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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Child Health Care. 2020 Nov 8;50(1):108–123. doi: 10.1080/02739615.2020.1833333

Unmet health need and perceived barriers to health care among adolescents living in a rural area

Heather K Hardin a,*, Hana Alchami b, David Lee c, M Susan Jones d
PMCID: PMC7787257  NIHMSID: NIHMS1641400  PMID: 33424079

Abstract

This study investigated the perceived health care needs, unmet health need, and barriers to health care in 224 rural-dwelling adolescents. A cross-sectional, descriptive design was used to survey adolescents attending a public high school in a low-resource, rural Indiana community. One in five adolescents reported an unmet health need. The most common barriers to health care were related to access, apathy, anxiety, and parenting issues. Implications include confidentiality protocols in family healthcare practices, school-based health centers, and intervention research targeting adolescents’ communication skills and healthcare consumer skills.

Keywords: unmet health need, adolescent health services, health services accessibility, rural health

People who live in rural areas have health disparities that result in higher mortality rates and shorter life expectancies than people who live in urban and suburban areas (Long et al., 2018; Spleen et al., 2014; Meit et al., 2014). They are more likely than their urban and suburban counterparts to be obese, smoke, or be diagnosed with cancer, diabetes, hypertension, or respiratory disease. Avoidance of health care is common among people who live in rural areas, which furthers unmet health needs and health disparities in this population (Douthit et al., 2015; Spleen et al., 2014). An unmet health need occurs when an individual perceives a need for health care, but does not use health care (Li et al., 2018). Barriers to health care are used to describe reasons for an unmet health need. Barriers to health care common to people living in rural areas include cultural beliefs, access to care issues (e.g. cost, transportation), and scarcity of health care available (Cordasco et al., 2016; Douthit et al., 2015; James et al., 2017).

Adolescents living in rural areas may have additional barriers to using health care and therefore, unmet health needs than adults who live in rural areas. In addition to the barriers described above, adolescents also perceive a lack of privacy and confidentiality in using health care in a rural area (Grilo et al., 2019). Many rural areas lack pediatric or adolescent specialists and as a result, adolescents frequently receive healthcare from the same provider and office staff as the rest of their family (Dixon et al., 2016; Secor-Turner et al., 2014). When an adolescent and their parents are all receiving health care from the same provider, the parent has increased contact with the healthcare provider (HCP) and office staff, providing additional opportunities to discuss the adolescent’s health care received (Beeson et al., 2016). This situation is additionally problematic when the office staff members are known acquaintances of the adolescent and parent, which is a common occurrence in a rural area.

Adolescents living in rural areas may be at greater risk of having unmet health needs than their adult counterparts (Secor-Turner et al., 2014). Health care avoidance is especially problematic among adolescents living in rural areas (Spleen et al., 2014). Use of health care among adolescents living in rural areas is low compared to other groups of adolescents, while having a higher burden of disease (Hardin et al., 2018; Douthit et al., 2015;). Adolescents living in rural areas have health disparities in tobacco use, contraception, obesity, and depressive symptoms (Meit et al., 2014). In general, adolescents’ unmet health needs are most frequently related to injuries, sexual health, and mental health (Clark et al., 2018). Financial access to care barriers are the most common barriers to general health care in adolescents (Hargreaves et al., 2015). Barriers to sexual health care include lack of parental support, along with issues related to confidentiality and minors’ consent (Fuentes et al., 2018). Adolescent’s barriers to mental health care include mental health care stigma, financial barriers, and self-reliance (Schneider et al., 2020). Many studies evaluating unmet health needs and barriers to health care do so from the caregiver or HCP perspective, rather than the adolescent’s perspective (Jon-Ubabuco & Dimmitt-Champion, 2019; Platell et al., 2017; Schnyder et al., 2020). It seems likely that unmet health needs and barriers to health care are also problematic among adolescents living in rural areas; however, there is little evidence from the adolescent’s perspective concerning unmet health needs and barriers to health care among adolescents living in rural areas.

