A qualitative exploration of factors influencing healthcare utilization among rural Missourians: “We have to be bleeding, broken”

Abstract

Researchers performed a hybrid inductive-deductive thematic analysis of 25 individual interviews to explore factors influencing healthcare utilization in rural Missouri. Data indicated that a desire for self-sufficiency, preference for natural interventions, and poor perception of rural healthcare quality may deter healthcare utilization. Influential subjective norms included respect for toughness and resilience, conservative approach to healthcare, view of the body as an instrument, and influence of faith and religion. Financial barriers and lack of accessible healthcare options were noted as key structural obstacles. Findings emphasize the importance of individual, cultural, and structural factors in shaping healthcare utilization in underserved communities.

1. Introduction

Rural health disparities have been well documented in the United States for decades (Ziller and Milkowski, 2020; Bikomeye et al., 2024), resulting in higher age-adjusted rates for all-cause mortality in rural areas across the country (Cosby et al., 2008). Today, relative to their urban counterparts, rural Americans are at elevated risk of death due to all five leading causes of mortality: heart disease, cancer, unintentional injury, stroke, and chronic lower respiratory disease (U.S. Department of Health and Human Services, 2020). The significance and timeliness of this issue are underscored by national policy initiatives aimed at improving access to high-quality healthcare in rural communities. The Platform Accelerating Rural Access to Distributed and InteGrated Medical care (PARADIGM) program, which targets structural barriers to healthcare, is one of several recent examples (U.S. Department of Health and Human Services, 2024).

The success of policies aimed at increasing healthcare access (the ability to use healthcare) ultimately depends upon their effectiveness in increasing healthcare utilization (actual healthcare use) (Nuako et al., 2022). A robust body of research exists regarding barriers to healthcare access in rural areas, including a shortage of healthcare providers (Health Resources and Services Administration), rural hospital closures (Johnson, 2023), and a lower likelihood of having healthcare insurance (McBride et al., 2022), highlighting their appropriateness as targets for policies intended to bolster utilization; simply put, individuals cannot utilize healthcare services they are unable to access. However, the presence or absence of structural barriers does not fully account for differences in healthcare utilization, which is also strongly affected by personal and cultural factors. Particularly poorly understood from a research perspective is the influence on healthcare utilization of rural culture, which has been described as an “unaddressed elephant in the room” (Farmer et al., 2012).

Challenges defining rural culture—including a lack of consensus on whether it exists and, therefore, can be defined—have restrained systematic examination of its effects on all aspects of health (Farmer et al., 2012). As a result, understanding of rural adults’ perspectives concerning their health, including when and from whom they seek healthcare, is limited, resulting in a pronounced gap in the knowledge base. Clinical practice wisdom, however, has appreciated the importance of this relationship for years (take, for example, the “farmer walks into an emergency room” trope recently popularized on social media (Flanary WE @DGlaucomflecken, 2022)). Furthermore, what little research exists on the topic has identified core values, such as a strong sense of independence and financial prudence, that importantly shape how rural adults make decisions about health behaviors, including healthcare utilization (Holmes and Levy).

1.1. Theory of Planned Behavior

The Theory of Planned Behavior is a psychological theory that attempts to explain how people make decisions and ultimately engage in specific behaviors (Ajzen, 1991), making it a useful lens through which to consider healthcare utilization. Like the Theory of Reasoned Action, its theoretical predecessor, the Theory of Planned Behavior regards one’s attitudes toward behaviors and the social pressures and expectations surrounding one’s actions (i.e., subjective norms) as powerful determinants of one’s behavioral intentions and, ultimately, one’s behavior. However, unlike the Theory of Reasoned Action, the Theory of Planned Behavior also accounts for perceived behavioral control—a person’s belief about the ease or difficulty of performing a behavior—acknowledging important variation in the extent to which individuals have control over their actions (Ajzen, 1991). Thus, it is particularly useful in understanding behavior in situations in which one may lack the ability or the necessary resources to engage in a behavior, as might be the case for an underinsured person wishing to access costly healthcare services or for someone wishing to visit a medical specialist in a rural area where such specialists are few in number. For these reasons, the Theory of Planned Behavior has been widely applied in research examining healthcare utilization and other health-promoting behaviors (U.S. Department of Health & Human Services et al.).

