Transportation Barriers to Health Care Access

Ahmed et al. [1] N = 413 adults
Urban (Dayton, Ohio), low SES 71 % female, 48 % Black, 42 % Appalachian Door to door survey on barriers to health care access “Difficulty finding transportation” (1) “Hard” or “very hard” time finding transportation (31 %) Arcury et al. [37] N = 1,059 adults
Rural (North Carolina), mixed SES, 662 female, 948 Whites, 112 Blacks Retrospective, comparing transportation barriers and health care utilization “Distance to care for… regular visit… for less serious emergency… for serious emergency” (3)
Has a driver’s license, any household member has a driver’s license, number of vehicles owned in household, days per week spent driving, relative or friend who regularly provides transportation for a family member, knowledge of organizations that provided transportation to health care and use of such transportation (7) Health care utilization associated with having a driver’s license (OR 2.29 more visits) and having a friend or relative who provides transportation (OR 1.58 more visits) Blazer et al. [14] N = 4,162 adults, age 65 +
Rural/Urban North Carolina), mixed SES, 62 % female, 68 % Non-Black (majority White) Retrospective cross-sectional survey (1986/87) analyzed for urban/rural variation of health service use, satisfaction, barriers to care Do you put off or neglect going to the doctor because of “distance or transportation”? (1) No difference between urban and rural residents in health service use; 7.7 % delayed care due to distance or transportation Borders et al. [54] N = 2,097 adults, age 65 +
Rural (West Texas), mixed SES 71 % female, 1949 Non-Hispanic, 148 Hispanic Telephone survey on barriers to health care access “Always/usually get transportation to doctor’s office” (1) Non- Hispanics (96 %) vs. Hispanics (90 %) could usually get transportation to clinic Branch et al. [36] N = 776 adults, age 65 +
Massachusetts, 95 % Medicare, 17 % Medicaid, 61 % privately insured, 64 % female Race not reported Retrospective survey interviews on barriers to health care access “You did not have a way to travel to the doctor” (1) Not having a way to get to the doctor (3 %); travel difficulties associated with lower income, being female, living alone, having less education Call et al. [56]^b N = 1,853 Minnesota Health Care Plan adult and parent enrollees
Minnesota, 65 % female adult enrollees, 47 % female parent enrollees, 1,314 Whites, 539 American Indians Mailed survey on barriers to health care access “Difficulties with transportation” (1) American Indians (39 %) vs. Whites (18 %) have difficulties with transportation Canupp et al. [49] N = 163 adults, mean age 26 with spinal cord injuries
Birmingham, Alabama, 25 % had income greater than 25,000 dollars, 14 % female, 63 % white Face to face survey on barriers to follow- up appointments Obstacles for follow-up included distance to travel and availability of transportation (2) Non-compliance with appointments associated with distance to travel (P = 0.004) and availability of transportation (P = 0.033) Crain et al. [15]^b N = 1,376 caretakers of children with asthma
8 metro inner-cities (locations not specified), low SES/74 % Medicaid, 36 % female, 73 % Black Face to face survey on barriers to health care access “Had no way to get there” (1) No way to get to clinic for follow-up care (16 %) Cunningham et al. [17] N = 2,864 adults with HIV
National, mixed SES, 847 females, 1,399 White/959 Black/415 Hispanic Face to face and telephone surveys on barriers to health care access and reasons for delaying care “In the last 6 months, have you ever had to go without health care because you didn’t have a way to get there?” (1) Postponed care because no transportation (15.4 %) (weighted for number of HIV persons in US who were under care from January to March 1996) Diamant et al. [18] N = 1,819 adults
Los Angeles, California, low SES, 69 % female, 56 % Hispanic/Latino, 23 % Black, 17 % White Face to face surveys on barriers to health care access “In the past 12 months, have you ever put off going to the doctor for medical care because you didn’t have a way to get there?” (1) Delayed care in prior 12 months (33 %)
Did not have transportation to get to the doctor (12 %) Fitzpatrick et al. [60] N = 4,889 Medicare eligible adults, age 65 +
Forsyth County, NC; Sacramento County, CA; Washington County, MD; Allegheny County, PA; mixed SES/ 70 % with supplemental private insurance, 59 % female, 83 % White Retrospective surveys on patterns of health care use and barriers to care “How much [moderate/very much/a whole lot] did each of the following affect your ability to see the doctor…transportation difficulty” (1) Cited a barrier to seeing the doctor (4 %); Of those citing a barrier, 21 % had transportation difficulties