The purpose of this study was to assess adolescents’ perceived healthcare needs, unmet health needs, and barriers to health care in a sample of adolescents living in a rural area. This study adapted the Behavioral Model of Health Services Use (referred to as the Behavioral Model hereafter) as a theoretical framework, which motivated variables measured in the study (Andersen, 2008). The Behavioral Model was designed to assess families’ use of health care, including predictors and outcomes of health care use, and has been used extensively since the 1960’s to assess factors influencing health behavior and health care use (Andersen, 2008). This study made use of four categories of variables in the Behavioral Model: individual predisposing characteristics, individual enabling characteristics, individual need characteristics, and health behaviors. According to the Behavioral Model, individual predisposing characteristics exist prior to the onset of need for health care, describe the propensity of individuals to use health care, and include demographic variables and beliefs about health or health care. Individual enabling characteristics facilitate access to health care and describe the income and assets individuals have available to them to help with obtaining health care. Individual need characteristics include variables that describe both subjective and objective health need. Health behaviors included the avoidance of using health care (Andersen, 2008), In this study, we adapted the Behavioral Model to measure individual characteristics (demographic variables, trust of HCP), individual enabling characteristics (household income, health insurance, transportation, usual source of health care), individual need characteristics (self-rated health, self-perceived need, diagnosed conditions), and health behaviors (unmet health need, barriers to health care).

Methods

A secondary analysis of a cross-sectional descriptive study was used to explore unmet health needs in adolescents attending a public high school in a low-income rural community in the Midwestern United States. The primary study focused on relationships between trust of the healthcare provider, lifestyle behaviors, and health care use in adolescents attending a public high school in a rural area (Hardin, et al., 2018). Study results found that trust of the healthcare provider predicted lifestyle behaviors, but did not predict health care use. The rural definition provided by the Office of Rural Health Policy was used to characterize rural in this study: “… an incorporated population of less than 50,000 with core census blocks of fewer than 1,000 people per square mile and surrounding census blocks with an overall density of fewer than 500 people per square mile” (Health Resources and Services Administration, 2018). The community where these data were collected was an incorporated population of approximately 6,000 individuals. Institutional Review Board approval was obtained (#12.0290). In addition, the school administrators and a community advisory committee made up of parents, teachers, and adolescents approved the survey questionnaires. School administrators requested a survey designed with passive consent/assent to reduce burden to the participants, parents, and the school.

Participants

All adolescents in grades 9 through 12 enrolled at the public high school were offered participation in the study. Youth were eligible to participate if they were (1) aged 14-19; (2) able to read, speak, and understand the English language; (3) able to complete a self-administered questionnaire; and (4) enrolled as a student at the public high school in a rural area. Exclusion criteria for this study were adolescent was unwilling to participate and parent of an adolescent minor refused consent. No parents refused consent; however, two youths were unwilling to participate. Two hundred and twenty four adolescents and emerging adults took part in the study.

Procedure

One week prior to data collection, the investigator provided school administrators with passive consent letters addressed to the parents of potential participants. The passive consent letters included information about the study and an opportunity to contact the investigator to decline participation. In the absence of expressed dissent, parental consent was assumed. Data were collected over two days in May 2014.

At the beginning of each class period that was surveyed, the investigator explained the study, anonymity of the study, and study procedures to the participants. The investigator and potential participants discussed the definition of healthcare provider (HCP) used in the study, which was the physician, nurse practitioner, or physician assistant usually seen for health care at the “doctor’s office.” The concepts of nurse practitioner and physician assistant were discussed and participants identified examples of local individuals in these professions. Participants were given an opportunity to ask questions about the study.

Participants included both adolescent minors (ages 14-17) and adolescent adults (ages 18-19). A cover sheet explaining the study and procedures were distributed to participants with the survey packets. Passive consent (for 18- to 19-year-old participants and parents of minor participants) and passive assent (for minor participants) were obtained. Three adolescents declined participation and were given a seek-and-find puzzle as an alternate activity. Paper and pencil questionnaires were self-administered in the classroom setting. The participants used the remaining class time (30 minutes) to complete the surveys. Most participants took approximately 15-20 minutes to complete the survey.