A more comprehensive examination of the Theory of Planned Behavior’s interrelated components (see Fig. 1) sheds additional light on its utility in understanding human behavior. As previously described, the Theory of Planned Behavior posits that one’s behavioral intentions and performance are influenced by attitudes, subjective norms, and perceived behavioral control. Per the theory, attitude refers to an individual’s evaluation and judgment about performing a specific behavior. It includes both cognitive components (beliefs about the outcome(s) of the behavior) and affective components (feelings associated with the behavior). Subjective norms represent perceived social pressure or influence from significant others, such as family members, friends, and neighbors. Subjective norms are further subclassified into descriptive norms (individuals’ perceptions of what others are doing) and injunctive norms (individuals’ perceptions of what others would approve or disapprove of regarding a specific behavior). Perceived behavioral control refers to an individual’s perception of the ease or difficulty of performing a particular behavior. It encompasses both self-efficacy (an individual’s belief in their ability to perform a behavior, given its ease or difficulty) and controllability (the extent to which an individual believes performance of the behavior is within their personal control) (Ajzen, 2002). When individuals perceive control over their actions, intention strongly predicts behavior. However, when individuals face external constraints (e.g., lack of necessary resources), perceived behavioral control circumvents intention and becomes a direct predictor of behavior.

Fig. 1.

Theory of planned behavior.

1.2. Study aim and context

We conducted the study described herein to generate a comprehensive understanding of influences on healthcare utilization among rural adults, utilizing the Theory of Planned Behavior as a lens through which to explore personal, cultural, and structural factors. Underpinning our exploration was an assumption that, while rural culture is unquestionably diverse and shaped by locality (Bennett et al., 2019), it exists, and it affects how individuals understand and interact with the world they inhabit (Farmer et al., 2012). In focusing specifically on healthcare utilization in rural Missouri, we situated our research in a region of the United States with both Midwestern and Southern influences (Edgell, 2024) in which small towns contribute significantly to robust agricultural economies (Missouri Department of Agriculture), recognizing both the diversity within the state and the many ways it differs from other places.

2. Materials and methods

We conducted a qualitative descriptive study (Sandelowski, 2000), which was approved by Institutional Review Boards (IRBs) at Washington University in St. Louis and the University of Missouri. With support from University of Missouri (MU) Extension and the Recruitment Enhancement Core of the Institute of Clinical and Translational Sciences at Washington University in St. Louis, we employed a purposeful sampling strategy, seeking an information-rich sample of study participants (Creswell and Poth, 2025a; Palinkas et al., 2015). Inclusion criteria required that study participants were (1) adults (i.e., age ≥ 18 years), (2) residing in a rural Missouri county, and (3) able and willing to verbalize informed consent to take part in research, per our IRB-approved protocol. For the purposes of our research, we defined a rural county as any county with a 2013 U.S. Department of Agriculture Rural-Urban Continuum Code > 3 (i.e., all counties designated as non-metro) (U.S. Department of Agriculture Economic Research Service).

2.1. Data collection and analysis

We conducted audio-recorded, semi-structured telephone interviews (average interview length = 62 min) with all consenting study participants. Our interview guide included a combination of open-ended questions (e.g., “Can you tell me about a time you were hurt or sick?”) with corresponding prompts (e.g., “What did you think, feel, and do?”) and more focused questions related to hypothetical scenarios (e.g., “Sheila is a 56-year-old woman who has been diagnosed with fibromyalgia [description of fibromyalgia provided]. She has been offered the following treatments: [treatments listed]. Which treatments should Sheila choose? Why?”). A contracted third-party vendor professionally transcribed all interviews in preparation for analysis.

