Introduction
Reduced access to veterinary care has been identified as the most significant animal welfare crisis in the United States today and should be a cause for concern for the veterinary industry.1,2 Over the past decade, there has been an increasing recognition in the fields of veterinary medicine and animal welfare that access to veterinary care is not distributed equitably across pet owner populations or geographic regions.1–5 Specifically, millions of dogs and cats do not receive veterinary care for preventative health, sick care, or emergency events due to financial, geographic, or demographic barriers experienced by the pet owner. An additional population of pets may not receive veterinary care due to the owner’s perceived value of veterinary care, especially preventative care, or a lack of knowledge surrounding the recognition of illness in pets. The consequences of pets not being able to obtain care include increased burden of disease in both the pet and human populations. Without proper care, preventable infectious and possibly zoonotic diseases increase in frequency, leading to potentially prolonged pain and suffering for the pets and increased risk of pathogen transmission to owners.1 In addition to such direct health impacts for pets and their owners, living and working with pets experiencing reduced care can cause emotional distress for the owners and their families, and for veterinary professionals respectively. Inability to access appropriate veterinary care may result in unnecessary or premature euthanasia, or owners may choose to relinquish their pets to animal shelters for them to receive care, in turn adding strain to already overcrowded sheltering systems.1,2
Of course, many pet owners successfully access veterinary care, as evidenced by the consistently heavy caseloads documented in general practices and even in specialty veterinary care facilities.6,7 However, several studies have identified specific barriers that prevent pet owners from obtaining veterinary care that need to be addressed if veterinary care access is to become more equitable.1–3,8–10 As awareness around disparities in access to veterinary care grows, so does the vocabulary in the field. Geographic areas or populations that may be experiencing reduced access to care have been informally referred to as “veterinary care deserts,”5 “veterinary deserts,”7,11–13 “underserved populations/communities,”1,14 or “care deserts.”4 But, there is no published definition of what is understood by a “veterinary care desert.”
Establishing a definition for veterinary care deserts allows professionals in the field to use the term uniformly and create more direct comparisons between communities. This will allow for targeted interventions and inform measures to assess program effectiveness. Providing guidance through a specific, parameterized definition can help organizations identify areas that are in greater need of accessible care more quickly than carrying out extensive surveys and individualized community assessments. Ultimately, this rapid detection of the location of veterinary care deserts saves time and resources and can expedite the development of solutions to start addressing the access to care gap.
Definitions for resource limitations have been established for numerous human health outcomes such as healthcare, food, and education deserts. These definitions provide guidelines that can be applied to communities to determine if an area lacks a specific resource. For example, a “food desert” has been defined as an area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower income neighborhoods and communities.15 The USDA Economic Research Service has developed parameters around key characteristics such as “limited access” and “lower income” to help identify areas that fit this definition.16 Other examples are present within human healthcare industry which commonly describes access by 5 dimensions which include acceptability, affordability, availability, accessibility, and accommodation.14,17 Such definitions of a deserts and access create consistent language and understanding among stakeholders and allow intervention impacts to be more objectively measured and compared.
We hypothesized that many of the themes and parameters that define deserts in other disciplines will apply to areas limited in access to veterinary care. Our objective was to explore themes and identify parameters used to define human resource deserts and synthesize them with published veterinary care barriers to establish a working definition for veterinary care deserts.
