Rural hospital closures and perceived access to care: A qualitative descriptive study in Tennessee










A Dissertation Presented for the
Doctor of Public Health 
Degree
The University of Tennessee, Knoxville












Amanda Marie Letheren
May 2021




















Copyright © 2021 by Amanda Marie Letheren
All rights reserved.















ACKNOWLEDGEMENTS

Thank you.

ABSTRACT

Background: Tennessee has suffered more hospital closures per capita than anywhere else in the nation. The impact of hospital closures on access to care in economically distressed, rural, Appalachian counties of Tennessee is of particular concern because these vulnerable communities face unique health challenges such as higher rates of mortality compared to the United States. Hospital closures may exacerbate these disparities and create additional barriers when accessing care.

Objectives: The aim of this study was to describe community residents’ perceptions of access to care following a hospital closure in a rural, economically distressed, Appalachian county of Tennessee.

Methods: This study used a qualitative descriptive approach, guided by Penchansky and Thomas’ framework of healthcare access, to present community residents’ perceptions of health and access to care following a hospital closure. Semi-structured interviews were conducted via telephone with 24 community residents from a rural, economically distressed, Appalachian county of Tennessee that recently experienced a hospital closure. Interviews were analyzed using conventional content analysis to identify themes.

Results: Results from interviews revealed four themes: access to care; stress and coping mechanisms; value for the hospital; and conflict. Access to care was negatively affected across all five dimensions of the healthcare access framework. Stress and coping mechanisms describe a rise in stress surrounding the closure of the hospital and, consequently, community residents engaging in unhealthy and healthy coping mechanisms such as putting off care or being more cautious. Value for the hospital describes the importance of a hospital for community viability. Conflict reveals negative emotions among community residents towards those in leadership positions.

Conclusion: This study revealed that a hospital closure has a multi-dimensional, negative impact on the community, and community residents valued their hospital for more than accessing healthcare. The results of this study provide a critical perspective to inform elected officials, healthcare professionals, and community leaders on how to more effectively and efficiently meet the rural health needs of their community. 


PREFACE

This page is optional.

TABLE OF CONTENTS

Chapter One Introduction to the Study	1
Statement of the Problem	1
Purpose of the Study	4
Research Questions	4
Conceptual Framework	4
Significance of the Study	5
Definition of Terms	7
Delimitations	8
Organization of the Study	9
Chapter Two Literature Review	10
What is Access to Care?	10
Conceptual Framework: A Model of Healthcare Access	13
The Appalachian Region	13
County Economic Status in Appalachia	15
The Triple Threat for Health Disparities	16
Health Perceptions in Appalachia	21
Barriers to Healthcare	22
Rural Hospitals	26
A History of Rural Hospital Closures	27
Challenges to Providing Hospital Care in Rural Areas	28
Impact on Access to Care	33
Conclusions	36
Chapter Three Methods	38
Why Qualitative Methods?	38
Research Design	38
Sample	39
Procedures	41
Chapter Four Findings	44
Descriptive Statistics	44
Definition of Health and Access to Care	48
Themes	49
Chapter Five Discussion	60
Summary of Findings	60
Interpretation of the Findings	61
Implications for Practice and Policy	63
Strengths and Limitations	63
Conclusions	63
References	64
Appendix	73
Vita	79



LIST OF TABLES

Table 2.1 Comparison of County Health Measures of Fentress County vs. TN (University of Wisconsin Population Health Institute, 2019b).	20
Table 3.1 Semi-structured interview guide	80


LIST OF FIGURES


Figure 2.1 Map of the Appalachia Region (Appalachian Regional Commission, n.d.-a)	14
Figure 2.2 County Economic Levels in Appalachia (Appalachian Regional Commission, 2019a).	17
Figure 2.3 Chart of Mortality Rates per 100,000 Population, 2008-2014, of the Appalachian Region compared to the U.S., Rural Appalachia, and Distressed Appalachia (Marshall et al., 2017).	19
Figure 3. 1 Recruitment Advertisement	84
Figure 4.1 Word Cloud of Health Definition	50
Figure 4.2 Word Cloud of Access to Care Definition	50



LIST OF ATTACHMENTS

Codebook (Codebook.xlsx)