We analyzed the transcribed interview content by performing a hybrid inductive-deductive thematic analysis (Fereday and Muir-Cochrane, 2006) in three phases. During the first phase, each transcript was independently coded by a minimum of two researchers who used NVivo qualitative research software (Lumivero) to apply descriptive labels to data segments they deemed pertinent to our study aim. After this initial inductive coding was completed, we met as a larger team to discuss researchers’ independently identified codes and reach consensus on specific analytic decisions. In the second phase, two researchers met to conduct deductive coding (also in NVivo), using the Theory of Planned Behavior as a framework to organize inductively coded data into well-defined theoretical constructs. In this phase of analysis, we prioritized our goal of generating a comprehensive understanding of participants’ experiences rather than identifying distinct behavioral influences. Correspondingly, we deductively labeled many data segments with multiple codes. For example, data segments labeled with the inductively derived code walk it off were deemed relevant to both attitudes and subjective norms. In the third and final phase of analysis, we met as a team to collectively develop broader themes that captured key ideas represented in the data. We attended to issues of methodological rigor throughout our analysis by maintaining a detailed audit trail of all our analytic decisions and by participating in regular peer debriefing, during which we engaged in in-depth conversations about analytic choices and engaged in reflexivity by discussing the influence of our individual and collective involvement in the research process (Barry et al., 1999).

3. Results

We interviewed 25 study participants (participant demographics are provided in Table 1). Below and in Table 2, we present our study findings embedded within the conceptual scaffolding established by the Theory of Planned Behavior, illustrating how attitudes, subjective norms, and perceived behavioral control influence healthcare utilization among rural Missourians. Although for purposes of clarity we describe our findings as separate themes corresponding to distinct theoretical domains, in reality they are highly interrelated rather than mutually exclusive. To safeguard confidentiality, all participant quotations are labeled with numerical codes rather than names or other identifying information.

Table 1.

Participant demographics.

	Overall (n = 25)
Age Range (n, %)
30–39	4 (16%)
40–49	5 (20%)
50–59	3 (12%)
60–69	9 (36%)
70–79	4 (16%)
Sex
Male	4 (16%)
Female	21 (84%)
Race
Asian	1 (4%)
Black/African American	2 (8%)
White	22 (88%)
Relationship Status
Single, never married	4 (16%)
Married or engaged	17 (68%)
Divorced or separated	2 (8%)
Widowed	2 (8%)
Highest Formal Education
High school or equivalent	5 (20%)
Some college/trade school	7 (28%)
Undergraduate degree	4 (16%)
Graduate degree	9 (36%)

Table 2.

Summary of study findings.

