A longitudinal assessment of adherence to breast and cervical cancer screening recommendations among women with and without intellectual disability

A Systematic Review to Evaluate the Barriers to Breast Cancer Screening in Women with Disability

Background: Breast cancer (BC) is one of the leading causes of mortality worldwide. There are observed disparities in patients with disability as compared to those without disability, which leads to poor BC screening attendance, thereby worsening disease management. Aim: The aim of this systematic review is to investigate if there are disparities in screening rates in women with disability as compared to those without disability, as well as the different factors that pose barriers to patients with disability for enrolment in BC screening programs. Method: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed published articles between 2008 and 2023, which assessed different factors that contributed to poor attendance in BC screening programs held across different countries. Detailed study characteristics were obtained, and methodological quality assessment was performed on the individual studies included in this review. Result: A total of fifty-three articles were identified as eligible studies based on the pre-defined inclusion and exclusion criteria. These included 7,252,913 patients diagnosed with BC (913,902 patients with disability/6,339,011 patients without disability). The results revealed there are demographic, clinical, financial, and service-related barriers that contributed to lower screening rates in disabled patients as compared to non-disabled. Patient age is the most common factor, with the highest effect observed for 80 years (vs. 30-44 years) [odds ratio (OR) = 13.93 (95% confidence interval (CI) = 8.27-23.47), p < 0.0001], followed by race/ethnicity for Hispanic (vs. non-Hispanic white) [OR = 9.5 (95%CI = 1.0-91.9), p < 0.05]. Additionally, patients with multiple disabilities had the highest rate of dropouts [OR = 27.4 (95%CI = 21.5-33.3)]. Other factors like education, income, marital status, and insurance coverage were essential barriers in screening programs. Conclusions: This study presents a holistic view of all barriers to poor BC screening attendance in disabled patients, thereby exacerbating health inequalities. A standardized approach to overcome the identified barriers and the need for a tailored guideline, especially for disability groups, is inevitable.

Principles for Service Delivery: Best Practices for Cervical Screening for Women with Disabilities

Background

Cervical cancer screening is an important public health priority, yet many marginalized groups are not reached by existing programs. The nearly 700 million women with disabilities globally face substantial barriers in accessing cervical cancer screening and have lower coverage, yet there is limited evidence on what would support enhanced uptake among this population.

Methods

We updated a systematic review to estimate the disparity in screening uptake for women with disabilities. We conducted a scoping review to understand key barriers and the inclusion of disability in existing screening policies and possible solutions to improve screening uptakes amongst women with disabilities. We then formulated key principles for improved service delivery for this group, targeted predominantly at clinicians.

Results

Our updated review identified an additional five new studies, and confirmed that women with disabilities were less likely to be screened for cervical cancer (RR=0.65, 0.50-0.84). Disability-specific barriers to accessing screening pertained to: (1) knowledge and autonomy; (2) logistics; and (3) stigma and fear. Few guidelines included specific considerations for women with disabilities. Our scoping review showed that improving access to care must focus on improving (1) autonomy, awareness, and affordability; (2) human resources; and (3) health facility accessibility.

Conclusion

Screening programmes and health providers must ensure women with disabilities are included in cervical cancer screening programmes and thereby help to achieve their right to health and eliminate cervical cancer as a public health issue.

Equitable Care for Patients With Disabilities: Considerations for the Gynecologic Health Care Professional

All patients deserve high-quality health care. Patients with disabilities have historically experienced discrimination in health care and subsequently detrimental health outcomes. Health care professionals often lack confidence and preparedness in treating patients with disabilities effectively. Barriers such as communication difficulties, biased assumptions, and inadequate equipment hinder comprehensive care. These barriers to care lead to health inequalities and a diminished overall quality of life for individuals with disabilities. Existing clinical guidelines for care of this underserved population are lacking. This article establishes a comprehensive educational framework and accessible reference tools for gynecologic health care professionals to enhance their ability to offer inclusive and effective care to patients with disabilities. Insights in this article stem from expert consensus among clinicians experienced in this field and ongoing dialog with community-based disability care partners. We present actionable steps to cultivate an open, adaptable, and patient-centric method to actively engage patients and to provide suitable accommodations when needed.