Methods
Scoping review
To identify themes and parameters used in human resource desert definitions and commonly reported barriers to veterinary care, we conducted a scoping literature review. Scoping reviews aim to explore topics broadly by identifying and comprehensively mapping existing sources and include many different study designs applicable to the research question. This type of review is used to inform practice, programs, and policy and identify gaps in the current literature.18 For this scoping review, we followed the 5-stage framework described by Arksey and O’Malley.18
Our objective was to develop a working definition for veterinary care deserts by building on themes and parameters used in human resource desert definitions and incorporating barriers identified as preventing pet owners from accessing veterinary care. With this in mind, we reviewed primary research publications, reviews, commentaries, conference proceedings, and theses, as well as policies, industry-commissioned reports, and other non–peer-reviewed publications from newspapers and online platforms related to human resource deserts, barriers to care or resource obtainment, and access to veterinary care. Sources considered were published between January 2000 and December 2022 and were accessed through PubMed, Wiley Library, Science Direct, and Google Scholar. Relevant organization websites were searched for related content and included: the American Society for the Prevention of Cruelty to Animals (ASPCA), AVMA, CDC, Humane Society of the United States (HSUS), USDA, United States Department of Health and Human Services (HHS), the WHO, and the World Organization for Animal Health (WOAH). The following keywords were used in our literature search: “access to care,” “access to veterinary care,” “barriers to care,” “care desert,” “education desert,” “food desert,” “healthcare desert,” “low cost veterinary care,” “veterinary care desert,” “veterinary desert,” and “reduced access to care.” Two authors (LB and SH) independently reviewed all identified publication titles and abstracts. Sources determined to be relevant to veterinary care deserts, healthcare deserts, food deserts, and education deserts were reviewed in full. Sources were excluded if they did not discuss specific reasons or themes for differences in access to the resource in question. All sources were categorized by type of desert: veterinary or human (healthcare, food, and education).
Identifying themes and parameters
To identify prominent themes used to define deserts and describe barriers to resource acquisition, we reviewed each source and tallied the number of times a theme (eg, transportation) was: (1) used to describe populations in the context of a definition or (2) identified as a barrier preventing populations from accessing resources (Supplementary Table S1). Themes were not counted if they were described as not contributing to lack of access to a resource or formation of a desert definition. Each theme identified in the veterinary and human categories was evaluated for its relevance to access to veterinary care and considered for inclusion in our veterinary care desert definition.
To understand how to define themes for our definition, we reviewed the specific parameters each source used to describe and quantify the themes they identified (eg, distance to a resource measured in miles or travel time). Parameters for our definition of veterinary care desert took into account additional characteristics unique to obtaining veterinary care. These included transportation modalities available for use with pets, since most public transportation in the US has pet restrictions, and frequency of use for veterinary clinics.
Results
Source selection
We reviewed 52 sources relating to veterinary care and 55 sources relating to human resource deserts (Figure 1). Of these, we included 37 veterinary and 42 human sources to inform the themes and parameters for our definition. The 42 human sources included 17 healthcare, 16 food, and 9 education sources.
Flow diagram of 107 full text sources reviewed in each category and the breakdown of number of sources included for the theme and parameter development in each category.
Citation: Journal of the American Veterinary Medical Association 262, 1; 10.2460/javma.23.06.0331
Themes identified
The most common themes related to veterinary care access identified in the 37 veterinary sources were client/owner income leven (68%; n = 25), geographic areas with low density of veterinary care facilities (62%; 23), and cost of veterinary care (60%; 22) (Supplementary Table S2) Two additional themes, owner access to transportation and the density of veterinary professionals, were described in 46% (n = 17) and 37% (14) of sources, respectively.
Themes identified in the veterinary care literature mirrored those used to establish definitions for human resource deserts. Common themes present in over 50% of the 42 human sources reviewed included: living in an area with low density of a resource (57%; n = 24); transportation barriers (55%; 23); and household income or poverty level (50%; 21) (Supplementary Table S2). Not surprisingly, specific themes appeared at different frequencies when evaluating healthcare, food, and education deserts individually. Cost of resources was mentioned in 35% (n = 6) and 56% (9) of healthcare and food desert sources respectively but was not mentioned in any of the 9 education desert sources reviewed. The number or density of professionals was commonly reported in relation to human healthcare deserts (47%; n = 8) but did not appear in food or education desert sources. Access to transportation was commonly identified as an important theme in healthcare and food deserts (76%; n = 13, and 81%; 13 respectively) but was only mentioned in 33% (3) of sources describing education deserts.
The 3 most commonly mentioned themes across all sources that we included in the definition were: owner income or poverty level; cost of care; and low density of a resource in an area. In addition, we included the number of professionals and access to transportation since these present barriers specifically relevant to accessing veterinary care and were prominent themes in some of the human sources. To simplify the language of the definition, themes were grouped into accessibility (transportation; distance to resource), affordability (owner income or poverty level; cost of care), and availability (density of professionals) and a working definition for veterinary care deserts was created:
“A veterinary care desert is a geographic area where accessible, affordable, and available veterinary care is limited.”