Organizing Theoretical Constructs	Themes	Participant Quotations
Attitude	Desire for self-sufficiency	“If [a health concern] ever escalates to a point where I know I can’t [manage] it, then I might consider listening to what a doctor tells me I need to do.” (Participant 101)
	Preference for natural interventions	“If I can do something non-drug related, I will [do it] first before I take any medications.” (Participant 107)
	Poor perception of rural healthcare quality	“[My primary care] appointment kept being postponed ... By the time I actually went in, the weekend before I went in, I went to [rural town] urgent care because I thought I was dying at night because I couldn’t sleep because I was choking. They told me it was bronchitis, and they gave me a medication for cough medicine and then sent me back home ... At my scheduled primary care appointment, [my doctor] kind of brushed me off too ... It took quite a bit to get him to listen, but he listened to the heart and thought he heard a prolapse [so he] sent me for the echo[cardiogram]. [The cardiologist] told me my ejection fraction was 13 percent and there wasn’t a whole lot he could do for me ... He told me to go home and rest, and they would call me on Tuesday with an appointment somewhere up in [large city]. (Participant 126)
Subjective Norms	Respect for toughness and resilience	“If you ever [get bucked off a horse], [you] get back on... You’re not a sissy on a farm.” (Participant 111)
	Conservative approach to healthcare	“We have to be bleeding, broken, or barfing to go to the hospital ... Otherwise ... we’ll take care of it at home.” (Participant 123)
	View of the body as an instrument	“They say if you don’t use [your body], you’ll lose it. I guess that’s the way I was raised ... Everybody that I’ve ever known has always worked all of their life. For me, not working is living off of someone or something, and I’m too responsible and accountable to live off of anyone or anything.” (Participant 103)
	Influence of faith and religion	“I had repeated urinary tract infections but [my family] wouldn’t take me to a doctor. People just prayed for me to get better.” (Participant 121) “I’m one of Jehovah’s Witnesses, and so per Bible instructions we do not take a blood transfusion. If I was in a car accident and they were wanting to give me blood or do a surgery or whatever ... I would refuse that.” (Participant 114) “My grandpa, a couple years ago, had stage four colon cancer ... Instead of opioids, we knew that some people do the medical marijuana ... Because of his religious beliefs and because of the stigma about that, he just wouldn’t do it.” (Participant 110)
Perceived Behavioral Control	Financial barriers	“My mom had teeth problems ... She didn’t have health insurance. I know that she was complaining a lot, using a lot of [over-the-counter oral pain relief gel] and [over-the-counter oral pain relief powder] that seemed too disgusting and at one point trying to use tobacco to numb it." (Participant 126)
	Lack of accessible healthcare options	"We can’t get [an appointment] for another five weeks. We call it ‘popcorn medicine.’ Whatever pops up first, we take it.” (Participant 123)

3.1. Attitude

Study participants discussed a desire for self-sufficiency as an important value guiding their approach to healthcare utilization. They expressed overwhelming support for first attempting to address or resolve medical issues at home without engaging formal healthcare services. One participant explained, “Our family’s attitude, it was never anti-doctor, but ‘let’s just wait and see what happens’ … I think all these little incidents, this little injury or whatever went on in life, was our parents’ way of teaching us how to handle situations later in life. It taught us responsibility. [It] taught us you can’t just whine about it … Bring us a solution” (Participant 106). Another stated, “We wouldn’t really go to the doctor. That was sort of the norm in my family. If you were hurt, you kind of walked it off” (Participant 104).

Related to the value of self-sufficiency was a strong preference for natural interventions. Participants commonly equated “natural” with “non-pharmacologic” and, thus, contrasted natural interventions with the much-maligned “just taking a pill” approach to addressing health concerns (e.g., “Effective pain management that isn’t just taking a pill should be normalized” [Participant 102]; “If I can do something non-drug related, I will [do it] first before taking any medications” [Participant 107]). Several participants described the use of folk remedies, including cultivating and using herbs and other plants (i.e., “roots and leaves” [Participant 120]), with some explicitly connecting this to ties to family or the land. Participant 122 recalled that when she was hurt, “I would go out to my grandma’s garden or go to her plants and pull off some aloe vera […] That was our culture. That was our history.” Among a long list of non-pharmacologic or health-promoting interventions mentioned were walking, yoga, quality sleep, physical therapy, cannabis use, deep breathing, and good nutrition.

Most participants expressed a poor perception of rural healthcare quality, which decreased their likelihood of utilizing local healthcare services. One participant stated, “If you need something done … you have to leave [rural area] to get it done properly. People usually say, if you stop at our hospital, your next step is going to a funeral home” (Participant 105). Several participants recounted problematic prior experiences with rural healthcare facilities and providers that informed their negative opinions (see also Table 2). Negative individual experiences were readily linked with broader access issues, with participants noting healthcare providers in rural areas to be poorly supported and “run ragged” (Participant 108).

