Article review
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SaminaT.SyedTravelBarriers.pdf
R E V I E W
Traveling Towards Disease: Transportation Barriers to Health Care Access
Samina T. Syed • Ben S. Gerber • Lisa K. Sharp
Published online: 31 March 2013
� Springer Science+Business Media New York 2013
Abstract Transportation barriers are often cited as bar-
riers to healthcare access. Transportation barriers lead to
rescheduled or missed appointments, delayed care, and
missed or delayed medication use. These consequences
may lead to poorer management of chronic illness and thus
poorer health outcomes. However, the significance of these
barriers is uncertain based on existing literature due to wide
variability in both study populations and transportation
barrier measures. The authors sought to synthesize the
literature on the prevalence of transportation barriers to
health care access. A systematic literature search of peer-
reviewed studies on transportation barriers to healthcare
access was performed. Inclusion criteria were as follows:
(1) study addressed access barriers for ongoing primary
care or chronic disease care; (2) study included assessment
of transportation barriers; and (3) study was completed in
the United States. In total, 61 studies were reviewed.
Overall, the evidence supports that transportation barriers
are an important barrier to healthcare access, particularly
for those with lower incomes or the under/uninsured.
Additional research needs to (1) clarify which aspects of
transportation limit health care access (2) measure the
impact of transportation barriers on clinically meaningful
outcomes and (3) measure the impact of transportation
barrier interventions and transportation policy changes.
Keywords Healthcare access � Transportation barriers � Medication access � Healthcare barriers
Introduction
Transportation is a basic but necessary step for ongoing
health care and medication access, particularly for those
with chronic diseases (Fig. 1). Chronic disease care requires
clinician visits, medication access, and changes to treat-
ment plans in order to provide evidence-based care.
However, without transportation, delays in clinical inter-
ventions result. Such delays in care may lead to a lack of
appropriate medical treatment, chronic disease exacerba-
tions or unmet health care needs, which can accumulate
and worsen health outcomes [1, 2].
Patients with transportation barriers carry a greater
burden of disease which may, in part, reflect the relation-
ship between poverty and transportation availability [3]. As
a result, understanding the relationship between transpor-
tation barriers and health may be important to addressing
health in the most vulnerable who live in poverty.
Transportation is often cited as a major barrier to health
care access [4–35]. Studies have found transportation barriers
impacting health care access in as little as 3 % or as much as
S. T. Syed (&) Section of Endocrinology, Diabetes and Metabolism, University
of Illinois at Chicago, 1819 W. Polk Street, M/C 640, Chicago,
IL 60612, USA
e-mail: [email protected]
B. S. Gerber
Jesse Brown Veterans Affairs Medical Center, Chicago,
IL 60612, USA
e-mail: [email protected]
B. S. Gerber
Institute for Health Research and Policy, University of Illinois
at Chicago, MC 275, 454 Westside Research Office Bldg.,
1747 West Roosevelt Road, Chicago, IL 60608, USA
L. K. Sharp
Institute for Health Research and Policy, University of Illinois
at Chicago, MC 275, 463 Westside Research Office Bldg.,
1747 West Roosevelt Road, Chicago, IL 60608, USA
e-mail: [email protected]
123
J Community Health (2013) 38:976–993
DOI 10.1007/s10900-013-9681-1
67 % of the population sampled [25, 36]. The wide variability
in study findings makes it difficult to determine the ultimate
impact that transportation barriers have on health.
This review summarizes and critically evaluates the
empirical evidence on transportation barriers to health care
access for primary and chronic disease care. For each of the
61 studies reviewed, we evaluated the population charac-
teristics, methods, measures of transportation barriers and
results (Table 1). Results are organized into three sections:
(1) measurement of transportation barriers, (2) transporta-
tion barriers and demographic differences, and (3) mea-
surement of the impact of transportation barriers.
Additionally, we define a research agenda based on gaps in
the literature and discuss potential intervention opportuni-
ties and public policy considerations.
Methods
We searched for peer-reviewed studies that addressed
transportation barriers in relation to ongoing health care
access. Inclusion criteria were as follows: (1) study
addressed access barriers for ongoing primary care or
chronic disease care; (2) study included assessment of
transportation barriers; and (3) study was completed in the
United States. Articles dealing with access to prenatal care,
emergency or acute care, or exclusive attention to general
screening and prevention were excluded as they may rep-
resent a single visit or limited time period of care.
We used PubMed with the following keyword search
terms (number of articles returned): transportation barriers
(963), transportation barriers clinic (129), transportation
barriers pharmacy (13), transportation barriers hospital
(183), transportation barriers doctor (69), transportation
barriers health access (276), and transportation barriers
chronic disease (33). Medical Subject Heading (MESH)
terms included health services accessibility AND trans-
portation (575). Additional background information was
found using the terms transportation barriers health access
to search Web of Science and Psych Info, and transpor-
tation barriers to search The New York Academy of
Medicine Library’s Grey Literature Report.
Abstracts were reviewed for inclusion criteria, and if
necessary, full text articles were also reviewed. A sec-
ondary review of bibliographies was also conducted. In the
final review, 61 articles met the inclusion criteria. The
search was concluded in December 2012.
Results
Measures of Transportation Barriers
Vehicle Access and Mode of Travel
Nine studies assessed the influence of vehicle access upon
access to health care, and all found a positive relationship
[24–26, 37–42]. Vehicle access refers to either owning a
car or having access to a car through a family member or
friend. Arcury et al. [37] studied the relationship of trans-
portation to health care utilization in 1,059 rural Appala-
chians and found that people who knew someone who
regularly provided rides to a member of their family had a
greater utilization of health care (Odds Ratio, OR 1.58).
Those with a driver’s license, independent of other factors,
also had greater health care utilization (OR 2.29).
Guidry et al. [26] surveyed 593 cancer patients throughout
Texas, and found 38 % of whites, 55 % of African Americans,
and 60 % of Hispanics identified poor access to a vehicle as a
barrier that could result in missing a cancer treatment.
A study by Salloum et al. [38] looked retrospectively
(2000–2007) at 406 cancer patients to see if patients were
more or less likely to receive first line chemotherapy based
on their demographics. Patients who were significantly less
likely to receive first line chemotherapy lived in neigh-
borhoods that had a higher percentage of households
without any vehicle. Distance to the nearest chemotherapy
facility was not a significant factor.
Rask et al. [40] studied obstacles to care for 3,897 urban,
low socioeconomic status (SES) adults in Atlanta and found
that walking or using public transportation to receive medi-
cal care was an independent predictor of not having a regular
source of care (OR 1.44). Patients who did not use private
transportation were also more likely to delay care (OR 1.45).
Patient
Improved Health Outcomes
Improved care based on clinical guidelines
Appropriate changes to medication regimen
Prevention of chronic disease complications
Timely Medical Care
Clinician Visit
Transportation
Timely Medication Access
New prescriptions/treatments
Medication refills
Fig. 1 Model of relationship between transportation, health care access and outcomes
J Community Health (2013) 38:976–993 977
123
T a
b le
1 S
tu d
ie s
o n
tr a n
sp o
rt a ti
o n
b a rr
ie rs
to h
e a lt
h c a re
a c c e ss
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
A h
m e d
e t
a l.
[1 ]
N =
4 1
3 a d
u lt
s
U rb
a n
(D a y
to n
, O
h io
), lo
w S
E S
7 1
%
fe m
a le
, 4
8 %
B la
c k
, 4
2 %
A p
p a la
c h
ia n
D o
o r
to d
o o
r su
rv e y
o n
b a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
‘‘ D
if fi
c u
lt y
fi n
d in
g tr
a n
sp o
rt a ti
o n
’’ (1
) ‘‘
H a rd
’’ o
r ‘‘
v e ry
h a rd
’’ ti
m e
fi n
d in
g
tr a n
sp o
rt a ti
o n
(3 1
% )
A rc
u ry
e t
a l.
[3 7
]
N =
1 ,0
5 9
a d
u lt
s
R u
ra l
(N o
rt h
C a ro
li n
a ),
m ix
e d
S E
S ,
6 6
2
fe m
a le
, 9
4 8
W h
it e s,
1 1
2 B
la c k
s
R e tr
o sp
e c ti
v e ,
c o
m p
a ri
n g
tr a n
sp o
rt a ti
o n
b a rr
ie rs
a n
d h
e a lt
h c a re
u ti
li z a ti
o n
‘‘ D
is ta
n c e
to c a re
fo r…
re g
u la
r v
is it
… fo
r
le ss
se ri
o u
s e m
e rg
e n
c y
… fo
r se
ri o
u s
e m
e rg
e n
c y
’’ (3
)
H a s
a d
ri v
e r’
s li
c e n
se ,
a n
y h
o u
se h
o ld
m e m
b e r
h a s
a d
ri v
e r’
s li
c e n
se ,
n u
m b
e r
o f
v e h
ic le
s o
w n
e d
in h
o u
se h
o ld
, d
a y
s
p e r
w e e k
sp e n
t d
ri v
in g
, re
la ti
v e
o r
fr ie
n d
w h
o re
g u
la rl
y p
ro v
id e s
tr a n
sp o
rt a ti
o n
fo r
a fa
m il
y m
e m
b e r,
k n
o w
le d
g e
o f
o rg
a n
iz a ti
o n
s th
a t
p ro
v id
e d
tr a n
sp o
rt a ti
o n
to h
e a lt
h c a re
a n
d u
se o
f su
c h
tr a n
sp o
rt a ti
o n
(7 )
H e a lt
h c a re
u ti
li z a ti
o n
a ss
o c ia
te d
w it
h
h a v
in g
a d
ri v
e r’
s li
c e n
se (O
R 2
.2 9
m o
re
v is
it s)
a n
d h
a v
in g
a fr
ie n
d o
r re
la ti
v e
w h
o p
ro v
id e s
tr a n
sp o
rt a ti
o n
(O R
1 .5
8
m o
re v
is it
s)
B la
z e r
e t
a l.
[1 4
]
N =
4 ,1
6 2
a d
u lt
s, a g
e 6
5 ?
R u
ra l/
U rb
a n
N o
rt h
C a ro
li n
a ),
m ix
e d
S E
S ,
6 2
% fe
m a le
, 6
8 %
N o
n -B
la c k
(m a jo
ri ty
W h
it e )
R e tr
o sp
e c ti
v e
c ro
ss -s
e c ti
o n
a l
su rv
e y
(1 9
8 6
/8 7
) a n
a ly
z e d
fo r
u rb
a n
/r u
ra l
v a ri
a ti
o n
o f
h e a lt
h se
rv ic
e u
se ,
sa ti
sf a c ti
o n
, b
a rr
ie rs
to c a re
D o
y o
u p
u t
o ff
o r
n e g
le c t
g o
in g
to th
e
d o
c to
r b
e c a u
se o
f ‘‘
d is
ta n
c e
o r
tr a n
sp o
rt a ti
o n
’’ ?