Family Caregivers' Attitudes and Perspectives About the Sexual and Reproductive Health of Women With Intellectual and Developmental Disabilities: An Online Survey

Although sexual and reproductive health is critically important for women with intellectual and developmental disabilities (IDD), there is limited research elucidating the role of family caregivers in assisting women with IDD access sexual and reproductive health services and information. Understanding the family caregivers' attitudes and perspectives is essential to improving access to sexual and reproductive health services and information for women with IDD. A cross-sectional online survey of family caregivers of women with IDD was administered between June and October 2018. Quantitative analysis was conducted for closed-ended responses, and qualitative analysis was conducted for open-ended responses. The analytic sample included 132 family caregivers. Most participants were parents and reported being closely involved in their family member's access to sexual and reproductive health services and information. Although most participants expressed that sexual and reproductive health services and information are essential for women with IDD, qualitative analysis of participants' open-ended responses revealed both supportive and restrictive attitudes and perspectives on sexual and reproductive health services and information for women with IDD. Supportive attitudes and perspectives included (1) "knowledge is power;" (2) supported decision-making; and (3) protection against sexual abuse. Restrictive attitudes and perspectives included (1) dependent on the individual; (2) lack of autonomy; and (3) placing responsibility on disability. Greater attention from policymakers and practitioners to systems-level changes, including universal and accessible sexual education for women with IDD, supported decision-making, and sexual abuse prevention measures, are urgently needed.

[Cancer in people with an intellectual disability in Germany: prevalence, genetics, and care situation]

Intellectual disability has a prevalence rate of approximately 1% of the population; in Germany, this is around 0.5-1 million people. The life expectancy of this group of people is reduced, with cancer being one of the most common causes of death (approx. 20%). Overall, the risk of cancer and mortality is increased compared to the general population.Certain genetic syndromes predispose to cancer in this vulnerable group, but associated comorbidities or lifestyle could also be risk factors for cancer. People with cognitive impairments are less likely to attend preventive check-ups, and challenges arise in medical care due to physical, communicative, and interactional characteristics. Optimized cooperation between clinical centers for people with disabilities and the respective cancer centers is required in order to tailor the processes to the individual.In Germany, there is a lack of data on the prevalence of cancer entities and the use and need for healthcare services. There is an urgent need to focus attention on cancer prevention, treatment, and research in the vulnerable and heterogeneous group of people with intellectual disabilities suffering from cancer in order to effectively counteract the increase in cancer-related deaths in this population group.The article summarizes specialist knowledge on cancer in people with an intellectual disability, identifies special features of treatment, presents care structures, and derives specific requirements for clinics and research.

Disparities in Breast Cancer Screening Rates Among Adults With and Without Intellectual and Developmental Disabilities

BACKGROUND

Individuals with intellectual and developmental disabilities may face barriers in accessing healthcare, including cancer screening and detection services. We sought to assess the association of intellectual and developmental disabilities (IDD) with breast cancer screening rates.

METHODS

Data from 2018 to 2020 was used to identify screening-eligible individuals from Medicare Standard Analytic Files. Adults aged 65-79 years who did not have a previous diagnosis of breast cancer were included. Multivariable regression was used to analyze the differences in breast cancer screening rates among individuals with and without IDD.

RESULTS

Among 9,383,349 Medicare beneficiaries, 11,265 (0.1%) individuals met the criteria for IDD. Of note, individuals with IDD were more likely to be non-Hispanic White (90.5% vs. 87.3%), have a Charlson Comorbidity Index score ≤ 2 (66.2% vs. 85.5%), and reside in a low social vulnerability index neighborhood (35.7% vs. 34.4%). IDD was associated with reduced odds of undergoing breast cancer screening (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.74-0.80; p < 0.001). Breast cancer screening rates in individuals with IDD were further influenced by social vulnerability and belonging to a racial/ethnic minority.

CONCLUSIONS

Individuals with IDD may face additional barriers to breast cancer screening. The combination of IDD and social vulnerability placed patients at particularly high risk of not being screened for breast cancer.

