Rural residents with disabilities confront substantial barriers to obtaining primary care

"Just trying to adjust to the new reality that seems to be changing every hour": Lessons learned from nation-wide peer meetings on COVID-19 with rural disability service providers

At the onset of the COVID-19 pandemic, providers of independent living services for rural disabled people were forced to adapt how they conducted their operations. This study is a primary analysis of data based on transcripts from eight meetings of a nationwide network of service providers, who met virtually to provide peer support during the unfolding pandemic. We used qualitative thematic analysis to understand the ways these service providers adapted to address the needs of rural disabled people during the pandemic. Each meeting was attended by Center for Independent Living (CIL) staff members (n = 40 to 150 participants per meeting). We identified four main themes describing organizational adaptations: 1) Providing core services remotely, 2) Regular check-ins, 3) Virtual group meetings became a mainstay of service provision, and 4) Barriers and solutions to virtual connectivity in rural areas. Although this was a predominantly challenging time, CIL staff identified ways their adaptations were beneficial. These included creating new ways to connect, reaching more people with disabilities, and cutting down on commuting time to provide services. CIL staff intended to continue using their adapted strategies and platforms for providing services, and thus projected these benefits would be long-lasting.

Further detailed objectification within comparative analysis of quality of life - based on some sociodemographic characteris-tics/parameters and related statistical analysis - between mothers of children with congenital versus acquired neuropathology

Abstract: This study aimed to determine whether there is a difference in quality of life between mothers of children with congenital neuropathology and, respectively, those with acquired neuropathology based on some sociodemographic characteristics/parameters, taking into account data from the specialized literature on the influence of sociodemographic characteristics/parameters on mothers with disabled children. 85 subjects (divided into two groups, congenital and acquired) were included in the study conducted at the National Clinical Centre of Neurorehabilitation for Children “Dr. N. Robanescu. To objectify – if existing – such differences, as mentioned above, we used the clinical, functional quantified evaluation instrument PedsQL- Family Impact Module (PedsQL-FIM). According to our data, there were statistically significant differences between groups for physical functioning, emotional functioning, communication, and worry. There were no statistically significant differences between the groups for daily activity, social functioning, cognitive functioning, and family relationships. We also found weak negative correlations between the following dimensions of PedsQL-FIM: emotional functioning, social functioning, and communication) and education for the former group; a weak positive correlation between worry and education, a weak negative correlation between emotional functioning and income level, and two moderate negative correlations between social functioning, daily activities, and income level for the latter group. We can conclude that the variable education had the most significant influence on the quality of life for mothers of children with congenital neuropathology, in contrast, the variable income level had the most significant influence on mothers of children with acquired neuropathology. Keywords: sociodemographic characteristics, quality of life, disability

Addressing transportation barriers to health care during the COVID-19 pandemic: Perspectives of care coordinators

Prior to the COVID-19 pandemic, transportation barriers prevented millions of Americans from accessing needed medical care. Then the pandemic disrupted medical and transportation systems across the globe. This research explored ways the COVID-19 pandemic changed how people experienced transportation barriers to accessing health care. We conducted in-depth interviews with social workers, nurses, and other care coordinators in North Carolina to identify barriers to traveling for medical care during the pandemic and explore innovative solutions employed to address these barriers. Analyzing these interviews using a flexible coding approach, we found that the pandemic exacerbated existing transportation barriers and created new barriers. Yet, simultaneously, temporary policy responses expanded the utilization of telehealth. The interviews identified specific advantages of expanded telehealth, including increasing access to mental health services in rural areas, reducing COVID-19 exposure for high-risk patients, and offering continuity of care for COVID-19 patients with other health conditions. While telehealth cannot address all medical needs, such as emergency or cancer care, it may be well-suited for preliminary screenings and follow-up visits. The findings provide insights on how post-pandemic telehealth policy changes can benefit individuals facing transportation barriers to accessing health care and support more accommodating and convenient health care for patients and their families.

Addressing transportation barriers to health care during the COVID-19 pandemic: Perspectives of care coordinators

Prior to the COVID-19 pandemic, transportation barriers prevented millions of Americans from accessing needed medical care. Then the pandemic disrupted medical and transportation systems across the globe. This research explored ways the COVID-19 pandemic changed how people experienced transportation barriers to accessing health care. We conducted in-depth interviews with social workers, nurses, and other care coordinators in North Carolina to identify barriers to traveling for medical care during the pandemic and explore innovative solutions employed to address these barriers. Analyzing these interviews using a flexible coding approach, we found that the pandemic exacerbated existing transportation barriers and created new barriers. Yet, simultaneously, temporary policy responses expanded the utilization of telehealth. The interviews identified specific advantages of expanded telehealth, including increasing access to mental health services in rural areas, reducing COVID-19 exposure for high-risk patients, and offering continuity of care for COVID-19 patients with other health conditions. While telehealth cannot address all medical needs, such as emergency or cancer care, it may be well-suited for preliminary screenings and follow-up visits. The findings provide insights on how post-pandemic telehealth policy changes can benefit individuals facing transportation barriers to accessing health care and support more accommodating and convenient health care for patients and their families.

Nonlinear Associations between Medical Expenditure, Perceived Medical Attitude, and Sociodemographics, and Older Adults’ Self-Rated Health in China: Applying the Extreme Gradient Boosting Model

Background: although China’s total health expenditure has been dramatically increased so that the country can cope with its aging population, inequalities among individuals in terms of their medical expenditures (relative to their income level) have exacerbated health problems among older adults. This study aims to examine the nonlinear associations between each of medical expenditure, perceived medical attitude, and sociodemographics, and older adults’ self-rated health (SRH); it does so by using data from the 2018 China Family Panel Studies survey. Method: we used the extreme gradient boosting model to explore the nonlinear association between various factors and older adults’ SRH outcomes. We then conducted partial dependence plots to examine the threshold effects of each factor on older adults’ SRH. Results: older adults’ medical expenditure exceeded their overall income. Body mass index (BMI) and personal health expenditure play an essential role in predicting older adults’ SRH outcomes. We found older adult age, physical exercise status, and residential location to be robust predictors of SRH outcomes in older adults. Partial dependence plots of the results visualized the nonlinear association between variables and the threshold effects of factors on older adults’ SRH outcomes. Conclusions: findings from this study underscore the importance of medical expenditure, perceived medical attitudes, and BMI as important predictors of health benefits in older adults. The potential threshold effects of medical expenditure on older adults’ SRH outcomes provide a better understanding of the formation of appropriate medical policy interventions by balancing the government and personal medical expenditure to promote health benefits among older adults.

Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study

BACKGROUND

Patients with disabilities often require healthcare accommodations in order to access high-quality, equitable healthcare services. While attention has been paid to accommodation needs in specific disability populations, limited research to date has explored healthcare accommodations that cross-cut diverse disability populations.