(1 )
N o
d if
fe re
n c e
b e tw
e e n
u rb
a n
a n
d ru
ra l
re si
d e n
ts in
h e a lt
h se
rv ic
e u
se ;
7 .7
%
d e la
y e d
c a re
d u
e to
d is
ta n
c e
o r
tr a n
sp o
rt a ti
o n
B o
rd e rs
e t
a l.
[5 4
]
N =
2 ,0
9 7
a d
u lt
s, a g
e 6
5 ?
R u
ra l
(W e st
T e x
a s)
, m
ix e d
S E
S 7
1 %
fe m
a le
, 1
9 4
9 N
o n
-H is
p a n
ic ,
1 4
8
H is
p a n
ic
T e le
p h
o n
e su
rv e y
o n
b a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
‘‘ A
lw a y
s/ u
su a ll
y g
e t
tr a n
sp o
rt a ti
o n
to
d o
c to
r’ s
o ffi
c e ’’
(1 )
N o
n -
H is
p a n
ic s
(9 6
% )
v s.
H is
p a n
ic s
(9 0
% )
c o
u ld
u su
a ll
y g
e t
tr a n
sp o
rt a ti
o n
to c li
n ic
B ra
n c h
e t
a l.
[3 6
]
N =
7 7
6 a d
u lt
s, a g
e 6
5 ?
M a ss
a c h
u se
tt s,
9 5
% M
e d
ic a re
, 1
7 %
M e d
ic a id
, 6
1 %
p ri
v a te
ly in
su re
d ,
6 4
%
fe m
a le
R a c e
n o
t re
p o
rt e d
R e tr
o sp
e c ti
v e
su rv
e y
in te
rv ie
w s
o n
b a rr
ie rs
to h
e a lt
h c a re
a c c e ss
‘‘ Y
o u
d id
n o
t h
a v
e a
w a y
to tr
a v
e l
to
th e
d o
c to
r’ ’
(1 )
N o
t h
a v
in g
a w
a y
to g
e t
to th
e d
o c to
r
(3 %
); tr
a v
e l
d if
fi c u
lt ie
s a ss
o c ia
te d
w it
h
lo w
e r
in c o
m e ,
b e in
g fe
m a le
, li
v in
g
a lo
n e ,
h a v
in g
le ss
e d
u c a ti
o n
C a ll
e t
a l.
[5 6
]b N
= 1
,8 5
3 M
in n
e so
ta H
e a lt
h C
a re
P la
n
a d
u lt
a n
d p
a re
n t
e n
ro ll
e e s
M in
n e so
ta ,
6 5
% fe
m a le
a d
u lt
e n
ro ll
e e s,
4 7
% fe
m a le
p a re
n t
e n
ro ll
e e s,
1 ,3
1 4
W h
it e s,
5 3
9 A
m e ri
c a n
In d
ia n
s
M a il
e d
su rv
e y
o n
b a rr
ie rs
to h
e a lt
h c a re
a c c e ss
‘‘ D
if fi
c u
lt ie
s w
it h
tr a n
sp o
rt a ti
o n
’’ (1
) A
m e ri
c a n
In d
ia n
s (3
9 %
) v
s. W
h it
e s
(1 8
% )
h a v
e d
if fi
c u
lt ie
s w
it h
tr a n
sp o
rt a ti
o n
C a n
u p
p e t
a l.
[4 9
]
N =
1 6
3 a d
u lt
s, m
e a n
a g
e 2
6 w
it h
sp in
a l
c o
rd in
ju ri
e s
B ir
m in
g h
a m
, A
la b
a m
a ,
2 5
% h
a d
in c o
m e
g re
a te
r th
a n
2 5
,0 0
0 d
o ll
a rs
, 1
4 %
fe m
a le
, 6
3 %
w h
it e
F a c e
to fa
c e
su rv
e y
o n
b a rr
ie rs
to fo
ll o
w -
u p
a p
p o
in tm
e n
ts
O b
st a c le
s fo
r fo
ll o
w -u
p in
c lu
d e d
d is
ta n
c e
to tr
a v
e l
a n
d a v
a il
a b
il it
y o
f
tr a n
sp o
rt a ti
o n
(2 )
N o
n -c
o m
p li
a n
c e
w it
h a p
p o
in tm
e n
ts
a ss
o c ia
te d
w it
h d
is ta
n c e
to tr
a v
e l
(P =
0 .0
0 4
) a n
d a v
a il
a b
il it
y o
f
tr a n
sp o
rt a ti
o n
(P =
0 .0
3 3
)
978 J Community Health (2013) 38:976–993
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
C ra
in e t
a l.
[1 5
]b N
= 1
,3 7
6 c a re
ta k
e rs
o f
c h
il d
re n
w it
h
a st
h m
a
8 m
e tr
o in
n e r-
c it
ie s
(l o
c a ti
o n
s n
o t
sp e c ifi
e d
), lo
w S
E S
/7 4
%
M e d
ic a id
,3 6
% fe
m a le
, 7
3 %
B la
c k
F a c e
to fa
c e
su rv
e y
o n
b a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
‘‘ H
a d
n o
w a y
to g
e t
th e re
’’ (1
) N
o w
a y
to g
e t
to c li
n ic
fo r
fo ll
o w
-u p
c a re
(1 6
% )
C u
n n
in g
h a m
e t
a l.
[1 7
]
N =
2 ,8
6 4
a d
u lt
s w
it h
H IV
N a ti
o n
a l,
m ix
e d
S E
S ,
8 4
7 fe
m a le
s, 1
,3 9
9
W h
it e /9
5 9
B la
c k
/4 1
5 H
is p
a n
ic
F a c e
to fa
c e
a n
d te
le p
h o
n e
su rv
e y
s o
n
b a rr
ie rs
to h
e a lt
h c a re
a c c e ss
a n
d
re a so
n s
fo r
d e la
y in
g c a re
‘‘ In
th e
la st
6 m
o n
th s,
h a v
e y
o u
e v
e r
h a d
to g
o w
it h
o u
t h
e a lt
h c a re
b e c a u
se y
o u
d id
n ’t
h a v
e a
w a y
to g
e t
th e re
? ’’
(1 )
P o
st p
o n
e d
c a re
b e c a u
se n
o tr
a n
sp o
rt a ti
o n
(1 5
.4 %
) (w
e ig
h te
d fo
r n
u m
b e r
o f
H IV
p e rs
o n
s in
U S
w h
o w
e re
u n
d e r
c a re
fr o
m Ja
n u
a ry
to M
a rc
h 1
9 9
6 )
D ia
m a n
t
e t
a l.
[1 8
]
N =
1 ,8
1 9
a d
u lt
s
L o
s A
n g
e le
s, C
a li
fo rn
ia ,
lo w
S E
S ,
6 9
%
fe m
a le
, 5
6 %
H is
p a n
ic /L
a ti
n o
, 2
3 %
B la
c k
, 1
7 %
W h
it e
F a c e
to fa
c e
su rv
e y
s o
n b
a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
‘‘ In
th e
p a st
1 2
m o
n th
s, h
a v
e y
o u
e v
e r
p u
t
o ff
g o
in g
to th
e d
o c to
r fo
r m
e d
ic a l
c a re
b e c a u
se y
o u
d id
n ’t
h a v
e a
w a y
to g
e t
th e re
? ’’
(1 )
D e la
y e d
c a re
in p
ri o
r 1
2 m
o n
th s
(3 3
% )
D id
n o
t h
a v
e tr
a n
sp o
rt a ti
o n
to g
e t
to th
e
d o
c to
r (1
2 %
)
F it
z p
a tr
ic k
e t
a l.
[6 0
]
N =
4 ,8
8 9
M e d
ic a re
e li
g ib
le a d
u lt
s, a g
e
6 5
?
F o
rs y
th C
o u
n ty
, N
C ;
S a c ra
m e n
to C
o u
n ty
,
C A
; W
a sh
in g
to n
C o
u n
ty ,
M D
;
A ll
e g
h e n
y C
o u
n ty
, P
A ;
m ix
e d
S E
S /
7 0
% w
it h
su p
p le
m e n
ta l
p ri
v a te
in su
ra n
c e ,
5 9
% fe
m a le
, 8
3 %
W h
it e
R e tr
o sp
e c ti
v e
su rv
e y
s o
n p
a tt
e rn
s o
f
h e a lt
h c a re
u se
a n
d b
a rr
ie rs
to c a re
‘‘ H
o w
m u
c h
[m o
d e ra
te /v
e ry
m u
c h
/a
w h
o le
lo t]
d id
e a c h
o f
th e
fo ll
o w
in g
a ff
e c t
y o
u r
a b
il it
y to
se e
th e
d o
c to
r… tr
a n
sp o
rt a ti
o n
d if
fi c u
lt y
’’ (1
)
C it
e d
a b
a rr
ie r
to se
e in
g th
e d
o c to
r (4
% );
O f
th o
se c it
in g
a b
a rr
ie r,
2 1
% h
a d
tr a n
sp o
rt a ti
o n
d if
fi c u
lt ie
s
B a rr
ie rs
to c a re
a ss
o c ia
te d
w it
h o
ld e r
a g
e ,
fe m
a le
g e n
d e r,
m in
o ri
ti e s,
lo w
e r
in c o
m e ,
la c k
o f
c o
m p
le m
e n
ta ry
in su
ra n
c e
F lo
re s
e t
a l.
[2 4
]
N =
2 0
3 c h
il d
re n
’s c a re
ta k
e rs
B o
st o
n ,
M a ss
a c h
u se
tt s,
lo w
S E
S ,
L a ti
n o
F a c e
to fa
c e
su rv
e y
o n
b a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
T ra
n sp
o rt
a ti
o n
p ro
b le
m s
in c lu
d in
g la
c k
o f
a c a r,
e x
c e ss
iv e
d is
ta n
c e ,
e x
p e n
se o
r
in c o
n v
e n
ie n
c e
o f
p u
b li
c tr
a n
sp o
rt a ti
o n
(n o
t sp
e c ifi
e d
)
T ra
n sp
o rt
a ti
o n
b a rr
ie r
a s
a re
a so
n th
e y
h a d
n o
t b
ro u
g h
t c h
il d
in fo
r a
m e d
ic a l
v is
it (2
1 %
); m
o st
c it
e d
re a so
n
L a c k
o f
a c a r
a s
m o
st fr
e q
u e n
t
tr a n
sp o
rt a ti
o n
d if
fi c u
lt y
(6 2
% )
C li
n ic
s lo
c a te
d to
o fa
r fr
o m
h o
m e
(1 1
% )
G ia
m b
ru n
o
e t
a l.
