Differences in Healthcare Access for Disabled People Living in Rural and Urban Areas

The primary research question guiding this review is: What are the barriers and facilitators to healthcare access for disabled individuals in rural vs. urban areas?

This systematic review was conducted in accordance with a pre-registered protocol. The protocol was registered in the International Prospective Register for Systematic Reviews (PROSPERO) on February 5th, 2025, with the registration number CRD42025648258. The review adheres to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, which was used as a guide for reporting all stages of the review process.

The review included all studies employing quantitative, qualitative, or mixed methods designs. To be included, studies had to be published in English in a peer-reviewed journal and had to focus on healthcare access for disabled individuals while also comparing or contrasting findings between rural and urban settings. Studies were excluded if they were discussion papers, dissertations, theses, commentaries, editorials, systematic reviews, scoping reviews, meta-analyses, or literature reviews. Dissertations and theses were excluded due to the potential for limited peer review, which may impact the reliability of their findings. Studies with low-quality evidence, such as case reports or case series, or those with insufficient data or an unclear methodology were also excluded.

Two research team members independently conducted a comprehensive literature search across six databases: PubMed, Scopus, CINAHL, Web of Science, Medline, and Embase. The search was conducted between January 1, 2010, and December 31, 2024, ensuring a focus on recent literature.

The search strategy included a combination of keywords and MeSH terms related to:

The full search strategy was adapted for each database's specific syntax to ensure maximum retrieval of relevant articles.

After retrieving articles from the databases, the search results obtained by both reviewers were uploaded to the Rayyan software, where duplicate records were automatically identified and removed using the platform's built-in duplicate detection feature. The unified list of unique studies was then used to facilitate the screening process. Two reviewers independently screened all articles by title and abstract to determine if they met the eligibility criteria. The process was blinded to prevent bias. Any disagreements between the two reviewers were resolved by a third reviewer. The full texts of all articles that passed the initial screening were then retrieved and independently evaluated for final inclusion. Discrepancies were again resolved through discussion and consensus among the three reviewers. The selection process is documented visually using a PRISMA flow diagram.

An evaluation of the quality of individual studies was performed using the Mixed Methods Appraisal Tool (MMAT), which is an effective tool for assessing the quality of quantitative, qualitative, and mixed-methods research. MMAT was selected due to its unique flexibility in evaluating studies across multiple methodologies. The appraisal process considered various dimensions of bias, including selection bias, measurement bias, and reporting bias. While MMAT provided a comprehensive framework, some challenges arose during the evaluation, particularly when interpreting the risk of bias in studies with insufficient reporting. To address these challenges, a third reviewer was involved to resolve any discrepancies through discussion, ensuring consistency in the evaluations. Each study was categorized into one of three levels of bias: “low risk of bias”, “some concern of bias”, and “high level of bias”. Studies with a sufficient sample size, a well-elaborated methodology, and clear reporting were categorized as “low risk of bias”. Those that had some methodological limitations, such as a possible risk for self-reporting bias, were categorized as “some concern of bias”. Studies with insufficient sample size, unelaborated methodology, or a high likelihood of reporting bias were categorized as “high level of bias”. To ensure the accuracy of the evaluation, two research team members independently assessed the risk of bias and quality of each study. In case of disparity, they consulted the third research team member to reconcile any differences.

This systematic review used a data extraction table developed by the principal researcher to systematically extract data from the included studies. The data charting tool was pilot-tested and refined by the research team to ensure it could reliably capture all intended data. Extracted data included study characteristics (author, year of publication, study design, and country), population details (age, type of disability), the specific setting of the study (rural or urban), key findings related to barriers and facilitators, and any reported outcomes. To ensure reliability, two reviewers independently extracted data from the included studies. Any discrepancies that arose during this process were resolved through discussion to reach a final consensus.

Data were synthesized qualitatively to describe and compare the findings from the included studies. A narrative synthesis was conducted to summarize the barriers and facilitators to healthcare access identified in rural and urban settings and to highlight common themes across the literature. A thematic analysis was also used to identify, analyze, and report patterns within the data. This involved an inductive coding approach, where themes related to barriers and facilitators emerged directly from the extracted data. To ensure the reliability and validity of this analysis, two reviewers independently coded the data before discussing and reaching a final consensus on the thematic framework. The final synthesis was cross-checked to ensure consistency and minimize potential bias.

Access to healthcare for disabled individuals in rural areas is shaped by a complex interplay of environmental, personal, and socioeconomic factors. A primary obstacle is the lack of physical and healthcare infrastructure. Rural areas often have fewer healthcare facilities and a limited number of healthcare professionals, leading to restricted access to specialized medical care, state-of-the-art clinics, and rehabilitation centers (3). This scarcity contributes to higher rates of unmet medical and rehabilitation needs, with rural residents having 13%–40% higher unmet healthcare needs than their urban counterparts. Individuals with more than one disability or those with physical disabilities are particularly affected, reporting the highest rates of unmet needs for care and rehabilitation services. These disparities are further compounded by a shortage of supportive infrastructure like transport networks (6).

