Sociation Today

Sociation Today®

ISSN 1542-6300


The Official Journal of the
North Carolina Sociological Association

A Peer-Reviewed
Refereed Web-Based 
Publication


Fall/Winter 2015
Volume 13, Issue 2




The Impact of Size of Place on Perceptions of Healthcare Services and Satisfaction with Healthcare Services among Rural Texans
Miranda Reiter
UNC-Pembroke

Jin Young Choi
Sam Houston State University

Abby Reiter
Wake Tech Community College

Gene Theodori
Sam Houston State University

    Rural residents in the U.S. face unique healthcare challenges which affect their urban counterparts far less often and to a far lesser extent. In fact, because of factors associated with rural living, rural residents face obstacles vastly different than those faced by urban residents. Cultural, Social, and economic differences, educational shortcomings, lack of acknowledgement by policymakers and the isolation of living in remote rural areas all work to hinder rural Americans in their efforts to lead healthy lives (National Rural Health Association 2013).

Access to and Quality of Healthcare Facilities in Rural Areas

    Healthcare access is relatively low in most rural areas. For instance, as compared to only 910 in urban areas, there are 2,157 Health Professional Shortage Areas (HPA’s) in rural and frontier areas. And while about one-fourth of the U.S. population lives in rural areas, only about ten percent of physicians practice there (Rural Healthy People 2010). Even the majority of rural area Emergency Medical Services (EMS) first responders are volunteers (Stanford School of Medicine 2010). Rural areas also tend to lack preventative, screening, and treatment services, oftentimes resulting in expensive and lengthy hospital stays for rural dwellers (RUPRI Health Panel 2014). Research also shows that, as compared to their urban counterparts, rural residents are more likely to report difficulty accessing care after hours (Ziller, Lenardson, and Coburn 2012).

    Access to healthcare services among rural residents is often hindered by transportation difficulties, making it hard to reach healthcare providers, as they often have to travel great distances to the nearest hospital or doctor (National Rural Health Association 2013). Further, most rural areas lack public transportation services to healthcare facilities often enjoyed by urban dwellers. Other obstacles impeding access to healthcare in rural areas include: extreme weather conditions, environmental and climatic barriers, and challenging roads (Stanford School of Medicine 2010). Certain characteristics of rural residents also put them at greater health disadvantage, as they are disproportionately poorer, older, and less educated than urban residents (Smith, Humphreys, and Wilson 2008).

    The healthcare facilities that do exist in rural areas tend to be small and provide limited services. Providing healthcare in rural areas tends to be a struggle, as affording and recruiting professionals can be challenging and requires unique strategies (Strasser 2003). At the local level, energy and attention might be so focused on assuring rural communities have physicians that the actual quality of healthcare facilities and services is overlooked (Moscovice and Rosenblatt 2000). Lower quality of healthcare in rural areas affects both rural-dwellers, as well as travelers to these locations who might need emergency care. A paucity of financial resources and barriers resulting from poor public transportation, among others, interferes with access to quality healthcare in rural areas (Merwin, Snyder, and Katz 2006). In fact, lack of health science libraries challenges rural healthcare providers who wish to keep up with evolving knowledge bases in their field and provide up-to-date quality healthcare in their communities (Merwin, Snyder, and Katz 2006). Further, research shows that rural specialists are less likely than urban specialists to be board certified, objectively indicating a relatively higher quality of care among urban specialists (Reschovsky and Staiti 2005). Also, rural physicians see more patients, as rural America is facing a shortage of practicing physicians (Gazewood, Rollins, and Glasska 2006), likely reducing care quality.

Differences in Health and Healthcare
Access within Rural Areas
 
    To better understand the effects of rural residency on health, access to healthcare services and quality of healthcare services, it is important to look beyond the rural-urban dichotomy examined in most studies on rural health. It is reported that health outcomes, such as mortality and morbidity rates, vary by community size and geographic location (Kroneman, Verheij, Tacken, and van der Zee 2010; Lewis, Meyer, Lehman, Trowbridge, Bason, Yurman, and Yin 2006; Morton 2004). For instance, Morton (2004) showed that large nonmetropolitan communities and rural communities adjacent to metropolitan areas tend to have lower mortality rates than remote rural communities, while residents living in the most remote rural areas tend to report the highest rates of pulmonary heart disease (Call, Casey, and Radcliff 2000). Further, Goins and Mitchell (1999) found that older individuals living in more rural areas are more likely to report chronic illness interference than those living in less remote areas. Choi, Reiter, and Theodori (2015) reported recently that size of place impacts health of rural Texans. The authors found that those individuals residing in small rural places generally reported better health than residents of medium-sized and large rural places.