[2 5
]b N
= 1
5 7
h e a d
st a rt
h e a lt
h c o
o rd
in a to
rs
N e w
Y o
rk C
it y
, N
e w
H a m
p sh
ir e ,
P u
e rt
o
R ic
o ,
U S
V ir
g in
Is la
n d
s
M a il
e d
su rv
e y
o n
b a rr
ie rs
to m
e d
ic a l
d ia
g n
o si
s a n
d tr
e a tm
e n
t fo
r h
e a d
st a rt
c h
il d
re n
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(4 )
in c lu
d e d
a c c e ss
to p
ri v
a te
tr a n
sp o
rt a ti
o n
, a c c e ss
to p
u b
li c
tr a n
sp o
rt a ti
o n
, c o
st o
f
tr a n
sp o
rt a ti
o n
, d
is ta
n c e
to p
ro v
id e r
B a rr
ie rs
to h
e a lt
h c a re
a c c e ss
in c lu
d e d
:
P ri
v a te
tr a n
sp o
rt a ti
o n
n o
t a v
a il
a b
le
(6 7
% )
D is
ta n
c e
to p
ro v
id e r
(6 3
% )
C o
st o
f tr
a n
si t
(6 3
% )
N o
p u
b li
c tr
a n
si t
a v
a il
a b
le (4
8 %
)
J Community Health (2013) 38:976–993 979
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
G u
id ry
e t
a l.
[2 6
]b N
= 5
9 3
a d
u lt
s w
it h
c a n
c e r
T e x
a s,
m ix
e d
S E
S ,
5 6
% fe
m a le
, 4
2 %
W h
it e ,
4 0
% B
la c k
, 1
5 %
H is
p a n
ic
M a il
e d
su rv
e y
o n
tr a n
sp o
rt a ti
o n
b a rr
ie rs
to c a n
c e r
tr e a tm
e n
t
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(4 )
in c lu
d e d
d is
ta n
c e
to tr
e a tm
e n
t c e n
te r,
a c c e ss
to a
v e h
ic le
, fi
n d
in g
so m
e o
n e
to d
ri v
e th
e m
to tr
e a tm
e n
t, m
o d
e o
f tr
a v
e l
B a rr
ie rs
to g
e tt
in g
c a n
c e r
tr e a tm
e n
t w
e re
g re
a te
st fo
r H
is p
a n
ic s,
th e n
B la
c k
s, th
e n
W h
it e s:
D is
ta n
c e
H is
p a n
ic (6
6 %
), B
la c k
(5 1
% ),
W h
it e
(3 7
% )
A c c e ss
to a
v e h
ic le
H is
p a n
ic (5
0 %
), B
la c k
(4 6
% ),
W h
it e
(1 9
% )
F in
d in
g so
m e o
n e
to d
ri v
e th
e m
H is
p a n
ic
(6 6
% ),
B la
c k
(5 5
% ),
W h
it e
(3 7
% )
H e c k
m a n
e t
a l.
[4 4
]
N =
2 2
6 a d
u lt
s w
it h
H IV
/A ID
S
U rb
a n
/r u
ra l
(W is
c o
n si
n ),
5 4
%
m a d
e \
$ 1
0 ,0
0 0
, 1
9 %
fe m
a le
, 6
9 %
W h
it e /2
3 %
B la
c k
M a il
e d
su rv
e y
o n
b a rr
ie rs
to c a re
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(2 )
in c lu
d e d
la c k
o f
tr a n
sp o
rt a ti
o n
a n
d lo
n g
d is
ta n
c e
to
p ro
v id
e r
w it
h li
k e rt
sc a le
ra n
g in
g fr
o m
1 (n
o p
ro b
le m
a t
a ll
) to
4 (m
a jo
r
p ro
b le
m )
M o
re ru
ra l
th a n
u rb
a n
p a ti
e n
ts c it
e d
p ro
b le
m s
w it
h d
is ta
n c e
(2 .8
6 v
s 1
.6 1
o n
li k
e rt
sc a le
; P
= 0
.0 0
1 ),
tr a n
sp o
rt a ti
o n
(2 .0
3 v
s 1
.6 2
o n
li k
e rt
sc a le
; P
= 0
.0 5
)
H o
ff m
a n
e t
a l.
[1 9
]
N =
3 4
a d
u lt
s w
it h
a st
h m
a
U rb
a n
(P it
ts b
u rg
h ),
m ix
e d
S E
S ,
9 4
%
fe m
a le
, ra
c e
n o
t re
p o
rt e d
M a il
e d
su rv
e y
s o
n 1
0 b
a rr
ie rs
to
c o
m p
li a n
c e
w it
h a st
h m
a c a re
‘‘ L
a c k
o f
tr a n
sp o
rt a ti
o n
’’ (1
) L
a c k
o f
tr a n
sp o
rt a ti
o n
a ss
o c ia
te d
w it
h
p a ti
e n
ts w
h o
g o
to th
e e m
e rg
e n
c y
ro o
m
fo r
th e ir
u su
a l
p la
c e
o f
c a re
(P =
0 .0
2 )
Jo h
n so
n e t
a l.
[2 0
]
N =
3 4
,5 0
4 h
o n
o ra
b ly
d is
c h
a rg
e d
v e te
ra n
s, a g
e 1
8 –
6 4
N a ti
o n
a l,
m ix
e d
S E
S ,
A m
e ri
c a n
In d
ia n
/
A la
sk a n
n a ti
v e ,
W h
it e
A n
a ly
si s
o f
N a ti
o n
a l
H e a lt
h In
te rv
ie w
S u
rv e y
(N H
IS )
(1 9
9 7
– 2
0 0
6 )
fo r
h e a lt
h
c a re
c o
v e ra
g e
a n
d re
a so
n s
fo r
d e la
y e d
c a re
B a rr
ie rs
to re
c e iv
in g
ti m
e ly
c a re
… tr
a n
sp o
rt a ti
o n
p ro
b le
m s
(n o
t sp
e c ifi
e d
)
A m
e ri
c a n
In d
ia n
/A la
sk a n
N a ti
v e
m o
re
li k
e ly
to d
e la
y c a re
th a n
W h
it e s
d u
e to
tr a n
sp o
rt a ti
o n
p ro
b le
m s
(O R
2 .9
)
K ri
p a la
n i
e t
a l.
[6 4
]
N =
8 4
a d
u lt
s
U rb
a n
(A tl
a n
ta ),
lo w
S E
S ,
4 1
% fe
m a le
,
8 8
% B
la c k
T e le
p h
o n
e su
rv e y
o n
b a rr
ie rs
to d
is c h
a rg
e
m e d
ic a ti
o n
a d
h e re
n c e
L e v
e l
o f
d if
fi c u
lt y
v is
it in
g p
h a rm
a c y
(n o
t
sp e c ifi
e d
)
P a ti
e n
t w
it h
d if
fi c u
lt y
v is
it in
g th
e
p h
a rm
a c y
le ss
li k
e ly
to fi
ll p
re sc
ri p
ti o
n
o n
d a y
o f
d is
c h
a rg
e (2
0 %
v s
5 5
% ;
P =
0 .0
0 2
)
T ra
n sp
o rt
a ti
o n
a ss
is ta
n c e
w o
u ld
im p
ro v
e
m e d
ic a ti
o n
u se
6 5
% )
K ru
z ic
h e t
a l.
[4 8
]b N
= 1
0 2
c a re
g iv
e rs
o f
c h
il d
re n
re c e iv
in g
m e n
ta l
h e a lt
h tr
e a tm
e n
t in
re si
d e n
ti a l
fa c il
it y
, g
ro u
p h
o m
e ,
o r
p sy
c h
ia tr
ic u
n it
3 1
U S
S ta
te s,
m ix
e d
S E
S ,
7 8
% w
h it
e
M a il
e d
su rv
e y
s o
n b
a rr
ie rs
to
p a rt
ic ip
a ti
o n
in c h
il d
re n
’s m
e n
ta l
h e a lt
h
tr e a tm
e n
t
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(3 )
in c lu
d e d
d is
ta n
c e ,
c o
st o
f tr
a n
si t,
la c k
o f
tr a n
si t
B a rr
ie rs
to p
a rt
ic ip
a ti
o n
in c a re
id e n
ti fi
e d
:
D is
ta n
c e
fr o
m p
ro v
id e r
(4 4
% )
C o
st o
f tr
a n
si t
(2 8
% )
L a c k
o f
a c c e ss
to tr
a n
si t
(1 0
% )
D is
ta n
c e
w a s
th e
m o
st im
p o
rt a n
t b
a rr
ie r
(2 2
% )
980 J Community Health (2013) 38:976–993
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
L a m
o n
t e t
a l.
[5 2
]a N
= 1
1 0
a d
u lt
s
C h
ic a g
o ,
m ix
e d
S E
S ,
2 6
% fe
m a le
, 6
7 %
w h
it e
R e tr
o sp
e c ti
v e
e v
a lu
a ti
o n
o f
a ss
o c ia
ti o
n
b e tw
e e n
c a n
c e r
su rv
iv a l
a n
d d
is ta
n c e
fr o
m p
a ti
e n
t’ s
re si
d e n
c e
to tr
e a ti
n g
in st
it u
ti o
n
D is
ta n
c e
(N /A
) P
a ti
e n
ts li
v in
g m
o re
th a n
1 5
m il
e s
fr o
m
in st
it u
ti o
n h
a d
1 /3
h a z a rd
ra ti
o fo
r
d e a th
, a n
d w
it h
e v
e ry
1 0
m il
e s
tr a v
e le
d ,
h a z a rd
o f
d e a th
d e c re
a se
d b
y 3
.2 %
C o
m p
a re
d w
it h
W h
it e s,
B la
c k
s h
a d
1 /3
th e
h a z a rd
ra te
o f
d e a th
O n
a v
e ra
g e ,
th o
se tr
a v
e li
n g
m o
re th
a n
1 5
m il
e s
w e re
m o
re o
ft e n
w h
it e ,
m a le
,
c o
ll e g
e e d
u c a te
d ,
h a d
h ig
h e r
fa m
il y
in c o
m e s
L e v
in e
e t
a l.
[6 7
]
N =
5 ,8
4 0
a d
u lt
st ro
k e
su rv
iv o
rs a g
e
4 5
?
N a ti
o n
a l,
S E
S n
o t
re p
o rt
e d
, in
c lu
d e d
B la
c k
s a n
d W
h it
e s
R e tr
o sp
e c ti
v e
su rv
e y
u si
n g
N H
IS d
a ta
(1 9
9 7
– 2
0 0
4 )
to id
e n
ti fy
in a b
il it
y to
a ff
o rd
m e d
ic a ti
o n
s
L a c k
o f
tr a n
sp o
rt a ti
o n
d e la
y in
g c a re
(1 )
P a ti
e n
ts w
h o
c o
u ld
n o
t a ff
o rd
m e d
ic a ti
o n
s
m o
re fr
e q
u e n
tl y
re p
o rt
e d
tr a n
sp o
rt a ti
o n
b a rr
ie rs
(1 5
v s.
