Longstanding Rural-Urban Disparities Exacerbated by COVID-19: The Experiences of Older Residents in West Texas: Lessons Learned

Introduction

The COVID-19 pandemic has resulted in more than 6.3 million deaths worldwide as of June 2022 and an estimated

533 million positive cases of COVID-19 [1]. The impact of COVID-19 has been devastating and pervasive, deepening longstanding health inequities among society’s most vulnerable, including rural communities which comprise

20% of the United States (US) population [2]. However, current reporting of the pandemic’s impact is limited by state-level aggregations [3] subsequently overlooking the urban-rural (i.e., county-level) differences. This oversight limits our understanding of the effects and responses to the COVID-19 pandemic while further widening the health disparity between individuals living in rural and urban settings. Therefore, this study bridges this gap by assessing and comparing rates of COVID-19 vaccination, COVID-19 prevalence, availability/utilization of healthcare resources, and services between urban- and rural-dwelling residents of the South Plains Texas Region.

Prior to the COVID-19 pandemic, evidence revealed disproportionate access to healthcare services, greater likelihood of medical and mental health comorbidities, and higher rates of poverty among rural dwellers [4]. These urban-rural disparities have resulted in persistent challenges in promoting the health and well-being of rural communities throughout and following the COVID-19 pandemic [5]. For example, rural residents face higher risks of severe illness and mortality from COVID-19 as they are likely older in age, have higher rates of underlying chronic diseases and disabilities, and have less access to healthcare [6]. Given that medical complications due to COVID-19 increase with age (i.e., 80% of mortality related to COVID-19 was among adults 60 or older) elderly rural dwellers are particularly at risk [6]. Incidence and mortality rates of COVID-19 in rural communities (crude mortality rate was 185.50) during 2020 also began to exceed the rates among urban (crude mortality rate was 123.70) communities-rural counties had 61.85 additional deaths due to COVID-19 per 100,000 population [7, 8]. Despite the overwhelming risk of COVID-19-related mortality among rural dwellers, there is a paucity of research comparing the effects of COVID-19 in West Texas between urban and rural communities.

Healthcare Infrastructure and Transportation Challenges

The literature has prominently documented the disparate access to healthcare services, particularly specialized care, among rural communities [9]. One empirically supported reason is transportation hurdles that rural communities face. More specifically, they are more likely to travel for extended periods to reach healthcare facilities, often through hazardous terrain, causing many rural dwellers to postpone their healthcare appointments, even when sick [10, 11]. Indeed, a previous study found among adults who received the COVID-19 vaccine in rural counties (38.9%), a large proportion (14.6%) traveled to nonadjacent counties for vaccination (i.e., farther from their county of residence). Whereas in urban areas, 45.7% received the COVID-19 vaccine and only 10.3% of persons in urban counties travel to receive the COVID-19 vaccine in nonadjacent counties [12]. These reports indicate COVID-19 testing sites may be difficult to travel to or even inaccessible to rural communities compared to urban communities.

Furthermore, research has documented that rural areas during the COVID-19 pandemic suffered from overcrowded hospitals, widespread hospital closure, and a lack of healthcare professionals. The CDC [5] reported 170 hospitals in rural America have closed since 2005, 700 more after the COVID-19 pandemic are at risk for closure, and a shortage of 600,000 healthcare professionals in rural communities [13], further limiting the availability of healthcare services for individuals in rural areas. As rural communities grapple with how to navigate the lack of access to proper healthcare, which impacts their ability to protect from and receive treatment for COVID-19, they may experience a greater level of distress due to this lack of access to proper healthcare. A systematic review has found rural dwellers, compared to urban dwellers, are more likely to experience psychological distress due to COVID-19 [14]. These results reflect poorer access to resources, lower SES status, education, and increased medical comorbidity among rural communities.

