Predicting barriers to primary care for patients with disabilities: a mixed methods study of practice administrators

Difference-attuned witnessing: Risks and potentialities of arts-based research

In this paper, we interrogate notions of affect, vulnerability and difference-attuned empathy, and how they relate to bearing witness across difference—specifically, connecting through creativity, experiencing the risks and rewards of vulnerability, and witnessing the expression of difficult emotions and the recounting of affect-imbued events within an arts-based process called digital/multi-media storytelling (DST). Data for this paper consists of 63 process-oriented interviews conducted before and after participants engaged with DST in a research project focused on interrogating negative concepts of disability that create barriers to healthcare. These retrospective reflections on DST coalesce around experiences of vulnerability, relationality, and the risks associated with witnessing one’s own and others’ selective disclosures of difficult emotions and affect-laden aspects of experiences of difference. Through analysing findings from our process-oriented interviews, we offer a framework for understanding witnessing as a necessarily affective, difference-attuned act that carries both risk and transformative potential. Our analysis draws on feminist Indigenous (Maracle), Black (Nash) and affect (Ahmed) theories to frame emerging concepts of affective witnessing across difference, difference-attuned empathy, and asymmetrical vulnerability within the arts-based research process.

Identification of targets for improving access to care in persons with long term physical disabilities

BACKGROUND

People with long-term physical disability (LTPD) continue to experience difficulties in accessing health care despite the focus of highlighting disparities in the last two decades.

OBJECTIVES

To describe health care utilization, accommodations and barriers experienced while accessing health care, and reasons why individuals delay or skip health care among people with LTPD.

METHODS

The current study was a part of a larger longitudinal survey administered to individuals with physical disability associated with one of four long-term conditions (MS; SCI; PPS; MD). Measures included demographics, health care utilization, barriers to health care, and reasons for delaying or skipping medical care from the sixth wave of data from 2015 to 2016.

RESULTS

Roughly 90% of all participants (N = 1159) saw at least one medical provider within 12 months. The most encountered barrier participants reported experiencing within that time was an office that did not have a safe transfer device to move them to an exam table (69%). Participants' physical function, quality of life, status of living with a spouse, diagnostic condition, and sex (male) were significantly associated with endorsing a barrier in accessing health care. The inability to afford out of pocket expenses was the highest reported reason for delaying health care.

CONCLUSIONS

People with LTPD access a variety of health care, including rehabilitation services, and continue to experience barriers when doing so. While understanding barriers individuals experience when accessing health care is important, it is equally important to document the type of care they delay or skip due to barriers.

Use of Accessible Examination Tables in the Primary Care Setting: A Survey of Physical Evaluations and Patient Attitudes

BACKGROUND

Accessible diagnostic equipment, including height-adjustable examination tables, is necessary to accommodate patients with disabilities. Studies demonstrate that only a minority of clinics provide accessible equipment. For clinics with this equipment, no studies have examined the use of such equipment in routine clinical care.

OBJECTIVE

In primary care clinics with and without height-adjustable examination tables, we compared the frequency and variation in physical evaluations on examination tables and patients' perceptions of quality care.

DESIGN

Survey administered to patients at two primary care clinics in Rochester, MN, in 2015. One clinic had height-adjustable examination tables in every exam room; the other clinic had none.

PATIENTS

A total of 399 English-speaking adult primary care patients (61% participation).

MAIN MEASURES

Participants were asked whether they were physically evaluated on a table during their clinical encounter. In addition, they completed two subscales of the Patient Perception of Quality of Care survey: Perceptions of Provider's Bedside Manner and Perceptions of Provider's Work.

KEY RESULTS

Overall, there were no differences between clinics in the likelihood of patients being examined on an exam table or in their perceptions of quality of care. Across both clinics, patients who reported a disability were 27% less likely to be examined on a table, were less likely to rate their provider's bedside manner favorably (74% vs. 59%) and to have positive perceptions of their provider's work (46% vs. 32%) than patients without disabilities.

CONCLUSIONS

The presence of accessible medical equipment was not associated with care delivered to patients. While this might not be meaningful for most patients, it could be problematic for patients with disabilities, who are less likely to be examined. Therefore, accessible equipment alone may not be sufficient to reduce disparities in the care experience. Provider- and organization-level factors must thus be considered in efforts to provide equitable care to patients with disabilities.

Inclusion of persons with disabilities in systems of social protection: a population-based survey and case-control study in Peru

OBJECTIVE

This study aims to assess the needs of people with disabilities and their level of inclusion in social protection programmes.

