Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites

DOI 10.1007/s10903-010-9410-0 BRIEF COMMUNICATION Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites Diana Silver Jan Blustein Beth C. Weitzman Ó Springer Science+Business Media, LLC 2010 Abstract Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a populationbased survey would yield information about substantial transportation barriers to health care. D. Silver (&) Steinhardt School of Culture, Education and Human Development, New York University, 35 West 4th Street, Room 1216, New York, NY 10003, USA e-mail: Diana.silver@nyu.edu J. Blustein Robert F. Wagner Graduate School of Public Service, New York University, 295 Lafayettte Street, New York, NY 10012, USA e-mail: Jan.blustein@nyu.edu B. C. Weitzman Steinhardt School of Culture, Education and Human Development, New York University, 82 Washington Square East, New York, NY 10003, USA e-mail: Beth.weitzman@nyu.edu Keywords Transportation Health care Primary care Suburban Low-income Immigrants Introduction Rapidly shifting demographics in America s suburbs pose challenges for health care leaders. Unlike the cities they surround, many suburban areas have limited experience and infrastructure to address the needs of poorer and immigrant populations. In a recent report from the Center for Studying Health System Change [1], health care leaders in the suburbs of 5 cities identified transportation barriers, insufficient and cultural linguistic competency, and a lack of awareness of community services as key challenges they faced in delivering care to a changing suburban population. However, there is little research on the extent to which the first of these perceived barriers (transportation) impedes care delivery for low-income, recent immigrant suburbanites. Some scholars have found that immigrant populations using public services may be reluctant to participate in studies because of concerns regarding discrimination and legal status [2, 3]. We conducted pilot research in a setting frequented by suburban low-income recent immigrants, namely public outpatient clinics in Nassau County, NY. We were motivated by to undertake this work because of hospital administrators concerns that a proposed bus fare hike (ultimately postponed) would have severe implications for clinics with already high no-show rates. In this pilot work, we were interested in (1) whether clients would be willing to participate in a survey about their health care challenges, given the historical reluctance of immigrant/undocumented people to participate in such surveys [4] and, (2) whether there would be signs of the reported transportation barriers, in a

population that had already successfully negotiated some of those barriers, as evidenced by their presence in a clinic. Methods Site, Sample, and Recruitment Procedures We conducted our work in Nassau County, New York, a first suburb that has recently experienced growth in low income, immigrant, and undocumented populations [5]. Our pilot study was conducted in four free-standing ambulatory care clinics run by the sole public hospital in the county. The county served by the Corporation is one of the most affluent and densely populated (with more than 4,700 people per square mile) in the United States, with a median household income in 2007 of more than $93,000, and a population of 1.35 million people. The county s population is 68.9% white, 12.4% Hispanic and 10.6% black; over the past decade, the Hispanic population has nearly doubled (American Community Survey 2008). The county is racially and economically segregated, with 47% of those receiving Medicaid living in just 7 of the 111 zip codes in the county [6]. One of the clinics is within walking distance of public housing operated by the county, and all four of the clinics are within two blocks of a public bus stop, where there is at least hourly scheduled service. Three of the clinics are served by two public bus lines each, the fourth is in a transportation hub where several lines converge. The clinics primarily provide reproductive health and pediatric services. In 2008, of the 78,988 patient visits to these clinics, 68% of those visits were made by Hispanic patients, 20.4% were made by African Americans. More than 75% of these visits were made by women. Three of the clinics each had approximately 22,000 visits in 2008, the fourth clinic had half that volume; however, the demographic characteristics of the patients did not substantially vary among the clinics. The clinics operate with a safety net mission, serving all regardless of ability to pay. Administrators report that more than one-third of clinic clients are uninsured. For the study, bi-lingual (English/Spanish) interviewers were on site for all clinic sessions during an 8 day period in May 2009. Clients were approached in the waiting room to determine their willingness to participate in the survey after checking in for their appointments. While some clients were called for their appointments before