Travel Burden for Healthcare among Rural Populations with Marvellous Akinlotan and Alva Ferdinand
Date: May 3, 2022
Duration: 31 minutes
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Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information
Hub. My name is Andrew Nelson. And in this podcast, we'll be talking with a variety of experts about providing
rural healthcare, problems they've encountered, and ways in which those problems can be solved.
This is the final episode of our three-part series about transportation in rural America.
Joining us today as Dr. Alva Ferdinand. She's the director of the Southwest Rural Health Research Center, that
center, funded by the Federal Office of Rural Health Policy, focuses on policy relevant research on meeting the
needs of rural populations, minority populations, and health disparities, including border health.
Also joining us from the SRHRC is Dr. Marvellous Akinlotan, where she is a research assistant professor. Now you
are both involved in researching and writing a policy brief entitled Rural-Urban Variations in Travel Burdens
for Care. So, Dr. Akinlotan, if I could ask you first, you spearheaded this project, why was this something that
you wanted to dig into and learn more about?
Dr. Marvellous Akinlotan: Thank you, Andrew. The last documentation of the national estimates
for the travel distance and time for medical care using the national household travel survey was done in the
year 2001. And so, it was important to look into the data to provide current national estimates of the travel
distance and time to medical or dental care, and to determine what has changed over time where the changes have
occurred and what groups have been mostly affected.
Dr. Alva Ferdinand: Yeah. I think that in just looking at the literature, there were lots of
studies sort of focusing on one particular disease, for example, cancer or looking at different types of cancers
and travel burden, for example, to radiation therapy or to other kinds of therapies for cancer related
conditions. But just generally speaking, there wasn't a nationally representative study that had been done for a
really long time. So I think that we were just curious to see, in the grand scheme of things, what does travel
burden look like for rural residents and how does that compare to urban residents. And I think one of the nice
things about what we do in the center and academics across the country is to sort of look at what we already
know how old that data might be and just work on providing contemporary findings to sort of see how far we've
come or not come. And I think that was one of the reasons that this was a really exciting project for us.
Andrew Nelson: Yeah. I can see how that could be kind of a secondary element of rural
that kind of gets overlooked providing the services are one thing, but people need to be able to get to the
doctor as well. Dr. Akinlotan, your research on travel burden built on information, as you said from the mid
2000s about travel behaviors of rural and urban residents for those seeking healthcare. What have you found has
changed since that time?
Dr. Marvellous Akinlotan: Yes. So for this study, we looked at three years, that's from the
national household travel survey. We looked at year 2001, year 2009, and year 2017. And those were the three
most recent versions of that dataset. We looked at the travel time and distance among urban residents and among
rural residents. And for urban residents, we found that the travel distance did not change significantly between
2001 and 2017, but for rural residents, the travel distance changed quite significantly. And so, in 2001, rural
residents were traveling about 15 miles to get care. But in 2017, that number had risen up to 18 miles. And that
change was statistically significant. When we looked that at a time, we did find that the travel time increased
for both urban and rural residents. So even though for those residing in urban area, they didn't necessarily
need to travel further, they still traveled longer. They still spent more time in their travels. And the same
finding was made for rural residents as well. When we also compared and looked at the rural urban differences in
the travel trends and found that compared to their urban counterpart, rural residents traveled seven miles
farther for care in 2001, but that number increased to 10 miles in 2017. Also for travel time, rural residents
traveled five more minutes to get care in 2001, but 10 more minutes in 2017. And so we found that the
rural-urban disparities widened over the study period.
Another measure we looked at was the travel burden, and that was defined as the percentage of trips that lasted
either 30 miles or 30 minutes. And we found that in rural areas, one in three trips for medical or dental care
lasted 30 minutes or more in 2001, but in 2017, almost one in two trips for medical or dental care lasted more
than 30 minutes. And so the travel burden increased substantially in rural areas as well.
Dr. Alva Ferdinand: I think, and thinking about rural residents not as a monolith, but sort of
understanding that there are different types of rural residents. There are racial and ethnic minorities. There
are folks that are covered with different types of insurance plans, et cetera. One of the interesting things for
me is just sort of seeing how for certain populations subpopulations, the story hasn't gotten better for them
either despite what we've seen as an evolving transportation system in the US with respect to rideshare, et
cetera. We're still seeing that minority populations. I think Blacks and Hispanics, in particular, are
continuing to face a very significant travel burdens.
Another thing that sort of popped out for me in reading the travel burden literature comprehensively, it was
of the burden that folks that are on public insurance, such as Medicaid and Medicare also face in trying to seek
care. Even though the findings that Dr. Akinlotan shared just now are really, really interest for rural and hold
true for the population at large, it's important to understand that when you see one rural community, you've
seen one rural community and that there are various subpopulations within rural that continue to face of
substantial travel burdens.