Poorer Health Status and Vaccine Hesitancy in Rural Communities

The CDC [15] reports that individuals in rural communities are more likely to die from the five leading causes of death given their older age, high rates of cigarette use, high blood pressure, obesity, lack of physical activity, high rates of poverty, and lack of access to healthcare. As rural populations are older and thus more likely to be immunocompromised, they are at the greatest risk for COVID-19-associated morbidity and mortality. One of the most efficient ways to prevent COVID-19 hospitalizations is through vaccinations [12]. COVID-19 vaccine hesitancy is the reluctance or unwillingness to be vaccinated and has been documented most notably in rural communities due to feelings of fear, misinformation/disinformation, lack of community health literacy, and medical distrust [10]. Therefore, it is important to understand the vaccination rates of rural versus urban community dwellers.

Prior evidence suggests rural communities are less likely to engage in preventive health behaviors [16]. One study found that rural dwellers reported negative attitudes toward the effectiveness of performing preventive behaviors, and had lower levels of information appraisal skills (i.e., less likely to evaluate the relevance and salience of health-related information) [17]. Misinformation is a persistent challenge to engaging in preventive health behaviors as it may lead to taking ineffective and potentially harmful remedies, ignoring healthcare guidelines, and engaging in behavior that increases the transmission of the virus [18]. Given that rural communities tend to have higher rates of individuals with low socioeconomic status (SES) and education, they may be more likely to trust health information from sources that are lower in accuracy and quality [10].

Knowledge Gaps

The COVID-19 pandemic taught us that challenges during a pandemic are predominantly around reducing the rate of COVID-19 transmissions in rural communities, which precedes the vaccination uncertainty. Rural communities lack the adequate health infrastructure needed to support a large capacity of COVID-19 patients. They are also isolated from specialized healthcare systems, have fewer opportunities to provide medical literacy pertaining to COVID-19, and have a staffing shortage of healthcare workers to serve the population. The exodus of medical staff, because of the COVID-19 pandemic, remains a significant barrier to broadening the scope of care and further impaired critical care to rural areas.  The COVID-19 pandemic has magnified the inequalities in healthcare that prevail among rural-urban communities. Unfortunately, as a result, the healthcare infrastructure in rural communities was not prepared to tackle the enormity of the COVID-19 pandemic or to protect those most at risk. Without research examining these disparities, it will lead to a continuation and increase of these disparities. We must learn from the pandemic to improve overall healthcare in rural areas and to prepare for the possibility of future pandemics.

Therefore, it is vital to understand urban and rural residents’ experiences during the pandemic to inform public health efforts in these areas. In the wake of the pandemic communities were faced with reduced access to care, overpopulated hospitals and shortage of healthcare workers, a widening digital divide, and unequal access to lifesaving treatments and vaccinations to fight against the virus. As society defines its path forward from the COVID-19 pandemic, we must reflect on the devasting and pervasive impacts of the pandemic. To improve the health and well- being of communities living in rural counties-we must understand how poor healthcare infrastructure impacts the ability to receive vaccinations and COVID-19 tests. It is through this critical deliberation can we examine previous inadequacies to confront the systemic barriers to access to healthcare and inform future reforms. To date, few studies have explored critical urban-rural differences in West Texas on residents’ experiences and access to health care. Therefore, the proposed study elucidates the availability of resources and services between rural and urban communities. This information will inform prevention and treatment strategies to ameliorate the impact of COVID-19 strains and future pandemics. More specifically, this study

• Assessed and compared the rates of COVID-19 vaccination, COVID-19 prevalence, and symptomology between urban- and rural-dwelling residents of the South Plains Texas Region;
• Examined COVID-19 prevention measures between urban- and rural-dwelling residents; and
• Evaluated availability/utilization of health care resources and services. Using county-level data, these results depicted COVID-19 trends in testing, cases, and fatalities across urban and rural counties in West Texas.