OBJECTIVE

To identify a deeper understanding regarding accommodations in healthcare settings that could apply across disability populations and promote equitable healthcare.

DESIGN

We conducted qualitative focus groups with patients with disabilities and caregivers to understand their experiences and preferences for healthcare accommodations.

PARTICIPANTS

We recruited patients and caregivers across all major disability categories to participate in focus groups. Participants were recruited through advocacy organizations and healthcare settings in Southeastern Minnesota.

APPROACH

A total of eight focus groups were conducted with 56 participants. Participants described their healthcare experiences and desires for healthcare accommodations. The multidisciplinary research team recorded, transcribed verbatim, and coded all focus groups. The team thematically coded transcripts using content analysis within and across focus groups to identify major themes.

KEY RESULTS

Patients identified four challenges and corresponding steps healthcare team could take to promote equitable care: (1) consistent documentation of disabilities and needed accommodations in the medical record; (2) allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes; (3) provide accommodations for administrative tasks, such as completing paper or electronic forms; and (4) adapt communication during interactions, such as speaking slower or using terms that patients can easily understand.

CONCLUSION

These identified themes represent specific opportunities for healthcare teams to effectively provide accessible care to patients with disabilities. Many of the accommodations require minimal financial investment, but did require behavioral changes by the healthcare team to ensure equitable healthcare.

Exploring Access to Independent Living Services for People With Disabilities Through a Transportation Network Analysis

Centers for Independent Living (CILs) are nonresidential, nonprofit agencies that provide independent living services to people with disabilities across the nation. The services CILs provide are invaluable to people with disabilities living independently in the community. Accessing CIL services can be challenging for people with disabilities, particularly for individuals in rural areas. A geographic analysis called a transportation network analysis is one method for assessing access to CIL services. We draw on the distribution of CILs across the country and in two rural states (Montana and Arkansas) to assess levels of geographic access using travel distance along national and local road networks. Incorporating data from the American Community Survey allowed us to estimate the number of people with disabilities living within certain distance thresholds from CILs. We saw increased access in urban areas where there is a higher concentration of CILs, suggesting that people with disabilities in rural areas have limited access to CIL services. We explore how partnering with Area Agencies on Aging has the potential to expand access to services for people with disabilities in rural areas, highlighting the utility of geographic analysis in social service provision.

Personalized Telerehabilitation for a Head-mounted Low Vision Aid: A Randomized Feasibility Study

SIGNIFICANCE

A recent trend in low vision rehabilitation has been the use of portable head-mounted displays to enhance residual vision. Our study confirms the feasibility of telerehabilitation and informs the development of evidence-based recommendations to improve telerehabilitation interventions to reduce device abandonment.

PURPOSE

To develop evidence-based recommendations for telerehabilitation, we conducted a feasibility study in preparation for a future randomized trial on the use of head-mounted displays.

METHODS

We recruited novice eSight Eyewear users, randomized 1:1: the experimental group received telerehabilitation by a low vision therapist using video conferencing; the control group completed at home self-training provided by the device manufacturer. The primary feasibility outcomes were whether the recruitment goal of 60 participants (30/group) was attainable within 1 year and how participants judged the accessibility and acceptability of the telerehabilitation. An exploratory outcome was the impact of telerehabilitation on eSight Eyewear use behavior.

RESULTS

Among 333 eSight users, 57 participants were enrolled, of which 35% withdrew from the study, whereas the remainder completed the 6-month follow-up. The withdrawal rate was higher in the control group but did not differ significantly from the experimental group. High accessibility (93% of participants accessed the platform) and global acceptability (100% overall satisfaction) were reported among those who completed the telerehabilitation protocol. The therapist had no difficulty judging the participants' reading performances qualitatively while participants used their device to read their eSkills and VisExc guides. Most participants improved their daily activities, based on qualitative reports of the attained goals. Seventy-nine percent of individuals declined to participate, whereas 16% of participants decided not to use eSight Eyewear anymore.

CONCLUSIONS

The data demonstrated the feasibility of a randomized controlled telerehabilitation study for people with low vision using a head-mounted display. Positive feedback from the participants and the therapist suggests the potential value of this modality for low vision services.

Physical accessibility of primary care facilities for people with disabilities: a cross-sectional survey in 31 countries

Background

Primary care is the first point of care, also for people with disabilities. The accessibility of primary care facilities is therefore very important. In this study we analysed comparative data on physical accessibility of general practices (GP practices) in 31 (mainly) European countries.

Methods

We used data from the QUALICOPC study, conducted in 2011 among GPs in 34 (mainly European) countries and constructed a physical accessibility scale. We applied multilevel analysis to assess the differences between and within countries and to test hypotheses, related to characteristics of the practices and of the countries.

Results

We found large differences between countries and a strong clustering of physical accessibility within countries. Physical accessibility was negatively related to the age of the GPs, and was less in single-handed and in inner city practices. Of the country variables only the length of the period of social democratic government participation during the previous decades was positively related to physical accessibility.

Conclusion

A large share of the variation in physical accessibility of GP practices was on the level of countries. This means that national policies can be used to increase physical accessibility of GP practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06120-0.

Exploring Access to Independent Living Services for People With Disabilities Through a Transportation Network Analysis

Centers for Independent Living (CILs) are nonresidential, nonprofit agencies that provide independent living services to people with disabilities across the nation. The services CILs provide are invaluable to people with disabilities living independently in the community. Accessing CIL services can be challenging for people with disabilities, particularly for individuals in rural areas. A geographic analysis called a transportation network analysis is one method for assessing access to CIL services. We draw on the distribution of CILs across the country and in two rural states (Montana and Arkansas) to assess levels of geographic access using travel distance along national and local road networks. Incorporating data from the American Community Survey allowed us to estimate the number of people with disabilities living within certain distance thresholds from CILs. We saw increased access in urban areas where there is a higher concentration of CILs, suggesting that people with disabilities in rural areas have limited access to CIL services. We explore how partnering with Area Agencies on Aging has the potential to expand access to services for people with disabilities in rural areas, highlighting the utility of geographic analysis in social service provision.

Perspectives of Interactions with Healthcare Providers Among Patients Who Are Blind

Healthcare providers' (HCPs) stereotypes about the incompetence of blind and low-vision patients may lead them to patronize blind patients, over-focus on impairments, and neglect the presenting problem. The content of perceived HCP stereotypes about blind patients in the clinical setting was examined from the patient perspective with seven focus groups, including a total of 42 individual participants. Most participants reported an interaction when their HCPs treated them as if they were incompetent, and discussed how perceived evaluations of their warmth and competence impacted whether their HCPs trusted and respected them. Participants also discussed their evaluations of their HCPs' warmth and competence, and how these evaluations impacted their trust and respect for the HCP. These results provide insight into blind patients' experiences interacting with their HCPs and can inform interventions to 1) help HCPs avoid stereotypic attitudes and 2) improve HCPs' comfort and abilities when working with patient with disabilities.