    Both individual and community characteristics have been used to explain health disparities between rural communities of varying sizes. For instance, residents of smaller, remote rural places tend to experience more material hardship (Center for American Progress 2011), are generally poorer (Ormond, Zuckerman, and Lhila 2000), and are more likely to lack health insurance (Hale, Bennett, and Probst 2010; Maine Rural Health Research Center 2009) than residents of larger areas. Unemployment rates are also generally higher in small, remote rural communities, while levels of educational attainment tend to be lower (Monnat and Pickett 2011). These areas are also characterized by low levels of investment in health infrastructure and limited healthcare resources (e.g., fewer physicians and health care facilities, weak or nonexistent public transportation system, longer distance to health care provider, lower quality of healthcare) (Bennett, Olatosi, and Probst 2008; Burrows, Suh, and Hamann 2012; Choi 2012; Fordyce, Chen, Doescher, and Hart 2007; Office of Shortage Designation 2013). Such socioeconomic disadvantages associated with residency in small, remote rural areas have been linked with greater risk of poor health among residents (Holmes, Slifkin, Randolph, and Poley 2006; Monnat and Pickett 2011; National Rural Health Association 2013).

    Although healthcare access is relatively low in most rural areas, certain rural dwellers are at an even greater disadvantage. Size of place and distance from metropolitan areas is linked with healthcare access and usage. People who live in smaller isolated areas and/or far from metropolitan areas or urban centers often face added difficulties in contacting healthcare services and facilities due to factors such as greater distance from such services, poorer quality roads, and lack of public transportation (Ricketts 1999). 

    There are huge variations in the economics, demography, culture, and environmental characteristics between rural places. For instance, larger rural towns that are closer in distance from larger metropolitan areas tend to have more in common with metropolitan areas than they do with remote, isolated small towns. Certain health services are expected to be non-existent in smaller places, while the lack of such services in larger rural places might be considered to be a critical shortage (Hart, Larson, and Lishner 2005). The environment in which physicians and other providers practice in rural areas also differs greatly both across rural places and between rural and urban areas (Hart 1998; Ricketts, Johnson-Webb, and Randolph 1999). Physicians who serve remote and smaller rural towns practice in a medical care delivery system characterized by financially deficient populations, vulnerable medical organizations, great distances to specialists and tertiary hospitals, longer working days, scarcity of collegial support, low access to innovative technologies, and relatively high fixed costs per delivered service. This situation creates especially difficult and trying circumstances for rural providers, as well as rural populations, especially those in the most remote and smallest areas (Rosenblatt 2001).

    Little attention in the extant literature has been paid to differences in perceived need of healthcare access and satisfaction with healthcare quality among rural residents. It is important to address this perceived need and satisfaction, as neglecting to consider them ignores the subjective experience of the residents. Perceived access to healthcare is crucial, as it increases the likelihood that individuals will seek out healthcare and utilize available services (Thorpe, Thorpe, Kennelty, and Chewning 2012). Satisfaction with healthcare quality is also important because it enhances community quality of life and life satisfaction (Rahtz, Sirgy, and Lee 2004).

    The purpose of this paper is to extend the literature on healthcare access among rural residents. Specifically, we examine the relationship between population size and residents’ satisfaction with the quality of medical/healthcare facilities and the quality of doctors in their community, as well as the perceived need of better access to primary healthcare providers, specialists, and medical/healthcare facilities in their community. A major contribution of this study is that we examine the need of healthcare access among rural Texans by the population size of the place in which they reside. We investigate the impact of size of place on respondents’ agreement that better access to primary healthcare providers, specialists, and medical and healthcare facilities (clinics, hospitals) is needed in their area. This is a more subjective measure of healthcare need and perceived quality of healthcare among rural residents than the objective measure of healthcare access used in most of the relevant literature. Another contribution of this study is that we examine the impact of size of place on residents’ satisfaction with the quality of medical/healthcare facilities and doctors within rural areas.

Methods

Sample

      Data for these analyses are taken from the 2013 Texas Rural Survey (TRS), a self-administered survey conducted by the Center for Rural Studies at Sam Houston State University. The data were collected via mail and online questionnaires between June 2013 and August 2013 from a random sample of Texas residents living in 22 rural places. Data include comprehensive information on several major topics, including medical and healthcare services, public services and community amenities, among others. 

