title: The effects of geography and spatial behavior on health care utilization among the residents of a rural region.
abstract: 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.
  
  
  METHODS
  A survey of 1,059 adults in 12 rural Appalachian North Carolina counties.
  
  
  METHODS
  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.
  
  
  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.
  
  
  RESULTS
  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.
authors.affiliation: Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157-1084, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Arcury
authors.forename: Wilbert M
authors.initials: WM
authors.lastname: Gesler
authors.forename: John S
authors.initials: JS
authors.lastname: Preisser
authors.forename: Jill
authors.initials: J
authors.lastname: Sherman
authors.forename: John
authors.initials: J
authors.lastname: Spencer
authors.forename: Jamie
authors.initials: J
authors.lastname: Perin
mesh_terms: D000328:Adult; D001061:Appalachian Region; D003430:Cross-Sectional Studies; D005260:Female; D005843:Geography; D015438:Health Behavior; D006297:Health Services Accessibility; D006304:Health Status; D006801:Humans; D016015:Logistic Models; D008297:Male; D008962:Models, Theoretical; D015999:Multivariate Analysis; D009657:North Carolina; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D019035:Rural Health Services / Q000706:statistics & numerical data*; D013037:Spatial Behavior; D014186:Transportation