Developing Content for the Food Environment Assessment Survey Tool (FEAST): A Systematic Mixed Methods Study with People with Disabilities

Almost 1 in every 8 adults in the U.S. have a physical disability that impairs mobility. This participatory project aimed to identify and describe environmental and personal barriers to healthy eating among people with mobility impairments using a rigorous, structured mixed methodology. Community-dwelling adults with a self-reported mobility impairment (N = 20, M = 40.4 years old, 60% female) participated in nominal group technique focus groups. The Ecologic Model of Obesity grounded stimulus questions asked about barriers to obtaining and preparing healthy food. Participants emphasized common barriers across everyday settings—focusing, for example, on the ability to reach shelved food inside the home, navigating to and inside stores and restaurants, and using delivery services. Home environments often did not afford suitable spaces for food preparation and storage. Participants reported inadequate transportation and numerous additional barriers in many settings to be able to eat healthfully. Participants reported lack of accessible transportation and architectural barriers inside stores, restaurants, and their own homes, highlighting the need for efforts aimed at improving accessibility and usability. Findings support the use of the Ecologic Model of Obesity to guide research and suggest the need for improvement in assessment practices and policies that enhance access to healthy food.

The invisible labor and multidimensional impacts of negotiating childcare on farms

Social science inquiries of American agriculture have long recognized the inextricability of farm households and farm businesses. Efforts to train and support farmers, however, often privilege business realm indicators over social issues. Such framings implicitly position households as disconnected from farm stress or farm success. This article argues that systematically tracing the pathways between farm households and farm operations represents a potentially powerful inroad towards identifying effective support interventions. We argue childcare arrangements are an underrecognized challenge through which farm household dynamics directly influence agricultural production. We draw on interviews and focus group data with farmers in the Northeastern United States to understand how farmer-parents access and negotiate childcare. Farmer-parents value raising children on farms, but express reluctance to expect current or future labor from them. Years with young children thus represent an especially vulnerable phase during a farm's trajectory. We identify and analyze social, economic, and cognitive pathways through which childcare impacts farm operations. Social pathways include relationship tensions and gendered on-farm divisions of labor; economic pathways include farm layout and structure; cognitive pathways include how farmers think about and plan for their operations. Explicitly acknowledging such issues can better equip farmer-parents to anticipate and plan for conflicting demands on their time.

A Volunteer Program in Maine to Transport Community Members to Health Care Appointments

Transportation to health care appointments is a well-known barrier for many people, especially people living in rural areas. At the Kennebec Valley Community Action Program (KVCAP), 1 of 8 regional transportation centers in Maine, a robust volunteer program consisting of 93 drivers complements a staff of 45 drivers and 23 office staff members. The volunteers drive approximately 5 to 40 hours per week and have served for an average 4.4 years (range, 1–26 y); their ages range from 23 to 88. The volunteer driver program consists of a volunteer coordinator who communicates with volunteers; staff members who schedule rides; a software application (app) that serves as an interface between the agency and the volunteers as they drive clients to and from medical and social service appointments; regular training; recognition events; and incentives. Most clients have no other transportation option and indicated in informal surveys conducted by KVCAP that they would not attend appointments if the volunteer program were not available. In rural settings, volunteer driving networks provide a viable model to help meet the transportation needs of the population. Recruitment and retention of volunteers is an ongoing effort.

Intersectionality, special populations, needs and suggestions: the Flint Women's study

BACKGROUND

Equitable access to services that promote health and wellbeing is an important component of social justice. A community-engaged participatory qualitative study was conducted in Flint, Michigan, USA, to understand the needs of special populations (young women, perinatal women and new mothers, older women, women with disabilities, and LGBTQIA women) and elicit their ideas about solutions.

METHODS

In-depth interviews (n = 100) were conducted. Participants were either women living in the Flint area, human service providers in the area, or both. A team of community and academic coders analyzed the data using an a priori framework.

RESULTS

Participants identified needs of different groups of women and suggested ways to address them. Access to healthy food, reducing healthcare costs, and improving transportation, job opportunities and affordable quality housing were crosscutting themes across all groups of women. Mentoring support was said to protect vulnerable young women from the risk of human trafficking. Older women were said to gain a sense of purpose, build their social support and reduce their loneliness by engaging in mentoring younger women. Women with disabilities were reported to benefit from infrastructure accessibility and authentic inclusion in all areas of life. Providing help that considers their dignity, pride and self-worth were suggested. LGBTQIA women were reported to have housing needs due to discrimination; mostly turned down as renters and can be rejected from faith-based homeless shelters. LGBTQIA women would also benefit from increased sensitivity among healthcare providers. For all groups of women, streamlining access to social services and other resources, building social support networks and increasing awareness about existing resources were recommended.

CONCLUSION

Efforts directed towards improving women's health and wellbeing should include perspectives and suggestions of diverse groups of women from the community. Acting on suggestions that emanate from the community's lived experiences may reduce inequalities in health and wellbeing.

Reaching People With Disabilities in Underserved Areas Through Digital Interventions: Systematic Review

BACKGROUND

People with disabilities need rehabilitation interventions to improve their physical functioning, mental status, and quality of life. Many rehabilitation interventions can be delivered electronically ("digitally") via telehealth systems. For people with disabilities in underserved areas, electronically delivered rehabilitation interventions may be the only feasible service available for them.

OBJECTIVE

The objective of this study was to evaluate the current status of digital interventions for people with disabilities in remote and underserved areas.

METHODS

A systematic review was conducted on this topic. Keyword searches in multiple databases (PubMed, CINAHL, and Inspec) were performed to collect articles published in this field. The obtained articles were selected based on our selection criteria. Of the 198 identified articles, 16 duplicates were removed. After a review of the titles and abstracts of the remaining articles, 165 were determined to be irrelevant to this study and were therefore removed. The full texts of the remaining 17 articles were reviewed, and 6 of these articles were removed as being irrelevant to this study. The 11 articles remaining were discussed and summarized by 2 reviewers.

RESULTS

These 11 studies cover a few types of disabilities, such as developmental disabilities and mobility impairments as well as several types of disability-causing disorders such as stroke, multiple sclerosis, traumatic brain injury, and facio-scapulo-humeral muscular dystrophy. Most of these studies were small-scale case studies and relatively larger-scale cohort studies; the project evaluation methods were mainly pre-post comparison, questionnaires, and interviews. A few studies also performed objective assessment of functional improvement. The intervention technology was mainly videoconferencing. Moreover, 10 of these studies were for people with disabilities in rural areas and 1 was for people in urban communities.

