The Southern Medical Journal (SMJ) is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists.

SMJ // Article

Original Article

Travel Costs and Health Disparities: The Impact of Rurality and Social Vulnerability on Hand Therapy Access in Alabama

Authors: Luke Anderson, BS, Emily Hecox, MD, Shelley Edwards, PhD, Marc E. Walker, MD, MBA

Abstract

Objective: Postoperative hand therapy is important for recovery and enhanced functional outcomes following hand surgery. Access to this essential care is limited in Alabama, however, particularly for vulnerable populations in rural areas where public transportation is scarce. These challenges are further amplified for patients who are unable to drive due to their injuries. This study aimed to quantify disparities and barriers to certified hand therapy access in Alabama.

Methods: Certified hand therapists in Alabama were identified through the Hand Therapy Certification Commission directory. Practice addresses were geocoded and paired with county center coordinates to calculate travel distances from each county center to the nearest certified hand therapist. These distances were then converted into one-way travel costs using Internal Revenue Service standard mileage rates. Counties were categorized by rurality using Rural-Urban Continuum Codes (RUCC) and assessed for social vulnerability using the Social Vulnerability Index (SVI), which considers socioeconomic, housing, and transportation factors. Statistical analyses, including t tests, χ2 tests, and multivariate regression, were used to evaluate patterns and predictors of travel costs.

Results: Alabama counties had a mean SVI of 0.67 ± 0.195—significantly higher than the national mean of 0.50 (P<0.0001). More than 80% of Alabama counties rank in the most vulnerable 50% of US counties, with Shelby County being the only county in the least vulnerable quartile (SVI 0.116). In addition, 36 counties (53.7%) are classified as rural (RUCC 4–9). Both SVI and RUCC independently correlated with increased travel costs. Multivariate regression modeling revealed that each unit increase in RUCC was associated with a $3.43 increase in travel costs (P<0.0001), and each 10% increase in SVI corresponded to a $1.64 increase in travel costs (P=0.006). These factors explained 56.4% of the variability in travel costs. Heatmaps visually highlighted higher travel costs in rural, socially vulnerable areas.

Conclusions: Rural and socially vulnerable populations in Alabama face significant travel barriers to accessing certified hand therapy. The combined impact of geographic isolation and social vulnerability underscores the need for targeted interventions to ensure equitable access to postoperative care.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Gutiérrez-Espinoza H, Gutiérrez-Monclus R, Román-Veas J, et al. Effectiveness of supervised physiotherapy versus a home exercise program in patients with distal radius fracture: a randomized controlled trial with a 2-year follow-up. Physiotherapy 2024;124:93–100.
 
2. Huisstede BM, van den Brink J, Randsdorp MS, et al. Effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome—a systematic review. Arch Phys Med Rehabil 2018;99:1660–1680.e21.
 
3. Hand Therapy Certification Commission. Home page. Accessed April 2025. https://www.htcc.org.
 
4. Hines FK, Brown DL, Zimmer JM. Social and Economic Characteristics of the Population in Metro and Nonmetro Counties, 1970 Agricultural Economic Report No 272. Washington, DC: US Department of Agriculture; 1975.
 
5. Sanders A, Cromartie J. Rural-Urban Continuum Codes - documentation. Accessed April 14, 2025. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/documentation.
 
6. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry. Social Vulnerability Index. Accessed April 14, 2025. https://www.atsdr.cdc.gov/place-health/php/svi/index.html.
 
7. AlabamaPossible. Barriers to prosperity data sheet: Alabama is the nation’s sixth poorest state. 2022. Accessed April 14, 2025. https://alabamapossible.org/2022/06/09/2022-barriers-to-prosperity-datasheet-alabama-is-the-nations-sixth-poorest-state.