The Interplay Between Individual and Regional Factors in Access to Healthcare among Underserved Populations

Christina Crabtree-Ide

The bridge to access: connecting rural patients with healthcare. Upper Peninsula of Michigan.

The bridge to access: connecting rural patients with healthcare. Upper Peninsula of Michigan.

Graduate Student Project


In the midst of a pandemic, what would people do if they couldn't get to the doctor? If supportive services-meal delivery, transportation for seniors, nutrition programs-are closed? Imagine if a patient lived in an environment with poor resources like that all the time? What allows some people to manage this challenge better than others? Prior strategies to close rural-urban disparities that only focused on patient education have failed, so in this study, we focus on the interplay between patient and community that lead to appropriate access. This is important because lack of access to primary care is one of the strongest predictors of mortality, poor quality of life, and is a major public health priority set by virtually all national and international public health organizations.

We examined the relationship between annual primary care visits, patient age, sex, income, and education and community resources and infrastructure. We used indices of community resources and county health that included rates of employment, county-level health behaviors, social and economic characteristics, clinical care structure of the community, and physical environment. We used data from the Health Survey of Upper Peninsula Adults (Western UP Health Department) and linked it to the Robert Wood Johnson Foundation's County Health Rankings.

Our research showed that some patient factors (income and education) may shield patients from the negative impact of their environment/community while other patient factors (age and gender) may be exacerbated by the environmental/community impact. Context matters!


Rural patients face challenges in accessing healthcare in the U.S. due to poor community-wide resources, economic deprivation, and geographic barriers. While previous research has focused either on individual-level risk factors or on regional policies to improve primary care utilization, we examined the interaction between individual and regional factors to determine their joint and separate impacts on access to primary care.

We assessed the relationships between individuals' sociodemographic characteristics and healthcare utilization by linking individual-level data and County Health Rankings, which provided county-level measures of infrastructure, health, and economic attributes. We assessed statistical interaction between individual and regional parameters.

Individual-level determinants of healthcare utilization varied significantly by community infrastructure and attributes and were both compounded and offset by regional characteristics. Individuals' barriers to primary care utilization may vary by community attributes; therefore, interventions should be tailored to both local demographics and local resources and infrastructure, especially in rural and remote regions.

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