Barriers to care associated with older age, female gender, minorities, lower income, lack of complementary insurance Flores et al. [24] N = 203 children’s caretakers
Boston, Massachusetts, low SES, Latino Face to face survey on barriers to health care access Transportation problems including lack of a car, excessive distance, expense or inconvenience of public transportation (not specified) Transportation barrier as a reason they had not brought child in for a medical visit (21 %); most cited reason
Lack of a car as most frequent transportation difficulty (62 %)
Clinics located too far from home (11 %) Giambruno et al. [25]^b N = 157 head start health coordinators
New York City, New Hampshire, Puerto Rico, US Virgin Islands Mailed survey on barriers to medical diagnosis and treatment for head start children Transportation barriers (4) included access to private transportation, access to public transportation, cost of transportation, distance to provider Barriers to health care access included: Private transportation not available (67 %)
Distance to provider (63 %)
Cost of transit (63 %)
No public transit available (48 %) Guidry et al. [26]^b N = 593 adults with cancer
Texas, mixed SES, 56 % female, 42 % White, 40 % Black, 15 % Hispanic Mailed survey on transportation barriers to cancer treatment Transportation barriers (4) included distance to treatment center, access to a vehicle, finding someone to drive them to treatment, mode of travel Barriers to getting cancer treatment were greatest for Hispanics, then Blacks, then Whites:
Distance
Hispanic (66 %), Black (51 %), White (37 %)
Access to a vehicle
Hispanic (50 %), Black (46 %), White (19 %)
Finding someone to drive them Hispanic (66 %), Black (55 %), White (37 %) Heckman et al. [44] N = 226 adults with HIV/AIDS
Urban/rural (Wisconsin), 54 % made < $10,000, 19 % female, 69 % White/23 % Black Mailed survey on barriers to care Transportation barriers (2) included lack of transportation and long distance to provider with likert scale ranging from l(no problem at all) to 4 (major problem) More rural than urban patients cited problems with distance (2.86 vs 1.61 on likert scale; P = 0.001), transportation (2.03 vs 1.62 on likert scale; P = 0.05) Hoffman et al. [19] N = 34 adults with asthma
Urban (Pittsburgh), mixed SES, 94 % female, race not reported Mailed surveys on 10 barriers to compliance with asthma care “Lack of transportation” (1) Lack of transportation associated with patients who go to the emergency room for their usual place of care (P = 0.02) Johnson et al. [20] N = 34,504 honorably discharged veterans, age 18–64
National, mixed SES, American Indian/ Alaskan native, White Analysis of National Health Interview Survey (NHIS) (1997–2006) for health care coverage and reasons for delayed care Barriers to receiving timely care… transportation problems (not specified) American Indian/Alaskan Native more likely to delay care than Whites due to transportation problems (OR 2.9) Kripalani et al. [64] N = 84 adults
Urban (Atlanta), low SES, 41 % female, 88 % Black Telephone survey on barriers to discharge medication adherence Level of difficulty visiting pharmacy (not specified) Patient with difficulty visiting the pharmacy less likely to fill prescription on day of discharge (20 % vs 55 %; P = 0.002)
Transportation assistance would improve medication use 65 %) Kruzich et al. [48]^b N = 102 caregivers of children receiving mental health treatment in residential facility, group home, or psychiatric unit
31 US States, mixed SES, 78 % white Mailed surveys on barriers to participation in children’s mental health treatment Transportation barriers (3) included distance, cost of transit, lack of transit Barriers to participation in care identified:
Distance from provider (44 %)
Cost of transit (28 %)
Lack of access to transit (10 %)
Distance was the most important barrier (22 %) Lamont et al. [52]^a N = 110 adults
Chicago, mixed SES, 26 % female, 67 % white Retrospective evaluation of association between cancer survival and distance from patient’s residence to treating institution Distance (N/A) Patients living more than 15 miles from institution had 1/3 hazard ratio for death, and with every 10 miles traveled, hazard of death decreased by 3.2 %
Compared with Whites, Blacks had 1/3 the hazard rate of death
On average, those traveling more than 15 miles were more often white, male, college educated, had higher family incomes Levine et al. [67] N = 5,840 adult stroke survivors age 45 +
National, SES not reported, included Blacks and Whites Retrospective survey using NHIS data (1997–2004) to identify inability to afford medications Lack of transportation delaying care (1) Patients who could not afford medications more frequently reported transportation barriers (15 vs. 3 %; P < 0.001) Littenberg et al. [53] N = 781 adult diabetics, 51 % age 65 +