ii

Chapter One
Introduction to the Study
In recent years, the number of rural hospital closures has increased significantly, raising substantial concern among the healthcare industry, policymakers, and the general public (Cecil G. Sheps Center for Health Services, 2020). Although research regarding rural hospital closures’ impact on access to care is limited, the available research generally draws similar conclusions: rural hospital closures may have adverse consequences for access to care and may disproportionally affect vulnerable communities (Muus, Ludtke, & Gibbens, 1995; Reif, DesHarnais, & Bernard, 1999; United States Government Accountability Office, 2018; Wishner, Solleveld, Rudowitz, Paradise, & Antonisse, 2016). Understanding closures from the perspective of community residents residing in vulnerable communities is critical when identifying barriers in access to care and developing appropriate policy responses. The aim of this study was to describe community residents’ perceptions of health and access to care following a hospital closure in a rural, economically distressed, and Appalachian county of Tennessee.
This chapter begins with a summary of the recent rural hospital closures in Tennessee and issues associated with access to care. The purpose of the study, research questions, definition of terms, delimitations, limitations, and significance of this research is also provided. The chapter will conclude with the organization of chapters in this study.  
Statement of the Problem
Tennessee, a dramatically unhealthy state, has suffered more hospital closures per capita than anywhere else in the nation (Tennessee Justice Center, 2018; United Health Foundation, 2018). Fourteen rural hospitals have closed in Tennessee since 2012, and many more are at risk (Cecil G. Sheps Center for Health Services, 2020). The increasing risk of hospital closures has fueled a discussion about healthcare delivery in vulnerable communities and how these closures affect community residents’ access to care. 
The impact of hospital closures on access to care in vulnerable communities, defined as a population that is more likely to be in poor health due, is of particular concern because these communities face unique health challenges (American Hospital Association, 2016; Marshall et al., 2017). Rural, economically distressed, and Appalachian communities of Tennessee are some of the most vulnerable in the United States. Not only do these communities face persistent poverty, geographic isolation, and a shrinking population, they also are on average older, sicker, and poorer than the rest of the nation  (Marshall et al., 2017; United States Government Accountability Office, 2018). Lower levels of education, lower income, and higher rates of disability are also apparent across the region, indicating a less healthy population overall (Marshall et al., 2017). Appalachia Tennessee suffers from higher rates of mortality including heart disease, cancer, chronic obstructive pulmonary disease, injury, stroke, diabetes, and suicide compared to the United States. These rates are even more severe in rural and economically distressed counties of Appalachia Tennessee, and these health disparities are widening (Marshall et al., 2017).
Distorted perceptions of health may contribute to these disparities (Ely, Miller, & Dignan, 2011). A study published by Griffith and colleagues found that Appalachian residents are more likely to report good health despite having one disease condition and/or participating in poor health behaviors (Griffith, Lovett, Pyle, & Miller, 2011). In fact, 74% perceived themselves as healthy, contradicting the fact that Appalachia is one of the unhealthiest regions in the United States (Griffith et al., 2011; Marshall et al., 2017). This disconnect suggests that Appalachian communities may view “health” and “access to care” differently than other communities. Further research is needed to investigate the meaning of the concepts “health” and “access to care” among rural, economically distressed, and rural communities of Tennessee.
The unique health challenges prevalent in Appalachia Tennessee may be compounded by the recent increase in rural hospital closures. While not all rural hospital closures have an adverse impact on access to care, hospital closures may exacerbate these disparities and create additional barriers when accessing healthcare services (United States Government Accountability Office, 1991; Wishner et al., 2016). For instance, a rural hospital closure may affect a resident’s ability to obtain necessary healthcare in a timely manner due to limited availability or absence of emergency and acute-care services, increased travel time to get care, and an outmigration of health care professionals in the area (Wishner et al., 2016). These barriers to access can result in delayed or unmet healthcare needs and may increase the risk of poorer health outcomes (Healthy People 2020, 2019). In fact, a 2019 study by researchers at the University of Washington found that a rural hospital closure increased mortality rates by 5.9 percent in the surrounding area (Gujral & Basu, 2019).  
As rural hospitals continue to close, it is crucial to understand the impacts on local access to care in vulnerable communities. Fentress County, the site of study, qualifies as a rural, economically distressed, and Appalachian county of Tennessee (Appalachian Regional Commission, 2019a; Health Resources and Services Administration, 2018). Fentress County is characterized as having a higher poverty rate and lower median household income as compared to the rest of the state and nation (United State Census Bureau, n.d.). Fentress County also serves higher rates of people who are uninsured, older, and disabled. Furthermore, Fentress County is designated by the U.S. Department of Health and Human Services as a Health Professional Shortage Area and a Medically Underserved Area (Tennessee Department of Health, 2018). Jamestown Regional Medical Center, the only hospital in Fentress County, closed in June 2019 and left community residents without timely access to care. Given their experiences of accessing care in Fentress County, the community resident perspective is critical in understanding the impact on access to care and identifying areas to reshape healthcare within their community.
Purpose of the Study
The purpose of this study was to describe community residents’ perceptions of health and access to care following a hospital closure in a rural, economically distressed, and Appalachian county of Tennessee through qualitative methods.
Research Questions
Three research questions guided this study:
 How do community residents from a rural and economically distressed, Appalachian county of Tennessee define health?
 How do community residents from a rural and economically distressed, Appalachian county of Tennessee define access to care?
 How do community residents describe the impact of a hospital closure on access to care in a rural and economically distressed, Appalachian county of Tennessee?
Conceptual Framework
Two frameworks guided this study: naturalistic inquiry and Penchansky and Thomas’ framework of healthcare access. The philosophical approach for this research was naturalistic inquiry, which is embedded within the constructivist paradigm (Lincoln & Guba, 1985). This philosophy states that there are multiple realities constructed by different individuals. These realities can only be studied in their natural setting because realities are whole and cannot be understood without their context (Lincoln & Guba, 1985). The aim of this naturalist inquiry was to describe community residents’ constructed meanings of reality regarding accessing care following a hospital closure. This approach would expect that community residents involved would have different experiences and perceptions of accessing care following a hospital closure. My job was to capture and describe these multiple constructed realities through open-ended interviews without deeming which perceptions were right or hold more truth.  
This study also followed Penchansky and Thomas’ framework of healthcare access to help construct interview questions, analyze data, and develop practice and policy recommendations (Penchansky & Thomas, 1981). Penchansky and Thomas define access to care as the fit between the patient and the health care system through five dimensions: availability, accessibility, accommodation, affordability, and acceptability (Penchansky & Thomas, 1981). This framework helped me to understand the different dimensions of access impacted by a rural hospital closure and offer solutions to improving access to care. This framework is explored further in Chapter Two.
Significance of the Study
United States healthcare expenditures have increased sharply from 5 percent of the economy in 1960 to 17.7 percent in 2018 (Centers for Medicare & Medicaid Services, 2019). Not only is the rise in healthcare spending unsustainable, this figure is more than twice the average among developed countries, and the United States still experiences worse health outcomes (Tikkanen & Abrams, 2020). A healthcare system with high costs and poor health outcomes is the result of many factors. One of these factors includes gaps in access to health care and is the focus of this study.
Evidence shows that access to affordable, quality health care is important for preventing, detecting, managing, and curing diseases and injury (Healthy People 2020, 2019). National and federal organizations have declared increasing access to health care services as a primary objective. Healthy People 2030, released by the U.S. Department of Health and Human Services, sets national objectives to improve the health and well-being of Americans. Improving access to quality health services, especially among the nation’s most vulnerable populations, is one of the objectives (Healthy People 2030, n.d.).  The American Hospital Association, a national organization that represents hospitals, healthcare networks, patients, and communities, has also declared ensuring access in vulnerable communities a top priority (American Hospital Association, 2016). 
The recent trend of rural hospital closures has raised substantial concern about the impact on access to care, especially in vulnerable communities. Interventions thus far have focused on short-term reimbursement fixes to keep rural hospitals open, but this is not enough (Flex Monitoring Team, n.d.). 18 rural hospitals closed in 2019, and 17, so far, closed in 2020 (Cecil G. Sheps Center for Health Services, 2020). As the United States healthcare delivery system continues to transform and recover from the current COVID-19 pandemic, more vulnerable communities will be at risk for losing their hospital. Long-term solutions are needed to preserve local access to care in these vulnerable communities. 
Understanding a particular community’s capacity to address issues is critical when determining the community’s options and future strategies (RUPRI Health Panel, 2017). Allowing community residents to share their voice, a perspective that is largely absent in the literature, is vital information when considering how to improve healthcare (Levy, Holmes, Mendenhall, & Grube, 2017). Qualitative methods may help capture this perspective best. By studying community residents’ perceptions of health and access to care following a rural hospital closure via open-ended questions, local elected officials, healthcare professionals, and community leaders can better understand the meaning of health and the factors influencing access to care. The results of this study could provide ideas for long-term interventions to improve and preserve local access to care in Fentress County that more effectively and efficiently meets the health needs of its community.  The results of this study may also have broader applicability by serving as a guide for other vulnerable communities who lost their hospital.
Definition of Terms
This section introduces and defines terminology in the study. 
Access
Penchansky and Thomas define access to care as the fit between the patient and the health care system, which encompasses the following five dimensions: availability, accessibility, accommodation, affordability, and acceptability (Penchansky & Thomas, 1981). For the purposes of this study, the “patient” is the community resident.
Community Resident
All individuals who reside in Fentress County.
Rural Hospital
A rural hospital, as classified by the Federal Office of Rural Health Policy, is any general, non-federal, short-term, acute hospital that is located outside a metropolitan area, or is located within a metropolitan area and has a Rural Urban Commuting Area (RUCA) equal to or greater than 4, or is a Critical Access Hospital (Cecil G. Sheps Center for Health Services, 2020; Health Resources and Services Administration, 2018) . 
Closed Hospital
A closed hospital, as defined by the Office of Inspector General, is any facility that no longer provides general, short-term, acute inpatient services (Rehnquist, 2003).
Distressed Counties
Every year, the Appalachian Regional Commission (ARC) creates an index of economic status for each United States county (Appalachian Regional Commission, 2019b). Economic status designations are created through the summation and average of each county's three-year average unemployment rate, per capita market income, and poverty rate compared to the national average. Counties are classified as distressed if they fall into the lower quartile for all three categories (Appalachian Regional Commission, 2019b). As of 2019, there are 15 distressed counties in Tennessee including: Lake, Lauderdale, Hardeman, McNairy, Perry, Wayne, Jackson, Clay, Grundy, Bledsoe, Fentress, Morgan, Scott, Hancock and Cocke.
Delimitations
This study was delimited to hospital closures located in rural and economically, distressed Appalachian counties of Tennessee. These vulnerable communities experience worse health disparities compared to the state as a whole (Marshall et al., 2017). This narrowed the scope of the study to two possible counties: Clay and Fentress. The study was further delimited to Fentress County because its only hospital closed, leaving residents without a hospital in their county as of June 2019. Participants who had lived in Fentress County for at least 5 years were included in the study. All study participants were 30 years and older regardless of gender, race, or ethnicity. It was beyond the scope of this research to investigate the reasons behind the hospital closure or other impact measures such as economic effects or health outcomes. 
Organization of the Study
Chapter 1 contains the background and statement of the problem, purpose of the study, research questions, significance of the study, definition of terms, delimitations, and limitations. Chapter 2 is a review of relevant literature related to the research questions. Chapter 3 is a detailed description of the methodology to be used in the study, including the research design, data collection procedures, and the data analysis plan. Chapter 4 will present the findings. Finally, Chapter 5 will provide overall conclusions of the study, implications for further research, and applications to rural health policy. 

Chapter Two
Literature Review
Unequal access to health care is still widely prevalent in the United States, especially in economically distressed and rural communities of Appalachia (Dickman, Himmelstein, & Woolhandler, 2017; Wilson, Kratzke, & Hoxmeier, 2012). People living in economically distressed or rural communities of Appalachia are more likely than the rest of the nation to die prematurely from seven of America’s leading causes of death including heart disease, cancer, chronic obstructive pulmonary disease, injury, stroke, diabetes, and suicide (Marshall et al., 2017). Ensuring access to care in these communities is critical for managing chronic health conditions, premature death, and reducing health disparities.
When framing a research study, it is important to provide a comprehensive background of the study topic. This literature review begins with an exploration of the concept “access to care” followed by the conceptual framework of the study. The second section provides an overview of the geography, economic status, health disparities, and health perceptions of the Appalachian Region. The third section discusses barriers to care in economically distressed, rural Appalachia areas organized by the conceptual framework. The fourth and fifth section explore the rural hospital landscape and existing research studies on rural hospital closures’ impact on access to care. The chapter concludes with gaps in the literature and how this study will address these gaps.
What is Access to Care?
Access to care is the most frequently used word when discussing the United States healthcare system, yet there is considerable confusion on what the concept of access to care means (Levesque, Harris, & Russell, 2013).  Many definitions and models of access to care have developed from a range of perspectives over time and have been driven primarily by issues in our healthcare system (Donabedian, 1972; Freeborn & Greenlick, 1973; Institute of Medicine Committee, 1993; Penchansky & Thomas, 1981; Russell et al., 2013). To some, access to care is equated with having health insurance coverage. Others equate access to having enough doctors or hospitals within a certain area (MacKinney et al., 2014). Furthermore, some define access as the utilization of health services (Aday & Andersen, 1974). This lack of agreement can create flawed health policy responses and perpetuate access to care issues seen within the healthcare system (Levy et al., 2017; Russell et al., 2013). To establish the basis of this study’s proposed framework, this section first investigates the three most common frameworks that attempt to understand individuals’ access to health care. 
The Behavioral Model of Health Services Use, created by Ronald Andersen, is the most common framework implemented in access research (Aday & Andersen, 1974; Ricketts & Goldsmith, 2005). It focuses on individual-level factors that influence health services utilization (Derose, Gresenz, & Ringel, 2011). This framework examines an individual’s use of health services based on three factors: predisposing factors (i.e. demographics), enabling factors (i.e. health insurance), and need factors (i.e. health status). Over time, the Behavioral Model has undergone multiple iterations. It has been revised to include measures of potential access, realized access, environmental factors, health behavior, and health outcomes (Derose et al., 2011). The Behavioral Model serves as a good framework if the objective of the research is to increase effective and efficient use of health services (Karikari-Martin, 2010).
Penchansky and Thomas’ 5 A’s
Penchansky and Thomas offer another approach to understanding access by focusing on barriers to accessing health care. Penchansky and Thomas define access as the ‘degree of fit’ between the patient and the healthcare system (Penchansky & Thomas, 1981). Fit is measured across five dimensions including availability, accessibility, accommodation, affordability, and acceptability (Penchansky & Thomas, 1981). Availability is the extent to which the volume and type of existing health care services meet the needs of the patient. Accessibility is the geographic relationship between patients and heath care services, such as distance traveled. Accommodation describes how well the healthcare system fits the patient’s needs and preferences, such as hours of operation. Affordability is the patient’s ability and willingness to pay care provided by the healthcare system. Acceptability describes the relationship of patient’s attitude towards the characteristics of the provider or facility and vice versa. This includes characteristics such as age, sex, ethnicity, and social class of the provider and patient, as well as type of insurance coverage of the patient (Penchansky & Thomas, 1981). This approach is most useful when subjective experiences of health care access are needed to inform policy (Karikari-Martin, 2010).
National Academy of Medicine
The National Academy of Medicine, formerly known at the Institute of Medicine, developed a framework for understanding individuals’ access to health care services. This framework defines access as “the timely use of personal health services to achieve the best possible health outcomes” (Institute of Medicine Committee, 1993). Most applications of this framework are used to highlight health outcomes, such as mortality and morbidity, as an indicator of health care access (Derose et al., 2011). This framework is most useful for monitoring access (Derose et al., 2011). 
Conceptual Framework: A Model of Healthcare Access
Penchansky and Thomas’s model was selected as the underlying framework for this study to help understand the subjective experiences of community residents accessing care following a hospital closure. While Penchansky and Thomas’s model recognizes that the process of access is dynamic, it is not often applied to structural transitions in the healthcare system, such as a closure of a hospital (Ricketts & Goldsmith, 2005). The dynamic process of accessing care depends largely on how community residents perceive the healthcare system and healthcare (Ricketts & Goldsmith, 2005). Therefore, understanding how community residents change or don’t change their process of accessing care following a hospital closure is important evidence when considering how to improve local access to care. 
The Appalachian Region
According to the Appalachian Regional Commission (ARC), established by Congress in 1965, the Appalachian Region is a 205,000 square-mile area stretching from northern Mississippi to southern New York along the Appalachian mountain range (Appalachian Regional Commission, 2011, n.d.-b). More than 25 million Americans live in one of the 420 counties, spanning across 13 states including West Virginia, Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia (Appalachian Regional Commission, n.d.-b). See Figure 2.1 for a map of Appalachia.
Although this definition offers a neat and succinct view of Appalachia, it is by no means comprehensive or completely accurate. It fails to the capture the diversity of geography, populations, economies, and culture that are apparent across the 13 states of Appalachia (Denham, 2016). For instance, although Appalachia is commonly referred and studied as rural, 