Parameterizing themes for our definition
Twenty-two of the 37 veterinary sources and 26 of the 42 human sources included specific parameters to further describe the themes identified. How themes were parameterized, and the specific data sources that were referenced, was highly variable across sources. The most commonly reported data sources included poverty level categories based on HHS poverty guidelines (36%; n = 8 veterinary sources with parameters and 30%; 8 human sources with parameters) and census data from the US Census Bureau (9%; 2 veterinary sources with parameters, and 34%; 9 human sources with parameters).
To make our definition understandable and applicable to different geographic areas, and to align with accepted methodologies, we chose to parameterize each theme based on criteria used for census tracts. The US Census Bureau defines census tracts as “small, relatively permanent statistical subdivisions of a county or statistically equivalent entity.”19 Census tracts are mostly bound by visible features such as roads, summarize population and demographic variables, including important social determinants of health,20 and are frequently used as the smallest descriptive population unit in human resource access research.19,21,22 Census data is publicly available and relatively easily accessible at the census tract level, which facilitates the application of our definition by diverse stakeholders.
Accessibility
Accessibility, or “physical accessibility,” incorporates the interaction of the location of a service or resource and the mobility of the individual aiming to access said service or resource.17 Accessibility parameters were reported in units of distance or time to the service in veterinary and human sources (Supplementary Table S3). In human sources, distance was the primary parameter used to define areas with reduced accessibility (65%; n = 17 of human sources with defined parameters). The distance parameter used in the USDA’s definition of a food desert classifies a census tract as a food desert if at least 500 people, or 33% of the population, live > 1 mile in urban areas, or > 10 miles in rural areas, from the nearest large grocery store.16,22 When assessing access to veterinary clinics, Neal and Greenberg23 reported the average distance clients drove to receive veterinary care as 4 miles in urban and 10 miles in rural areas, but overall most clients traveled between 2 and 6 miles.
A distance parameter was chosen to help designate areas most likely to be experiencing reduced access to veterinary services because it is a parameter easily measured and has impact on clients’ ability to transport pets to points of service. For our definition, we classified a census tract as having low accessibility to veterinary care if the distance from the center of the census tract to a veterinary care facility exceeds 2 miles for urban areas and 10 miles for rural areas.
Affordability
Affordability describes the economic capacity of an individual to utilize a service and encompasses both direct and indirect costs.17,24 Sources most commonly discussed the income level of patients or clients and the cost of the resource or service when evaluating affordability (Supplementary Table S4). Income level or poverty rate was the most common parameter used to describe affordability (77%; n = 17 of veterinary sources with parameters, and 42%; 11 of human sources with parameters). Sources which used household income as a parameter often created income categories that varied from 4 to 21 categories.3,9,14,25,26 Others used proportion of the population at poverty level or created categories of population percentages above poverty levels based on the HHS federal poverty guidelines.1,2,27,28
We used percent poverty rate to encompass affordability in the definition to align with human resource definitions and acknowledge the challenge of affording the high cost of veterinary care for low-income clients. Based on the yearly HHS federal poverty guidelines, a census tract by our definition would be considered “low income” if the poverty rate is ≥ 20% or if the median family income in the census tract is ≤ 80% of the metropolitan’s for urban areas or the statewide median family income for rural areas.16 For reference, per 2022 HHS poverty guidelines, a family of 4 with an income of ≤ $27,750 is considered in poverty. A family of 4 with an income of $41,625 is at 150% poverty level, and an income of $55,500 is at 200% poverty level.
