Translating policy principles into practice to improve health care access for adults with intellectual disabilities: A research review of the past decade

ADAPTATION AND TESTING OF THE DEVELOPMENTAL DISABILITY ATTITUDES IN NURSING CARE INSTRUMENT

Background and Purpose: Individuals with developmental disability (DD) often experience poor health outcomes, potentiated by healthcare inequities. Nurses have the potential to reduce these inequities through the quality of care provided. The quality of care provided by nursing students, the future generation of nurses, is affected by the attitudes of their clinical nursing faculty. The purpose of this study was to adapt and test an instrument to specifically measure the attitudes of clinical nursing faculty toward providing care to people with DD. Methods: The Disability Attitudes in Health Care (DAHC) instrument was adapted to create the new Developmental Disability Attitudes in Nursing Care (DDANC) instrument. Results: Content experts reviewed the DDANC for content validity (CVI = 0.88), followed by testing for internal consistency reliability (Cronbach's alpha = 0.7). The study respondents had overall positive attitudes toward the care of people with DD. Conclusions: The DDANC is an acceptably valid and reliable instrument to assess attitudes of clinical nursing faculty toward providing care to people with DD.

A Comparison of Health Disparities Among Americans With Intellectual Disability and/or Autism Spectrum Disorder and Americans With Other Disabilities

This article uses recent survey data to compare and contrast American adults with intellectual disability (ID) and/or autism spectrum disorder (ASD) and those with other disabilities with regard to overall health, access to health care, and other aspects of community participation. Although people with ID and/or ASD and others with disabilities share many issues related to poorer health and access to care compared to the general population, adults with ID and/or ASD reported different experiences and outcomes than other people with disabilities. An examination of these differences provides insights into policy changes and targeted interventions that might improve overall health and community inclusion specifically for people with ID and/or ASD.

Evaluating the Impact of a Clinician Improvement Program for Treating Patients with Intellectual and Developmental Disabilities: The Challenging Case of Mississippi

In recent years, people with intellectual and developmental disabilities (IDD) have moved from institutionalized settings to local community residences. While deinstitutionalization has yielded quality of life improvements for people with IDD, this transition presents significant health-related challenges. Community clinicians have typically not been trained to provide sound medical care to people with IDD, a subpopulation that exhibits unique medical needs and significant health disparities. This study reports the results of a comprehensive evaluation of an IDD-focused clinician improvement program implemented throughout Mississippi. DETECT (Developmental Evaluation, Training and Consultative Team) was formed to equip Mississippi’s physicians and nurses to offer competent medical care to people with IDD living in community residences. Given the state’s pronounced health disparities and its clinician shortage, Mississippi offers a stringent test of program effectiveness. Results of objective survey indicators and subjective rating barometers administered before and after clinician educational seminars reveal robust statistically significant differences in clinician knowledge and self-assessed competence related to treating people with IDD. These results withstand controls for various confounding factors. Positive post-only results were also evident in a related program designed specifically for medical students. The study concludes by specifying a number of implications, including potential avenues for the wider dissemination of this program and promising directions for future research.

Agency, social and healthcare supports for adults with intellectual disability at the end of life in out-of-home, non-institutional community residences in Western nations: A literature review

BACKGROUND

The nature and quality of end-of-life care received by adults with intellectual disabilities in out-of-home, non-institutional community agency residences in Western nations is not well understood.

METHOD

A range of databases and search engines were used to locate conceptual, clinical and research articles from relevant peer-reviewed journals.

RESULTS

The present authors present a literature review of the agency, social and healthcare supports that impact end-of-life care for adults with intellectual disabilities. More information is needed about where people with intellectual disabilities are living at the very end of life and where they die.

CONCLUSIONS

The support needs for adults with intellectual disabilities will change over time, particularly at the end of life. There are some areas, such as removing barriers to providing services, staff training, partnerships between agencies and palliative care providers, and advocacy, where further research may help to improve the end-of-life care for adults with intellectual disabilities.