Differences in Telemedicine Use Between People With and Without an Intellectual or Other Developmental Disability During the COVID-19 Pandemic

Telemedicine utilization of people with an Intellectual or Other Developmental Disability (IDD) during the COVID-19 Pandemic is not well known. This study compares telemedicine utilization of those with and without IDD prior to the pandemic to after it began. Using the Utah All Payers Claims Database from 2019 to 2021, the study identified telemedicine utilization of adults aged 18 to 62 years old in 2019. Propensity score matching was used to minimize observed confounders of subjects with and without IDD in 2019. Negative binomial regression was used to identify factors that were associated with telemedicine utilization. The final number of subjects in the analysis was 18 204 (IDD: n = 6068, non-IDD: n = 12 136 based on 1:2 propensity score matching). The average (SD) age of the subjects was 31 (11.3) years old in 2019. Forty percent of the subjects were female, about 70% of subjects were covered by Medicaid in 2019. Average (SD) number of telemedicine use in 2020 (IDD: 1.96 (5.97), non-IDD: 1.18 (4.90); P < .01) and 2021 (IDD: 2.24 (6.78) vs 1.37 (5.13); P < .01) were higher for the IDD group than the non-IDD group. The regression results showed that the subjects with IDD had 56% more telemedicine encounters than those in the non-IDD group (Incidence Rate Ratio (IRR) = 1.56, P < .01). The growth of telemedicine during the COVID-19 pandemic has the potential to reduce persistent healthcare disparities in individuals with IDD. However, quality of telemedicine should be considered when it is provided to improve health of subjects with IDD.

Strategies for Accessible Breast Screening for People With Intellectual Disability

INTRODUCTION

People with intellectual disability are less likely to participate in breast screening than people without intellectual disability. They experience a range of barriers to accessing breast screening, however, there is no consensus on strategies to overcome these barriers. Our objective was to reach consensus on the strategies required for accessible breast screening for people with intellectual disability.

METHODS

Fourteen experts participated in a modified on-line Delphi that used Levesque's model of health care access as the theoretical framework. At the end of each round descriptive and thematic analyses were completed. Data was then triangulated to determine if consensus was reached.

RESULTS

After 3 rounds, 9 strategies were modified, 24 strategies were added and consensus was reached for 52 strategies across the 5 dimensions of access. Key areas of action related to (i) decision making and consent, (ii) accessible information, (iii) engagement of peer mentors, (iv) service navigators, and (v) equipping key stakeholders.

CONCLUSIONS

The resulting strategies are the first to articulate how to make breast screening accessible and can be used to inform health policy and quality improvement practices.

Disparities in Cervical Cancer Screening by Disability Types: a Systematic Review

Previous studies showed that the receipt of cervical cancer screening among women with disabilities is low. Some disparities may also exist within the subpopulation of women with disabilities. This systematic review synthesized the current literature on the receipt of cervical cancer screening by disability type. PubMed, ProQuest, EBSCO, PsycINFO, MEDLINE, and Google Scholar searches were performed to identify studies between April 2012 and January 2022. A total of ten studies met the inclusion criteria and were included in this review. All studies employed a cross-sectional approach (n = 10) and most used multivariable logistic regression (n = 7). Two of the ten articles included classified disability types as basic action difficulties and complex activities, while eight of the articles classified it as either hearing, vision, cognitive, mobility, physical, functional, language disability, or autism. The association between disability types and cervical cancer screening was inconsistent across publications. All the studies except for one however indicated that evidence of lower screening rates exists within the subpopulation of women with disability. The available evidence supports the conclusion that disparities in cervical cancer screening are evident in disability subgroups; however, evidence is inconsistent regarding which disability type experiences lower receipt of screening. Screened articles utilized different definitions for disability adding to the inconsistency in the results. More focused research using a standardized definition for disability is required to determine which disability type experiences significant disparities in cervical cancer screening. This review highlights the need for healthcare organizations to target specific tailored interventions to improve the quality of care for specific disability subgroups.

