Enabling our instruments: accommodation, universal design, and access to participation in research

A prospective non-randomized feasibility study of an online membership-based fitness program for promoting physical activity in people with mobility impairments

BACKGROUND

People with mobility limitations have a disproportionately higher rate of acquiring secondary conditions such as obesity, cardiovascular comorbidity, pain, fatigue, depression, deconditioning, and type 2 diabetes. These conditions often result from poor access to home and community-based health promotion/wellness programs. The aim of this project was to determine the feasibility of delivering an online community membership-based fitness program for individuals with mobility impairments.

METHODS

For this prospective single-arm study, participants were recruited from members of a community fitness facility that serves people with physical disabilities and chronic health conditions. While all members had access to the online platform, individuals had to opt-in to participate in the research component. Activity options included 16 pre-recorded videos and 9 live exercise classes. During the 8-week program, participants had an opportunity to earn three exercise incentives for reaching certain activity milestones. Enrollment percentage, attendance, and attrition were tracked to assess program feasibility and acceptability. Changes in participant-reported outcomes including self-reported physical activity, psychosocial outcomes, and health-related quality of life (HRQOL) were examined using non-parametric analyses.

RESULTS

A total of 146 eligible individuals were screened of which 33 enrolled (22.6%). Two participants withdrew from the study, so a total of 31 were used for analyses. Participants included 29 women and 12 Black people with an average age of 60 (± 15.9) years. Health conditions included stroke, post-polio, arthritis, neuropathy, cerebral palsy, and obesity. Ten participants used an assistive device to get around inside the home. Twenty-six participants (78.8%) completed the online program, and 5 participants earned all 3 participation incentives. The mean number of live Zoom exercise classes attended by the participants was 12.8 (range = 0-43) over 8 weeks; 3 of 31 participants did not attend any classes. On average, participants watched 128 min (range = 0-704 min) of pre-recorded videos; 6 of 31 participants did not view any pre-recorded videos. Self-reported physical activity showed the largest improvement (11.15 units; 95% CI, 3.08, 19.56) with an effect size of 0.51 (Cohen's d).

CONCLUSIONS

This pilot study of an online membership-based fitness program for people with mobility impairments demonstrated preliminary effectiveness in increasing physical activity and was found to be feasible and acceptable. Feasibility endpoints do indicate potential to improve retention. These results suggest that online delivery of exercise programs can broaden the reach of specialized community fitness programs and is a promising direction for future work and fully powered trials are warranted to assess intervention efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05138809. Registered September 2, 2021, ClinicalTrials.gov PRS: Record Summary NCT05138809.

The Moderation Effect of Disability Status on the Associations Among ACEs, Mental Health, and Binge Drinking

PURPOSE

Mental health and substance use social workers must be prepared to work with people with disabilities, as this population has higher rates of adverse childhood experiences (ACEs), and ACEs can lead to mental health and substance use problems. The study's purpose is to assess the moderating effect of disability on the interrelationships among ACEs, mental health, and binge drinking.

MATERIALS AND METHODS

Using data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) survey, we first used multigroup confirmatory factor analysis to establish the underlying factor structure of the ACEs questionnaire for respondents with and without disabilities. Next, we used multigroup structural equation modeling to assess the mediating effect of mental health difficulties on the association between ACEs and binge drinking for respondents with and without disabilities.

RESULTS

A three-factor measurement model (emotional or physical abuse, sexual abuse, and household dysfunction) demonstrated excellent model fits. Mental health difficulties significantly mediated the association between ACEs and binge drinking for all respondents. Disability status was a statistically significant moderator of a few associations, with more mental health variance explained by ACEs for the disabled respondents. Direct paths showed household dysfunction and sexual abuse had greater impacts on mental health for disabled respondents, and indirect paths showed these factors also had greater impacts on binge drinking among disabled respondents.

DISCUSSION AND CONCLUSION

To prevent mental health and binge drinking problems among disabled individuals, we need evidence-based interventions to identify their ACEs and provide accessible, trauma-informed treatments to them.

'Being disabled' as an exclusion criterion for clinical trials: a scoping review

BACKGROUND

People with disabilities (PWDs) are often excluded from biomedical research, but comprehensive data regarding their participation in clinical trials are not available. The objective of this study was to assess the rates of exclusion of PWDs from recent medical scientific research.

METHODS

The protocol of the study was designed according to PRISMA-ScR (PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for Scoping Reviews) guidelines. All completed interventional clinical trials registered on ClinicalTrials.gov between 2010 and 2020 regarding the 10 leading causes of global disability-adjusted life-years according to the Global Burden of Disease Study were analysed. An exclusion criterion from the study was considered explicit if it could be associated with one of the following seven categories: disability, physical impairment, cognitive impairment, behavioural or psychiatric disorders, language and communication impairment, sensory impairment. Comorbidities not more clearly defined and researcher discretion regarding exclusion of study participants were considered to be 'implicit exclusion criteria'. We assessed the appropriateness of explicit exclusion criteria in relation to the primary objectives of the trials and labelled them as 'absolute', 'relative' or 'questionable'.

RESULTS

The total number of trials analysed was 2710; 170 were paediatric trials (6.3%), 2374 were adult trials (87.6%) and 166 were trials including subjects of all ages (6.1%). Explicit exclusion criteria were found in 958 trials (35.3%). The disability category most frequently excluded was behavioural or psychiatric disorders, present in 588 trials (61.4%). In only 3% and 1% of the trials, the exclusion criteria were considered either 'absolute' or 'questionable', while in 96% the exclusion criteria were judged as 'relative'. Implicit exclusion criteria were present in 1205 trials (44.5%).

CONCLUSIONS

This study highlights the high rate of exclusion of PWDs from biomedical research and the widespread use of ill-defined exclusion criteria in clinical trials. It underscores the importance of more inclusive study designs so that PWDs can become active participants in research.