    After all places – both incorporated places (concentrations of populations with legally defined boundaries) and census designated places (concentrations of populations that are locally identifiable by name but not legally incorporated) (U.S. Census Bureau 2012) – throughout Texas with populations of 10,000 or less were identified, one place within each of three population categories (499 or fewer, 500-1,999, and 2,000-10,000) was randomly selected within each of the seven Rural Economic Development Regions classified by the Texas Department of Agriculture. Because the West Region includes a large number of places in the 499 or fewer population category, an additional place with a population of 499 or fewer in this area was included in the study, resulting in a total of 22 randomly selected study sites.

    Following a modified tailored design method (Dillman, Smyth, and Christian 2009), collection of household survey data began in early June 2013, beginning with an informational letter that was mailed to a stratified random sample of 5,608 households across the 22 study sites. The informational letter informed residents that their households were randomly selected to participate in the study in both English and Spanish on the other. The letter also instructed residents to complete the questionnaire in one of two ways: (1) online at the provided URL, or (2) by returning the mailed questionnaire they would soon receive. Due to no mistaken addresses and no rejections to participate, we sent the survey to 5,608 households.

    The survey questionnaire was mailed to the sampled households later in June 2013. In order to obtain a representative sample within the households, a cover letter was included requesting that the questionnaire be completed by the adult in the household who had most recently had a birthday. The 52-item survey questionnaire took about 50 minutes to complete and was offered in English and Spanish. After two follow-up mailings during July and August, 757 completed questionnaires were returned.

Variables

    Age is measured in years, and sex was self-reported by respondents. Race was categorized as either (1) white or (2) other racial category. Education was categorized as (1) having at most a high school diploma or equivalency, or (2) having some college or higher. Income was categorized as either (1) having an income at or above the Texas median income or (2) having an income below the Texas median income, and Insurance status was measured by self-reported (1) having some type of health insurance or (2) having no health insurance.

    Size of place was measured by the resident population of the place in which respondents lived. Places were grouped into one of the three population size categories: small rural places with populations of less than 500; medium-sized places with populations of 500 to 1,999; and large places with populations of 2,000 to 10,000.

    The need for better access to healthcare facilities and services inside the community was measured by three items on the TRS 2013:

  1. We need better access to primary healthcare providers in my community.
  2. We need better access to specialists in my community.
  3. We need better access to medical and healthcare facilities (clinics, hospitals) in my community.
    We used a dichotomous measure of these variables: (1) "strongly agree" and "agree" and (0) "strongly disagree" and "disagree."

    Satisfaction with the quality of healthcare facilities and services in the respondents' community was measured by two items on the TRS 2013:
  1.  I am satisfied with the quality of medical/healthcare facilities provided in my community.
  2. I am satisfied with the quality of doctors in my community.  
     We used a dichotomous measure of these variables: (1) "strongly agree" and "agree" and (0) "strongly disagree" and "disagree."

Analysis

    First, we ran descriptive statistics to determine the distributions of demographic characteristics, as well as other key variables, including size of place; agreement of need for better access to primary care providers, specialists, and medical and healthcare facilities; and satisfaction with the quality of healthcare services and facilities, and doctors in the community.
    
    We then ran five analytic models using binary logistic regression techniques to predict respondents’ satisfaction with the quality of, and agreement of need for, healthcare services and facilities in the community. The predictor variables in these models were: sex, age, race, education level, income, health insurance status, and size of place. The outcome variables being predicted for these five models were: (1) agreement that better access to primary healthcare providers is needed in the community; (2) agreement that better access to specialists is needed in the community; (3) agreement that better access to medical and healthcare (clinics, hospitals) is needed in the community; (4) agreement of satisfaction with the quality of medical/healthcare facilities in the community; and (5) agreement of satisfaction with the quality of doctors in the community.

Results

    As shown in Table 1, 56.2% of the respondents were female and 43.8% was male; 75.9% was white, and the mean age was about 60 years old (59.94). About a third (34%) of the respondents had a high school diploma or less, while approximately two-thirds (66%) had at least some college education. This sample is a bit more highly educated than the nation, as 57% of Americans 25 and over had at least some college education in 2012 (Pew Research Center 2013). Slightly more than half of the respondents (51.8%) reported incomes at or above the Texas median income, and most (91%) reported having some type of health insurance. The breakdown of the sample by size of place was: small (25.9%), midsize (40.7%), and large (33.4%).

