Background

Somerset County is the southernmost county in Maryland, situated between the Chesapeake Bay and the Atlantic Ocean (Somerset County, 2024). Nearly one-third of county residents are impoverished, more than any other county in Maryland (NIMHHP, 2024). Residents face food and housing insecurities, limited public transportation, and unemployment, among other social drivers of health disparities (TidalHealth, 2022).

Somerset County is home to Maryland’s last inhabited island group, Smith Island (SI) (SI United, 2025). The island encompasses three villages, including Ewell, Rhodes Point, and Tylerton, located 12 miles from Crisfield, Maryland and accessible only by boat (SI United, 2025). The isolated nature of SI has led to a strong sense of community among residents who are “… bound together by faith, work, our connection to the water, and a rich history …” (SI United, 2025, p. 1). SI’s history dates back to 1608, with an economy supported primarily by blue crab and oyster harvesting (SI United, 2025). The United States Census (2020) reports a total population of 202, resident median age of 57.2, and a 48.2% employment rate.

The island is informally governed by residents and the church. There are no police, stop signs or lights, grocery stores, pharmacies, or schools. School-age children are ferried to the mainland daily to attend classes, and two volunteer fire departments provide emergency medical services. In 2019, TidalHealth initiated a telehealth and acute care program on SI with a nurse practitioner (NP) and pharmacist traveling to the island bi-weekly from March to November to provide acute and chronic healthcare management. A full-time TidalHealth medical assistant, native to the island, provides year-round medical support for residents.

As with other communities in Somerset County, SI residents are disproportionately affected by chronic diseases (TidalHealth, 2022). Residents engage in little physical activity, aside from manual labor (Forsthoffer, 1997; Windemuth & Murphy, 2011). Food options are limited to native seafood and a small convenience store on the island (Windemuth & Murphy, 2011). Fresh fruit and vegetables are not readily accessible and must be delivered by boat (Windemuth & Murphy, 2011).

To date, there have been no qualitative or quantitative studies examining healthcare engagement among SI residents. Therefore, the aim of this study was to explore the lived experiences of SI residents’ engagement with healthcare. Researchers hypothesized that the rural nature of SI has a significant impact on residents’ engagement with healthcare.

Methods

Design, Sample, & Measures

Phenomenology was utilized to explore the lived experiences of SI residents’ engagement with healthcare. Phenomenology was most appropriate for this study to describe the lived experiences of participants as they experience a phenomenon and to understand the common essence of the phenomenon (Crewell & Poth, 2018). Non-probability sampling was employed. SI residents were invited to participate through recruitment flyers posted in a private resident-only social media group and in common areas throughout the island. Residents were eligible to participate if they were over the age of 18, English-speaking, and SI was their primary residence.

Data collection occurred following institutional review board approval from the Richard A. Henson Research Institute at TidalHealth. Participants provided written informed consent prior to completing a seven-question demographic questionnaire. Informed consent and demographic questionnaire documents were locked in a file cabinet, accessible only by the principal investigator.

Participants then participated in semi-structured interviews conducted by the principal investigator and two subinvestigators over three days. Interviews were conducted conveniently on SI in one of three private clinic consultation rooms. Each interview was audio recorded utilizing pseudonyms to ensure participant anonymity. Data collection continued until thematic saturation was achieved wherein the information shared by participants was repetitive with confirmation of previously collected data (Speziale & Carpenter, 2007).

Qualitative Analysis Strategy

Audio recordings were transcribed verbatim and reviewed for accuracy. Investigators immersed themselves in the data, reading and re-reading each transcript. Recurrent concepts were organized into meaning units and clustered into patterns and categories. Patterns and categories were revised until consensus by all three investigators was achieved as recommended by Flanagan and Beck (2024).

Lincoln and Guba’s (1985) framework was utilized to establish data trustworthiness. Transcription of each interview, confirmation of transcript accuracy, and data immersion established credibility. Dependability and confirmability were established through audit trails including research notes and interpretation of patterns and categories identified during data analysis. Authenticity and transferability were achieved through direct quotes to support identified themes. Finally, member checks were conducted to enhance credibility and trustworthiness of the data.