Andrew Nelson: And Dr. Akinlotan, you mentioned that this disparity had increased in the last
or 20 years. What causes were you able to identify for that disparity?
Dr. Marvellous Akinlotan: So just looking at the datasets that we used, the causes weren't
apparent, but we could look at our findings and also take a contextual look at what has been going on in rural
areas to make sense of that finding. Well, first one of the causes we see would be the closure of rural
hospitals. Data from the UNC Sheps Center on rural hospital closures lets us know that they were about 126
complete and partial rural hospital closures between 2005 and 2017. And so, for residents who lived close to, or
in communities where they were hospital closures, you can imagine that they would've had to travel even further
to get care following the closure, whether it was full or partial.
In addition to that, there have been fewer primary and specialty services available in rural areas over time.
that has also meant that rural residents would need to travel even further. And the third cause or probable
cause would be fewer options for public transportation. As opportunities for public transportation continue to
dwindle over time, those who had to rely on public transportation to get medical or dental care would have to
seek for other options, which may have translated into spending more time.
Andrew Nelson: Can you tell us a little bit about the rural experience of travel when people
living in rural areas are seeking after-hours care?
Dr. Marvellous Akinlotan: First aspect of the study we conducted that was the policy brief. We
looked at characteristics of the trips made at night, and we found that rural trips that were made between
midnight and 7:00 AM were 22 miles farther and 24 minutes longer than urban nights trips. And so, just looking
at that tells us that there's higher burden for rural residents who needed care in the middle of the night.
There was no way to tell whether those trips were emergent or not, but one came infer that traveling at 2:00 AM
for care would be something that was at least pretty urgent, would be for a condition that was pretty urgent.
And that also lets us know that emergency and urgent care centers were more likely to be located farther away in
rural areas, and there might also be consequences associated with that. We weren't able to capture that from our
data. But for an individual who needed to get access to urgent care or emergency care, having to travel 22 miles
further or even 24 minutes longer, one can only tell what consequences or what complications may have resulted
from having to wait or travel much longer just to get care in the middle of the night.
Dr. Alva Ferdinand: I think that certainly we were limited in what the data that we used could
tell us, but I think in thinking about the literature in general, what we know is that when access is difficult
for individuals, sometimes what ends up happening is that they forgo care. So a condition that may not have
escalated to the point of needing emergency care at 2:00 AM, for example, may have been mitigated if access was
somewhat better, a little bit easier to reach a primary care physician, for example, or perhaps even a specialty
physician as the case might be. And so, I think when we're thinking about those hours, not too many people would
elect to go to find a physician at 2:00 AM as opposed to 3:00 PM or 11:00 AM for an outpatient visit. So what
that sort of tells us is that there might be some forgone care and delayed care happening as well, such that
when they do eventually need to seek care, the disease condition is much higher or more detrimental than perhaps
it could have been if access to outpatient care was more readily available.
Andrew Nelson: You can definitely have kind of a domino effect, I suppose, with relatively
trivial things becoming very serious just because of that impediment to access. Rural areas often don't have as
many public transit options. How does that reliance on personal automobiles affect access to care?
Dr. Marvellous Akinlotan: We knew from the literature that nearly 4% of rural households, which
is almost 2 million rural residents do not have access to a car. And in addition to that, rural areas are also
much less likely to have access to public transportation. And so, in the light of this, they may be forced to
rely on friends and family for transportation. And without reliable options for transportation, the special
populations such as older adults, those with disabilities special needs will be personally vulnerable to
isolation. In addition to the foregone care, missed appointments, delayed care, they may also be vulnerable to
isolation, which can also increase the risk of mobility and mortality.
Dr. Alva Ferdinand: I think that in thinking about how transportation is evolving in general,
we've been talking quite a lot about autonomous vehicles and the impact that they might have in reducing some
disparities and inequities that we see throughout the country. And this might be something that we think about
and delve into the research as autonomous vehicles become a thing as it were. I think that rideshare, certainly
rideshare and other types of transportation have really evolved and come to be pretty commonplace in
metropolitan areas of the United States. But I think there's certainly still a lag in these kinds of innovations
for rural populations. And so, I think it's going to be important for us to kind of see how the transportation
infrastructure evolves and how that impacts rural residents throughout the United States.
Andrew Nelson: Can you tell us a little bit about the financial impact of large distances that
people need to traverse to get access to rural healthcare? For example, how gas prices might impact whether or
not rural residents can get the care that they need?
