Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States

Specialist use among privately insured children with disabilities

OBJECTIVE

To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities.

DATA SOURCES AND STUDY SETTING

A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study.

STUDY DESIGN

This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns.

DATA COLLECTION/EXTRACTION METHODS

This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm.

PRINCIPAL FINDINGS

Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001.

CONCLUSIONS

Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures

BACKGROUND

Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes.

METHODS

We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics.

RESULTS

Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay.

CONCLUSION

Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

Internal Medicine Program Directors' Perceptions About Accommodating Residents with Disabilities: A Qualitative Study

BACKGROUND

While 26% of US adults are disabled, only 3.1 to 9.3% of practicing physicians report having a disability. Ableism within medical training and practice diminishes physician diversity and wellbeing and contributes to healthcare disparities.

OBJECTIVE

Explore physician barriers to disability equity and inclusion by examining internal medicine (IM) program directors' (PD) perspectives about recruiting and accommodating residents with disabilities (RWD).

DESIGN

Qualitative study involving semi-structured virtual interviews (conducted December 2022-September 2023; analyzed through December 2023).

PARTICIPANTS

PDs were recruited via email. Purposive sampling captured program diversity in size, location, and affiliations. Convenience sampling ensured PD diversity by gender, race/ethnicity, and age.

APPROACH

Coders analyzed thematic and discursive content of interview transcripts to characterize PD perspectives about RWDs and accommodations.

KEY RESULTS

Of the 15 programs represented, 4 had ≤ 49 and 8 had ≥ 100 total residents. Three were community-based; the rest had academic affiliations. On average, PDs had 17 (SD 8.2) years in practice. Most (11/15) identified as White race; 8/15 as female; and none as disabled. PDs characterized disability as a source of grit and empathy but also as an intrinsic deficit. They worried RWDs could have unpredictable absences and clinical incompetencies. Perceived accommodation challenges included inexperience, workload distribution, information asymmetry about accommodation needs or options, barriers to disclosure (e.g., discrimination concerns), and insufficient accommodation advertising. Perceived facilitators included advanced planning; clear, publicized processes; and access to expertise (e.g., occupational health, ombudsmen).

CONCLUSIONS

PDs held contradictory views of RWDs. PD insights revealed opportunities to alleviate PD-RWD information asymmetry in recruitment/accommodation processes, which could help align needs and improve representation and inclusion.

Medical care use and mortality rate after the onset of disability: A 6-year follow-up study based on national data in Taiwan

BACKGROUND

The onset of disability is a major health challenge, and people with disability can be particularly underserved in the years immediately after the disability onset.

OBJECTIVE

To analyze the excess mortality rate of people with recent-onset disability and their health-care utilization during the period after disability onset (1-6 years after onset).

METHODS

We used whole-population claims data from 2015 to 2020 (for approximately 23 million individuals) from Taiwan's National Health Insurance (NHI) system. These NHI claims data were linked to the National Death Records and National Disability Registry. Each individual with a disability was followed until their death or December 31, 2020. The age-standardized mortality rate and outpatient and inpatient utilization were compared between individuals with and without disability. Finally, Cox regressions were estimated to determine excess mortality for the individuals with disability.

RESULTS

The age-standardized mortality rates for the people with disability and those without disability were 1020.35/10,000 and 463.83/10,000, respectively. The people with disability utilized significantly more medical care under the NHI system. Mortality rates differed substantially among disability types. The Cox regression revealed a hazard ratio of 1.47 (95% CI = 1.46, 1.48) for all-cause mortality for people with disability, and significant sex differences in mortality risk were observed for some causes of death.

CONCLUSION

According to the excess mortality rates within 6 years of disability onset observed in this study, the NHI may not be sufficient to reduce health disparity between people with and without disabilities. In addition, specific characteristics of each type of disability should be considered.

Influenza epidemiology and treatment in people with a visual disability: A retrospective cohort study

BACKGROUND

Visual disabilities (VD) are expected to rise with an aging population. Persons with VD experience a higher prevalence of chronic and acute diseases. Despite the significance of influenza to this population, there is limited data comparing influenza care disparities between those with VD and those without.

OBJECTIVE

The study aimed to determine the influenza burden and associated healthcare utilization in individuals with VD compared to those without disabilities.

METHODS

A retrospective cohort study was conducted using the Korean National Health Information Database, encompassing three influenza seasons (2011-2012 to 2013-2014). The influenza incidence and incidence rate ratio (IRR) was calculated. Adjusted IRRs were calculated using a zero-inflated Poisson model. We assessed the risk of admissions and 30-day post-influenza mortality, employing logistic regression or survival analysis.

RESULTS

A total of 504,374 patients (252,964 patients with VD and 251,410 controls) were followed for 1,471,480 person-years. The influenza incidence was higher in the VD cohort than in the control (8.8 vs. 7.8 cases per 1000 person-years). VD cohort had a higher influenza IRR (adjusted IRR 1·13, 95% confidence interval [CI] 1·02-1·25). Severe VD exhibited higher hospitalization risk (adjusted odds ratio [OR] 1·29, 95% CI 1·10-1·20) and increased medical costs. Severe VD was a significant risk factor for mortality (adjusted Hazard Ratio 1·89, 95% CI 1·04-3·45).

CONCLUSIONS

People with VD have a higher influenza incidence, while their outcomes are comparable to those without. Nevertheless, severe VD significantly contributes more to hospitalization, mortality, and medical costs than controls.

Behavioral weight loss interventions for people with physical disabilities: A systematic review

AIM

The aim of this study is to examine which interventions lead to clinically significant weight loss among people with physical disabilities.

METHODS

We systematically searched three electronic databases (PubMed, Scopus, and CENTRAL) including studies until May 2022 to find randomized controlled trials on behavioral interventions and weight-related outcomes in people with physical disabilities. Pharmacological or surgical interventions were excluded. Study quality was evaluated using the Cochrane Risk of Bias Tool. Interventions were grouped as dietary, physical activity, education/coaching, or multi-component. Mean weight changes, standard deviations, confidence intervals, and effect sizes were extracted or calculated for assessment of the intervention effect.

RESULTS

Sixty studies involving 6,511 participants were included in the qualitative synthesis. Most studies (n = 32) included multi-component interventions, incorporating dietary and physical activity components. Limited evidence suggests that extensive dietary interventions or long-term multi-component interventions might lead to a clinically relevant weight reduction of at least 5% for older individuals (age > 50) with mild-to-moderate mobility impairments.

DISCUSSION

Due to the high heterogeneity of studies and low study quality, it can be assumed that the range of applicability of the findings is questionable. Further research should examine younger age groups (i.e., children, adolescents, and adults under 40 years) and compare different settings such as schools, clinics, nursing homes, and assisted living facilities.

Exploring the healthcare access challenges faced by visually impaired young women in Nepal: Navigating sexual harassment and stigma within healthcare settings

Introduction

Despite global progress in gender equality, still not every woman has access to safe and the highest quality health care. Visually impaired young adult women represent one of the most vulnerable groups with a poorer ability to access necessary healthcare services. This study aims to explore and comprehend the experiences of visually impaired young adult women in accessing healthcare services in Nepal.

Methods

A descriptive phenomenological study was conducted among 16 visually impaired women aged 20 to 35 years who had utilized healthcare services within the past 12 months. Face-to-face, in-depth interviews were conducted for data collection, and thematic analysis was conducted for data analysis.