3 %
; P
\ 0
.0 0
1 )
L it
te n
b e rg
e t
a l.
[5 3
]
N =
7 8
1 a d
u lt
d ia
b e ti
c s,
5 1
% a g
e 6
5 ?
V e rm
o n
t, 5
8 %
w it
h p
ri v
a te
in su
ra n
c e /
5 8
% M
e d
ic a re
/2 0
% M
e d
ic a id
/5 %
m il
it a ry
/2 %
u n
in su
re d
, 5
4 %
fe m
a le
,
9 7
% w
h it
e
M a il
e d
su rv
e y
s, fa
c e
to fa
c e
in te
rv ie
w s,
a n
d d
is ta
n c e
m e a su
re m
e n
ts to
e v
a lu
a te
th e
ro le
o f
tr a v
e l
b u
rd e n
a s
a b
a rr
ie r
to
in su
li n
u se
D is
ta n
c e
(N /A
) L
o n
g e r
d ri
v in
g d
is ta
n c e
a ss
o c ia
te d
w it
h
le ss
u se
o f
in su
li n
(O R
fo r
u si
n g
in su
li n
fo r
e a c h
k m
o f
d ri
v in
g d
is ta
n c e
0 .9
7 )
M a lm
g re
n
e t
a l.
[6 1
]
N =
1 2
5 a d
u lt
s, a g
e 6
2 ?
S e a tt
le ,
lo w
S E
S ,
7 1
% w
o m
e n
, 7
7 %
W h
it e
F a c e
to fa
c e
su rv
e y
o n
h e a lt
h st
a tu
s a n
d
a c c e ss
o f
h e a lt
h c a re
a n
d u
n m
e t
n e e d
s
‘‘ W
h ic
h o
f th
e fo
ll o
w in
g h
a v
e e v
e r
m a d
e
it h
a rd
to g
e t
c a re
? …
n o
tr a n
sp o
rt a ti
o n
… d
is ta
n c e
to o
fa r’
’ (2
)
P ro
b le
m s
o b
ta in
in g
c a re
(4 6
% )
N o
tr a n
sp o
rt a ti
o n
(1 0
% )
In su
ffi c ie
n t
in c o
m e
to m
e e t
p e rs
o n
a l
n e e d
s w
a s
a ss
o c ia
te d
w it
h m
o re
fi n
a n
c ia
l a n
d st
ru c tu
ra l
b a rr
ie rs
M a rt
in e z
e t
a l.
[5 8
]b N
= 1
0 7
H IV
y o
u th
, a g
e 1
5 -2
4
C h
ic a g
o ,
N e w
a rk
, N
e w
Y o
rk ,
M ia
m i,
5 1
% w
it h
st a b
le h
o u
si n
g ,
6 4
% fe
m a le
,
7 3
% B
la c k
F a c e
to fa
c e
su rv
e y
s o
n p
ro c e ss
o f
tr a n
si ti
o n
in g
H IV
y o
u th
fr o
m d
ia g
n o
si s
to tr
e a tm
e n
t in
c lu
d in
g n
e e d
s a ss
e ss
m e n
t
a n
d b
a rr
ie rs
to c a re
B a rr
ie rs
to a c c e ss
in g
h e a lt
h c a re
… tr
a n
sp o
rt a ti
o n
to h
e a lt
h c a re
se tt
in g
s (1
)
T ra
n sp
o rt
a ti
o n
to h
e a lt
h c a re
w a s
a b
a rr
ie r
(4 0
% )
M u
se y
e t
a l.
[2 7
]b N
= 5
6 a d
u lt
d ia
b e ti
c s
U rb
a n
(A tl
a n
ta ),
lo w
S E
S ,
2 1
w o
m e n
,
1 0
0 %
B la
c k
F a c e
to fa
c e
su rv
e y
s o
n p
re c ip
it a ti
n g
c a u
se s
o f
d ia
b e ti
c k
e to
a c id
o si
s (D
K A
)
L a c k
o f
m o
n e y
fo r
tr a n
sp o
rt a ti
o n
to
p h
a rm
a c y
(1 )
D K
A c a u
se d
b y
c e ss
a ti
o n
o f
in su
li n
(6 7
% );
5 0
% o
f th
e se
p a ti
e n
ts c it
e d
la c k
o f
m o
n e y
fo r
in su
li n
o r
fo r
tr a n
sp o
rt a ti
o n
to th
e p
h a rm
a c y
N e m
e t
e t
a l.
[5 1
]b N
= 3
9 0
a d
u lt
s, a g
e 6
5 ?
R u
ra l
(O rl
e a n
s C
o u
n ty
, V
e rm
o n
t) , in
c o
m e
le ss
th a n
5 0
,0 0
0 d
o ll
a rs
, g
e n
d e r
a n
d ra
c e
n o
t sp
e c ifi
e d
M a il
e d
su rv
e y
s o
n m
e a su
re s
o f
h e a lt
h
c a re
a ss
o c ia
ti o
n
D is
ta n
c e
(N /A
) D
is ta
n c e
to d
o c to
r w
a s
n o
t a ss
o c ia
te d
w it
h u
ti li
z a ti
o n
o f
h e a lt
h c a re
O k
o ro
e t
a l.
[5 0
]b N
= 4
6 ,6
5 9
a d
u lt
s, a g
e 6
5 ?
N a ti
o n
a l,
m ix
e d
in c o
m e /a
ll in
su re
d ,
6 5
%
fe m
a le
, 8
7 %
W h
it e
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
b e h
a v
io ra
l ri
sk
fa c to
r su
rv e il
la n
c e
sy st
e m
(2 0
0 2
) to
e x
p lo
re b
a rr
ie rs
to c a re
fo r
a d
u lt
s o
ld e r
th a n
a g
e 6
5
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
in c lu
d e d
n o
tr a n
sp o
rt a ti
o n
o r
d is
ta n
c e
(1 )
9 %
o f
th o
se w
h o
c o
u ld
n o
t o
b ta
in n
e e d
e d
m e d
ic a l
c a re
c it
e d
d is
ta n
c e
o r
n o
tr a n
sp o
rt a ti
o n
a s
b a rr
ie r
to c a re
J Community Health (2013) 38:976–993 981
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
P e sa
ta e t
a l.
[3 9
]
N =
1 0
1 c h
il d
re n
’s fa
m il
ie s
M id
w e st
e rn
m e tr
o p
o li
ta n
c li
n ic
(l o
c a ti
o n
n o
t sp
e c ifi
e d
), lo
w S
E S
, 5
4 %
B la
c k
,
4 1
% W
h it
e
T e le
p h
o n
e su
rv e y
o n
d y
n a m
ic s
b e h
in d
m is
se d
a p
p o
in tm
e n
ts
T ra
n sp
o rt
a ti
o n
p ro
b le
m s
(n o
t sp
e c ifi
e d
) T
ra n
sp o
rt a ti
o n
a s
th e
p ri
m a ry
re a so
n fo
r
m is
se d
a p
p o
in tm
e n
ts (n
o ri
d e
o r
c a r)
(5 1
% )
P h
e le
y e t
a l.
[6 8
]b N
= 2
2 ,7
0 3
a d
u lt
a p
p o
in tm
e n
ts
In n
e r
c it
y M
in n
e a p
o li
s, lo
w S
E S
, ra
c e
n o
t
re p
o rt
e d
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
c h
a n
g e
in ra
te
o f
fa il
e d
a p
p o
in tm
e n
ts d
u ri
n g
p u
b li
c b
u s
st ri
k e
R a te
o f
fa il
e d
a p
p o
in tm
e n
ts p
e r
1 0
0
sc h
e d
u le
d a p
p o
in tm
e n
ts (N
/A )
S tr
ik e
p e ri
o d
a ss
o c ia
te d
w it
h in
c re
a se
d
m is
se d
v is
it s
if v
is it
w a s
w it
h a
n u
rs e
(R R
1 .1
7 ,
P v
a lu
e =
0 .0
1 );
n o
im p
a c t
o n
d o
c to
r’ s
v is
it s
P ro
b st
e t
a l.
[4 5
]
N =
2 ,4
3 2
h o
u se
h o
ld s
N a ti
o n
a l
H o
u se
h o
ld T
ra v
e l
S u
rv e y
(N H
T S
), m
ix e d
S E
S ,
6 2
% fe
m a le
,
7 1
% W
h it
e
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
2 0
0 1
N a ti
o n
a l
H o
u se
h o
ld T
ra v
e l
S u
rv e y
to d
e te
rm in
e
tr a v
e l
b u
rd e n
to h
e a lt
h c a re
b y
g e o
g ra
p h
y a n
d ra
c e
T ra
v e l
b u
rd e n
s m
e a su
re d
b y
d is
ta n
c e
g re
a te
r th
a n
3 0
m il
e s
o r
ti m
e g
re a te
r
th a n
3 0
m in
; m
o d
e o
f tr
a v
e l,
d a y
a n
d
ti m
e o
f tr
ip ,
d ri
v e r/
p a ss
e n
g e r
st a tu
s,
tr a ffi
c ,
re g
io n
(n o
t sp
e c ifi
e d
)
R u
ra l
re si
d e n
c e
a ss
o c ia
te d
w it
h h
ig h
e r
tr a v
e l
b u
rd e n
b y
d is
ta n
c e
(O R
2 .6
7 )
a n
d
ti m
e (O
R 1
.8 0
)
B la
c k
s h
a d
h ig
h e r
tr a v
e l
b u
rd e n
s b
y ti
m e
(O R
3 .0
4 )
c o
m p
a re
d to
u rb
a n
re si
d e n
c e
a n
d W
h it
e s
R a sk
e t
a l.
[4 0
]
N =
3 ,8
9 7
a d
u lt
s
U rb
a n
(A tl
a n
ta ),
lo w
S E
S ,
5 3
% fe
m a le
,
8 9
% B
la c k
F a c e
to fa
c e
su rv
e y
to d
e te
rm in
e
c o
rr e la
ti o
n o
f o
b st
a c le
s to
m e d
ic a l
c a re
,
la c k
o f
c a re
, o
r d
e la
y in
c a re
L a c k
o f
tr a n
sp o
rt a ti
o n
(1 )
W a lk
in g
o r
u si
n g
p u
b li
c tr
a n
sp o
rt a ti
o n
to
re a c h
h o
sp it
a l
m o
re li
k e ly
to n
o t
h a v
e a
re g
u la
r so
u rc
e o
f c a re
(O R
1 .4
7 )
If n
o p
ri v
a te
tr a n
sp o
rt a ti
o n
, m
o re
li k
e ly
to
d e la
y c a re
(O R
1 .6
0 )
L a c k
o f
p ri
v a te
tr a n
sp o
rt a ti
o n
w a s
a n
in d
e p
e n
d e n
t p
re d
ic to
r o
f n
o t
h a v
in g
a
re g
u la
r so
u rc
e o
f c a re
a n
d d
e la
y in
g c a re
R e if
e t
a l.