CONCLUSIONS

A small number of small-scale studies have been conducted on digital interventions for people with disabilities in underserved areas. Although the results reported in these studies were mostly positive, they are not sufficient to prove the effectiveness of telehealth-based digital intervention in improving the situation among people with disabilities because of the small sample sizes and lack of randomized controlled trials.

Measuring changes in device use of a head-mounted low vision aid after personalised telerehabilitation: protocol for a feasibility study

INTRODUCTION

A recent trend in low vision (LV) has been towards the use of portable head-mounted displays (HMDs) to enhance residual vision. The decision process around the (non-)use of such devices have been identified as multifactorial. Among important barriers identified in the context of magnifying LV aids were transportation issues and insufficient training. In recent years, telerehabilitation has become of growing interest in healthcare because it allows individuals to remain at home while receiving rehabilitation services. A recent pilot study indicated encouraging outcomes; however, very few applications of telerehabilitation for LV have been tested systematically.

METHODS AND ANALYSIS

To help guide evidence-based practice recommendations for this modality, we will carry out a feasibility study to assess the recruitment, retention, accessibility and acceptability of an eventual fully randomised trial of telerehabilitation for people with LV using HMDs. We will recruit 60 participants aged 18+ years among prospective eSight Eyewear owners, randomised 1:1 into two parallel groups. The active intervention will be the telerehabilitation operated by a LV therapist; the control arm will be the current self-training standard provided by the device vendor. The primary feasibility outcome measures will be: time to recruit participants, loss to follow-up, accessibility and acceptability of the telerehabilitation (satisfaction of the users and LV therapist). Exploratory outcomes will be the impact of telerehabilitation on eSight Eyewear use behaviour (discontinuance rate), and validated measures of assistive-technology-related quality of life.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Review Board of the Centre de Recherche Interdisciplinaire en Réadaptation de Montréal métropolitain (CRIR# 1286-1217). Dissemination is planned via local, national and international healthcare conferences and peer-reviewed journal publications.

Systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health

Telehealth is an alternative method of delivering health care to people required to travel long distances for routine health care. The aim of this systematic review was to examine whether patients and their caregivers living in rural and remote areas are satisfied with telehealth videoconferencing as a mode of service delivery in managing their health. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42017083597) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of Ovid Medline, Embase, CINAHL, ProQuest Health Research Premium Collection, Joanna Briggs Institute and the Cochrane Library was conducted. Studies of people living in rural and remote areas who attended outpatient appointments for a health condition via videoconference were included if the studies measured patient and/or caregivers' satisfaction with telehealth. Data on satisfaction was extracted and descriptively synthesised. Methodological quality of the included studies was assessed using a modified version of the McMaster Critical Review Forms for Quantitative or Qualitative Studies. Thirty-six studies of varying study design and quality met the inclusion criteria. The outcomes of satisfaction with telehealth were categorised into system experience, information sharing, consumer focus and overall satisfaction. There were high levels of satisfaction across all these dimensions. Despite these positive findings, the current evidence base lacks clarity in terms of how satisfaction is defined and measured. People living in rural and remote areas are generally satisfied with telehealth as a mode of service delivery as it may improve access to health care and avoid the inconvenience of travel.

Inter- and intra-household perceived relative inequality among disabled and non-disabled people in Liberia

Evidence suggests that people with disabilities are the most marginalised and vulnerable group within any population. However, little is known about the extent of inequality between people with and without disabilities in contexts where the majority of persons experience extreme poverty and hardship. This includes in Liberia, where very little is understood about the lives of disabled people in general. This study uses a multidimensional wellbeing framework to understand perceived relative inequality associated with disability by assessing several facets of wellbeing across and within households containing disabled members (N = 485) or households with no disabled members (N = 538) in Liberian communities (Total individuals surveyed, N = 2020). Statistical comparisons (adjusted for age, sex, education and wealth differences and clustered at the household, village and county level) reveal that disabled Liberians are managing similarly to non-disabled Liberians in terms of income and education, but experience many perceived relative inequalities including in life satisfaction, transport access, political participation and social inclusion. Our results further suggest that disability may lead to perceived relative inequality at the household level in terms of trust held in neighbours. However, they also show that being the head of a household may protect against perceived relative inequality in certain dimensions (e.g. healthcare and transport access, political participation) irrespective of disability status. Results are discussed in terms of practical implications for development efforts in Liberia and for disabled people in other low- and middle-income settings.

A Telehealth Privacy and Security Self-Assessment Questionnaire for Telehealth Providers: Development and Validation

Background

Telehealth is a great approach for providing high quality health care services to people who cannot easily access these services in person. However, because of frequently reported health data breaches, many people may hesitate to use telehealth-based health care services. It is necessary for telehealth care providers to demonstrate that they have taken sufficient actions to protect their patients’ data security and privacy. The government provided a HIPAA audit protocol that is highly useful for internal security and privacy auditing on health care systems, however, this protocol includes extensive details that are not always specific to telehealth and therefore is difficult to be used by telehealth practitioners.

Objective

The goal of this study was to develop and validate a telehealth privacy and security self-assessment questionnaire for telehealth providers.

Methods

In our previous work, we performed a systematic review on the security and privacy protection offered in various telehealth systems. The results from this systematic review and the HIPAA audit protocol were used to guide the development of the self-assessment questionnaire. The draft of the questionnaire was created by the research team and distributed to a group of telehealth providers for evaluating the relevance and clarity of each statement in the draft. The questionnaire was adjusted and finalized according to the collected feedback and face-to-face discussions by the research team. A website was created to distribute the questionnaire and manage the answers from study participants. A psychometric analysis was performed to evaluate the reliability of the questionnaire.

Results

There were 84 statements in the draft questionnaire. Five telehealth providers provided their feedback to the statements in this draft. They indicated that a number of these statements were either redundant or beyond the capacity of telehealth care practitioners, who typically do not have formal training in information security. They also pointed out that the wording of some statements needed to be adjusted. The final released version of the questionnaire had 49 statements. In total, 31 telehealth providers across the nation participated in the study by answering all the statements in this questionnaire. The psychometric analysis indicated that the reliability of this questionnaire was high.

Conclusion

With the availability of this self-assessment questionnaire, telehealth providers can perform a quick self-assessment on their telehealth systems. The assessment results may be used to identify possible vulnerabilities in telehealth systems and practice or demonstrate to patients the sufficient security and privacy protection to patients’ data.