Results

Our study revealed a range of challenges faced by visually impaired young women that impeded their healthcare-seeking. These challenges included sexual harassment by male healthcare providers, disability-related stigma, financial difficulties, limited autonomy in decision-making, and a lack of disability-friendly healthcare facilities and services. Particularly, experiencing sexual harassment from male healthcare providers, coupled with underlying disability-related stigma, profoundly influenced the avoidance of healthcare. To navigate these challenges, some women sought support by having family members or friends accompany them or by requesting to be seen by a female healthcare provider. Nevertheless, financial dependence on families and women lacking employment and income led to a feeling of burden on the family, contributing to a reluctance among women to seek expensive healthcare. Social organization-based, collaborative efforts and peer support networks played a significant role in breaking down barriers and improving overall healthcare experiences.

Conclusions

While integrating disability-friendly healthcare services and infrastructure is essential, fostering attitudinal and behavioral change-particularly among male healthcare providers-is more important to ensure safety for young women in healthcare settings. The implementation of anti-sexual harassment policies is imperative to ensure a safe and respectful environment. Community mobilizing and peer group-based programs can be tested for increasing visually impaired women's utilization of relevant healthcare services.

Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018

OBJECTIVE

Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance.

METHODS

This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination.

RESULTS

Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]).

CONCLUSIONS

CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.

Comparison of Participation in Strength Activity Among People With and Without Disabilities: 2013-2017 Behavioral Risk Factor Surveillance System

BACKGROUND

The current physical activity guidelines recommend engagement in strength activities at least 2 days per week. Currently, there is a lack of literature examining strength activities among people with disabilities. The purpose of this study is to estimate and compare the prevalence of engagement in strength activities and adherence to strength activity guidelines among adults with and without disabilities in the United States.

METHODS

A total of 1,005,644 adults (18-80 y old) with and without disabilities from the 2013 to 2017 Behavioral Risk Factor Surveillance System were included in this secondary data analysis. Descriptive analyses were performed to describe the prevalence of strength activity behaviors of adults with and without disabilities. Logistic and Poisson regression models were performed to evaluate the relative contribution of disability status on strength activity behaviors.

RESULTS

A higher proportion of participants without disabilities (46.42%, 95% CI, 46.18-46.65) reported engaging in strength activities compared with participants with disabilities (30.68%, 95% CI, 30.29-31.08; P < .01). Participants with disabilities were less likely to engage in strength activities (odds ratio = 0.51, 95% CI, 0.50-0.52; adjusted odds ratio = 0.75, 95% CI, 0.73-0.77) and meet strength activity guidelines (odds ratio = 0.56, 95% CI, 0.54-0.57; adjusted odds ratio = 0.75, 95% CI, 0.73-0.77) than participants without disabilities.

CONCLUSION

Experiencing a disability is associated with lower engagement in strength activities; thus, it is important to identify effective and efficient approaches to promoting strength activities among people with disabilities.

Come Roll with Me: An Interprofessional Experience to Promote Disability Awareness

Problem: One in four American adults have a disability, which makes people with disabilities the largest minority group in the United States (U.S.). Chronic diseases are prevalent within this population, which faces myriad barriers that limit access to healthcare and create significant health care disparities. Yet, disability awareness programs are limited in U.S. medical schools and graduates report a sense of unpreparedness to care for this population. Intervention: Come Roll with Me (CRWM) was implemented as an interprofessional, preclinical experience to provide medical and Doctor of Physical Therapy (DPT) students an opportunity to engage with wheelchair users and one another. Students rotated through four stations with a licensed physical therapist and wheelchair user facilitator. Stations included (1) manual wheelchair self-propulsion, (2) accessible parking, (3) transfers, and (4) open dialog on barriers to healthcare led by the wheelchair user. Context: This study sought to assess the impact of CRWM on students' understanding of the barriers and health disparities faced by individuals with disabilities. Assessment was conducted using course evaluations, thematic analysis of student reflection essays and a focus group with the wheelchair user facilitators to determine if CRWM met pre-implementation program goals and objectives, including the Interprofessional Educational Collaborative (IPEC) core competencies. Impact: Student reflections from both disciplines indicated that learners were able to identify a variety of barriers faced by people with disabilities and prioritize methods to mitigate these factors. Approximately 91% of medical students agreed or strongly agreed that CRWM was effective in their learning on course evaluations. Wheelchair user facilitators noted three important outcomes of CRWM: educating, teaming, and impact on students. Lesson Learned: Come Roll with Me is a robust educational activity, as evidenced by the program meeting all goals and objectives as well as (IPEC) core competencies. It provides students a unique opportunity to learn about disability from another profession and wheelchair users. People with disabilities and DPT students are a unique and underutilized pool of educators in undergraduate medical education.

Counting disability in the National Health Interview Survey and its consequence: Comparing the American Community Survey to the Washington Group disability measures

BACKGROUND

The objective of the National Health Interview Survey (NHIS) is to provide data that can be used to monitor the health of the US population.

OBJECTIVE

In this study, we evaluate whether the disability questions currently used in the NHIS - the Washington Group questions - threaten the ability of this survey to fulfil its stated objective for disabled people.

METHODS

Data were from the 2011-2012 NHIS with linkage to mortality status through 2019. We examined whether people who reported a disability in the American Community Survey disability questions had their disability counted in the Washington Group questions. We then examined the consequence of use of the Washington Group as opposed to the American Community Survey questions, on estimates of disability prevalence and comparative mortality risk.

RESULTS

We find that when compared to their predecessor, the American Community Survey disability questions, the Washington Group questions accounted for less than half of disabled people, primarily counting disabled people with more than one disability status, but not counting many disabled people with only one disability status. As a result of this undercount, disability prevalence rates based on the Washington Group questions underestimate the size of the disabled population in the US, and overestimate the comparatively higher mortality risk associated with disability status.

CONCLUSIONS

These results underscore the need to re-evaluate the disability questions used in the NHIS, and invest in the development of improved and expanded disability questionnaires for use in national surveys.

Remote delivery of a weight management intervention for adults with intellectual disabilities: Results from a randomized non-inferiority trial

BACKGROUND

Remote delivery of multi-component weight management interventions results in clinically meaningful weight loss in adults without intellectual disabilities (ID), but the effectiveness of remotely delivered weight management interventions in adults with ID has not previously been evaluated.

OBJECTIVE

To determine if a weight management intervention delivered remotely could achieve weight loss (kg) at 6 months that is non-inferior to in-person visits in adults with ID and overweight or obesity (BMI ≥25 kg/m2).

METHODS

Participants were randomized to a 24-mo. trial (6 mos weight loss,12 mos weight maintenance, 6 mos. no-contact follow up) to compare weight loss achieved with the same multicomponent intervention delivered to individual participants in their home either remotely (RD) or during face-to-face home visits (FTF).

RESULTS

One hundred twenty adults with ID (∼32 years of age, 53 % females) were randomized to the RD (n = 60) or the FTF arm (n = 60). Six-month weight loss in the RD arm (-4.9 ± 7.8 kg) was superior to 6-month weight loss achieved in the FTF arm (-2.1 ± 6.7 kg, p = 0.047). However, this may be partially attributed to the COVID-19 pandemic, since weight loss in the FTF arm was greater in participants who completed the intervention entirely pre-COVID (n = 33,-3.2 %) compared to post-COVID (n = 22, -0.61 %). Weight loss across did not differ significantly between intervention arms at 18 (p = 0.33) or 24 months (p = 0.34).