Figure 2.1 Map of the Appalachia Region (Appalachian Regional Commission, n.d.-a)


not all counties of Appalachia are rural. According to the ARC, 42% of Appalachians live in rural areas (Marshall et al., 2017). While this percentage is still more than double the national average, it is misleading to think that Appalachia does not have any metropolitan areas.
While geography is an important factor when defining Appalachia, some have attempted to define it as a cultural region. Fatalism, religiosity, individualism, and self-reliance are all historical values tied to Appalachian culture (Ford, 1962). However, empirical evidence reveals that not all parts of the region ascribe to these cultural values (Coyne, Demian-Popescu, & Friend, 2006). These common misconceptions often create stereotypes when trying to describe a population, and this is true for Appalachia (Denham, 2016). For centuries, Appalachia has been ruled by negative stereotypes such as hillbillies, holler dwellers, and moonshiners. As offensive as these stereotypes are, they still persist today and are barriers to truly understanding those living in the region (Denham, 2016). Whether a distinct culture exists in Appalachia is still debated, but what is most important to recognize is that Appalachia is a region of diverse people, geography, and culture.
County Economic Status in Appalachia
The Appalachian Region is most often characterized as a socially and economically disadvantaged part of the United States. Although pockets of wealth exist, Appalachia is largely made up of people who are older, disabled, unemployed, and have a low income. Based on the 2010-2014 American Community survey data, the median household income was 19% lower in Appalachia than the nation as a whole, with average wages of $45,585 per year for those in Appalachia compared with $56,135 for those in the nation (Marshall et al., 2017). Additionally, the percentage of people receiving disability benefits, generally defined as having at least one health issue, is 2.2% higher in Appalachia than the nation as a whole (Marshall et al., 2017). These statistics indicate a less healthy population overall. Progress has been made to reduce these disparities, but gaps still remain, particularly among the Region’s economically distressed and rural areas (Klesta, 2009; Marshall et al., 2017). 
To improve the socioeconomic conditions of the Appalachian Region, the ARC monitors the economic status of Appalachian counties and identifies those in distress every fiscal year. Economic status is determined by comparing a county’s three-year average per capita market income, poverty rates, and unemployment rates with the national averages. Each one of Appalachia’s 420 counties is then classified into one of five economic status designations—distressed, at-risk, transitional, competitive, or attainment. As of 2019, 81 counties in Appalachia are classified as distressed. These counties are considered the most economically depressed counties and rank in the worst 10 percent of the nation’s counties (Appalachian Regional Commission, n.d.-c). Among the 81 distressed counties across Appalachia, 11 are located in Tennessee. Out of the 11 distressed counties in Tennessee, 9 are considered rural: Bledsoe, Clay, Cocke, Fentress, Grundy, Hancock, Jackson, Scott, Van Buren (Appalachian Regional Commission, 2019a). Fentress County is the county of interest for this study and is explored later in this chapter. See Figured 2.2 for a complete map of county economic levels in Appalachia.
The Triple Threat for Health Disparities
Appalachia continues to suffer poorer health compared to the rest of the nation (Marshall et al., 2017; McGarvey, Leon-Verdin, Killos, Guterbock, & Cohn, 2011; Morrone, Kruse, & Chadwick, 2014). In fact, a recent report released by the Appalachian Regional Commission, the Robert Wood Johnson Foundation, and the Foundation for a Healthy Kentucky found health disparities widening between the Region and the rest of the nation (Marshall et al., 2017). The Region lags the rest of the country in 33 out of 41 population health indicators, including higher 

Figure 2.2 County Economic Levels in Appalachia (Appalachian Regional Commission, 2019a). 


mortality rates for seven of the leading 10 causes of death: heart disease, cancer, chronic obstructive pulmonary disease, injury, stroke, diabetes, and suicide. These rates are even more severe in the Region’s rural and economically distressed counties (see Figure 2.3). For example, the heart disease mortality rate in Appalachia is 17% higher than the national rate. Rural areas in Appalachia fair worse. The heart disease mortality rate for rural Appalachian counties is 34% higher than the national rate. Economic status also plays a role, as economically distressed counties have a heart disease mortality rate that is 47% percent higher than the national rate (Marshall et al., 2017). The summative effects of these three different risk factors—Appalachia, rural, and economically distressed—will be referred to as the “triple threat” for health disparities throughout this chapter.
Site of Study
Fentress County is the county of interest for this study and is considered a “triple threat” for health disparities in the state of Tennessee; it is classified as Appalachian, rural, and economically distressed. According to the United States Census Bureau, 18,523 people live in Fentress County, with a median household income of $35,084, less than Tennessee’s $50,972 and less than half of the nation’s $60,293 (United State Census Bureau, n.d.). Fentress County’s poverty rate is 20.6%, higher than the statewide average of 13.9%, and the population is aging (United State Census Bureau, n.d.). In terms of health outcomes, Fentress County ranks 74th out of 95 counties in a state that ranks 42nd out of 50 states (United Health Foundation, 2018; University of Wisconsin Population Health Institute, 2019b). More specifically, Fentress County ranks 57 in social and economic factors, 39 in health behaviors, 92 in clinical care, and 17 in physical environment (University of Wisconsin Population Health Institute, 2019b). See Table 
2.1 for a more complete picture of health measures in Fentress County.

Figure 2.3 Chart of Mortality Rates per 100,000 Population, 2008-2014, of the Appalachian Region compared to the U.S., Rural Appalachia, and Distressed Appalachia (Marshall et al., 2017).


Table 2.1 Comparison of County Health Measures of Fentress County vs. TN (University of Wisconsin Population Health Institute, 2019b).
	