3.2. Subjective norms

Participants described a highly prevalent respect for toughness and resilience in rural areas, citing these as hallmark traits, especially of rural adults working in hazardous occupations (e.g., grain mill operator, farmer) or engaging in potentially dangerous pastime activities (e.g., all-terrain vehicle or horseback riding). One participant noted, “My dad, he … didn’t mope around and complain about something. [He] just worked through it and kept going. My mom was a very strong woman. She kept the family together. She kept everybody fed and made our clothes” (Participant 118). This societal expectation to accept difficulties and approach them with a sense of composure and fortitude was echoed by several other participants. One elaborated, “The people that tend to live in a rural area are people that are used to struggling, and they work really hard, and they’ve lived through worse” (Participant 110). Another participant discussed her son’s military career and multiple deployments, reflecting, “My son, before he went to school every morning, he’d go out and break the ice on the pond so the cows can drink. He did that ever since he was five or six years old. I think that made him what he is today” (Participant 111).

Related to an individualized desire for self-sufficiency (previously described as an attribute of rural attitudes toward healthcare utilization), there was a broader social norm that participants described as a conservative approach to healthcare. Participants shared a general consensus that the use of formal healthcare services should be avoided unless they were absolutely necessary. The majority of interviewees cited examples of broken bones or excessive blood loss as a respectable severity of illness or injury to warrant medical intervention. Participant 110 explained, “Living in a rural area … you get over stuff or, if you know it’s no big deal, you put a [bandage] on it or whatever. You’re definitely not going to call a doctor if you have a cough.”

Among participants, there was a shared view of the body as an instrument that enabled hard work and fulfilling one’s familial and social responsibilities. One participant explained, “Getting bodily weakness is considered a weakness of the person … People don’t want to be seen as weak, hav[ing] weak moral fiber” (Participant 123). Participants linked this perspective to a hesitation to utilize healthcare services out of concern that healthcare providers would recommend medical interventions that would prohibit work, caregiving, and other purposeful activities. Participant 101 discussed this as a particular concern among rural men: “They don’t believe in doctors, or they just don’t ever want to take the time to see one. I think what it is, a lot of times they’re afraid the doctor’s going to tell them they need surgery. Most of the people I know can’t afford to be down for six weeks.”

All participants were asked about issues of faith and religion in the context of health concerns, with several highlighting the perceived importance of prayer (for oneself and others), a higher power as a source of hope, and instrumental support (e.g., bringing food to the home of someone who is sick) provided by churches and other faith communities. However, these were infrequently described as influences on healthcare utilization itself. Rather, they were salient contextual factors shaping the experience of illness and injury. A minority of participants discussed the influence of faith and religion specifically on decisions regarding healthcare utilization. Examples (see also Table 2) included prohibitions against blood transfusions for Jehovah’s Witnesses, disapproval of medical marijuana rooted in religious views, and belief that sin causes disease or inhibits healing.

3.3. Perceived behavioral control

Participants cited numerous financial barriers that impeded their utilization of healthcare services, even in response to medical trauma. Participant 116 recalled the series of events that followed her lumbar spinal fracture, which necessitated her transfer from a local hospital to a larger urban hospital for surgery: “[When] inquiring about an ambulance to take me … to [large urban hospital], which was a three-and-a-half-hour ride—I hate to think of what that bill was—but [the local hospital said,] ‘If you don’t have insurance, I wouldn’t even bother with that.’ I didn’t. [My husband] laid me in the back of his car. The hospital put me on a board to stabilize my spine.” Several other participants shared similar stories, further emphasizing the fear of financial burden as not only a major obstacle to accessing healthcare services (see Table 2) but also a leading cause of delay in seeking formal care. For example, Participant 114 stated, “If we had better insurance, I might go [to the hospital]. Whereas now, I will just kind of wait it out and see how it goes.”