CONCLUSION

Our results suggest that remote delivery is a viable option for achieving clinically relevant weight loss and maintenance in adults with ID.

NCT REGISTRATION

NCT03291509.

Paving the Way to Active Living for People with Disabilities:: Evaluating Park and Playground Accessibility and Usability in Delaware

Objectives

To evaluate the accessibility and usability of parks and playgrounds in New Castle County, Delaware, for people with disabilities, with a particular focus on identifying environmental barriers that may impede access to these public spaces and potentially affect physical activity (PA) participation for the chronic disease prevention and mitigation.

Methods

Using a cross-sectional observational design, teams of trained University of Delaware students utilized the Community Health Inclusion Index (CHII) Tool to assess the accessibility of ten suburban and urban parks and playgrounds from April to November 2023. The tool evaluated various elements of public spaces, including public transit, parking, pathways and multi-use trails, entrances, playground equipment, and health promotional materials. Descriptive statistics were calculated for the accessibility and usability of each element.

Results

Significant barriers to accessibility and usability were identified. Over half of the sites lacked nearby public transit stops, and many trails and playgrounds were not fully accessible to people with disabilities. While some areas demonstrated good accessibility, such as well-maintained pathways and appropriately designed crosswalks, barriers like uneven surfaces, insufficient curb cuts, and inadequate van-accessible parking spaces were common. Most playgrounds lacked equitable play equipment, with less than half having ground materials suitable for mobility devices.

Conclusions

The study underscores the need for substantial improvements in the design, construction, and maintenance of Delaware parks and playgrounds to better support people with disabilities. Enhancing accessibility is crucial for promoting PA participation. The findings support the development of inclusive recreational and PA environments, aligning with the Americans with Disabilities Act, to reduce chronic disease health disparities faced by people with disabilities.

Policy Implications

This study highlights the need for revised policy measures to enhance park accessibility, advocating for infrastructure improvements and inclusive designs to ensure equitable recreation and physical activity opportunities for people with disabilities.

Economic precarity and changing levels of anxiety and stress among Canadians with disabilities and chronic health conditions throughout the COVID-19 pandemic

Early in the COVID-19 pandemic, multiple event stressors converged to exacerbate a growing mental health crisis in Canada with differing effects across status groups. However, less is known about changing mental health situations throughout the pandemic, especially among individuals more likely to experience chronic stress because of their disability and health status. Using data from two waves of a targeted online survey of people with disabilities and chronic health conditions in Canada (N = 563 individuals, June 2020 and July 2021), we find that approximately 25% of respondents experienced additional increases in stress and anxiety levels in 2021. These increases were partly explained by worsening perceived financial insecurity and, in the case of stress, additional negative financial effects tied to the pandemic. This paper understands mental health disparities as a function of social status and social group membership. By linking stress process models and a minority stress framework with a social model of disability, we allude to how structural and contextual barriers make functional limitations disabling and in turn, life stressors.

Weight history of individuals with and without physical disability in the International Weight Control Registry

Background

People with physical disabilities (PWD) have an increased risk of obesity and related comorbidities compared with people without physical disabilities (PWoD). Previously identified contributors to weight loss maintenance pose challenges to PWD. However, it is not known if PWD experience less success in weight management.

Methods

Six hundred and nine participants in the International Weight Control Registry (IWCR) were eligible for this analysis (PWD, n = 174; PWoD, n = 435). Self-reported weight history metrics were compared using general linear models. Perceived weight history category was compared using Chi-squared tests. Importance of diet and physical activity strategies for weight management were compared using Wilcoxon rank-signed tests.

Results

PWD reported higher current body mass index (BMI) (36.1 ± 0.7 vs. 31.0 ± 0.5; p < 0.0001) and more weight loss attempts (9.1 ± 0.7 vs. 7.1 ± 0.4; p = 0.01) than PWoD. Current weight loss percentage (PWD 13.0 ± 1.0; PWoD, 13.0 ± 0.6; p = 0.97) and weight loss category (χ 2 [3, N = 609] = 2.9057, p = 0.41) did not differ between the groups. There were no differences in any weight strategy between PWD who were successful and those who regained.

Conclusions

PWD and PWoD in the IWCR achieved similar levels of weight maintenance success. However, higher BMI and more weight loss attempts suggest that PWD may face challenges with weight management. More research is needed to identify strategies leading to success for PWD.

Smoking cessation interventions for U.S. adults with disabilities: A systematic review

INTRODUCTION

People with disabilities disproportionately use tobacco products. However, little is known about cessation interventions tailored for people with disabilities. The objective of this study was to conduct a systematic review of smoking cessation interventions for adults with disabilities.

METHODS

Six electronic databases (Cochrane, CINAHL Plus [EBSCOhost], Embase [Ovid], Medline [Ovid], PsycINFO [Ovid], and Web of Science) were searched to identify eligible interventions for people with disabilities (e.g., vision, hearing, mobility, communication, cognition, self-care) through July 2023. Two independent coders evaluated the records and extracted data from studies that met inclusion criteria. Qualitative synthesis was conducted on the included studies in 2023.

RESULTS

One randomized controlled trial and one nonrandomized study met the inclusion criteria. Both studies used mindfulness-based procedures to reduce cigarette use in adults with mild intellectual disability. The outcome was defined as self-reported cigarette use at follow-up, which ranged from 1 year to 3 years. Limited information was provided on how the interventions were tailored to meet the unique needs of people with disabilities in either study.

CONCLUSION

Two interventions conducted in adults with mild intellectual disability showed promising results using mindfulness-based procedures; however, the studies did not address barriers reported by people with disabilities, nor tailor the interventions to meet the needs of the target population. Research is needed to address tobacco use disparities among people with a range of disabilities. Current cessation interventions would be enhanced by integrating disability identifiers alongside other demographic information in future studies and reporting subgroup analyses in adults with disabilities.

[Oncologic Care of Breast Cancer Patients with Preexisting Disabilities: Results of a Qualitative Study on Perceived Barriers, Communication Difficulties, and Needs]

Up to now, people with disabilities have received little consideration in health care with regard to their individual needs. This study gathers information on the internal perspective of breast cancer patients with a pre-existing disability with regard to needs and barriers in oncological care. For this purpose, qualitative, guideline-based interviews were conducted and analysed using qualitative content analysis. Twenty-three patients with physical disabilities, chronic physical illnesses, sensory disabilities, mental illnesses and/or intellectual disabilities were included. Depending on the type of disability, patients faced different barriers. In order to reduce the barriers experienced by people with disabilities in care, it is necessary to promote cooperation between care providers from different care sectors and to train care providers in dealing with people with disabilities.

Is there a sexual difference in the relationship between sociodemographic information and the unmet dental care needs of disabled adults? An analysis from a national survey on persons with disabilities

BACKGROUND

Health status and health care utilization in people with disabilities are more likely to be poorer than those without disabilities. Previous studies showed that there were gaps in health-related conditions by sociodemographic information and gender but the association between these factors was not explained. This study aims to analyze the relationship between sociodemographic information and the unmet dental care needs of people with disabilities and explore the effect of sex within this relationship.

METHODS

The 2014 national survey on persons with disabilities was used, which separated unmet healthcare needs into medical and dental services. Unweighted samples included 6,824 people with disabilities in total and 6,555 (96.1% of the total, weighted as 6,583) people aged 20 years or older were selected as the study population. Frequency and chi-square tests were conducted to determine differences in the prevalence of unmet dental needs based on socioeconomic information, chronic diseases, and behavioral factors after applying weights. Logistic regressions were performed using an adjusted model with sociodemographic information, chronic diseases, and behavioral variables. All analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA).