A call to action for more disability-inclusive health policy and systems research

To date, the exclusion of people with disability participating in research has limited the evidence base informing health system strengthening policy and practice more generally, and addressing disability-related inequalities in access to health services and better health outcomes more particularly. Given that more than 1 billion people, or 16% of the world's population, have a disability, we may fail to respond to the needs of a large proportion of the population unless we are purposeful with inclusion. Our research in this area indicates that online qualitative methods can be effective in engaging under-represented groups and are essential to ensure their input into health policy and systems research. This has important implications for researchers whose responsibility it is to make all health research disability inclusive, for ethical and methodological reasons, so they do not perpetuate the under-representation of people with disability in health policy and systems research. Our paper puts forward several recommendations to facilitate more people with disability participating in health policy and systems research. By critically reflecting on a health system strengthening research project, in which we purposefully aimed to support the participation of people with disability, we identify lessons learnt and issues to consider when planning and conducting accessible research. We also propose a set of actions for moving the agenda forward.

Making Pain Research More Inclusive: Why and How

Current knowledge about mechanisms and interventions for pain has largely been derived from samples that are healthier, wealthier, younger, and more likely to be White than the general population. Failure to conduct inclusive pain research not only restricts generalizability and application of findings, but also hampers the discovery of mechanisms and the development of measures and interventions that are valid across population subgroups. Most of all, inclusive practices are critical to ensure that underrepresented groups derive equitable benefit from pain research. Here, we provide guidance for the pain research community on how to adopt inclusive research practices. We define "inclusion" to encompass a range of identities and characteristics, including racialized group/ethnicity, disability status, gender identity, sexual orientation, and age. We first describe principles relevant to promoting inclusion in pain research, including attention to: 1) stakeholder engagement; 2) structural factors underlying inequities; 3) the limitations of "disparity" research; 4) intersectionality; and 5) universal design. Next, we provide checklists with practical strategies for making studies more inclusive at each stage of the research process. We conclude by calling for system-level changes to ensure that the future of pain research is socially just, scientifically productive, and responsive to the needs of all people. PERSPECTIVE: This paper offers guidance on promoting inclusion of underrepresented groups in pain research. We describe principles relevant to conducting more inclusive research; eg, attention to stakeholder engagement, structural factors, and universal design. We provide checklists with practical strategies for inclusion at each stage of the research process.

Examination of the Relationships Among Social Networks and Loneliness on Health and Life Satisfaction in People with Spinal Cord Injury/Dysfunction

OBJECTIVE

To examine the associations among social networks and loneliness on health and life satisfaction in adults with chronic spinal cord injury/dysfunction (SCI/D).

DESIGN

Cross-sectional telephone survey study.

SETTING

Tertiary spinal cord injury rehabilitation center in Ontario, Canada.

PARTICIPANTS

Community-dwelling adults with chronic SCI/D (N=170).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The main outcome measures were the Short-Form 36 to assess health and the Life Satisfaction-11 to assess life satisfaction.

RESULTS

A hierarchical regression model predicting physical health accounted for 24% (P<.001) of the variance. The only social network variable to significantly contribute to the model was having a higher proportion of network members living in one's household (P<.05). A model predicting mental health accounted for 44% (P<.001) of the variance, with having a higher proportion of network members living in one's household (P<.05) and lower feelings of loneliness (P<.001) associated with better mental health. Finally, the model predicting life satisfaction accounted for 62% (P<.001) of the variance, with lower greater levels of social network intimacy (P<.01) and lower feelings of loneliness (P<.001) being significant predictors.

CONCLUSIONS

These findings highlight the importance of having access to network members in one's home for better physical and mental health after SCI/D as well as the negative association between loneliness and mental health and life satisfaction. There is a need for approaches to ensure that people with SCI/D in the community feel supported to mitigate feelings of loneliness to optimize their health and wellbeing.

Quality of life and vocational education service quality in students with intellectual disability

The aim of the study was to investigate the relation between subjective quality of life and quality of vocational education services from the view of students with intellectual disability who participate in public special vocational education schools in Greece. The level of quality of life and quality of special vocational education services was explored. The article presents a functional description of service quality in special vocational education and operationalizes quality of life for students with disability. Instruments were developed and adapted in line with the participatory research paradigm. Convenience sampling was used. Data was gathered from 131 students with intellectual disability. All measures showed good evidence of internal consistency and construct validity. The findings suggest relationship between quality of life and quality of special vocational education services received by students with intellectual disability. Low levels of self-determination are highlighted. Practical implications concerning the application of the instruments in special education settings as measures for the quality assessment and the evaluation of educational interventions are discussed.

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.

Adapting a health behavioral change and psychosocial toolkit to the context of physical disabilities: Lessons learned from disabled women with young children

BACKGROUND

Mothers with physical disabilities (MPDs) face the behavioral and psychosocial changes of the motherhood transition with fewer resources, additional barriers, and higher risks than nondisabled mothers. In this study we sought guidance from MPDs on adaptations needed to a health promotion toolkit for behavioral and psychosocial health that was originally developed for nondisabled, primarily low-income, women.

OBJECTIVE

To identify general themes for adaptations that would increase the suitability of the toolkit for MPDs.

METHODS

11 MPDs were interviewed by videoconferencing in a mixed-methods study about their perspectives on improving relevance of the existing toolkit for this population. The toolkit contained three components: assessment scale, feedback template on assessment results, and a decision aid related to behavior change. Interviews were analyzed using qualitative content analysis.

RESULTS

Nine themes for improving suitability of the toolkit for MPDs were identified. Themes covered: Using non-judgment language; including strengths, not just risks; using exercise items applicable to persons with physical disabilities; being aware that functional ability was the key body image concern; considering motivational stages of behavioral change; providing choice in goal-setting for change; including suggestions for social support; identifying resources for health and adaptive parenting; and making health promotion resources available in alternative platforms (paper, electronic).

CONCLUSIONS

The MPDs' feedback revealed ways that our toolkit for behavioral and psychosocial health could be improved to be inclusive of MPDs. The participatory methods utilized here are also recommended in designing new or revising existing materials aimed at enhancing health promotion for people with disabilities.

Content development, accessibility and feasibility of a self-report tool for use in programmes serving youth with cognitive disabilities: The Participatory Experience Survey

INTRODUCTION

Participation in community-based recreation and leisure activities may afford valuable opportunities to young people with cognitive disabilities (CD) to develop important self-determination skills needed for success in adulthood. To evaluate whether these programmes are achieving their intended impact, it is important to have a tool that captures the perspective of the participants using an accessible method. This article describes the content development and evaluation of accessibility and feasibility of the Participatory Experience Survey (PES).