An Adapted Cancer Screening Education Program for Native American Women With Intellectual and Developmental Disabilities and Their Caregivers: Protocol for Feasibility and Acceptability Testing

BACKGROUND

Women with intellectual and developmental disabilities (IDD) do not undergo breast and cervical cancer screening at the same rate as women without IDD. IDDs are diagnosed in childhood, are lifelong, and involve difficulties in adaptive behaviors and intellectual functioning. Native American women also experience disparities in breast and cervical cancer screenings. Despite known disparities, women with IDD are often not included in health promotion programs, and there is a need for evidence-based programming for those with intersectional identities, such as Native American women with IDD.

OBJECTIVE

This study aims to assess the feasibility and acceptability of My Health My Choice (MHMC), an adaptation of the Women Be Healthy 2 program. There are 2 parts to the study: adaptation of the Women Be Healthy 2 program and feasibility and acceptability testing of MHMC.

METHODS

Individuals aged over 18 years who identify as Native American females with IDD and their caregivers (N=30 women-caregiver dyads) are eligible for the study. Participants, who are affiliated with 2 partnering sites in Arizona (1 rural and 1 urban), complete pre- and postsurveys assessing knowledge, self-efficacy, and screening expectations before and immediately after completing the program. In addition, all participants complete brief satisfaction surveys after each of the 6 educational sessions. A subsample of Native American women with an IDD (n=12), caregivers (n=12), and community health educators (n=2) who participate in the MHMC program will provide semistructured qualitative input regarding the content, delivery, and cultural relevance of the program.

RESULTS

The adaptation of the culturally responsive MHMC program was completed in August 2021. In November 2021, the project team began recruitment for feasibility and acceptability studies. Feasibility will be examined using participation metrics, and acceptability will be measured using satisfaction measures. Pre- and postmeasures in cancer screening knowledge, self-efficacy, and screening expectations will examine improvements among participants.

CONCLUSIONS

The results of feasibility and acceptability testing of MHMC will guide future implementation studies of the program.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37801.

Breast Cancer Screening Among Women With Intellectual Disability in Denmark

IMPORTANCE

Breast cancer-specific mortality is increased among women with intellectual disability (ID), and knowledge about participation in breast cancer screening in this group is needed.

OBJECTIVE

To examine participation in the Danish national breast cancer screening program among women with ID compared with women without ID.

DESIGN, SETTING, AND PARTICIPANTS

This dynamic population-based cohort study assessed participation in the Danish national breast cancer screening program initiated in 2007, targeting women aged 50 to 69 years with a screening interval of 2 years. In all, 6357 women with ID born between 1941 and 1967 and eligible for the screening program were identified in national registers. Women entered the study between January 1, 2007, and December 31, 2017. Subsequently, 273 women were excluded due to a history of carcinoma in situ or breast cancer, and 489 due to registration errors in registers. Each woman was individually age-matched with 10 women without ID (reference group). All women were followed up until March 31, 2021, or censoring (due to death, carcinoma in situ, or breast cancer). Data were analyzed from December 1, 2021, to June 31, 2022.

EXPOSURES

Intellectual disability was defined as being registered with an ID diagnosis or a diagnosis most likely leading to ID or residing at an institution for persons with ID.

MAIN OUTCOMES AND MEASURES

Participation in breast cancer screening (fully, partly, and never).

RESULTS

A total of 5595 women with ID and 49 423 age-matched women in the reference group were included in the analysis. Of these, 2747 women with ID (49%) and 24 723 in the reference group (50%) were 50 years of age at study entry; for those older than 50 years, the median age was 51 years (IQR, 50-58 years) in both groups. In all, 1425 women with ID (25%) were fully screened according to guidelines for the Danish breast cancer screening program compared with 30 480 women in the reference group (62%). Women with ID had nearly 5 times higher odds of never being screened compared with the reference group (odds ratio, 4.90 [95% CI, 4.60-5.22]). In all, 2498 women with ID (45%) and 6573 in the reference group (13%) were never screened. The proportion of never-screened women increased with severity of ID, from 834 of 2287 (36%) among women with mild ID to 173 of 212 (82%) among women with profound ID.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that women with ID are markedly less likely to participate in breast cancer screening compared with women without ID. These findings further suggest a need for tailored guidelines and approaches for breast cancer screening in this group of women.

