Objective. This analysis determines the importance of geography and spatial behavior as predisposing and enabling factors in rural health care utilization, controlling for demographic, social, cultural, and health status factors. Data Sources. A survey of 1,059 adults in 12 rural Appalachian North Carolina counties. Study Design. This cross-sectional study used a three-stage sampling design stratified by county and ethnicity. Preliminary analysis of health services utilization compared weighted proportions of number of health care visits in the previous 12 months for regular check-up care, chronic care, and acute care across geographic, sociodemographic, cultural, and health variables. Multivariable logistic models identified independent correlates of health services utilization. Data Collection Methods. Respondents answered standard survey questions. They located places in which they engaged health related and normal day-to-day activities; these data were entered into a geographic information system for analysis. Principal Findings. Several geographic and spatial behavior factors, including having a driver's license, use of provided rides, and distance for regular care, were significantly related to health care utilization for regular check-up and chronic care in the bivariate analysis. In the multivariate model, having a driver's license and distance for regular care remained significant, as did several predisposing (age, gender, ethnicity), enabling (household income), and need (physical and mental health measures, number of conditions). Geographic measures, as predisposing and enabling factors, were related to regular check-up and chronic care, but not to acute care visits. Conclusions. These results show the importance of geographic and spatial behavior factors in rural health care utilization. They also indicate continuing inequity in rural health care utilization that must be addressed in public policy.
Background: "Activity space" has been used to examine how people's habitual movements interact with their environment, and can be used to examine accessibility to healthcare opportunities. Traditionally, the standard deviational ellipse (SDE), a Euclidean measure, has been used to represent activity space. We describe the construction and application of the SDE at one and two standard deviations, and three additional network-based measures of activity space using common tools in GIS: the road network buffer (RNB), the 30-minute standard travel time polygon (STT), and the relative travel time polygon (RTT). We compare the theoretical and methodological assumptions of each measure, and evaluate the measures by examining access to primary care services, using data from western North Carolina.
This analysis examines prevalence and identifies the predictors of complementary and alternative medicine (CAM) use among adults living in a rural region and analyzes the general health concerns for which rural adults use CAM remedies. Data are from a cross-sectional survey of 1,059 adults residing in 12 nonmetropolitan counties in Appalachian North Carolina conducted in 1999. “Home remedies” is the most extensively used CAM category in this population, with “honey-lemon-vinegar-whiskey and herbs” being the most widely used. The use of specific home remedies is associated with age, gender, and education. Chiropractors are the only widely used alternative therapist. Home remedies are differentially used to treat health conditions.
The increasing availability of georeferenced datasets creates new opportunities to perform spatial analysis of social science and public health survey data, but also raises ethical issues regarding the potential for unintended violation of the confidentiality of respondents. This article examines these ethical challenges by reflecting on the experience of a study mapping the facilities that provide abortion-related services in Cambodia. The technique of masking is examined as a potential method for preventing reidentification of respondents in georeferenced surveys. Broader solutions are offered for ways to balance the potentially conflicting goals of spatial analysis and protection of confidentiality.
Biomedical ethics provides the foundation for a model of client-centered care that can assure the good quality of family planning and other reproductive health services in developed and developing countries. Client concerns mirror the four ethical principles of autonomy, justice, beneficence, and nonmaleficence. Autonomy reflects clients' desire for full information and respect from providers so that they can exercise their right to make their own informed decisions. Justice, for clients, means fair treatment and ready access to services, regardless of one's socioeconomic status, education, ethnic group, or residence. Beneficence means that providers possess the technical competence and understanding needed to act in the best interest of their clients, as clients expect. Nonmaleficence translates into client concerns about safety--that no harm will come to them as a result of seeking services. Putting these ethical principles into practice requires changing providers' attitudes from paternalistic to client centered. Assessments of client satisfaction can help family planning programs identify and respond to client values and even raise client expectations about the care they should receive. Managers also can contribute to good quality care by meeting providers' professional needs for training, supervision, supplies, record keeping, and so on. Family planning programs around the world are focusing on these ethical concerns to emphasize respect for client values, appropriate decision making, broader access to services, and basic safety issues. Although they use a variety of techniques, all these quality assurance and improvement initiatives share an ethically based, client-centered philosophy.
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