	Measures
	Fentress County
	TN

	Health Outcomes
	Premature death
	10,800
	9.300

	
	Poor or fair health
	25%
	20%

	Social & Economic Factors
	Some college
	39%
	61%

	
	Unemployment
	4.2%
	3.5%

	Health Behaviors
	Adult Smoking
	25%
	23%

	
	Adult Obesity
	27%
	33%

	Clinical Care
	Uninsured 
	12%
	11%

	
	PCPs
	2,270:1
	1,400:1

	Physical Environment
	Long commute – driving alone
	35%
	35%




Health Perceptions in Appalachia
Some research suggests that distorted perceptions of health in Appalachia may be one reason behind these disparities (Ely et al., 2011). There is strong evidence to support that perception of health is a powerful predictor of future health outcomes (Menec, Chipperfield, & Perry, 1999). In fact, self-rated health, a common measure of health perception, has been well-established in the literature as a strong predictor of mortality, perhaps even greater than objective measures of health (DeSalvo, Bloser, Reynolds, He, & Muntner, 2006; Schnittker & Bacak, 2014; Vejen, Bjorner, Bestle, Lindhardt, & Jensen, 2017). However, in Appalachia, evidence reveals that there is a disconnect between self-rated health and objective health measures (Ely et al., 2011; Griffith et al., 2011). A study published by Griffith and colleagues evaluated self-rated health in Appalachian adults and found that objective measures of health did not match their self-rated health responses (Griffith et al., 2011). In fact, 74% perceived themselves as healthy, contradicting the fact that Appalachia is one of the unhealthiest regions in the United States (Griffith et al., 2011; Marshall et al., 2017). Ely and colleagues found similar results when comparing perceived and objective health status among a rural, Appalachian population with elevated risk of chronic disease (Ely et al., 2011). Over 60% of the sample perceived themselves as generally healthy despite engaging in poor health behaviors and having excess weight (Ely et al., 2011). This disconnect suggests that Appalachian adults may view health differently from researchers and other populations. If access to care is indeed the “fit” between the patient and healthcare system, then exploring perceptions of health in triple threat communities is needed in facilitating the next step of accessing that care. 
Barriers to Healthcare
Many residents who live in triple threat communities face multiple barriers when accessing health care. These barriers can result in unmet health care need and contribute to widening disparities (Healthy People 2020, 2019). Although access to care alone is not sufficient for improved health, it is necessary in facilitating optimal health, productivity, and well-being in society (MacKinney et al., 2014). The most common barriers when accessing care in triple threat communities are organized by Penchansky and Thomas’ five dimensions of access to health care below. It is important to recognize that these five dimensions are interdependent and overlap.
Availability 
The availability of health care resources is critical to health care access. Availability refers to the number and type of health care services, such as the supply of primary care providers (Penchansky & Thomas, 1981). The shortage of primary care providers in triple threat communities may mean patients experience longer wait times, delayed care, or no care at all (Dassah, Aldersey, McColl, & Davison, 2018). According to the Robert Wood Johnson Foundation, the patient to primary care physician ratio in Appalachia is 1,497:1 as compared to the national ratio of 1,322:1 (Marshall et al., 2017). This ratio is even worse in the Region’s rural and distressed counties of 1,798:1 and 2,444:1 respectively. In Fentress County, site of study, the patient to primary care physician ratio is 2,270:1, and the trend is worsening (University of Wisconsin Population Health Institute, 2019a). This shortage of primary care physicians can limit the supply of healthcare services offered in the area and prevent residents in receiving healthcare when needed (Liu, 2007). 
Accessibility
The accessibility of healthcare services has been a long-time concern in remote locations. Accessibility refers to the geographic relationship between patients and healthcare services, including transportation resources, distance, time, and cost (Penchansky & Thomas, 1981). For example, having reliable transportation directly impacts an individual’s ability to access healthcare to support one’s health and wellbeing (Henning-Smith, Evenson, Corbett, Kozhimannil, & Moscovice, 2017). Transportation issues are especially prevalent in rural areas where long distances are common and public transportation options are lacking (Henning-Smith et al., 2017). Rural residents are more likely to travel farther to healthcare services than urban residents (Rural Health Information Hub, 2019b). According to a recent study by the Pew Research Center, rural residents live an average of 10.5 miles from the nearest hospital. That’s about twice as far or seven minutes longer than people in urban areas (Lam, Broderick, & Toor, 2018). At current, the closet hospital to Fentress County is 28 miles or 41 minutes away. This increase in travel time can be particularly burdensome to older individuals requiring multiple visits to healthcare facilities to manage their chronic disease, or low-income individuals who cannot afford to take time off work. 
Affordability
Affordability is the relationship between prices of services, ability to pay, and perception of value, all of which can facilitate or impede community residents from accessing care (Penchansky & Thomas, 1981). Lower incomes and higher poverty rates are associated with higher incidence of diseases and mortality rates due to a decreased ability to afford resources that lead to heathier outcomes (Khullar & Chokshi, 2018; Wagstaff, 2002). According to the 2010-2014 American Community survey, the median household income in Appalachia was $45,585, with rural households earning $36,265 (Marshall et al., 2017). Economically distressed counties in Appalachia were even worse off, with a median household income of $32,777 (Marshall et al., 2017). As of 2018, the median household income for Fentress County was $35,084 (United State Census Bureau, n.d.). Additionally, higher poverty rates are also common in rural and economically distressed communities. The household poverty rate from 2010-2014 was 17.2% in the Appalachian Region compared to the national rate of 15.6% (Marshall et al., 2017). In the Appalachian Region’s rural areas, 23.0% of households were below the poverty line. The poverty rate was even higher in the Appalachian Region’s distressed counties at 26.9% (Marshall et al., 2017). In Fentress County, the poverty rate was 20.6% as of 2018 (United State Census Bureau, n.d.).
In addition to lower incomes and higher poverty rates, rural populations are less likely to be covered by employer-sponsored insurance than the urban population (Newkirk II & Damico, 2014). Lack of health insurance coverage is another potential barrier to accessing health care and has been identified as a risk factor for premature mortality (Wilper et al., 2009). The percentage of people under age 65 without health insurance in the Appalachian Region is 15.8 percent, which is better than the national average of 16.8 percent. However, rural and distressed counties of Appalachia fair worse than the national average, with 18.2 and 18.7 percent uninsured respectively (Marshall et al., 2017). Interestingly, the percentage of those without insurance in Fentress County is 13.4%. Although having insurance may mitigate access problems, it still does not eliminate access problems (Allen, Call, Beebe, McAlpine, & Johnson, 2017).
Acceptability
Acceptability is a broad concept that describes the relationship between the patient’s perception of the provider’s and facility’s characteristics and provider acceptance of the patient (Penchansky & Thomas, 1981). For example, patients may experience discrimination from the healthcare provider or staff which can deter them from seeking healthcare services in the future. On the other hand, providers may have attitudes about the characteristics of their patients or their insurance provider. For instance, a provider may choose not to see Medicaid patients (Penchansky & Thomas, 1981). Acceptability also addresses whether available healthcare services are appropriate to the norms, expectations, and cultural behaviors of the population (Savedoff, 2009). For example, establishing trust with a healthcare professional is crucial in an Appalachians’ acceptance of information and use of health care services (Behringer & Friedell, 2006). However, gaining trust is difficult when low education and health literacy rates are common in the area. Less education is associated with lower levels of health literacy, and consequently, less capacity to understand health information (Lazar & Davenport, 2018). In 2010-2014, 57.1% of adults ages 25 to 44 in the Appalachian Region had some type of postsecondary education versus 63.3% in the nation (Marshall et al., 2017). Adults in the Appalachian Region’s rural areas were 49.0% likely to have attended a postsecondary institution. Only 45.0% of adults living in distressed counties had attended a post-secondary institution (Marshall et al., 2017). Only 39% of Fentress County residents had some post-secondary institution (University of Wisconsin Population Health Institute, 2019a).
Accommodation
Accommodation describes how well the healthcare system fits the patient’s needs and preferences, better known as “customer service” (Penchansky & Thomas, 1981). When services provided, such as hours of operation and walk-in services, do not meet the needs of the community, they are less likely to seek or use services (Penchansky & Thomas, 1981). Those living in rural areas are more likely to have decreased communication with providers, trouble with scheduling appointments during hours of operation, and delays in receiving referrals (Jolly, 2019).
Rural Hospitals
Rural hospitals, as classified by the Federal Office of Rural Health Policy, are any general, non-federal, short-term, acute hospital that is located outside a metropolitan area, or is located within a metropolitan area and has a Rural Urban Commuting Area (RUCA) equal to or greater than 4 or is a Critical Access Hospital (Cecil G. Sheps Center for Health Services, 2020; Health Resources and Services Administration, 2018). As of 2016, there were 5,198 community hospitals in the United States. Of these, 3,377 are considered urban hospitals while 1,821 are considered rural hospitals (American Hospital Association, 2019a).
Rural hospitals are often smaller than urban hospitals and provide access to basic health care services such as inpatient, outpatient, emergency medical services, obstetrical services and others. Not only do they provide important health services, rural hospitals are also vital to the community’s economy and are often their largest employer (American Hospital Association, 2019b). They provide jobs, attract businesses and retirees, and stimulate local purchasing (American Hospital Association, 2019b). Rural hospitals are also vital when the community faces particular health issues like the current COVID-19 pandemic  (Centers for Disease Control and Prevention, 2020). 
The rate of rural hospital closures has increased significantly in recent years. Since 2005, 175 rural hospitals have closed and hundreds more are at risk of closing (Cecil G. Sheps Center for Health Services, 2020). Although hospital closings are not always a bad thing (i.e. underutilized by their community), many policymakers worry that hospital closures could have negative effects for their constituents. For the 60 million people who live in rural America, their hospital is an important, and often their only, source of health care (U.S. Census Bureau, 2010). As healthcare delivery evolves in the United States, some communities may be at risk of losing essential access to health care services.
A History of Rural Hospital Closures
Although the rate of rural hospital closures is on the rise, rural hospital closures are not necessarily a new phenomenon. In fact, hundreds of rural hospitals closed following adoption of the Prospective Payment System in 1983 (United States Government Accountability Office, 2018). Prior to 1983, hospitals were reimbursed retrospectively by Medicare. Under this system, hospitals were paid based on the services charged and offered little incentive to control costs (Guterman & Dobson, 1986). In an attempt to reduce growth in hospital costs and limit the depletion of Medicare Part A Trust Fund, the Department of Health and Human Services proposed a plan for a Prospective Payment System (PPS) of hospitals under Medicare (United States Government Accountability Office, 2018). PPS reimbursements are fixed and are not dependent on hospital expenditures (Carroll, 2019). Many rural hospitals could not sustain the costs required to maintain operation under PPS, and 5% of rural hospitals closed between 1985 and 1988 (Guterman & Dobson, 1986; United States Government Accountability Office, 2018). 
In response to the increasing rate of rural hospital closures following implementation of PPS, the Medicare Rural Hospital Flexibility (Flex) Program was implemented by the Balanced Budget Act of 1997 (Rural Health Information Hub, 2019a). The Flex Program allowed designation of rural hospitals as Critical Access Hospitals (CAHs) with the goals of reducing financial distress and improving access to health care in rural areas (Rural Health Information Hub, 2019a). There are over 1300 CAHs in the United States (Flex Monitoring Team, n.d.) CAHs receive more generous, cost-based reimbursement by Medicare for inpatient and outpatient services. This reimbursement is designed to protect rural populations’ access to essential health care services (Flex Monitoring Team, n.d.). The flex program prevented the closure of many rural hospitals, and hospital closures slowed in the late 1990s and early 2000s. However, the rate has been increasing ever since the Great Recession of 2008-2009, and the causes of the closures are still not yet well understood (Gujral & Basu, 2019; Kaufman et al., 2016). 
Challenges to Providing Hospital Care in Rural Areas
To understand why rural hospitals continue to close, the next section discusses the many challenges hospitals face operating in a rural area. This section explores four issues unique to rural hospitals including 1) rural designation 2) demographics 3) operational difficulties and 4) financial difficulties.
Rural Designation 
Determining what qualifies as a rural hospital or rural resident can be challenging due to various definitions created by federal, state, and local agencies. The most common definitions of rural are by the Federal Office of Management and Budget (OMB), the United States Census Bureau, and the United States Department of Agriculture Economic Research Service (USDA-ERS).
The OMB categorizes counties as metropolitan, micropolitan, or neither (Health Resources and Services Administration, 2018). Metropolitan counties contain a core-based statistical area (CBSA) of 50,000 or more residents. Micropolitan counties contain a CBSA of 10,000 to 50,000 residents (Health Resources and Services Administration, 2018). All remaining counties are categorized as neither. Counties that are not categorized as metropolitan are considered rural (Health Resources and Services Administration, 2018). 
The U.S. Census Bureau has different criteria and classifies areas as urban based on population density at the census block or tract level (U.S. Census Bureau, 2018). Urbanized Areas (UAs) consist of areas with 50,000 people or more, and Urban Clusters (UCs) consist of areas with 2,500 to 50,000 people. Rural areas are all areas outside of urbanized areas or urban clusters (U.S. Census Bureau, 2018). 