Results

Before analysis was conducted, county-level data were downloaded as Excel spreadsheets from the DSHS website, and line graphs were drawn to illustrate trends in:

Cumulative COVID-19 cases per 100,000 residents (Figure 2), Cumulative COVID-19 tests performed per 100,000 residents (Figure 3), and Cumulative COVID-19 fatalities per 100,000 residents (Figure 4) across the five selected counties of interest.

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County-Level Data of COVID-19 Cases, Testing, and Fatality

As shown in Figure 2, the number of COVID-19 cases per 100,000 residents increased the most for Lubbock County residents, most notably around October 2020 into January 2021. The number of COVID-19 cases per 100,000 residents decreased among rural county residents but was less than the overall cases of Lubbock County residents. In January 2021, the COVID-19 cases for rural counties averaged around 8,000 (per 100,000 residents) while for Lubbock County residents averaged around 15,000 (per 100,000 residents) cases. Figure 3 depicts total number of COVID-19 tests per 100,000 residents. As shown in Figure 3, in January 2021, the number of COVID-19 tests administered was around 80,000 (per 100,000 residents) for Lubbock residents and averaged around 20,000 to 40,0000 (per 100,000 residents) for rural county residents. Parmer and Bailey residents were the least likely to be tested for COVID-19 (30,000 total COVID-19 tests per 100,000 residents) and Hockley residents were the most likely among rural counties to receive the COVID-19 test (40,000 total COVID-19 tests per 100,000 residents). Figure

4 depicts the total number of COVID-19 fatalities per 100,000 residents. In January 2021, as shown in Figure 4, Lubbock and Bailey had the lowest number of fatalities (~200 per 100,000 residents), while rural counties Parmer (350 per 100,000 residents), Hockley (~400 per 100,000 residents), and Cochran (~450 per 100,000 residents) had the highest number of fatalities.

Health Behaviors and COVID-19 Experiences

A little over a quarter of participants (n = 79, 26.07%) were previous smokers, while 21 participants (6.93%) reported being current smokers. A majority of participants (n = 196, 64.68%) had never smoked. Only one participant (0.33%) reported currently vaping or using tobacco products, while two participants (0.66%) reported vaping or using tobacco products in the past.

Participants reported on their history of COVID-19 testing, symptoms, and preventative behaviors. At the time surveyed, a total of 230 participants (75.90%) reported not having been tested for COVID-19 (75.91%), while 73 had been tested (24.09%) for COVID-19 (see Table 2). Among those tested, 31 were diagnosed with COVID-19 (42.47%), while 38 (52.05%) were negative for COVID-19, and 4 participants were awaiting results. The majority of participants (n=299; 98.70%) diagnosed with COVID-19 reported symptoms that lasted for 10-14 days, with the exception of 4 people (1.30%) for whom the symptoms lasted for a month or longer. Among those reporting diagnosed cases of COVID-19 among household members, the majority (n=290; 95.71%) of household members’ symptoms lasted for about 2 weeks. However, at the time surveyed, only 13 participants (4.36% of the total sample) to their knowledge had come in direct contact in the past 24 hours with a person who had recently tested positive for COVID-19. Lubbock participants reported having been tested (n=54; 38.30%) and testing positive (n=23; 42.59%) for COVID-19 more often than the combined counties subsample (testing: n=19; 11.73%; p <.001) suggesting greater access to testing in Lubbock (Table 2).

When participants (overall sample) were asked if they experienced any of the following symptoms in the past 7 days: a significant number of people did not experience any fever (n = 301, 99.34%), dry cough (n = 285, 94.06%), shortness of breath (n = 286, 94.39%), decreased smell/taste (n = 293, 96.70%), nausea or vomiting (n = 299, 98.68%), sore throat (n = 294, 97.03%), muscle or joint aches (n = 279, 92.08%), or diarrhea/gastrointestinal problems (n = 294, 97.03%). Several participants (n = 7, 16.28%), experienced other symptoms not listed, including headache, arthritis, lack of energy, and tiredness. No differences were reported between Lubbock and rural counties subsamples (p >.05). Only 28 participants (18.67%) visited a doctor, nurse, or health care professional in-person to take care of their symptoms. Moreover, 15 participants (10.34%) called a doctor, nurse, or health care professional to take care of some of their symptoms. Lastly, only 3 participants (2.05%) had been referred to tele Health medicine.

