Table 2:

Domains and themes generated from the rural healthcare providers’ focus group interviews and selected quotes

Domain	Themes	Selected quotes
Overview of traumatic brain injury in the community	Many TBIs due to sports, falls, motor vehicle crashes, occupational accidents	My population has a huge TBI and concussion risk because it’s just the sports, it’s the nature of where we live here, we mountain bike, we ski, we do stupid stuff, so I really had not done a lot of concussion until I moved here and started working here almost four years ago. Common causes – it varies somewhat with age. Falls seems to make up the greatest number of mild traumatic brain injury in the older folks and particularly [inaudible] they can deteriorate more rapidly and more severely. Other causes are widely varied, motor vehicles crashes in either car or motorcycle type injuries certainly make up a portion of the younger portion of our people.
	Providers feel well prepared to treat mild TBIs in patients	I think the diagnosis and really the treatment is fairly – I feel like our providers have a pretty good grip on that. I am fairly comfortable with the mild traumatic brain injury assessment – probably easier than it was years ago because they have imaging, CT scanning imaging readily available 24/7, which years ago we didn’t have and made this whole thing a little bit more difficult. So, the assessment isn’t as difficult in that sense we should feel a little more comfortable.
	TBI is relatively common injury	I would say it’s probably a solid handful of times in a given month – to be safe. We do a lot of sporting events and that’s honestly the first thing that pops into my mind- especially the football season. I feel like we are getting those two or three times a week at that point. I’m 1–2 per month with falls and injuries, anywhere from pediatric to the old.
	Increased awareness of TBI in recent years	I think there has been a shift for us anyway with people recognizing, this is not just traumatic brain injury, but people do interpret injuries as being emergent more often than not, so I agree they tend to show up in the emergency department more. Otherwise in the past they used to show up in the office the next day or the next week. A better-informed public has helped bring people in a little earlier. People seem to view that falls with head injury is something they recognize as potential risk for something worse and they do tend to head towards the emergency department more commonly than they used to.
Provider challenges in diagnosing TBI	Lack of awareness among public of seriousness of injury	My barriers right now are delay in presentation due to lack of public awareness, or maybe awareness without the buying into the concussion as being important.
	Pushback/hesitance from athletes, parents, and coaches	Athletes, family, and even coaches … have been particularly reluctant to have players see us. There is this perception that once you get diagnosed with an injury you are going to be out of playing and people cannot deal with that. I think as far as the diagnosis most of us here would feel comfortable. Our roadblock in this is being able to convince family members, parents especially, and high school athletes of the significance of this and finding a way to get them on board with an absence of participation for some length of time.
	Young children and older adults more difficult to diagnose	Children are much more difficult, and the really young, especially falls, motor vehicular accident, etc. because you don’t have the ability to talk, you just go off their history. The physical exam, in mild injury, you can’t tell, children are difficult. They may or may not have any sequela[e] at all, externally, but just that history. And they also have difficulty learning, behaviors, irritability, crying, etc. that really cause major problems later. Those are the issues in the young. The old, of course, they don’t remember, they have difficulty, and they have a higher risk of bleeding four to eight days later. So they’re difficult because of their high risk and understanding the underlying cause.
Patient barriers to seeking TBI care	Lack of transportation	It is not just TBI, transportation is a problem for all medical care in these areas that are spread out.
	Lack of insurance or money	High deductible insurances – I think that’s one thing. Sometimes I think particularly in our youth, parents sometimes are reluctant to bring their athlete in if they don’t think it’s that big of a deal, so to speak. If they have a high deductible insurance, they would rather stay home and monitor them so they probably – maybe sometimes wait until their symptoms have gotten bad before they seek health care.
	Adults don’t want to take time off of work	I would say people that work, I’m thinking of my farmers as much as anything, they just don’t come in when they get a head injury.
Challenges in managing TBI	Lack of specialists in area	I think that is also super-overwhelming for the patient. For us here, we are like, ‘oh go to neurology,’ well the closest one is [in nearest small city] and they’re like ‘I’m not driving [there].’ [...]I send a few of the younger kids up to Children’s [hospital]. Their concussion program is phenomenal but that is a four-hour drive for us.
	Long wait times for follow-up appointments	I sometimes have patients that have trouble – their primary care unfortunately – well for better or for worse – is an urgent care or a practice where it’s hard to get in. I have run into challenges there where they can’t get in for a week or they say go to the urgent care and the urgent care doesn’t feel comfortable with it and refers them to neuroloqy, which does not happen for several weeks. That would probably be the main problem I see besides insurance.
	Patients may be unable to afford follow-up care	I would say framed that way – I would say absolutely finances are going to be a problem. We have patients on high deductible plans. I’m 100% sure that they very much think twice about coming in for everything else so they have to be thinking twice about coming in for a mild traumatic brain injury – rural culture is shake it off, buck up, cowboy kind of thing. I would say the finances are a barrier and that is not just for concussion that is for everything.
Opportunities for improvement	Benefits of practicing in rural area	In rural areas, it’s all up to the individual doctor and the parents and the child. To me, it’s easier and better there because I can actually see the patient on a daily or once a week or twice a week basis until they’re completely recovered.
	Need for public education on TBI	People have a cavalier attitude about the TBI, not understanding how much long-term negative effect it can have … Education and helping people understand the sequence from a mild TBI to long term problems that can lead to education on that would be helpful in bringing people in and less resistance to being seen.
	Need for additional clinical training/education	I think one of the things that is common to all of us is we have to have continuing medical education. We all know the basics – if the CDC [Centers for Disease Control and Prevention] were to come out with a program where we could obtain some level of continuing medical education to refresh our knowledge.
	Increased use of telehealth/telemedicine	[Because of COVID-19] we now have access to care through tele[medicine] so that has made an enormous difference as well for us to be able to do neurology appointments. It has been so nice to be able to do that. Concussion appointments through children’s [hospital] – all that kind of stuff – has been able to go online and that has made a huge difference for access to care. Not that I want COVID to still be around but it has been hugely helpful in that respect in being able to get access to care.

TBI, traumatic brain injury.