Published: 2022-04-27

Pathway analysis to characterize the relationships between healthcare access and healthcare visits in the United States using the health information national trends survey

Qinglin Hu, Xiaobing Li, Mercedes M. Morales-Alemán


Background: Americans had fewer healthcare visits compared to their counterparts in other developed countries. The lack of regular check-ups can contribute to worsening health conditions. Insurance coverage, access to transportation to healthcare services, and having accessed health information via the internet are known to be associated with frequency of healthcare visits. However, there is limited literature detailing the direct and indirect influences of these variables on frequency of patients’ healthcare visits. We aimed to understand the interactive relationship between insurance coverage, access to transportation to healthcare services, and having accessed health information via the internet on frequency of patient healthcare visits.

Methods: We used data from the 2018 Health Information National Trends Survey (N=3504), the only survey year providing the source for information on insurance coverage, access to transportation to healthcare services, and having accessed health information via the internet. We used descriptive statistics, random parameter binary logistic regression, and pathway analysis to describe and analyze the associations between these determinants of healthcare access and healthcare visits.

Results: Results indicated that access to transportation to healthcare services (18.32%) and having insurance coverage (27.89%) were directly associated with healthcare visit frequency whereas the association between having accessed health information via the internet and reporting a healthcare visit, compare to the former two, was weaken (10.87%). Residential area (rural/urban), health conditions, age, race/ethnicity, employment status were directly associated with visit frequency whereas income status and education level were associated with healthcare visits indirectly through insurance.

Conclusions: Better understanding interactive relationships between healthcare access determinants will be key to the development of healthcare access interventions aimed at reducing healthcare disparities.


Healthcare access, Healthcare visits, Pathway analysis, Healthcare disparities

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Atkinson NL, Saperstein SL, Pleis J. Using the Internet for Health-Related Activities: Findings From a National Probability Sample. Journal of Medical Internet Research. 2009;11(1).

Rutten LJ, Squiers L, Hesse B. Cancer-related information seeking: hints from the 2003 Health Information National Trends Survey (HINTS). J Health Commun. 2006;11(1):147-56.

Gulliford M. What does 'access to health care' mean? J Health Serv Res Policy. 2002;7(3):186-8.

Goddard M, Smith P. Equity of access to health care services: Theory and evidence from the UK. Social Science & Medicine. 2001;53(9):1149-62.

Developing Healthy People 2030. U.S. Department of Health and Human Services.

Garfield R, Orgera RK, Damico A. The Uninsured and the ACA: A Primer - Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act. 2019, Kaiser Family Foundation: Menlo Park, CA.

Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976-93.

Douthit N. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611-20.

Call KT. Barriers to Care in an Ethnically Diverse Publicly Insured Population Is Health Care Reform Enough? Medical Care. 2014;52(8):720-7.

Berchick ER, Hood E, Barnett JC. Health Insurance Coverage in the United States. U.S. Census Bureau. 2017;60-264.

Transportation and the role of hospitals., in Social determinants of health series. 2017: Chicago, IL.

Massey PM. Where Do U.S. Adults Who Do Not Use the Internet Get Health Information? Examining Digital Health Information Disparities From 2008 to 2013. J Health Commun. 2016;21(1):118-24.

Jacobs W, Amuta AO, Jeon KC. Health information seeking in the digital age: An analysis of health information seeking behavior among US adults. Cogent Social Sciences. 2017;3.

Woolhandler S, DU. Himmelstein, Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance. Ann Intern Med. 2020;173(1):63-4.

Tipirneni R. Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost. JAMA Netw Open. 2018;1(7):e184796.

Sohn H. Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course. Popul Res Policy Rev. 2017;36(2):181-201.

Rask KJ. Obstacles Predicting Lack of a Regular Provider and Delays in Seeking Care for Patients at an Urban Public Hospital. Jama-Journal of the American Medical Association. 1994;271(24):1931-3.

Probst JC. Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey. BMC Health Serv Res. 2007;7:40.

Wallace R. Access to health care and nonemergency medical transportation-Two missing links. Management and Public Policy. 2005;2005(1924):76-84.

Lamont EB. Is patient travel distance associated with survival on phase II clinical trials in oncology? J Natl Cancer Inst. 2003;95(18):1370-5.

Guidry JJ. Transportation as a barrier to cancer treatment. Cancer Practice. 1997;5(6):361-6.

Houstis NE. Exercise Intolerance in Heart Failure With Preserved Ejection Fraction: Diagnosing and Ranking Its Causes Using Personalized O2 Pathway Analysis. Circulation. 2018;137(2):148-61.

Kao PY. Pathway analysis of complex diseases for GWAS, extending to consider rare variants, multi-omics and interactions. Biochim Biophys Acta Gen Subj. 2017;1861(2):335-53.

Douglass CH. Pathways to ensure universal and affordable access to hepatitis C treatment. BMC Med. 2018;16(1):175.

Hoven H, Wahrendorf M, Siegrist J. Occupational position, work stress and depressive symptoms: a pathway analysis of longitudinal SHARE data. J Epidemiol Community Health. 2015;69(5):447-52.

Li X. Pathway analysis of relationships among community development, active travel behavior, body mass index, and self-rated health. International Journal of Sustainable Transportation. 2021;1-17.

Spadaro JV, Rabl A. Pathway analysis for population-total health impacts of toxic metal emissions. Risk Anal. 2004;24(5):1121-41.

Liu J. Behavioral pathways in bicycle-motor vehicle crashes: From contributing factors, pre-crash actions, to injury severities. Journal of safety research. 2021;20(4):108-12.

Adanu EK. An analysis of the effects of crash factors and precrash actions on side impact crashes at unsignalized intersections. Journal of advanced transportation. 2021;2021.

Survey, H.I.N.T., HINTS Methodology Report. 2018, National Cancer Institute.

Liu J, Li X, Khattak AJ. An integrated spatio-temporal approach to examine the consequences of driving under the influence (DUI) in crashes. Accident Analysis & Prevention. 2020;146.

Lidbe A, Li X, Adanu EK, Nambisan S, Jones S. Exploratory analysis of recent trends in school travel mode choices in the US. Transportation research interdisciplinary perspectives. 2020;6.

Kaplan SH. Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33(12):1176-87.

Anderson M, Dobkin C, Gross T. The Effect of Health Insurance Coverage on the Use of Medical Services. American Economic Journal-Economic Policy. 2012;4(1):1-27.

Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care. 2004;42(2):176-82.

Arcury TA. Access to transportation and health care utilization in a rural region. J Rural Health, 2005;21(1):31-8.

Ashwood JS. Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending. Health Aff (Millwood). 2017;36(3):485-91.

Reed ME. Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians. JAMA Netw Open. 2020;3(6):e205873.