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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.

Further research must address the transportation behavior related to health care and the factors that influence this behavior. This information will inform policy alternatives to address geographic barriers to health care in rural communities.

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This pilot research project sought to provide a postoccupation assessment of a new mental health inpatient unit in East London, built under the Private Finance Initiative scheme. Qualitative discussion groups or unstructured interviews were used to explore the views of people who had been service users (but were currently well) and of nursing staff and consultants working in the new hospital. The participants gave their views on the aspects of the hospital which were beneficial or detrimental to well-being and the reasons for their views. Informants discussed hospital design in terms of: (1) respect and empowerment for people with mental illness; (2) security and surveillance versus freedom and openness; (3) territoriality, privacy, refuge, and social interactions; (4) homeliness and contact with nature; (5) places for expression and reaffirmation of identity, autonomy, and consumer choice; and (6) integration into sustainable communities. Themes emerging from this research were interpreted in light of ideas from geographical research on therapeutic landscapes constituted as physical, social, and symbolic spaces, as well as research from environmental psychology. The findings have practical implications for hospital design and underline the need to consider empowerment of patients in decisions over hospital design. We note the challenges involved in determining therapeutic hospital design given changing models of care in psychiatry, lack of consensus over models of care, and the varying and somewhat conflicting requirements these imply for the physical, social, and symbolic attributes of design of hospital spaces. We also note the implications of our findings for an interpretation of therapeutic landscapes as contested spaces.

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