they could be invited to participate in the survey, of those who were approached, 94% of these agreed to participate. Clients were eligible to participate if they were English or Spanish speaking, were over 18, and identified themselves as either patients or the responsible adult accompanying a patient to clinic (e.g. mother of a pediatric patient). The protocol was approved by New York University s Human Subjects Review Committee in May 2009. Data Collection The interviewer-administered survey included both closeended and open ended questions on basic demographic characteristics, mode of transportation to the clinic on the day of the survey, the extent of problems with transportation to the clinic in the past, and experiences with the public bus system (a copy of the survey is appended with this submission). In addition to recording answers to the oral survey, interviewers completed daily observation forms with information regarding clinic operations and environment, patient flow, community setting, and impressions of the interview process. This qualitative information, along with notations from open-ended responses, was reviewed for common themes, and checked for accuracy in a longer debriefing session with each interviewer conducted by the one of the authors (DS). Measures and Analysis Frequencies were used to characterize the sample, their transportation patterns, and clinic use. Chi-square tests of association were used to test the relationship between demographic characteristics and self-reports of transportation and clinic use. The survey included two open ended questions: patients who reported missing a clinic appointment because of transportation problems were asked Can you tell me about that?, and patients who reported that they did not always use the bus to travel to the clinic were asked Why don t you use the bus more often to travel to the clinic?. For each of these questions, researchers reviewed responses and identified common themes; data were then re-coded into these categories. Data were analyzed using SPSS Version 16. In a small number of cases, interviewers did not follow skip patterns correctly resulting in missing data. For no variables were more than 10% of the cases missing. Findings The characteristics of the 698 respondents are detailed in Table 1. Nearly 68% of patients were interviewed in Spanish. 74% of the sample identified themselves as Hispanic and 16.5% as African American. More than 83% were women, and 80% were 45 years or younger, consistent with the reproductive health/pediatric care mission of the clinic. Over 53% had been clinic users for over a year; 66% were there for their own care, while 31% were there to obtain care for their child. In conversation with interviewers, many of the respondents volunteered that they were recent

Table 1 Characteristics of respondents at four suburban community health clinics (n = 698) Characteristics N Valid percent Gender Female 567 83.5 Male 112 16.9 Race/ethnicity Hispanic 500 73.6 African American 112 16.5 Asian/Pacific Islander 20 2.9 White 20 2.9 Other 23 3.3 Native American 2 0.3 Declined to identify 2 0.3 Age, years 18 25 192 29.1 26 45 359 51.4 46 65 90 13.7 [65 18 2.7 Language used for survey Spanish 471 67.6 English 226 32.4 Duration of tie with clinic First visit 88 12.6 Less than a year 237 34.0 One year or more 373 53.4 Patient for today s visit Respondent 436 65.9 Respondent s child 208 31.4 Other family member/friend of respondent 18 2.7 Clinic site Clinic #1 (Elmont) 150 21.5 Clinic #2 (Freeport) 194 27.8 Clinic #3 (Hempstead) 174 24.9 Clinic #4 (Westbury) 180 25.8 Some categories do not total 698 due to missing data (interviewer failed to record response) immigrants from El Salvador, Ecuador, Guatemala, Mexico and Haiti. On the day of the interview, nearly half of the patients (47.0%) had traveled to the clinic by car (Table 1). Over a quarter (26.5%) had walked to the clinic, and a relatively small fraction (15.1%) had used a public bus. Those using the bus were asked about the length of time of their journey; 29.5% reported less than 20 min, while 59% reported bus rides lasting 20 40 min. A substantial minority had used other forms of transportation (11.7%); these included taxis and van service. Nearly one quarter (169, or 23.5%) reported having missed or rescheduled a clinic appointment in the past due to transportation problems. Almost a third (30.9%) reported having chronic problems with transportation (once a week or 2 3 times a month). The reporting of prior transportation problems which resulted in missed or rescheduled appointments was not associated with gender, race/ethnicity, age, or clinic (analyses not shown). Of the 169 people who reported having previously had transportation difficulties that resulted in rescheduling or missing health care appointments, many cited the unreliability and inefficiency of the public bus system (Table 2). In response to open-ended questions, subjects reported that the public buses did not come often