The United States Department of Agriculture Economic Research Service (USDA-ERS) and the Federal Office of Rural Health Policy (FORHP) collaborated to use components of each definition when determining rural or urban classification. FORPH classifies all non-metropolitan counties as rural and further categorizes rurality using Rural-Urban Commuting Areas (RUCAs) codes (Health Resources and Services Administration, 2018). The RUCAs are a census tract-based classification scheme based on measures of urbanization, population density, and daily commuting. Primary RUCA codes delineate metropolitan and nonmetropolitan areas based on primary commuting patterns. Tracts inside metropolitan counties with primary RUCA codes 4-10 are classified as rural (Health Resources and Services Administration, 2018). 
Although there will never be a one-size fits all rural definition, these definitions under-bound or over-bound rurality to some extent, which in turn, affects resource allocation (Hart, Larson, & Lishner, 2005) . For example, the OMB definition classifies an entire county as metropolitan as long as 50% of the county falls under the metropolitan designation (Smith et al., 2013). Davidson and Shelby County are the most densely populated counties in Tennessee, yet neither are exclusively urban (Roehrich-Pactrick, Moreo, & Gibson, 2016). In this case, rural is being under-bounded and urban is being over-bounded. Therefore, if a program or policy is based on nonmetropolitan status according to the OMB definition, rural hospitals within Davidson and Shelby County would not be eligible. This is important to recognize because many program and policy decisions that serve rural populations are made on the basis of these common definitions (Hart et al., 2005). Each definition can produce dramatically different results and may not funnel resources to the rural community in need.
Demographics
Demographics of the community play a large role in rural hospital viability. The physical isolation of rural areas and a shrinking population results in low population density and, consequently, low volume occupancy in hospitals. Low volume occupancy is associated with financial distress of hospitals (United States Government Accountability Office, 1991). There are inherent, fixed costs required to keep a rural hospital running, and these fixed costs must be spread over fewer patients, raising the unit cost of care. (United States Government Accountability Office, 1991). This can reduce hospital profitability, which creates difficulties in maintaining and updating hospital services and in recruiting and retaining health care professionals (The Council of State Governments, 2019; United States Government Accountability Office, 1991). 
Other demographic factors such as an older, sicker, and poorer patient population affect rural hospital viability. Rural hospitals serve a disproportionately older population that suffers from higher rates of disability and are more likely to engage in risky health-related behaviors as compared to the patient population served by urban hospitals (The Council of State Governments, 2019; United States Government Accountability Office, 2018). These patients usually require more health care services and suffer from poorer health compared to younger patients (The Council of State Governments, 2019). 
Rural hospitals also serve more uninsured and publicly insured patients as compared to urban hospitals. In fact, 30.7% of Fentress County residents are on Tennessee’s state Medicaid program compared to 20.7% of the state as a whole (Annie E. Casey Foundation, n.d.). This means that rural hospitals rely heavily on government subsidized health insurance for revenue. The problem is government subsidized health insurance reimburses less than the costs of providing care to Medicare and Medicaid patients (American Hospital Association, 2019c). For every dollar spent on Medicare and Medicaid patients, hospitals are reimbursed 87 cents (American Hospital Association, 2019c). These low Medicare and Medicaid reimbursements further decreases a rural hospital’s profitability and resilience to policy change (Thomas, Holmes, & Pink, 2016). Furthermore, rural hospitals are more likely to incur uncompensated costs by uninsured patients (Balasubramanian & Jones, 2016). By federal law, hospitals are required to provide care for emergency situations regardless of the patient’s ability to pay. Uncompensated care incurs significant debt to rural hospitals, increasing financial distress and risk of closure (Balasubramanian & Jones, 2016). 
Operational Difficulties
Different payment reform models are being explored to transition rural hospitals from volume-based to value-based payments. However, new models bring their own challenges to rural hospitals. The Patient Protection and Affordable Care Act of 2010 dramatically reshaped healthcare in the United States by establishing a number of value-based payment approaches such as the Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program. The Hospital Readmissions Reduction Program (HHRP) was established by a provision in the Affordable Care Act that reduces payments to hospitals with relatively high readmission rates (exempt are Critical Access Hospitals) with the goal of improving the quality of hospital care (Boccuti & Casillas, 2015). Hospitals are penalized for excessive readmissions within a 30-day period (Boccuti & Casillas, 2015). This is problematic because rural hospitals treat some of the sickest and poorest patients (Centers for Disease Control and Prevention, 2019b). The HRRP penalty for having to re-admit patients soon after they are released is difficult for rural hospitals to avoid. Penalties incurred under this program reduces hospital’s Medicare revenues leading to more financial distress.
The Hospital Value-Based Purchasing Program (HVBP) was established by another provision in the Affordable Care Act intended to encourage hospitals to provide high-quality care more efficiently by adjusting payments to hospitals based on the quality of care they provide (U.S. Government Accountability Office, 2017). Based on the results of quality performance, CMS adjusts Medicare payments, leading to bonuses or penalties for hospitals. Hospitals that serve a high proportion of low-income patients generally score lower in quality compared to all participating hospitals (U.S. Government Accountability Office, 2017). Because rural hospitals tend to serve a high proportion of low-income patients, penalties reduce a hospital’s Medicare revenues leading to more financial distress.
Financial Difficulties 
The failure to expand Medicaid is another contributing factor to rural hospital closures. Although the Patient Protection and Affordable Care Act of 2010 decreased the number of uninsured people in the United States., nearly 30.1 million adults still remain uninsured because 13 states have chosen not to expand Medicaid (Centers for Disease Control and Prevention, 2019a; Kaiser Family Foundation, 2014). Studies reveal that states who accepted federal money for Medicaid expansion are experiencing less hospital closures than states who refused to expand (United States Government Accountability Office, 2018). In a study published by the Commonwealth Fund, Medicaid expansion states saved an estimated $6.2 billion in uncompensated care costs, leading to greater financial stability and viability of rural hospitals (Dranove, Gartwaite, & Ody, 2017). In states that chose not to expand Medicaid, care that could have been covered under Medicaid remains uncompensated and becomes another financial challenge for rural hospitals (Dranove et al., 2017).
It’s also important to recognize that a pandemic, such as the current and evolving COVID-19 outbreak, may be another contributing factor to rural hospital closures specifically in 2020 (Diaz, Chhabra, & Scott, 2020). Elective and non-essential surgeries, an important revenue source for rural hospitals, were suspended for weeks in the beginning to help contain the spread of the virus. The effect of the pandemic on rural hospitals is still evolving, however, suspending these profitable surgeries may be another factor that sends rural hospitals into financial distress (Diaz et al., 2020). 
Impact on Access to Care
Several earlier studies have explored the effects of rural hospital closures on access to care that occurred during the 1990s (Fleming, Williamson, Hicks, & Rife, 1995; Muus et al., 1995; Rosenbach & Dayhoff, 1995; United States Government Accountability Office, 1991). Some documented that hospital closures can negatively affect community residents’ access to care, particularly among vulnerable community residents who are older, low income, disabled, or pregnant (Fleming et al., 1995; Hart, Pirani, & Rosenblatt, 1991; Muus et al., 1995; Reif et al., 1999). Fleming and colleagues examined the implications to access to care resulting from 25 rural hospitals closures by travel distance and time to nearest open hospital (Fleming et al., 1995). The results indicated that residents’ access to care were negatively affected due to increased burden of travel time and distance, with an average travel time of 30 minutes to the nearest hospital. Vulnerable populations were also more negatively affected. A 30-minute travel time may be particularly difficult for people who are older if they lack transportation or need immediate care. However, there was a net improvement in service availability in the remaining open hospitals. This change indicated an improvement in access to specific services, with the trade-off of additional travel time (Fleming et al., 1995).  
Reif and colleagues interviewed health professionals about the impact of hospital closures on community residents’ access to care from 6 different closure sites across the United States (Reif et al., 1999). Health professionals perceived some negative effects on access to care including distress of residents about the loss of their emergency room and increased travel time for hospital services. Health professionals also perceived a greater negative effect for vulnerable populations, specifically those who are older, of lower income, or have a disability (Reif et al., 1999). Hart and colleagues found similar results from a survey with mayors based on 130 hospital closures across the United States (Hart et al., 1991). They indicated that the major consequence of the hospital closure was diminished access to care. They also perceived that health status deteriorated and an increased burden of travel time and distance (Hart et al., 1991). Moreover, Muus and colleagues surveyed residents from rural North Dakota about the perceived causes and effects of a hospital closure that occurred in their community (Muus et al., 1995). Findings indicated that the closure diminished health care access, particularly emergency care, and 17% said they or a family member did not seek medical attention because of inconvenience (Muus et al., 1995). 
Other earlier studies also found that rural hospital closures produced negative effects for residents in terms of access, however, effects were minimal. The United States Government Accountability Office (GAO) (United States Government Accountability Office, 1991) analyzed national level data and conducted 11 case studies of selected rural hospitals located in Illinois, Mississippi, Montana, and Texas. Most rural hospital closures GAO studied did not significantly reduce access to care for residents. In these areas, alternative sources of care were available and utilized by many residents at least two years before the closures. Hospital use declined among residents in closure areas, however, it declined to rates comparable to the U.S. average. This suggests that residents were still able to obtain hospital care after a closure. However, problems in access appeared to worsen following a closure in some areas, particularly for residents of lower income and those needing emergency care (United States Government Accountability Office, 1991).
More recent research studying hospital closures in the 2000s generally draw similar conclusions as the 1990s: closures may be associated with decreased access to health care for residents. The U.S. GAO did a review of the literature funded by the Department of Health and Human Services between 2013 and 2017 and found that hospital closures can affect community residents’ access to care, particularly among those who are elderly and low income (United States Government Accountability Office, 2018). The Kaiser Commission on Medicaid and the Uninsured and the Urban Institute conducted three case studies of hospital closures in 2015 in Kentucky, Kansas, and South Carolina funded by HHS (Wishner et al., 2016). Their results revealed that hospital closures primarily reduced local access to care, especially primary and emergency care, influenced health care providers to leave the community post-closure, and worsened pre-existing barriers when accessing specialty care. Hospital closures particularly affected those who are older and of low-income to delay or forgo lab work due to longer travel time and distance (Wishner et al., 2016). Additionally, another HHS funded study found that of the 125 rural hospitals that closed in the United States between 2005 and 2017, 43% were more than 15 miles to the nearest hospital and 15% were more than 20 miles (Clawar, Thompson, & Pink, 2018). The authors concluded that even if distance to the next nearest hospital was the only downside for a community losing its hospital, the additional travel burden created an access problem for residents (Clawar et al., 2018).  
Conclusions
Three major gaps are apparent in the literature. First, no study to our knowledge has considered how a hospital closure affects access to care in an Appalachian, rural, and economically distressed county of Tennessee. Considering that health disparities are most severe for rural and economically distressed counties of Appalachia, and rural hospitals are often a sole provider of healthcare, hospital closures could potentially have serious negative effects on local access to care in triple threat communities. Second, the community resident perspective is consistently absent in the literature. The community resident is a key stakeholder in health care, yet only one of the studies mentioned above explored the perceptions of community residents of access to care following a hospital closure, and this study is dated (Muus et al., 1995). Third, exploring health perceptions in triple threat communities is necessary in understanding how residents may view health, and consequently, how they view accessing that care for health. If Appalachians view themselves as generally healthy when evidence shows that the region is generally unhealthy, further research is needed to understand this disconnect. 
The recent rise of rural hospital closures presents a timely opportunity to study the perceptions of community residents seeking access to care in rural, Appalachian, and economically distressed communities of Tennessee. This study is the first to explore a hospital closure in a “triple threat” or Appalachian, rural and economically distressed county from the viewpoint of the community resident. This study attempts to rectify limitations of previous studies by describing the perceived impact of access to care in a rural and economically distressed county of Tennessee through a community residents’ lens and by exploring how community residents think about and define health and access to care based on their beliefs, values, and knowledge. Chapter 3 will address the methodology used in this study. 


