360 JHHSA WINTER 2006

URBA/RURAL DIFFERECES I ACCESS AD

BARRIERS TO HEALTH CAREFOR PEOPLE WITH
MULTIPLE SCLEROSIS

ROBERT J. BUCHAA
Mississippi State University

ALEXA STUIFBERGE
University of Texas at Austin

BOIE J. CHAKRAVORTY
Tennessee State University

SUOJI WAG
Texas A&M University

LI ZHU
Texas A&M University System Health Sciences Center

MYUGSUK KIM
Texas A&M University

ABSTRACT

Context: People living in rural areas face barriers when

seeking health care, often experiencing difficulties accessing health
providers or facilities. Little is known about barriers to the use of
health care confronting people with multiple sclerosis (MS) in rural
areas.
Purpose: To identify any rural/urban differences in access and
barriers to health services, including MS-focused care, among people
with MS.
Methods: The data were collected in a survey of 1,518 people
with MS living in all 50 States. The study included three geographic
subgroups: urban areas; adjacent rural areas; and more remote rural
areas.
Findings: We found significant rural/urban differences in
access and barriers to care among people with MS, especially for MS-
focused care. Significantly smaller proportions of people with MS
JHHSA WINTER 2006 361

from adjacent and more remote rural areas reported no difficulty

getting MS-related care than their urban counterparts.
Conclusions: Greater difficulty accessing MS-related care
experienced by people with MS in rural areas has negative implications
for the quality of the MS care they receive.

ITRODUCTIO

People living in rural areas face barriers when

seeking health care, often experiencing difficulties
accessing health providers or facilities (Medicare Payment
Advisory Commission, 2001; Arcury, et al, 2005). Rural
residents confront physical barriers to care, including lack
of public transportation, terrain-related problems, and long
travel distances to care (Goins, Williams, Carter, Spencer,
and Solovieva, 2005; Auchinloss and Hadden, 2002; Bull,
Krout, Rathbone-McCuan, and Shreffler, 2001).
Geographic and spatial variables are linked to the
utilization of regular and chronic care visits by people
living in rural areas (Arcury, et al.). While problems
accessing care among the general rural population have
been documented, little is known about barriers to the use
of health care services facing people with multiple sclerosis
(MS) in rural areas. An earlier study analyzed urban/rural
differences in barriers to health-promoting behaviors
among people with MS, with lack of convenient facilities a
common barrier reported by people with MS living in rural
areas (Stuifbergen, 1999). The objective of our study is to
focus on rural/urban differences in access and barriers to
health care services, including MS-focused care, among
people with MS.

Methodology
The data presented in this study were collected in a
survey of 1,518 people with MS living in all 50 States. The
survey sample was identified using the membership of the
National Multiple Sclerosis Society (NMSS). This study
362 JHHSA WINTER 2006

included three geographic subgroups: metropolitan

statistical areas (MSA); rural areas, located within 50 miles
of an MSA; and rural areas, located more than 50 miles
from an MSA. Earlier studies have used MSAs to define
urban areas in health-related studies (Reschovsky and
Staiti, 2005; Shi, et al., 2005; Ricketts, Johnson-Web, and
Randolph, 1999).

Survey Sample
Initial contact was made with potential survey
respondents through a pre-notification letter that explained
the purpose of the study and included a toll free number for
respondents to call to participate in a computer-assisted
telephone interview. ZIP codes within the NMSS
membership data base were used to randomly select
potential survey respondents to receive pre-notification
letters until at least 500 participants completed telephone
interviews for each of the three geographic subgroups. The
survey process, which began in October, 2004 and was
completed in January, 2005, included mailing the pre-
notification letter to NMSS members in 10 sequential
waves until at least 500 participants completed telephone
interviews for each of the three geographic subgroups. A
total of 5,181 pre-notification letters were mailed, with 263
returned as undeliverable, and 1,518 NMSS members
completed the telephone survey (31 percent participation
rate). No respondent was barred from participating if 500
interviews had been completed for a geographic subgroup.
Telephone interviews were completed by 505
people with MS living in MSAs; 500 people with MS
living in rural areas, less than 50 miles from an MSA; and
513 people with MS living in rural areas more than 50
miles from an MSA. In the remainder of this paper we use
the term “urban” to refer to the MSA subgroup, “adjacent
rural areas” to refer to the rural areas less than 50 miles
JHHSA WINTER 2006 363

from an MSA, and “more remote rural areas” to refer to

rural areas more than 50 miles from an MSA.

