Transportation Justice and Health

Abstract

Policy Points.

• The health care sector is increasingly investing in social conditions, including availability of safe, reliable, and adequate transportation, that contribute to improving health.

• In this paper, we suggest ways to advance the impact of transportation interventions and highlight the limitations of how health services researchers and practitioners currently conceptualize and use transportation.

• Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy.

Transportation as a Social Determinant of Health

The health care sector is increasingly investing in social conditions to improve health care utilization and outcomes. ¹ , ² , ³ , ⁴ Under the umbrella of social determinants of health, advocates, researchers, and policymakers have shifted attention upstream to better understand the mechanisms and potential interventions to address social risk (e.g., housing insecurity, poverty, lack of education and employment opportunities, food insecurity) to improve health and well‐being and ameliorate long‐standing inequities.

Transportation is one of these core social determinants and yet the understanding of transportation in health care has heavily focused on a limited view of transportation insecurity rather than adopting the more inclusive approach of transportation justice. Transportation justice “describes a normative condition in which no person or group is disadvantaged by a lack of access to the opportunities they need to lead a meaningful and dignified life”. ⁵ In this perspective, we will characterize the existing research investigating transportation as a social determinant of health and propose applying a more holistic transportation justice framework to systemic problems in health care including two case examples.

Previous health services research has identified transportation insecurity as a common social risk impacting an estimated one in four people in the United States, with higher rates among adults experiencing poverty. ⁶ The Accountable Health Communities Model, a large Centers for Medicare and Medicaid Services study involving 28 sites across the United States, found that approximately 35% of participants reported a health‐related social need, with transportation being one of the most common needs reported. ⁷ , ⁸ Transportation impacts health through many mechanisms that can promote or detract from health. ⁹ Transportation services and infrastructure—private vehicles, public transportation, shared rides, sidewalk and roadway design—influence peoples’ ability to reach the grocery store for food, to connect with social services and their community, to safely move in space, and to stay physically active. Conversely, transportation can negatively impact health through exposure to pollution or injury. Within the health care sector, transportation is essential for health service utilization—i.e., clinic appointments, diagnostic services, and picking up medications from the pharmacy. Prior research estimated that 5.8 million individuals in the United States miss or delay medical care because of a lack of transportation. ¹⁰

Despite the increased recognition that transportation influences health through multiple mechanisms, studies investigating associations between transportation interventions and health are limited in number and quality. We lack a shared and validated screening tool for transportation insecurity in health care. ¹¹ , ¹² Solomon and colleagues identified eight studies in a recent review of transportation interventions and health, with only one high quality study. ¹³ In a second systematic review of transportation interventions’ impact on health and health care utilization, Shekelle and colleagues identified 12 studies, with all but one focused on interventions that focused solely on transportation to medical appointments. ¹⁴ These reviews highlight the dearth of robust studies on interventions to address the breadth of how transportation is a determinant of health. Furthermore, research is limited by interventions not effectively targeting those facing transportation insecurity and the reliance on proxy outcomes, specifically health service utilization (i.e., missed appointments, on‐time arrival, show rates) rather than health outcomes. ¹⁵ , ¹⁶ There is limited to no data on the impacts of interventions designed to improve transportation to destinations outside the health care system and their associated health outcomes.

The limited evidence base supporting effective transportation interventions is a barrier to the growing policy and payer interest in identifying and addressing this social risk. ¹² , ¹⁷ The framework of transportation underlying the current body of research on transportation and health is largely as a physical entity (a vehicle) moving people from point A to point B without attention to the landscape where people reside (which will impact their transportation availability and barriers) and individuals’ mobility needs. This narrow understanding of transportation is exacerbated by a similarly narrow focus on mobility in health research. Although health care is well‐versed in evaluating mobility up to the level of movement around one's home—for example, screening for fall risk and interventions to prevent falls—there has been little integration with expanding the understanding of mobility to movement around one's community and beyond. ¹⁸ This disconnect between the focus in health care on mobility defined as an individual characteristic vs. urban planners’ emphasis on community mobility such as public transportation or mode of travel may be bridged by expanding our understanding of how individuals move around their homes and beyond. There is a need to broaden how we understand the relationship among mobility, transportation, and health at a community level.

Failing to include the full scope of how transportation impacts mobility and health has hampered early efforts to develop transportation interventions that meaningfully improve health outcomes and promote health equity. ¹⁹ Future health services research will benefit from applying conceptual frameworks of mobility, transportation, and transportation justice used in the social sciences disciplines to inform how we think about and intervene on transportation.