Developing a Health-Related Quality-of-Life Measure for People With Intellectual Disability

Using principles of community-based participatory research we developed a new theory-based measure of health-related quality of life (HRQOL) for individuals with intellectual disability (ID). We recruited adults with ID (n = 129) to take part in interviews and review successive versions of HRQOL items. Critical input about content and understandability shaped the items, as did input from four focus groups of parents/caregivers (n = 16) and representative stakeholders from community-based agencies (n = 7). The resulting HRQOL measure, called the HRQOL-IDD, contains 42 items. The response format depicts a gradient of fluid-filled cups ("none" to "full") to represent frequency of experience of each item on a 5-point scale.

Experiences of patients with intellectual disabilities and carers in GP health information exchanges: a qualitative study

BACKGROUND

Accurate health information exchange (HIE) is pivotal for good quality of care. However, patients with intellectual disabilities (ID) face challenges in processing and exchanging health information around GP consultations. Knowledge of HIE barriers and facilitators, including the roles of carers, may help to improve GP care for people with ID.

OBJECTIVE

To gain more insight into HIE barriers and facilitators for ID patients in GP care.

METHODS

A qualitative study exploring GP consultation experiences of people with ID (n = 35), professional carers (n = 20) and relatives (n = 15). Transcripts from interviews and focus groups were analyzed using a framework analysis approach.

RESULTS

Analyses resulted in four themes: (i) Recognizing patient health needs; (ii) Impaired doctor-patient communication; (iii) Carers' mediating roles during consultations; and (iv) Patients' autonomy and self-determination. Barriers related to communication skills, lack of time, continuity of carers and physicians, information alignment between relative or professional carer and the GP, and information transfer and recording within the patient network. Facilitating factors related mainly to carer interventions, personal connections with patients and GP communication with patients and carers outside the consultation.

CONCLUSION

There is considerable HIE potential in patients themselves, as well as in their network, although many barriers have to be overcome to profit from this. GP practices are recommended to adjust consultations and communication practices and to facilitate deployment of the patient's network, while still considering patient autonomy.

Health information exchange for patients with intellectual disabilities: a general practice perspective

BACKGROUND

Inadequate health information exchange (HIE) between patients with intellectual disabilities (ID), their carers, and GPs may lead to ineffective treatment and poor treatment compliance. Factors influencing HIE are largely unexplored in previous research.

AIM

To provide insight into the perceived HIE facilitators of GPs and general practice assistants, and the barriers in GP consultations for patients with ID.

DESIGN AND SETTING

An interview-based study with GPs (n = 19) and general practice assistants (n = 11) in the Netherlands.

METHOD

Semi-structured interviews were conducted on topics relating to stages during and around GP consultation. Transcripts were coded and analysed using framework analysis.

RESULTS

The main themes were impaired medical history taking and clinical decision making, and fragile patient follow-up. Factors negatively influencing HIE related to patient communication skills and professional carers' actions in preparing the consultation and in collecting, recording, and sharing information. HIE barriers resulted in risk of delay in diagnosis and treatment, misdiagnosis, unnecessary tests, and ineffective treatment regimens. HIE facilitators were described in terms of GP adjustments in communication, planning of consultations, and efforts to compensate for fragile follow-up situations.

CONCLUSION

Inadequate HIE should be seen as a chain of events leading to less effective consultations, substandard treatment, and insufficient patient follow-up. The results indicate a mismatch between GPs' expectations about professional carers' competencies, responsibilities, and roles in HIE and the setting in which professional carers operate. Further research should focus on how daily GP practice can be attuned to the practicalities of HIE with patients with ID and their professional carers.