METHOD

Participant observation and focus group sessions were conducted in conjunction with a summer youth programme hosted by a special education advocacy organisation. Photos were used to guide identification of factors influencing both negative and positive experiences. Findings informed question content. Three groups of stakeholders, parents of youth with CD (Group 1), service providers (Group 2), and experts in cognitive disability and/or programme planning (Group 3) reviewed the PES to provide feedback on the relevance and accessibility of the measure. After stakeholder feedback was incorporated, cognitive interviewing was conducted with young people with CD to assess instrument accessibility and appropriateness for use in context.

RESULTS

Youth described their participation in three categories: personal, social and environmental. Stakeholder Groups 1 and 2 identified 15 questions as needing revisions. Seven additional questions were added based on suggestions from stakeholder Group 3. Cognitive interviewing led to revision of 13 questions and removal of 16 questions due to issues related to vocabulary, item meaning, response bias, repetitiveness and length.

CONCLUSION

The PES has the potential to offer programmes a means to more fully include young people with disabilities in programme evaluations, leading to better-structured, more supportive programmes. Additional validity and feasibility work is needed to confirm these initial findings.

Conceptualization, operationalization, and content validity of the EQOL-questionnaire measuring quality of life and participation for persons with disabilities

BACKGROUND

Measurement of quality of life demands thoroughly developed and validated instruments. The development steps from theory to concepts and from empirical data to items are sparsely described in the literature of questionnaire development. Furthermore, there seems to be a need for an instrument measuring quality of life and participation in a population with diverse disabilities. The aim of this paper was to present and discuss the initial steps in the development of the Electronic Quality of Life questionnaire (EQOL).

METHODS

The development of EQOL included six steps: 1) Establishing conceptual understanding; 2) Development of interview guides which build on the conceptual understanding; 3) Qualitative interviews of 55 participants (10-40 years old) with different types and severities of disabilities; 4) Conceptualization of domains identified in the qualitative data through thematic analysis; 5) Operationalization of the identified domains into items and; 6) Evaluation of content validity of the first version of the EQOL-measure. Content validity was examined by cognitive interviews with participants in the target group as well as by continuous feedback from an advisory board.

RESULTS

We identified six domains (function and health, environment (physical and social), social network, wellbeing, occupation, and managing strategies) based on themes derived from the qualitative interviews and on conceptual discussions within the author group. These domains were incorporated in a conceptual model and items were generated to measure the content of each domain. Participants expressed satisfaction with EQOL but most participants felt that there were too many items.

CONCLUSIONS

In total, 191 items were included in the questionnaire. Participants felt that the EQOL-questionnaire was relevant to their quality of life and participation. We have shown that it is possible to include quality of life and participation for people with various disabilities in one instrument. Although capturing less detail than a condition specific instrument, EQOL includes aspects perceived important for people with disabilities who are not included in general surveys. This is relevant when for example evaluating environmental adaptations and when comparing populations with various disabilities.

Test accommodations for individuals with neurological conditions completing the NIH Toolbox-Cognition Battery: An evaluation of frequency and appropriateness

OBJECTIVES

First, to evaluate the frequency with which individuals with neurological conditions require test administration accommodations for the NIH Toolbox-Cognition Battery (NIHTB-CB). Second, to evaluate the appropriateness of accommodations provided by administrators, including adherence to NIHTB-CB Reasonable Accommodations Guidelines.

METHOD

Adults with traumatic brain injury, spinal cord injury, or stroke (n = 604) completed the NIHTB-CB and other assessments as part of a multisite study. We provide a descriptive, secondary analysis of test administrator notes to determine use and appropriateness of accommodations.

RESULTS

Of the 604 participants, 450 (75%) completed the NIHTB-CB using standard administration procedures, but 137 (22.6%) encountered accessibility challenges that required accommodations. Participants with motor function impairments were most likely to receive at least 1 of 3 kinds of accommodations: (a) use of nonstandard methods of entering responses using standard input devices, (b) use of alternate input devices, or (c) help from the test administrator to enter a response. Fatigue and/or impulsivity led to nonstandard administration by 48 (7.9%) individuals. Post hoc audit of test administrator notes revealed that despite careful instructions and supervision, 49 (56.3%) of the accommodated administrations breached standardization and scores could not be interpreted using test norms.

CONCLUSION

Although the NIHTB-CB was developed for individuals without neurological impairment, most individuals with neurological conditions completed the standardized administration without accommodations. When accommodations were needed, administrators did not adhere to the official Reasonable Accommodations Guidelines in more than half of the cases. (PsycINFO Database Record

Asynchronous brain-computer interface for cognitive assessment in people with cerebral palsy

OBJECTIVE

Typically, clinical measures of cognition require motor or speech responses. Thus, a significant percentage of people with disabilities are not able to complete standardized assessments. This situation could be resolved by employing a more accessible test administration method, such as a brain-computer interface (BCI). A BCI can circumvent motor and speech requirements by translating brain activity to identify a subject's response. By eliminating the need for motor or speech input, one could use a BCI to assess an individual who previously did not have access to clinical tests.

APPROACH

We developed an asynchronous, event-related potential BCI-facilitated administration procedure for the peabody picture vocabulary test (PPVT-IV). We then tested our system in typically developing individuals (N  =  11), as well as people with cerebral palsy (N  =  19) to compare results to the standardized PPVT-IV format and administration.

MAIN RESULTS

Standard scores on the BCI-facilitated PPVT-IV, and the standard PPVT-IV were highly correlated (r  =  0.95, p  <  0.001), with a mean difference of 2.0  ±  6.4 points, which is within the standard error of the PPVT-IV.

SIGNIFICANCE

Thus, our BCI-facilitated PPVT-IV provided comparable results to the standard PPVT-IV, suggesting that populations for whom standardized cognitive tests are not accessible could benefit from our BCI-facilitated approach.

Experiences from intrathecal baclofen treatment based on medical records and patient- and proxy-reported outcome: a multicentre study

PURPOSE

To investigate patient satisfaction with intrathecal baclofen treatment, complications from the treatment, and the impact of general expectations on treatment outcome in relation to satisfaction.

METHODS

A multicentre study with cross-sectional design. Data were collected through questionnaires and patient records. Patients were recruited from six outpatient intrathecal baclofen clinics in Sweden. Eighty-three patients who had been treated with intrathecal baclofen for 1-4 years were included. For patients unable to communicate, data were collected through a proxy. The Patient Global Impression of Change was used to measure patients' general satisfaction with change from intrathecal baclofen treatment. The Life Orientation Test - revised, was used to measure general expectations/optimism.