[2 1
]b N
= 9
4 H
IV c a se
m a n
a g
e rs
U rb
a n
/R u
ra l
(N o
rt h
C a ro
li n
a ),
8 6
%
fe m
a le
, 5
9 %
W h
it e
M a il
e d
su rv
e y
o n
b a rr
ie rs
to h
e a lt
h c a re
fo r
H IV
p a ti
e n
ts
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(2 )
in c lu
d e d
la c k
o f
a d
e q
u a te
tr a n
sp o
rt a ti
o n
a n
d lo
n g
tr a v
e l
d is
ta n
c e s
to h
e a lt
h c a re
se rv
ic e s
L a c k
o f
tr a n
sp o
rt a ti
o n
w a s
a m
a jo
r b
a rr
ie r
fo r
a c c e ss
in g
c a re
fo r
c li
e n
ts (4
1 %
)
L o
n g
tr a v
e l
d is
ta n
c e s
to h
e a lt
h c a re
se rv
ic e s
w a s
a m
a jo
r b
a rr
ie r
fo r
a c c e ss
in g
c a re
fo r
c li
e n
ts (3
3 %
)
R it
tn e r
e t
a l.
[6 2
]
N =
1 ,0
8 3
, a d
u lt
s, m
e a n
a g
e 7
8
M e tr
o S
o u
th F
lo ri
d a ,
lo w
S E
S ,
8 3
8
w o
m e n
, 8
1 8
W h
it e ,
2 5
2 H
is p
a n
ic
G ro
u p
a d
m in
is te
re d
su rv
e y
o n
h e a lt
h c a re
a c c e ss
b a rr
ie rs
in a n
e ld
e rl
y p
o p
u la
ti o
n
w h
o u
se d
a y
ti m
e m
e a l
p ro
g ra
m s
a n
d
m o
st ly
u se
p u
b li
c tr
a n
sp o
rt a ti
o n
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(n o
t sp
e c ifi
e d
) L
a c k
o f
tr a n
sp o
rt a ti
o n
w a s
re a so
n fo
r n
o t
re c e iv
in g
c a re
in p
a st
6 m
o n
th s
(6 .1
% )
R u
st e t
a l.
[2 2
]
N =
3 0
,6 7
7 a d
u lt
s
N a ti
o n
a l,
m ix
e d
S E
S ,
ra c e
v a ri
e d
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
2 0
0 5
N a ti
o n
a l
h e a lt
h in
te rv
ie w
su rv
e y
(N H
IS )
to
e x
p lo
re re
la ti
o n
sh ip
b e tw
e e n
E D
v is
it s
a n
d b
a rr
ie rs
to h
e a lt
h c a re
‘‘ N
o tr
a n
sp o
rt a ti
o n
’’ (1
) L
ik e li
h o
o d
o f
E D
v is
it in
1 y
e a r
if a t
le a st
1 b
a rr
ie r
v s
n o
b a rr
ie r:
1 in
3 a d
u lt
s
(3 3
% )
v s
1 in
5 (2
0 %
)
O f
5 a c c e ss
b a rr
ie rs
, ‘‘
n o
tr a n
sp o
rt a ti
o n
’’
w a s
g re
a te
st O
R (O
R 1
.8 8
)
982 J Community Health (2013) 38:976–993
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
S a ll
o u
m
e t
a l.
[3 8
]a N
= 4
0 6
a d
u lt
s w
it h
c a n
c e r
S o
u th
e a st
M ic
h ig
a n
, m
e d
ia n
in c o
m e
4 8
,0 0
0 d
o ll
a rs
/p a ti
e n
ts h
a d
to b
e
e n
ro ll
e d
in a
h e a lt
h c a re
p la
n in
th e
1 y
e a r
p re
c e d
in g
c a n
c e r
d ia
g n
o si
s/ 1
2 %
d id
n o
t o
w n
c a rs
in h
o u
se h
o ld
, 4
1 %
fe m
a le
, 6
9 %
W h
it e ,
2 9
% B
la c k
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
fa c to
rs
a ss
o c ia
te d
w it
h a d
h e re
n c e
to
c h
e m
o th
e ra
p y
g u
id e li
n e s
in p
a ti
e n
ts
w it
h n
o n
-s m
a ll
c e ll
lu n
g c a n
c e r
(2 0
0 0
– 2
0 0
7 )
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(2 )
in c lu
d e d
v e h
ic le
a c c e ss
a n
d d
is ta
n c e
to tr
e a tm
e n
t
fa c il
it y
P re
d ic
to rs
o f
c h
e m
o th
e ra
p y
u n
d e ru
se
in c lu
d e d
lo w
e r
v e h
ic le
a c c e ss
in th
e
n e ig
h b
o rh
o o
d (O
R 6
.9 6
)
D is
ta n
c e
tr a v
e le
d w
a s
n o
t a ss
o c ia
te d
w it
h
a d
h e re
n c e
to c h
e m
o th
e ra
p y
tr e a tm
e n
t
g u
id e li
n e s
N o
ra c ia
l d
if fe
re n
c e s
in th
e re
c e ip
t o
f
c h
e m
o th
e ra
p y
(n e it
h e r
u n
d e r
o r
o v
e ru
se )
S a rn
q u
is t
e t
a l.
[4 7
]
N =
6 4
a d
u lt
s w
it h
H IV
R u
ra l
(C a li
fo rn
ia ),
m a jo
ri ty
m a d
e le
ss
th a n
2 0
,0 0
0 d
o ll
a rs
/y e a r,
1 0
0 %
fe m
a le
R e tr
o sp
e c ti
v e
fa c e
to fa
c e
su rv
e y
s o
n
b a rr
ie rs
to h
e a lt
h c a re
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(4 )
in c lu
d e d
m o
d e
to tr
a v
e l,
tr a v
e l
ti m
e ,
d if
fi c u
lt y
tr a v
e li
n g
, la
c k
o f
tr a n
sp o
rt a ti
o n
M o
st c o
m m
o n
re a so
n fo
r m
is se
d
a p
p o
in tm
e n
ts w
a s
tr a n
sp o
rt a ti
o n
b a rr
ie rs
(3 7
.5 %
); a s
c o
m m
o n
a s
‘‘ n
o t
fe e li
n g
p h
y si
c a ll
y w
e ll
’’
D if
fi c u
lt y
tr a v
e li
n g
to a p
p o
in tm
e n
t
4 5
.3 %
L a c k
o f
tr a n
sp o
rt a ti
o n
3 1
.2 %
T ra
n sp
o rt
a ti
o n
c h
a ll
e n
g e s
a ss
o c ia
te d
w it
h
lo w
e r
in c o
m e
S il
v e r
e t
a l.
[4 2
]b N
= 6
9 8
a d
u lt
s
N e w
Y o
rk C
it y
su b
u rb
, lo
w S
E S
, 8
3 %
fe m
a le
, 7
3 %
H is
p a n
ic
F a c e
to fa
c e
su rv
e y
s o
n tr
a n
sp o
rt a ti
o n
b a rr
ie rs
to c li
n ic
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(6 )
in c lu
d e d
‘‘ h
o w
d id
y o
u tr
a v
e l
to th
e c li
n ic
to d
a y
, (i
f b
y
b u
s) a p
p ro
x im
a te
ly h
o w
m u
c h
ti m
e d
id
y o
u sp
e n
d o
n th
e b
u st
to tr
a v
e l
fr o
m
y o
u r
h o
m e
to th
e c li
n ic
, h
a v
e y
o u
e v
e r
m is
se d
a c li
n ic
a p
p o
in tm
e n
t b
e c a u
se o
f
tr a n
sp o
rt a ti
o n
p ro
b le
m s,
in a
ty p
ic a l
m o
n th
h o
w o
ft e n
d o
y o
u h
a v
e
tr a n
sp o
rt a ti
o n
p ro
b le
m s,
h o
w o
ft e n
d o
y o
u u
se th
e b
u s
(o ft
e n
/s o
m e ti
m e s/
n e v
e r
fo r
w o
rk /g
ro c e ri
e s/
c li
n ic
o r
h o
sp it
a l/
v is
it fa
m il
y o
r fr
ie n
d s)
, (i
f a p
p li
e s)
w h
a t
is th
e m
a in
re a so
n th
a t
y o
u d
o n
’t u
se th
e
b u
s m
o re
o ft
e n
to tr
a v
e l
to th
e c li
n ic
? ’’
M is
se d
o r
re sc
h e d
u le
d a n
a p
p o
in tm
e n
t
d u
e to
tr a n
sp o
rt a ti
o n
p ro
b le
m s
(2 3
.5 %
)
C h
ro n
ic tr
a n
sp o
rt a ti
o n
p ro
b le
m s
(3 0
% )
D if
fi c u
lt ie
s a ff
o rd
in g
tr a n
sp o
rt a ti
o n
to
c li
n ic
(n e a rl
y 2
5 %
)
B u
s u
se rs
tw ic
e a s
li k
e ly
to re
p o
rt h
is to
ry
o f
m is
se d
/r e sc
h e d
u le
d a p
p o
in tm
e n
ts
(4 0
% v
s. 1
8 %
c a r
u se
rs ;
P \
0 .0
0 1
)
S k
in n
e r
e t
a l.
[4 6
]
N =
3 8
,8 6
6 h
o u
se h
o ld
s o
f c h
il d
re n
w it
h
sp e c ia
l h
e a lt
h c a re
n e e d
s
U rb
a n
/R u
ra l
(n a ti
o n
a l)
, lo
w S
E S
, 8
3 %
w h
it e ,
9 %
B la
c k
R e tr
o sp
e c ti
v e
a n
a ly
si s
fr o
m 2
0 0
0 to
2 0
0 2
N a ti
o n
a l
S u
rv e y
o f
C h
il d
re n
w it
h
S p
e c ia
l H
e a lt
h C
a re
N e e d
s fr
o m
th e
N a ti
o n
a l
C e n
te r
fo r
H e a lt
h S
ta ti
st ic
s to
e x
a m
in e
b a rr
ie rs
to h
e a lt
h c a re
n e e d
s
fo r
u rb
a n
a n
d ru
ra l
sp e c ia
l n
e e d
s
c h
il d
re n
‘‘ tr
a n
sp o
rt a ti
o n
/n o
t a v
a il
a b
le in
a re
a ’’
(1 )
T ra
n sp
o rt
a ti
o n
/s e rv
ic e
n o
t a v
a il
a b
le in
a re
a w
a s
a b
a rr
ie r
fo r
a n
y k
in d
o f
c a re
(O R
1 .5
8 ),
fo r
o b
ta in
in g
p re
sc ri
p ti
o n
s
(O R
3 .5
8 ),
fo r
th e ra
p y
(O R
2 .5
0 )
S m
it h
e t
a l.