Perceptions of Health and Healthcare of People With Intellectual and Developmental Disabilities in Medicaid Managed Care

This study examined perceptions of health and healthcare of people with intellectual and developmental disabilities (IDD) receiving Medicaid Managed Care. Exploratory, semistructured interviews were conducted with 23 participants. Findings indicate that participants generally expressed being in good health and defined good health as (a) absence of pain, disease, and symptoms; (b) adherence to or not requiring treatment; (c) physical self-care; (d) mental or spiritual self-care; and (e) ability to perform the activities one wants to do. Participants conceptualized healthcare as (a) ensuring needs are met through access to services, (b) obtaining quality services, (c) navigating the healthcare system successfully, and (d) receiving humanizing healthcare. This study has implications for improving healthcare and communications between people with IDD and healthcare providers.

'You must carry your wheelchair'--barriers to accessing healthcare in a South African rural area

Background

There is international evidence that people with disabilities face barriers when accessing primary healthcare services and that there is inadequate information about effective interventions that work to improve the lives of people with disabilities, especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities.

Objective

In this study, we explore the challenges faced by people with disabilities in accessing healthcare in Madwaleni, a poor rural Xhosa community in South Africa.

Design

Purposive sampling was done with 26 participants, using semi-structured interviews and content analysis to identify major themes.

Results

This study showed a number of barriers to healthcare for people with disabilities. These included practical barriers, including geographical and staffing issues, and attitudinal barriers.

Conclusions

It is suggested that although there are practical barriers that need to be addressed, attitudinal barriers could potentially be addressed more easily and cost effectively.

Identifying state resources and support programs on e-government websites for persons with intellectual and developmental disabilities

This descriptive cross-sectional study identified resources and programs that are available nationwide on the Internet to support individuals and families with intellectual and developmental disabilities (I/DD), with a focus on intellectual disability. This evaluation included easily identifiable information on specific resources and highlighted unique programs found in individual states that were linked from e-government websites. Researchers documented the ease of access and available information for all 50 states and the District of Columbia. A number of disparities and areas for improvement were recorded for states and I/DD websites. The researchers conclude that a number of additional health and support services will be needed to address the growing needs of this vulnerable population.

Test of an intervention to improve knowledge of women with intellectual disabilities about cervical and breast cancer screening

BACKGROUND

There is a critical need for evidence-based health education interventions for women with intellectual disabilities (IDs) to promote receipt of preventive health screenings. Previous research has established Women Be Healthy, an 8-week classroom-style intervention designed to teach women with IDs about breast and cervical cancer screenings, as a promising practice. However, additional research is needed to determine how to further improve screening-related knowledge gains. This study aimed to test a modified version of Women Be Healthy, Women Be Healthy 2, and compare its effectiveness in increasing knowledge gains to the original intervention.

METHOD

Women living in the community across one state in the United States were randomly assigned to a treatment (n = 98), delayed treatment, (n = 35), or no intervention group (n = 65). Women in the treatment group received Women Be Healthy, and women in the delayed treatment group received the modified Women Be Healthy 2. Baseline and post-intervention interviews were conducted to measure knowledge of cervical and breast cancer screening. Knowledge scores were compared across groups.

RESULTS

Among the nine knowledge items measured, one breast knowledge measure and one cervical knowledge measure showed statistically significant group differences; marginally significant differences were observed for two other knowledge measures. After adjusting for covariates, women who received Women Be Healthy 2 had increased knowledge overall compared with the women receiving no intervention.

CONCLUSION

Women Be Healthy 2 is promising, but additional efforts appear necessary to increase the knowledge women with IDs have about cervical and breast cancer screening.

Promoting health of people with intellectual disabilities: Views of professionals working in group homes

Deinstitutionalisation has influenced the life situation for people with intellectual disabilities, whilst the experiences of health promotion in group homes now are limited. This study aimed to explore aspects important to consider when promoting health amongst persons with intellectual disabilities in group homes, from the perspective of professionals. Semi-structured interviews were conducted with seven professionals and were analysed with thematic analysis. The overarching theme 'sense of security' was identified as a prerequisite for health promotion, together with the sub-themes 'resources in the organisation', for example, respectful treatment of the residents, and `resources of the residents', for example, meaningfulness and social connectedness. Findings were discussed from the perspective of health assets which is defined as the factors contributing to maintain and sustain health. The importance of strengthening external assets, that is, resources in the society and the organisation, to promote internal assets, that is, residents' individual resources, and ultimately their health, is emphasised.