Chapter Three
Methods
The purpose of this study was to explore and describe the perceived impact of a hospital closure on access to care in a rural and economically distressed, Appalachian county of Tennessee. This descriptive qualitative study examined this topic through a community residents’ lens to gain a variety of experiences and perspectives. This chapter describes the selection of the research design chosen for this study and its alignment with the established research question. This chapter also includes participant selection, recruitment and data collection procedures, and data analysis plan. 
Why Qualitative Methods?
Naturalistic inquiry relies heavily on qualitative methods because they are more adaptable to the many multiple realities constructed in the minds of individuals (Lincoln & Guba, 1985). Such methods are best for understanding what people do, know, think, and feel through the use of observations, interviews, and analyzing documents (Patton, 2002). To understand the multiple realities constructed by community residents when accessing care after a rural hospital closure, it is crucial to understand their personal experiences with their local healthcare system and their perceptions of these experiences (Flick, 2014). Thus, qualitative methods are required for approaching our research question.
Research Design
This study used a qualitative descriptive approach to present a truthful account of the community residents’ perceptions of accessing care after a rural hospital closure. Qualitative 

Sandelowski recommends qualitative descriptive methodology when straight descriptions of data and observations are wanted (Sandelowski, 2000). Researchers stay close to the surface of their data in an effort to provide facts and meanings given by the participants. Because this study sought to provide a truthful description of community residents’ perceptions of accessing care, qualitative description was deemed the most appropriate approach to answer the research questions (Sandelowski, 2000). 
Sample
Setting of Study
Our study took place in an economically disadvantaged, Appalachian county of Tennessee: Fentress County. Jamestown, the county seat of Fentress County, closed the doors of its 85-bed Jamestown Regional Medical Center hospital on June 13, 2019. It was the only hospital in a county inhabited by 17,959 residents (United State Census Bureau, n.d.). Jamestown Regional Medical Center was an acute care hospital that provided inpatient medical care and other related services for surgery, acute medical conditions or injuries. The hospital also offered emergency services, radiology/nuclear medicine/imaging, rehabilitation services, and wound care. 
The top three zip codes of residence for inpatients of Jamestown Regional were 38556, 38553, and 38504. 38565 and 38577 are also considered Fentress County. At current, the closest hospital to Fentress County, Livingston Regional Hospital, is 28 miles or 41 minutes away. Cumberland Medical Center is 37 miles or 49 minutes away, and Cookeville Regional Medical Center is 51 miles or 1 hour and 4 minutes. 
Participant Selection and Recruitment
Purposeful, criterion specific sampling and snowball sampling methods will be used to recruit participants from the target county. Purposeful sampling allows for the selection of information-rich cases for the proposed study (Sandelowski, 2000). This sampling strategy is common in qualitative description inquiry and encouraged by the naturalistic paradigm (Sandelowski, 2000).
Passive recruitment, informing the community about the research study through public advertisements and waiting for volunteers to call, will be used to recruit study participants. Public advertisements will consist of social media posts and newspaper ads. Social media posts will consist of Facebook and Twitter platforms. An ad in the Fentress Courier, the local newspaper, will be submitted. Prospective participants who respond to these will contact the principal investigator directly via phone or email and will be screened. Snowball sampling will also be used by asking each participant to share the project information to any eligible participant who may be interested in taking part in the study. 
Inclusion criteria to participate in this study included the following: must be 30 years or older and must reside in Fentress County for at least 5 years. Participants who are at least 30 years old at the time of the study means that they were at least 25 years old when the hospital closed and no longer classified as a “young adult.” This increases the likelihood that participants may have used the closed hospital. Additionally, participants who have resided in Fentress County for at least 5 years or more increases the likelihood that they may have had an experience with the closed hospital. 
Sample Size
Qualitative research typically focuses on a small number of cases in-depth, but what constitutes “small” in qualitative research is relative (Patton, 2002; Sandelowski, 1995). Sample size depends on “what you want to find out, why you want to find it out, how the findings will be used, and what resources (including time) you have for the study” (Patton, 2002). Because the goal of this study and sampling strategy is to seek information-rich cases, or depth, as opposed to number of cases, or breadth, sample selection until the point of redundancy is recommended (Sandelowski, 1995). 
Despite the ambiguity in sample size, Patton suggests that qualitative researchers specify a minimum sample based on the researcher’s judgment and study’s purpose (Patton, 2002). Factors to consider when specifying a minimum sample size include research design, sampling strategy, how often the phenomena is being researched, as well as other research using the same research design (Bradshaw, Atkinson, & Doody, 2017). A recent systematic review regarding characteristics of qualitative descriptive studies found that 24 out of 55 articles had a sample size between 11-20; The 8-10, 21-30, 31-50, and greater than 50 participant ranges were less than ten studies (Kim, Sefcik, & Bradway, 2017). Based on the above factors, I anticipate a minimum sample size of 15 participants to reach saturation, or when information is redundant. However, the researcher has the flexibility to change the minimum sample size based on new information if necessary (Patton, 2002). 
Procedures
Data Collection
Following recruitment, data will be collected using semi-structured individual interviews, which is a typical data collection strategy for qualitative description (Sandelowski, 2000). The interview guide will use open-ended questions based on naturalistic inquiry and Penchansky and Thomas’s model of access to care. See Table 3.1. Participants will describe their personal experiences and thoughts about their access to care after the Jamestown hospital closure and explain what access to care means to them. Interviews will be conducted face-to-face in Fentress County by the researcher. If a face-to-face interview is not possible, a phone or Zoom call will be utilized. Interviews will be audio recorded, transcribed, and uploaded to NVivo for further analysis. Eligible participants will also complete a demographic questionnaire prior to the interview.
Procedures
	Participants completed a one-time, semi-structure interview via telephone. A semi-structured interview guide (Table 3.1) informed answers to the study’s three research questions. Interview questions were based on research questions, literature…To confirm interview guide quality, the PI pilot-tested the interview guide with three different individuals, including two from a rural, Tennessean county. Interviews were conducted between May and August 2020, ranging from 20-60 minutes in length.
Data Analysis
Data were analyzed by hand using conventional content analysis to identify themes, which is the analysis of choice for qualitative description (Sandelowski, 2000). The analysis was performed in a stepwise iterative fashion as described by Saldana, from the development of codes to the generations of themes. The first five interviews were independently reviewed and two researchers performed initial coding (KB and AL). These two investigators then met to compare codes, thus enabling the process to be reflexive as each investigator discussed their own perspectives and assumptions. An initial coding framework was developed and AL applied to the rest of the interviews. Through a series of meetings and discussions, the coding framework was revised as necessary based on new findings. Coding occurred by hand, which allows…. This process allowed for the development of preliminary categories and themes. These were shared with all members of the research team and, through discussion, were refined. All authors provided methodological and content expertise to ensure trustworthiness of the study. Qualitative content analysis is inductive, meaning that codes are generated from the data themselves. However, researchers may begin analysis with a set of pre-existing codes, under the condition that these codes may be modified or rejected in an effort to best reflect what the data says (Sandelowski, 2000). Pre-existing codes will be guided by Penchansky and Thomas’s model of access to care but may evolve in order to capture the meanings given by the participants. The expected outcome of this qualitative descriptive study is a straight descriptive summary of community residents’ perceptions of accessing care following a hospital closure in Fentress county.
All data were read repeatedly to achieve immersion and obtain a sense of the whole. Then data were read using line-by-line analysis to identify codes appearing to capture key thoughts or concepts. The various codes were compared based on differences and similarities and sorted into categories. To ensure qualitative rigor and trustworthiness of the data, two researchers analyzed the data separately. 