Caring for Adults With Significant Levels of Intellectual Disability in Outpatient Settings: Results of a National Survey of Physicians

Between 1% and 2% of the U.S. population has an intellectual disability (ID) and often experience disparities in health care. Communication patterns and sedation use for routine medical procedures are important aspects of care for this population. We explored physicians' communication patterns and sedation use in caring for patients with significant levels of ID through a mailed survey of 1,400 physicians among seven specialties in outpatient settings (response rate = 61.0%). Among physicians who saw at least one patient with significant levels of ID in an average month, 74.8% reported usually/always communicating primarily with someone other than the patient. Among specialists, 85.5% (95% CI: 80.5%-90.5%) reported doing so, compared to 69.9% (95% CI: 64.4%-75.4%) for primary care physicians (p < 0.001). Also, 11.4% reported sedating at least one patient with significant levels of ID for a routine procedure. Three quarters of physicians reported communicating primarily with persons other than the patient usually or always-an approach that, in some instances, may not align with best medical practice. The percentage of physicians who report sedating at least one individual is associated with significant ID and the physician's volume of patients with significant ID.

County-Level Social Vulnerability and Breast, Cervical, and Colorectal Cancer Screening Rates in the US, 2018

IMPORTANCE

Area-level factors have been identified as important social determinants of health (SDoH) that impact many health-related outcomes. Less is known about how the social vulnerability index (SVI), as a scalable composite score, can multidimensionally explain the population-based cancer screening program uptake at a county level.

OBJECTIVE

To examine the geographic variation of US Preventive Services Task Force (USPSTF)-recommended breast, cervical, and colorectal cancer screening rates and the association between county-level SVI and the 3 screening rates.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used county-level information from the Centers for Disease Control and Prevention's PLACES and SVI data sets from 2018 for 3141 US counties. Analyses were conducted from October 2021 to February 2022.

EXPOSURES

Social vulnerability index score categorized in quintiles.

MAIN OUTCOMES AND MEASURES

The main outcome was county-level rates of USPSTF guideline-concordant, up-to-date breast, cervical, and colorectal screenings. Odds ratios were calculated for each cancer screening by SVI quintile as unadjusted (only accounting for eligible population per county) or adjusted for urban-rural status, percentage of uninsured adults, and primary care physician rate per 100 000 residents.

RESULTS

Across 3141 counties, county-level cancer screening rates showed regional disparities ranging from 54.0% to 81.8% for breast cancer screening, from 69.9% to 89.7% for cervical cancer screening, and from 39.8% to 74.4% for colorectal cancer screening. The multivariable regression model showed that a higher SVI was significantly associated with lower odds of cancer screening, with the lowest odds in the highest SVI quintile. When comparing the highest quintile of SVI (SVI-Q5) with the lowest quintile of SVI (SVI-Q1), the unadjusted odds ratio was 0.86 (95% posterior credible interval [CrI], 0.84-0.87) for breast cancer screening, 0.80 (95% CrI, 0.79-0.81) for cervical cancer screening, and 0.72 (95% CrI, 0.71-0.73) for colorectal cancer screening. When fully adjusted, the odds ratio was 0.92 (95% CrI, 0.90-0.93) for breast cancer screening, 0.87 (95% CrI, 0.86-0.88) for cervical cancer screening, and 0.86 (95% CrI, 0.85-0.88) for colorectal cancer screening, showing slightly attenuated associations.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, regional disparities were found in cancer screening rates at a county level. Quantifying how SVI associates with each cancer screening rate could provide insight into the design and focus of future interventions targeting cancer prevention disparities.

Disability and Participation in Breast and Cervical Cancer Screening: A Systematic Review and Meta-Analysis