Overall, the total sample of participants from both Lubbock and rural counties tested for COVID-19 at a low rate. However, Lubbock participants were more likely to have been tested and tested positive for COVID-19 than participants from rural counties. No differences were found among the symptoms of COVID-19 between participants from the Lubbock and rural counties.

Discussion

This is the first study to explore urban-rural differences in COVID-19 experiences, including mental health, among residents of the South Plains Texas region. The urban subsample was derived from Lubbock County (population 310,569). The rural population is represented by four rural counties: Bailey County (population 7,000), Cochran County (population 2,853), Hockley County (population 23,021), and Parmer County (population 9,605). Among our sample of 303 adult participants, we found nearly a quarter of participants tested for COVID-19 in 2019/2020. Among those tested, approximately 42% tested positive for COVID-19. Surprisingly, the results indicated that most individuals in rural and Lubbock took precautions to prevent the COVID-19 pandemic but testing for COVID-19 was significantly higher in Lubbock compared to rural areas in rural West Texas. This may be due to the expansive measures taken by the City of Lubbock Health Department (CLHD) to distribute large vaccines early during the pandemic with an average of 3,000 people a day [21]. The campaign partnered with Citibus, the city’s public transportation, to provide commuters with free transportation to the CLHD. However, given this campaign was being disseminated in Lubbock, these results indicate a possible barrier to testing for persons in rural Texas during the COVID-19 pandemic.

There were quite a few similarities between participants from rural and Lubbock County regarding adherence to safety precautions (e.g., mask-wearing, social distancing). These results were surprising as past research [22] has indicated that persons in rural areas were less likely to adhere to safety precautions during the COVID-19 pandemic. This could be due to the majority of the sample being older and at higher risk for testing positive for COVID-19 and fearful of negative outcomes affecting older adults at a higher rate following a COVID-19 diagnosis. Also, most of the participants, even in rural areas (over 85%) reported they had at least a high school education indicating the sample might be more educated and, therefore, follow CDC guidelines and have the ability to identify misinformation. Further, even though individuals in both Lubbock, Texas and the rural counties endorsed adhering to safety precautions, they endorsed frustrations with being/feeling socially isolated from others, concerns about safety precautions (e.g., pro- and anti- mask wearing sentiments; believing the mask spreads bacteria), vaccine distribution (i.e., several participants were anxiously awaiting the vaccine), and access to COVID-19 information about the vaccine. However, these concerns and feelings of isolation by the majority of participants did not appear to lead to mental health symptoms in this sample.

Even though there were similarities regarding adherence to safety precautions and mental health symptoms there were some differences between urban and rural county residents as participants from rural Texas were likely less likely to have received a flu vaccine-a preventive measure to protect against the severe effects of the COVID-19 illness. The divergent experiences between residents of the Lubbock County and rural subsample are likely due to the following:

• Greater access to healthcare among the urban sample compared to the surrounding rural areas,
• Larger community spread of COVID-19 in the urban sample given the population density, and
• Higher reported health insurance in the urban sample compared to residents in surrounding rural counties.

The results therefore suggest greater access to testing, care, and treatment in the urban versus rural sample. County-level data also confirmed differential access to health care and treatment as Lubbock County led testing, incidence, and fatalities of COVID-19 compared to rural areas. Lubbock County residents, despite having the highest rate of COVID-19 cases, had the greatest number of residents tested for COVID-19, and the lowest fatality rates. On the contrary, rural residents had the lowest number of COVID-19 cases, the lowest number of residents tested for COVID-19, and the highest COVID-19 fatalities.