Measures

An investigator-developed demographic instrument measured self-reported age, sex, race, ethnicity, family structure, household income, health insurance, transportation difficulty, usual source of health care type, and HCP-diagnosed conditions in adolescent and emerging adult participants. Age was measured as a continuous variable between 14-19 years old. Sex was measured as a dichotomous variable (male, female). Race was measured with categorical multiple response options (American Indian or Alaska Native, Asian, Black, Native Hawaiian or Pacific Islander, White). Ethnicity was measured as a dichotomous variable (not Hispanic, Hispanic). Family structure was measured with categorical multiple response options (Do you live with your…? biological father, step-father, foster father/adoptive father, grandfather, someone else, no father figure), which was recoded to dichotomous (does not live with biological father, lives with biological father) and was duplicated with a similar mother figure item. Household income was measured with a proxy variable that indicated participation in the National School Lunch Program (Do you receive free or reduced lunch at school? No, I pay for my lunch; Yes, I receive reduced price lunch; Yes, I receive free lunch). Responses were recoded to a dichotomous variable (no, yes) indicating participation in the National School Lunch Program (Nicholson et al., 2014). Health insurance was measured as a categorical variable (private, military, Medicaid, other, none, don’t know) and recoded to a dichotomous variable (does not have health insurance, has health insurance). Transportation difficulty was measured with a 4-point Likert-style ordinal response (very difficult, somewhat difficult, not too difficult, not at all difficult) and recoded to a dichotomous variable (no or low transportation difficulty, some or very difficult transportation). Usual source of health care was measured as a categorical variable (doctor’s office, clinic, urgent care center, emergency department, don’t know, none) and recoded to a dichotomous variable (no, yes) indicating that usual source of health care was at the doctor’s office or health clinic, rather than at an urgent care center, emergency room, don’t know, or no usual care source. Self-rated health was determined using a single item measured on a 5-point Likert-style scale (excellent, very good, good, fair, poor) (α = .92) (Manning et al., 1982), which was recoded to a dichotomous variable (good/fair/poor, excellent/very good) indicating lower or higher level of self-rated health. The variables HCP-diagnosed conditions (Has a healthcare provider diagnosed you with any of the following conditions?) were measured dichotomously (no, yes) and included the following conditions: acne, attention deficit hyperactivity disorder, anemia, allergies, asthma, depression, diabetes, high blood pressure, overweight, obese, and none of the above.

Trust of Healthcare Provider.

Trust of HCP was included in this study as a health belief influencing health care and measured with the Wake Forest Physician Trust scale, which was designed to measure patient trust of the primary care provider (Hall et al., 2002). Reliability of the Wake Forest Physician Trust scale has been good in adults (α = .93; Hall et al., 2002) and in this sample (α = .90; Hardin, et al., 2018). Although the name of this scale suggests it measures only trust in physicians, it was developed and tested for use with a variety of HCPs, including physicians, nurse practitioners, and chiropractors. The Wake Forest Physician Trust scale has 10 items scored on a 5-point Likert-style scale (strongly disagree, disagree, neutral, agree, strongly agree) with three items reverse scored. It has a seventh-grade reading level and examples of items include: 1) Your doctor is totally honest in telling you about all of the different treatment options available for your condition, and 2) Sometimes your doctor does not pay full attention to what you are trying to tell him/her.

Unmet Health Need and Barriers to Health Care.

A three-item foregone care instrument was used to evaluate subjective health need, unmet health need, and perceived barriers to health care (Elliott & Larson, 2004). The foregone care instrument contained three sequential items, which measured self-perceived need for health care, unmet health need, and perceived barriers to health care. Self-perceived need for health care (Have you needed to see a doctor or nurse in the last 12 months?) was measured dichotomously (no, yes). Unmet health need was a two-part question that required an affirmative response for self-perceived need for health care and a negative response to need met (Did you go see a doctor or nurse about your health at that time?), which was measured dichotomously (no, yes). Perceived barriers to health care was measured with one item (If not, why?) with twelve categorical multiple response options (e.g. couldn’t pay, parent would not go). Each of the twelve barriers to health care were recoded dichotomously (no, yes) for analysis.