Transportation presents a significant, specific barrier (Table 2). Public transportation networks in rural areas are often weak or nonexistent, and specialized transport for people with assistive devices is scarce. Long distances, poor roads, and the high cost of private transport can make independent travel impossible, deterring access to care, especially for those with chronic diseases or multiple disabilities. These barriers can lead to delayed diagnoses and poorer health outcomes. Financial constraints, such as low incomes and inadequate insurance coverage for transport, further reinforce these difficulties, placing rural residents with disabilities at a significant disadvantage (3).

In rural Louisiana, these issues are particularly pronounced, with people with disabilities facing a distinct set of challenges and support systems. Participants in one study cited a lack of transportation, limited local specialized care, and inadequate insurance coverage as primary barriers. Financial limitations were a significant concern, as many were unable to work due to their disabilities, leading to high out-of-pocket spending on medications and appointments. For some, this meant they couldn't afford all their necessary medications or even avoided doctor visits because of the cost. The study identified an especially vulnerable group as those with incomes too high for Medicare/Medicaid eligibility who still struggled to pay for healthcare, feeling they “fall through the cracks” of the system. Despite these obstacles, key facilitators were also present, including strong social support from family and friends, transportation assistance, continuity of care, and a high level of trust in their physicians, which helped them navigate these challenges (10).

In addition to these physical barriers, architectural inaccessibility within healthcare facilities remains a major impediment. The lack of ramps, handrails, lifts, and accessible toilet facilities is a widespread issue in medical centers, a problem exacerbated in rural settings where such accommodations are less common. This averseness towards using rehabilitation units points to a need for improved infrastructure that adheres to accessibility standards (3). Beyond physical access, communication and literacy barriers also hinder the delivery of health information, necessitating the development of special materials like Braille, large-print, audio formats, and digital media to improve accessibility (11).

Socioeconomic and cultural factors also complicate access (9). Individuals with disabilities in rural regions have higher unmet needs due to lower educational attainment, fewer job opportunities, and financial limitations that often prevent them from affording necessary services. Cultural attitudes may also contribute to a reluctance to seek care, especially for preventive services (5). Research shows that behavioral norms vary significantly between rural and urban populations, with rural residents having lower rates of seat belt use, higher smoking rates, and lower vaccination rates (12). Additionally, studies have found that rural residents are more likely to report no need for preventive care like dental and mental health counseling. For example, a logistic regression analysis showed that rural residents were more than twice as likely to report no need for mental health counseling compared to their urban counterparts, even when controlling for other factors (7). These findings suggest that addressing deeply rooted behavioral norms and perceived needs is crucial for making preventive care services effective, even when access is improved.

Urban areas, despite their abundance of healthcare facilities, present a unique set of challenges for people with disabilities. A primary obstacle is system overcrowding, which can lead to frustratingly long wait times and potentially compromise the quality of care. This is particularly difficult for individuals with complex and ongoing health needs who require timely access to services. Additionally, socioeconomic disparities in cities create significant barriers. Residents in low-income urban areas often face a lack of insurance and limited finances, which restricts their access to high-quality facilities and can exacerbate healthcare inequalities (6).

Another major hurdle, common to both urban and rural settings, is navigating health insurance (8). Even with a wider selection of providers in cities, many people struggle to understand the specifics of their plans, like who is in-network, what services are covered, and what their out-of-pocket costs will be. This administrative complexity can lead to delayed treatment or even prevent it altogether due to communication breakdowns between providers and insurance companies. This issue is often more severe for rural residents, who have fewer local in-network options and may have to travel long distances or pay out-of-pocket for necessary services.

The bureaucratic burden of securing care is a significant concern for people in both locations. The time and effort required to get pre-authorizations for treatment, along with the frequent rejection of claims for essential procedures, are major stressors. This burden disproportionately affects disabled individuals who need consistent, long-term care. A lack of transparent communication between insurers and physicians only adds to this complexity. While urban residents might have more access to local support programs to help with these hurdles, rural residents often don't have this same assistance.

Finally, physical and architectural barriers persist even in urban environments. Despite the concentration of facilities, a lack of basic accessible features like ramps, handrails, elevators, and accessible restrooms can still make it difficult for people with disabilities to get the care they need (3). This highlights that the mere presence of numerous healthcare facilities in a city doesn't guarantee equitable access for all residents (See Table 2).