Availability
Availability describes the adequacy of the supply of a service or resource and considers the number of service points as well as the capacity to provide the service.14,17,29 This metric differs from accessibility, which focuses on distance or time to a service or resource and focuses on supply within the industry (Supplementary Table S5). The most common parameters used to assess availability in human healthcare and in veterinary medicine were ratios of providers to households or to patients/clients (30%; n = 4 of human healthcare sources, 18%; 4 of veterinary sources). Several human healthcare sources based their ratio parameters on criteria for a “Health Professional Shortage Area” (HPSA) as published by HHS’s Health Resources and Services Administration (HRSA).21 The Veterinary Care Accessibility Project (VCAP) researched the number of veterinary employees per households similar to that of HPSA for human medicine. The VCAP found a mean of 2.52 and median of 1.68 veterinary employees per 1,000 households (range, 0 to 170) across all counties in the lower 48 states.30 Given the focus of our work on veterinary medicine, we chose to follow the data available from VCAP and identify a census tract as having low availability if it resides within a county that has 0 to 0.8 veterinary employees per 1,000 households.30
Definition with parameters
We incorporated specific parameters into our definition to provide guidelines for stakeholders aiming to identify veterinary care deserts in their communities. Data included in our definition are publicly available by census tract. A census tract should be considered for inclusion in a veterinary care desert if it fits the criteria described for low accessibility, low affordability, and low availability.
“A veterinary care desert is a geographic area (census tract) where accessible, affordable, and available veterinary care is limited.”
Low accessibility—A veterinary care facility is located > 2 miles and > 10 miles from the census tract’s center for urban and rural areas respectively.
Low affordability—The census tract’s poverty rate is ≥ 20% or the median family income ≤ 80% of the metropolitan’s or statewide median family income for urban and rural areas, respectively.
Low availability—The census tract is located in a county with 0 to 0.8 veterinary employees per 1,000 households.
Discussion
Accessibility describes physical accessibility and considers both the location of a service or resource and the mobility of the person seeking said service. We define accessibility as the distance a client is located from a veterinary care facility as distance is relatively easy to estimate or measure. However, there are several other aspects of a location or a person’s ability to get to a location that affect accessibility. Some examples include public transportation restrictions when bringing pets, public transportation timetables, a person’s ability to afford to own and maintain a car, safety of the area in which the service is located, presence of sidewalks or bike lanes, and ease of parking near a location.
Studies looking at human healthcare and food access barriers around accessibility have found transportation to be a commonly reported barrier.17,31–37 While transportation was discussed broadly in most sources reviewed, some authors demonstrated how transportation goes beyond just the measure of distance to a resource. A person’s ability to obtain a driver’s license, owning or knowing someone who owns a personal vehicle, and utilization of public transportation are present barriers to access.36 These same factors present barriers to owners seeking veterinary care for their pets. The Access to Veterinary Care Coalition 2018 report1 found that after cost, lack of transportation was one of the greatest barriers to owners wanting to obtain veterinary care. However, we did not identify any veterinary sources specifically discussing challenges related to transportation with detailed breakdown of actionable intervention points. Further research is needed to understand transportation barriers specifically as they relate to accessing veterinary care. As information around transportation barriers for veterinary clients grows, this parameter may be updated.
There are 2 different components to the challenge of defining affordability: 1) the income of pet owners, and 2) the cost of veterinary services. For this definition, we chose to define affordability using pet owner’s income. This metric is available and easily accessed in public census data which presents information at a relatively granular level allowing for more targeted interventions. There is also evidence that low income earners struggle more compared to middle and high income earners to afford veterinary care and have larger pet populations that are potentially affected by lack of access to suitable veterinary care.1,3,28,38 The goal of the parameters used in our definition of veterinary care desert is to identify areas most likely to be experiencing reduced access to care. Focusing on areas with predominantly low income levels will increase the likelihood that these areas are identified.
The challenge to afford veterinary care goes beyond just owner income. The Access to Care Coalition 2018 report1 found 8 out of 10 pet owners were not able to obtain desired preventative care due to finances, regardless of income levels, and middle income pet owners were as likely to cite inability to afford care when seeking sick care for pets as those with the lowest income. Many households across all income brackets report strong feelings that their pet is a part of their family.1 One survey by CareerBuilder39 found that pets were in the top 4 items participants would not give up despite financial hardship with 37% reporting they would keep their pets. However, veterinary care is a service industry that requires owners to recognize a pet’s needs and choose to spend their income on the pet’s medical wellbeing. The Access to Care Coalition 2018 report1 stated that 13% of owners who did not report experiencing a barrier to care did not seek preventative care for their pets. Income level did not appear to be the driving factor for the decision to pursue preventative care for those reporting no barriers. A study by the Human Society of the United States Pets for Life program showed that when structural barriers were removed, owners that originally did not pursue services were more likely to utilize services showing that owner utilization can change even if barriers are not initially perceived.40 Further research and programming focused on educating owners on the value of preventative care can provide information about this market population and motivate changes in veterinary care use habits.
