Roadblocks to Rural Health: State Transportation Policies’ Impact on Health Care Access in Virginia’s Rural Communities: 2021–2022

Abstract

Individual and community-level transportation barriers are known drivers of health disparities, especially in rural areas. In a 2021–2022 community-based project to improve cancer screening at federally qualified health centers in Virginia, Department of Transportation policy governing road signage emerged as an unexpected but actionable barrier. Following successful advocacy for road signs directing patients to a rural federally qualified health center, screening rates increased. This highlights the need to recognize unexpected access barriers and engage nontraditional partners, such as transportation agencies, to reduce regulatory-level barriers. (Am J Public Health. 2026;116(2):175–179. https://doi.org/10.2105/AJPH.2025.308285)

Individual and community-level transportation barriers impede timely access to health care, particularly among vulnerable and rural populations.^1–4 They contribute to racial and rural cancer disparities,^2,5 affecting stage at detection, access to guideline-concordant care, emergency department visits, survival, and mortality.^2,6,7

STUDY OBJECTIVE

We present a practice-based observation from a community-based participatory research (CBPR) project involving our academic team, Central Virginia Health Services’ Brunswick Health Center (BHC), and a local community organization in Brunswick County, Virginia, to increase colorectal and cervical cancer screening at federally qualified health centers (FQHCs). Although BHC staff knew of long-standing challenges regarding the visibility of its facility, significance as a structural barrier was not apparent to academic partners until they visited. The issue, although familiar to the clinic, was clarified through the CBPR process and collaborative problem solving. The challenge pertained to the Virginia Department of Transportation (VDOT) policy that restricted signage on limited-access highways (i.e., major roads with few intersections, entrances, or exits). BHC sits on an unnamed dirt road branching off a limited-access highway, making it hard to find.

RESEARCH QUESTIONS

We sought to (1) explore the impacts of regulatory transportation barriers on FQHC access locally and statewide, and (2) provide a template for advocacy to potentially increase cancer-screening access via improved visual access to a rural FQHC.

PARTICIPANTS, SAMPLE, GEOGRAPHIC LOCATION, SETTING, AND YEAR OF STUDY

We obtained demographic data from the US Census Bureau and county health rankings, and participating FQHCs reported patient visits and cancer-screening rates using 2019 internal records. BHC is part of a network of 18 clinics that served 45 792 patients in 2019. Of these, 23.5% were uninsured and 28.9% were insured by Medicaid. BHC provides primary care, cancer screening, behavioral health services, and dental services. In 2019, BHC reported that 1568 patients were eligible for colorectal or cervical cancer screening; of these, 25% and 22%, respectively, were screened. Brunswick County has a high proportion of Black residents (53% vs 20% statewide) as well as twice the state’s poverty rate (20.8% vs 10.2%) and an uninsured rate near 10%.⁸ BHC was one of five FQHCs participating in Project COALESCE (January 2021–December 2022), a CBPR study pairing FQHCs with local community organizations to identify and address barriers to cancer screening,⁹ which is known to be lower among FQHC patients.¹⁰

Before Project COALESCE, BHC requested—but was denied—an exemption to VDOT policy to install signage directing patients to the clinic. The exemption process itself posed an insurmountable administrative burden: VDOT required a formal petition supported by the town government, an independently commissioned traffic and safety analysis, and legal review to show that boundary changes or exceptions would not conflict with existing statutes. Alternative options included pursuing a statewide regulatory amendment, lobbying for a statutory change through the legislature, and filing litigation—each of which require extensive financial resources, technical expertise, and political capital far beyond the capacity of a small, rural FQHC. Although we conducted Project COALESCE from 2021 to 2022, we used 2019 data as the baseline to reflect typical pre–COVID-19 pandemic screening rates and to avoid 2020 distortions from COVID-19 disruptions.

METHODS

In line with CBPR principles,¹¹ we collaborated with BHC, community organizations, and other stakeholders to advocate policy change to improve health care and cancer-screening access. We used institutional resources to complete BHC’s exemption application and petition to reclassify sections of the nearby highway so that signage could be installed. Goals included catalyzing efforts to create a permanent statutory fix to help other FQHCs avoid the time-consuming exemption request process. This action-oriented approach exemplifies how CBPR can translate community-identified challenges into advocacy efforts. Our advocacy included the following:

• •We engaged with a consultant from VDOT to conduct an engineering review and create a report describing BHC, its patient population, and the consequences of diminished facility visibility.
• •We approached residents, the town government, and other stakeholders to request letters of support for signage and to describe to them BHC’s importance to community health.
• •We requested meetings with VDOT and local and state elected officials to explain the issue and garner their support.

Our analytic approach emerged from CBPR discussions in which the issue of directional signage at BHC prompted questions about whether other FQHCs faced similar geospatial barriers. To explore the scope and potential effects of VDOT policy on FQHC access, we obtained address data for all 202 FQHCs and Look-Alikes (i.e., health centers that meet all the requirements to qualify as an FQHC but do not receive the full federal Section 330 grant funding that FQHCs receive) in Virginia from the Health Resources and Services Administration’s (HRSA’s) 2021 database. This aligned with the project’s active period (2021–2022). We geocoded addresses and used ArcGIS (Esri, Redlands, CA) to identify FQHCs located at or within 3200 feet of limited-access highways; this is equivalent to the distance between the index FQHC and the nearest rural highway. This threshold, although not derived from an average or distribution, provided a practical starting point for exploratory spatial comparisons.

