Self-reported Barriers to Surgical Access in Rural Alabama: A Quality Controlled Assessment of Patient Perspectives

Special Article – Rural Medicine

Austin Med Sci. 2020; 5(1): 1038.

Self-reported Barriers to Surgical Access in Rural Alabama: A Quality Controlled Assessment of Patient Perspectives

Smood B and Paxton R*

Department of Community Medicine and Population Health College of Community Health Sciences Institute for Rural Health Research, The University of Alabama, USA

*Corresponding author: Raheem J. Paxton, Department of Community Medicine and Population Health College of Community Health Sciences Institute for Rural Health Research, The University of Alabama, USA

Received: December 13, 2019; Accepted: January 11, 2020; Published: January 18, 2020


Limited data exist on the barriers to surgical care in rural America. Prior studies have focused primarily on select procedures and not patient-reported barriers. As part of medical student’s capstone project during a rural medicine acting internship at a regional campus, we adapted and piloted a survey to examine barriers to surgery in the rural Deep South.

Methods: A participatory process was used to modify an existing survey. The final survey was piloted in a convenient sample of adults (N=10, Mean age = 61, 100% rural, 50% female). Descriptive statistics were used to characterize the study population.

Results: Among patients surveyed, 80% self-reported comorbid conditions. Commonly reported barriers to surgical care were lost wages due to surgery (75%), no one to care for family or belongings while out for surgery (75%), fear of surgery and/or complications (75%), and surgery not being an emergency (50%). The average distance travelled to receive surgery was 25 miles, or 31 minutes.

Discussion: Our data indicate that rural adults have several comorbid conditions and perceive that factors of affordability (e.g., lost wages) and acceptability (e.g., fear of surgery) are the most significant hurdles to surgery. Additional research and larger samples are needed to examine potential differences and disparities that may exist.

Keywords: Rural medicine; Healthcare barriers; Disparities; Surgery


Rural populations experience significant challenges that contribute to poor health [1,2]. The challenges that are most concerning are those related to access to adequate healthcare. Studies have indicated that rural adults experience financial burdens, geographic isolation, lack of transportation, and high patient to provider ratios, which hinder adequate access to care [3-6]. The barriers to care experienced by rural Americans often translate to greater disease burden and higher mortality rates when compared to urban Americans [7].

The barriers observed in general access to care often translate to even greater deficits in access to surgical care [8,9]. Studies conducted in the United States correlate poor surgical outcomes in rural areas to lower socioeconomic status and inadequate access to surgical facilities and/or specialists [1,2,10-13]. In rural developing countries, common patient-reported barriers to surgical care include structural (i.e. distance to care, lacking nearby facilities/specialists), cultural (i.e. fears of surgery, or societal norms that discourage seeking care) and financial (i.e. lost wages during/after surgery, direct costs) factors [4]. To our knowledge, the patient-reported barriers experienced by rural Americans have not been adequately examined. Prior studies have focused exclusively on selected surgical procedures, and rarely address patient-perceived barriers to surgical care, particularly among populations with considerable disease burden [1-3,6,7,9-18]. Americans living in the rural Deep South are vulnerable especially to adverse health outcomes as a result of financial, geographic, contextual, and cultural barriers [1,2,6-8,10,14]. Thus, there is a need to elucidate the patient-reported perceived barriers that contribute to inadequate surgical care [15].

The purpose of this study was to address a significant gap in the literature by identifying patient-perceived barriers to surgical care through convenient sampling of adults living in the rural Deep South. This work reflects a capstone project of a third-year medical student’s community engagement as a requirement of an 8-week sub-internship in rural family medicine at the Tuscaloosa Regional Campus of the University of Alabama at Birmingham.

To do so, we applied a systematic approach to account for response bias. We used a participatory process to identify, adapt, and pilot our instrument in a rural patient population. To maximize participation and prevent misinterpretation, clear definitions and short surveys in plain language are requisite, particularly in rural communities where literacy is low [19-22]. Therefore, we sought to develop a survey that accurately assessed patients’ opinions regarding access to surgical care in order to provide important context when considering potential solutions. We provide a reliable, pilot-tested survey distributed to patients that can serve as a guiding framework for future investigations that may identify targeted solutions for addressing the perceived barriers to surgical care apparent to rural adults.