Chapter Four
Findings
The purpose of this chapter is to report the study findings. The findings are organized into three sections. The first section consists of the descriptive statistics including demographics of the sample. The second section presents definitions of health and access to care. The third section presents the themes that emerged through analysis. 
Descriptive Statistics
The findings of this qualitative study are based on interviews with twenty-four community residents of Fentress County, Tennessee (n=24). Over half of the participants (54%) were recruited through snowball sampling, while 29% and 16.7% were recruited through social media and newspaper advertisements, respectively. Demographic information was collected from each participant at the beginning of the interview and is summarized in Table 4.1. Half of the participants were born in Fentress County, with length of residence ranging from 5 years to 72 years. Ages ranged from 30 to 80, with the median being 51 years of age. Approximately 67% of the sample, or 16 participants, were female. Over half or 54% were married. 83.3% had either graduated from high school or had post high school training. 6 participants were employed full or part time, 6 were retired, 6 were unemployed, 3 self-employed, and 3 homemakers. 18 participants or 75% had health insurance coverage. Of the 18 participants who had health insurance coverage, 14 had state government sponsored health insurance. 5 participants or 20.8% were uninsured. 1 participant was unsure whether they had health insurance or not. 
Table 4.1 Demographic characteristics of study sample (n=24)
	Case Number
	Length of Residence (years)
	Age (years)
	Sex
	Marital Status
	Education
	Employment Status
	Health Insurance

	Alice
	6
	63
	F
	Divorced
	Post high school training/some college

	Retired
	State/government sponsored health insurance
and insurance purchased directly from an insurance company

	Betsy
	45 
	48
	F
	Married
	Post high school training/some college

	Working- full time
	Employer-sponsored health insurance

	Colleen
	15 
	60
	F
	Living with a partner
	High school graduate/GED
	Working- full time
	Employer-sponsored health insurance

	Dee
	5 
	30
	F
	Married
	None to 12th grade
	Homemaker
	State/government health insurance

	Elizabeth
	56 
	56
	F
	Married
	Post high school training/some college

	Working- full time
	Employer sponsored health insurance

	Fay
	15 
	66
	F
	Married
	High school graduate/GED
	Working- part time
	State/government sponsored health insurance

	Grace
	7 
	56
	F
	Divorced
	High school graduate/GED
	Other: Self-employed
	Insurance purchased directly from an insurance company

	Anthony
	40
	75
	M
	Widowed
	High school graduate/GED
	Retired and working- part time
	State/government sponsored health insurance
and Insurance purchased directly from an insurance company

	Helen
	42
	42
	F
	Married
	Post high school training/some college

	Homemaker
	State/government sponsored health insurance

	Bobby
	11 
	48
	M
	Married
	None to 12th grade
	Unemployed and looking for work
	State/government sponsored health insurance


	Ina
	7
	38
	F
	Living with partner
	Post high school training/some college

	Wanting to work but unemployed due to health-related reason; disability
	State/government sponsored health insurance


	Jessica
	38 
	38 
	F
	Married
	High school graduate/GED
	Other: Self-employed
	No health insurance

	Charles
	68
	70
	M
	Divorced
	Post high school training/some college

	Retired
	State/government sponsored health insurance


	Kat
	17 
	48
	F
	Married
	High School graduate/GED
	Homemaker
	State/government sponsored health insurance;

	David
	17 
	50
	M
	Married
	None to 12th grade
	Wanting to work but unemployed due to health-related reason;
Disability
	State/government sponsored health insurance


	Ethan
	42
	42
	M
	Living with a partner
	Post high school training/some college

	Other: Self-employed
	No health insurance

	Leah
	20 
	32 
	F
	Living with a partner
	None to 12th grade
	Unemployed and looking for work
	No health insurance

	Melanie
	31 
	31
	F
	Married
	High school graduate/GED
	Working- full time
	No health insurance

	Nikki
	35
	56
	F
	Married and separated
	High school graduate/GED
	Wanting to work but unemployed due to health-related reason;
Disability 
	State/government sponsored health insurance


	Forrest
	28 
	32
	M
	Married
	High school graduate/GED
	Temporarily laid off
	No health insurance

	George
	55
	72 
	M
	Never been married
	High school graduate/GED
	Retired
	State/government sponsored health insurance


	Rose
	43
	72
	F
	Married
	Post high school training/some college

	Retired
	State/government sponsored health insurance
and Insurance purchased directly from an insurance company

	Savanna
	30 
	30 
	F
	Living with a partner
	Post high school training/some college

	Working- part time
	Not sure

	Henry
	72 
	80
	M
	Married
	Post high school training/some college

	Retired 
	State/government sponsored health insurance





Definition of Health and Access to Care
When analyzing perceptions of health, participants were asked to describe what health means to them (see Figure 4.1 for word cloud). Good health was most often characterized as remaining independent. Bobby remarked, “Good health is just feelin’ like takin’ care of the day, you know? I mean, just bein’ able to get up, feel real good, do what you want to do." Good health was also commonly characterized as having access to healthcare such as doctors and hospitals. Dee commented, “to me it means, bein' able to say, 'Hey, there's somethin' wrong with me. I need to go to the doctor.' And bein' able to have that access to a regular doctor or to a regular hospital.” Other perceptions of good health included “no health issues,” “taking care of yourself,” “well-being,” and “quality of life.”
When analyzing perceptions of access to care, participants were asked to describe what access to care means to them (see Figure 4.2 for word cloud). Access to care was most commonly characterized as being available or being able to get what you need. David described access as “it means bein’ able to get it when you need it, when it's there, availability.” In particular, participants mentioned the availability of emergency services. Fay described access as, “It means having some place to go if you have an emergency and bein’ able to, maybe, have someone save your life.” Convenience was another important term to describe good access to care. Elizabeth said, “A normal person in today’s 21st century should not expect to have to travel so far to get medical attention…And if you’re seeking medical attention that’s not in your doctor’s office, then it’s pretty much an emergent care. And you should not have to travel from county to county.” Participants also stressed the importance of timely medical care when describing access. Ina remarked, “Access to care is knowing that when you get hurt, you'll be able to get to somebody who can and will help you in a appropriate amount of time,” while Colleen described timely as, “I can pick up the phone and call my doctor and get an appointment within 24 hours if I feel it's necessary.”
Themes
Four distinct themes emerged from the research data. The major themes identified from the findings of this study included:
 Loss of hospital negatively affects all five dimensions of access to care.
 Loss of hospital creates stress among community residents. Community residents respond with adaptive and maladaptive coping mechanisms.
 Loss of hospital jeopardizes the health of a compromised community. 
 Loss of hospital creates conflict in the community. 
Theme I: Loss of hospital negatively affects all five dimensions of access to care.
“The poorest of access is still better than none."-Bobby

Theme 1 describes participants’ difficulties accessing health care after the closure of the hospital. The prevailing categories followed Thomas and Penchansky’s framework of access to care and include availability, accessibility, affordability, accommodation, and acceptability. 
Availability. Discussions regarding volume and type of health care services included concerns with supply of providers and lack of services. Participants reported healthcare providers closing their facilities and leaving the area soon after the closure of the local hospital. Bobby remarked, “With the closin' of the hospital, also came closing of some local doctors that we had here, too." As a result, participants described existing healthcare providers flooded with the number of patients to care for. Helen reflected on her experience accessing existing healthcare facilities as, "It's just everything is overcrowded." Participants also described a lack of healthcare 

