any duration from the clinical setting would negatively impact their evaluations. One possible approach could be to move the intervention to a clerkship seen as less critical to students' futures, or to make it elective. Yet, this self-selection would then defeat the underlying purpose of assessing whether incorporating the arts into the clinical space can be beneficial to all students.

Conclusions

In this pilot trial, we demonstrate proof of principle for the integration of visual arts into the clinical educational space and for running a rigorous trial of the medical arts concept. Studies of arts curricula in medicine have not previously utilized randomization, contact time controls, nor have they focused upon the most at-risk subset of medical students. While there were no statistically significant changes in psychometric outcome measures, observation of and reflection on art did not jeopardize educational performance. Focus group discussions suggest numerous possible benefits of integrating an arts curriculum into the clinical space, as well as potential problems. Further coordinated, multi-institutional study is needed to more firmly establish the appropriate role of the arts in modern undergraduate medical education.

Availability of data and materials

De-identified supporting data are available by written request and pending agreement by all authors. Focus group transcripts are redacted to ensure confidentiality. Any potentially identifying demographic information (name, date, age, race) will be removed from educational data to ensure compliance with the Family Educational Rights and Privacy Act (U.S. Code Title 20).

Abbreviations

IM:

Internal Medicine

NBME:

National Board of Medical Examiners

MCAT:

Medical College Admissions Test

VA:

Veterans Affairs

JSPE-S:

Jefferson Scale of Professional Empathy-Student

TOAS:

Tolerance of Ambiguity Scale

MAAS:

Mindful Attention Awareness Scale

SGS:

Short Grit Scale

UMMA:

University of Michigan Museum of Art

ANOVA:

Analysis of variance

References

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Acknowledgments

The authors wish to thank the students of the University of Michigan Medical School for participation in this study as well as house officers and faculty of the Internal Medicine Residency Program and VA Ann Arbor Healthcare System, respectively, for their support of student participation.

Previous presentations

This work was previously presented as an Innovation in Medical Education poster at the Society for General Internal Medicine's Annual Meeting, April 2019, Washington, DC and as an oral abstract at the American Society for Bioethics and Humanities Annual Meeting, October 2019, Pittsburgh, PA.

Funding

Financial and logistical support was provided by the University of Michigan Medical Arts Program. The funder played no role in the study design or data interpretation.

Author information

Authors and Affiliations

1. Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA

Garth W. Strohbehn, Stephanie J. K. Hoffman, Molly Tokaz & Nathan Houchens

2. Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA

Garth W. Strohbehn, Nathan Houchens, Sanjay Saint & Vineet Chopra

3. Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA

Stephanie J. K. Hoffman, Nathan Houchens, Suzanne Winter, Sanjay Saint & Vineet Chopra

4. Patient Safety Enhancement Program, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA

Nathan Houchens, Suzanne Winter, Martha Quinn, David Ratz, Sanjay Saint & Vineet Chopra

5. University of Michigan Museum of Art, Ann Arbor, MI, USA

Ruth Slavin

6. Office of the Provost, University of Michigan, Ann Arbor, MI, USA

Ruth Slavin

7. Medical Arts Program, University of Michigan Medical School, Ann Arbor, MI, USA

Ruth Slavin & Joel D. Howell

8. University of Michigan School of Public Health, Ann Arbor, MI, USA

Martha Quinn

9. Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA

David Ratz, Sanjay Saint & Vineet Chopra

10. Division of General Internal Medicine, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109, USA

Joel D. Howell

11. Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA

Joel D. Howell

12. Department of History, University of Michigan, Ann Arbor, MI, USA

Joel D. Howell

13. Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA

Joel D. Howell

Contributions

GWS, NH, RS, SS, VC, and JDH conceived of and designed the research. GWS, SJKH, MT, RS, and SW participated in the acquisition of data. GWS, SW, MQ, and DR participated in analysis of data. GWS, SJKH, MT, NH, SW, MQ, SS, VC, and JDH contributed to interpretation. All authors had access to the data and had active roles in authoring the manuscript. All authors approve of the submitted version.

Corresponding author

Correspondence to Joel D. Howell.

Ethics declarations

Ethics approval

The study was granted exemption by the institutional review boards of both the University of Michigan Medical School and the Veterans Affairs Ann Arbor Healthcare System. Participants provided written informed consent to participate.

Consent for publication

Not applicable to this manuscript.

Competing interests

The authors declare no competing interests relevant to the manuscript.

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Strohbehn, G.W., Hoffman, S.J.K., Tokaz, M. et al. Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial. BMC Med Educ 20, 481 (2020). https://doi.org/10.1186/s12909-020-02386-w
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DOI: https://doi.org/10.1186/s12909-020-02386-w

Keywords

Arts in medicine

Clinical clerkship

Empathy

Grit

Mindfulness

Cluster-randomized trial

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Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial - BMC Medical Education

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Background Arts exposure is associated with positive psychological constructs. To date, no randomized, controlled studies have integrated art into clinical medical education or measured its effects on positive psychological constructs or educational outcomes. In this study, we assessed the possibility and potential benefits of integrating visual arts education into a required internal medicine (IM) clinical clerkship.