This research highlights disparities in COVID-19 experiences among urban and rural communities in access to testing. Our findings coincide with robust findings that have detailed differential COVID-19 trends in urban and rural areas [3, 23, 24]. Altogether, these findings call for the need to better address healthcare access in rural areas through telemedicine and other innovative approaches. One of the ways prior studies improved access to accurate health information is through tailored health communication approaches [25], which enhance information appraisal, increase motivation to process information, and promote behavioral change. One of the more accessible ways to implement tailored health communication strategies is by working with local health professionals in rural communities, like primary care providers and nurse practitioners, who can then disseminate pivotal and reliable information about local health departments [26].

Limitations

We acknowledge the potential for selection bias and/ or sample bias due to our different recruitment strategies in Lubbock, Texas, and the surrounding rural communities. Participant recruitment in the rural counties took place previously within the context of Project FRONTIER, an epidemiological study initiated in 2006 to investigate cognitive decline and associated risk factors longitudinally among a multi-ethnic sample of adults in rural West Texas. Recruitment efforts for the project included distributing flyers, providing community presentations (in English and Spanish), mailouts, and door-to-door solicitation with the purpose of recruiting a multi-ethnic (Hispanic/Latino and non-Hispanic/Latino) sample aged 40 and above. Conversely, in Lubbock, TX we relied on a convenience sample of older adult participants. Recruitment efforts for this program include posting announcements at TTUHSC, advertisements in the Golden Gazette (a local free monthly newspaper targeting older adults), and reminder postcards. Lubbock, TX study participants also included older adults who participated in the Retired and Senior Volunteer Program. Recruitment strategies and program activities are conducted solely in English. Thus, the Lubbock County subsample tended to be older and racially homogenous (predominantly White, non-Hispanic, or Latino) as compared to the rural counties subsample. As a result, future studies should attempt to create equal demographic distributions between both urban and rural samples.

Conclusion

This study is the first to explore the COVID-19 experiences between urban and rural communities living in West Texas. Our findings detail the differential COVID-19 trends of urban and rural areas in access to testing [25]. Altogether, these findings call for the need to better address healthcare access in rural areas through telemedicine and other innovative approaches. The COVID-19 pandemic has had far-reaching impacts on the lives of individuals around the world, especially older adults in the South Plains Texas region. Future work should seek to pinpoint the COVID-19 risk factors that increase one’s susceptibility to worse health outcomes and lingering symptomology. It will be important, as the COVID-19 pandemic continues and future pandemics are likely, to learn about vaccine uptake, acceptance, hesitance, as well as short- and long-term side effects of the vaccine in urban and rural populations. While there has been an increasing awareness of rural health disparities in the past several years, the same challenges that were elucidated in the 20th century still remain prevalent today [9]. We urge researchers to not only identify public health concerns but to begin developing public health solutions and monitoring health changes, especially to decrease the rural disparities regarding unequal access to healthcare. Solutions should focus on including community members in health promotion and partnering with organizations as health partners to ensure the accurate spread of information, and work with dwellers that face transportation and digital hurdles, to increase the scope of care.

Statement Regarding Research Ethics and Patient Consent

Written informed consent was obtained from all participants prior to enrollment. Individuals who were not deemed to be cognitively functional were excluded from the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgements

We would like to thank our data collectors (Veronica Lopez, Susan Thompson, and Cordelia Aguirre) and Project FRONTIER participants for their involvement in this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the Garrison Institute on Aging, which is supported by TTUHSC institutional funds and the Garrison Family Foundation.

Research Ethics and Patient Consent

Written informed consent was obtained from all participants prior to enrollment. Individuals who were not deemed to be cognitively functional were excluded from the study.

Research Data

Data are available from the Project FRONTIER (https:// www.ttuhsc.edu/centers-institutes/garrison-aging/project- frontier.aspx) for researchers who meet the criteria for access to de-identified Project FRONTIER data.