Vermont, 58 % with private insurance/ 58 % Medicare/20 % Medicaid/5 % military/2 % uninsured, 54 % female, 97 % white Mailed surveys, face to face interviews, and distance measurements to evaluate the role of travel burden as a barrier to insulin use Distance (N/A) Longer driving distance associated with less use of insulin (OR for using insulin for each km of driving distance 0.97) Malmgren et al. [61] N = 125 adults, age 62 +
Seattle, low SES, 71 % women, 77 % White Face to face survey on health status and access of health care and unmet needs “Which of the following have ever made it hard to get care? … no transportation…distance too far” (2) Problems obtaining care (46 %) No transportation (10 %)
Insufficient income to meet personal needs was associated with more financial and structural barriers Martinez et al. [58]^b N = 107 HIV youth, age 15–24
Chicago, Newark, New York, Miami, 51 % with stable housing, 64 % female, 73 % Black Face to face surveys on process of transitioning HIV youth from diagnosis to treatment including needs assessment and barriers to care Barriers to accessing health care… transportation to health care settings (1) Transportation to health care was a barrier (40 %) Musey et al. [27]^b N = 56 adult diabetics
Urban (Atlanta), low SES, 21 women, 100 % Black Face to face surveys on precipitating causes of diabetic ketoacidosis (DKA) Lack of money for transportation to pharmacy (1) DKA caused by cessation of insulin (67 %); 50 % of these patients cited lack of money for insulin or for transportation to the pharmacy Nemet et al. [51]^b N = 390 adults, age 65 +
Rural (Orleans County, Vermont), income less than 50,000 dollars, gender and race not specified Mailed surveys on measures of health care association Distance (N/A) Distance to doctor was not associated with utilization of health care Okoro et al. [50]^b N = 46,659 adults, age 65 +
National, mixed income/all insured, 65 % female, 87 % White Retrospective analysis of behavioral risk factor surveillance system (2002) to explore barriers to care for adults older than age 65 Transportation barriers included no transportation or distance (1) 9 % of those who could not obtain needed medical care cited distance or no transportation as barrier to care Pesata et al. [39] N = 101 children’s families
Midwestern metropolitan clinic (location not specified), low SES, 54 % Black, 41 % White Telephone survey on dynamics behind missed appointments Transportation problems (not specified) Transportation as the primary reason for missed appointments (no ride or car) (51 %) Pheley et al. [68]^b N = 22,703 adult appointments
Inner city Minneapolis, low SES, race not reported Retrospective analysis of change in rate of failed appointments during public bus strike Rate of failed appointments per 100 scheduled appointments (N/A) Strike period associated with increased missed visits if visit was with a nurse (RR 1.17, P value = 0.01); no impact on doctor’s visits Probst et al. [45] N = 2,432 households
National Household Travel Survey (NHTS), mixed SES, 62 % female, 71 % White Retrospective analysis of 2001 National Household Travel Survey to determine travel burden to health care by geography and race Travel burdens measured by distance greater than 30 miles or time greater than 30 min; mode of travel, day and time of trip, driver/passenger status, traffic, region (not specified) Rural residence associated with higher travel burden by distance (OR 2.67) and time (OR 1.80)
Blacks had higher travel burdens by time (OR 3.04) compared to urban residence and Whites Rask et al. [40] N = 3,897 adults
Urban (Atlanta), low SES, 53 % female, 89 % Black Face to face survey to determine correlation of obstacles to medical care, lack of care, or delay in care Lack of transportation (1) Walking or using public transportation to reach hospital more likely to not have a regular source of care (OR 1.47)
If no private transportation, more likely to delay care (OR 1.60)
Lack of private transportation was an independent predictor of not having a regular source of care and delaying care Reif et al. [21]^b N = 94 HIV case managers
Urban/Rural (North Carolina), 86 % female, 59 % White Mailed survey on barriers to health care for HIV patients Transportation barriers (2) included lack of adequate transportation and long travel distances to health care services Lack of transportation was a major barrier for accessing care for clients (41 %)
Long travel distances to health care services was a major barrier for accessing care for clients (33 %) Rittner et al. [62] N = 1,083, adults, mean age 78
Metro South Florida, low SES, 838 women, 818 White, 252 Hispanic Group administered survey on health care access barriers in an elderly population who use daytime meal programs and mostly use public transportation Transportation barriers (not specified) Lack of transportation was reason for not receiving care in past 6 months (6.1 %) Rust et al. [22] N = 30,677 adults