It is well established that access to preventative care, such as breast or cervical cancer screening, can reduce morbidity and mortality. Certain groups may be missed out of these healthcare services, such as women with disabilities, as they face many access barriers due to underlying inequalities and negative attitudes. However, the data have not been reviewed on whether women with disabilities face inequalities in the uptake of these services. A systematic review and meta-analysis were conducted to compare the uptake of breast and cervical cancer screening in women with and without disabilities. A search was conducted in July 2021 across four databases: PubMed, MEDLINE, Global Health, and CINAHL. Quantitative studies comparing the uptake of breast or cervical cancer screening between women with and without disabilities were eligible. Twenty-nine studies were included, all from high-income settings. One third of the 29 studies (34.5%, n = 10) were deemed to have a high risk of bias, and the remainder a low risk of bias. The pooled estimates showed that women with disabilities have 0.78 (95% CI: 0.72–0.84) lower odds of attending breast cancer screening and have 0.63 (95% CI: 0.45–0.88) lower odds of attending cervical cancer screening, compared to women without disabilities. In conclusion, women with disabilities face disparities in receipt of preventative cancer care. There is consequently an urgent need to evaluate and improve the inclusivity of cancer screening programs and thereby prevent avoidable morbidity and mortality.

Factors Promoting Breast, Cervical and Colorectal Cancer Screenings participation: A Systematic Review

Objective

The present study aims at systematically reviewing research conducted on factors promoting breast, cervical and colorectal cancer screenings participation.

Methods

A literature search in MEDLINE/PubMed and PsycInfo from January 2017 to October 2021 was performed. Data extraction, researchers' full agreement and the inclusion criteria produced 102 eligible studies. Data were narratively synthesized and critically interpreted.

Results

Multiple factors favoring or hindering breast, cervical and colorectal cancer screenings were identified and summarized as factors operating at the individual level (background information, individual characteristics, emotions related to screening procedure and to cancer, knowledge and awareness), at the relational level (relationships with healthcare staff, significant others, community members), and at the healthcare system level (systems barriers/policy, lack of staff). A critical appraisal of studies revealed a fragmentation in the literature, with a compartmentalization of studies by type of cancer screening, country and specific populations of destination.

Conclusions

Overall findings indicated that greater integration of research results obtained independently for each cancer diagnosis and within the different countries/populations could foster a more comprehensive understanding of factors potentially enhancing the participation in breast, cervical and colorectal cancer screenings worldwide. This review, which is grounded in the current context of globalization and superdiversification in population, can help to enhance a better integration between research and practices, by supporting the development of more effective and inclusive evidence‐based interventions and health‐promotion campaigns worldwide. Research and practical implications are highlighted and discussed.

A systematic review of the barriers and facilitators influencing the cancer screening behaviour among people with intellectual disabilities

Individuals with intellectual disabilities (ID) may require assistance in accessing healthcare services, including cancer screening. A better understanding of the factors affecting cancer screening utilisation among these individuals is needed for the development of strategies to promote screening uptake in them. This review aimed to explore the facilitators of and barriers to cancer screening utilisation among people with ID. A literature search was conducted using five databases, and an additional snowball search yielded 16 studies for inclusion in the review. Overall, the methodological quality of these studies was good (43-100%). In this review, we noted barriers to screening among individuals with ID, including perceptions of fear, distress, and embarrassment; unpreparedness for screening; negative interactions with healthcare professionals; a lack of knowledge about cancer screening; mobility issues; a high severity of ID; and a lack of ability to provide consent and communicate verbally. Facilitators to screening among these individuals were also identified, including living in a supervised setting, prior use of other healthcare services, being educated about screening via social media, having carers accompany them to screening appointments, and having dual insurance coverage or a higher income. Our review highlights the current needs of individuals with ID undergoing cancer screening. Strategies should be developed to address these needs, such as the provision of training to healthcare professionals on how to conduct screening for people with ID.

[Barriers to breast cancer screening for people with disabilities]

A significant increase in breast cancer is expected in the coming decades among people with disabilities. However, their participation rate in screening programs is significantly lower than women without disabilities. Our objective was therefore to analyse the barriers to breast cancer screening in people with disabilities based on a recent review of the international literature. The articles analysed were retrieved from the PUBMED database from 2014 to 2020 using the following keywords "breast cancer", "screening" and "disability". A total of 37 studies were included, including 30 original articles and 7 meta-analyses. The main barriers to performing breast cancer screening for women with disabilities were environmental factors such as lack of adapted transportation means or difficult access to medical facilities and mammography. To a lesser extent, the unsupportive views of family caregivers and health care staff about screening were also barriers to screening acceptance by people with disabilities. In general, breast cancer screening is a useful public health measure that reduces the burden of treatment and breast cancer-related mortality. Screening is useful for women over 50 years of age who have a sufficiently long-life expectancy, generally estimated at more than 10 years. Educational measures are needed to reduce the barriers to screening for PH who meet these criteria, their caregivers, and their providers so that they can actively participate in health care, rather than being marginalized because of their disability.