The Slifka Study Sample

The Slifka Study, funded by the NMSS, is a
longitudinal study of a representative sample of more than
2,000 people with MS in the United States (Minden, et al.,
2006; Minden, Frankel, Hadden, Srinath, and Perloff, 2004;
Minden, Frankel, and Hadden, 2003). Recently released
data from the Slifka study allow comparisons of a
representative sample of people with MS to the survey
results for the urban/rural subgroups analyzed in our study.
About 83 percent of people with MS in the Slifka sample
live in urban areas (Minden, et al., 2003), making the urban
subgroup from our study the most appropriate to compare
to the Slifka sample.
The Slifka sample and our urban subgroup are
consistently similar for a range of demographic
characteristics. For example, 77 percent of the Slifka
sample (Minden, et al., 2006) and 77 percent of the urban
subgroup in this study are female. Similarly, the Slifka
sample and the urban subgroup have nearly identical
proportions of Caucasians (88 percent vs. 87 percent) and
married people (67 percent vs. 66 percent) (Minden, et al.,
2006). In terms of MS disease characteristics, again the
urban subgroup in this study is consistently similar to the
Slifka sample when comparing the average number of years
since MS diagnosis, the course of MS, difficulty walking,
and overall health status. Comparisons of the urban
subgroup in this study with the Slifka sample, which was
designed to represent the entire MS population in the
United States (Minden, et al., 2006; Minden, et al., 2004;
Minden, et al., 2003), illustrate a consistency for a range of
demographic and MS characteristics.
364 JHHSA WINTER 2006

Participation and Confidentiality

The pre-notification letter sent to recruit potential
survey respondents stated that participation in the study
was voluntary and there were no negative consequences for
refusal. This letter also stated that the person could decline
to answer any of the survey questions and still participate in
the study, with all responses remaining confidential. In
addition, the interviewer told each respondent during the
introduction of the telephone interview that no responses
from any individual would be released to anyone but the
researchers. This interview introduction also mentioned
that the research had been reviewed by the Institutional
Review Board for Human Subjects in Research at Texas
A&M University (approval received on January 27, 2004).

Survey Questionnaire
One section of the questionnaire focused on access
to health care, asking if there was one particular clinic,
health center, doctor’s office or other place that
respondents usually went if sick or needed advice about
their health. If there was not one place, respondents were
asked to explain why they did not have one usual source for
their medical care. The telephone interviewer then asked
about “the place you go most often for your routine or
regular medical care,” with a number of possible responses
(including “other”) provided by the interviewer.
The interviewer then asked people with MS about
“the place you go most often for your MS-focused medical
care,” with a number of possible responses (including
“other”) provided. The first option for a response provided
by the interviewer was “the same place I go for routine or
regular care.” The purpose of this question was to learn not
only where respondents went for their MS-focused care,
but also to determine any urban/rural differences in the
proportion of people with MS who received their MS-
JHHSA WINTER 2006 365

focused care from the same physician who provided their

routine care.
Another section of the questionnaire focused on
physical barriers to care. The interviewer asked “about any
physical barriers that interfered with your ability to gain
access to health facilities.” The questionnaire asked if
respondents ever had difficulty getting health care
procedures because the equipment could not accommodate
their MS. The interviewer then asked about any barriers or
obstacles experienced obtaining needed MS-related care
and routine health care.

Analyses of Survey Results

The survey results were analyzed using the
statistical software package SAS, with standard procedures
used (such as proc freq, proc univariate, etc.) to produce the
results presented in the two tables created for this study.
We first obtained sampled quantities for the various survey
characteristics, such as percentages, means, medians,
standard deviations, etc. To test for statistically significant
urban/rural differences, we used two sample tests for
comparisons of proportion (e.g., proportion of respondents
who had no difficulty getting MS-focused care). We used
the two-way contingency table chi square test for
categorical data (e.g., the place respondents went to receive
routine care). The urban subgroup was used as the
reference group in the calculation of any statistically
significant differences.

RESULTS

Health Care Locations

Table 1 presents rural/urban comparisons of health
care locations utilized by survey respondents. A
significantly larger proportion of people with MS living in
more remote rural areas (88.9 percent) usually went to one
366 JHHSA WINTER 2006

clinic, health center, or doctor’s office when sick or in need

of medical advice about their health than people with MS in
urban areas (83.8 percent). When those without one source
for medical care were asked why, significantly larger
proportions of respondents from adjacent rural areas (18.0
percent) and more remote rural areas (16.4 percent)
reported that no place was available or close enough
compared to their urban counterparts (5.3 percent).
The telephone interviewer asked respondents where
“you go most often for your routine or regular medical care
(please consider this regular or routine care separately from
any MS-focused care you may receive),” with significant
rural/urban differences observed. People with MS living in
urban areas were more likely to visit a doctor’s office or an
HMO for routine care while rural MS residents from both
rural subgroups were more likely to go to a general clinic
or health center for routine care. The interviewer also
asked respondents where they went most often for their
MS-focused care, with significant rural/urban differences
noted. Significantly larger proportions of respondents from
urban areas received their MS-focused care in a doctor’s
office/HMO (43.2 percent) different from the place they
received their regular or routine care or at an MS clinic/MS
health center (18.4 percent) compared to respondents from
more remote rural areas (32.0 percent and 14.1 percent,
respectively). In contrast, respondents from more remote
rural areas were significantly more likely to receive their
MS-focused care (34.2 percent) at the same place they went
for routine care than their urban counterparts (22.4
percent).
JHHSA WINTER 2006 367