Results

Sample Characteristics

Participants (N=17) were 20 to 83 years of age (M=61.71, SD 18.37) and lived on SI an average of 39.94 years (SD=31.91). A majority of participants were female (n=12, 71%) and had completed high school (n=13, 76%). Most participants (n=12, 71%) reported having a PCP; however, nearly half (n=8, 47%) had not visited their PCP within the past 12 months. Participants reported traveling off SI for medical appointments zero to 15 times within the past 12 months (M=2.88, SD 4.69).

Qualitative Findings

Three primary themes emerged during qualitative data analysis: (1) barriers to accessing healthcare, (2) value of NP care, and (3) community support. All names below are pseudonyms.

Theme 1: Barriers to Accessing Healthcare
Transportation and financial considerations were reported as significant barriers to accessing healthcare. The weather significantly impacts transportation availability. Seth shared, “if the tide is too high, you can’t get on or off the island, and that’s a big issue for keeping appointments” while Amy added, “bad weather is one of the biggest barriers to getting care. You might have everything planned out, but then the wind or tide disrupts it.” Participants also acknowledged the difficulty for older adults to get on and off the boat in winter or bad weather conditions, citing safety concerns.

As a result of the weather and delayed or cancelled boat transportation, participants shared difficulties with medical offices. David contributed, “some offices don’t understand when we cancel at the last minute due to the wind or tide” and Seth added, “the offices get frustrated when you’ve had this appointment for three months, but three months ago I didn’t know what the wind was going to be doing … everything we do over here is dependent on the weather.” Rescheduling appointments leads to delays in care as the next available appointment may be weeks or months away.

Interviews revealed the financial considerations including the cost of transportation to the mainland and lost wages from missing work. Namely, Chris shared, “the ferry cost alone discourages some people from going to appointments unless it’s absolutely necessary.” Jonathan added, “when you factor in ferry fees and lost income from missing work, it adds up quickly just to make a simple doctor’s visit” and “working on the water and being self-employed, I can’t take time off.”

Some residents attempt to “bundle appointments together” or with another resident because, “the cost of transportation makes trips unrealistic.” Participants also shared the need to “rush back” to the boat to return home. Bradley stated, “if you need something urgent and miss the boat, you have to stay overnight, which involves hotel costs and food expenses.” Accordingly, most residents attempt to secure early morning appointments to ensure they can return home and avoid extra expenses.

Theme 2: Value of NP Care
Participants acknowledged the invaluable role of NPs. Jeremy shared, “having healthcare here has really impacted the community positively.” NPs were cited as increasing access to care for island residents. Robert stated, “if there’s a NP here, I’ll take care of issues quickly. Without that, I might just put them off until they become serious” while Miranda added, “having NPs here means we can catch problems early and address them before they turn into bigger issues” and “I feel more confident managing my health on the island. It’s a huge relief not having to deal with the stress of travel for every issue.”

NP care was characterized as convenient. Robert shared, “I like that I can come in and get seen quickly without needing to miss a whole day or plan a trip to the mainland” and Debbie added, “I’ve had care here for things like blood pressure checks and basic screenings, and it was just like going to my primary care on the mainland.” Participants further acknowledged the role of NPs identifying concerning health conditions and referring to appropriate specialists.

While participants recognized the invaluable role of NPs, they expressed a desire for expanded services. Brian shared, “sometimes I feel like I need a specialist instead of just primary care, but I put it off if it’s not urgent” and Ebony added, “sometimes you just rub things off and don’t pursue care because it’s such a hassle to leave the island.” An overarching request from participants was increased services available on SI; Mary stated, “if [they] could do everything that’s done in Salisbury, it would save us from putting off care.”

Theme 3: Community Support
Community support and unity on SI are unparalleled, particularly when residents are in need. Due to the remote and impoverished nature of the island, many residents do not have a vehicle on the mainland. Accordingly, residents coordinate appointments to share rides, although Kim acknowledged, “we try to make ‘em together, which is near impossible.” Residents support one another with shared rides to local grocery stores and visits to long-term care facilities.