Household Immigration Status Had Differential Impact On Medicaid Enrollment In Expansion And Nonexpansion States

Recent research has shown that concern about the apprehension and deportation of undocumented immigrants can affect how members of their households who are eligible for public benefits choose to participate in public programs. The extent to which this "chilling effect" broadly affects adults' Medicaid enrollment nationally remains unclear, in part because of the difficulty of isolating undocumented immigrants in survey data. In this study we identified households that likely included undocumented immigrants and then examined whether gains in health care coverage due to the expansion of Medicaid eligibility under the Affordable Care Act (ACA) were dampened for eligible people living in households with mixed immigration status. We found no significant differences in coverage gains for people in mixed- relative to non-mixed-status households in expansion states. Coverage gains were significantly lower, however, for people in mixed-status households relative to those in non-mixed-status households in nonexpansion states. These findings suggest that household immigration status may have dampened the "woodwork effect," whereby the ACA enhanced knowledge about program availability, in turn increasing Medicaid enrollment in nonexpansion states among people previously eligible for the program but not enrolled in it.

Factors affecting access to primary health care services for persons with disabilities in rural areas: a "best-fit" framework synthesis

Background

Access to primary health care (PHC) is a fundamental human right and central in the performance of health care systems, however persons with disabilities (PWDs) generally experience greater barriers in accessing PHC than the general population. These problems are further exacerbated for those with disabilities in rural areas. Understanding PHC access for PWDs is particularly important as such knowledge can inform policies, clinical practice and future research in rural settings.

Methods

We conducted a synthesis of published literature to explore the factors affecting access to PHC for PWDs in rural areas globally. Using an adapted keyword search string we searched five databases (CINAHL, EMBASE, Global Health, Medline and Web of Science), key journals and the reference lists of included articles. We imported the articles into NVivo and conducted deductive (framework) analysis by charting the data into a rural PHC access framework. We subsequently conducted inductive (thematic) analysis.

Results

We identified 36 studies that met our inclusion criteria. A majority (n = 26) of the studies were conducted in low-and middle-income countries. We found that PWDs were unable to access PHC due to obstacles including the interplay of four major factors; availability, acceptability, geography and affordability. In particular, limited availability of health care facilities and services and perceived low quality of care meant that those in need of health care services frequently had to travel for care. The barrier of geographic distance was worsened by transportation problems. We also observed that where health services were available most people could not afford the cost.

Conclusion

Our synthesis noted that modifying the access framework to incorporate relationships among the barriers might help better conceptualize PHC access challenges and opportunities in rural settings. We also made recommendations for policy development, practice consideration and future research that could lead to more equitable access to health care. Importantly, there is the need for health policies that aim address rural health problems to consider all the dimensions and their interactions. In terms of practice, the review also highlights the need to provide in-service training to health care providers on how to enhance their communication skills with PWDs. Future research should focus on exploring access in geographical contexts with different health care systems, the perspectives of health care providers and how PWDs respond to access problems in rural settings.

Electronic supplementary material

The online version of this article (10.1186/s41256-018-0091-x) contains supplementary material, which is available to authorized users.

Residential location of people with chronic spinal cord injury: the importance of local health care infrastructure

Background

People with spinal cord injury (SCI) suffer from complex secondary health conditions and rely on specialized health care services, which are often centralized and difficult to reach for individuals living in remote areas. As a consequence, they might move to regions where they expect better access to care. The aims of this study were: 1) to identify regions where people with SCI live compared with the general population, 2) to examine whether their choice of residence is related to the availability of local health care infrastructure, and 3) to ascertain determinants of their consideration to change residence when aging.

Methods

This study used information from a nationwide Swiss SCI cohort and inpatient hospital discharge data. To detect clusters in the distribution of people with chronic SCI in Switzerland, a spatial cluster detection test was conducted using the normative population of a region as offset. To identify associations between the residential location of people with SCI and infrastructure variables, a negative binomial model was set up at a regional level with the frequency of people with SCI as outcome, geographical indicators as explanatory variables, and the normative population as offset. Determinants of the consideration to change residence when aging were investigated using logistic regression models.

Results

People with SCI were not living equally distributed among the normative population, but clustered in specific areas. They were more likely than the general population to reside close to specialized SCI centers, in areas with a high density of outpatient physicians, and in urban regions. People with SCI living in rural areas were more likely to consider relocating when aging than those living in urban areas. However, only a few people with SCI considered moving closer to specialized centers when such a move required crossing language barriers.

Conclusions

Good access to appropriate health care services and amenities of daily life seems to play such an important role in the lives of people with SCI that they are willing to choose their residential location based on local availability of appropriate health care services.

Disability Characteristics of Community-Based Rehabilitation Participants in Kayunga District, Uganda

BACKGROUND

Approximately 80% of individuals with disability reside in low- and middle-income countries where community-based rehabilitation (CBR) has been used as a strategy to improve disability. However, data relating to disability severity among CBR beneficiaries in low-income countries like Uganda remain scarce, particularly at the community or district level.

OBJECTIVES

To describe severity of disability and associated factors for persons with physical disabilities receiving CBR services in the Kayunga district of Uganda.

METHODS

A cross-sectional sample of 293 adults with physical disabilities receiving a CBR service in the Kayunga district was recruited. Disability severity was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS2.0), and analyzed as a binary outcome (low: 0-9, high: 10-48). Inferential statistics using odds ratios were used to determine factors associated with impairment severity.

FINDINGS

The mean WHODAS 2.0 score of persons with physical disabilities was 12.7 (standard deviation = 8.3). More than half (52.90%) of people with physical disabilities reported a high level of functional impairment. Increased disability severity was significantly associated with limited access to assistive devices (adjusted odds ratio [AOR] = 4.55, 95% confidence interval [CI]: 1.87-14.08, P < .001), and increased use of medical health care (AOR = 5.55, 95% CI: 1.84-16.79, P = .002).

CONCLUSION

These findings suggest a high level of moderate to severe functional impairments in persons with physical disabilities receiving CBR in Kayunga district. These data provide support for efforts to enhance CBR's ability to liaise with local health care, education, and community resources to promote access to needed services and ultimately improve the functional status of persons with disabilities in low-resource settings.