RESULTS

General satisfaction with intrathecal baclofen treatment was high; 51/77 patients reported "much improved" or "very much improved." There was no relationship between the two main outcomes (general satisfaction and general expectations/optimism) (r_s = 0.12, p = 0.382). The two groups; those who could and those who could not communicate, did differ regarding personal characteristics and should be evaluated as such.

CONCLUSIONS

Most patients/proxies reported a high level of satisfaction with intrathecal baclofen treatment. The reported satisfaction with intrathecal baclofen treatment was not dependent on general expectations. Implications for Rehabilitation Patients with intrathecal baclofen treatment report low levels of health and quality of life at the same time as they are highly satisfied with their treatment. Intrathecal baclofen should be equally offered to both optimistic and less optimistic patients. Patients who are able to/not able to communicate, differs in characteristics and should be informed and followed up in different ways in daily clinical practice.

Reducing Barriers to Patient-Reported Outcome Measures for People With Cognitive Impairments

The field of rehabilitation has increasingly called for the use of patient-reported outcome measures (PROMs) in research and practice. Given that many rehabilitation patients present with conditions associated with cognitive impairments, it is imperative to reduce barriers to PROM use for this population. The purpose of this article is to develop a comprehensive understanding of cognitive accessibility that can prospectively inform the design of PROMs. We put forth the following definition of cognitive accessibility for PROMs: cognitive accessibility is present when assessment design anticipates respondent variability in cognitive abilities and, to the greatest extent possible, reduces cognitive demands and/or supports cognitive processes to enable respondents with a range of cognitive abilities to interpret and respond to assessment items as intended. Our operationalization of cognitive accessibility in measurement in the field of rehabilitation is informed by 2 assumptions: (1) cognitive accessibility results from an interaction between the individual's capacities and the demands of the assessment and assessment context, and (2) individuals with cognitive impairments have the right to be involved in decisions about their lives, including health care decisions. This article proposes 3 design features that can be optimized for cognitive accessibility: content, layout, and administration procedures. We end with a discussion of next steps that the field of rehabilitation measurement can undertake to advance our understanding of cognitive accessibility.

Conducting Accessible Research: Including People With Disabilities in Public Health, Epidemiological, and Outcomes Studies

People with disabilities are largely absent from mainstream health research. Exclusion of people with disabilities may be explicit, attributable to poorly justified exclusion criteria, or implicit, attributable to inaccessible study documents, interventions, or research measures. Meanwhile, people with disabilities experience poorer health, greater incidence of chronic conditions, and higher health care expenditure than people without disabilities. We outline our approach to "accessible research design"-research accessible to and inclusive of people with disabilities. We describe a model that includes 3 tiers: universal design, accommodations, and modifications. Through our work on several large-scale research studies, we provide pragmatic examples of accessible research design. Making efforts to include people with disabilities in public health, epidemiological, and outcomes studies will enhance the interpretability of findings for a significant patient population.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Differences in quality of life outcomes among depressed spinal cord injury trial participants

OBJECTIVE

To assess the role that treatment response plays in a randomized controlled trial of an antidepressant among people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD) in explaining quality of life (QOL), assessed both globally as life satisfaction and in terms of physical and mental health-related QOL.

DESIGN

Multivariable analyses were conducted, controlling for demographic, neurologic, and participatory factors and perceived functional limitations.

SETTING

Rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the Project to Improve Symptoms and Mood after Spinal Cord Injury randomized controlled trial, 124 participated in this study. All participants were between the ages of 18 and 64 years, at least 1 month post-SCI, met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for MDD, and completed the core measures used in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the Medical Outcomes Study 12-Item Short-Form Health Survey.

RESULTS

Reduction in depressive symptoms over the course of a 12-week trial was predictive of increased QOL, which was measured as life satisfaction and mental well-being, within the context of other explanatory factors. However, reduction in symptoms did not explain differences in physical well-being among those with MDD. Perceived functional disability explained all 3 indices of QOL.

CONCLUSIONS

Greater recognition has been given to QOL outcomes as endpoints of clinical trials because these often reflect participants' reported outcomes. Our findings support the association of QOL to the reduction of depression symptoms among trial participants. This association differs depending on how QOL is defined and measured, with stronger relations observed with life satisfaction and mental well-being among those diagnosed with MDD. The lack of association between depression and physical well-being may be explained by participants' subjective interpretation of physical well-being after SCI and their expectations and perceptions of improved physical health-related QOL based on the use of assistive technology. Consistent with our findings, pain is likely to play a role in decreasing physical QOL among those with incomplete injuries. Practicing caution is suggested in using physical well-being as an endpoint in trials among people with SCI.

Short Form health surveys and related variants in spinal cord injury research: a systematic review

CONTEXT

'Short Form' health surveys - such as the SF-36 and SF-12 - are widely used in medical research. Spinal cord injury (SCI) is no exception, despite oft-cited concerns regarding measurement properties for populations with physical impairment.

OBJECTIVE

To provide a comprehensive overview of the use of Short Form health surveys and their variants within the SCI literature.

METHODS

Papers published between database inception and September 2012 were identified from 11 electronic databases; a supplementary reference list search was also conducted. Data extraction focused on details regarding the range of different Short Form surveys and variants used in SCI research, the respective frequency of use, the nature of reporting (complete versus partial reporting) and the method of survey administration.

RESULTS

One hundred seventy-four papers were identified. Thirty-six-item Short Form health surveys were frequently administered as complete instruments (n = 82); in 69 of these 82 studies (84%), it was not clearly stated which 36-item version had been used (e.g. SF-36v1, SF-36v2, RAND-36). Data for individual items and domains were often reported (29% of identified studies), indicating significant partial use of standardized measures. Modified variants of standardized health surveys were administered in 12 studies.

CONCLUSION

Although standardized Short Form health surveys are common within SCI research, attempts to add, delete, or modify items have resulted in a number of variants, often with minimal supportive psychometric evidence. Using established, generic outcome measures is appealing for a number of reasons. However, validity is paramount and requires further explicit consideration within the SCI research community.