Statistical Analysis

Statistical analyses were performed with SPSS Statistics Version 25 software (IBM, 2018) to analyze the data. Frequencies and means were used to describe the sample. The relationship between unmet health need and individual characteristics were evaluated using correlations. Predictors of unmet health need were analyzed using logistic regression.

Results

A convenience sample included 224 youths, ages 14-19 years. The sample was mostly non-Hispanic White (95%) and female (54%). More than a third used the National School Lunch Program—a proxy variable for low household income. More than two-thirds had health insurance, three-fifths reported a HCP-diagnosed chronic condition, and nearly three-quarters reported a self-perceived need for healthcare in the past year (see Table 1). The demographic variable totals (age, sex, race, ethnicity, household income) were similar to aggregate school data. All chronic condition diagnoses were self-reported and were similar to national or regional rates (Meit et al., 2014), with the exception of overweight and obesity diagnoses. This sample had low rates of self-reported overweight or obesity diagnosis, which has also been identified in other studies, and was likely related to weight stigma, and parent and healthcare provider factors (Hardin et al., 2020; Farran et al., 2013; Lee et al., 2016; Lydecker & Grilo, 2017).

Table 1.

Demographic characteristics

Characteristic n (%) or M±SD
Age 16.4 ± 1.47
Sex
 Male 100 (44.6%)
 Female 121 (54.0%)
Race/Ethnicity
 White 210 (95.0%)
 Native American 8 (3.6%)
 Asian 7 (3.2%)
 Black 5 (2.3%)
 Hispanic 13 (5.8%)
 Multiracial 7 (3.2%)
 Missing 3 (1.3%)
Family structure
 Father lives in the home 125 (55.8%)
 Mother lives in the home 174 (77.7%)
Household income
 Low-income 82 (36.6%)
 Not low income 140 (62.5%)
Has health insurance 152 (67.9%)
Self-perceived need 163 (72.8%)
Has a chronic condition diagnosis 136 (60.7%)
 Acne 44 (19.6%)
 Attention deficit hyperactivity disorder 23 (10.3%)
 Anemia 6 (2.7%)
 Allergies 88 (39.3%)
 Asthma 35 (15.6%)
 Depression 27 (12.1%)
 Diabetes 9 (4.0%)
 High blood pressure 13 (5.8%)
 Overweight 24 (10.7%)
 Obesity 13 (5.8%)
Unmet health need in past 12 months 39 (17.4%)
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Note: Totals and percentages reflect participant responses and therefore may not equal 100%.

Unmet health need was reported by 17.4% of participants, with the most common reason reported being “thought or hoped the problem would go away” (see Table 2). Of those reporting an unmet health need, 59% were girls and 41% were boys. While 39 youths reported an unmet health need in the past year, these individuals identified 77 barriers to health care—approximately two barriers to health care per participant.

Table 2.

Structural and nonstructural barriers of unmet health need in adolescents living in a rural area

Variable Male Female
 Responses M ± SD n (%) n (%) n (%)
Unmet health need 39 (100%) 16 (15.8%) 23 (19.0%)
 Yes
Barriers, overall 2.0 ± 1.2
Structural barriers
 Couldn’t pay 11 (28.2%) 2 (14.3%) 9 (39.1%)
 Parent or guardian would not go 9 (23.1%) 1 (7.1%) 8 (34.8%)
 Had no transportation 3 (7.7%) 1 (7.1%) 2 (8.7%)
 Didn’t know where to go 1 (2.6%) 0 (0.0%) 1 (4.3%)
 No one available to go along 0 (0.0%) 0 (0.0%) 0 (0.0%)
 I am not treated with respect there 0 (0.0%) 0 (0.0%) 0 (0.0%)
Nonstructural barriers
 Thought/ hoped the problem would go away 22 (56.4%) 8 (57.1%) 14 (60.9%)
 Afraid of what the doctor would say or do 8 (20.5%) 2 (14.3%) 6 (26.1%)
 Hard to find the time 7 (17.9%) 2 (14.3%) 5 (21.7%)
 Didn’t want my parents to know 4 (10.3%) 0 (0.0%) 4 (17.4%)
 Afraid someone might see me 2 (5.1%) 0 (0.0%) 2 (8.7%)
 Didn’t know where to go 1 (2.6%) 0 (0.0%) 1 (4.3%)
 Too embarrassed 0 (0.0%) 0 (0.0%) 0 (0.0%)
 Fix it myself 0 (0.0%) 0 (0.0%) 0 (0.0%)
Unknown barriers
 Other reason not listed 10 (25.6%) 5 (35.7%) 4 (17.4%)
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Correlations were used to evaluate associations between unmet health need and study variables. A significant inverse relationship was found between unmet health need and family structure–living with father (r = −.23, p ≤ .01), having a primary care provider as the usual source of health care (r = −.15, p ≤ .05), living in a low-income household (r = −.16, p ≤ .05), greater trust of HCP (r = −.19, p .≤ 01), acne diagnosis (r = −.17, p ≤ .01), and asthma diagnosis (r = −.15, p ≤ .05). A significant positive relationship was found between unmet health need and having no health insurance (r = .17, p ≤ .05).