RESULTS

Analysis of the sociodemographic factors related to unmet dental care revealed that they were higher in women and the elderly. In the fully adjusted logistic model, most of the sociodemographic information was significantly associated with unmet dental needs. The lowest group was 4.18 times more likely to have unmet dental care needs than the richest group, and females and middle-school graduates were almost twice as likely to experience unmet dental care needs than males and university graduates. Considering the interaction effect of age on unmet dental needs depending on sex differences, the odds ratio decreased for females with every annual increase in both models. Compared with the younger group, the older group showed a lower risk of having unmet dental needs, especially in females.

CONCLUSIONS

The factor most closely related to the unmet dental care needs of disabled people was socioeconomic problems. Its influence also differed by sex and age. Therefore, economic support measures and sexual differences are needed for long-term policy consideration to reduce the unmet dental care needs of disabled people.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status

BACKGROUND

Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits.

OBJECTIVE

This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status.

METHODS

Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response.

RESULTS

Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP.

CONCLUSIONS

Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

Diet quality, diet-related factors and disability status among male adults of reproductive age in the USA

OBJECTIVE

To examine diet quality and diet-related factors among male adults of reproductive age with and without disabilities.

DESIGN

Cross-sectional data from the National Health and Nutrition Examination Surveys, 2013-2018.

SETTING

Disability was reported as serious difficulty hearing, seeing, concentrating, walking, dressing and/or running errands due to physical, mental or emotional conditions. Diet quality was assessed by the Healthy Eating Index (HEI)-2015 and diet-related factors included self-rated diet healthfulness, food security and food assistance programmes. Multivariable linear regression estimated differences in HEI-2015 scores. Multivariable Poisson regression estimated adjusted prevalence ratios (aPR) and 95 % CI for diet-related factors.

PARTICIPANTS

In total, 3249 males, 18-44 years; of whom, 441 (13·4 %) reported having disabilities.

RESULTS

Compared with males without disabilities, those with disabilities had a 2·69-point (95 % CI: -4·18, -1·20) lower mean total HEI-2015 score and approximately one-third to half of a point lower HEI-2015 component scores for greens and beans, total protein foods, seafood and plant proteins, fatty acids and added sugars. Males with any disabilities were more likely to have low food security (aPR = 1·57; 95 % CI: 1·28, 2·92); household participation in food assistance programmes (aPR = 1·61; 95 % CI: 1·34, 1·93) and consume fast food meals during the previous week (1-3 meals: aPR = 1·11; 95 % CI: 1·01-1·21 and 4 or more meals: aPR = 1·18; 95 % CI: 1·01-1·38) compared with males with no disabilities.

CONCLUSIONS

Factors affecting diet and other modifiable health behaviours among male adults of reproductive age with disabilities require further investigation. Health promotion strategies that are adaptive to diverse populations within the disability community are needed.

Impairment and Disability Identity and Perceptions of Trust, Respect, and Fairness

Importance

Most studies use impaired functioning alone to specify populations with disabilities. However, some people with functional impairments do not identify as disabled. With functional status-based definitions, studies have shown disparate care quality for people with disabilities.

Objective

To examine whether impairment and disability identity have different associations with perceived health care experiences and explore factors associated with disability identification.

Design, Setting, and Participants

This cross-sectional study used a nationally representative survey of US adults conducted from April 20 through May 31, 2021, and analyzed between June 1 and August 31, 2022. Survey participants were 1822 English- or Spanish-speaking adults responding either online or via telephone.

Exposures

Using 8 survey questions, participants were grouped according to presence of impairment and disability identity.

Main Outcomes and Measures

Likert scale measures of trust, respect, and fairness (henceforth, procedural justice measures) were dichotomized. Sociodemographic characteristics and rates of procedural justice responses were compared across groups. Multivariable logistic regressions adjusting for baseline characteristics were performed to (1) estimate associations of impairment and disability identity with perceptions of procedural justice and (2) explore factors associated with disability identification. Analyses applied survey weights.

Results

Of 6126 individuals invited to participate, 1854 (30.3%) completed the survey. Thirty-two were excluded due to unreportable gender, for a final analytic sample of 1822 participants. Participants with impairments (n = 816; mean [SD] age, 48.1 [17.0] years; 51.2% women, 48.8% men) had worse perceptions on 7 of 10 procedural justice measures (crude) compared with those without impairments (n = 1006; mean [SD] age, 49.6 [18.1] years, 55.1% female, 44.9% male). Among respondents with impairments, those who did (n = 340) vs did not (n = 476) identify as disabled gave better ratings for clinician communication efforts (a lot of effort, 38.8% vs 31.0%) and having health goals understood (understood very or fairly well, 77.2% vs 70.1%) but gave worse ratings for respect (almost never felt inferior or talked down to, 66.1% vs 59.1%). Disability identification was associated with more reports of unfair treatment (31.0% vs 22.4%; adjusted odds ratio, 1.65; 95% CI, 1.12-2.42) and of being unafraid to ask questions or disagree (50.5% vs 40.1%; adjusted odds ratio, 1.51; 95% CI, 1.04-20.19). Income and employment were associated with disability identification.

Conclusions and Relevance

In this cross-sectional survey study of US adults, health care perceptions differed between groups defined by impairment status and disability identity. These findings suggest that, alongside functional measures, health systems should capture disability identity to better address disparities for people with impairments.

Triage Procedures for Critical Care Resource Allocation During Scarcity

Importance

During the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination.

Objective

To analyze the role of comorbidities and long-term prognosis in state triage procedures.

Design, Setting, and Participants

This cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication.

Main Outcomes and Measures

Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival.

Results

Overall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term.

Conclusions and Relevance

In this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

Promoting Healthy Behaviors Among Adolescents and Young Adults With Intellectual Disability: Protocol for Developing a Digital Intervention With Co-Design Workshops

BACKGROUND

Intellectual disability (ID) is a neurodevelopmental disorder associated with a poorer health profile and higher mortality. Young people with ID have more sedentary lifestyles than their typically developing peers. Consequently, this group is at significant risk of developing lifestyle diseases (ie, noncommunicable diseases) later in life. Increasing physical activity and eating a healthier diet have been argued to be effective ways to improve the health of adolescents and young adults with ID. Digital interventions are a viable option for improving health behaviors.

OBJECTIVE

This research protocol describes a co-design approach using workshops to develop a digital intervention that promotes healthy behaviors, including increasing physical activity and eating a healthier diet, among adolescents and young adults with ID.

METHODS

A participatory design using a co-design approach will be applied as a strategy to include potential users of the digital intervention and other stakeholders in the research process, comprising research design, data collection, and data analysis. A total of 7 to 10 workshops will be conducted aimed at developing a digital intervention and will include procedures for assessing needs; facilitators and barriers to health promotion; physical, mental, and social well-being; participation; and relationships. The workshops will include 12 to 18 stakeholders with experience of clinical practice and research related to young people with ID, including relatives, as well as adolescents and young adults (aged 16-25 years) with mild to moderate ID. Participants will perform a mixture of individual and group work using whiteboards, sticky notes, felt-tip pens, cards, balls, stickers, and wireframe templates. Data analysis will take place concurrently with data collection as an iterative process. Transcribed data from the audio and video recordings of the groups' discussions will be analyzed following a qualitative methodological procedure.