Table 1
Rural/Urban Comparisons of Health Care Locations

Urban Adjacent More Remote

Survey Characteristic Areas Rural Areas Rural Areas

Visit One Clinic or 83.8% 87.6% 88.9%

Physician's Office (423) (438) (456)c

If Not One Clinic/Office, Why?

Two or more places for care 56.0% 50.8% 49.1%
Have not needed a doctor 12.0% 18.0% 10.9%
Have many health needs 12.0% 4.9% 5.5%
Do not like/trust doctors 10.7% 6.6% 10.9%
Previous doctor not available 6.7% 11.5% 14.5%
No insurance/cannot afford 6.7% 4.9% 5.5%
No place convenient 5.3% 18.0%c 16.4%c
Other 12.0% 8.2% 5.5%

Routine Care*
Doctor's office or HMO 72.8% 67.7%a 55.3%a
General clinic/health center 17.2% 26.0% 37.4%
Hospital outpatient 6.4% 3.4% 3.5%
Hospital emergency room 1.0% 1.0% 1.6%
Other 2.6% 1.8% 2.4%

MS-Focused Care*
Doctor's office or HMO 43.2% 38.3% 32.0%a
Same place as routine care 22.4% 26.7% 34.2%
MS clinic/health center** 18.4% 17.9% 14.1%
Clinic or health center 6.1% 8.2% 10.7%
Hospital outpatient 6.1% 6.2% 4.6%
Other - neurologist 1.8% 0.8% 0.4%
Other - cannot Afford 1.2% 1.2% 3.0%
Other 1.0% 0.8% 1.0%

* For this survey question there were more than two possible responses. The
significance level reported in this table for this survey response resulted from a
Chi-square test that compared all possible categories for the survey response.
** Includes responses of "medical
university."
a
p <0.001; b p <0.01; c p <0.05
368 JHHSA WINTER 2006

Barriers to Care
The telephone interviewer also asked survey
participants if they had any difficulties getting health care
due to physical barriers in the environment, with the
responses given in Table 2. When asked about physical
barriers that interfered with access to health care facilities,
a significantly larger proportion of people with MS in
urban areas reported lack of accessible parking spaces (14.3
percent) compared to their counterparts in more remote
rural areas (8.4 percent). About 15 percent of respondents
in each geographic subgroup responded that they had
difficulty getting a health procedure because the medical
equipment did not accommodate their MS-related
impairments. For example, for those respondents who
reported these difficulties, more than 70 percent in each
geographic subgroup could not get on the exam table.

Access to Care
In addition, the telephone interviewer asked about
any barriers or obstacles experienced in obtaining needed
MS-related care. Table 3 shows that significantly smaller
proportions of people with MS in adjacent rural areas (44.9
percent) and more remote rural areas (43.6 percent)
reported no difficulty getting MS-related care than their
urban counterparts (52.9 percent). In contrast, people with
MS living in both rural subgroups were more than twice as
likely as people with MS in urban areas to report lack of
nearby or convenient facilities as a barrier to receiving MS-
related care. In addition, respondents from more remote
rural areas (26.8 percent) were significantly more likely to
report that lack of money was a barrier to MS-related care
than urban respondents (20.0 percent). The level of their
impairment was a barrier to MS-related care for a
significantly larger proportion of respondents in adjacent
rural areas (14.6 percent) compared to urban respondents
(10.2 percent).
JHHSA WINTER 2006 369

Table 2
Rural/Urban Comparisons of Physical Barriers to Care

Urban Adjacent More Remote

Survey Characteristic Areas Rural Areas Rural Areas

Physical Barriers to
Health Facilities
No accessible parking 14.3% 11.0% 8.4%b
Doors too difficult to open 13.7% 16.0% 14.0%
Layout of facility difficult 10.3% 9.6% 8.4%
No transportation 9.7% 14.0%c 10.1%
Other barriers 7.9% 5.8% 5.7%
No ramp to building 5.9% 6.8% 8.6%
Other 8.9% 7.2% 7.0%

Had Difficulty Getting 14.7% 15.4% 15.2%

Health Procedure (74) (77) (78)
Equipment Could Not
Accommodate MS?