Healthcare inequities among adults with developmental disability: An integrative review with implications for nursing education

AIM

This integrative review synthesized research on the healthcare inequities experienced by adults with developmental disability in the United States and discussed implications for nursing education.

BACKGROUND

Individuals with developmental disability are living longer with chronic comorbidities and experience healthcare inequities.

METHOD

Application of inclusion criteria to database and ancestry searches resulted in 26 articles that were assessed for quality and analyzed thematically.

RESULTS

Three categories of inequity were identified: knowledge deficits, communication challenges and poor quality of care. Knowledge deficits and communication challenges can lead to frustration, errors and unmet needs. Poor quality of care encompasses the decreased availability and access to services, limited health promotion participation and higher rates of hospitalizations and complications for adults with developmental disability.

CONCLUSION

Healthcare inequities may be reduced by targeting patient and provider knowledge. Inclusion of developmental disability content and clinical experiences in nursing education may improve care and reduce inequities for this underserved population.

A scoping review documenting cancer outcomes and inequities for adults living with intellectual and/or developmental disabilities

INTRODUCTION

Emerging evidence suggests adults with intellectual and/or developmental disabilities (IDD) may be at risk of inequities in cancer experiences and outcomes. Individuals with IDD may experience multiple barriers that could worsen outcomes and experience. These barriers may be connected to features of IDD or the healthcare system overall. Future research and program planning to support adults with IDD and cancer must be informed by evidence that acknowledges potential disparities, underlying determinants, and knowledge deficits.

OBJECTIVE

We conducted a scoping review to systematically map the evidence describing and comparing cancer-related outcomes along the cancer continuum from risk to mortality for adults with IDD. We identified specific factors observed to influence those outcomes.

METHODS

We followed the expanded Arksey & O'Malley framework for conducting the scoping review. We searched for literature in PubMed and Embase databases. We abstracted cancer-related data, IDD-related data, and data related to physical and social determinants of health.

RESULTS

Of the 2796 studies retrieved, 38 were included for review. Most studies focused on screening outcomes and experiences. Studies reported that adults with IDD experienced inequities at various points along the cancer continuum. Numerous social and physical determinants of health influenced the experiences and outcomes of adults with IDD.

CONCLUSION

This scoping review identified significant gaps in the literature. Of note was the focus on cancer screening and lack of attention to larger systems of oppression that may influence poor cancer experiences and outcomes for adults with IDD. There is strong need to improve both quality and quantity of research in this area.

Gynecologic Care in Women With Down Syndrome: Findings From a National Registry

OBJECTIVE

To estimate receipt of recommended gynecologic care, including cancer screening and menstrual care, among women with Down syndrome in the United States.

METHODS

We conducted a retrospective cohort study of women participating in DS-Connect, the National Institute of Health's registry of women with Down syndrome. Using 2013-2019 survey data, we estimated the proportion of women receiving recommended age-appropriate well-woman care (Pap tests, mammogram, breast examination, pelvic examination) and compared receipt of gynecologic care to receipt of other preventive health care. We also estimated proportion receiving care for menstrual regulation.

RESULTS

Of 70 participants with Down syndrome, 23% (95% CI 13-33) of women received all recommended gynecologic components of a well-woman examination. Forty-four percent (95% CI 32-56) of women aged 18 years and older reported ever having a gynecologic examination, and 26% (95% CI 15-37) reported ever having a Pap test. Of women aged 40 years or older, 50% (95% CI 22-78) had had a mammogram. Fifty-two percent (95% CI 41-65) had tried medication for menstrual regulation, and 89% (95% CI 81-96) received all recommended components of nongynecologic routine health care.

CONCLUSION

Women with Down syndrome received gynecologic care, including cancer screening, at lower-than-recommended rates and at substantially lower rates than other forms of health care. Efforts to improve gynecologic care in this vulnerable population are needed.