National, mixed SES, race varied Retrospective analysis of 2005 National health interview survey (NHIS) to explore relationship between ED visits and barriers to health care “No transportation” (1) Likelihood of ED visit in 1 year if at least 1 barrier vs no barrier: 1 in 3 adults (33 %) vs 1 in 5 (20 %)
Of 5 access barriers, “no transportation” was greatest OR (OR 1.88) Salloum et al. [38]^a N = 406 adults with cancer
Southeast Michigan, median income 48,000 dollars/patients had to be enrolled in a health care plan in the 1 year preceding cancer diagnosis/12 % did not own cars in household, 41 % female, 69 % White, 29 % Black Retrospective analysis of factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer (2000–2007) Transportation barriers (2) included vehicle access and distance to treatment facility Predictors of chemotherapy underuse included lower vehicle access in the neighborhood(OR 6.96)
Distance traveled was not associated with adherence to chemotherapy treatment guidelines
No racial differences in the receipt of chemotherapy (neither under or overuse) Sarnquist et al. [47] N = 64 adults with HIV
Rural (California), majority made less than 20,000 dollars/year, 100 % female Retrospective face to face surveys on barriers to health care Transportation barriers (4) included mode to travel, travel time, difficulty traveling, lack of transportation Most common reason for missed appointments was transportation barriers (37.5 %); as common as “not feeling physically well”
Difficulty traveling to appointment 45.3 %
Lack of transportation 31.2 %
Transportation challenges associated with lower income Silver et al. [42]^b N = 698 adults
New York City suburb, low SES, 83 % female, 73 % Hispanic Face to face surveys on transportation barriers to clinic Transportation barriers (6) included “how did you travel to the clinic today, (if by bus) approximately how much time did you spend on the bust to travel from your home to the clinic, have you ever missed a clinic appointment because of transportation problems, in a typical month how often do you have transportation problems, how often do you use the bus (often/sometimes/never for work/groceries/clinic or hospital/ visit family or friends), (if applies) what is the main reason that you don’t use the bus more often to travel to the clinic?” Missed or rescheduled an appointment due to transportation problems (23.5 %)
Chronic transportation problems (30 %)
Difficulties affording transportation to clinic (nearly 25 %)
Bus users twice as likely to report history of missed/rescheduled appointments (40 % vs. 18 % car users; P < 0.001) Skinner et al. [46] N = 38,866 households of children with special health care needs
Urban/Rural (national), low SES, 83 % white, 9 % Black Retrospective analysis from 2000 to 2002 National Survey of Children with Special Health Care Needs from the National Center for Health Statistics to examine barriers to health care needs for urban and rural special needs children “transportation/not available in area” (1) Transportation/service not available in area was a barrier for any kind of care (OR 1.58), for obtaining prescriptions (OR 3.58), for therapy (OR 2.50) Smith et al. [59]^b N = 147 caregivers of asthmatic children
Urban (St.Louis, Missouri), low SES, race not reported Scaled survey of pros and cons to primary care follow-up after ED visit for asthma Finding transportation to get to appointment (1) Finding transportation was a barrier for parents to obtain follow-up care Strauss et al. [54] N = 973 adult diabetics
Vermont/New Hampshire/northern New York, 98 % insured/21 % Medicaid, 55 % female, 97 % White Analysis of Vermont Diabetes Information System to examine relationship between driving distance and glycemic control Driving distance (N/A) Longer driving distances from home to site of primary care was associated with poorer glycemic control with each 22 miles of driving distance associated with a 0.25 % increase in hemoglobin Alc Tierney et al. [66]^a,^b N = 46,722 all ages (23,015 in 1993; 23,707 in 1994)
Indiana, Medicaid recipients, 66 % Black Cohort study comparing health care utilization of Medicaid patients before (1993) and after(1994) a change in transportation reimbursement policy Health care utilization (N/A) Visits to hospital based primary care clinics declined (16 %)
Visits to neighborhood health clinics increased (7 %)
Emergency and urgent care visits fell (8%)
Visits for medication fills fell (18 %)
Hospitalizations increased slightly with no change in number of inpatient days Wallace et al. [3] N = 5,000 (2002 National transportation availability and use survey by bureau of transportation statistics- BTS)^c Retrospective analysis of BTS, NHIS, MEPS to estimate magnitude of transportation barriers to health care and populations affected nationally Transportation barriers