Making the best match: selecting outcome measures for clinical trials and outcome studies

Selecting an appropriate outcome measure is a critical step in designing valid and useful clinical trials and outcome studies. This selection process needs to extend beyond examining basic psychometric properties to consider additional features of instruments that may affect their validity and utility for the study's purpose. This article discusses these additional factors and their potential impact on outcome measurement. Guidelines are proposed to help clinical researchers and consumers of clinical research literature evaluate the match between the study purpose, population, and instrument.

Effects of concurrent respiratory resistance training on health-related quality of life in wheelchair rugby athletes: a pilot study

PURPOSE

To compare the effects of 9 weeks of training with a concurrent flow resistance (CFR) device versus a concurrent pressure threshold resistance (CPTR) device on health-related quality of life (HRQoL) in wheelchair rugby (WR) athletes.

METHOD

Twenty-four male WR athletes (22 with tetraplegia, 1 with a spastic cerebral palsy, and 1 with congenital upper and lower limb deformities) were matched by lesion level, completeness of injury, and rugby classification prior to being randomly assigned to 1 of 3 groups: (1) CPTR (n=8), (2) CFR (n=8), or (3) controls (CON, n=8). Pre/post testing included assessment of HRQoL as measured by the Short-Form Health Survey Version 2.0 (SF-36v2). Manufacturer protocol guidelines for the CFR and CPTR groups were followed for breathing exercises.

RESULTS

Sixteen participants completed the study (CPTR=4, CFR=5, CON=7). The Mann-Whitney U rank order revealed significantly greater reductions in bodily pain (P = .038) and improvements in vitality (P = .028) for CFR versus CON.

CONCLUSION

Results from this study suggest that training with a CFR device improves some aspects of HRQoL (eg, vitality and bodily pain) in WR athletes. Further research with a larger sample size is needed to examine the impact of these devices on improving HRQoL for wheelchair athletes.

Development of items that assess physical function in children who use wheelchairs

PURPOSE

To assess the content, format, and comprehension of the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric physical function related to mobility items for children who use wheelchairs (WCs).

METHODS

During a cognitive interview, 14 children, aged 8 to 12 years, who use WCs, verbalized their thoughts when answering PROMIS items. The questionnaire appraisal system was used to code summarized text from the interviews.

RESULTS

The children requested items be more specific and include options for reporting adaptive ways of performing and participating. How they would answer the item depended on the situation and specific environmental supports and constraints they may have experienced.

CONCLUSIONS

As rehabilitation professionals develop and use self-reported outcome measures, they should explore what is important to children who use WCs regarding their views on physical functioning, the influences of the environment, and variability in the use of devices to assist with functional mobility.

Incidence and risk factors of poststroke falls after discharge from inpatient rehabilitation

OBJECTIVE

To investigate the incidence of falls and risk factors for falls in persons who had a stroke.

DESIGN

Telephone survey.

SETTING

Tertiary university hospital.

PATIENTS AND METHODS

Patients who had a stroke and were admitted to the rehabilitation unit between April 2006 and July 2008 were listed and contacted by telephone from February 2009 to August 2009.

MAIN OUTCOME MEASUREMENTS

Information obtained from the interviews, which were performed 20 ± 8 months after discharge from inpatient rehabilitation, included demographic data, information about falls, and current ambulatory function. After the telephone interview, medical records of participants during admission were reviewed.

RESULTS

Of the 404 enrolled patients, 330 were included in the analysis. Of the 330 patients, 62 (19%) had a history of a fall after stroke onset. Of 222 ambulatory patients, 51 patients (23%) fell. Falls frequently occurred in winter, and most falls occurred indoors (70%). Twenty-nine percent of patients experienced repeated falls. About half of those who fell were injured, and 11% sustained fractures. Patients who had a stroke and had severe deficits showed a lower probability of poststroke falls. In a subgroup analysis of patients with ambulatory capacity, left-sided hemiplegia/hemiparesis was associated with an increased risk of falls.

CONCLUSIONS

This study reveals a high incidence of poststroke falls after discharge from inpatient rehabilitation. More caution should be taken for patients with ambulatory ability and left hemiplegia/hemiparesis because they are more vulnerable to falls after a stroke. An increased prevalence of fear of falling in people who fell suggests that an appropriate intervention to reduce fear of falling should be provided to patients who have had a stroke.

A framework for understanding modifications to measures for diverse populations

OBJECTIVE

Research on health disparities and determinants of health disparities among ethnic minorities and vulnerable older populations necessitates use of self-report measures. Most established instruments were developed on mainstream populations and may need adaptation for research with diverse populations. Although information is increasingly available on various problems using these measures in diverse groups, there is little guidance on how to modify the measures. A framework of issues to consider when modifying measures for diverse populations is presented.

METHODS

The authors describe reasons for considering modifications, the types of information that can be used as a basis for making modifications, and the types of modifications researchers have made. Recommendations are made to test modified measures to assure their appropriateness, and suggestions are provided on reporting modifications in publications using the measures.

DISCUSSION

The issues open a dialogue about what appropriate guidelines would be for researchers adapting measures in studies of ethnically diverse populations.

Modification of the SF-36 for a headache population changes patient-reported health status

BACKGROUND

Using standard quality of life and disability measures may not accurately capture these constructs in specific health populations such as headache patients. Modifying the wording of standard measures such as the Short-Form 36 (SF-36) should be considered in order to make them more applicable to specific patient populations.

OBJECTIVE

To investigate the possibility that headache patients may not consider their headaches when responding to SF-36 questions pertaining to health, physical health, pain, and bodily pain.

METHODS

The wording of several SF-36 questions were adapted for a headache population by making specific reference to "headaches" when asking people to rate the impact of health issues on their life. The results of the modified "Headache" SF-36 were compared with a similar population of transformed migraine patients who had completed the "Standard" SF-36.

RESULTS

Significant differences were found between scores for the "Standard" SF-36 group and the "Headache" SF-36 group across all SF-36 variables except for "General Health."

CONCLUSIONS

Misinterpretation of the concepts of "health,""physical health,""pain," and "bodily pain," although commonly used by the SF-36 in many populations, could influence responses on this measure, as respondents may not relate their head/headaches to these constructs. To ensure that accurate data are obtained in relation to the quality of life of headache patients, consideration should be given to using a form of the SF-36 that has been modified to allow appropriate interpretation of the questions completed by headache patients.

