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J Gen Intern Med. 2011 Nov;26 Suppl 2:648-54. doi: 10.1007/s11606-011-1762-1.

Distance is relative: unpacking a principal barrier in rural healthcare.

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VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region (VRHRC-CR), Iowa City VA Medical Center, 601 Highway 6 West, Mailstop 152, Iowa City, IA 52246-2208, USA.



Distance to healthcare services is a known barrier to access. However, the degree to which distance is a barrier is not well described. Distance may impact different patients in different ways and be mediated by the context of medical need.


Identify factors related to distance that impede access to care for rural veterans.


Mixed-methods approach including surveys, in-depth interviews, and focus groups at 15 Veterans Health Administration (VHA) primary care clinics in 8 Midwestern states. Survey data were compiled and interviews transcribed and coded for thematic content.


Surveys were completed by 96 patients and 88 providers/staff. In-depth interviews were completed by 42 patients and 64 providers/staff. A total of 7 focus groups were convened consisting of providers and staff.


Distance was identified by patients, providers, and staff as the most important barrier for rural veterans seeking healthcare. In-depth interviews revealed specific examples of barriers to care such as long travel for common diagnostic services, routine specialty care, and emergency services. Patient factors compounding the impact of these barriers were health status, functional impairment, travel cost, and work or family obligations. Providers and staff reported challenges to healthcare delivery due to distance.


Distance as a barrier to healthcare was not uniformly defined. Rather, its importance was relative to the health status and resources of patients, complexity of service provided, and urgency of service needed. Improved transportation, flexible fee-based services, more structured communication mechanisms, and integration with community resources will improve access to care and overall health status for rural veterans.

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