Correlations were used to evaluate associations between barriers to health care and individual predisposing characteristics. Most barriers to health care were not correlated with any study variables, but associations were identified with two of the barriers to health care. A significant inverse relationship was found between “afraid of what the doctor would say or do” and household income (r = −.35, p ≤ .05) and trust of HCP (r = −.41, p ≤ .05). A significant inverse relationship was found between “didn’t want my parents to know” and trust of HCP (r = −.45, p ≤ .01).

To further evaluate barriers to health care, correlations were used to evaluate associations between barriers to health care and need variables. A positive relationship was found between the barrier to health care “parent wouldn’t go” and self-reported diagnosis of obesity (r = .45, p ≤ .01) and overweight (r = .41, p ≤ .05). A significant positive association was found between “didn’t want my parents to know” and diagnosis of anemia (r = .36, p ≤ .05). A significant positive relationship was found between “afraid of what the doctor would say or do” and depression diagnosis (r = .34, p ≤ .05). A relationship was identified between “other reason not listed” and diagnosis of attention deficit hyperactivity disorder.

Barriers to health care were categorized as either structural barriers or nonstructural barriers (see Table 2). Structural barriers include access to care issues, while nonstructural barriers were social or affective in nature. The most common structural barrier to health care was “couldn’t pay,” while the most common nonstructural barrier was “thought or hoped the problem would go away.”

Chi-square tests for independence evaluated differences in unmet need by age and sex. There were no differences by sex in endorsement of having an unmet health need. There was a trend toward older adolescents (17-19 years old) being more likely than younger adolescents (14-16 years old) to endorse having an unmet health need (χ2 [1, n = 222] = 2.88, p = .09, phi = .13).

Predictors of unmet health need were identified using logistic regression. Variables with a significant correlation of at least ±.15 were entered into the logistic regression equation. The logistic regression model was statically significant (χ2 (7) = 34.92, p ≤ .01; see Table 3), explained 27% of the variance in unmet health need, and correctly classified 83.6% of cases. Protective effects were found for adolescents whose fathers lived in the household and those who reported an acne diagnosis. There was a trend towards the protective effect of identifying an HCP or clinic as the usual source of health care (p = .08), rather than using the urgent care center or emergency department as the usual source of care.

Table 3.

Predictors of unmet health need among adolescents living in a rural area

Model
B Odds ratio
Lives with father −1.30* .27
Acne diagnosis −2.15* .47
HCP as usual source of health care −0.76 .47
x2 34.92* df = 7
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Note:

*

p <.01

Discussion

Unmet health need.

This study made use of the Behavioral Model to evaluate unmet health need and barriers to health care in adolescents living in rural areas. The results of this study indicate that adolescents living in rural areas continue to have unmet health needs. An unmet health need occurs when an individual perceives a health need, but does not use health care (Li et al., 2018). In this study, 17.4% of adolescents reported an unmet health need in the past 12 months. These results are similar to a nationally representative study of adolescents (N = 14,800) that found that 19.2% of adolescents overall reported unmet health need, while 17.6% of white non-Hispanic adolescents reported an unmet health need (Hargreaves et al., 2015).