Mapping Rural Road Networks from Global Positioning System (GPS) Trajectories of Motorcycle Taxis in Sigomre Area, Siaya County, Kenya

Effective transport infrastructure is an essential component of economic integration, accessibility to vital social services and a means of mitigation in times of emergency. Rural areas in Africa are largely characterized by poor transport infrastructure. This poor state of rural road networks contributes to the vulnerability of communities in developing countries by hampering access to vital social services and opportunities. In addition, maps of road networks are incomplete, and not up-to-date. Lack of accurate maps of village-level road networks hinders determination of access to social services and timely response to emergencies in remote locations. In some countries in sub-Saharan Africa, communities in rural areas and some in urban areas have devised an alternative mode of public transport system that is reliant on motorcycle taxis. This new mode of transport has improved local mobility and has created a vibrant economy that depends on the motorcycle taxi business. The taxi system also offers an opportunity for understanding local-level mobility and the characterization of the underlying transport infrastructure. By capturing the spatial and temporal characteristics of the taxis, we could design detailed maps of rural infrastructure and reveal the human mobility patterns that are associated with the motorcycle taxi system. In this study, we tracked motorcycle taxis in a rural area in Kenya by tagging volunteer riders with Global Positioning System (GPS) data loggers. A semi-automatic method was applied on the resulting trajectories to map rural-level road networks. The results showed that GPS trajectories from motorcycle taxis could potentially improve the maps of rural roads and augment other mapping initiatives like OpenStreetMap.

Pennsylvania Otolaryngologists as a Model for the Implications of Practice Location of Osteopathic vs Allopathic Surgical Subspecialists

Background

Evidenced-based models should be used to predict future implications of the single accreditation system for graduate medical education. Compared with other states, Pennsylvania has a relatively high number of osteopathic physicians (ie, DOs) and may be used as a model for a health care system with an increased DO presence.

Objective

To compare the geographic distribution of otolaryngologist DOs with otolaryngologist allopathic physicians (ie, MDs) in Pennsylvania and identify differences in community size (urban, urbanized, and rural) in which these physicians practice.

Methods

A list of otolaryngologist practice locations in Pennsylvania was developed using Centers for Medicare and Medicaid Services data, the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery Masterfile, and the American Medical Association Physician Masterfile. The United States Census data were used to document the general population of those locations. The samples of individual otolaryngologist DOs and MDs were then analyzed by determining where each otolaryngologist practiced, identifying the type of community in which they practiced, and then comparing the percentage of otolaryngologist DOs and MDs who practiced in each community type (urbanized area, urban cluster, and rural). A χ2 analysis was used to determine whether a difference existed in practice location between otolaryngologist DOs and MDs.

Results

Of the 47 otolaryngologist DOs, 32 (70%) practiced in cities with a population of 49,999 or less. More than half (120 of 238) of the otolaryngologist MDs practiced in cities larger than 50,000, and 96 of 238 (40%) practiced in cities with a population of at least 200,000. χ2 analysis showed a significant difference in the geographic distribution of otolaryngologist DOs and MDs (P=.012).

Conclusion

A correlation exists between the practice location of otolaryngologists in Pennsylvania and the medical degree they hold.

Chronic pain experience and pain management in persons with spinal cord injury in Nepal

BACKGROUND AND AIMS

Chronic pain is the frequent and significantly challenging complications in persons with spinal cord injury (SCI). Socio-cultural background may lead people perceive and manage pain differently. The study aims to describe the chronic pain experience and pain management of SCI persons in Nepal.

METHODS

A descriptive cross sectional study was conducted among purposively selected sample of 120 SCI persons with chronic pain living in the eight districts of Bagmati Zone of Nepal. The data were collected using the International Spinal Cord Injury Pain Basic Data Set Version 2 (ISCIPBDS-2) and Open-ended Pain Management Questionnaire. The data were analyzed using descriptive statistics and content analysis method.

RESULTS

The back (n=84), lower legs/feet (n=63) and buttocks/hips (n=51) was found as the common pain locations. In common, the onset of pain was found within the first 6 month of the injury. Overall pain intensity and pain interference were found to be at the moderate level. The SCI persons used pain medications and non-pharmacological pain management. Ibuprofen was the commonly used pain medication and commonly used non-pharmacological pain management methods included physical support (e.g. massage, exercise), relaxation (e.g. distraction, substance abuse), coping (e.g. acceptance, praying), and traditional herbs.

CONCLUSIONS

SCI persons had chronic pain experience which interfered with their daily living. They used pain medications and non-pharmacological pain management methods based on their beliefs, knowledge, and community resources in Nepal.

IMPLICATIONS

This study provides some evidence to help the team of rehabilitation professional to plan and help SCI persons with chronic pain. Based on these findings, chronic pain management intervention for SCI persons should be developed and supported continuously from hospital to home based community context of Nepal.

Health care eligibility and availability and health care reform: Are we addressing rural women's barriers to accessing care?

BACKGROUND

Rural populations in the U.S. face numerous barriers to health care access. The Patient Protection and Affordable Care Act (PPACA) was developed in part to reduce health care access barriers. We report rural women's access barriers and the PPACA elements that address these barriers as well as potential gaps.

METHODS

For this qualitative study, we analyzed two datasets using a common framework. We used content analysis to understand rural, focus group participants' access barriers prior to PPACA implementation. Subsequently, we analyzed the PPACA text.

RESULTS

Participants described health care access barriers in two domains: availability and eligibility. The PPACA proposes solutions within each domain, including health care workforce training, Medicaid expansion, and employer-based health care provisions. However, in rural settings, access barriers likely persist.

DISCUSSION

While elements of the PPACA address some health care access barriers, additional research and policy development are needed to comprehensively and equitably address persistent access barriers for rural women.

Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study

Objective

We aim to explore the barriers to accessing primary care for socio-economically disadvantaged older people in rural areas.

Methods

Using a community recruitment strategy, fifteen people over 65 years, living in a rural area, and receiving financial support were recruited for semi-structured interviews. Four focus groups were held with rural health professionals. Interviews and focus groups were audio-recorded and transcribed. Thematic analysis was used to identify barriers to primary care access.

Findings

Older people’s experience can be understood within the context of a patient perceived set of unwritten rules or social contract–an individual is careful not to bother the doctor in return for additional goodwill when they become unwell. However, most found it difficult to access primary care due to engaged telephone lines, availability of appointments, interactions with receptionists; breaching their perceived social contract. This left some feeling unwelcome, worthless or marginalised, especially those with high expectations of the social contract or limited resources, skills and/or desire to adapt to service changes.

Health professionals’ described how rising demands and expectations coupled with service constraints had necessitated service development, such as fewer home visits, more telephone consultations, triaging calls and modifying the appointment system.

Conclusion

Multiple barriers to accessing primary care exist for this group. As primary care is re-organised to reduce costs, commissioners and practitioners must not lose sight of the perceived social contract and models of care that form the basis of how many older people interact with the service.

Views of teenage children about the effects of a Parent's mobility disability

BACKGROUND

Few U.S. studies have explored how children experience a parent's mobility disability and its effects on their daily lives.

OBJECTIVE

We aimed to engage youth ages 13-17 who had at least one parent with mobility disability in describing their perceptions of their parent's disability and its consequences for their daily and family life.

