Urban-Rural Divide and Telehealth

Author: Ivan Ayala

Image: Stephanie King

COVID-19 Cases, Deaths, and Trends in the US | CDC COVID Data TrackerFind national and local rates for COVID cases and deaths in the United States.

A COVID-19 tracker map may be used to visually compare urban and rural communities in the context of COVID-19 cases and mortality (CDC, 2020).

Urban-Rural Divide

The urban-rural healthcare divide is a social determinant of health that may at times be overlooked or underemphasized. To best combat social inequity in the context of public health, it is imperative that we better understand the consequences that these spatial inequities pose on the well-being of the most vulnerable populations in the United States. Some of these consequences being rural communities driven by lower life expectancy, higher rates of chronic obstructive pulmonary disease (COPD), gaps in cardiovascular mortality, and as of recently, higher comorbidity rates for COVID-19 (data for this fact collected up to June 2020), along with other health measures (Gaffney et al., 2020; Hammond et al., 2020; Peters, 2020; Singh et al., 2017).

Some of which may contribute to increased vulnerability to COVID-19 complications when paired with the potential lack of health services that often plagues rural communities; thus, further increasing their susceptibility to major complications (Peters, 2020).

What is Telehealth?

To help mitigate the overall negative effects of COVID-19, as well as other illnesses, telehealth was introduced as a way to provide patients with quality clinical care while keeping both health care providers and patients safe via electronic consults (Jaffe et al., 2020). Telehealth is not a new concept. It became more emphasized with the introduction of a pandemic as it was approximated that 76% of all U.S. hospitals had incorporated the use of telehealth in order to meet the needs of various patients in their facilities prior to the pandemic (Jaffe et al., 2020). Although the concept of telehealth is noble, it has fallen short of its perceived ability to provide individuals who are residing in rural communities with the quality health care that they deserve. In reality, the use of telehealth during the COVID-19 pandemic has created yet another health barrier, the digital divide, for many patients (DeGuzman et al., 2020; Jaffe et al., 2020).

The Digital Divide

Barriers contributing to the digital divide:

Higher cost for fixed internet speeds in rural areas (DeGuzman et al., 2020; Jaffe et al., 2020)
Satellite internet only means of access to internet (DeGuzman et al., 2020; Jaffe et al., 2020)
- In some cases may not provide real time video chatting
Age (DeGuzman et al., 2020; Jaffe et al., 2020)

The digital divide has effectively created a health gap fostered by individuals' access to stable, fast, and reliable broadband connections (DeGuzman et al., 2020). When exploring the digital urban-rural divide in the context of COVID-19 and telehealth, research is limited. However, it has been found that 97% of the U.S. population residing in urban communities have access to internet that is fast enough to participate in telehealth, while their counterpart rural Americans lag with a 65% of the population being able to access the internet that supports telehealth communication (Jaffe et al., 2020). For this reason, along with the other mentioned barriers, research indicates that telehealth has not been successful in reducing health inequities during the pandemic of 2020. It has widened the urban-rural health care divide, as rural community members are presumed to use telehealth at a lower rate when compared to urban populations (Jaffe et al., 2020).

National Broadband MapBroadbandNow's national broadband map is an attempt to provide the most accurate, up-to-date map of availability, speeds, and pricing in the U.S.

Website that may be used to visually compare broadband access between urban and rural communities (National Broadband Map, 2020).

Telehealth and Air Quality

How does telehealth fit into the story of COVID-19 improving our nation's air quality? Before answering this question we must make note of the limited-to-no research that has been conducted on the urban-rural divide on air quality in the context of COVID-19. We must also investigate if there is any benefit in air quality created by the use of telehealth.

Variables associated with telehealth and its impact on air quality:

Appointment durations (Holmner et al., 2014)
Emission produced using and manufacturing the telehealth equipment (Holmner et al., 2014)
Travel to and from appointments (Holmner et al., 2014)

The research team was able to find a correlation which indicated that increasing the use of telehealth could have massive impacts on the health industries carbon footprint (Holmner et al., 2014). The research was conducted in a rural environment; therefore, we would expect less of an impact in an urban community as the researchers have noted that there is often less travel involved for patients to get to and from appointments in the urban context (Holmner et al., 2014).

General Effects of COVID-19 on Air Quality

When we look at the indirect impacts that COVID-19 has had on nations' air quality, we see that the proposed lockdowns to combat the widespread of this illness have led to improvements in air quality all over the world (Rupani et al., 2020). So much so that China temporarily observed a reduction in the rate of deaths caused by air pollution (Rupani et al., 2020). The staggering changes in air quality were linked to the reductions in both oil use and the manufacturing of coal (Rupani et al., 2020).

Learn more about COVID-19 and air quality on these companion student pages.

Number of Air Pollution deaths in 2017 to give a perspective of how deadly air pollution is (Rupani et al., 2020)

Telehealth and Social Justice

Benefits of improved access to telehealth in the context of built environment:

Improved air quality
Quality health care more readily accessible to patients

Sadly we cannot reap the rewards of telehealth until we come together to challenge the social inequities standing in the way of patients accessing telehealth at equitable rates across both urban and rural communities.

What should we do?