[5 9
]b N
= 1
4 7
c a re
g iv
e rs
o f
a st
h m
a ti
c c h
il d
re n
U rb
a n
(S t.
L o
u is
, M
is so
u ri
), lo
w S
E S
, ra
c e
n o
t re
p o
rt e d
S c a le
d su
rv e y
o f
p ro
s a n
d c o
n s
to p
ri m
a ry
c a re
fo ll
o w
-u p
a ft
e r
E D
v is
it fo
r a st
h m
a
F in
d in
g tr
a n
sp o
rt a ti
o n
to g
e t
to
a p
p o
in tm
e n
t (1
)
F in
d in
g tr
a n
sp o
rt a ti
o n
w a s
a b
a rr
ie r
fo r
p a re
n ts
to o
b ta
in fo
ll o
w -u
p c a re
J Community Health (2013) 38:976–993 983
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
S tr
a u
ss e t
a l.
[5 4
]
N =
9 7
3 a d
u lt
d ia
b e ti
c s
V e rm
o n
t/ N
e w
H a m
p sh
ir e /n
o rt
h e rn
N e w
Y o
rk ,
9 8
% in
su re
d /2
1 %
M e d
ic a id
,
5 5
% fe
m a le
, 9
7 %
W h
it e
A n
a ly
si s
o f
V e rm
o n
t D
ia b
e te
s
In fo
rm a ti
o n
S y
st e m
to e x
a m
in e
re la
ti o
n sh
ip b
e tw
e e n
d ri
v in
g d
is ta
n c e
a n
d g
ly c e m
ic c o
n tr
o l
D ri
v in
g d
is ta
n c e
(N /A
) L
o n
g e r
d ri
v in
g d
is ta
n c e s
fr o
m h
o m
e to
si te
o f
p ri
m a ry
c a re
w a s
a ss
o c ia
te d
w it
h
p o
o re
r g
ly c e m
ic c o
n tr
o l
w it
h e a c h
2 2
m il
e s
o f
d ri
v in
g d
is ta
n c e
a ss
o c ia
te d
w it
h a
0 .2
5 %
in c re
a se
in h
e m
o g
lo b
in
A 1
c
T ie
rn e y
e t
a l.
[6 6
]a ,b
N =
4 6
,7 2
2 a ll
a g
e s
(2 3
,0 1
5 in
1 9
9 3
;
2 3
,7 0
7 in
1 9
9 4
)
In d
ia n
a ,
M e d
ic a id
re c ip
ie n
ts ,
6 6
% B
la c k
C o
h o
rt st
u d
y c o
m p
a ri
n g
h e a lt
h c a re
u ti
li z a ti
o n
o f
M e d
ic a id
p a ti
e n
ts b
e fo
re
(1 9
9 3
) a n
d a ft
e r(
1 9
9 4
) a
c h
a n
g e
in
tr a n
sp o
rt a ti
o n
re im
b u
rs e m
e n
t p
o li
c y
H e a lt
h c a re
u ti
li z a ti
o n
(N /A
) V
is it
s to
h o
sp it
a l
b a se
d p
ri m
a ry
c a re
c li
n ic
s d
e c li
n e d
(1 6
% )
V is
it s
to n
e ig
h b
o rh
o o
d h
e a lt
h c li
n ic
s
in c re
a se
d (7
% )
E m
e rg
e n
c y
a n
d u
rg e n
t c a re
v is
it s
fe ll
(8 %
)
V is
it s
fo r
m e d
ic a ti
o n
fi ll
s fe
ll (1
8 %
)
H o
sp it
a li
z a ti
o n
s in
c re
a se
d sl
ig h
tl y
w it
h
n o
c h
a n
g e
in n
u m
b e r
o f
in p
a ti
e n
t d
a y
s
W a ll
a c e
e t
a l.
[3 ]
N =
5 ,0
0 0
(2 0
0 2
N a ti
o n
a l
tr a n
sp o
rt a ti
o n
a v
a il
a b
il it
y a n
d u
se su
rv e y
b y
b u
re a u
o f
tr a n
sp o
rt a ti
o n
st a ti
st ic
s- B
T S
)c
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
B T
S ,
N H
IS ,
M E
P S
to e st
im a te
m a g
n it
u d
e o
f
tr a n
sp o
rt a ti
o n
b a rr
ie rs
to h
e a lt
h c a re
a n
d
p o
p u
la ti
o n
s a ff
e c te
d n
a ti
o n
a ll
y
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
N a ti
o n
a l
h e a lt
h in
te rv
ie w
su rv
e y
(1 )
M E
P S
(3 )
N a ti
o n
a l
tr a n
sp o
rt a ti
o n
a v
a il
a b
il it
y a n
d
u se
su rv
e y
(n o
t sp
e c ifi
e d
)
3 .6
m il
li o
n A
m e ri
c a n
s (e
st im
a te
d )
m is
s a t
le a st
o n
e m
e d
ic a l
tr ip
a y
e a r
b e c a u
se o
f
tr a n
sp o
rt a ti
o n
a n
d p
o p
u la
ti o
n is
m o
re
li k
e ly
to b
e o
ld e r,
p o
o re
r, fe
m a le
,
m in
o ri
ty ,
le ss
e d
u c a te
d
5 3
.7 %
o f
c h
il d
re n
w h
o m
is se
d c a re
d u
e
to tr
a n
sp o
rt a ti
o n
li v
e in
m e tr
o a re
a s
o f
1
m il
li o
n o
r m
o re
w h
il e
o n
ly 4
7 .5
% o
f a ll
U .S
. c h
il d
re n
li v
e in
th e se
a re
a s
W a sh
in g
to n
e t
a l.
[6 3
]
N =
3 ,6
1 1
a d
u lt
v e te
ra n
s
N a ti
o n
a l,
m ix
e d
S E
S ,
1 0
0 %
fe m
a le
,
2 3
% m
in o
ri ti
e s
T e le
p h
o n
e su
rv e y
o f
b a rr
ie rs
to h
e a lt
h
c a re
a c c e ss
R e a so
n fo
r d
e la
y e d
c a re
o r
u n
m e t
n e e d
… tr
a n
sp o
rt a ti
o n
d if
fi c u
lt ie
s (1
)
3 5
.7 %
o f
th o
se o
v e r
a g
e 6
5 re
p o
rt e d
tr a n
sp o
rt a ti
o n
d if
fi c u
lt ie
s
W e a th
e rs
e t
a l.
[3 4
]
N =
3 0
0 a d
u lt
c a re
ta k
e rs
o f
a m
ig ra
n t
c h
il d
le ss
th a n
a g
e 1
3
4 c o
u n
ti e s
in E
a st
e rn
N o
rt h
C a ro
li n
a ,
7 3
% o
f c h
il d
re n
la c k
e d
in su
ra n
c e ,
n e a rl
y 7
0 %
c h
il d
re n
w e re
fo re
ig n
b o
rn
(6 2
% fr
o m
M e x
ic o
)
F a c e
to fa
c e
su rv
e y
s o
f fa
c to
rs a ss
o c ia
te d
w it
h u
n m
e t
m e d
ic a l
n e e d
s fo
r c h
il d
re n
o f
m ig
ra n
t w
o rk
e rs
P ri
m a ry
re a so
n fo
r th
e la
st e p
is o
d e
o f
u n
m e t
m e d
ic a l
n e e d
… la
c k
o f
tr a n
sp o
rt a ti
o n
(1 )
5 3
% o
f c h
il d
re n
h a d
u n
m e t
m e d
ic a l
n e e d
L a c k
o f
tr a n
sp o
rt a ti
o n
w a s
p ri
m a ry
re a so
n
fo r
la st
e p
is o
d e
o f
u n
m e t
m e d
ic a l
n e e d
(8 0
% )
984 J Community Health (2013) 38:976–993
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
W e lt
y e t
a l.
[6 5
]
N =
1 4
3 a d
u lt
m e m
b e rs
o f
e p
il e p
sy .c
o m
w it
h e p
il e p
sy
W o
rl d
w id
e ,
(1 1
9 U
S /2
4 o
u ts
id e
U S
),
7 5
% fe
m a le
, S
E S
n o
t re
p o
rt e d
, ra
c e
n o
t
re p
o rt
e d
W e b
su rv
e y
o n
im p
a c t
o f
li m
it e d
tr a n
sp o
rt a ti
o n
o n
m e d
ic a ti
o n
a d
h e re
n c e
T ra
n sp
o rt
a ti
o n
a s
a b
a rr
ie r
to m
e d
ic a ti
o n
a c c e ss
(8 )
in c lu
d in
g ‘‘
a p
p ro
x im
a te
ly
h o
w fa
r fr
o m
y o
u r
h o
m e
is y
o u
r
p h
a rm
a c y
lo c a te
d (m
il e s)
; if
y o
u d
o n
o t
d ri
v e ,
a re
th e re
o th
e r
fo rm
s o
f
tr a n
sp o
rt a ti
o n
a v
a il
a b
le ;
w h
a t
b e st
d e sc
ri b
e s
y o
u r
p ri
m a ry
m o
d e
o f
tr a n
sp o
rt a ti
o n
, d
o y
o u
e v
e r
h a v
e tr
o u
b le
p ic
k in
g u
p p
re sc
ri p
ti o
n m
e d
ic a ti
o n
s o
n
ti m
e b
e c a u
se o
f tr
a n
sp o
rt a ti
o n
p ro
b le
m s,
h o
w o
ft e n
d o
tr a n
sp o
rt a ti
o n
p ro
b le
m s
k e e p
y o
u fr
o m
g e tt
in g
y o
u r
p re
sc ri
p ti
o n
m e d
ic a ti
o n
s o
n ti
m e ,
h o
w
o ft
e n
d o
y o
u e v
e r
m is
s d
o se
s o
f
m e d
ic a ti
o n
b e c a u
se y
o u
c a n
n o
t g
e t
to
th e
p h
a rm
a c y
to p
ic k
u p
y o
u r
m e d
ic a ti
o n
s, d
o y
o u
b e li
e v
e y
o u
h a v
e
se iz
u re
s b
e c a u
se y
o u
a re
n o
t a b
le to
p ic
k u
p y
o u
r m
e d
ic a ti
o n
s o
n ti
m e ,
d o
y o
u fe
e l
y o
u w
o u
ld m
is s
fe w
e r
d o
se s
o f
m e d
ic a ti
o n
if tr
a n
sp o
rt a ti
o n
w a s
n o
t a n
is su
e ? ’’
P a ti
e n
ts w
h o
c o
u ld
n o
t d
ri v
e v
s th
o se
w h
o
c o
u ld
:
T ro
u b
le p
ic k
in g
u p
m e d
ic a ti
o n
s o
n ti
m e
d u
e to
tr a n
sp o
rt a ti
o n
b a rr
ie rs
(5 1
% v
s
2 0
% )
W o
u ld
m is
s fe
w e r
d o
se s
if tr
a n
si t
n o
t a n
is su
e (4
5 v
s. 2
2 %
)
T h
o u
g h
t h
a d
se iz
u re
s b
e c a u
se d
id n
o t
g e t
m e d
ic a ti
o n
s o
n ti
m e
(2 8
v s.