Participants discussed a widespread lack of accessible healthcare options in rural areas, citing a scarcity of providers, services, and facilities, including inpatient hospitals, doctors’ offices, and pharmacies. Many opted to travel to larger cities for healthcare whenever possible, citing service shortages (e.g., [Rural areas] are going to have less specialties. They’re going to have less available for you there” [Participant 110]). The cost and hassle of lengthy travel required to access healthcare in larger cities was often cited as an explanation for lower rates of preventive and other non-emergent healthcare utilization among rural adults. Citing the local availability of some preventive services, Participant 106 wondered, “If I had to drive to [large city] for a mammogram every year, would I get it?” Those wishing to access healthcare locally reported often encountering long appointment wait times. Participant 108 provided the following example: “My primary physician over here is probably about 11 miles one way. If I call him for an appointment, I’d be lucky to get in next week. Rural areas are totally underserved.”

4. Discussion

In conducting this study, we aimed to generate a comprehensive understanding of influences on healthcare utilization among rural Missourians. More specifically, we employed the Theory of Planned Behavior as a lens through which to explore the influence of personal, cultural, and structural factors on healthcare utilization within the corresponding respective theoretical constructs of attitude, subjective norms, and perceived behavioral control.

In several respects, our findings align well with those of previous studies, particularly concerning perceived behavioral control. As has been repeatedly identified in prior research (Johnston et al., 2019; Iglehart, 2018; Mullens et al., 2024; Maclaren et al., 2024), our study participants readily identified structural barriers to healthcare utilization, including financial barriers (e.g., lack of income or wealth, lack of insurance or being underinsured, unavailability of time off from work and other responsibilities) and lack of accessible healthcare options, including healthcare providers, services, and facilities. In addition, while it was identified as an influential attitude rather than a factor pertaining to perceived behavioral control, given that it was discussed as a deterrent rather than a barrier to healthcare utilization, study participants’ poor perception of rural healthcare quality is discussed in some (while not all) prior research (U.S. Department of Health and Human Services, 2020). These well-documented issues underpin numerous efforts to increase accessible, high-quality healthcare in rural communities, as reflected in the U.S. Department of Health and Human Services’ most recent Rural Action Plan (U.S. Department of Health and Human Services, 2020).

Less accounted for in the extant research are the place-based personal and cultural factors that influence healthcare utilization in rural communities. Study participants’ description of a desire for self-sufficiency, preference for natural interventions, and conservative approach to healthcare suggest that—in some instances—lower observed rates of healthcare utilization may reflect the values and preferences of rural individuals and communities, as opposed to being solely attributable to structural barriers, consistent with key behavioral influences identified in the Theory of Planned Behavior. Researchers studying decision-making regarding healthcare utilization have identified these qualities among individuals referred to as medical minimizers (Groopman and Hartzband, 2012), defined as those who prefer to avoid medical interventions they perceive to be unnecessary. For example, individuals identified as medical minimizers might disagree with statements such as, “If I feel unhealthy, the first thing I do is go to the doctor and get a prescription,” but would likely readily agree with statements like, “If I have a health issue, my preference is to wait and see if the problem gets better on its own before going to the doctor” (Scherer et al., 2016). While medical minimization is not inherently problematic, it can lead individuals to potentially reject evidence-based, high-benefit care (Scherer et al., 2020) and, thus, warrants continued attention.