METHODS

Participants videoed and photographed their experiences following general guidelines from the researchers about topics of interest. Participants made their own choices about what they submitted. We used conventional content analysis to identify broad themes.

RESULTS

The mean (standard deviation) age of the 10 participants was 15.2 (1.9) years; 5 were male; 9 participants were white. All 5 girls submitted multiple self-focused (selfie) videos made in their bedrooms; the 5 boys submitted more diverse data files. Several broad themes or topics emerged including: the effects of timing and trajectory of the parent's disability; perceptions of early maturity and responsibility; fears and frustrations relating to the parent's disability; support and emerging resilience; and sense of social justice. Participants generally felt their parents' disability made them become - compared to their peers - more mature, responsible, capable of performing household tasks, and aware of disability civil rights.

CONCLUSIONS

Participants raised many issues that health care providers should be aware of when youth have parents with mobility disability. A parent's mobility disability may be associated with resilience but also may pose challenges for youth. More research is needed to understand better adolescents' experiences and how clinicians might best assist these youth.

Access to health care for persons with disabilities in rural South Africa

BACKGROUND

Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa.

METHODS

The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis.

RESULTS

Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age.

CONCLUSIONS

This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.

SCI peer health coach influence on self-management with peers: a qualitative analysis

STUDY DESIGN

A process evaluation of a clinical trial.

OBJECTIVES

To describe the roles fulfilled by peer health coaches (PHCs) with spinal cord injury (SCI) during a randomized controlled trial research study called 'My Care My Call', a novel telephone-based, peer-led self-management intervention for adults with chronic SCI 1+ years after injury.

SETTING

Connecticut and Greater Boston Area, MA, USA.

METHODS

Directed content analysis was used to qualitatively examine information from 504 tele-coaching calls, conducted with 42 participants with SCI, by two trained SCI PHCs. Self-management was the focus of each 6-month PHC-peer relationship. PHCs documented how and when they used the communication tools (CTs) and information delivery strategies (IDSs) they developed for the intervention. Interaction data were coded and analyzed to determine PHC roles in relation to CT and IDS utilization and application.

RESULTS

PHCs performed three principal roles: Role Model, Supporter, and Advisor. Role Model interactions included CTs and IDSs that allowed PHCs to share personal experiences of managing and living with an SCI, including sharing their opinions and advice when appropriate. As Supporters, PHCs used CTs and IDSs to build credible relationships based on dependability and reassuring encouragement. PHCs fulfilled the unique role of Advisor using CTs and IDSs to teach and strategize with peers about SCI self-management.

CONCLUSION

The SCI PHC performs a powerful, flexible role in promoting SCI self-management among peers. Analysis of PHC roles can inform the design of peer-led interventions and highlights the importance for the provision of peer mentor training.

Use of a Wearable Activity Device in Rural Older Obese Adults: A Pilot Study

Objective: Assess the feasibility and acceptability of Fitbit for supporting behavioral change in rural, older adults with obesity. Method: Eight adults aged ≥65 with a body mass index (BMI) ≥30kg/m² were recruited from a rural practice and provided a Fitbit Zip device for 30 days. Participants completed validated questionnaires/interviews. Results: Mean age was 73.4 ± 4.0 years (50% female) with a mean BMI of 34.5 ± 4.5kg/m². We observed reductions in exercise confidence (sticking to it: 34.5 ± 3.3 to 30.9 ± 4.3, p = .04; making time: 18.9 ± 1.3 to 17.0 ± 2.6, p = .03) but no changes in patient activation (45.4 ± 4.3 vs. 45.0 ± 3.9). All reported high satisfaction, seven (87.5%) found Fitbit easy to use, and five (62.5%) found the feedback useful. The majority (n = 6 [75.0%]) were mostly/very satisfied with the intervention. Consistent themes emerged regarding the benefit of self-monitoring and participant motivation. Common concerns included finding time to exercise and lack of a peer group. Conclusion: Use of Fitbit is feasible/acceptable for use among older rural obese adults but may lead to reduced confidence.

Risk Factors for Six Types of Disability among the Older People in Thailand in 2002, 2007, and 2011

Background. There is an important need to characterize risk factors for disability in Thailand, in order to inform effective prevention and control strategies. This study investigated factors associated with risk of 6 types of disability in Thailand's ageing population in 2002, 2007, and 2011. Methods. Data came from the Cross-Sectional National Surveys of Older Persons in Thailand conducted by the National Statistical Office (NSO) in 2002, 2007, and 2011. Stratified two-stage sampling was employed. Interviews of 24,835, 30,427, and 34,173 elderly people aged 60 and above were conducted in the respective study years. Prevalence of disabilities was measured, and factors associated with disability risk were assessed with probability-weighted multiple logistic regression. Results. Disability prevalence decreased slightly over the study period. The characteristics with greatest positive impact on disability prevalence were not working over the past week (average impact: 61.2%), age (53.7% per decade), and suffering from one or more chronic illnesses (46.3%). Conclusions. The strong observed positive impact of not working on disability prevalence suggests that raising the mandatory retirement age might result in some reduction of disability risk. Also, the observed positive impact of living with others (versus alone) on disability risk was somewhat unexpected.

Catastrophic Health Expenditures for Households with Disabled Members: Evidence from the Korean Health Panel

Persons with disabilities use more health care services due to ill health and face higher health care expenses and burden. This study explored the incidence of catastrophic health expenditures of households with persons with disabilities compared to that of those without such persons. We used the Korean Health Panel (KHP) dataset for the years 2010 and 2011. The final sample was 5,610 households; 800 (14.3%) of these were households with a person with a disability and 4,810 (85.7%) were households without such a person. Households with a person with a disability faced higher catastrophic health expenditures, spending about 1.2 to 1.4 times more of their annual living expenditures for out-of-pocket medical expenses, compared to households without persons with disabilities. Households having low economic status and members with chronic disease were more likely to face catastrophic health expenditures, while those receiving public assistance were less likely. Exemption or reduction of out-of-pocket payments in the National Health Insurance and additional financial support are needed so that the people with disabilities can use medical services without suffering financial crisis.

Medical care ideals among urban and rural residents in Thailand: a qualitative study

BACKGROUND

Health care is generally considered to be more highly valued in urban areas than in rural areas. However, studies have reported that there is no difference in the health care values of urban and rural areas in the Kingdom of Thailand, with some studies even indicating that these values are stronger in rural areas. We, therefore, conducted interviews and implemented a qualitative investigation and analysis aimed at elucidating ideals relating to the medical environment among the Kingdom's urban and rural citizens.

METHODS

The study targeted Thai citizens residing in urban and rural areas. The city of Khon Kaen, located in Khon Kaen Province in northeastern Thailand, was selected as the urban area for the study. We selected Donyang village, located in the same province, as the rural study area. In July 2014, we conducted semi-structured group interviews, applying the Constructivist Grounded Theory (CGT) analytical approach.