DESIGN

Population based-survey with a nested case-control study.

SETTING

Morropon, a semiurban district located in Piura, northern Peru.

PARTICIPANTS

For the population survey, a two-stage sampling method was undertaken using data from the most updated census available and information of each household member aged ≥5 years was collected. In the nested case-control study, only one participant, case or control, per household was included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Disability was screened using the Washington Group short questionnaire. A case, defined as an individual aged ≥5 years with disabilities, was matched with one control without disabilities by sex and age (±5 years). Information was collected on socioeconomic status, education, health and rehabilitation and social protection participation.

RESULTS

The survey included 3684 participants, 1848 (50.1%) females, mean age: 36.4 (SD: 21.7). A total of 290 participants (7.9%; 95% CI 7.0% to 8.7%) were classified as having disability. Adults with disabilities were more likely to be single (OR=3.40; 95% CI 1.54 to 7.51) and not to be working (OR=4.36; 95% CI 2.26 to 8.40), while those who did work were less likely to receive the national minimum wage (ie, 750 PEN or about US$265; p=0.007). People with disabilities were more likely to experience health problems. There was no difference between those enrolled in any social protection programme among participants with and without disabilities.

CONCLUSIONS

People with disabilities were found to have higher needs for social protection, but were not more likely to be enrolled in social protection programmes. The Peruvian social protection system should consider adding disability status to selection criteria in their cash transfer programmes as well as implementing disability-specific interventions.

Accessibility of outpatient healthcare providers for wheelchair users: Pilot study

The Americans with Disabilities Act (ADA) requires full and equal access to healthcare services and facilities, yet studies indicate individuals with mobility disabilities receive less than thorough care as a result of ADA noncompliance. The objective of our pilot study was to assess ADA compliance within a convenience sample of healthcare clinics affiliated with a statewide healthcare network. Site assessments based on the ADA Accessibility Guidelines for Buildings and Facilities were performed at 30 primary care and specialty care clinics. Clinical managers completed a questionnaire on standard practices for examining and treating patients whose primary means of mobility is a wheelchair. We found a majority of restrooms (83%) and examination rooms (93%) were noncompliant with one or more ADA requirements. Seventy percent of clinical managers reported not owning a height-adjustable examination table or wheelchair accessible weight scale. Furthermore, patients were examined in their wheelchairs (70%-87%), asked to bring someone to assist with transfers (30%), or referred elsewhere due to an inaccessible clinic (6%). These methods of accommodation are not compliant with the ADA. We recommend clinics conduct ADA self-assessments and provide training for clinical staff on the ADA and requirements for accommodating individuals with mobility disabilities.

How to accommodate women with mobility limitations in biological studies

People with disabilities should be routinely included in research studies if there is no specific reason for their exclusion. Regardless, they may be inadvertently excluded because of the procedures of the study. By conducting a community-based biological study with women aging with mobility limitations, these authors gained further understanding of their accommodation needs during research participation. The women aging with mobility limitations offered specific physical, cultural, or environmental needs that could have influenced the methods, procedures, and possible outcomes involved when conducting a biological study with this community living population. The authors and participants identified methodological challenges for women with mobility impairments within three key areas: recruitment procedures, laboratory procedures, and community-based data collection. The authors propose possible solutions to these identified challenges. It is our hope that this will begin a larger dialogue on how to routinely accommodate people with disabilities in biological research studies.

Accommodations for patients with disabilities in primary care: a mixed methods study of practice administrators

Structural barriers that limit access to health care services for people with disabilities have been identified through qualitative studies; however, little is known about how patients with disabilities are accommodated in the clinical setting when a structural barrier is encountered. The purpose of this study was to identify how primary care medical practices in the United States accommodated people with disabilities when a barrier to service is encountered. Primary care practice administrators from the medical management organization were identified through the organization’s website. Sixty-three administrators from across the US participated in this study. Practice administrators reported that patients were examined in their wheelchairs (76%), that parts of the exam where skipped when a barrier was encountered (44%), that patients were asked to bring someone with them (52.4%) or that patients were refused treatment due to an inaccessible clinic (3.2%). These methods of accommodation would not be in compliance with requirements of the Americans with Disabilities Act. There was not a significant difference (p>0.05) in accommodations for patients with disabilities between administrators who could describe the application of the ADA to their clinic and those who could not. Practice administrators need a comprehensive understanding of the array of challenges encountered by patients with disabilities throughout the health care process and of how to best accommodate patients with disabilities in their practice.