    Descriptive statistics for the outcome measures show that about three-fourths (73%) of the respondents reported the need of better access to primary health care providers in their community. Close to 80% reported the need of better access to specialists, and 70.3% reported the need of better access to medical and healthcare facilities in their community. Almost half of the respondents reported that they were satisfied with the quality of medical/healthcare facilities (48.4%) and doctors (51%) in their community (See Table 1).

 

Table 1.  Summary Statistics (N=754)

Variables

Mean or %

SD

Min.-Max.

 

 

 

 

Predictors

 

 

 

 

 

 

 

Sex

 

 

 

Male

43.8

 

 

Female

56.2

 

 

Age

59.94

15.16

17-92

White “Race”

75.9

 

 

Education Level

 

 

 

High school diploma or less

34

 

 

At least Some College

66

 

 

Income Level

 

 

 

Below TX Median

48.2

 

 

At or Above TX Median

51.8

 

 

Health Insurance

 

 

 

With

91.0

 

 

Without

9.0

 

 

Size of place

 

 

 

Small

25.9

 

 

Midsize

40.7

 

 

Large

33.4

 

 

 

 

 

 

Outcome Measures

 

 

 

 

 

 

 

Needs better access in the community:

 

 

 

Primary Care

73.0

 

 

Specialists

78.9

 

 

Healthcare Facilities

70.3

 

 

 

 

 

 

Satisfied with community:

 

 

 

Healthcare Facilities

48.4

 

 

Quality of Doctors

51.0

 

 

 

 

 

 

 

 

 

 

   
    Results from logistic analyses predicting agreement that better access to primary healthcare providers, specialists, and medical and healthcare facilities were needed in their community are presented in Table 2. In all of the models, being white, as opposed to being of another racial group, significantly decreases the respondents’ odds of agreeing that healthcare access is needed in their community (OR= .448** for primary healthcare providers; OR= .360** for specialists; and OR= .353** for medical and healthcare facilities). Being male is associated with a decrease (OR= .603*) in odds of reporting agreement that better access to primary healthcare providers is needed in the respondents’ community. Size of place was a significant predictor of agreement that better access to both primary healthcare providers and medical and healthcare facilities were needed in the respondents’ place of residence. Specifically, residing in a small place, as compared to living in a large place, increases the odds of reporting agreement that better access to primary healthcare providers is needed in the community by almost two times (1.956). There were no significant effects for living in a mid-sized place compared to living in a small place. Further, residency in a small place and residency in a mid-sized place, as compared to residency in a large place, increases the odds of agreement by over two times that the respondent reported agreement that better access to medical and healthcare facilities is needed in the community (OR= 2.219** for small places and OR= 2.016** for midsize places). But, living in a small place compared to living in a mid-sized place did not significantly affect agreement that better access to medical and healthcare facilities is needed in the community.


Table 2. Odds Ratios Predicting Agreement that Better Access to Healthcare Facilities and Services in the Community is Needed

 

Primary Care Odds Ratio

Primary Care Estimate

Primary Care S.E.

Specialists Odds Ratio

Specialists Estimate

Specialists S.E

Healthcare Facilities Odds Ratio

Healthcare Facilities

Estimate

Healthcare Facilities

S.E.

Intercept

7.111**

1.962

.591

18.539**

2.920

.682

6.930**

1.936

.591

Male

.603*

-.505

.210

.774

-.256

.230

.798

-.226

.207

Age

1.001

.001

.008

.997

-.003

.008

.996

-.004

.007

White

.448**

-.803

.278

.360**

-1.022

.337

.353**

-1.043

.287

High school or less education

.742

-.299

.243

.655

-.422

.261

1.243

.218

.245

Income at or above TX Median

.737

-.305

.234

.682

-.382

.258

.726

-.320

.228

Having Health Insurance

.778

-.251

.400

.817

-.203

.442

.750

-.288

.403

Size of placea

 

 

 

 

 

 

 

 

 

