Improving healthcare access in rural Hawaiʻi: A multi-method investigation to mitigate existing barriers

Abstract

Having adequate healthcare access includes having sufficient insurance coverage, and also the ability to receive timely and quality care from healthcare professions. Poor access to healthcare services can lead to negative health outcomes, unmanaged chronic diseases, and a shorter life expectancy. Many factors contribute to healthcare inaccessibility including insufficient insurance coverage, cultural competency issues, financial barriers, provider workforce shortage, and a lack of transportation. Transportation is an understudied barrier to healthcare though it is critical to timely access services. Residents living in Hawai‘i face unique transportation-related issues due to the non- contiguous nature of the state. Hawai‘i is a geographically isolated archipelago comprised of six inhabited islands, which are separated by mountains and open ocean. Many residents of neighbor island and rural communities travel long distances for healthcare services. Much of this travel requires flying to the island of Oʻahu as the neighbor islands of Kauaʻi, Maui, Molokaʻi, Lānaʻi, and Hawaiʻi island have a shortage of healthcare providers and offer extremely limited specialty care services due to the lack of advanced medical equipment available. In these flights, neighbor islands residents may experience airline delays or cancellations, therefore postponing necessary care. All of this can have a negative impact on their overall health. Given the importance of this understudied topic, this three-study dissertation focused on healthcare access and transportation in the state of Hawai‘i. Study 1 analyzed demographic and socioeconomic factors as predictors for healthcare accessibility in Hawaiʻi. A secondary analysis was conducted using five waves of data (2018- 2022) from the Behavioral Risk Factor Surveillance System (BRFSS) to determine whether the participants were able to see a doctor for a regular checkup within the past year. Adjusted results indicate potential risk factors for poor healthcare access: working-class age (18-64-year-olds), low-income, unmarried, uninsured, neighbor island residency, and self-employment. Study 2 explored transportation-related barriers that Molokaʻi and Lānaʻi residents face for healthcare services. Eight community members from the islands of Molokaʻi and Lānaʻi were identified through purposive sampling and participated in semi-structured individual interviews and sequential focus group sessions. Participants shared their frustration with limited transportation options, the lack of insurance benefits in covering transportation, and the expensive costs they pay out-of-pocket when traveling to see providers. Although participants preferred decreasing the need to travel altogether, they also shared other ideas for solutions to these challenges, including the benefits of having additional airlines service the islands, improving insurance coverage for transportation benefits, and funding more specialists to frequently visit to provide care on island. Study 3 conducted a systematic review to identify the current literature, strengths, and gaps surrounding existing transportation interventions created to improve healthcare access among rural communities in the United States. The six articles that met the inclusion criteria discussed that transportation interventions are successful when they are easy to use for the patient, low-cost for the healthcare facility and insurance provider, and extend to patients living in the most remote areas. However, there have been issues with patients not being picked up on time, recruiting and retaining drivers, and the overwhelming nature of having to manage the interventions. The studies demonstrate that it would be beneficial for either healthcare facilities or insurance providers to assign a single point of contact to arrange transportation for the patients. In addition, driver recruitment and reliability could be improved by increasing incentives and penalties. Taken together, these three studies identified (1) which populations are most impacted by healthcare inaccessibility in Hawaiʻi, (2) what specific challenges these populations face when accessing and utilizing healthcare services, and (3) potential evidence-based solutions that could be implemented to decrease these barriers. Future research should identify funding sources as well as assess viability and sustainability of these solutions. These three studies can inform future interventions to improve healthcare accessibility and long-term health outcomes for residents living in rural communities in Hawaiʻi.