RESULTS

We interviewed ten people in Khon Kaen (the urban area) and seven people from Donyang village (the rural area). Five major and distinctive themes emerged from the interviews. These were: locally appropriate standards of medical care, support for local lifestyles, satisfaction with local medical personnel, healthy lifestyles that do not rely on medical services, and desire for regional autonomy/desire to serve the region in terms of medical care. All of these themes were evident in both study areas. Thus, rather than relying on advanced medical services, both urban and rural Thai citizens expressed the desire to continue living within communities (considered as "families"), contributing to them, and tending to all of their health care needs within their communities.

CONCLUSIONS

This study revealed five common themes relating to forms of medical care regarded as ideal among urban and rural citizens of Thailand. Its findings could potentially have important implications for areas characterized by urban-rural inequities relating to the accessibility and utilization of medical services.

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

Background

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

Objective

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

Design

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

Results

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

Conclusions

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

Health care experiences and perceptions among people with and without disabilities

BACKGROUND

Little is known about health care experiences among people with and without disabilities.

OBJECTIVE

We sought to explore perceptions of people with and without disabilities related to their health care experiences.

METHODS

Nineteen persons with and without disabilities participated in one of four focus groups. Focus groups were conducted in the physical world in Milwaukee, WI and in the virtual world in Second Life(®) with Virtual Ability, a well-established community designed by and for people with a wide range of disabilities. A grounded theory methodology was employed to analyze focus group data. Inclusion of physical and virtual world focus groups enabled people with a wide range of disabilities to participate.

RESULTS

While some participants described instances of receiving good care, many discussed numerous barriers. The main themes that emerged in focus groups among both persons with and without disabilities related to their health care experiences including poor coordination among providers; difficulties with insurance, finances, transportation and facilities; short duration of visits with physicians; inadequate information provision; feelings of being diminished and deflated; and self-advocacy as a tool. Transportation was a major concern for persons with disabilities influencing mobility. Persons with disabilities described particularly poignant experiences wherein they felt invisible or were viewed as incompetent.

CONCLUSIONS

Both persons with and without disabilities experienced challenges in obtaining high quality health care. However, persons with disabilities experienced specific challenges often related to their type of disability. Participants stressed the need for improving health care coordination and the importance of self-advocacy.

"How did that happen?" Public responses to women with mobility disability during pregnancy

BACKGROUND

Little is known about current societal attitudes toward women with significant mobility disability who are visibly pregnant.

OBJECTIVE

To use qualitative descriptive analysis methods to examine perceptions of women with significant mobility disability about how strangers reacted to their visible pregnancies.

METHODS

In late 2013, we conducted 2-h telephone interviews with 22 women with significant mobility difficulties who had delivered babies within the prior 10 years. The semi-structured, open-ended interview protocol addressed wide-ranging pregnancy-related topics, including statements from strangers. Most participants were recruited through social networks, coming from 17 states nationwide. We used NVivo to sort the texts for content analysis.

RESULTS

The women's mean (standard deviation) age was 34.8 (5.3) years; most were white, well-educated, and higher income, although half had Medicaid during their pregnancies; and 18 used wheeled mobility aids. Eighteen women described memorable interactions with strangers relating to their pregnancies or newborn babies. Strangers' statements fell into six categories: (1) curious; (2) intrusively and persistently curious; (3) hostile, including concerns that taxpayers would end up supporting the mother and child; (4) questioning woman's competence as a potential parent; (5) oblivious, not recognizing visible pregnancy or motherhood; and (6) positive. Many women reported strangers asking how their pregnancy had happened. The women doubted that visibly pregnant women without disabilities evoke the same reactions from strangers.

CONCLUSIONS

Women with mobility disability who are visibly pregnant may perceive reactions from strangers that appear intrusive. Planning ahead for handling such encounters could reduce the stresses of these interactions.

How do adults with physical disability experience primary care? A nationwide cross-sectional survey of access among patients in England

OBJECTIVES

Almost a quarter of adults in England report a longstanding condition limiting physical activities. However, recent overseas evidence suggests poorer access to healthcare for disabled people. This study aimed to compare patient-reported access to English primary care for adults with and without physical disability.

DESIGN

Secondary analysis of the 2010/11 General Practice Patient Survey (response rate 35.9%) using logistic regression.

SETTING AND PARTICIPANTS

1,780,977 patients, from 8384 English general practices, who provided information on longstanding conditions limiting basic physical activity. 41,389 of these patients reported unmet need to see a doctor in the previous 6 months.

OUTCOMES

Difficulty getting to the general practitioner (GP) surgery as a reason for unmet need to see a doctor in the preceding 6 months; difficulty getting into the surgery building.

RESULTS

Estimated prevalence of physical disability was 17.2% (95% CI 17.0% to 17.3%). 17.9% (95% CI 17.4% to 18.4%) of patients with an unmet need to see a doctor were estimated to experience this due to difficulty getting to the surgery, and 2.2% (95% CI 2.2% to 2.3%) of all patients registered with a GP were estimated to experience difficulty getting into surgery buildings. Adjusting for gender, age, health status and employment, difficulty getting to the surgery explaining unmet need was more likely for patients with physical disability than for those without. Similarly, difficulty getting into surgery buildings was more likely among physically disabled patients. Both associations were stronger among patients aged 65-84 years.

CONCLUSIONS

Adults in England with physical disability experience worse physical access into primary care buildings than those without. Physical disability is also associated with increased unmet healthcare need due to difficulty getting to GP premises, compared with the experience of adults without physical disability. Increasing age further exacerbates these problems. Access to primary care in England for patients with physical disability needs improving.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

Teaching self-management skills in persons with chronic lower limb swelling and limited mobility: evidence for usability of telerehabilitation

The purpose of this study was to evaluate the usability of telerehabilitation as a method of teaching self-management for chronic swelling of the lower limbs in persons with limited mobility. An in-home telerehabilitation self-management education protocol for chronic swelling of the lower limbs, termed Telerehabilitation to Empower You to Manage and Prevent Swelling (TR-PUMPS), was implemented using the Versatile and Integrated System for Telerehabilitation (VISYTER) software platform. Participants (n=11) were 36–79 years old, predominately female (72.7%) and diagnosed with a variety of health conditions. Participants’ perceived usability scores of the remote delivery of TR-PUMPS was high with a median score of 6.67 (range 4.90 – 7.00) on a Likert scale: 1= disagree to 7= agree. There was no correlation between participants’ familiarity with information technology and their perception of telerehabilitation usability. These results support telerehabilitation as a viable method for teaching a home-based, self-management protocol for chronic swelling.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.