Sample and Survey design

Study participants were recruited from a Federally Qualified Healthcare Center (FQHC) in a rural city in the Deep South during two summer months of 2018. All survey participants were asked to participate in a self-reported survey and provide feedback based on their perception of surgical barriers in their respective communities. The instrument was pre-piloted for survey modification purposes. The final survey was established when 10 consecutive patients were able to complete the survey without assistance or suggestions for improvement. Only these 10 surveys were used in the analysis of this study, establishing a ‘true sample’ for this pilot study. The Flesch– Kincaid Grade score was 8.3, indicating statements were written in plain English and easily understood by 13 to 15 year old students. Eligibility criteria included living in rural Alabama (Pickens County) for more than 10 years, some high school education, and being an established patient at the local FQHC. Anonymized surveys were collected on paper and responses were manually transferred into a secure access database for analysis. The study protocol was approved by the University of Alabama Institutional Review Board as part of a larger community needs assessment study.


To administer the survey, nursing staff provided patients with the questionnaire upon entering the exam room, which could be completed while waiting for the physician. Patients were educated on the purpose of the questionnaire, which included a written description of the study with consent to participate. Participation was voluntary. No incentive was provided. Patients were instructed that surgery is defined as any procedure requiring general anesthesia (“being put to sleep”). Distance travelled for surgery was calculated as the mileage from the home city to the hospital where participants reported receiving the procedure.

Survey modifications

Participant feedback was sought for general suggestions to improve the questionnaire, including readability, areas needing clarification, and length. Suggested modifications were incorporated at the end of one week intervals. In total, five versions of the questionnaire were distributed before establishing the final form of the survey. Primary concerns during survey development included that the survey was too long, which should be able to be completed before the physician entered the room.

Scaled responses for the primary endpoint were modified from a five-point Likert format and reduced to three-point responses including “Yes, No, or Maybe” [23]. Text size was increased, as many patients cited not having their reading glasses as a reason for not completing the survey. Open-ended responses we removed in the final product, but incorporated the commonest open-ended responses from pilot-surveys.


Barriers to Surgical Care: The instrument utilized for this study consisted of 19 of 38 barrier-specific items of a questionnaire that was developed and validated previously [24]. Items that were not relevant to rural Americans and those that were redundant were removed. The remaining 19-items pertained to the following domains: acceptability (e.g., fear of pain, anesthesia, complications), affordability (e.g., cost and lost wages), and accessibility (e.g., distance and time between referral and procedure). The original items was rated on a binary scale (yes or no). We revised the rating scale by adding a response category (i.e., maybe). Participants were asked to respond to the 19-items based on their perceptions of barriers in the community. Perceived barriers influencing access to surgical care were classified among three previously defined dimensions including: acceptability, accessibility, and affordability [24].

Those who had not received surgery that was previously recommended were asked to answer additional questions regarding their interest in the surgery, and check off the barriers that prevented the surgery. Additional questions, such as, “how hard is it for your community to get surgery if they needed it” and “types of surgeries previously had” were asked. The former was rated on a Likert-type response scale that included the following responses: “much harder, somewhat harder, not harder or easier, somewhat easier, much easier” [23]. The second question allowed participants to indicate whether or not they had a particular surgery.

Sociodemographic and medical characteristics

Study participants also self-reported their age, gender, education, insurance status, current employment, and chronic health conditions. A modified version of the Charleston Comorbidity index was utilized and total number of chronic health conditions were computed by summing the number of conditions indicated on the instrument.

Statistical Analysis

Descriptive statistics were computed to examine participant responses. Simple frequencies, percentages, means, standard deviations, and ranges were computed. Survey reliability was calculated using Chronbach’s alpha. As this is a pilot study with a small sample size, no significance tests were computed. All data were analyzed with SPSS version 24.0.


Patient Characteristics

A total of 11 final surveys were distributed, and 10 were completed (90%). One patient declined to participate. We intentionally recruited 5-male and 5-female participants. All participants self-reported their race as Caucasian. Descriptive statistics of study participants were reported in Table 1. On average, participants were 61 years old (range 27-86) at survey completion, reported a previous diagnosis of high blood pressure (80%) or depression (40%), had Preferred Provider Organization insurance (40%), and completed at least some college (50%). Participants were either employed full-time (40%) or retired (40%). The average number of self-reported comorbid conditions was 3 (range 0 to 8; Table 2).