The evidence of pet owners struggling to afford veterinary care regardless of their income level presents a challenge for the industry to provide necessary care to pets while staying within owners’ financial boundaries and covering the costs of providing care. The concept of “affordable veterinary care” is, therefore, challenging to define in simple terms. However, affordable veterinary care should be a focus for the industry for all pet owners both within and outside veterinary care deserts. Many veterinary professionals, whether doctors or support staff, are struggling financially due to high student loan debt and relatively low income. Veterinarians experience many challenges that affect their mental health including debt, shortage of staff, and the emotional toll of working with animals and clients in distress.41 Several sources identified cost of veterinary care as a major barrier to seeking care or ability to follow treatment recommendations leading to more animals receiving no or little care from veterinarians.1,3,42,43 Methods to reduce the cost of veterinary care and avoid non-treatment include embracing spectrum of care or incremental care approaches, payment plans, improved owner education about veterinary services, utilizing staff appropriately based on training, and maintaining lean inventory to prevent waste.12,38,41,44,45 Finding solutions to the affordability challenge will benefit pets, owners, and veterinary professionals alike.
Availability of a service often refers to both the number of service points and supply of professionals able to provide a service. The capacity within human healthcare is regularly assessed within geographic areas and within specialty services. The availability of healthcare professionals is a common parameter used to determine “Health Professional Shortage Areas” or healthcare deserts.21 We took a similar approach to identify areas most likely to be experiencing reduced availability of veterinary care. The Veterinary Care Accessibility Project (VCAP) created a map readily available online for all counties in the contiguous 48 states showing the number of veterinary employees per 1,000 households.23 Further analysis shows about 2,000 of the 3,000 counties have less than the mean of 2.5 veterinary employees per 1,000 households and about 1,500 counties have less than the median of 1.68 veterinary employees per 1,000 households resulting in possibly millions of pets living in counties with potentially low veterinary services.23,30 The VCAP includes veterinarians, technicians, and support staff as “veterinary employees” as the ability to provide veterinary services goes beyond just the work of veterinarians. Using a range of 0 to 0.8 veterinary employees per 1,000 households includes an estimated 700 to 1,000 counties in the lower 48 states that could be categorized as “low availability.”
The availability parameter was the most difficult to determine as there is limited published data estimating the ratio of veterinary professionals to the population and no easily accessible source for the number of veterinary professionals in a given area. Furthermore, without additional research it is difficult to determine the number of veterinary employees that would be considered adequate to meet demands in a given area. For these reasons, a range was proposed for this parameter to allow each organization the chance to further examine availability in an area which meets the other 2 criteria (affordability and accessibility) of a veterinary care desert. The parameter chosen has limitations as it is only published at the county level when the rest of the definition focuses on the census tract level. This parameter requires further research to create a value or calculation to be applied to census tracts allowing organizations to determine if an area had low availability and can be updated as new results are available.
The veterinary medical profession appears to be in an availability crisis. There is a shortage of veterinary technicians and certain specialties of veterinarians such as food animal, public health, and shelter medicine practioners.6,46 The factors that are contributing to professional shortage mirror some of those that are driving up cost of veterinary care and include expense and debt load of attending veterinary school, high turnover rate of veterinarians and veterinary technicians, veterinarian desire to work fewer hours, and burnout or compassion fatigue.6,47 Veterinarians have one of the highest turnover rates in the healthcare industry, at about 26%, twice the turnover rate of human physicians.6,47 Furthermore, the cost of burnout for veterinary staff related to turnover and reduced work hours is estimated to be $997 million and $933 million, respectively.47
Some sources suggest that the industry’s turnover trend related to burnout is related to declining practice productivity and inefficiencies in practice rather than a shortage of staff alone. Salois and Golab 2021 report6 that veterinarians are seeing fewer patients per hour and average productivity declined by 25% in 2020. This, combined with the 6.5% increase in appointments seen in 2020, can make practices feel busier and contribute to feelings of being overworked and burnout. The decrease in productivity means more resources such as increased hours in a workday or increased staff are needed to meet the demand.6 These trends appeared during the COVID-19 pandemic which greatly altered the daily operations of most veterinary practices and could change as COVID-19 restrictions ease and operation adjusts accordingly.