RESULTS

This study protocol provides a systematic record of the scientific methodologies used when developing the digital intervention and provides insights into the potential practical solutions and challenges when following a co-design approach in which relatives and professionals, as well as adolescents and young adults with ID, are included as research partners. Recruitment of participants started in April 2023. Data collection, analysis, and reporting will be completed in December 2023.

CONCLUSIONS

This study will explore the effectiveness of workshops at gathering rich, reliable, and valid data in a co-design approach with participants. The results will provide increased knowledge in how to use technology to develop novel, evidence-based, and scalable interventions that adolescents and young adults with ID can and want to use to motivate physical activity and a healthier diet. The project will provide a simple and cognitively accessible digital solution for promoting lifestyle behaviors tailored to the needs of adolescents and young adults with ID.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47877.

Reduced lip seal strength and missing teeth are associated with poorer masticatory performance in young adults with intellectual disabilities: a cross-sectional analytical study

BACKGROUND

Alterations in oral health have a negative impact on the quality of life of persons with intellectual disabilities (PwIDs). Chewing is a process that influences and determines optimal oral health. However, little is known about how intellectual disability (ID) affects masticatory performance. This study aimed to analyse the differences in masticatory performance between young adults with IDs, young adults without IDs and older adults without IDs.

METHODS

A cross-sectional analytical design was used. The masticatory performance was evaluated with a chewing gum validated instrument. In addition, the labial and tongue strength was assessed with the Iowa Oral Performance Instrument. We compared the masticatory performance between groups using one-way analysis of covariance. Body mass index, muscle mass, missing teeth, lip strength and tongue strength were included as separate covariates. A multivariate regression analysis was performed to identify which independent variables could explain masticatory performance in each group.

RESULTS

Thirty-two PwIDs, 31 young adults without IDs and 32 older adults without IDs were recruited. PwIDs showed poorer masticatory performance compared with older adults (mean difference: -3.06, 95% confidence interval: -3.87 to -2.26) and healthy controls (mean difference: -2.38, 95% confidence interval: -3.19 to -1.57). The analysis of covariance showed significant difference between groups in the masticatory performance (F = 47.35, P < 0.001, η_p ²  = 0.507). Missing teeth (P < 0.001), right lip strength (P = 0.025) and tongue strength (P = 0.007) as covariables showed a significant interaction with the model. In the PwID group, lip strength and lack of teeth explained 58% of the variance in masticatory performance (R²  = 0.580, standard error = 1.12, P < 0.001).

CONCLUSIONS

Persons with intellectual disabilities have a poorer masticatory performance than adults without IDs. Our findings indicate that the primary determinants of optimal masticatory function in PwIDs are the strength of the lip seal and the number of missing teeth.

The somatic care of patients with comorbid mental disorders: protocol of a mixed-methods study aiming to identify barriers to and enablers of utilization of somatic healthcare (SoKo)

BACKGROUND

Healthcare for people with somatic and comorbid mental diseases can pose a challenge to the healthcare system. The aim of the SoKo study (the Somatic care of patients with mental Comorbidity) is to assess the current state of care and the facilitators and barriers of somatic care of people with somatic disorders and comorbidity of a mental disorder.

METHODS

The study is conducted as a mixed-methods approach and will include (a) descriptive and inferential analysis of secondary claims data of persons insured by a German statutory health insurance company in North Rhine-Westphalia (Techniker Krankenkasse, TK-NRW), (b) qualitative individual interviews and group discussions, and (c) based on (a) and (b), quantitative surveys of both patients and physicians. We intend to analyse a sample of claims data of about 2.6 million persons insured by TK-NRW (group comparisons between TK-NRW insured persons with a diagnosis of a prevalent somatic disease [ICD-10-GM E01-E07, E11, E66, I10-I15, I20-I25, I60-I64] with and without comorbidity of a mental disorder [F00-F99]), in order to assess the uptake of somatic care by people with mental and somatic comorbidity. In addition, primary data from patients with the aforementioned somatic illnesses and a mental comorbidity as well as primary data from physicians (general practitioners and medical specialists) will be collected. The focus here will be on support factors and barriers in the somatic care of people with mental comorbidity.

DISCUSSION

Up to now, there have been no published results of a systematic collection of both secondary and primary data on the utilisation of different care services of somatically ill patients with mental comorbidity for Germany. The present mixed-methods study aims to address this gap.

TRIAL REGISTRATION

The trial is registered with the German Clinical Trials Register DRKS: DRKS00030513. The trial was registered on 3rd February 2023.

From inequity to access: Evidence-based institutional practices to enhance care for individuals with disabilities

People with disabilities experience barriers to care in all facets of health care, from engaging with the provider in a clinical setting (attitudinal and communication barriers) to navigating a large institution in a complex health care environment (organizational and environmental barriers), culminating in significant health care disparities. Institutional policy, culture, and physical layout may be inadvertently fostering ableism, which can perpetuate health care inaccessibility and health disparities in the disability community. Here, we present evidence-based interventions at the provider and institutional levels to accommodate patients with hearing, vision, and intellectual disabilities. Institutional barriers can be met with strategies of universal design (i.e., accessible exam rooms and emergency alerts), maximizing electronic medical record accessibility/visibility, and institutional policy development to recognize and reduce discrimination. Barriers at the provider level can be met with dedicated training on care of patients with disabilities and implicit bias training specific to the surrounding patient demographics. Such efforts are crucial to ensuring equitable access to quality care for these patients.

Disparities in influenza vaccination for U.S. adults with disabilities living in community settings by race/ethnicity, 2016-2021

BACKGROUND

There is a paucity of data examining disparities in influenza vaccination at the intersection of disability and race.

OBJECTIVE

To compare the prevalence of influenza vaccination between U.S. adults (≥18 years) with and without disabilities living in community settings, and to examine changes in influenza vaccination over time by disability status and race/ethnicity groups.

METHODS

We analyzed cross-sectional data from the Behavioral Risk Factor Surveillance System (2016-2021). We calculated the annual age-standardized prevalence of influenza vaccination (last 12 months) in individuals with and without disabilities (2016-2021), and examined percentage changes (2016-2021) by groups of disability status and race/ethnicity.

RESULTS

From 2016 to 2021, the annual age-standardized prevalence of influenza vaccination was consistently lower in adults with disabilities as compared to those without disabilities. In 2016, 36.8% (95%CI: 36.1%-37.4%) of adults with disabilities had an influenza vaccine versus 37.3% (95%CI: 36.9%-37.6%) of those without disabilities. In 2021, 40.7% (95%CI: 40.0%-41.4%) and 44.1% (95%CI: 43.7%-44.5%) of adults with and without disabilities had an influenza vaccine. The percentage change in influenza vaccination from 2016 to 2021 was lower among people with disabilities (10.7%, 95%CI: 10.4%-11.0%; vs. no disability: 18.4%, 95%CI: 18.1%-18.7%). Among adults with disabilities, Asian adults reported the largest percentage increase in influenza vaccination (18.0%, 95% CI: 14.2%, 21.8%; p: 0.07), and Black, Non-Hispanics adults reported the lowest (2.1%, 95% CI: 1.9%, 2.2%; p: 0.59).

CONCLUSIONS

Strategies to increase influenza vaccination in the U.S. should address barriers faced by people with disabilities, particularly the intersectional barriers faced by people with disabilities from racial and ethnic minority groups.

