Running head: INCOME, EDUCATION, AND HEALTHCARE ACCESS 1

The Relationship Between Household Income, Parental Education, and Healthcare Access for
Children in Rural Households: A Literature Review
Sabrina Fernandez
Emory University







INCOME, EDUCATION, AND HEALTHCARE ACCESS 2

The Relationship Between Household Income, Parental Education, and Healthcare Access for
Children in Rural Households: A Literature Review
Introduction
About 20% of Americans live in rural areas (Laditka, Laditka, & Probst, 2009), which is
defined by the U.S. Census as any area that is not considered urban (U.S. Census Bureau, 2014).
Health disparities in rural areas increase with the level of rurality (Monnat & Beeler Pickett,
2011), leading to poorer health outcomes, lower self-rated health, and increased barriers to
obtaining equitable healthcare. Compared to urban areas, rural residents are more likely to be
disabled, uninsured, face financial barriers, and have higher rates of asthma, diabetes,
cardiovascular events, cancer mortality, and infant mortality, especially if they are African-
American (Do, Frank, & Finch, 2012). Because rural residents also face higher cost burdens
associated with travel, these and other circumstances suggest that rural areas face many barriers
to accessing primary care, which only increase with level of rurality (Laditka et al., 2009). These
barriers increase the incidence of unnecessary hospitalizations from treatable health issues such
as diabetes, dehydration, and asthma (Laditka et al., 2009). Increasing rurality is also associated
with higher postneonatal mortality rates, which is much more significant than in metropolitan
centers (Sparks, McLaughlin, & Stokes, 2009).
In Georgia, over half of the counties are considered rural. This rurality affects every facet
of healthcare in these counties. Rural counties in Georgia, compared to urban counties, have
increased rates of premature death, poor health, and low birth weights, as well as increased rates
of smoking and obesity; they experience poorer health outcomes due to low rates of health
insurance, and there is a severe lack in health facilities available, leading to an increased number
of preventable hospital stays (University of Wisconsin, 2013). These areas are also marked by
INCOME, EDUCATION, AND HEALTHCARE ACCESS 3

increased poverty, unemployment, and violent crime rate, with decreased quality in physical
environments such as access to clean and safe water (University of Wisconsin, 2013). With
increased poverty, lower rates of education, and limited healthcare access in these counties, it is
necessary to evaluate their relationship to the level of rurality and their effect on children. This
study will explore the associations of household income, parental education, and health care
access for children living in rural households.
Household Income and Healthcare Access
While associations have been found linking income and health outcomes for families,
there is little evidence linking annual household income and healthcare access as it relates to
children, especially within the context of a rural setting. In the U.S., 1 in 5 children live below
poverty, and these families are more likely to be single and young, have low educational
attainment, and low earning potential (Brooks-Gunn & Duncan, 1997). Family income has also
been shown to have substantial effects on child and adolescent well-being, where poor children
are almost twice as likely to be in poor health as compared to non-poor children (Brooks-Gunn &
Duncan, 1997). More important, though, is the duration and timing of povertychildren living
in poverty for longer duration and during early years of schooling experience worse outcomes,
especially as it relates to cognitive delays (Brooks-Gunn & Duncan, 1997). It was also found that
women living below the poverty line during pregnancy were 80% more likely to have a low birth
weight baby as compared to those women with incomes above the poverty level (Brooks-Gunn
& Duncan, 1997). Income level has one of the greatest effects on child outcomes and is
considered one of the most important factors in poor families (Brooks-Gunn & Duncan, 1997).
The relationship between children and healthcare access is very limited; research often
focuses on adults and does not evaluate the potential effect on children. Income also been found
INCOME, EDUCATION, AND HEALTHCARE ACCESS 4

to have an effect on morbidity and premature mortality within the U.S. (Cheng & Kindig, 2012).
Income is especially significant when related at the county level. Low income counties were
found to have a stronger association between income and premature mortality, but found that at
the county level, risk factors other than income affected this relationship (Cheng & Kindig,
2012). Research also emphasizes that income inequality (the gap between the bottom 5% and the
top 1%) across a population affects individual health and well-being, where increased income
inequality is linked with higher mortality among adults and higher infant mortality (Sparks et al.,
2009). When a higher percentage of a countys population is in poverty, there is a decreased
likelihood of having health insurance, worse self-assessed health, and higher probability of being
obese (Chen & Gotway Crawford, 2012). Higher levels of income inequality also affects how a
population ages, threatening well-being across a population (Brandt, Deindl, & Hank, 2012).
Overall, literature focuses on the relationship of income with health outcomes and adults, not
healthcare access and children. This is a severe gap that needs continued research to address.
Parental Education and Healthcare Access
Literature that focuses on the associations between parental education and healthcare
access are almost nonexistent; general population education is often grouped into a broader
socioeconomic category that does not evaluate its individual impact on a topic. In the U.S.,
education is often associated with poor health. Americans with less than high school education
are four times more likely to rate their health as poor compared to people who had postsecondary
education (Prus, 2011). If education assists people in acquiring and interpreting health
information, those with lower education levels may not effectively utilize healthcare (Sparks et
al., 2009). Those that identified as high school dropouts and had not obtained a GED had at least
one major problem (economic, social, health), and when all other demographic variables were
INCOME, EDUCATION, AND HEALTHCARE ACCESS 5