Transportation and Mobility Justice

As a framework developed within urban planning and drawing from the environmental justice movement, transportation justice calls for implementing new mobility and transportation systems over reforming existing ones and seeks to address the upstream structural determinants that lead to the inequitable distribution of transportation's benefits (e.g., access to jobs and services ²⁰ ) and its harms (e.g., air pollution, ²¹ displacement, ²² and increased negative interactions with law enforcement ²³ ). Transportation justice advocates encourage researchers and planners to center community priorities by adopting a community‐ or society‐centric approach in favor of a state‐centric one. ⁵ Although state‐centric strategies such as agency‐led analysis and seeking public input through traditional public hearings and meetings are well‐established approaches that prioritize quantitative data and reproducibility, they put the priority‐setting power and privileged knowledge in the hands of professional experts, an approach that misses the “ground truth” understood by community members who are experts due to their lived experiences. ⁵ Examples of society‐centric strategies for transportation justice include community‐led analysis and community mobilization, both of which can empower communities to identify and address community needs. ⁵

Transportation justice adopts a broader understanding of how transportation impacts health beyond access and health care utilization. The emphasis on the role of transportation in facilitating living a meaningful and dignified life encapsulates much more than whether an individual misses a health care appointment due to transportation barriers. The distribution of transportation resources in our communities exposes people differentially to associated benefits and harms. By focusing specifically on outcomes of health care utilization, health services researchers investigating transportation as a social determinant of health are missing other pathways by which transportation might positively and negatively influence health and well‐being.

Another strength of transportation justice is that it acknowledges that the unfair distribution of transportation resources is not an accident. Inequitable transportation and inequitable health are both the result of systematic policy decisions based in unjust systems of oppression, including racism. ⁵ These systemic injustices have led to the inequitable distribution of resources in our communities, such as the benefits and harms of transportation services and infrastructure. ²⁴ , ²⁵ These inequitable neighborhood contexts are fundamental social conditions that must be addressed if we are to ameliorate persistent health inequities. ²⁶ Inevitably, the transformative work of transportation justice will require researchers and policymakers to break out of traditional silos to address the interconnected patterns of injustice that have led to the unfair distribution of transportation and other social determinants of health. Health system leaders may be motivated to incorporate innovative approaches to addressing transportation needs as evidence in policy changes supporting screening and addressing social risk, and health services research increasingly demonstrate the associations among unmet social needs, worse health outcomes, and higher utilization of emergency department and hospitalization services. ²⁷ , ²⁸ , ²⁹

Applying Transportation Justice to Health Care‐Related Transportation Investments

We propose a framework for applying the principles of transportation justice to research, quality improvement, and program development/evaluation related to the associations between transportation and health (Figure 1). In this framework, we must acknowledge key contexts surrounding any discussion of transportation and health. First, historical and current policies perpetuate systemic injustices that impact both transportation and health. Second, the health system and community members both exist in the same overlapping community. Our framework distinguishes between community members and the health system to identify state‐centric (e.g., institution‐led) vs. society‐centric (e.g., community‐led) partnership dynamics—terms from the transportation justice discipline that reflect whose perspective is prioritized in decision making. Our framework also acknowledges that members of the health system exist within the community it serves.

Figure 1.

Proposed Framework Applying the Principles of Transportation Justice to Research, Quality Improvement, and Program Development/Evaluation Related to the Associations Between Transportation and Health [Colour figure can be viewed at wileyonlinelibrary.com]

The foundation of society‐centric transportation investigation and improvement is trust between community members and the health system. To shift from a traditional state‐centric approach where health systems and health services researchers would determine a conceptual model, conduct a baseline assessment, develop an intervention, and define outcomes and success, our framework emphasizes the importance of starting each process with community members and redistributing decision‐making power. The role of the health system in our framework emphasizes understanding, listening, supporting, and amplifying rather than conducting steps independent of the community. Our framework also highlights the broader understanding of transportation and mobility in the environment—seeking to extend beyond individual vehicles or mobility as the only mode of transportation considered—and thus emphasizing the wider range of health and well‐being outcomes these types of interventions might impact.

The case examples that follow, access to dialysis treatment and driving cessation for older adults, illustrate the application of a transportation justice framework to common health problems influenced by transportation. We also characterize the potential input of community members and the health system at each stage of development and evaluation (Table 1):

1. Establishing a shared model of transportation as a determinant of health,

2. Conducting a baseline assessment of the transportation/mobility environment,

3. Designing and implementing an intervention to facilitate the transportation necessary to live a meaningful and dignified life, and

4. Measuring outcomes to evaluate impact on well‐being.

Table 1.

