Access to health care remains a major problem for the residents of rural communities in the US. Through the project Geographic Accessibility of Health in Rural Areas (R01 HS09624) we have developed a rich, detailed and theoretically based data set of the geographic, social, cultural, and health status factors that affect access and utilization of health care services among rural community residents. This application is for a competing renewal that will allow the investigators to fully exploit this data set. We have completed a great deal of work in the initial 2-year project period. We established community entree. We completed interviews in 1,059 households for 1,059 adults and 302 children in the mountainous region of western North Carolina. The survey interview data are entered and a Geographic Information System (GIS) database is established. Weights are calculated for each sample unit. A data management system is implemented. Measures are being constructed, and analyses to test the confirmatory hypotheses have begun. All of this has been accomplished in line with the project schedule originally proposed. We are now requesting support over a 4- year period in which we will complete 3 specific aims. First, we will complete the analyses of the confirmatory and exploratory hypotheses on the relationships of geography to health care utilization presented in the original proposal. Second, we will determine the complex effects of transportation and activity spaces on access and utilization of health services among rural community residents through more detailed measurement and analysis of the survey data. While considered important factors affecting health care utilization, transportation and activity space have been difficult concepts to effectively measure. However, GIS technologies enable us to test hypotheses on these important aspects of health services utilization with multivariate models. Third, we will delineate the beliefs and perceptions of rural community residents about the effects of geography, transportation and activity space relative to their access and utilization of health are services through the systematic collection and analysis of qualitative in-depth interviews with rural community residents. The quantitative models that will result from the first and second specific aims will provide only a portion of the explanation of variability in the utilization of health services. Qualitative analysis of rural residents' beliefs and perspectives of health services will provide additional explanation. By integrating these qualitative interpretations with the quantitative survey models the results of this study will be better able to inform rural health care planning and policy.