Using this criterion, we found that 123 FQHCs (61% of all HRSA-listed centers) were situated at or within 3200 feet of limited-access highways, suggesting that VDOT signage policies may have broad implications beyond BHC. Collectively, these FQHCs serve approximately 239 000 patients. To validate current clinic status, we repeated this analysis using the updated 2023 HRSA database, which identified 56 centers meeting the same proximity threshold. These findings highlight the potential for systemic impact if policy adjustments are pursued.

KEY FINDINGS

We did not observe any statistically significant differences, but affected FQHCs had higher rurality measures (4% vs 1%; P = .24) and a slightly lower proportion of Black residents (23% vs 30%; P = .72). We observed little variation across other demographic variables. In 2023, approximately 773 365 patients received care at potentially affected FQHCs (Figure 1), demonstrating potential scope of impact.

FIGURE 1—

Map of State-Owned Roads and FQHCs in Virginia: 2021

Note. FQHC = federally qualified health center. Affected FQHCs (red triangles) are located within 3200 feet of a limited-access highway and potentially affected by Virginia Department of Transportation signage restrictions. Unaffected FQHCs (yellow dots) are located farther than 3200 feet from limited-access highways and are not subject to these restrictions.

As a result of advocacy efforts, VDOT agreed to install directional signs reading “Community Health Center” on either side of the highway and issued a permit allowing BHC to place a larger sign in front of the clinic (Figure 2). The small, unnamed road leading from the highway to BHC was given a name to further facilitate access, and VDOT agreed to conduct site surveying. VDOT also screened maps and imagery of other FQHCs statewide to identify similar directional, safety, and visibility challenges (e.g., limited roadway visibility, lack of frontage, complex geometrics, unnamed roads).

FIGURE 2—

Directional Signage Installed by the Virginia Department of Transportation on a Limited-Access Highway Near Federally Qualified Health Centers: Brunswick County, VA, January 2022

Source. Photos courtesy of a community member.

EVALUATION, TRANSFERABILITY, AND ADVERSE EFFECTS

At the end of the project (December 2022), after signage installation in January 2022, BHC reported that 1747 patients were eligible for colorectal or cervical cancer screening, up from 1568 in 2019. Of these, 1228 were screened, representing postintervention screening rates of 69% for colorectal cancer and 71% for cervical cancer. This reflects 44– and 49–percentage point increases over the 2019 baseline rates of 25% and 22%. Although we cannot establish causality, clinic staff attributed this improvement partly to improved visibility and strengthened partnerships with community organizations developed through the project.

BHC’s permit to install directional signage is a notable victory, with VDOT’s commitment to investigate other health care facilities that may benefit from exemptions or zoning changes. Although cancer screening increased after signage installation, we cannot establish causality or rule out other factors—such as community outreach, staff changes, or unrelated health policy shifts—that may explain these changes. Although further research is needed, state-level solutions could include modifying VDOT policy to exempt health care facilities from signage restrictions and simplifying exception processes. The most sustainable approaches involve cross-sector collaborations¹² to align transportation and health policy, such as joint task forces consisting of VDOT, health and local government officials, FQHCs, clinicians, patients, public health professionals, and other stakeholders. Community-engaged research partnerships could provide data-driven insights into transportation design that support local health and cancer care needs.

When unexpected barriers arise, CBPR researchers should remain flexible and curious, and they should collaborate with communities to address them.¹¹ Policymakers should consider similar barriers in their communities and identify opportunities for cross-sector change.¹³ Health care facilities should consider potential navigational or facility visibility issues and how they might be remedied. Advocates can bolster signage petitions with letters of endorsements from local governments, FQHC staff and patients, and engineering safety data.

SCALABILITY

Transportation barriers often vary by community context.¹⁴ This case, however, highlights an overlooked barrier that disproportionately affects rural FQHC patients. The partnership successfully removed a significant obstacle through multisectoral collaboration. This approach is key to reducing structural health care access barriers and improving public health. The advocacy and partnership model offers a replicable framework. Future qualitative research could explore traditional and nontraditional transportation barriers—such as signage policies and wayfinding challenges—and inform collaborative disparity reduction. Quantitative work with affected FQHCs is needed to assess signage effects. Research and interventions that identify nontraditional transportation and other barriers and develop tailored solutions with local and state agencies (e.g., transportation agencies) may help reduce cancer disparities in other communities.

PUBLIC HEALTH SIGNIFICANCE

FQHCs play a critical role in reducing cancer disparities¹⁵; however, their impact depends on resolving access barriers, including findability, transportation, appointment availability, affordability, and care coordination. This case shows how transportation agencies influence health care access. Cross-sector collaboration can mitigate policy barriers and improve outcomes. Transportation policy—including that on signage and public transit—is a public health issue.^13,14 Achieving healthy communities requires aligning infrastructure with health care access goals.