North Carolinians living in rural communities are disproportionately impacted by barriers to health care access that extend beyond their urban counterparts. Although some challenges exist across both settings, rural residents face greater geographical isolation, transportation barriers, workforce shortages, broadband limitations, digital literacy challenges, and other social drivers of health (SDOH).1 Shortages of primary care, dental, and mental health providers further exacerbate these challenges. Of the 100 counties across North Carolina, 93 are designated as Health Professional Shortage Areas (HPSAs) for primary care, 97 for mental health, and 93 for dental health.2 While structural challenges exacerbate inequities, there are other considerations when examining health care access in rural North Carolina.

Beyond structural challenges, cultural factors also influence health care access and outcomes in rural communities. Providing whole-person, person-first care is imperative to address persistent health disparities, particularly for diverse racial and ethnic populations. By taking an intersectional approach to practice that considers how factors such as race, ethnicity, immigration status, religion, gender identity, social class, and ability shape health experiences, providers can individualize care without making assumptions about cultural norms. Culture is often overlooked within discussions of SDOH despite its influence on health beliefs, behaviors, help-seeking patterns, and health care utilization.3

Additionally, limited health literacy, stigma, and language differences may lead to larger gaps in health care access for rural populations and are often working against their health status. Rural communities may have limited knowledge or access to health information, misconceptions or variance in beliefs regarding health care practices, or limited health resources simply because they aren’t available in a native language. These persistent barriers can lead to lower quality of care and poorer clinical health outcomes for rural communities.

One population group within rural North Carolina, individuals with limited English proficiency (LEP) or a limited ability to communicate in English, faces further barriers in accessing quality health care that extend beyond simple miscommunications. The United States is home to 29.6 million individuals with LEP, a population that faces persistent health care disparities when compared to their English-proficient counterparts.4 North Carolina houses more than one million residents who speak a language other than English, and more than half of these residents are classified as LEP.5 In rural communities, these effects are magnified because patients have fewer provider options, must travel further for care, and may rely on smaller health care systems with limited multilingual resources. Without language-concordant providers or professional interpreters, patients with LEP experience poorer chronic disease outcomes, longer hospital stays, and increased risk of adverse events. Patients also report difficulty understanding diagnoses, treatment plans, and medical instructions regardless of patient health literacy.6 Understanding health information is foundational to achieving positive health outcomes, and for patients, language access is a building block to that understanding.

Creating multilingual health care environments challenges systems that have historically prioritized English-dominant norms7. Language access programs that assess community needs, publicize available resources, and train staff in effective interpreter use are crucial in building trust between patients and health care providers.8 Professional interpreters improve patient understanding and can often serve as cultural liaisons. Offering these services may also relinquish the burden of family members serving as interpreters and caregivers simultaneously.

To drive meaningful change in rural communities, health care systems and providers must ensure consistent availability of high-quality language services. Despite implementation barriers, several strategies can strengthen language access in rural communities. These include integrating language support into telehealth platforms, increasing multilingual signage and patient education, recruiting multilingual providers, and utilizing Community Health Workers as cultural liaisons.6

Language access is not a standalone issue—it intersects with nearly every challenge facing rural health care in North Carolina. Provider shortages, transportation barriers, digital divides, and limited health care infrastructure already place rural residents at an increased risk for delayed care and poorer health outcomes. For individuals with LEP, these barriers are compounded when critical health information, services, and communication are inaccessible in their preferred language.

As North Carolina’s rural communities become increasingly diverse, equitable language access must be viewed as a core component of quality care. Investments in interpretation services, multicultural workforce development, culturally responsive care, and community-based partnerships can strengthen trust and improve health outcomes.9 Addressing language access alongside the broader issues facing rural health systems is essential to ensure that all North Carolinians, regardless of location or language spoken, have a fair opportunity to achieve optimal health.

Acknowledgments

The North Carolina Rural Health Association (NCRHA), a program of the Foundation for Health Leadership and Innovation (FHLI), advocates for better health and health care for every North Carolinian, regardless of who they are or where they live. The author currently serves as the lead for this body of work and acknowledges the North Carolina Medical Journal’s ongoing partnership and support.

Correspondence

Address correspondence to Kelsey Cervone, 2401 Weston Pkwy Ste 203, Cary, NC 27513 (Kelsey.cervone@foundationhli.org).