Women's Healthcare Utilization in Primary and Acute Care Contexts

In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g., strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. The research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas. Study 1: In addition to racial discrimination, Black Appalachian women often face other obstacles involving other types of negative interpersonal experiences when seeking healthcare. Despite these known disparities, Black women are frequently underrepresented in Appalachian health research. This study investigated healthcare experiences for sixteen Black Appalachian women using semi-structured interviews to identify and subsequently address ways to eliminate barriers to care.
Interview questions utilized the theory of intersectionality and the Social Ecological Model to create a framework to describe the complexity of healthcare utilization and barriers to care while providing context into each participant's background and lived experience. Interview questions explored four topics: 1) barriers to medical care; 2) social support; 3) ideal and actual healthcare experiences; and 4) desired changes to improve quality of care. We used an inductive analysis process to create a robust thematic coding schema, organizing responses into 60 total themes and 141 codes, and reported the most frequent. Our results explore the ways in which one's intersectional identity as a Black Appalachian woman affects interpersonal interactions and experiences when engaging with the healthcare system. Participants frequently reported barriers related to scheduling conflicts and delays, experiences with rushed appointments and inhospitable providers and support staff, and desires for accurate collection of medical information. Participant responses often emphasized difficulties with the organization of the medical system, revealing specific areas for future intervention to improve quality of care for Black Appalachian women.
Study 2: Use of the emergency department (ED) for low acuity conditions (e.g., back pain, dental pain, sore throat) and primary care places an additional strain on ED staff and resources, while increasing waiting and treatment times for high acuity patients. Factors such as race, gender, and insurance type have a strong association with the likelihood of a patient using the ED for a low acuity concern. Women are more likely to utilize healthcare services, which also holds true in the context of the ED. Using a sample of adult women from Virginia, West Virginia, Tennessee, North Carolina, and Kentucky, I investigated which demographic factors, age, race, geographic location (metro, nonmetro, rural), employment, and insurance coverage, affect a patient's likelihood to visit the ED for a low acuity condition within a southwestern Virginia hospital system. Log-binomial regression was used to estimate unadjusted and adjusted prevalence ratios of acuity level by race, age, rurality level, employment, and insurance type with corresponding 95% CIs. Our sample included 28,222 female patients who visited the ED between January 1, 2021 and September 30, 2022. Low acuity visits accounted for 15.9% (n=4,485) of visits during the timeframe. In summary, our results suggest that older age and location in non-metro area are the most salient factors contributing to a higher likelihood of low acuity ED visits among women. Race, a primary variable of interest, did not have the relationship to acuity that was expected based on previous literature; Black women patients were less likely to have a low acuity visit than white women patients. During our study period, overall number of visits remained steady, while there was an increase in proportion of low acuity visits. Further research is needed into the underlying causes to more definitively explain this increase.