Scientific reasons for including persons with disabilities in clinical and translational diabetes research

Despite disparities in health problems and outcomes, people with disabilities are underrepresented in diabetes research. This results in a lack of evidence-based knowledge regarding best approaches in caring for this population. This article addresses the need for research that includes people with disabilities and describes the common reasons persons with disabilities are not included in research, including scientists' concerns regarding threats to a study's internal validity and cost. Arguments are provided as to how involving people with disabilities in research will improve our science and reduce disparities in this population. In addition to the ethical reasons for including persons with disabilities in research, the ability to generalize study findings to this population and thus speed our development and translation of this knowledge for use by clinicians is discussed. The bias in study conclusions that arise from study samples that do not include persons with disabilities and its possible effect on care delivery are presented. Two strategies that researchers can use to increase the inclusion of persons with disabilities in research are described: (1) Universal Design of Research and (2) intervention optimization study designs. Universal Design of Research includes research design processes such as the use of multisensory formats for recruiting participants, approaches to designing and presenting research instruments and interventions, and methods of data collection to promote the inclusion of participants with a wide range of abilities in research studies. Intervention optimization study designs offer an efficient way for scientists to rapidly build the most potent interventions for a wide range of people, including those with disabilities participating in mainstream research.

Identifying factors associated with self-rated health according to age at onset of disability

PURPOSE

Although later-onset disability has been associated with poor self-rated health (SRH), factors mediating differences in SRH related to age at onset of disability remain unclear. The present study was designed to identify the variables explaining poor SRH in later-onset disability. We examined chronic disease and functional status as alternatives to psychosocial adaptation as explanatory variables.

METHOD

Our data were taken from the seventh National Survey for People with Disabilities among Korean individuals ≥18 years of age (n =5311).

RESULTS

Those with later-onset disability (onset ages 20-40, 41-64 and ≥65 years) showed higher age-adjusted odds ratios (ORs) for poor SRH compared with those with earlier-onset disability (onset ages 0-19 years). The ORs for poor SRH in individuals with later-onset disability were not substantially changed after adjusting for confounding variables including alternatives to psychosocial adaptation (chronic diseases and functional status) as explanatory variables.

CONCLUSIONS

Failure to explain poor SRH in later-onset disability with explanatory variables other than psychosocial adaptation indirectly supports the role of psychosocial adaptation in differences in SRH related to age at onset. Because we could not include appropriate measures of psychosocial adaptation, the use of additional instruments should be considered in future studies.

Factors associated with self-reported mammography use for women with and women without a disability

BACKGROUND

Although their risk of breast cancer is similar to that of women without a disability, women with a disability might be less likely to obtain a mammogram within the recommended time frame. The purpose of this study was to expand our knowledge of the association between mammography use and having a disability by controlling for sociodemographic and health variables.

METHODS

Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) were used to obtain prevalence of self-reported mammography use in the past 2 years among U.S. women ≥40 years of age (n=204,981) as well as women 50-74 years of age (n=122,374). Logistic regression was used to estimate associations between disability and obtaining a mammogram for each age cohort, controlling for sociodemographic factors.

RESULTS

Prevalence of self-reported mammography use is lower for women with a disability (72.2% for women ≥40 years of age and 78.1% for women 50-74 years of age) than women without a disability (77.8% and 82.6%, respectively). Women with a disability had lower odds of mammography use than women without a disability for both age cohorts (≥40, adjusted odds ratio [aOR] 0.92, p=0.01; 50-74 years, aOR 0.92, p=0.03).

CONCLUSIONS

Disparities in obtaining a mammogram at recommended screening intervals persist for women with disabilities. This demonstrates the need for continued health promotion and prevention activities directed toward women with a disability to improve their accessibility to obtaining a mammogram.

Labour market outcomes for people with a spinal cord injury

The consequences of spinal cord injury are profound and extend well beyond the immediate loss of mobility and sensation. Employment is a well-recognised rehabilitation goal. In this study, we examine the impact of a publicly funded "package" of services that is designed to enable people with a spinal cord injury to return to the workplace. Specifically, this package of services provided client directed assistance for assisting the recipient with the activities of daily living (e.g., bathing, food preparation, etc.). We combine primary data collection methods well developed in other scientific disciplines, but less frequently utilised within economics, with traditional econometric techniques, to present a novel approach to this methodological issue. The Spinal Injuries Survey Instrument was developed and administered using a matched sampling approach. Collected data included, labour market outcomes, exposure to the packages, as well as clinical and demographic covariates commonly identified by the spinal cord injury literature. Concern for endogeneity was addressed by collecting data on several variables that might serve as suitable instruments for the econometric work and measures of otherwise-unobserved sources of heterogeneity. For example, a psychological measure of "attributional style was adapted from the field of psychology in order to control for a potentially confounding source of latent individual heterogeneity, viz. "motivation". While our results find zero marginal effect of support packages on labour market outcomes, we find that training undertaken post-injury and age are both positively correlated with labour market participation.

Enabling a survey of primary care to measure the health care experiences of adults with disabilities

PURPOSE

To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties.

METHODS

Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish.

RESULTS

Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%.

CONCLUSIONS

It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities.

Structure of health-related quality of life among people with and without functional limitations

PURPOSE

The objective of this study was to assess the factor structure of nine health-related quality of life (HRQOL) survey items among people with and without disabilities or functional limitations (FL) and determine whether factor loadings were similar for the two groups.

METHODS

Data were from US states and territories in the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). Confirmatory factor analyses assessed fit of the data to a previously found factor structure.

RESULTS

A two-factor structure was confirmed, conceptually representing physical and mental health. Although this structure fit data for both people with and without FL, factor loadings were significantly different for the two groups. In all but one instance, factor loadings were higher for people with FL than for people without FL.

CONCLUSIONS

Results suggest that people with and without FL conceptualize physical and mental HRQOL similarly. However, the nine items analyzed appear to be a better reflection of the latent constructs of physical and mental HRQOL in the population of people with FL than those without FL.

Sharing of lessons learned from multisite research

PURPOSE

To highlight key considerations for planning and implementing multisite research based on experiences and reflections in conducting a large, international, multisite study.

DESCRIPTION

Successes and challenges encountered throughout a multisite study process, and collective recommendations for future researchers are presented. Considerations addressed include creation of the research team and a "community of practice," study preparation and management time, approval by institutional review boards, training of future researchers, recruitment and retention of participants, and dissemination and translation of study materials to consumers.