The state of the science of health and wellness for adults with intellectual and developmental disabilities

Historically, people with intellectual and developmental disabilities (IDD) have experienced health disparities related to several factors including: a lack of access to high quality medical care, inadequate preparation of health care providers to meet their needs, the social determinants of health (e.g., poverty, race and gender), and the failure to include people with IDD in public health efforts and other prevention activities. Over the past decade, a greater effort has been made to both identify and begin to address myriad health disparities experienced by people with IDD through a variety of activities including programs that address health lifestyles and greater attention to the training of health care providers. Gaps in the literature include the lack of intervention trials, replications of successful approaches, and data that allow for better comparisons between people with IDD and without IDD living in the same communities. Implications for future research needed to reduce health disparities for people with IDD include: better monitoring and treatment for chronic conditions common in the general population that are also experienced by people with IDD, an enhanced understanding of how to promote health among those in the IDD population who are aging, addressing the health needs of people with IDD who are not part of the disability service system, developing a better understanding of how to include people with IDD in health and wellness programs, and improving methods for addressing the health care needs of members of this group in an efficient and cost-effective manner, either through better access to general medical care or specialized programs.

The National Task Group on Intellectual Disabilities and Dementia Practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities

Adults with intellectual and developmental disabilities (I/DD) are increasingly presenting to their health care professionals with concerns related to growing older. One particularly challenging clinical question is related to the evaluation of suspected cognitive decline or dementia in older adults with I/DD, a question that most physicians feel ill-prepared to answer. The National Task Group on Intellectual Disabilities and Dementia Practices was convened to help formally address this topic, which remains largely underrepresented in the medical literature. The task group, comprising specialists who work extensively with adults with I/DD, has promulgated the following Consensus Recommendations for the Evaluation and Management of Dementia in Adults With Intellectual Disabilities as a framework for the practicing physician who seeks to approach this clinical question practically, thoughtfully, and comprehensively.

A case report for diagnosing anxiety in people with intellectual disability: the role of nurses in the application of a multidimensional diagnostic guideline

PURPOSE

The purpose of this article is the presentation of a multidimensional guideline for the diagnosis of anxiety and anxiety-related behavior problems in people with intellectual disability (ID), with a substantial role for the nurse in this diagnostic process.

DESIGN AND METHODS

The guideline is illustrated by a case report of a woman with ID with severe problems.

FINDINGS

It appears that a multidimensional diagnostic approach involving multidisciplinary team efforts can result in a more accurate diagnosis and improved subsequent treatment.

PRACTICE IMPLICATIONS

Nurses should be engaged in the diagnostic process because of their ability to make direct observations and to actively participate in carrying out all parts of the guideline.

Cost as a barrier to dental care among people with disabilities: a report from the Florida behavioral risk factor surveillance system

Many individuals who have disabilities or complex health conditions do not have adequate access to comprehensive oral health care. An examination of the literature indicates a variety of contributing factors. This study reports on cost of care as a barrier to oral health care. Data from the 2007 Florida Behavioral Risk Factor Surveillance System (BRFSS) were used (n = 33,777). Respondents who reported activity limitation or the use of special equipment were considered to have a disability. Lack of access to dental care due to cost during the past year was assessed. More individuals with a disability reported not seeing a dentist due to cost versus people without disabilities (30% vs. 16%). After adjusting for confounding variables, Floridians with disabilities were 60% more likely to report cost as a barrier to dental care (OR = 1.60, 95% CI 1.32-1.94). Cost of dental care is an access to oral health barrier for Floridians with disabilities. Improving access to dental care for this population will require consideration of financial issues.