Veterinarians in practice have seen the productivity and staffing struggles cause delayed and even denied care to pets furthering their emotional challenges as they question their purpose and Hippocratic oath.46 Suggested strategies to help veterinary practices in the short term include incorporation of telemedicine and technology to streamline processes, focusing on current employee talents and utilize veterinary technicians to the top of their license, and fostering a culture of wellbeing in the workplace and strong relationships between leaders and employees.6 There is not one strategy that will change availability of veterinary professionals, therefore, stakeholders should begin to leverage multiple tools to help reduce the professional shortage and reduced productivity problems.
When researching barriers to veterinary medicine, the theme of education was referenced several times (35%, n = 13 of veterinary sources). The way education was defined differed between sources to either reference the level of education the owner received (ie, high school diploma, bachelor’s degree, etc) or the knowledge around veterinary care needs for their pets. Education level is a known social determinant of health when assessing health outcomes for human populations showing those with higher education level more likely to live longer, healthier lives.8,20 Education level has been shown to correlate to health literacy with higher education levels having higher health literacy.48 Other human healthcare studies have shown that individuals with lower education levels (less than high school) utilize emergency departments more than higher education levels.49 Several studies in human healthcare and food deserts did not include education level as a parameter as it is highly correlated with other sociodemographic variables.37 More studies are needed to understand the role owner education level has on seeking veterinary care and pet health outcomes and to identify methods by which animal health education can improve veterinary care access.
Our approach to defining veterinary care deserts has limitations similar to those seen in research defining healthcare, food, and education deserts. The definition and parameters described only measure “potential access” and not “realized access” or “utilization.” While “potential access” describes where owners can receive veterinary care, “realized access” or “utilization” measures where owners actually go for care. As the definition is applied to different communities and more information becomes available, the specific definition parameters may need to be revisited to account for these differences.
In its current form, the definition is very broad and considers only the most common companion animal species (ie, dogs and cats). To date, most of the research on veterinary care barriers has focused on the needs of dog and cat owners seeking primary or urgent care. Therefore, when applying the definition to different communities it may not capture other animal species or veterinary specialty care deserts that owners may experience. Organizations should consider their mission and use the definition as a starting point that can be expanded and adapted to meet their specific needs. For example, there is a recognized shortage of large animal/food animal veterinarians. The current definition could be used to help identify specific large animal deserts when considering only large animal practices/practitioners, but that specific information may not be as readily available. As more information is collected about communities and their veterinary care needs, the utility and limitations of, our definition will be clarified, and more species- or specialty-specific definitions may be created.
Identifying veterinary care deserts is only the first step in closing the access to care gap. Simply increasing presence in a community identified as a veterinary care desert may not be enough. Engaging the community to identify their specific veterinary care needs and building trust within target populations can help the success of programs and interventions aimed at serving veterinary care deserts.28
Establishing a working definition for veterinary care deserts is the first step toward the goal of increasing veterinary care access. The next objective is to pilot our definition in large, demographically diverse areas that span both urban and rural communities. Applying the definition to census tracts around the country will help identify areas most likely experiencing reduced access to veterinary care and allow research efforts and program implementation to be focused on the population most in need to start addressing the access to care gap.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
The authors thank Ruth Harris at the Western University of Health Sciences Harriet K. and Philip Pumerantz Library for helping guide the study design.
Disclosures
Gillian Angliss is an Associate Editor for JAVMA. She declares that she had no role in the editorial direction of this manuscript.
No AI-assisted technologies were used in the generation of this manuscript.
Funding
Laura Bunke was funded through San Diego Humane Society and Western University of Health Sciences College of Veterinary Medicine shelter medicine resident program. Scarlett Harrison received Western University of Health Sciences College of Veterinary Medicine 2022 Student Summer Research Grant.
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