Dr. Marvellous Akinlotan: Our data showed that more than half of rural residents agreed or
strongly agreed that the price of gasoline affects their travel compared to just 45% of urban residents stating
that the price of gasoline was a barrier to their travel. And one can also infer that with the higher travel
burden, just imagine one in two trips for medical or dental care taking up to 30 minutes or more than 30 miles,
spending more than 30 miles to get to care, with that burden would also come the increased costs of gasoline.
But from the literature, we know that compared to urban households, rural residents are less likely to reduce
their travel when gasoline prices rise, because they have less transit options and they have fewer and they have
less access to rideshare services. And so, they have fewer opportunities to adapt their travel patterns. So one
can see that the financial impact is there and the price of gasoline is a problem, but they are still less
likely to reduce their travel just because of that because they have fewer options to travel.
Andrew Nelson: Beyond that, have you found that there are any particular groups of rural
residents that are especially impacted by transportation challenges?
Dr. Marvellous Akinlotan: There are two major groups that came to mind. The first group will be
groups that have conditions that limit mobility. Those are more likely to be older adults, those with
disabilities and special needs children, for example. And for older adults, definitely elevated burden of
transportation will reduce the likelihood that they need to leave the communities where they leave to get into
long term care. And improving transportation among that population would also reduce isolation and improve
mental health. But apart from the special groups that we already mentioned, and Dr. Ferdinand mentioned this
much earlier in the podcast, we also looked at the travel burden by race and ethnicity and found that over time,
the travel time and distance increased disproportionately for Blacks and Hispanics.
For example, the travel distance for rural Hispanics increased by 11 miles and 19 minutes in 2017 compared to
2001. And that was the highest increase of any of the other groups. There were also substantial increases for
Blacks as well. The distance for Whites didn't increase as much. And so, this suggests that the increased travel
burden that we are seeing among rural populations over time, the brunt of that is being born by the minority
populations, particularly the rural Hispanics. So these groups are definitely more impacted by transportation
challenges. And that's important to note.
Dr. Alva Ferdinand: What we know from the literature, as I mentioned previously, is that folks
that are covered through public insurance, Medicaid really stands out, because certainly the Medicare program is
sort of the based on age and citizenship and that kind of thing. But if you're covered on Medicaid, it means
that you're in the lower income categories. And what we learned from our work is that if you make less than
$25,000 a year, that you were also more likely to have substantial travel burden associated with finding
appropriate care for a health condition. So if we think about the jobs that are tied to that bracket of salary,
there's probably less flexibility. You're probably not necessarily able to work from home. So if we're thinking
about the pandemic, for example, you might actually have higher exposure to infectious disease such as COVID-19,
and really not much of a choice in terms of getting childcare or arranging for expectation like with an Uber or
renting a car for a day, for example. Those options are very limited, if you happen to be in that income
Andrew Nelson: What are some potential solutions to address these rural travel burdens?
Dr. Marvellous Akinlotan: Well, the first is telehealth. Increasing access to telehealth for
entire rural population, but particularly for the minority population and adapting it in such a way that it can
be used by them is critical. Providing travel discounts so that individuals who need to travel and have cost as
a barrier are able to overcome that is another potential solution. Ridesharing services, and they are currently
programs in different pockets of the country that want to use ridesharing platforms, such as Uber or Lyft to
improve travels specifically for medical care.
Another important solution is bringing increasing access to primary care. In the literature, there was a study
done some time ago that... I think this was a qualitative study and it was like the rural resident saying,
“Okay, we get it if we need to travel further for specialty care. But for primary care, which is what we
need on a fairly consistent basis, it's important that is close by.” And I know, Dr. Ferdinand still in
lines here, but she would often say, “Rural residents sometimes... They just want to see someone in white
coat.” Someone who, whether a nurse practitioner, someone who has some qualification and can address their
health conditions. If that's available at a primary level, that is a good solution. That's an important
solution. And then, they know that for specialty care, the potential for further travel is still is welcome.
Andrew Nelson: Dr. Ferdinand, you've already mentioned one possible solution to the rural
healthcare burden that I thought was very interesting, and that was autonomous vehicles. Could you expand on
that a little bit?