enough, were slow, often crowded, and frequently late. Nearly one quarter reported difficulties affording transportation to the clinic. Mode of transportation to the clinic on the day of the interview was substantially associated with reported prior transportation difficulties (Table 3). Those who had arrived by bus were disproportionately likely to have a history of having missed or rescheduled an appointment due to Table 2 Modes of transportation and history of transportation difficulties among respondents at four suburban community health clinics N Valid percent All patients (n = 698) Mode of transportation to clinic today Car 327 47.0 Bus 105 15.1 Walked 183 26.3 Other (includes taxi, van service) 81 11.7 Ever missed/rescheduled clinic appointment due to transportation problems? No 530 76.5 Yes 163 23.5 Frequency of transportation problems in a typical month At least 1/week 61 9.9 2 3 times/month 129 21.0 Once a month or less 424 69.0 Patients who reported ever missing/rescheduling a clinic appointment (n = 163)* Reason for missing or rescheduling Ride unreliable or shared car 22 12.6 Bus late, unreliable, took too long 55 31.6 Taxi late or did not come 15 8.6 Difficulty accessing bus 15 8.6 Unable to afford taxi 15 8.6 Unable to afford bus 9 5.2 Gas too expensive 8 4.6 No way to get to the clinic 11 6.3 Other miscellaneous 24 13.8 Some categories do not total 698 due to missing data (interviewer failed to record response) * Total exceeds 163 because some respondents gave multiple answers

Table 3 Mode of transportation to clinic on day of survey, by history of transportation difficulties, demographic characteristics, and clinic site (ALL) History of transportation difficulties Mode of transportation N = 698 Car Bus Walked Other* n = 327 n = 105 n = 183 n = 81 Ever missed/rescheduled a clinic appointment due to transportation problems? No 266 (81.8%) 63 (60.0%) 153 (84.1%) 48 (59.2%) Yes 59 (18.2%) 42 (40.0%) 29 (15.9%) 33 (40.7%) Frequency of transportation problems in a typical month 1 Once a month or less 224 (77.2%) 52 (55.9%) 107 (65.6%) 41 (60.2%) 2 3 times/month 45 (15.5%) 26 (28.0%) 38 (23.3%) 20 (29.9%) At least 1/week 21 (7.2%) 15 (16.1%) 18 (11.0%) 7 (10.4%) Demographic characteristics Gender Male 69 (21.7%) 14 (14.0%) 25 (13.8%) 4 (5.1%) Female 249 (76.3%) 86 (86.3%) 156 (86.2%) 76 (94.9%) Race/ethnicity African-American 54 (16.5%) 19 (18.1%) 27 (14.8%) 12 (14.8%) Hispanic/Latino 214 (65.4%) 73 (69.5%) 146 (79.8%) 67 (82.7%) Neither African American nor Hispanic/Latino 59 (18.0%) 13 (12.4%) 10 (5.5%) 2 (2.5%) Age 18 25 years 77 (24.8%) 23 (24.2%) 59 (33.9%) 33 (41.3%) 26 45 years 170 (54.8%) 53 (55.8%) 96 (55.2%) 40 (50.0%) 46 65 years 56 (18.1%) 16 (16.8%) 13 (7.5%) 5 (6.3%) 65? years 7 (2.3%) 3 (3.2%) 6 (3.4%) 2 (3.0%) Clinic site Clinic #1 (Elmont) 108 (33.0%) 15 (14.3%) 22 (12.0%) 5 (6.1%) Clinic #2 (Freeport) 79 (24.2%) 43 (41.1%) 42 (23.0%) 29 (35.8%) Clinic #3 (Hempstead) 54 (16.5%) 36 (34.3%) 59 (32.2%) 24 (29.6%) Clinic #4 (Westbury) 86 (26.3%) 11 (10.5%) 60 (32.0%) 23 (16.0%) In a small number of cases, interviewers failed to follow skip patterns correctly, resulting in missing data. For each variable, valid percents are presented * Other includes taxi and Able ride 1 The associations are significant at P \.001 level All other associations are significant at P B.05 level transportation difficulties, and also reported a disproportionately high rate of transport problems in a typical month. Indeed, bus users were twice as likely as car users to report a prior history of missing/rescheduling (40.0% of bus riders versus 18.2% of car users (P \.001), and were also twice as likely to report transportation problems at least once a week (16.1% versus 7.2% (P \.001). Many of the patients indicated dependence on friends and family members for rides to the clinic; for some, this sometimes resulted in missing appointments when arranged rides did not materialize. Various taxi riders volunteered that they took taxis because they did not have access to a car (either their own, or someone who could drive them). When prompted, subjects noted that taxi fares varied between $5 and $12 each way. When asked why they did not take the bus, some (largely new immigrants) said that they would not know how to obtain information about bus schedules and bus stops. Others indicated that they would not feel comfortable on the bus, viewing it as unsafe or too crowded, particularly with small children. Many recounted previous difficulties with the bus schedule. Discussion and Conclusions We found a high degree of willingness to participate in a survey among this clinic population. While arguably our sample was not representative of the population (in that