removed, education remained a significant predictor for health-related social problems such as
food insecurity, housing instability, and poor healthcare access (Hassan et al., 2013). As health-
related social problems increase in a patient, negative health outcomes such as obesity, poorly
controlled asthma, and higher hospitalization rates also increase (Hassan et al., 2013). Patients
with less than 12 years of education were also more likely to be inactive, obese and smokers
(Boardman, Alexander, Miech, Macmillan, & Shanahan, 2012).
Education as a factor for health is frequently grouped into a broader category that
includes multiple socioeconomic factors. For example, research has shown that counties with
worse socioeconomic scores, which include lower education achievement, are associated with
more unhealthy days (Jia, Moriarty, & Kanarek, 2009) and have greater odds of reporting bad
health (Monnat & Beeler Pickett, 2011). Low educational attainment increases the risks of poor
health due to negative social conditions and reduced access to quality health care services
(Monnat & Beeler Pickett, 2011). But research on smoking and education levels has also found
that this correlation is not statistically significant (Charafeddine, Van Oyen, & Demarest, 2012).
However, much like income, the relationship between parental education and healthcare access is
incomplete and research focuses more on health outcomes in adults rather than healthcare access
in children.
Conclusion
Much research has been dedicated to discovering the associations between socio-
economic, sociodemographic, and other factors affecting health outcomes. But the literature
often fails to highlight specific socioeconomic factors and their effect on healthcare access for
children in rural areas. Research that has been done to relate specific factors, such as education
and income, to healthcare access has been severely limited. Many findings support the presence
INCOME, EDUCATION, AND HEALTHCARE ACCESS 6

of relationships between these factors, but fail to describe the significance of them as it relates to
children in rural households. Often, healthcare access for children is not evaluated at all; instead,
research focuses on health outcomes in adult populations. Such varied and incomplete literature
findings does not present a thorough assessment of these specific socioeconomic factors and
their effect on healthcare access for children in rural areas.
Beginning in 2009, anonymous surveys were collected from parents in the counties of
Burke, Lincoln, and Screven in rural Georgia. The surveys aimed to assess HPV vaccination
beliefs, attitudes, and acceptability among parents of children aged 9-13 residing in these rural
counties (Thomas, Strickland, DiClemente, Higgins, et al., 2013). Sociodemographic and
socioeconomic data were also collected, including household income, parental education level,
and whether or not parents accessed healthcare for their children every year via childhood
vaccinations. The proposed study will be a descriptive correlational study via secondary analysis
that will evaluate specific socioeconomic factors and explore their association to health care
access. The primary aim of the study will be to explore the associations of household income,
parental education, and health care access for children living in rural households. The study will
seek to answer the primary research question, What is the association of annual household
income and parental education level on health care access for children ages 9-13 living in three
rural counties of Georgia.
Because remote rural counties are often characterized by persistent poverty and low
education (Monnat & Beeler Pickett, 2011), there is a need to evaluate socioeconomic factors in
relation to rurality and assess the impact on access to healthcare. By working within small rural
communities and established data, rather than a larger data set, a narrative can be created that
details the factors influencing healthcare access in these counties of rural Georgia. This has
INCOME, EDUCATION, AND HEALTHCARE ACCESS 7

immense significance because it can begin to establish a clinical and scientific pathway for how
to address healthcare access disparities in these areas. The focus of this study will help to
highlight the factors that influence healthcare access for children in rural settings. Clinically, the
study can start to identify ways to improve patient care and education, and in communities can
begin to improve patient outreach and target health programs to fit all needs. At county-levels,
this study can also be a small part in a larger approach that begins to influence policy to bridge
the gaps in healthcare access. In analyzing this data from rural counties in Georgia, the study will
enhance available research on this topic and begin to form a pathway for tangible change.
INCOME, EDUCATION, AND HEALTHCARE ACCESS 8

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