Rural Women's Preventive Service Utilization: The Role of Cultural Barriers

Purpose: From 1983–1999, women's life expectancy declined in 180 U.S. counties. This “reversal of fortune” disproportionately affects rural women, as 173 of 180 counties with statistically significant life expectancy decline are in the Deep South, along the Mississippi River, and in Appalachia (Ezzati, Friedman, Kulkarni, & Murray, 2008). While utilization of preventive care is associated with a reduction in mortality among women, little attention is paid to rural women's access to preventive services. Access to preventive care is often predicted by availability of insurance, having a usual source of care, and distance to care; however, predictors may be more complex for rural populations due to elements of rural culture such as self-reliance and independence (Brems, Johnson, Warner, & Roberts, 2006; Sambamoorthi & McAlpine, 2003). This paper seeks to identify important predictors of the utilization of preventive services for rural women living in the South.

Methods: The analytic sample for this study (n = 3,251) uses telephone survey data collected for an evaluation of the Southern Rural Access Program, a Robert Wood Johnson Foundation initiative to improve access to healthcare services in eight southern states. Random digit dialing techniques and a second-stage randomization scheme were used to obtain participants who lived in the targeted area for at least 12 months. Preventive care utilization was measured by respondents' receipt of an annual physical examination. The questionnaire contained standard indicators assessing access to care, as well as items addressing understudied factors, including perceived difficulty regarding travel and attitudes toward seeing doctors. Data analyses consisted of descriptive statistics and multivariate logistic regression.

Results: Descriptive analyses revealed that many respondents were not receiving preventive services, as 82% of women reported not having a routine check-up in the last year. Logistic regression analyses, controlling for state of residence, indicated that respondents reporting a usual source of care were 148% more likely to have a yearly check-up (CI = 1.93,3.18; p < .001), while respondents reporting no health insurance were 51% less likely to have a yearly check-up (CI = .39,.61; p < .001). Attitudes toward doctors were also significant predictors of preventive care utilization, suggesting cultural barriers. When asked on a 5-point Likert scale whether someone should call the doctor when they notice any symptom of illness, respondents were 12% less likely to have a yearly check-up for every unit change in agreement (CI = .82,.96; p = .003). Similarly, when asked whether someone should get a regular physical examination at least once a year even if they're feeling well, respondents were 39% less likely to have a yearly check-up for every unit change in agreement (CI = .53,.71; p < .001).

Implications: Findings indicate that rural women experience unique barriers to preventive services. Identifying these barriers can inform social work practice and public health strategies targeting rural areas. In addition, interventions to improve access to preventive care for women in rural areas must be tailored to ameliorate unique cultural barriers that rural women face.