Small

1.956*

.671

.278

1.054

.052

.294

2.219**

.797

.270

Midsize

1.565

.448

.233

1.156

.145

.261

2.016**

.701

.232

**< 0.01, * < 0.5

aReference category is Large Place

 
     As displayed in Table 3, age is significantly, but weakly, predictive of respondents' agreement that they are satisfied with the quality of medical/healthcare facilities and the quality of doctors in their place of residence (OR= 1.019** for medical/healthcare facilities and OR= 1.018** for doctors). Respondents at or above the Texas median income were 1.492 times more likely than those with lower incomes to agree that they were satisfied with the quality of medical/healthcare facilities in their place of residence. Consistent with the results in Table 2, size of place was a significant, but weak, predictor of respondents’ satisfaction with quality of medical/healthcare facilities and with the quality of doctors in their place of residence. For instance, living in a small place, as compared to living in a large place, decreased the odds of respondents agreeing that they were satisfied with the quality of medical/healthcare facilities by 0.529 times, while living in a mid-sized place, as compared to living in a large place, increased the odds of respondents agreeing that they were satisfied with the quality of medical/healthcare facilities in their place of residence by 0.613 times. But, there were no significant differences among respondents living in a small area compared to those living in a mid-sized area, concerning their satisfaction with the quality of healthcare facilities. Similarly, residing in a small place, as compared to living in a large place, decreased the odds of respondents agreeing that they were satisfied with the quality of doctors by 0.478 times, while living in a mid-sized place, as compared to living in a large place, decreased the odds of respondents agreeing that they were satisfied with the quality of doctors in their place of residence by 0.545 times. But, living in a small place compared to living in a mid-sized place did not significantly affect respondent likelihood that respondents were satisfied with the quality of physicians in their residential area.

Table 3. Odds Ratios Predicting Agreement of Satisfaction with the Quality of Healthcare Facilities and Services in the Community

 

Healthcare Facilities Odds Ratio

Healthcare Facilities Estimate

Healthcare Facilities S.E.

Doctors Odds Ratio

Doctors Estimate

Doctors S.E

Intercept

.237**

-1.440

.505

.312*

-1.164

.499

Male

1.170

.157

.187

1.338

.291

.188

Age

1.019**

.019

.007

1.018**

.018

.007

White

1.001

.001

.224

1.012

.012

.225

High school or less education

1.222

.201

.215

1.105

.100

.216

Income at or above TX Median

1.492*

.400

.204

1.278

.245

.204

Having Health Insurance

1.365

.311

.333

1.426

.355

.330

Size of placea

 

 

 

 

 

 

Small

.529**

-.637

.244

.478**

-.738

.246

Midsize

.613*

-.489

.212

.545**

-.607

.214

**< 0.01, * < 0.5

aReference category is Large Place
Discussion

    This study provides important insight into perceived heath care access and satisfaction with health care services among rural Texans. First, being white decreases the odds of respondents agreeing that greater access to healthcare is needed in their community. Further, being white, and being male, both decrease the odds of the respondent agreeing that greater access to primary care is needed. This is consistent with extant research (Harris 2010; Kronenfeld 2010) on stratification and access to societal resources, including healthcare.

     Overall, lack of access to adequate healthcare is a problem for rural residents (Moscovice and Rosenblatt 2000). But we find that size of place among rural residents has an effect on perceived need of better healthcare access. There is a compounding effect when socioeconomic disadvantage of this population is considered, as residents of smaller places tend to suffer from economic, social, cultural and educational deficiencies that are exacerbated by their inadequate access to, and quality of, healthcare (Litaker, Koroukian and Love 2005). Residents of smaller, often isolated, places commonly face added difficulties in contacting healthcare services and facilities (Pathman, Konrad, Dann and Koch 2004; Richards, Farmer, and Selvaraj 2005) due to factors such as greater distance from such services, poorer quality roads, and lack of public transportation (Ricketts 1999). In all, research on size of place and access to, and quality of, healthcare is suggestive that rural/nonrual disparities exist.

     As reported, respondents living in smaller places, as compared to those living in larger places, were at almost two times greater odds of reporting the need for better access to primary healthcare. Although this difference was not significant in our research, this finding makes sense because rural areas have fewer physicians and longer distance to healthcare providers than larger, less rural areas (Hays, Wynd, Veitch and Crossland 2003; Pathman, Konrad, Dann and Koch 2004; Richards, Farmer, and Selvaraj 2005). Physicians who practice in these small, rural areas serve financially deficient populations, work for vulnerable medical organizations, travel great distances to specialists and tertiary hospitals, work longer working days, suffer from scarcity of collegial support, have low access to innovative technologies, and suffer relatively high fixed costs per delivered service. These combine to make for particularly problematic and trying circumstances for rural providers, as well as rural populations, especially those in the most remote and smallest areas (Rosenblatt 2001). As we find, residents in small rural places perceive healthcare disparities in terms of access and quality.