1 8
% )
L iv
in g
c lo
se r
a n
d h
a v
in g
m a il
se rv
ic e
p h
a rm
a c ie
s d
id n
o t
im p
ro v
e re
c e ip
t o
f
o n
ti m
e re
fi ll
s
W h
e e le
r
e t
a l.
[3 3
]
N =
3 0
3 re
c e n
tl y
h o
sp it
a li
z e d
a d
u lt
s w
it h
d ia
b e te
s
U rb
a n
(A tl
a n
ta ),
lo w
S E
S ,
4 6
% fe
m a le
,
9 1
% B
la c k
F a c e
to fa
c e
su rv
e y
s o
n b
a rr
ie rs
to fo
ll o
w -
u p
d ia
b e te
s c a re
a ft
e r
h o
sp it
a l
d is
c h
a rg
e
‘‘ n
o tr
a n
sp o
rt a ti
o n
to g
e t
to d
o c to
r’ ’
(1 )
M o
st c o
m m
o n
b a rr
ie r
to fo
ll o
w -u
p c a re
w a s
n o
tr a n
sp o
rt a ti
o n
(6 0
% )
J Community Health (2013) 38:976–993 985
123
T a
b le
1 c o
n ti
n u
e d
A u
th o
r P
o p
u la
ti o
n M
e th
o d
s M
e a su
re o
f tr
a n
sp o
rt a ti
o n
b a rr
ie rs
(# o
f it
e m
s)
R e su
lt s
Y a n
g e t
a l.
[4 1
]
N =
1 8
3 c a re
g iv
e rs
o f
c h
il d
re n
a tt
e n
d in
g
p e d
ia tr
ic c li
n ic
U rb
a n
(H o
u st
o n
, T
e x
a s)
, lo
w S
E S
/8 0
%
M e d
ic a id
, 4
4 %
H is
p a n
ic , 2
8 %
A fr
ic a n
A m
e ri
c a in
F a c e
to fa
c e
a n
d te
le p
h o
n e
su rv
e y
s o
f
tr a n
sp o
rt a ti
o n
b a rr
ie rs
to k
e e p
in g
a p
p o
in tm
e n
ts
T ra
n sp
o rt
a ti
o n
b a rr
ie rs
(1 6
) in
c lu
d e d
‘‘ fo
rm s
o f
tr a n
sp o
rt a ti
o n
m o
st o
ft e n
u se
d to
c li
n ic
, fo
rm o
f tr
a n
sp o
rt a ti
o n
to
la st
a p
p o
in tm
e n
t k
e p
t, tr
a v
e l
ti m
e in
m in
u te
s to
c li
n ic
fo r
la st
a p
p o
in tm
e n
t
k e p
t, u
su a l
tr a v
e l
ti m
e to
c li
n ic
, n
u m
b e r
o f
m is
se d
a p
p o
in tm
e n
ts in
la st
1 2
m o
n th
s d
u e
to tr
a n
sp o
rt a ti
o n
p ro
b le
m s’
’ a n
d y
e s/
n o
it e m
s in
c lu
d e d
‘‘ e v
e r
u se
d H
o u
st o
n b
u se
s, a c c e ss
to a
c a r,
c o
st o
f tr
a n
sp o
rt a ti
o n
to o
h ig
h in
H o
u st
o n
, d
if fi
c u
lt y
g e tt
in g
to la
st
a p
p o
in tm
e n
t, e v
e r
m is
se d
a p
p o
in tm
e n
t
d u
e to
tr a n
sp o
rt a ti
o n
p ro
b le
m ,
e v
e r
ta k
e n
a c h
il d
to a
c lo
se r
c li
n ic
, e v
e r
la te
to a p
p o
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986 J Community Health (2013) 38:976–993
123
Flores et al. studied 203 children’s caretakers and found
that 21 % of inner-city children faced transportation bar-
riers to timely health care. Of these, 62 % cited lack of a
car as the specific barrier, which exceeded other reasons
including excessive distance, expense, or inconvenience of
public transportation [24].
Two studies reported that 25 % of patients missed an
appointment due to transportation problems [41, 42]. Yang
et al. [41] studied 183 urban caregivers from Houston and
their children’s missed appointments, finding that an
inability to find a ride resulted in at least one missed
appointment for 25 % of the sample. The study also found
that 82 % of those who kept their appointments had access
to a car, compared to just 58 % of those who did not keep
their appointments. Similarly, in a study of 698 low-
income adult patients, Silver et al. [42] found that 25 % of
missed appointments/rescheduling needs were due to
transportation problems and bus users were twice as likely
to miss their appointments compared to car users.
One study investigated transit accessibility to health care
by either public transit or by foot in various low income
counties in the Bay Area [43]. Results revealed that transit
accessibility to a hospital, defined as getting to a hospital or
clinic in 30 min or less by public transit or � mile by foot, varied from 0 to 28 %. Additionally, 55 % of missed
appointments or late arrivals were due to transportation
problems.
Collectively, these studies suggest that lack or inacces-
sibility of transportation may be associated with less health
care utilization, lack of regular medical care, and missed
medical appointments, particularly for those from lower
economic backgrounds.
Urban and Rural Geography
Urban and rural locations often differ in transit options,
cost of transit, and availability of and distance to health
care providers. Despite this, results were mixed in the four
studies that compared the impact of transportation barriers
on health care access for urban and rural residences [14,
44–46]. Blazer et al. [14] surveyed 4,162 urban and rural
adults over 65 in North Carolina to investigate why patients
delayed or neglected to see a doctor. The study showed no
difference between urban and rural adults in either their use
of health services or identification of transportation barri-
ers. Similarly, a study by Skinner et al. [46] included
38,866 households, and found no difference in reports of
delayed care between urban and rural parents after con-
trolling for SES.
In contrast, three studies found that rural patients face
greater transportation barriers to health care access than
their urban counterparts [44–46]. Rural patients reported
more problems with transportation and travel distance to
health care providers and had a higher burden of travel for
health care when measured by distance and time traveled
[45]. In a study by Sarnquist et al. [47] that did not make
urban comparisons, but included 64 rural, adult HIV
patients, 31 % were lacking transportation and 37 % were
missing appointments due to transportation problems.
Travel Burden by Time and Distance
Nine studies evaluated distance as a barrier to health care
access with mixed results [25, 26, 48–54]. Six found that
distance was a barrier to care [25, 26, 48–51]. Of those, five
investigated a variation of the question, ‘Is distance a
barrier to health care access?’, to measure the impact of
distance [25, 26, 48–50]. The sixth study explored the
association between distance to providers and patient
reported health care utilization [51]. In contrast, two
studies found that distance to a provider was not associated
with differences in health care utilization [53, 54]. Sur-
prisingly, one study by Lamont et al. [52] found that a
longer distance to one’s health care facility was associated
with improved health care access. Two studies looked at
the relationship of distance to either medication use or
clinical outcomes, reporting that longer driving distances
from one’s physician are associated with less insulin use or
poorer glycemic control independent of social, clinical or
economic factors [53, 54].
Transportation Barriers and Demographic Differences
Transportation Barriers and Ethnic Differences
Of six studies comparing transportation barriers to health
care access across ethnic groups, five found differences [3,
20, 26, 45, 55, 56]. To understand whether ethnic differ-
ences independently account for differences in transporta-
tion barriers, socioeconomic factors must be considered
because they can influence transportation variables [57].
Three studies used national data sets to explore trans-
portation barriers to health care access in minorities, and all
controlled for SES [3, 20, 45]. A large secondary analysis
of National Health Interview Survey (NHIS) data, Medical
Expenditure Panel Survey (MEPS) data, and Bureau of
Transportation Statistics (BTS) data, by Wallace et al. [3],
estimated that 3.6 million people do not obtain medical
care due to transportation barriers. These individuals were
more likely to be older, poorer, less educated, female, and
from an ethnic minority group. Individuals carrying the
highest burden of disease also faced the greatest burden of
transportation barriers. In the second study, Johnson et al.
[20] analyzed NHIS data from 1997 to 2006 to compare
reasons for delayed health care access between 34,504
American Indian/Alaskan Natives and White Veterans, and
J Community Health (2013) 38:976–993 987
123
found that American Indian/Alaskan Natives were more
likely to delay care due to transportation problems.
A third study by Probst et al. [45] utilized a cross-sec-
tional household survey, conducted by the US Department
of Transportation, to look at ethnic differences in burden of
travel for health care. Burden of travel was measured as
greater than 30 min or 30 miles to a health care provider.
Distance traveled did not vary significantly, but African
Americans had higher burdens of travel as compared to
Whites even after controlling for mode of travel and SES.
In contrast, a study by Borders et al. [55] controlled for
SES and found no significant difference in transportation
barriers between rural Hispanics and Whites accessing
health care in Texas.
Finally, two additional studies found differences by
ethnicity, although they did not control for SES. In a study
of 593 adults with cancer, Guidry et al. [26] found that
Hispanics’ transportation barriers to cancer treatment were
greater than those of African Americans, and African
Americans’ barriers were greater than Whites. Transpor-
tation barriers included distance to treatment center, access
to a vehicle, and finding someone to drive them to treat-
ment. Call et al. [56] contrasted barriers to health care
access between 1,853 American Indians and Whites
enrolled in the Minnesota Health Care program. The study
found that 39 % of American Indians reported transporta-
tion barriers compared to 18 % of Whites.
Overall, studies that explored health care access and
transportation barriers among members of ethnic minorities
and Whites suggested that access is superior for Whites
even after controlling for SES.
Special Populations: Children, the Elderly, and Veterans
Certain populations may face unique circumstances with
transportation barriers to health care access. For children,
significant transportation barriers to health care access have
been repeatedly identified [15, 24, 34, 39, 41, 48, 58, 59].
In two separate studies of inner-city children, 18–21 % of
respondents cited transportation barriers as the reason for
not bringing a child in for needed health care [15, 24].
Among migrant farm workers, 80 % cited lack of trans-
portation as the primary reason for the last episode that
their child faced an unmet medical need [34].