In an emergency, the community rallies to ensure the infirm receive expeditious access to care. Emergency medical services are accessible via a Maryland State Police Medevac Helicopter or by boat. Betsy contributed, “it is nice to see everyone come together when the ambulance is dispatched. People block the roads and set up the landing zone.” While not all residents have a boat, personal boats are readily offered during an emergency. Andrew stated, “I remember being injured and the chopper was busy. Too busy … my neighbor ended up taking me by boat.”

Discussion

This phenomenological study explored the lived experiences of SI residents’ engagement with healthcare. Most participants reported having a PCP, although more than half had not had a visit within the past year. Three primary themes emerged including barriers to accessing healthcare, value of NP care, and community support. The first theme “barriers to accessing healthcare” underscores the rural nature of SI. Transportation to medical appointments by boat is significantly impacted by weather including wind and high tides. Medical office staff frustration and lack of understanding of the nuances of transportation from SI further exacerbate health disparities contributing to delays in accessing care.

Round-trip boat fares and lost wages from missing work influence residents’ decisions to access healthcare. Residents frequently weigh earning money against traveling to the mainland for health maintenance, chronic disease management, and acute illnesses. The potential for unexpected delays while on the mainland are significant considerations when deciding to access healthcare. Unexpected delays may lead to missing the boat, resulting in additional expenses for an overnight stay and time away from work. These critical decisions further exacerbate health disparities and align with challenges reported by Farmer and Nimegeer (2014) including limited access to healthcare facilities and providers. Similarly, Brundisini et al. (2013) reported transportation and weather as barriers to accessing healthcare in rural and remote areas.

The second theme “value of NP care” highlights the impact of NP care on SI, minimizing gaps in care by addressing acute and chronic conditions. The American Association of Nurse Practitioners (2020) reports patients living in rural communities are five times more likely to gaps in primary care services which can be filled by highly qualified NPs. Participants further expressed the ability to receive care without the added expense of round-trip boat fare and missing work, clearly emphasizing the positive impact and value of NP care. Expanded hours and services are therefore necessary to reduce health disparities.

The third theme “community support” reflects the unity and bond among SI residents. Residents maintain a support network to overcome logistical challenges associated with living on SI. The community’s ability to coordinate appointments, share rides, and provide emergency care highlights residents’ resilience and resourcefulness. This theme aligns with prior research by Farmer and Nimegeer (2014) wherein rural Scottish communities reported “community spirit” and “resourceful adaptable community members” as community health assets (p. 6).

Recommendations for Practice

SI is a small, yet vibrant community with a rich history. This study provides valuable insight and implications for healthcare providers, public officials, health systems, and public health experts. Tailored and targeted interventions are necessary to remove barriers and increase access to care for SI residents.

Enhanced telehealth services for primary and specialty care providers may provide a viable option to overcome geographical barriers and ensure continuity of care (Coombs et al., 2022; Hunter et al., 2022). Public officials may support this initiative through funding for expanded WIFI and broadband services on the remote island (Goodridge & Marciniuk, 2016; Hirko et al., 2020). In the interim, grant funding and re-allocating transportation resources, among other sustainable solutions, would reduce barriers for residents seeking care. Health systems should provide training to medical office personnel regarding the unique challenges experienced by rural residents. This increased awareness is integral to build and maintain trust among rural residents and healthcare providers.

Limitations

This study was limited by a convenience sample of SI residents. Interviews were conducted in person during standard clinic hours of operation, which may have limited the ability of home-bound and working residents to participate. Moreover, while strategies were implemented to minimize bias and coercion, the researchers provide medical care to SI residents, which may be a limitation. Future research should examine healthcare engagement among SI residents by generation to determine if variations exist.

Conclusion

The results of this study may inform the development of healthcare strategies and policies not only for SI but also for other rural and isolated communities facing similar challenges. By understanding the lived experiences of rural communities, healthcare providers, public officials, health systems, and public health experts can more effectively innovate care delivery to reduce disparities.

References

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