Strategies to account for a tendency toward medical minimization should include aiming for a clinician-patient relationship rooted in an understanding of rural values (e.g., desire for self-sufficiency, preference for natural interventions, and conservative approach to healthcare). For example, our study findings suggest that emphasizing the importance of seeking preventive healthcare to retain patients’ autonomy, independence, and purposeful physical function for as long as possible might be more effective messaging than framing healthcare as a strategy to promote early disease detection. For example, health systems might engage rural adults by crafting education, interventions, and supports that align with the tendency towards minimization and support the desire for self-sufficiency. Supported self-management is a framework that empowers patients with pertinent information and encourages self-agency; patients can manage their own health with the support of an available clinical or peer support worker with clearly defined limitations and thresholds to present to the healthcare system for evaluation (Islam et al., 2023; Kumah et al., 2021; Barker et al., 2017). Many disease-oriented patient materials focus on enlightening the public regarding which specific instances indicate a need to seek healthcare (e.g., Act F.A.S.T for early stroke recognition (Centers for Disease Control and Prevention), color-coded Asthma Action Plans that educate patients about specific symptoms to be cognizant of and whether they should manage at home, see their primary care provider, or go to the emergency department (McClatchey et al., 2023)). In addition, investment in public health services (e.g., community nutrition programs, greenspace and nature-based interventions, and recreation and physical activity opportunities) and other strategies that offer health-promoting services outside of traditional medical settings warrant further consideration (Ziller and Milkowski, 2020; Bikomeye et al., 2022). Participants’ discussion of faith as an important component of well-being, while not necessarily a factor in decisions about healthcare utilization, underscores the potential promise of partnering with faith communities, relying on close-knit community involvement to advance health promotion initiatives.

Although our study underscores the importance of cultural values and promoting patient-directed care, structural barriers remain at the forefront of discussions about healthcare utilization in rural communities. While health-positive attitudes and social norms shared by the participants in this study provide fertile soil for healthcare utilization centered around preserving independence and promoting a high quality of life, the contradiction between health-conscious rural values and disproportionally higher rates for all-cause mortality in rural areas cannot be ignored. Extrapolating the Theory of Planned Behavior to rural Missourians offers a possible explanation for the disagreement of intention and behavior, emphasizing that health-promoting intentions can only be a strong predictor of healthcare utilization in situations where rural Missourians perceive high control over their actions. However, when individuals face external constraints, limited perceived behavioral control due to financial barriers and lack of accessible healthcare are likely to impede healthcare utilization despite cultural values. Consistent with the Theory of Planned Behavior, these study findings offer strong support for the continued development and evaluation of policy initiatives aimed at increasing availability of affordable, accessible healthcare in rural communities, while also emphasizing the need for that care to be culturally congruent and relevant to the lives of rural residents as the intended beneficiaries of such services.

4.1. Study limitations

This study had numerous limitations. First, our sample was drawn solely from adults residing in rural Missouri counties; the transferability of our findings to other states or geographic regions cannot be assumed (Creswell and Poth, 2025b). Second, consistent with our qualitative research approach, our sample was not intended to fully represent all rural Missouri adults. With regard to race, in particular, our sample was largely homogeneous, including 22 of 25 participants who identified as white. Although this mirrors the racial composition of the overwhelming majority of rural Missouri (U.S. Census Bureau), it nonetheless risks minimizing or erasing the experiences of racial minorities, which are likely inadequately reflected in the current study findings. Finally, participants’ involvement in the research study was limited to one telephone interview, precluding prolonged engagement with study participants and triangulation of data sources (Creswell and Poth, 2025b). Future research employing additional qualitative methodologies such as ethnography would enrich understandings of contextual and cultural factors influencing healthcare utilization among rural Missourians (Creswell and Poth, 2025c).

5. Conclusions

Healthcare utilization in rural Missouri communities is influenced by personal, cultural, and structural factors, all of which must be understood to effectively address longstanding place-based health disparities. In addition to developing, implementing, and evaluating sorely needed policies to address barriers to formal healthcare services, consideration of increased investment in public health initiatives that expand health-promoting opportunities into naturally occurring communities or are offered in natural settings, such as Missouri’s abundant forests, lakes, and trails (Missouri Department of Natural Resources), is recommended. On an individual level, clinician-patient relationships should be rooted in shared decision-making and mutual understanding of patients’ unique needs, values, and preferences. Across all systems levels, services should be designed and delivered in a culturally congruent manner that addresses the challenges of rural healthcare and builds on the significant assets of rural communities.