Impact of social-, health-, and disability-related factors on pregnancy outcomes in women with intellectual and developmental disabilities: A population-based latent class analysis

BACKGROUND

Studies have shown women with intellectual and developmental disabilities (IDD) have elevated risks of perinatal complications, but few studies have examined how social, health, and disability-related factors affect these risks.

OBJECTIVES

To identify and describe subgroups of pregnant women with IDD according to social, health, and disability-related factors and examine the risks of perinatal complications in these subgroups compared to women without IDD.

METHODS

We performed a population-based cohort study in Ontario, Canada, of women with (n = 1922) and without (n = 1,126,854) IDD, with a singleton birth in 2003-2018. We used latent class analysis (LCA) to identify subgroups of women according to social (e.g., age), health (e.g., chronic medical conditions), and disability-related (e.g., IDD type) characteristics. Modified Poisson regression was then used to compare the risks of hypertensive disorders of pregnancy, cesarean delivery, and preterm birth across identified subgroups to women without IDD.

RESULTS

The LCA identified 4 classes of women with IDD: (1) young women who were mostly healthy and had little primary care before pregnancy (n = 253); (2) older women who were mostly healthy (n = 795); (3) young to mid-aged women who had significant comorbidities (n = 181); and (4) young women, many of whom were autistic, who had some medical comorbidities and significant psychiatric comorbidities (n = 693). Class 3 consistently had the greatest risks of perinatal complications, across all IDD groups, compared to women without IDD.

CONCLUSIONS

These findings underscore the importance of multidisciplinary care approaches tailored to the needs of at-risk women with IDD, in the preconception and perinatal periods.

COVID-19 disproportionately impacts access to basic needs among households with disabled members

BACKGROUND

The COVID-19 pandemic has disproportionately impacted disabled people, especially those who are members of marginalized communities that were already denied access to the resources and opportunities necessary to ensure health equity before the pandemic.

OBJECTIVE

Compare COVID-19 impact on basic needs access among households with and without disabled adults.

METHODS

An online survey was distributed to households with children enrolled in one of 30 socially vulnerable elementary or middle schools in San Diego County, California. We measured disability using the single-item Global Activities Limitations Indicator. We measured pandemic impacts on basic needs access using the RADx-UP common data elements toolkit. We then assessed number of impact items reported by household disability using multivariable linear regression, adjusting for household income, household size, education, parent gender, and child's ethnicity.

RESULTS

Of 304 participants, 41% had at least one disabled household member. Participants reporting a disabled household member were more likely to report challenges accessing basic needs, such as food, housing, healthcare, transportation, medication, and stable income during the pandemic (all p < 0.05). Difficulty accessing basic needs was significantly associated with household income and parent gender in the final regression model.

CONCLUSIONS

Households with a disabled member were significantly more likely to experience difficulty accessing basic needs during the COVID-19 pandemic. This has important implications for the disproportionate impact of COVID-19 on disabled people, especially those from low-income communities that already face barriers to accessing resources. To improve COVID-19 outcomes for disabled people, we must focus on meeting their basic needs.

Diving into Health: A Mixed Methods Study on the Impact of Scuba Diving in People with Physical Impairments

The impacts of scuba diving on people with physical impairments are unknown. Grounded on the social identity approach to health, the aim of this study was to test and describe the relationships between scuba diving social identity, self-efficacy, social health, psychological health, physical health, health-related quality of life (HRQOL), and disability level among recreational scuba divers with physical impairments. A mixed methods explanatory sequential design was employed. The quantitative strand used an 80-item cross-sectional survey, with the data analyzed via a path analysis. The qualitative strand used 1:1 interviews across 3 case study groups; the data were analyzed using deductive and inductive analyses. Mixing occurred via a joint display with meta-inferences. The quantitative results (n = 78) indicated that self-efficacy was a significant predictor of social health, psychological health, physical health, HRQOL, and disability level. The qualitative findings (n = 15) consisted of six themes, whereby participants described scuba as a positive social identity that provides them with meaning, purpose, and belonging. Furthermore, they described scuba diving as a positive contributor to their self-efficacy, social health, psychological health, physical health, and quality of life. During the mixing of data, the quantitative and qualitative results did not match on the influence of scuba diving social identity on self-efficacy, social health, psychological health, physical health, HRQOL, and disability level. A further analysis revealed that the range restriction impaired the conclusive quantitative evidence on the scuba diving social identity variable. The meta-inferences derived from the data integration suggest that scuba diving plays a role in the self-efficacy, health, HRQOL, and disability level among scuba divers with physical impairments. The findings point to the potential of scuba diving as a health promotion recreational activity and rehabilitation modality for people with physical impairments.

It’s time for the NIH to formally designate people with disabilities as a US health disparity population

This commentary discusses the implications of the report and recommendations of the Working Group on Diversity's Subgroup on Individuals with Disabilities, recently endorsed by the full Advisory Committee to the Director (ACD) of the National Institutes of Health (NIH). We suggest that one of these recommendations, the formal designation of people with disabilities as a US health disparity population, can be enacted immediately, which would spur new federal investment in disability-based disparities research.

Adapting an evidence-based physical activity questionnaire for people with physical disabilities: A methodological process

BACKGROUND

Practitioners and researchers often adapt tools, practices, and programs to meet the needs of culturally diverse population groups, but do not consider populations with disability. While there is some research on guidelines for adapting evidence-based programs, there is no systematic process for adapting survey instruments. Rather than creating separate instruments for people with physical disabilities (PWD), it is critical that instruments are designed to capture data on people with and without disabilities for comparison purposes. Given the disproportionately high rates of physical inactivity and obesity in PWD, we developed a methodology to adapt an evidence-based physical activity instrument.

OBJECTIVE

To create a methodology to adapt surveys to be inclusive of PWD and use the methodology to adapt an evidence-based physical activity survey.

METHODS

A framework was developed to adapt a physical activity survey instrument (International Physical Activity Questionnaire, IPAQ) to be inclusive of PWD. The framework, referred to as SAVe-IT, includes five steps: Step 1) Select survey instrument to adapt; Step 2) Adapt the survey instrument; Step 3) Verify adaptations with experts; Step 4) Implement pilot test; Step 5) Test the tool to confirm reliability.

RESULTS

The adapted IPAQ passed review by the expert panels and the pilot test (n = 20). Assessment of test-retest reliability (n = 30) yielded strong intraclass correlation coefficients of 0.950 for the total score for the whole sample, 0.950 for PWD (n = 15) and 0.952 for people without disability (n = 15).

CONCLUSIONS

The SAVe-IT framework resulted in the successful adaptation of the IPAQ and can be used in populations with and without physical disabilities.

People With Functional Disability and Access to Health Care During the COVID-19 Pandemic: A US Population-based Study

INTRODUCTION

The COVID-19 pandemic and nationwide restriction measures have disrupted health care delivery and access for the general population. There is limited evidence about access to care issues (delayed and forgone care) due to the pandemic among people with disability (PWD).

METHODS

This study used the 2020 National Health Interview Survey data. Disability status was defined by disability severity (moderate and severe disability), type, and the number of disabling limitations. Descriptive analysis and multivariate logistic regression (adjusted for sociodemographic and health-related characteristics) were conducted to estimate delayed/forgone care (yes/no) between PWD and people without disability (PWoD).