The elderly may face a unique combination of access
barriers due to disability, illness and likely a greater need
for frequent visits to their clinician. Among the elderly
reporting any barrier to health care access, 3–21 % repor-
ted having transportation barriers, although insurance sta-
tus and income varied among studies [9, 14, 36, 55, 60–62].
Additional studies of more low-income elderly may be
necessary to clarify the role of transportation barriers to
health care access.
Two studies examined transportation barriers to health
care access for Veterans, a group that often has access to
the federal health care system and may receive federally
supported transportation assistance. In one study, 19 % of
Veterans with colorectal cancer had difficulty with trans-
portation to appointments, and a second study found that
35 % of female Veterans over age 65 had transportation
barriers to health care access [23, 63].
Measuring the Impact of Transportation Barriers
Missed Clinic Appointments
Two studies selected patients for research specifically
because of missed health care appointments to identify the
reasons. In one study of 200 children with a history of
missed appointments, 51 % parents identified transporta-
tion barriers as the primary reason for missing clinic
appointments [42]. In another study, Yang et al. [41] sur-
veyed 183 caregivers of urban children in Texas, and
grouped patients based on show rates for a single
appointment over a 9-week period. There was a 26 % no
show rate overall. For those with a history of missed
appointments, 50 % cited transportation problems com-
pared to 30 % of those who kept appointments. Factors
associated with missed appointments included not owning
a car and not having access to a car.
Pharmacy and Medication Access
Five studies explored the relationship between transporta-
tion barriers and medication access with all reporting an
inverse association [27, 64–67]. Kripalani et al. [64] studied
patterns of discharge medication fills in 84 adults living in
urban Atlanta. The study found that following hospital dis-
charge, patients reporting difficulty visiting the pharmacy
had lower prescription fill rates than those not reporting
difficulty (20 vs. 55 % respectively). Additionally, 65 % of
patients felt transportation assistance would improve medi-
cation use after discharge. Musey et al. [27] examined the
causes for 56 diabetic ketoacidosis [DKA] admissions at
Grady Memorial Hospital in Atlanta. He found that 67 % of
DKA admissions were related to stopping insulin and 50 %
of those patients cited either lack of money for insulin or for
transportation to get their medicine.
Welty et al. [65] created an online survey through epi-
lepsy.com to study the relationship between transportation
barriers and anti-epileptic use. The study included 143 web
site members and found that 45 % of respondents who
could not drive said they would miss fewer doses of their
medications if transportation was not a problem.
Tierney et al. [66] examined the relationship between
transportation policy and health care utilization in a cohort
988 J Community Health (2013) 38:976–993
123
study of 46,722 Medicaid patients, and found that restric-
tion of Medicaid payments for transportation resulted in
decreased medication refills. A study by Levine et al. [67]
found that transportation barriers were associated with not
being able to afford medications, emphasizing that those
with low incomes are often the hardest hit by all barriers,
including transportation.
Natural Experiments
Two studies have looked at natural experiments to provide
real-world insight on the impact of transportation barriers
on access to care [66, 68]. One retrospective study by
Pheley et al. [68] examined the impact of a 2-week mass
transit strike on missed appointments at an inner-city clinic
serving a low-income population in Minneapolis. There
was no difference in the number of missed appointments
between strike and non-strike periods with doctors, but
there was an increase of 4.7 failed appointments per 100
scheduled nurse visits (relative risk 1.17).
Another study by Tierney et al. [66] looked at a Med-
icaid cohort to examine the impact of a policy change that
restricted Medicaid payments for transportation on health
care utilization. The study focused on the 6-month pre-
policy period and the 6-month post-policy period for
46,722 Medicaid patients using an inner-city public hos-
pital and associated clinics. Results revealed that visits to
community clinics increased, hospitalizations increased
slightly, and visits to hospital based primary care clinics,
urgent care clinics, and emergency departments fell.
Discussion
This literature review on transportation barriers and access
to health care yielded several important findings. First,
patients with a lower SES had higher rates of transportation
barriers to ongoing health care access than those with a
higher SES (Table 1). Additionally, transportation barriers
impacted access to pharmacies and thus medication fills
and adherence. Finally, while distance from a patient to a
provider would intuitively seem to be a barrier to health
care access, the evidence is inconclusive.
Poorer populations face more barriers to health care
access in general, and transportation barriers are no
exception. In 25 separate studies, 10–51 % of patients
reported that transportation was a barrier to health care
access (Table 1). This is very significant because when
patients cannot get to their health care provider, they miss
the opportunity for evaluation and treatment of chronic
disease states, changes to treatment regimens, escalation or
de-escalation of care and, as a result, delay interventions
that may reduce or prevent disease complications (Fig. 1).
Ultimately, transportation barriers may mean the dif-
ference between worse clinical outcomes that could trigger
more emergency department visits and timely care that can
lead to improved outcomes [22]. Since patients who carry
the highest burden of disease face greater transportation
barriers, addressing these barriers to avoid worsening
health seems logical [3]. While there may be differences in
transportation barriers based on ethnicity or geography,
they may disappear after accounting for socioeconomic
factors such as income or insurance. Additionally, studies
that reported low rates of transportation barriers to health
care access often did not include more vulnerable popula-
tions, such as lower income or uninsured patients.
Mixed Evidence
Some aspects of transportation barriers, such as distance,
showed mixed evidence regarding the impact on health
care access. Distance does not necessarily equate to travel
burden and different measures of distance may alter the
results. For example, studies that measured the impact of
distance subjectively, by asking patients whether distance
to the provider was a barrier to health care access or not,
concluded it was a barrier [25, 26, 48–50]. However, other
studies that objectively measured the distance between
homes and health care facilities and subsequent health care
utilization found distance was not a barrier [52–54]. A
patient may live in a wealthy suburb, own several cars, and
have no problem accessing health care, even at a distance.
Conversely, a seemingly shorter distance for a patient who
has to walk or cannot afford public transit may prove to be
too far of a distance, and hence be identified as a barrier by
the patient.
Special Populations
Existing studies on the elderly suggest that transportation is a
less significant barrier to health care access compared to
younger populations. However, these studies lacked inclu-
sion of lower-income elderly populations and did not address
concerns that may be more relevant to the elderly, such as
safety and disability access. It is possible that the elderly may
have fewer competing demands, such as not having to share a
car with family members who need a car for work or trans-
porting children. However, additional studies are needed
with more representative samples of elderly adults before
any conclusions can be drawn about transportation barriers
to health care access in this population.
Traveling Forward: Interventions and Public Policy
Collaboration between health policy makers, urban plan-
ners, and transportation experts could lead to creative
J Community Health (2013) 38:976–993 989
123
solutions that address transportation barriers to health care
access while considering patient health, cost, and effi-
ciency. Such collaboration could also lead to studies in
areas that are lacking research, such as research on trans-
portation policy and its impact on health outcomes outside
of injury prevention [8]. These collaborations could also
use prior research to guide interventions and public policy.
In the studies reviewed, access to a vehicle was con-
sistently associated with increased access to health care
even after controlling for SES. Future interventions should
consider this link in addition to public transit discounts or
medical transportation services. For example, there have
been interventions that provide access to cars to improve
access to jobs, and these programs could be used as models
for providing cars to improve health care access [69].
Additionally, reimbursement for travel should be inves-
tigated further to determine the role it plays in keeping
appointments and avoiding fragmented care. In Tierney’s
natural experiment study, which examined the impact of
lower Medicaid payments for transportation on health care
utilization, several changes occurred in health care utiliza-
tion rates. These included an increase in community clinic
use and hospitalizations, with a decrease in visits to urgent
care clinics and emergency departments [66].
New technological innovations such as telehealth may
also address transportation barriers by reducing travel
needs over time. Telehealth services may include video
conferencing, remote monitoring, and other disease man-
agement support at a distance. One approach to providing
patient-centered care is to evaluate transportation and other
barriers to ongoing health care encounters, and provide
telehealth services when beneficial and cost-effective.
Medication access may also be improved as more services
for home medication delivery become available.
Limitations
This review was restricted in scope and had several limi-
tations. Studies with an exclusive focus on screening,
prevention, and prenatal and pregnancy care were not
evaluated and may have different findings. A majority of
the studies used cross-sectional designs thus making cause
and effect conclusions difficult (Table 1). The diversity of
demographic, geographic, social variables, and outcome
measures also make study-to-study comparisons difficult.
Efforts to generate a valid measure of transportation bar-
riers for consistent measurement may help to perform
future meta-analyses across studies. Prospective studies of
local changes in transportation options may also help
contribute to the evidence, and although randomized trials
would help isolate the impact of transportation interven-
tions they would be impractical to execute [70].
Additionally, the studies on transportation barriers to
health care access rely largely on self-report, and lacked an
exploration of whether patients were unaware of available
services or assistance. While some studies investigated the
impact of transportation barriers on objective outcomes
such as missed appointments or medication fills, these
studies were in the minority. Whether transportation bar-
riers contribute to differences in health outcomes needs to
be explored further with objective outcome measures. By
demonstrating that transportation barriers lead to missed
appointments, poorer medication adherence, and thus
poorer diabetes or blood pressure control, transportation
barriers could be more strongly linked to health access and
outcomes (Fig. 1).
Conclusion
Transportation barriers to health care access are common,
and greater for vulnerable populations. The studies
reviewed may help guide both the design of interventions
that address transportation barriers and the choice of
measures used in assessing their effectiveness. Future
studies should focus on both the details that make trans-
portation a barrier (e.g., cost, mode of travel, public transit
safety, vehicle access) and objective outcome measures
such as missed appointments, rescheduled appointments,
delayed medication fills, and changes in clinical outcomes.
Such studies would help clarify both the impact of trans-
portation barriers and the types of transportation interven-
tions needed. Millions of Americans face transportation
barriers to health care access, and addressing these barriers
may help transport them to improved health care access
and a better chance at improved health [3].
Acknowledgments We would like to acknowledge Dr. Shannon Zenk and Kathy Korytkowski for their editing and support in the
preparation of this manuscript.
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- Traveling Towards Disease: Transportation Barriers to Health Care Access
- Abstract
- Introduction
- Methods
- Results
- Measures of Transportation Barriers
- Vehicle Access and Mode of Travel
- Urban and Rural Geography
- Travel Burden by Time and Distance
- Transportation Barriers and Demographic Differences
- Transportation Barriers and Ethnic Differences
- Special Populations: Children, the Elderly, and Veterans
- Measuring the Impact of Transportation Barriers
- Missed Clinic Appointments
- Pharmacy and Medication Access
- Natural Experiments
- Discussion
- Mixed Evidence
- Special Populations
- Traveling Forward: Interventions and Public Policy
- Limitations
- Conclusion
- Acknowledgments
- References
