Rural Hospital Closures in Tennessee: Centering Community Residents' Voices to Identify Public Health Ethical Issues and Inform Policy Strategies.

The US is witnessing rapid hospital closures in rural communities, with devastating consequences for community residents beyond decreased access to health care services. Hospital closures have been associated with outmigration of younger generations due to loss of employment opportunities and economic decline, and with creating uncertainty and a sense of powerlessness among residents. While great efforts have been undertaken to document the effects of hospital closures on health care access, particularly during the COVID-19 epidemic, limited attention has been given to the public health ethics associated with dismantling health care for populations in greatest need. Drawing on the narratives of community stakeholders and residents, several themes evolved around processes, structures, and spillover effects of hospital closures on their daily lives, including decision making processes of when and how to close hospitals. Concerns arose regarding lack of transparency and disregard for alternative health care services to meet the needs of rural communities. The researchers analyzed participants' stories using the six core values of the American Public Health Association's code of ethics to determine the extent to which the multilevel crisis emerging from rural hospital closures contradicts the public health ethical responsibility of ensuring access to health care in rural communities. Centering the voices of rural community stakeholders and residents is critical to inform and guide public health strategies and in turn address health care needs of rural communities.