RESULTS

Among 17,528 US adults, 40.7% reported living with disability. A higher proportion of respondents with severe and moderate disability reported delaying care than PWoD (severe=33.2%; moderate=27.5%; PWoD=20.0%, P <0.001). The same was true for forgone medical care (severe=26.6%; moderate=19.0%; PWoD=12.2%, P <0.001). Respondents with a moderate disability {delayed [odds ratio (OR)=1.33, 95% confidence interval (CI)=1.19, 1.49]; forgone [OR=1.46, 95% CI=1.28, 1.67]} and a severe disability [delayed (OR=1.52, 95% CI=1.27, 1.83); forgone (OR=1.84, 95% CI=1.49, 2.27)] were more likely to report delayed medical care and forgone medical care compared with PWoD. These findings were consistent across the models using disability type and the number of limitations.

CONCLUSIONS

PWD were more likely to experience COVID-19-related delays in or forgone medical care compared with PWoD. The more severe and higher frequency of disabling limitations were associated with higher degrees of delayed and forgone medical care. Policymakers need to develop disability-inclusive responses to public health emergencies and postpandemic care provision among PWD.

Decomposing Disability Inequality in Unmet Healthcare Needs and Preventable Hospitalizations: An Analysis of the Korea Health Panel

Objectives: This study examines the inequality between people with and without disabilities regarding unmet healthcare needs and preventable hospitalization. Methods: We used the Korea Health Panel of 2016-2018; the final analytical observations were 43,512, including 6.95% of persons with disabilities. We examined the differences in contributors to the two dependent variables and decomposed the observed differences into explained and unexplained components using the Oaxaca-Blinder approach. Results: Unmet healthcare needs and preventable hospitalizations were 5.6% p (15.36% vs. 9.76%) and 0.68% p (1.82% vs. 0.61%), respectively, higher in people with disabilities than in those without, of which 48% and 35% were due to characteristics that the individual variables cannot explain. Decomposition of the distributional effect showed that sex, age, and chronic disease significantly increased disparities for unmet healthcare needs and preventable hospitalization. Socioeconomic factors such as income level and Medical aid significantly increased the disabled-non-disabled disparities for unmet healthcare needs. Conclusion: Socioeconomic conditions increased the disparities, but around 35%-48% of the disparities in unmet healthcare needs and preventable hospitalization were due to unexplained factors, such as environmental barriers.

Time Series Trend in High BMI and High Out-of-Pocket Expenditure Among Women With Disability

Health with disability is directly related not only to an individual's quality of life but also to national medical finance. This study focuses on trends in BMI and out-of-pocket (OOP) expenditure of both types of indirect cost exclusion and inclusion. Participants were women with disability (n = 3200) and women without disability (n = 53 082) among adults aged 19 and older from Korea Health Panel from 2009 to 2016. Women with disability had a higher BMI (23.9) than women without disability (22.7), and this time series trend was significant for 8 years (P < .0001). Annual OOP expenditures of both types were higher for women with disability than for women without disability (P < .0001): excluding indirect costs, $518.9 versus $649.4; Including indirect costs, $534.5 versus $681.8. The y-intercept of disability itself and slope of one unit of BMI for both types of annual OOP expenditure is significant (P < 0001): excluding indirect cost, $29.0 and $4.4; including indirect cost, $35.2 versus $4.6. In women with disability, annual OOP expenditure for both types were higher when they were physically inactive (P < .05): excluding indirect cost, $714.1 versus $823.1; including indirect cost, $746.2 versus $880.0. When physical inactivity and overweight and obesity interacted, it increased more than normal weight in dose response manner (P < .05): excluding indirect costs, $799.2 < $800.3 < $886.1; Including indirect costs, $860.2 < $845.9 < $927.5. These results suggest that women with disability are in relatively poor health. It is proposed that inequality of BMI for women with disability can be developed as an agenda from health policy.

Is health a priority? Examining health-related support needs in adults with intellectual disability through a self-determination framework

BACKGROUND

People with intellectual disabilities experience inequities in healthcare. Those are maintained by individual limitations as well as environmental factors. In this context, health needs are less likely to be expressed, identified and met.

METHOD

We led a survey in 832 adults with intellectual disabilities to identify if health was set as a priority and if so, what were their major health-related support needs (in terms of physical, social and psychological health).

RESULTS

67.1% of participants reported at least one need. Most frequently, two or more types of needs were reported with gender and living facility having an effect on whether participants would report these needs, but these did not affect which type of needs were reported.

CONCLUSIONS

Health-related support needs are highly prevalent and diversified in people with intellectual disabilities. This study emphasizes the importance to consider health as a global concept as well as the relationships between health and self-determination.

Integrated Behavioral Health in Primary Care for Adults with Complex Childhood Onset Medical and Developmental Diagnoses

Increased life expectancy for individuals with complex pediatric-onset conditions means most of this population survive into adulthood. While this is great news for individuals and their families, the traditional adult medical model must adapt to extend the care provided by specialty pediatric practices to primary care. In this paper, we introduce a model of integrated behavioral health (IBH) in a primary care practice for adults with childhood onset medical and developmental conditions. Our discussion includes the role of IBH providers (i.e., psychologists, psychiatrists, and social workers) as members of the integrated team, patient engagement and response to treatment, and innovative ways we strive to meet patient needs. Our review of electronic health records of patients seen at the UR Medicine Complex Care Center suggest that IBH is feasible and highly utilized, with 216 patients (40%) having had contact with an IBH provider on the team at least once. We discuss the challenges of meeting the longer-term needs of this complex patient population and our directions for future growth including creating peer and caregiver support networks, expanding services offered, and continued collaboration with community partners.

Health care utilization in young adults with childhood physical disabilities: a nationally representative prospective cohort study

BACKGROUND

Young people with physical disabilities face barriers to accessing health care; however, few studies have followed adolescents with physical disabilities longitudinally through the transition of care into adulthood. The objective of this study was to investigate differences in health care utilization between adolescents with physical disabilities and those without during the transition period from adolescent to adult care.

METHODS

We utilized the National Longitudinal Study of Adolescent to Adult Health, a prospective cohort study following adolescents ages 11-18 at baseline (1994-1995) through adulthood. Baseline physical disability status was defined as difficulty using limbs, using assistive devices or braces, or having an artificial limb; controls met none of these criteria. Health care utilization outcomes were measured seven years after baseline (ages 18-26). These included yearly physical check-ups, unmet health care needs, and utilization of last-resort medical care, such as emergency departments, inpatient hospital wards, and inpatient mental health facilities. Multiple logistic regression models were used to predict health care utilization, controlling for age, sex, race/ethnicity, insurance status, and history of depression.

RESULTS

Thirteen thousand four hundred thirty-six participants met inclusion criteria, including 4.2% with a physical disability and 95.8% without. Half (50%) of the sample were women, and the average age at baseline was 15.9 years (SE = 0.12). In logistic regression models, those with a disability had higher odds of unmet health care needs in the past year (Odds Ratio (OR) 1.41 95% CI 1.07-1.87), two or more emergency department visits in the past five years (OR 1.34 95% CI 1.06-1.70), and any hospitalizations in the past five years (OR 1.36 95% CI 1.07-1.72). No statistically significant differences in preventive yearly check-ups or admission to mental health facilities were noted.

CONCLUSIONS

Young adults with physical disabilities are at higher risk of having unmet health care needs and using last-resort health care services compared to their non-disabled peers.

