Understanding Structural Ableism and Systemic Inequities In Cervical Cancer Screening for Women with Mobility Disabilities In Hawaiʻi: A Mixed Methods Study

Background and Purpose

Women with mobility disabilities face significant disparities in preventive care, specifically cervical cancer screening (CCS), yet their experiences are often obscured by aggregated data and medicalized perspectives. Grounded in the Andersen Behavioral Model and Critical Disability Theory, this explanatory sequential mixed-methods study investigated CCS disparities in Hawaiʻi. The study sought to identify sociodemographic and economic predictors of non-guideline concordance and explore healthcare provider (HCP) perceptions of the systemic barriers and facilitators to screening.

Methods

Phase One utilized secondary data from the Hawaiʻi Behavioral Risk Factor Surveillance System (BRFSS; 2021-2023) to establish relationships between disability status, sociodemographic and health characteristics, and CCS outcomes (n=398,491) using weighted analyses. Phase Two consisted of semi-structured interviews with Hawaiʻi-based HCPs (n=11) to contextualize the quantitative findings. Qualitative data were analyzed using Reflexive Thematic Analysis to identify the structural, clinical and attitudinal barriers and facilitators.

Results

Phase One reveals that women with mobility disabilities in Hawaiʻi (8% of the sample) are disproportionately older, unpartnered, and economically marginalized. Mobility disability was significantly associated with reliance on public insurance, poverty, health comorbidities, and missing appointments due to transportation/cost. Among all women in the state, non-guideline concordance was most prevalent among Pacific Islander, Filipino and Native Hawaiian participants, as well as those with no insurance coverage and lower incomes.

Phase Two identified four central themes: (1) the broader health care system culture; (2) social and geographic influences; (3) clinical-level barriers and facilitators; and (4) future opportunities. The high cost of living negatively impacts healthcare access at both provider and patient levels. Regional provider shortages are more pronounced in areas with higher concentrations of disability and, in conjunction with the management of chronic health conditions, contribute to the deprioritization of CCS. Furthermore, financial structures of health care lead to the funneling of Medicaid patients (many of whom have disabilities) to often overextended safety net clinics, as private practitioners can find it financially unsustainable to care for this population. Most systems lacked standardized disability documentation and/or staff training in disability-conscious care. Despite structural barriers, providers are intrinsically motivated to ensure screening accessibility, and patient-centered and trauma-informed care philosophies are key facilitators.

Conclusions and Implications

Synthesis of findings demonstrates that CCS disparities are not a reflection of individual limitations but of the structural ableism baked into the healthcare environment. Policy implications include utilizing federal rural health funding to mandate disability and accommodations documentation in statewide electronic records. For social work, this study calls for explicitly centering disability in curricula and including reproductive justice in core competencies. By positioning social workers at the intersection of primary care and social service enrollment, we can transform the healthcare landscape from reactive management to proactive, systemic equity.