Make higher broadband speeds accessible to everyone
Emphasize training the less tech-savvy on how to use telehealth
Emphasize the air quality benefits of using telehealth over in-person consultations

By following the three recommended interventions, along with other interventions not explored on this page, we can use the pandemic to our advantage and potentially help decrease the negative impacts we as humans have had and continue to have on our environment. We can also help make our country a more equitable place to live in by allowing everyone to have equitable access to telehealth care. We must focus on this urban-rural digital divide because quality health care and good air quality are both human rights.

Desktop 2020.12.11 - 21.20.57.04.mp4

Podcast (3:04m)

Summary Podcast Script

Hello, my name is Ivan Ayala, and I would like to begin this summary podcast by thanking you for taking the time out of your day to visit my page on telehealth and COVID-19. So, let's go ahead and get started.

The urban-rural divide, is a social determinant of health that is often forgotten and is left out of public health conversations. If not left out of the conversation we often look at it from a county level micro perspective. Instead, we should be focusing on looking at the urban-rural divide in the context of a national macro social determinant of health, as COVID-19 has shown us yet again that health inequities exist within this built environment.

COVID-19 has shown us that telehealth during the pandemic was introduced as a method to reinforce social distancing, while still providing individual patients with the health care that they deserved. However, with limited research in this area, we were also able to identify that this approach to quality health care was in itself a health barrier. It brought up plenty of social inequities to question, but the biggest inequity brought to light was the digital divide.

We were able to see individuals having disproportionate access to telehealth when comparing rural and urban locations. It became apparent that rural communities had far less access to telehealth in comparison to their urban counterparts. This meant that during a pandemic, in which rural communities were actually experiencing higher rates of COVID-19 comorbidity, the rural residents were disproportionately able to decrease their risk of exposure to the virus via electronic consultations.

On top of which, environmental social justice came to play. We were able to identify that urbanized cities across the globe were experiencing increases in air quality. This increase in air quality would prove to be disproportionate as the biggest changes were observed at the urban level. Research indicates that telehealth may have the greatest potential to decrease carbon emission produced by the medical field; therefore, increasing air quality, especially in the context of rural communities health care emissions. However, due to our countries disproportionate distribution of broadband access to telehealth, this does not appear to be the case.

In order to allow patients to more readily access quality health care in the form of telehealth, while simultaneously increasing the overall air quality of our planet there are a few things we can do. We should begin to make higher broadband speeds accessible to everyone; thus, reducing the digital divide. We should begin to emphasize training the less tech-savvy on how to use telehealth. We should emphasize the air quality benefits of using telehealth over in-person consultations. These interventions should make telehealth more equitable for everyone across the country, as well as help to decrease the carbon footprint left behind by the medical field.

We must focus on this urban-rural digital divide because quality health care and good air quality are both human rights.

References

CDC. (2020). CDC COVID Data Tracker. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days

DeGuzman, P. B., Siegfried, Z., & Leimkuhler, M. E. (2020). Evaluation of rural public libraries to address telemedicine inequities. Public Health Nursing, 37(5), 806-811. 10.1111/phn.12777

Gaffney, A. W., Hawks, L., White, A. C., Woolhandler, S., Himmelstein, D., Chrisiani, D. C., & McCormick, D. (2020). Health Care Disparities Across the Urban-Rural Divide: A National Study of Individuals with COPD. The Journal Of Rural Health, 1-10. 10.1111/jrh.12525

Gavin, K. (2020). Telehealth Visits Skyrocket for Older Adults, but Concerns and Barriers Remain. M Health Lab. https://labblog.uofmhealth.org/rounds/telehealth-visits-skyrocket-for-older-adults-but-concerns-and-barriers-remain

Hammond, G., Luke, A. A., Elson, L., Towfighi, A., & Joynt Maddox, K. E. (2020). Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality. Stroke, 51(7), 2131-2138. 10.1161/STROKEAHA.120.029318

Holmner, A., Ebi, K. L., Lazuardi, L., & nilsson, M. (2014). Carbon Footprint of Telemedicine Solutions - Unexplored Opportunity for Reducing Carbon Emissions in the Health Sector. PLoS one, 9(9), e105040. 10.1371/journal.pone.0105040

Jaffe, D. H., Lee, L., Huynh, S., & Haskell, T. P. (2020). Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19. Population Health Management, 23(5), 368-377. 10.1089/pop.2020.0186

National Broadband Map. (2020). BroadbandNow. https://broadbandnow.com/national-broadband-map

Peters, D. J. (2020). Community Susceptibility and Resiliency to COVID-19 Across the Rural-Urban Continuum in the United States. The Journal of Rural Health, 36(3), 446-456. doi.org/10.1111/jrh.12477

Rupani, P. F., Nilashi, M., Abumalloh, R. A., Asadi, S., Samad, S., & Wang, S. (2020). Coronavirus pandemic (COVID-19) and its natural environmental impacts. International Journal of Environmental Science and Technology, 17, 4655-4666. 10.1007/s13762-020-02910-x

Singh, G. K., Daus, G. P., Allender, M., Ramey, C. T., Martin, E. K., Perry, C., De Los Reyes, A. A., & Vedamuthu, I. P. (2017). Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 2935-2916. International JOurnal of Maternal and child Health and Aids, 6(2), 139-164. 10.21106/ijma.236

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