National health interview survey (1)
MEPS (3)
National transportation availability and use survey (not specified) 3.6 million Americans (estimated) miss at least one medical trip a year because of transportation and population is more likely to be older, poorer, female, minority, less educated
53.7 % of children who missed care due to transportation live in metro areas of 1 million or more while only 47.5 % of all U.S. children live in these areas Washington et al. [63] N = 3,611 adult veterans
National, mixed SES, 100 % female, 23 % minorities Telephone survey of barriers to health care access Reason for delayed care or unmet need… transportation difficulties (1) 35.7 % of those over age 65 reported transportation difficulties Weathers et al. [34] N = 300 adult caretakers of a migrant child less than age 13
4 counties in Eastern North Carolina, 73 % of children lacked insurance, nearly 70 % children were foreign born (62 % from Mexico) Face to face surveys of factors associated with unmet medical needs for children of migrant workers Primary reason for the last episode of unmet medical need… lack of transportation (1) 53 % of children had unmet medical need
Lack of transportation was primary reason for last episode of unmet medical need (80 %) Welty et al. [65] N = 143 adult members of epilepsy.com with epilepsy
Worldwide, (119 US/24 outside US), 75 % female, SES not reported, race not reported Web survey on impact of limited transportation on medication adherence Transportation as a barrier to medication access (8) including “approximately how far from your home is your pharmacy located (miles); if you do not drive, are there other forms of transportation available; what best describes your primary mode of transportation, do you ever have trouble picking up prescription medications on time because of transportation problems, how often do transportation problems keep you from getting your prescription medications on time, how often do you ever miss doses of medication because you cannot get to the pharmacy to pick up your medications, do you believe you have seizures because you are not able to pick up your medications on time, do you feel you would miss fewer doses of medication if transportation was not an issue?” Patients who could not drive vs those who could:
Trouble picking up medications on time due to transportation barriers (51 % vs 20%)
Would miss fewer doses if transit not an issue (45 vs. 22 %)
Thought had seizures because did not get medications on time (28 vs. 18 %)
Living closer and having mail service pharmacies did not improve receipt of on time refills Wheeler et al. [33] N = 303 recently hospitalized adults with diabetes
Urban (Atlanta), low SES, 46 % female, 91 % Black Face to face surveys on barriers to follow- up diabetes care after hospital discharge “no transportation to get to doctor” (1) Most common barrier to follow-up care was no transportation (60 %) Yang et al. [41] N = 183 caregivers of children attending pediatric clinic
Urban (Houston, Texas), low SES/80 % Medicaid, 44 % Hispanic, 28 % African Americain Face to face and telephone surveys of transportation barriers to keeping appointments Transportation barriers (16) included “forms of transportation most often used to clinic, form of transportation to last appointment kept, travel time in minutes to clinic for last appointment kept, usual travel time to clinic, number of missed appointments in last 12 months due to transportation problems” and yes/no items included “ever used Houston buses, access to a car, cost of transportation too high in Houston, difficulty getting to last appointment, ever missed appointment due to transportation problem, ever taken a child to a closer clinic, ever late to appointment due to transportation problem, ever miss appointment because auto being used by other person, ever not schedule appointment because of transportation problem, ever miss sick visit because of transportation problem, ever late to an appointment because of lack of parking, ever miss appointment because parking too expensive?” Overall, 131 missed appointments out of 497 appointments (26.4 %)
Kept appointment:
Access to a car (82 %)
Missed in past due to transportation problems (30 %)
31 % of the show group missed appointments in the past due to reasons other than transportation
Did not keep appointment:
Access to a car (58 %)
Missed in past due to transportation problems (50 %)
56 % of the no show group missed appointments in the past due to reasons other than transportation Zullig et al. [23] N = 954 veterans with colorectal cancer
Minnesota, mixed SES, 100 % male, 76 % White Mailed survey on transportation barriers to cancer treatment and follow-up “How often was it difficult to get transportation to or from your treatment or follow-up appointment?” “Often” and “always” difficult (19 %)