Adolescents’ whose father lived in the household with them and youths with an acne diagnosis were less likely to report an unmet health need. There was a trend toward significance of adolescents who had an HCP as the usual source of health care (rather than using the urgent care center or emergency department) as less likely to report an unmet health need. These results suggest that adolescents living with their father or having a diagnosis of acne were more likely to receive needed healthcare. Previous evidence suggests youths receive many benefits related to family structure and access to timely healthcare is one of them (Reczek et al., 2016). These results suggest adolescents living in rural areas and their parents/caregivers prioritize healthcare for acne. Other samples have found that adolescents and their families’ also value health care for acne (Desai et al., 2017; Ford et al., 2016).

Barriers to health care.

Adolescents reporting unmet health need encountered an average of two barriers to receiving health care. The most common reasons cited explaining unmet health need in this study were: (1) thought or hoped my problem would go away, (2) couldn’t pay, (3) parent or guardian would not go, and (4) afraid of what the doctor would say or do. Other studies of unmet health need among adolescents have reported similar barriers to healthcare. The most common barrier, “thought or hoped my problem would go away,” suggests a low priority to the health concern or ambivalence about treatment. The second most common barrier, “couldn’t pay,” is an access to care barrier. Unfortunately, access to health care problems are widespread in the United States’ healthcare system and are especially problematic in rural areas (Douthit et al., 2015). The third most common barrier, “afraid of what the doctor might say or do,” suggests anxiety concerning treatment. This may reflect inexperience with the healthcare system or a sensitive health need. Similar themes were found in other studies of adolescent barriers to health care. In a nationally representative sample, the most common barriers to healthcare included perceived low importance, cost, nonfinancial access to healthcare problems, and negative consequences of health care (Hargreaves et al., 2015).

Low trust of HCP was inversely associated with two adolescent barriers to health care: (1) afraid of what the doctor might say or do, and (2) didn’t want my parents to know. The relationship between “afraid of what the doctor might say or do” and low trust of HCP likely reflects a lack of experience with health care or confidentiality concerns. “Didn’t want my parent to know,” suggests concerns around privacy, confidentiality, and a growing independence from parents, which is developmentally appropriate for adolescents (Hadiwijaya et al., 2017; Meeus, 2016). Adolescents living in rural areas face more barriers to using health care than adults. In addition to the barriers described above, adolescents also perceive a lack of privacy or confidentiality in using general or family health care (Corry & Leavey, 2017). Many rural areas lack pediatric or adolescent specialists (Marcin et al., 2016) and as a result, adolescents and their family members all receive treatment from the same HCP and office staff. Evidence suggests that in general, neither adolescents, parents, nor the office staff have a clear understanding of minors’ confidentiality (Pampati et al., 2019). When an adolescent and their parents are all receiving health care from the same HCP, the parent has increased contact with the HCP and office staff, providing additional opportunities to discuss the adolescent’s health care received. This situation is additionally problematic when the office staff members are known acquaintances of the adolescent and parent, which is a common occurrence in rural areas.

To further evaluate barriers to health care, correlations were used to evaluate associations between barriers to health care and need variables. Inverse relationships were found between “afraid of what the doctor would say or do” and household income and trust of HCP. The inverse relationship between fear of HCP and trust of HCP likely reflects a sensitive health care need or inexperience with health care. There is also evidence that people with low incomes are less trusting of HCP (Hardin et al., 2018). An inverse relationship was also found between “didn’t want my parents to know” and trust of HCP, which also reflects concern about confidentiality or a sensitive health care need (Corry & Leavey, 2017). Evidence suggests adolescents’ most common unmet health needs are related to sexual health or mental health (Clark et al., 2018), and both are sensitive health concerns.