Case Examples Applying a Transportation Justice Framework to Current Problems in Health Care Systems and Communities

	Case Example 1: Dialysis	Case Example 2: Driving Cessation
Shared model of transportation as a determinant of health	Community members: develop conceptual models linking transportation, mobility, and kidney health; define priorities and/or research questions related to the impact of transportation on development of kidney disease (e.g., access to healthy food, opportunities for physical activity) and utilization of health services such as primary care and dialysis transportation	Community members: develop conceptual model, define priorities and/or research questions related to the experience of driving and using alternative transportation options after driving cessation
	Health system: collaborate with researchers and community members to integrate comprehensive models of the impact of transportation and mobility on kidney health; this may include considering access to healthy food, access to preventive care and treatment of high blood pressure and diabetes, education and employment opportunities, access to safe areas for exercise, understanding the role of racism in shaping transit and mobility landscape	Health system: seek to understand how older adults and their caregivers in the community conceptualize transportation as a determinant of health; contribute established models related to stress‐coping strategies and stages of change to support and augment the key relationships identified by community members
Baseline assessment of transportation/mobility environment	Community members: community members assess current transportation resources and barriers to accessing care to prevent kidney disease (primary care, grocery store, pharmacies, physical activity) and access dialysis services	Community members: older adults and their caregivers assess baseline transportation resources considering the local community's resource environment (e.g., proximity to pharmacies, grocery stores, destinations for leisure, etc.)
	Health system: listen and integrate identified transportation resources and facilitators into models of transportation and health	Health system: listen to the baseline assessment of older adults and their caregivers; support the age‐friendly strengths identified in this assessment
Intervention to facilitate transportation necessary to live a meaningful and dignified life	Community members: community members prioritize interventions (coordination of transportation options, integration of transportation services across sectors, location of health facilities) to reduce transportation barriers to prevent kidney disease and receive dialysis care when needed	Community members: older adults and other community members prioritize efforts to meet their transportation and mobility goals while transitioning to not driving
	Health system: bring together community members, local government, health system, and transit decision makers in integrating transportation solutions across sectors	Health system: recruit key stakeholders in transportation, urban planning, and local government as well as community groups that support and promote healthy aging
Measure outcomes to evaluate impact on well‐being	Community members: community members determine when and how transportation barriers are addressed and next steps to improve transportation and health	Community members: older adults and their caregivers determine what constitutes success (e.g., transportation needs are being met with comfortable and convenient options)
	Health systems: ongoing collaboration with community members and stakeholders to maintain sustainability of transportation solutions and disseminate findings to community, practitioners, and researchers	Health system: amplify success of the alternative transportation options and disseminate research findings in geriatrics and gerontology fields

Case Example: Transportation Justice and Dialysis Care

In the United States, over 80% of all individuals receiving dialysis treatment for end‐stage kidney disease get their care at an in‐center dialysis facility. As most patients receive three times weekly treatment, this translates into approximately 300 one‐way trips per patient annually. Yet how individuals get to their dialysis treatment and the impact of travel on patients, caregivers, and communities is not often considered as part of dialysis care. The lack of integrated transportation into dialysis care has grave consequences. Missed dialysis treatments result in higher morbidity with increased hospital and emergency room visits, increased mortality, and higher costs to those impacted by these events and to the health care system. ³⁰ , ³¹ , ³² , ³³ , ³⁴

Medicaid programs and some Medicare Advantage plans provide nonemergency medical transportation benefits as one way to address transportation barriers. Yet these services typically are limited to vehicle‐based solutions (e.g., offering a voucher to public transit, setting up ride service). Medicare, which is the largest insurer of patients on hemodialysis, is not required to provide transportation services. As a result, transportation to dialysis becomes an issue patients need to solve individually. Each transportation solution depends on an individual's insurance, local services (such as city, county, or state transportation), and personal and community resources. Although a ride is critical for many individuals to get to dialysis, it is not sufficient. Prior studies report that missed dialysis treatments are not only related to transportation barriers but also associated with younger age, identifying as belonging to non‐White race, navigating depression, a substance use disorder, or chronic pain. ³¹ Thus getting to dialysis also involves understanding how people navigate and move through space in their everyday lives.

Applying a transportation justice framework to the context of dialysis requires moving upstream in approaches to access and care (see Table 1). It would entail turning to community members to understand their transportation and mobility needs. Such an approach would attend to the specific mobility opportunities, existing resources, and transportation services available to an individual before someone initiates in‐center hemodialysis. This approach may mean asking questions such as the following:

1. Is in‐center dialysis the correct mode for this individual?

2. What other supports exist for them?

3. Can transportation, rather than being just a means, be leveraged to build community—whether through social cohesion, job creation, or reduction of environmental impact?

Furthermore, a justice orientation would consider how the lack of mobility and transportation influences individuals’ ability to access care before end‐stage kidney disease and has shaped the ability of individuals with elevated blood pressure and diabetes to shop for healthy food, safely move about in space for physician activity, and access primary care. Addressing transportation only once someone starts dialysis misses important opportunities to address how and why kidney disease disproportionately affects communities of color.