Figure 4.1 Word Cloud of Health Definition

Figure 4.2 Word Cloud of Access to Care Definition


services in the community, highlighting no emergency or specialized care services. Betsy emphasized, "We do not have an emergency care facility. We do not have anything critical care, any type of facility, in this town,” while Colleen acknowledged the lack of specialists in the area, "We don't have any specialists in Jamestown at all."
Accessibility. Discussions regarding proximity to healthcare facilities included concerns with rural roads, time or distance, cost of travel, and transportation. Participants described the inhospitable conditions of driving in a rural area, such as challenging roads, unmarked streets, limited signal, and livestock crossing areas. As Bobby remarked "I mean that is a curvy, curvy, curvy down the side of that mountain road." Participants also reported longer travel times and distances to receive care, particularly in emergency situations. When describing distance to the nearest hospital, Dee stressed, “You have to go all the way to Cookeville or all the way to Crossville.” Longer travel times and distances to receive care also resulted in significant cost on patients including gas, mileage, and forgoing work. For instance, Anthony commented on the cost of travel as, "A lot of people don't have money for the gas to drive to Cookeville." 
Inadequate transportation was also a common barrier that emerged in interviews, especially among older populations. Ina described that she had no source of transportation, "There's no one available to take me [to the hospital],” while Leah stressed the lack of transportation resources among individuals who are older, “Especially with these elder people because some of ‘em can’t drive, and some of ‘em, you know, can’t drive their own vehicles or can’t see to drive.” Some noted that transportation services were available through certain health insurances but must be called in advance to schedule an appointment. As Nikki reflected on her transportation struggles, she said, “I can get transportation with my insurance, but you have to have a three-day notice to give ‘em before you can get the transportation…I mean, when you need it then, who wants to call three days ahead to get into see the doctor when you need ‘em now?” Participants also expressed concerns about a lack of transportation options for returning home from the hospital. 
Affordability. Discussions regarding participant’s ability and willingness to pay for care included financial difficulties and inadequate health insurance coverage. Participants reported difficulty in affording health care costs after the closure of the hospital, including higher medical bills and an overall “financial burden.” When describing an emergency situation, Jessica said "[My friend] couldn't afford the ambulance bill” to the nearest hospital 35 miles away. Participants also expressed frustration with health insurance, noting that health insurance was essential in receiving care yet did not have it or did not know what it would cover. Melanie noted, "We don't have health insurance, so we can't afford to go to a doctor." Charles commented on his insurance, “[The ambulance] sent the bill to Medicare, and I turn it into my insurance. Medicare didn’t pay half of that bill,” while Anthony observed, “Sometimes [the ambulances] have been known to run people to Nashville. Can you imagine what a bill like that is?”  
Accommodation. Discussions regarding capacity of providers to meet patients’ needs included hours of operations and waiting times. Participants reported challenges with wait times when scheduling an appointment or when waiting to be seen by a provider. Helen noted, "We have a health department, but there's such a long waiting line even just for a nurse practitioner.” Participants also highlighted limited hours to receive care. When reflecting on emergency situations, Elizabeth commented, "The walk-in clinic is from 8:00 to 8:00, so if you get hurt after hours, then, you know, you're gonna have to travel…"
Acceptability. Discussions regarding the relationship between provider and patient included concerns about familiarity and insurance acceptance. Familiarity, or a personal connection, with the facility and provider was emphasized by participants. Alice revealed the personal connection she had with her providers by calling them by first name. Betsy described familiarity as, "When you go to another facility now, you're looking for that comfort, uh, personal contact.”  There was a “knowing” participants missed with the closing of their local hospital. Dee reflected on her experiences as, “when I go to other hospitals for any reason, I’m just like—I feel—I don’t know. I feel out of place. I don’t know anybody there. It’s nice to be able to go somewhere, and you know, see somebody and be like ‘Oh, yeah…I went to school with them.’” Participants also described limited acceptance of health insurance among existing health care providers. Leah commented on her experiences accessing care and being uninsured as, "We only have two doctors' offices, and if you don't have insurance, they won't see you." Participants also described how the local hospital was the only healthcare facility that would accept uninsured patients and appreciated that the emergency department never refused to see them. 
Theme II: Loss of hospital creates stress among community residents. Community residents respond with adaptive and maladaptive coping mechanisms.
“I had to Google it. I had to Google like, how to know when to go to the hospital and everything.”-Savanna

Theme II consisted of two categories: stress and coping mechanisms. Stress is defined as a feeling of emotional or physical tension that comes from any event or thought, while coping mechanisms refers to strategies to minimize stress. Community residents described an increase in stress levels associated with difficulties accessing care after the closure of the local hospital. Having received care at the local hospital for many years, participants did not know where they would receive care now, which generated a sense of fear and uncertainty. When describing how the closing of the hospital has impacted the community’s access to care, Rose commented, “I know that people I’ve talked to are frightened. And they said, ‘Oh you can’t get sick. You can’t afford to get sick.’” 
Emergency situations also generated stress among participants. Betsy described the prevalence of emergencies as "It's everyday. Somebody is battling something very critical in this community.” Emergency situations often caused participants to second-guess themselves and, consequently, increased levels of stress. When her husband spiked a fever, Dee reflected, “I was, like, freakin’ out ‘cause he was hallucinating and everything else. And I’m like, ‘What do I do? Do I call an ambulance? They’re gonna take him all this way. What are they gonna do in the ambulance to help him?’ And the fact that I didn’t know there was so much, like, in the middle that I just did not know, um, I just decided not to call anybody. And I was just like ‘I’ll just take this into my own hands, and hopefully he doesn’t die’…It turned out well. But, when I think about it, I’m thinkin’, ‘Oh, my gosh. What as I thinkin’?”
Some participants noted their personal responsibility of having to take care of a loved one, which generated feelings of stress. As a daughter, mother, and wife, Helen described her stress as, “It was scary [when the hospital closed]—especially to have kids. And with a husband that—he had a heart attack…[and] my mom and dad are both older.” Participants also expressed concern for other community residents who are more in need of a hospital, such as in emergency situations, or for community residents who are older. For example, Ina commented, “It's a different feeling now when there's a bad wreck somewhere. You can tell it on Facebook, 'Hey, there's a bad wreck over on 62. Pray for the families.’”
To manage stress, community residents described adaptive and maladaptive coping mechanisms. Adaptive coping mechanisms refer to more positive coping strategies and included figuring out a solution to accessing care after the closing of the hospital. Colleen described, "We discuss alternatives. You know, we wanna think about what's going on, and - and how we're gonna take care of ourselves when this happens." Other adaptive coping mechanisms included being more cautious to avoid potential problems or dangers: “You have to try to be as careful as you can” (Fay) and having hope: “I heard that one of the doctors here was gonna—was workin’ on tryin’ to get the hospital open. And, god, I pray that he is” (Nikki). 
Maladaptive coping mechanisms refer to strategies that are more negative and included self-medicating and postponing care. Ina described self-medicating as, "I use my essential oils and CBD oil and that kind of stuff and I can limp through," while Nikki described self-medicating as, “I’m taking everything you can get over the counter. Too much of it. It’s literally made me sick to my stomach trying to get out of pain.” In many cases, participants chose to postpone or avoid accessing care. Reflecting on emergency situations, Forrest commented, “Usually, whenever I got so sick, I would just go to the emergency room and let the ER bill me. Well, not anymore. I’ll just be sick and try to cure it with home remedy stuff, or, you know, find a family member that’s got some medicine from the last time they were sick.”
Theme III: Loss of hospital jeopardizes the health of a compromised community. 
"A hospital is the heartbeat of your community."-Helen

	Theme III consisted of three categories: community health, value of hospital, and negative health consequences. Community health refers to the collective well-being of the community and encompasses health behaviors and health issues participants observed of themselves and within the community. There were mixed opinions about whether their community was healthy or unhealthy. Some participants perceived their community as healthy. Dee observed, “We got a lot of people who work outside. And, even in their older age, they’re still workin’ outside. They’re still—physically able to do the things they can do.” Engaging in healthy behaviors was also common across participants and included behaviors such as exercising and eating right. 
On the other hand, most participants perceived their community as unhealthy, observing many health issues including drug use, obesity, diabetes, cancer, tobacco use, and farm accidents. Participants acknowledged that age and socioeconomic status contributed to poorer health in their community. Anthony observed, “This is a predominantly older, retirement [community]…and most of ‘em are getting old enough to have health problems,” while Helen acknowledged, “it’s a low-income community…people don’t have insurance unless they have TennCare….And I guess, like myself, they kinda let [their health] go to do other things to get by, until they had to.” Other participants acknowledged the lack of opportunities and resources to be healthy, such as limited physical activity options and lack of access to healthcare facilities. Alice noted that “I live in a small community, and I really don’t think they have anything that meets my needs that I would like to have” when describing challenges in being healthy such as exercising. Bobby associated the health of the community with the lack of a hospital, “I don’t think that the community is as healthy as it could be…and you know, not havin’ a hospital has really, really added to that.”
Participants also described engaging in unhealthy behaviors such as smoking and poor diet. Ethan commented, “I smoke cigarettes, which I know it's bad, but." Avoiding healthcare providers was also common across participants. Leah mentioned, “I don’t like goin’ to the doctor anyway,” while Bobby observed, "A lot of people around here…they've got to be on their deathbed to even go [to the doctor]." Furthermore, when observing health behaviors in the community, Collen noted, “No matter how old they are 20, 30, 40, or in their 50s—well, some people in their 50s are startin’ to think twice about it, their health is not important…One person said that they were gonna eat whatever they wanted, and then just take a pill for the problem.”
When considering the health of their community, participants stressed the importance of the local hospital serving as a halfway point to stabilize patients and transfer to a better hospital. Ethan noted, "Jamestown did a good job of gettin' me ready to go to a better hospital." Not only did participants value the hospital for healthcare, participants described that the local hospital provided some “peace of mind” or security and confidence in knowing that the hospital was there. "An emergency room close by is something that I feel more comfortable with,” said Dee. Participants also described the importance of their local hospital in community viability. Fay acknowledged, “Somebody doesn’t wanna move here if there’s no hospital.” Dee emphasized the jobs it provided, "The biggest thing is--you know, the hospital closing, it-it was jobs for our community that's already hurting in that department.” Furthermore, some participants felt that their community could not survive without the hospital. Betsy commented, "I'm really crumbled as to how we are gonna survive,” while Savanna expressed "It makes me wanna move.” 
	Without the hospital, participants perceived negative health consequences in their community. Participants described situations in which individuals were not able to receive timely care due to the closing of the hospital. Dee described, “One of my friends, because it’s so hard to get in the doctor’s, she laid there and had a massive stroke, and she passed away.” Rose reflected on the outcome of her husband who had a stroke as, “He can swallow now, but still no speech. So when you hear those words, those two little words, “too late,” it says it all.” As a result, worse health outcomes were perceived in the community as a whole. Charles described, “I think the health in our community has declined for the most part since the hospital closed… I think we probably have lost people because they had to be shipped a long ways.”
Theme IV: Loss of hospital creates conflict in the community. 
"Surely, the government, the state, somebody will step in and say, 'Hey, look now. Y'all can't just leave these people with nothin'…And sure enough, one day we were left with nothing."-Bobby

Theme IV consisted of two categories: attribution of blame and responsibility and discontent. Participants expressed an overall sense of anger and resentment toward the closing of the local hospital. Some participants blamed the local government for the hospital going “downhill” and its ultimate closure. Alice stated, “"Shame on [the government] for closing this place down," while Bobby recounted, “It made me feel like the people from the outside, the powers, they just didn’t care anymore.” Other participants blamed the hospital owner. Ethan commented, “When Rennova bought this hospital, they took everybody to court that owed them…So that company just bought up this hospital and tried to get as much of the debt out of it as they could, and it wasn’t long before it shut down…it’s almost like a ponzi scheme.” 
Ina voiced, “If you’re gonna own something like a hospital that’s absolutely detrimental to smaller places that don’t have as much access to care…