     The current study is among the first to include subjective reports of respondents' assessments of quality of healthcare facilities and physicians among residents. We find that living in a smaller area or a mid-sized place, as compared to a larger area, decreases satisfaction with the quality of medical/healthcare facilities. This is no surprise, as only twelve percent of national spending on hospital care goes to rural hospitals, while rural hospitals make up half of all hospitals in the U.S. (American Hospital Association 2011). The quality of physicians in rural areas is possibly lower than that of physicians in more urban areas. For instance, the average age of practicing physicians is higher in rural areas, meaning that the average rural physicians graduated from medical school years, or even decades, before the average urban physician. This likely impacts older physicians' knowledge of more recent medical technologies and up-to-date training, possibly affecting patient satisfaction. In fact, we found that those living in small or mid-sized places of residence were less likely to report satisfaction with the quality of the physicians in their place of residence. This is troubling, as rural residents are aging rapidly (The Housing Assistance Council 2014), and are among those with the highest mortality and disease rates (Center on an Aging Society 2003), but the lowest health insurance coverage (U.S. Department of Health and Human Services 2013).

    This is the first study, to our knowledge, that considers the subjective reports of rural Texan respondents’ access to, and quality of, healthcare and doctors. While this research provides useful contributions to extant literature on healthcare access and satisfaction among rural residents, there are some minor limitations. First is the relatively low response rate. Although the TRS data are based on a random sample, nonresponse can induce nonresponse bias (Groves 2006), as certain characteristics of those individuals who did not respond may differ from those who did respond. And, because the data were collected via paper surveys and web-based surveys, individuals who are illiterate would not be able to participate in the study. Therefore, these voices are not included in the results. As with all self-reported surveys, there is potential for participant reporting error and respondent bias (Sax, Gilmartin, and Bryant 2003).

    This research points towards a few policy implications. First, access to medical and healthcare needs to be improved in rural areas, especially smaller, more isolated places. These areas tend to be among the most lacking in these resources, partly due to a paucity of financial resources and less political clout. Further, access to primary physicians is lower in more rural areas. This is because younger physicians generally prefer to practice in more urban areas which offer them more attractive lifestyle options (Rabinowitz, Diamond, Markham, and Wortman 2008). Healthcare reform aimed at promoting rural medical practice, recruitment for all types of rural healthcare professionals, and incentives to practice in rural areas are necessary to ameliorate rural/nonrural healthcare disparities (Dolea, Stormont, and Braichet 2010).  And, enhancing physician attachment in less dense areas is also necessary in maintaining them in these. But, because physician retention seems less of a problem than physician recruitment in areas with lower population size, improving physician recruitment strategies in these areas is critical locations (Pathman, Konrad, Dann, and Koch 2004).

    Also, adoption of health information technologies in rural America is much slower than in other places (Flex Monitoring Team 2006). Such technologies help improve patient safety, efficiencies, and quality of care. For instance, Chaudhry et al. (2006) found that health information technologies had an especially large impact on increasing adherence to guideline- or protocol-based care, enhancing quality of care. Further, new technologies in the Internet, communications, and advanced "smart devices"  can likely improve emergency medical response to incident disasters related to high numbers of fatalities by improving mass-casualty field care, safety of providers, field incident command, informatics support, regional emergency department and hospital care, and so on (Chan, Killeen, Griswold, and Lenert 2004). Medical workforce shortages and lower quality healthcare services and facilities in rural areas exist even though these areas typically have greater need for medical services, as compared to nonrural places (Center on an Aging Society 2003; National Advisory Committee on Rural Health and Human Services 2008). In order to improve health information technologies in rural areas, a nationwide effort to provide affordable and accessible high-level telecommunications technology and broadband to rural areas is imperative.

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Editorial Board:
Editor:
George H. Conklin,
 North Carolina
 Central University
 Emeritus

Robert Wortham,
 Associate Editor,
 North Carolina
 Central University

Board:
Rebecca Adams,
 UNC-Greensboro

Bob Davis,
 North Carolina
 Agricultural and
 Technical State
 University

Catherine Harris,
 Wake Forest
 University

Ella Keller,
 Fayetteville
 State University

Ken Land,
 Duke University

Steve McNamee,
 UNC-Wilmington

Miles Simpson,
 North Carolina
 Central University

William Smith,
 N.C. State University