Case Example: Transportation Justice and Driving Cessation

Aging is associated with increasing likelihood of chronic health conditions and medication use which can subsequently decrease driving safety. ³⁵ Drivers aged 70 years and older are more likely to make critical errors in driving that increase their risk for crashes. ³⁶ Many older drivers begin to self‐regulate their driving, avoiding driving at night or in bad weather for example, and ultimately they may stop driving completely.

Unfortunately, alternative transportation options for older adults are often limited. At least one in three older adults reports not being able to make needed or desired trips outside the home. ³⁷ Driving cessation is associated with serious negative impacts on social participation, community engagement, and mental health ³⁸ , ³⁹ as well as physical function and risk of mortality. ⁴⁰ , ⁴¹ These adverse outcomes are not related to the act of driving but instead to the loss of mobility and independence that driving affords.

The current focus in health care is on screening and evaluating older adults for driving safety. Interventions have focused on maintaining driving skills as long as possible and coordinating transportation to medical appointments when it is not. Our transportation justice framework would acknowledge the many ways that being a nondriver could be beneficial or detrimental to an individual's health (Table 1). Beyond just the access to health care that transportation provides, transportation interventions for nondriving older adults could aim to promote physical activity and social participation. Alternatively, interventions could have the potential to limit older adults’ mobility independence through expensive or time‐limited transportation options and increase their exposure to air pollution, communicable diseases, and stress. This framework would acknowledge upstream determinants of health that perpetuate inequities associated with the transition to nondriving. Women, older adults with less accumulated wealth, and minoritized older adults face higher odds of driving cessation than their male, wealthier, and White counterparts. ⁴² , ⁴³ , ⁴⁴

Conclusion

Transportation is a social determinant that fundamentally shapes individual and population health. Yet gaps persist between our recognition that transportation plays a foundational role in health and the health sector's current conceptualization of transportation and the translation of that conceptualization to intervention design and delivery. Transportation justice may help the health care sector to conceptualize transportation beyond individuals and vehicles and instead incorporate the historical and contemporary context of transportation and mobility.

Transportation includes routine medical activities such as visiting clinics and traveling to the pharmacy. But as we highlight, health services researchers, policymakers, and practitioners must also begin to understand transportation as interwoven into the fabric of health and society. Transportation is not necessary just to make it to an appointment, but is also how people access healthy food, education, employment opportunities, and exercise. It determines their ability to move freely and safely through space free of violence or exposure to air and noise pollution. Transportation is also interlinked globally with our changing climate and the disproportionate impact on marginalized communities. The framework we propose pushes the health care sector to transform how it has considered the role of transportation and health. Rather than continuing to promote a model of transportation that links home to medical facilities, transportation and health must move to understand and address the interconnection of transportation to all aspects of health and well‐being.

Centrally, this transformation requires incorporating community conceptualization, experience, and needs of transportation and mobility. Advocacy groups, and particularly communities of color, are leading this movement by calling for a mobility justice approach that takes the transportation justice framework even further, shifting attention to the individuals that experience inequitable safety and mobility.

“Mobility justice demands that ‘safety’ and equitable mobility address not only the construction of our streets but the socioeconomic, cultural, and discriminatory barriers to access and comfort different communities experience within public spaces. We must shift focus from the modes of transit people use to the bodies and identities of the people using those modes by centering the experiences of marginalized individuals and the most vulnerable communities. It acknowledges that safety is different for different people, and should be defined by those most economically and legally vulnerable.” ⁴⁵

This work is complex, and requires intention and cross‐sector collaboration with community members as key sources of knowledge and decision makers. In addition, bringing stakeholders from the Department of Transportation, local government, and the health sector to understand how community members experience transportation, mobility, and safety is critical to develop transportation solutions that can support, rather than harm, community health. This could mean revisiting the location of clinics, where regional transit lines are built, and the funding provided for transportation. It is not just about getting people to dialysis or primary care to avoid emergency room or hospitalizations, but moving transportation further upstream to allow all people, and particularly those belonging to the most disadvantaged communities, the opportunities to move freely in space and lead a healthy and dignified life.

Funding/Support: Kellia J. Hansmann is supported by the Advanced Fellowship in Women's Health through the Department of Veterans Affairs. Dr. Hansmann’s effort was supported with resources and use of facilities at the William S. Middleton Veterans Hospital in Madison, WI. This funder had no role in obtaining the data, planning the study, analysis, or reporting. Na'amah Razon is supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR001860 and linked award KL2 TR001859. The content is solely the responsibility of the authors and does not necessarily represent the official views of these funders.

Acknowledgments: The authors would like to thank Carolyn McAndrews and Laura Gottlieb for their thoughtful feedback on earlier drafts of this paper.

Conflict of Interest Disclosures: The authors have no conflicts of interest to declare.