To evaluate potential health needs related to barriers to health care, associations between barriers to health care and diagnosed conditions were assessed. The relationships between “parent wouldn’t go” and diagnosis of obesity and overweight seem unlikely, but evidence suggests parents do not recognize their child’s overweight or obesity as a legitimate health concern (Lee et al., 2016). An association between “didn’t want my parents to know” and diagnosis of anemia, suggests either a nutrition problem or menstrual problems. Menstrual problems would likely be perceived by girls as a sensitive health concern (Lawal et al., 2020). The relationship between “afraid of what the doctor would say or do” and depression diagnosis also suggests a sensitive health need. Evidence suggests that youth perceive stigma concerning mental health care and do not believe general or family HCPs are equipped to provide mental health care (Corry & Leavey, 2017). Additionally, a relationship was identified between “other reason not listed” and diagnosis of attention deficit and hyperactivity disorder. This may also reflect a mental health care concern, but due to the vagueness of the response, this association needs further evaluation.

A common theme among several barriers to healthcare seem to be related to a lack of communication between adolescents and their parents. Associations between parent-related barriers and self-reported diagnoses suggest adolescents perceive parents as a barrier to health care for overweight/obesity and anemia concerns. Evidence suggests adolescents and parents struggle to discuss sensitive issues, such as weight and menstrual concerns, due to parents’ lack of health knowledge or discomfort with the topic (Bellis et al., 2020; Winkler et al., 2018). Adolescents and parents report moderate to high levels of interest in a variety of health topics and learning adolescent-parent communication skills (Ford et al., 2016). Future intervention research should address limitations and barriers within adolescent-parent communication to facilitate discussions about sensitive health concerns and address adolescents’ unmet health needs.

Limitations.

The limitations of this study include a nonrandom sample, cross-sectional study design, homogenous group of research participants, and self-reported data. The small, nonrandom, and mostly non-Hispanic white convenience sample may limit the generalizability of the study findings. To offset these limitations, the principal investigator offered participation to all adolescents in the 9th and 12th grades by collecting data in a required course. This assured that all students in the 9th and 12th grades were offered participation in the study and provided balanced participation among both younger and older adolescents.

Future Research.

Adolescents living in rural areas perceived access to health care to be a point of conflict with parents. This may be related to parents’ health beliefs, parents’ lack of knowledge about adolescent health, adolescents’ health beliefs, or adolescent-parent communication barriers. Future research should include measures of adolescent-parent communication and parents’ health beliefs.

More than a quarter of the adolescents reporting unmet health need reported an unidentified barrier to health care. While this study used an existing measure of adolescent barriers to health care, additional barriers exist. Future work should work to clarify these unidentified barriers to health care for adolescents living in rural areas. A simple solution would be to add an open response with “other barrier not listed” for participants to clarify the health service barriers faced.

Implications for Clinical Practice

The results of this study have implications for healthcare policy, practice, and research. Family healthcare practices located in rural areas should institute strong confidential healthcare policies and procedures for adolescents. Whether a lack of confidentiality is real or perceived in rural healthcare practices, it creates barriers to health care for adolescents. Rural healthcare practices need to make it clear that privacy and confidentiality are taken seriously by enacting routine patient education and staff training. An alternative for meeting the health care needs of adolescents living in rural areas is the provision of school-based health care. School-based health care overcomes many of the barriers identified by adolescents in this study (access, parenting, fear). However, many rural schools do not meet the minimum recommendation for school health care, which is to have a full-time registered nurse on staff all day at every school (Holmes et al., 2016), much less have budgets to support coordinated school health programs. Rural schools may collaborate with universities or healthcare systems to implement mobile health unit programs to address the healthcare challenges associated with rural schools’ modest budgets for school health initiatives (Guerra et al., 2017; Khanna & Narula, 2016). Additionally, researchers should develop and test interventions to teach healthcare consumer skills and communication skills to youths. Adolescents in this study perceived parents and fear of HCP as barriers to receiving needed health care. Healthcare consumer skills and communication skills could help adolescents living in rural areas become better advocates for their unmet health needs.

Acknowledgments

This work was supported by the National Institutes of Health [1T32NR015433-01] and the Rural Nurses Organization [dissertation grant].

Footnotes

Author Disclosure Statement: No competing financial interest exists.

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials

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