people who have successfully arrived at clinic probably experience fewer barriers than those who were unable to attend), we still found transportation was a serious problem that impeded access to care. The public bus system was a major contributor to these difficulties. While we would not suggest that the statistics reported here are readily generalizable, the magnitude of transportation difficulty reported by our suburban sample meets (and in many cases exceeds) that found in several national population-based studies [7, 8], and is comparable to that found in several samples of patients in rural settings. [9 11]. Our findings are consistent with the perceptions of suburban health care leaders interviewed reported by Felland [1]. This pilot work is a first step in estimating the burdens faced by new populations in suburban areas in getting reliable transportation; however, a population based approach is needed to more accurately gauge the scope of the problem. While such a survey may be challenging to field because of language and response issues, transportation barriers in changing suburban America warrants further attention from those concerned with access to care. Appendix: Transportation Survey 1. How long have you been coming to this clinic? This is my first visit I have been coming for less than a year I have been coming for more than a year 2. How did you travel to the clinic today? By car By bus Able-Ride (subsidized van service for those with medical conditions that do not permit them to drive) Walked Other (specify) INTERVIEWER: If answer is by bus proceed to q3. For any other response, proceed to q4. 3. [If by bus to #2] Approximately how much time do you spend on the bus to travel from your home to the clinic? (if your trip includes a transfer, please include the time that you wait for a bus to transfer) less than 20 minutes 20 40 minutes 40 or more minutes 4. Have you ever missed a clinic appointment because of transportation problems? If yes, can you tell me about that? 5. In a typical month, how often do you have transportation problems? a. At least once a week b. 2-3 times a month c. Once a month or less 6. Do you use the bus: a. to get to work? b. to buy groceries? c. to visit family or friends? d. to travel to the clinic or hospital? Often Sometimes Never Proceed to q8 INTERVIEWER: If answer to 6d is sometimes or never proceed to q7. If the answer to 6d is often, proceed to q8. 7. What is the main reason that you don t use the bus more often to travel to the clinic? a. Have other transportation b. Too expensive c. Schedule isn t convenient d. Doesn t stop near my house e. Other reason: (Fill in) 8. Today, will you visit the doctor or nurse, or are you here to accompany a child/family member/friend? I will visit the doctor My child Other family member/friend 9. If you are here for care for yourself, would you be willing to tell me whether you are getting care for any of these? If you would prefer not to respond, that s fine. SHOW PATIENT CARD WITH DIAGNOSES AND ASK THEM TO POINT RATHER THAN SAY THE DIAGNOSIS ALOUD. A. diabetes B high blood pressure C heart problems D breathing problems E pregnancy/maternity care 10. Are you: 18-25 years old 26-35 years old 36-55 years old 55+ Refused 10. Which best describes you? African American Hispanic White Other Thank you! Subject receives $1.00 Subject is given contact card For Interviewer: Initials: Date Clinic: Interview was conducted in: English Spanish Patient is: Male Female IF interview not completed, why? patient was called to see provider during interview Other reason: (fill in) References 1. Felland LE, Lauer JR, Cunningham PJ. Suburban poverty and the health care safety net. Res Briefs. 2009;13:1 12. 2. Nandi A, et al. Access to and use of health services among undocumented Mexican immigrants in a US urban area. Am J Public Health. 2008;98(11):2011 20. 3. Guendelman S, et al. The effects of child-only insurance coverage and family coverage on health care access and use: Recent findings among low-income children in California. Health Serv Res. 2006;41(1):125 47. 4. Standish K, et al. Household density among undocumented Mexican immigrants in New York City. J Immigr Minor Health. 2008;12(3):310 8.

5. Berube A, Kneebone E. Two steps back: City and suburban poverty trends: 1999 2005 in Living Cities Census Series. Washington, DC: Brookings Institution; 2006. 6. Michael S, Eichberg S. Vital signs: measuring long Island s social health. Garden City, NY: Adelphi University; 2006. 7. Pathman DE, Ricketts TC, Konrad TR. How adults access to outpatient physician services relates to the local supply of primary care physicians in the rural southeast. Health Serv Res. 2006; 41(1):79 102. 8. Okoro CA. Access to health care among older adults and receipt of preventive services. Results from the Behavioral Risk Factor Surveillance System, 2002. Prev Med. 2005;40(3):337 43. 9. Arcury TA, et al. Access to transportation and health care utilization in a rural region. J Rural Health. 2005;21(1):31 8. 10. Blazer DG. Health services access and use among older adults in north carolina: urban vs. rural residents. Am J Public Health. 1995;85(10):1384 90. 11. Coronado GD, et al. Use of Pap test among Hispanics and non- Hispanic whites in a rural setting. Prev Med. 2004;38(6):713 22.