Nursing perspectives on cancer screening in adults with intellectual and other developmental disabilities

Health care disparities have been documented in cancer screenings of adults with intellectual and other developmental disabilities. Developmental disabilities nurses were surveyed to better understand and improve this deficiency. Two thirds of respondents believed that adults with intellectual and developmental disabilities received fewer cancer screenings compared with the general population. The most frequently cited barriers to cancer screenings were as follows: patient need for sedation, unsuccessful attempts at screening, and failure of the primary care clinician to order cancer screening tests. Nurses observed that health care providers frequently did not tailor cancer screening recommendations to individuals' family histories, life expectancies, or their disability-specific cancer risks. The authors suggest interventions to improve cancer screening centered around education and training, accessibility, financing-insurance, modification of procedures, and patient tracking.

Are women with functional limitations at high risk of underutilization of mammography screening?

OBJECTIVES

Women with functional limitations face obstacles in adhering to established mammography guidelines owing to personal factors and barriers within the health care system. Whereas some studies have focused on either physical or cognitive limitations that correlate with lower rates of cancer screening, this study examined multiple functional limitations (physical, psychological, and sociability) and mammography screening.

METHODS

Data from the 2000 National Health Interview Survey were analyzed for 9,505 women aged > or =40 years. We hypothesized that women with functional limitations (physical, psychological, and/or sociability) are less likely to receive screening mammography. Access variables (insurance coverage and usual source of health care) and utilization variables (physician contact and receipt of clinical breast examination) were included. Using multiple logistic regression (MLR), we estimated the relative contribution of functional limitations on mammography use after accounting for sociodemographic characteristics and confounding variables.

RESULTS

An estimated 34.6% of women had physical limitations, 16.1% sociability limitations, and 8.1% psychological limitations. After controlling for all other variables, MLR analysis indicated that women with moderate or severe sociability limitations were less likely than their unimpaired counterparts to utilize mammography (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.48-0.81). Interestingly, women with severe physical limitations were more likely than physically able women to utilize mammography screening (OR, 1.28; 95% CI, 1.07-1.53). Women with no insurance, no usual care, and no doctor's visit within the past year were substantially less likely to use mammography screening.

CONCLUSIONS

Sociability limitations, lack of access to health care, and limited regular checkups played significant roles in underutilization of screening mammography.

Health indicators and intellectual disability

PURPOSE OF REVIEW

Health disparities are evident between people with intellectual disabilities and the general population. Despite the potential of indicators for measuring disparities and planning interventions to address inequalities- currently a priority health policy target- few studies have mapped the physical or mental health of people with intellectual disabilities onto the growing territory of health disparities, health information systems and health indicators. This review summarizes recent publications about the role of indicators in gathering optimal health information on behalf of this segment of the population.

RECENT FINDINGS

Studies related to measures of the health of people with intellectual disabilities are presented in three sections: information captured in general population surveys; measures of health status of people with intellectual disabilities at country and regional levels; and their use of healthcare systems. The work of the Pomona group of European partners who have devised and applied a set of health indicators specifically for people with intellectual disabilities is presented.

SUMMARY

Health indicators yield data to identify health conditions, plan interventions and compare populations or segments of the population. It is suggested that better definitions, measures and surveillance will yield comparable information to inform public health policy and clinical practice.

Emerging policy challenges in intellectual disabilities

The forces shaping intellectual disability policy-making are diverse; while many of the policy issues reviewed in this issue are specific to intellectual disabilities, there are others that transcend disability-specific concerns. Our review is organized around six emerging demographic and socio-cultural trends that may directly and profoundly impact the intellectual disability field: aging, changing labor markets, immigration, families, federalism, and culture. Each of these trends is discussed in terms of their relevance and potential impact on disability policy.