Doctoral Dissertations

Orcid ID

Date of Award


Degree Type


Degree Name

Doctor of Philosophy



Major Professor

Carole R. Myers

Committee Members

Carole R. Myers, Patricia Roberson, Liem Tran, Sangwoo Ahn


Twenty Tennessee hospitals have closed since 2010, increasing the distance and travel time to care, especially for rural communities with prevailing health disparities. Associated mortality increases are concerning, especially from time-sensitive events, like heart attacks. Twenty-seven of the state’s rural hospitals are considered immediate- or high-risk for closure, increasing concerns regarding future access and worsening health disparities. Nevertheless, scant studies have examined the impact of these closures on Tennesseans’ health outcomes.

The Vulnerable Populations Conceptual Model (VPCM), the framework for this study, iteratively links resources, relative risk, and health status in a circular predictive model. Consequently, this study serves to answer the following overarching question: Considering Tennessee’s hospital closures since 2010, what is the relationship between the state’s disparate rural health outcomes and the growing distance/travel time to hospital and emergency care?

This retrospective ecological study employed a spatial generalized linear mixed-effects regression model (GLMM), using publicly available datasets from the U.S. Census Bureau, Department of Homeland Security, HRSA, the CDC, and the Tennessee Department of Health. Analyses ascertained the relationships between distance and travel times to hospital and emergency services and other environmental and human capital resources to county-level all-cause and time-sensitive mortality rates from 2010-2019.

In our bivariate analyses, access to hospital and emergency care correlated significantly with county-level mortality rates. However, the significance level diminished in the GLMMs (adjusted for county-level median household income, median age, ethnicity, rurality, and uninsured status). Nonetheless, the clinical significance of the travel time and distance to hospital and emergency care mortality effects cannot be understated, especially for the poor and underserved.

This study should inform long-term equitable resource investment to improve the health and well-being of all, especially those residing in Tennessee’s rural areas. Investing in and improving the health of individual communities serves to improve their socioeconomic status and trigger a “virtuous cycle” of enhanced well-being and economic gains. This study may not be fully generalizable but provides a foundation for assessing rural health disparities nationwide. Furthermore, the spatial methodology provides an analytic platform for future health disparities research.

Available for download on Monday, December 15, 2025

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