Cancer diagnoses among older people with intellectual disability compared with the general population: a national register study

BACKGROUND

Cancer occurrence among older people with intellectual disability (ID) is poorly documented, so we investigated the frequency and distribution of cancer in older people with ID compared with the general population.

METHOD

People with ID who were ≥55years old and alive at the end of 2012 (n = 7936; ID cohort) were identified through a national register of people with ID who received social services in Sweden to optimise the individual's opportunity for good living conditions in daily life. An equally large reference cohort from the general population (gPop cohort) was matched by year of birth and sex. Cancer diagnoses registered in inpatient and outpatient specialist care were collected for 2002-2012 from the ID cohort and compared with diagnoses in the gPop cohort.

RESULTS

A lower total cancer frequency was observed in the ID cohort, which contained 555 cancers, compared with 877 cancers in the gPop cohort [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.57-0.70]. Women accounted for 60% of cancers in the ID cohort. Breast and gynaecological organ cancers had similar or slightly lower frequencies in the ID cohort than in the general population, with breast OR of 0.95, uterine corpus OR of 1.00 and ovary OR of 0.73. Surprisingly, cancer frequency of the digestive organs (OR: 0.67), including the colon (OR: 0.82), was lower than in the general population. Cancers of the prostate (OR: 0.25), urinary tract (OR: 0.42) and lung were less frequent than in the general population.

CONCLUSIONS

Cancer was diagnosed less frequently in the ID cohort than in the gPop cohort. However, cancers of the breast and colon-rectum remain frequent in people with ID and therefore warrant prevention policies, monitoring and screening similar to those of the general population.

Disparities in cancer-related healthcare among people with intellectual disabilities: A population-based cohort study with health insurance claims data

Background

Concerns have been raised about the accessibility and quality of cancer‐related care for people with intellectual disabilities (ID). However, there is limited insight into cancer incidence and the utilization of cancer care at the ID population level to inform targeted cancer control strategies. Therefore, we aimed to examine differences in the utilization of cancer‐related care between people with and without ID, identified through diagnostic codes on health insurance claims.

Methods

In a population‐based cohort study, Dutch individuals of all ages who received residential care through the Chronic Care Act due to an ID (n = 65 183) and an age and sex‐matched sample of persons without ID (1:2 ratio), who were cancer‐free at enrollment in 2013 were followed through 2015. Incidence rates (IRs) of newly started cancer care and IR ratios (IRRs) with 95% CIs were used to compare groups. Separate analyses were performed per cancer type.

Results

Individuals with ID received less cancer‐related care than individuals without (IRR = 0.64, 95% CI 0.62‐0.66). Differences increased with age and were larger for females than for males. Utilization of care for cancers within the national screening program (female breast, cervical, and colon cancer) was lower for people with ID compared to people without ID.

Conclusion

Cancer may be underdiagnosed and/or undertreated in people with ID, or cancer is truly less prevalent in this population. In particular, the differences detected between males and females with ID, and the potential underutilization of national screening programs, require urgent follow‐up investigations.

Ensuring the Reproductive Rights of Women with Intellectual Disability

BACKGROUND

Women with intellectual disability experience disparities in sexual and reproductive health care services.

METHODS

To explore perceptions of caring for persons with disability, including individuals with intellectual disability, we conducted open-ended individual interviews with 20 practicing physicians and three video-based focus group interviews with an additional 22 practicing physicians, which reached data saturation. Interviews were transcribed verbatim. We used conventional content analysis methods to analyse transcripts.

RESULT

Physicians indicated that intellectual disability can pose challenges to providing sexual and reproductive health care. Observations coalesced around four themes: (1) communication; (2) routine preventive care; (3) contraception and sterilization; and (4) conception and parenthood. Observations raised concerns about equity of access to reproductive care for women with intellectual disability.

CONCLUSIONS

In our sample of physicians, we found attitudes that might compromise reproductive care for women with intellectual disability, suggesting that gaps remain in ensuring reproductive rights of women with intellectual disability.

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability

INTRODUCTION

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions.

METHOD

To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied.

RESULTS

There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings.

CONCLUSION

Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services.