Community-based interventions are vital for improving healthcare access for people with disabilities in rural communities. These programs provide essential services like transportation and home healthcare, often through community-based health workers. Research shows that communities with resources such as rehabilitation facilities and social programs have fewer unmet needs among their disabled residents. However, this isn't a complete solution. For example, in China, even after accounting for these community factors, rural residency was still a predictor of unmet health needs, suggesting that other barriers persist (6). This means that while community-based interventions are critical, they must be part of a larger strategy to fully address the healthcare challenges faced by disabled individuals in rural areas.

Mobile health units also play a key role in bringing healthcare directly to rural communities (13). These units eliminate the need for long and difficult travel to distant medical centers, which is a major advantage for people with limited mobility. Mobile clinics are often equipped with advanced medical equipment and staffed by professionals who can offer a wide range of services, from general check-ups to specialized care like rehabilitation. By bringing flexible and accessible services directly to communities with limited resources, these units are highly effective in reducing healthcare disparities and improving health outcomes for rural populations with disabilities.

Urban areas, with their well-developed infrastructure, offer unique facilitators for healthcare access. One of the most significant is telemedicine and other technological advances. In cities, where internet connectivity and computer literacy are higher, telemedicine is a viable alternative for people with physical barriers to visiting health centers (14). For those with mobility impairments, it eliminates the need for travel, which is a huge benefit for patients who need regular check-ups or special care, as it minimizes the physical and logistical challenges of navigating a busy city (6). Telemedicine also helps address the issue of overcrowding and long wait times by allowing patients to schedule visits faster than through traditional means.

Beyond telemedicine, urban areas benefit from other technological innovations like electronic health records (EHR) and AI-powered platforms (15). These systems help improve coordination among specialists and primary care providers, which is essential for people with disabilities who often need interdisciplinary treatment. AI can assist with early illness detection and provide predictive recommendations. Together, these technologies create a more integrated and responsive healthcare system, giving disabled individuals greater autonomy and control over their health without requiring repeated physical visits.

Finally, urban areas are able to offer a greater concentration of specialized healthcare services and professionals (11). For people with disabilities who require specific and complex interventions, this is a significant advantage. For example, studies show that while only about 44% of rural residents had access to a rehabilitation center, nearly all urban residents reported the same availability (3). This higher concentration of professionals also offers a broader choice of care, which can help reduce wait times for necessary services. Furthermore, well-developed urban transportation systems make it easier for people with disabilities to reach these facilities.

Policymakers need to make it a priority to allocate money and resources to eliminate inequities in healthcare access. This means providing funding for telemedicine centers and offering financial assistance to low-income individuals with disabilities, especially in rural communities. Hospitals should also be required to meet accessibility standards, creating a genuinely inclusive healthcare system (3). Shifting resources to help disadvantaged groups in both rural and urban areas is a critical step toward reducing the disparity in healthcare access.

Engaging with local communities and stakeholders is the key to making healthcare interventions successful in the long run. Community-based programs, which are built on local knowledge and resources, can be incredibly effective in helping people get the care they need in places where barriers are high. For example, in rural areas, programs that encourage social engagement and community-based rehabilitation show great promise. Involving local organizations in designing and implementing these interventions ensures the solutions are relevant to the community and are more likely to last.

There are significant unmet healthcare needs among people with disabilities, and it's especially apparent in rural areas. Nearly 45.6% of adults with disabilities report they need but don't receive rehabilitation services, 15.4% need medical care, 13.7% need more accessible facilities, and 10.2% need more care services. These disparities are particularly pronounced in rural regions, where people with disabilities are 13%–40% more likely to have unmet healthcare needs than their urban counterparts (6). To tackle these disparities, policy interventions must improve accessibility to health facilities, create more opportunities for social participation, and increase the number of health workers in rural regions.

More studies are needed to investigate the root causes of healthcare access disparities among people with disabilities. Researchers should explore how stigma, social beliefs, and cultural values influence healthcare access, especially in rural and impoverished communities. We also need more long-term studies to determine how effective telemedicine and community interventions are at removing healthcare barriers for people with disabilities in different geographical settings.

Healthcare providers need better training so they can effectively care for the unique needs of people with disabilities. This training should make providers more aware of the challenges people with disabilities face and the various stigmas that hinder their access to healthcare. The goal is to provide a more inclusive environment where individuals with disabilities can get the services they need without facing discrimination.

Finally, this systematic review calls for specific policy responses and community-level interventions that are designed with the particular needs of people with disabilities in both rural and urban areas in mind. Policymakers must invest in transport infrastructure, telemedicine, and rehabilitation centers, while also guaranteeing accessible healthcare facilities. Only by addressing these complex, multi-faceted problems can we work toward a truly equitable healthcare system for all.