Equipment Could Not

Accommodate MS:
Couldn't get on exam table 75.7% 72.7% 70.5%
Couldn't measure weight 52.7% 46.8% 38.5%
Couldn't measure height 29.7% 35.1% 25.6%
Couldn't have mammogram 23.0% 14.3% 15.4%
MRI table 8.1% 9.1% 7.7%
X-Ray 5.4% 6.5% 3.8%
Other 13.5% 13.0% 11.5%

a
p <0.001; b p <0.01; c p <0.05
370 JHHSA WINTER 2006

Table 3
Rural/Urban Comparisons of Access to Care

Urban Adjacent More Remote

Survey Characteristic Areas Rural Areas Rural Areas

Difficulty Getting MS Care:

No difficulty 52.9% 44.9%c 43.6%b
Fatigue 25.3% 28.5% 28.8%
Lack of money 20.0% 23.8% 26.8%c
Care interferes
with responsibilities 15.4% 11.8% 14.6%
Lack of time 12.8% 13.7% 12.8%
No transportation 10.6% 13.8% 9.5%
Level of impairment 10.2% 14.6%c 14.2%
No nearby facilities 10.0% 23.2%a 23.1%a
No one to take
person to care 10.0% 13.2% 12.4%
Lack of child care 5.8% 3.5% 3.0%c

Difficulty Getting Routine Care:

No difficulty 65.3% 65.9% 64.8%
Fatigue 18.3% 20.2% 17.8%
Lack of money 14.9% 16.3% 16.6%
Care interferes
with responsibilities 12.4% 7.6%c 6.9%b
Lack of time 9.4% 8.8% 9.3%
Level of impairment 9.2% 9.6% 9.5%
No one to take
person to care 8.4% 8.2% 8.1%
No transportation 8.2% 8.4% 7.5%
No nearby facilities 6.4% 9.2% 10.5%c
c
Lack of child care 4.8% 2.0% 2.0%c

a
p <0.001; b p <0.01; c p <0.05
JHHSA WINTER 2006 371

Table 3 illustrates that about two thirds of survey

respondents in each urban/rural subgroup reported no
difficulty getting routine care. For those respondents
reporting difficulty getting routine care, significantly larger
proportions of urban respondents replied that going to care
interfered with other responsibilities, and that lack of child
care was a barrier to this care as well, compared with
respondents from both rural subgroups. However, a
significantly larger proportion of people with MS in more
remote rural areas identified lack of nearby or convenient
facilities as a barrier to routine care than urban respondents.

DISCUSSIO

We found significant rural/urban differences in

access and barriers to care among people with MS,
especially for MS-focused care. People with MS in urban
areas were significantly more likely to access MS-focused
care at their doctor’s office/HMO different from the place
they received their regular or routine care or at an MS
clinic/MS health center, while people with MS living in
more remote rural areas were significantly more likely to
access their MS-focused care at the same place they
received routine care. In addition, significantly smaller
proportions of people with MS from adjacent and more
remote rural areas reported no difficulty getting MS-related
care than their urban counterparts.
Previous studies have found significant urban/rural
differences in the availability of primary and specialty
physician services in general throughout the United States
(Reschovsky and Staiti, 2005; Miller and Zuckerman,
1991; Grumbach, Hart, Mertz, Coffman, and Palazzo,
2003; Burnett, Mark, Midtling, and Zellner, 1995). Rural
physicians are significantly less likely to practice in
medical specialties and other surgical subspecialties, and
more likely to be in general practice, than their urban
372 JHHSA WINTER 2006

counterparts (Miller and Zuckerman, 1991). The supply of

primary care physicians and especially specialists is also
lower in rural areas of the United States than in urban areas
(Reschovsky and Staiti, 2005; Rosenblatt and Hart, 1999;
Schur and Franco, 1999).
Although not MS-focused, these urban/rural studies
of the availability of specialty care indicate that people with
MS living in rural areas are more likely to receive their
MS-focused care from primary care physicians (or travel
greater distances to receive this MS care from specialists)
than people with MS in urban areas. We found that people
with MS living in rural areas are more likely than people
with MS in urban areas to have problems accessing MS-
related care. Specialty care and care provided by MS
specialists are associated with expertise in new MS
treatments and management of side-effects, as well as
increased likelihood that patients receive MS-related tests
and treatments (Vickrey, et al., 2000; Schwartz, Brotman,
LaRocca, and Lee, 1998; Vickrey, et al., 1999). Hence, the
greater difficulty accessing MS-related care experienced by
people with MS in rural areas has negative implications for
the quality of the MS care they receive.

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