Dr. Alva Ferdinand: Yeah, certainly. So I know at Texas A&M University, we have Texas
Transportation Institute, which does a lot of testing on top autonomous vehicles. I think we have of a few buses
on campus that are running and folks are being invited to try those out. So I think that having a personal
vehicle has been shown in our work to be a barrier to accessing healthcare. But I think that to the extent that
there are, for example, fleets of autonomous vehicles that can be dispatched to rural and remote areas, that
might be something that policy makers try to invest in, in the future. I think we're currently seeing lots of
investments on the telehealth side of things, which is pretty interesting because I think that while telehealth
is welcomed by lots of urban and maybe even millennial individuals, I think that we need to do a little bit more
digging on how accepted telehealth services are to rural residents. I think we are making lots of investments in
that infrastructure, but I think that there's a level of comfort that has to go hand in hand with that modality
And I think that's something that we need to explore a little bit more. I'm just thinking about my parents. For
example, older patients, older generations might actually want to see a human being in person, and so telehealth
for them may not be something that they immediately think of as an alternative to getting in a car and driving
to access care. So I think telehealth certainly is one potential solution. I think autonomous vehicles, as they
begin to roll out, like I said, I think that we can think about it more broadly than just an individual buying
an autonomous vehicle because they don't want to have to spend the cognitive load on driving. I think that we
can even now begin to creatively think about how we can leverage autonomous vehicles in a way that really
benefits rural residents in the US.
Andrew Nelson: That's really interesting. We often think of autonomous vehicles as being kind
luxury things for wealthy people, but it's interesting to consider the benefits that kind of technology could
have for people on the other end of the economic spectrum. We're wrapping things up here. I'll ask you first,
Dr. Akinlotan, do you have anything lined up for your research center in terms of further considering the issue
of rural travel burdens?
Dr. Marvellous Akinlotan: Going forward in the light of the current expansion of telehealth, we
would like to see how, for example, how different racial groups are responding to the increased uptake of
telehealth. Particularly as we found in our study, rural Hispanics and rural Black residents, and of course,
rural Whites as well. Just wanted to see whether there's a racial variation in the uptake of telehealth. And
then, one aspect we couldn't delve into, as I said earlier was whether the travel burden differed by the type of
care that was sought. So primary care we wanted to know... We will want to know in the future, what is the
average time and travel... What is the average travel distance and time to get primary care compared to
specialty care. Because in this data set, everything was lumped together.
And then, for those with different types of insurance coverage, what are the variations, those who have Medicaid.
I mean, we can already... We can suspect those who are covered by Medicaid, I'm more like it's a travel further,
but we would like to have more hard evidence of that. And then, look at those who are covered by private
insurance, what is the travel distance? Rural residents are more likely to be older, so we want to know the
travel distance among those who are covered by Medicare and how that also impacts their care. So just looking at
these three measures by other metrics such as insurance status and the type of care sought will be important for
Dr. Alva Ferdinand: Again, just thinking about the literature in general, there's lots of
studies on travel burden associated with cancer and different types of cancer, colorectal, uterine, et cetera, I
am particularly curious about the travel burden associated with other kinds of conditions, some of the ones that
kind of float to the top in the US. So diabetes comes to mind, heart disease, COPD, for example. I just wonder
for folks that have those particular conditions, what the travel burden looks like. And I think, to Marvellous's
point earlier, I think certainly access to primary care is going to help with some of that. And so, what we know
is that in the primary care setting, you can kind of get some information and counseling on lifestyle changes
that might help with those particular conditions.
And so, if we are continuing to see that the burden of travel associated with getting treatment for those kinds
of conditions also remains high, I think that tells us that we have an opportunity to really try to work on this
so that when we're thinking about healthy people, for example, the initiative set out by health and human
services to meet certain benchmarks for reductions in certain diseases. I think that it's more than what new
drugs can we come up with. It's more than how many more providers can we put in certain places. It's also about
looking at the transportation burden as it currently is and really trying to think creatively about how to
reduce that burden so that the gaps that we see in meeting healthy people benchmarks aren't as wide as they
currently are. And so, I'm sort of excited to look into that. I know that's something, the leading causes of
death is something that the center tries to look at very closely.
And I think that providing some recommendations, I'm thinking about transportation as an important piece of that
is also going to be something that we'll look at in the future. I think it might also be interesting to look at
potentially avoidable hospitalizations for things like ambulatory care sensitive conditions. So again, those
conditions that could be managed pretty well in an outpatient setting, I think that as we're trying to work on
these issues of travel burden and trying to reduce them, I think that we should also be looking to see how those
efforts play into reducing unnecessary care in emergency departments, for example, which we know is
substantially more expensive to obtain than care that you would otherwise have gotten in an outpatient setting.
So I think for me, if I'm thinking futuristically, I would want to see how efforts in our travel burden
reductions translate into outcomes in the emergency department setting, as an example.
Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today,
we spoke to Dr. Alva Ferdinand and Dr. Marvelous Akinlotan from the Southwest Rural Health Research Center. Look
in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining
to rural health. Join us next time for a discussion about palliative care here on Exploring Rural Health.