IMPORTANCE TO MEMBERS

Multisite research has the potential to create knowledge for pediatric physical therapy through collaboration among knowledgeable researchers and expert practitioners and by increasing the potential for generalization of findings. Effective planning, including anticipation of challenges, is critical to a successful study. Our collective experiences may assist practitioners and researchers in planning, implementing, and completing future multisite studies.

Advancing rehabilitation research: An interactionist perspective to guide question and design

The purpose of this position statement is to propose an interactionist framework to bring together the existing literature and provide a unifying direction for rehabilitation research. The framework comprises three components: the conceptual model, the research question, and the research design. The interactionist conceptual model has been adapted from the World Health Organization International Classification of Functioning, Disability, and Health. The model forms the starting point that guides the specification of the research question, which, in turn, guides the selection of research design. This approach demands that the question takes precedence and that there be an extensive repertoire of research designs, each of which is valued for its 'goodness-of-fit' with the question, rather than an a priori, single hierarchical ordering of designs. Research designs must be appropriate for questions that examine the disability experience, development over the lifespan, multifaceted interventions, low incidence conditions, and development of new interventions. Analytical challenges include dealing with confounding, mediating, and moderating variables. Rehabilitation researchers--and those who fund their work--should consider and value the use of diverse research methods to best answer the questions posed from the interactionist perspective.

Disparities in smoking behaviors among those with and without disabilities from 2001 to 2005

OBJECTIVES

Past research has suggested smoking disparities among individuals with disabling conditions. We contrasted smoking behaviors of those with and without disabilities from 2001 to 2005.

DESIGN

Descriptive correlational study.

SAMPLE

Telephone interviews were conducted in all states with noninstitutionalized adults. Half were female; most were Anglo (70.5%) and had at least a high school education (90%). Their average age was 45 years. Approximately 19% of the sample reported being disabled.

MEASUREMENT

We analyzed 4 years of data from the population-based Behavioral Risk Factor Surveillance System.

RESULTS

While individuals with disabilities were more likely to report ever having smoked than nondisabled respondents, current smoking behaviors were more similar in the 2 groups, and the difference was not statistically significant when demographic factors were included in the model. Smoking behavior decreased somewhat for nondisabled persons between 2001 and 2005, but remained fairly constant for those with disabilities. However, those with disabilities were more likely than those without disabilities to have attempted to quit smoking in all years.

CONCLUSIONS

Findings underscore the importance of smoking cessation programs tailored to people with disabilities. The role of the public health nurse in addressing smoking cessation at the individual, system, and community level is discussed.

Validity, responsiveness, and minimal important difference for the SF-6D health utility scale in a spinal cord injured population

OBJECTIVE

To determine the feasibility, acceptability, discriminative validity, responsiveness, and minimal important difference (MID) of the SF-6D for people with spinal cord injury (SCI).

METHODS

A total of 305 people with SCI completed the SF-36 health status questionnaire at baseline and at subsequent occurrence of a urinary tract infection (UTI) or 6-month follow-up. Normative SF-36 data were obtained from the Australian Bureau of Statistics. SF-36 scores were transformed to SF-6D utility values using Brazier's algorithm. We used UTI as the external criterion of clinically important change to determine responsiveness and two categories of the SF-36 transition question ("somewhat worse" and "somewhat better") as the external criterion to determine the MID. Derived SF-12 responsiveness was also assessed.

RESULTS

The mean SF-6D values were: 0.68 (SD 0.21, n = 305) all patients; 0.66 (SD 0.19, n = 167) tetraplegia; 0.72 (SD 0.26, n = 138) paraplegia; 0.57 (SD 0.15, n = 138) with UTI. The Australian normative SF-6D mean value was 0.80 (SD 0.14, n = 18,005). The SF-6D was able to discriminate between SCI and the Australian normative sample (effect size [ES] = 0.86), tetraplegia-paraplegia (ES = 0.23), and it was responsive to UTI (ES = 0.86 SF-36 variant, ES = 0.92 SF-12 variant). The MID for respondents who reported being somewhat worse or somewhat better at follow-up was 0.03 (SD 0.17, n = 108/305), while the MID for only those who were somewhat worse was 0.10 (SD 0.14, n = 58).

CONCLUSIONS

The content of the SF-6D is more appropriate than that of the SF-36 for this physically impaired population. The SF-6D has discriminative power and is responsive to clinically important change because of UTI. The MID is consistent with published estimates for other disease groups.

Age at disability onset and self-reported health status

BACKGROUND

The critical importance of improving the well-being of people with disabilities is highlighted in many national health plans. Self-reported health status is reduced both with age and among people with disabilities. Because both factors are related to health status and the influence of the age at disability onset on health status is unclear, we examined the relationship between disability onset and health status.

METHODS

The U.S. 1998-2000 Behavioral Risk Factor Surveillance system (BRFSS) provided data on 11,905 adults with disability. Bivariate logistic regression analysis modeled the relationship between age at disability onset (based on self-report of duration of disability) and fair/poor self-perceived health status, adjusting for confounding variables.

RESULTS

Key variables included demographics and other measures related to disability and general health status. Disability onset after 21 years of age showed significant association with greater prevalence of fair/poor health compared to early disability onset, even adjusting for current age and other demographic covariates. Compared with younger onset, the adjusted odds ratios (OR) were ages 22-44: OR 1.52, ages 45-64: OR 1.67, and age > or =65: OR 1.53.

CONCLUSION

This cross-sectional study provides population-level, generalizable evidence of increased fair or poor health in people with later onset disability compared to those with disability onset prior to the age of 21 years. This finding suggests that examining the general health of people with and those without disabilities might mask differences associated with onset, potentially relating to differences in experience and self-perception. Future research relating to global health status and disability should consider incorporating age at disability onset. In addition, research should examine possible differences in the relationship between age at onset and self-reported health within specific impairment groups.

Personal assistance, income and employment: the spinal injuries survey instrument (SISI) and its application in a sample of people with quadriplegia

INTRODUCTION

Our aim was to ascertain what effect access to personal care package (PCP) has on the labour market activities of people who have a spinal cord injury (SCI). We developed a new instrument called the spinal injuries survey instrument (SISI). The SISI is a 35-item instrument, which contains items on health, education, employment, along with measures of personal assistance, mobility and psychological attribution style.

