Left behind: forgone medical care due to transportation barriers among adults with physical impairments and disabilities that prevent physical activity in small and rural communities

• Adults with PID-PA, especially chronic PID-PA, faced multiple transportation barriers to essential healthcare. • On-demand ride-sourcing use was associated with higher likelihood of forgone healthcare. • Multi-level interventions needed to improve healthcare and transport equity. Adults with physical impairments or disabilities that prevent physical activity (PID-PA) face significant transportation barriers to essential healthcare, often forgoing care despite higher healthcare needs. While on-demand ride-sourcing services (e.g., Uber and Lyft) may improve mobility, concerns remain about the current level of inclusivity and equity, especially for individuals with more complex needs. Whether on-demand ride-sourcing will facilitate mobility or further isolate certain people with PID-PA is largely unknown. This study examined the transportation barriers to healthcare among people with temporary and chronic PID-PA and assessed the role of alternative access strategies, with particular attention to small and rural communities where residences are dispersed and transit options are limited. A cross-sectional online survey was conducted in nine such communities in Texas, yielding 416 valid responses for analysis. Fisher’s exact tests, logistic regression models, and mediation analysis were used to assess associations between adults with PID-PA and variables such as forgone necessary healthcare due to lack of transportation, use of on-demand ride-sourcing, and alternative transportation options. Among participants, people with PID-PA were more likely to use rides provided by others and telemedicine. However, logistic regression models showed that having chronic PID-PA and using on-demand ride-sourcing for healthcare were positively associated with forgone necessary medical care due to transportation barriers. Moreover, on-demand ride-sourcing use did not mediate the relationship between chronic PID-PA and forgone necessary healthcare. This result indicates that ride-sourcing services do not effectively reduce transportation barriers for individuals with chronic PID-PA. Instead, dependence on such services may be associated with forgoing necessary medical care. The study highlights substantial challenges to using on-demand ride-sourcing in small and rural communities, including limited physical/digital accessibility, affordability concerns, and unreliable service. To improve transportation equity for people with PID-PA, interventions must address broader systemic issues affecting the accessibility of ride-sourcing.