Americans Aging With Disabilities Are More Likely to Have Multiple Chronic Conditions

Using data from the 2010 to 2017 National Health Interview survey, bivariate and multivariate regression analyses were utilized to estimate the percentage and odds of having multiple chronic conditions (two or more, three or more) among U.S. adults ages 65 and over with and without disabilities, controlling for sociodemographic factors and presence of psychological distress. Older adults with and without disabilities in the United States most frequently reported having hypertension, arthritis, and diabetes. Regression results indicate that older adults with disabilities are significantly more likely to experience two or more and three or more chronic conditions than older adults without disabilities, controlling for sociodemographic factors and health behaviors. These findings highlight a need for improvement in coordinated care that considers both disability and multiple chronic conditions in the management of patient health to support well-being in aging.

Access and engagement with places in the community, and the quality of life among people with spinal cord damage

OBJECTIVES

This study aims to investigate the association between self-reported accessibility and engagement with health services and places in the community, and quality of life (QOL) for people with spinal cord damage (SCD).

DESIGN

Cross-sectional survey.

SETTING

Community.

PARTICIPANTS

Two-hundred and sixty-six people with a SCD residing in Australia (M_age = 62.34, SD_age = 15.95).

OUTCOME MEASURE

The International Spinal Cord Injury Quality of Life Basic Data Set.

RESULTS

Univariate regressions demonstrated that accessing a higher number of places in the community was significantly associated with favorable self-reported psychological health (β = .160, P < .01), physical health (β = .144, P < .01), overall well-being (β = .206, P < .01), and QOL (β = .187, P < .01). In contrast, reporting a higher number of inaccessible places was significantly associated with unfavorable self-reported psychological health (β = -.171, P < .01), physical health (β = -.270, P < .001), overall well-being (β = -.238, P < .001), and QOL (β = -.244, P < .001). Being older and living with injury or onset of damage longer were significantly associated with favorable scores across all outcomes (P < .01) except physical health.

CONCLUSIONS

Community engagement can have a considerable impact on the self-reported health and QOL of people with SCD. Interventions aimed at increasing community engagement, particularly for people who have recently experienced SCD are warranted.

An overview of systematic reviews to determine the impact of socio-environmental factors on health outcomes of people with disabilities

People with disabilities are often subject to intersecting layers of social and economic disadvantage and other barriers that drive health inequity. As a result, they frequently experience worse health than people without disabilities, beyond the direct effects of their health condition or impairment. The aim of this overview of systematic reviews was to summarise the evidence on the impact of socio-environmental factors (i.e. social, physical or attitudinal) on the health outcomes of disabled people. A systematic search of five databases (MEDLINE, PsycINFO, Embase, CINAHL and Scopus) for English-language articles from January 2000 to April 2021 was conducted. Abstracts were screened by two reviewers and reviews were critically appraised. Key data were extracted by topic, population, disability type, critical appraisal method, socio-environmental themes and health outcomes. There were 23 systematic reviews identified examining adult (60.9%) or child and young (8.7%) disabled people, with 30.4% not specifying an age range. Reviews examined people with neurological or physical (39.1%), intellectual (17.4%), sensory (8.7%) or a range of (34.8%) disabilities. Three key health outcomes (i.e. access to healthcare, health-promoting behaviour and care quality) and several recurring socio-environmental themes related to the health outcomes of disabled people were identified. Disabled people encounter common social, physical and attitudinal factors that hinder their health outcomes in terms of access to services and quality healthcare. Many preventive health services were identified as either inaccessible or not meeting the needs of disabled people. Greater involvement of disabled people in service design and awareness raising is essential.

Adverse childhood experiences and cognitive disability in the 2019 United States behavioral risk factor surveillance system

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Adverse childhood experiences are positively associated with cognitive disability.

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The associations varied significantly by race and ethnicity.

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Larger associations were observed among Hispanic respondents.

A growing number of studies have found associations between adverse childhood experiences (ACEs) and adult well-being, with disparities between subpopulations. Limited research exists about the association between ACEs and cognitive disability, and variations by race and ethnicity. This study reports a cross-sectional analysis of 2019 Behavioral Risk Factor Surveillance System (BRFSS) data (n = 93 692) conducted in 2021. Logistic regression models examined the association between ACEs and cognitive disability (as defined by serious difficulty concentrating, remembering or making decisions because of a physical, mental, or emotional condition) and whether the association varied by race and ethnicity, adjusting for demographics, (age, gender, marital status), socioeconomic factors (income and education), and perceived general health. Exposures to 1, 2, 3, and 4 or more ACEs were associated with elevated odds of cognitive disability; the association varied by race and ethnicity (p for interaction less than 0.05). In stratified analyses, ACEs were positively associated with cognitive disability among the American Indian/Alaskan Native group, though significant only among those reporting 4 ACEs or more (OR: 2.89; 95% CI 1.25, 6.66). A dose response was observed for Black, White and Hispanic groups though the association was larger among Hispanic respondents. The elevated odds of cognitive disability associated with ACEs warrant additional research to understand mechanisms underlying this relationship across racial and ethnic groups. Additionally, interventions to prevent cognitive disability may benefit from considering ACEs across all populations, particularly among those with highest prevalence.

Gender Identity, Disability, and Unmet Healthcare Needs among Disabled People Living in the Community in the United States

Disabled adults and transgender people in the United States face multiple compounding and marginalizing forces that result in unmet healthcare needs. Yet, gender identity among disabled people has not been explored, especially beyond binary categories of gender. Using cross-sectional survey data, we explored the rates of disability types and the odds of unmet healthcare needs among transgender people with disabilities compared to cisgender people with disabilities. The rates of disability type were similar between transgender and cisgender participants with two significant differences. Fewer transgender participants identified physical or mobility disability as their main disability compared to cisgender participants (12.31%/8 vs. 27.68/581, p < 0.01), and more transgender participants selected developmental disability as their main disability compared to cisgender participants (13.85%/9 vs. 3.67%/77, p < 0.001). After adjusting for sociodemographic characteristics, the odds of disabled transgender participants reporting an unmet need were higher for every unmet need except for preventative services.

Retrospective analysis of the Special Olympics Health Promotion database for nutrition-specific variables

BACKGROUND

Studies have shown that individuals with intellectual disabilities (ID) exhibit a high prevalence of obesity and poor-quality diet. The population of individuals with ID include athletes that participate in Special Olympics.

AIM

In order to develop appropriate educational programs for the Special Olympics Athletes in Connecticut, a baseline of the various health and nutrition variables needed to be established by examining the existing data in the Special Olympics International's Health Promotion database.

METHODS

A retrospective analysis was performed using data from the Special Olympics International (SOI) Health Promotion database. The study population included athletes at least 20 years of age (n = 47,932) and divided into sub-groups of non-USA, USA and Connecticut (CT). The data was provided by SOI to the research team in a de-identified form covering the time frame of 2014-2019. The existing data was originally collected by trained SO volunteers and included age, height, weight, bone mineral density (BMD), blood pressure (BP) variables and a health habits questionnaire. In addition to basic descriptive statistics, analysis was performed using Chi Squared Analysis and ANOVA with post-hoc. A significance level of p value ≤ 0.05 was used for all analyses.

RESULTS

Results show a high prevalence of obesity, high blood pressure, low bone mineral density and a poor-quality diet across all groups. CT athletes were older and had a more even distribution by gender compared to the non-USA and USA groups. CT athletes had a high prevalence of obesity, HTN, and low BMD, as well as, a poor quality diet reflected by high frequency of consumption of sweetened beverages, fast food and snack food. CT athletes also did not consume the recommended daily servings of calcium containing foods or fruits and vegetables.

CONCLUSION

This data will be used to develop educational programs that will help to improve the overall health of Special Olympics Athletes in Connecticut.