MATERIALS AND METHODS

The SISI was administered, with the Short Form 36 (SF-36) health status instrument, to 250 people with an SCI. The response rate was 72%. A retrospective, matched case-control sampling approach matched individuals who received a PCP, with a cohort who did not. The matching criteria included the site and severity of spinal lesion, age and gender.

RESULTS

Although data on the reliability of the instrument are currently lacking, our empirical results are consistent with other studies: (1) mean annual health care costs (AUD$8741) are comparable with Walsh's estimates (2) SF-36 data support Kreuter's contention that mental health is resilient to SCI and (3) a post-injury employment rate of 29.7% corroborates Murphy et al. We present additional data describing income, educational attainment and family support.

DISCUSSION

Our discussion borrows a conceptualization of disability by Sen, that includes both an 'earning handicap' (an impediment to earn income) and a 'conversion handicap' (an impediment to the enjoyment of income). Our application of the SISI provides evidence of both. The labour income of people with quadriplegia is AUD$10,007 per annum, while diminished health status, increased out-of-pocket health expenditure and loss of time suggest a conversion handicap.

Measuring quality of life in prosthetic practice: benefits and challenges

There is an increasing awareness that the inclusion of quality of life as an outcome measure is important in ensuring a client-centred and holistic assessment. This review outlines the benefits of quality of life as an outcome measurement in the field of prosthetics. It introduces the key concepts and challenges in the definition and assessment of quality of life post-amputation, including the relative advantages and disadvantages of adopting generic, disease/condition specific, dimension specific and individualized measures of quality of life. In conclusion, the review delineates and recommends issues and guidelines for consideration when undertaking quality of life research and assessment. A co-ordinated approach by practitioners in the field of prosthetics is necessary to ensure the inclusion of quality of life as an outcome measure and to ensure its measurement in a standardized and rigorous manner.

Response Shift Theory: Important Implications for Measuring Quality of Life in People With Disability

Measurement of health-related quality of life (HRQOL) in people with disability can be problematic. Ambiguous or paradoxical findings can occur because of differences among people or changes within people regarding internal standards, values, or conceptualization of HRQOL. These "response shifts" can affect standard psychometric indices, such as reliability and validity. Attending to appraisal processes and response shift theory can inform development of HRQOL measures for people with disability that do not confound function and health and that consider important causal indicators such as environment. By design, most HRQOL measures equate function with health, necessarily leading to a lower measured HRQOL in people with functional impairments regardless of their level of self-perceived health. In this article, we present theoretical and conceptual distinctions building on response shift theory and other current developments in HRQOL research. We then submit a set of suggested directions for future measurement development in populations with disabilities that consider these distinctions and extend their use in future measurement developments.

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

This article extracts principles from two Surgeon General reports, Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation (2002) and Call to Action to Improve the Health and Wellness of Persons with Disabilities (2005), and combines them with the Objectives from Chapter 6 of Healthy People 2010 to create a policy framework. This framework is used to review literature from the past decade on access to health care and health promotion for persons with intellectual and developmental disabilities (IDD). Review of the literature indicates an emerging evidence base for health promotion programs for persons with IDD. Research in health care and health promotion access requires improvements in surveillance and measurement of quality of life, as well as increased participation of persons with IDD and their families in its implementation. While international guidelines for primary health care have been developed for people with IDD, US guidelines are specialty focused and address specific conditions. Despite its recognized importance, there is surprisingly little information on training programs for health care providers to improve care of persons with IDD. Financing of health care continues to threaten access to comprehensive care for persons with IDD, particularly regarding coordination of care and availability of providers who accept Medicaid patients. Community-based sources of health care have been slow to emerge, and there is clear need for assumption of responsibility for providing care to persons with IDD. Future US policy should include consideration of environmental factors in health care access.

A Pilot Study to Modify the SF-36V Physical Functioning Scale for Use With Veterans With Spinal Cord Injury

OBJECTIVE

To develop a valid and reliable spinal cord injury (SCI) specific physical functioning (PF) scale for the Veterans Health Administration (VHA) version of the 36-Item Short-Form Health Survey.

DESIGN

A mixed qualitative and quantitative research design was used. In phase 1, a pool of SCI-specific PF items was generated based on focus groups with patients and health care providers. In phase 2, the psychometric properties of the SCI-specific PF scale were established.

SETTING

A VHA SCI center.

PARTICIPANTS

The sample consisted of valid responses from 359 veterans with traumatic SCI who were seen at a VHA SCI center during the prior year (2002).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Physical functioning in people with SCI.

RESULTS

Exploratory factor analysis was conducted separately on respondents with lower neurologic-level injuries (paraplegia, 53% [n=190]) and those with higher neurologic-level injuries (tetraplegia, 45% [n=163]) and identified 9 items loading on 1 factor in both groups. These 9 items were included in separate item response theory (IRT) model analyses for each subgroup. Based on the IRT analysis, 1 item was eliminated, resulting in an 8-item, SCI-specific PF scale.

CONCLUSIONS

Although several of the items in the SCI-specific PF scale showed floor effects, particularly in people with tetraplegia, we found excellent reliability and strong support of convergent and divergent validity of the scale.

Participation survey/mobility: psychometric properties of a measure of participation for people with mobility impairments and limitations

OBJECTIVE

To describe the development and psychometric properties of a self-report survey of participation by people with mobility limitations, the Participation Survey/Mobility (PARTS/M).

DESIGN

The information obtained during interviews and focus groups was used to develop items for the PARTS/M. Demographics and measures of disability, health, and functioning were collected. The PARTS/M was administered twice.

SETTING

Primarily in the midwestern United States.

PARTICIPANTS

Purposeful sample of 604 people with mobility limitations having a diagnosis of spinal cord injury, multiple sclerosis, cerebral palsy, stroke, or postpoliomyelitis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

PARTS/M is composed of 20 major life activities that are placed in 6 domains used in the activity/participation component of the International Classification of Functioning, Disability and Health: self-care; mobility; domestic life; interpersonal interactions and relationships; major life areas; and community, social, and civic life. For each activity, questions were asked about components of participation including frequency, health-related limitations, importance, choice, satisfaction, use of assistive technology, and use of personal assistance.

RESULTS

PARTS/M domains and components of participation had good internal consistency and stability. Composite participation scores were developed for participation components and domains.

CONCLUSIONS

PARTS/M is a reliable measure of some aspects of participation in major life activities for people with mobility impairments and limitations living in community settings.