Health disparities of adults with intellectual disabilities: what do we know? What do we do?

How are medical students learning to care for patients with intellectual disabilities? A scoping review

BACKGROUND

Individuals with intellectual disabilities experience barriers to quality healthcare. To reduce this disparity, equipping medical trainees with the knowledge and skills required for treating this patient population is critical. Our aim is to describe the breadth of instructional interventions and identify gaps in intellectual disability medical education curricula.

METHOD

Using scoping review methods, the intellectual disability programmes described in 27 articles were evaluated and their coverage of the six core competencies on disability for health care education was examined.

RESULTS

The most frequently represented core competencies were disability conceptual frameworks, professionalism and communication, and clinical assessment, which were, in most programmes, fulfilled by activities involving individuals with intellectual disabilities. Uneven competency coverage warrants consideration.

CONCLUSIONS

Considerable variabilities exist in medical school curricula on intellectual disabilities. Using core competencies on disability for health care education for curricular design and evaluation would provide a coherent training experience in this important area.

Disparities in outcomes of colorectal cancer surgery among adults with intellectual and developmental disabilities

BACKGROUND

Disparities in colorectal cancer screening have been documented among people with intellectual and developmental disabilities (IDD). However, surgical outcomes in this population have yet to be studied. The present work aimed to evaluate the association of IDD with outcomes following colorectal cancer resection.

METHODS

All adults undergoing resection for colorectal cancer in the 2011-2020 National Inpatient Sample were identified. Multivariable linear and logistic regression models were developed to examine the association of IDD with risk factors as well as outcomes including mortality, complications, costs, length of stay (LOS), and non-home discharge. The study is limited by its retrospective nature and did not capture disease staging or time of diagnosis.

RESULTS

Among 722,736 patients undergoing colorectal cancer resection, 2,846 (0.39%) had IDD. Compared to patients without IDD, IDD patients were younger and had a higher burden of comorbidities. IDD status was associated with increased odds of non-elective admission (AOR 1.40 [95% CI 1.14-1.73]) and decreased odds of treatment at high-volume centers (AOR 0.64 [95% CI 0.51-0.81]). Furthermore, IDD patients experienced significantly greater LOS (9 vs 6 days, p<0.001) and hospitalization costs ($23,500 vs $19,800, p<0.001) relative to neurotypical patients. Upon risk adjustment, IDD was significantly associated with 2-fold increased odds of mortality (AOR 2.34 [95% CI 1.48-3.71]), 1.4-fold increase in complications (AOR 1.41 [95% CI 1.15-1.74]), and 6.8-fold increase in non-home discharge (AOR 6.83 [95% CI 5.46-8.56]).

CONCLUSIONS

IDD patients undergoing colorectal cancer resection experience increased likelihood of non-elective admission, adverse clinical outcomes, and resource use. Our findings highlight the need for more accessible screening and patient-centered interventions to improve quality of surgical care for this at-risk population.

Facilitating choice when engaging young people with disabilities: reflections from co-researcher training

BACKGROUND

A collaborative approach is critical in inclusive research and should incorporate taking time to build relationships with co-researchers based on trust and shared understanding. Involvement can often be seen as tokenistic and in order to avoid this, it is important to provide opportunities for people to exercise choice throughout the research process.

MAIN BODY

The current paper outlines learnings from a co-researcher training process for young people with disabilities to identify the ways in which meaningful choice can be facilitated with this group. While conducting training of co-researchers in topics such as research methods, we were continuously led by the group with regards to the directions that the sessions took and promoted problem solving with the group to accommodate the unique needs of all members. The overall aim of a wider project was to develop research capacity in a group of young people with disabilities through co-researcher training and this paper will report on learnings from this work with regards to how we sought to provide opportunities for the co-researchers to exercise choice within research projects. Feedback from the group of young people highlighted the variety of needs and expectations that must be accommodated in such a process and therefore, allowing them to dictate the extent and manner of their engagement is key. Young people with disabilities are a heterogeneous group and therefore, some methodologies and ways of working required adaptation in order to facilitate meaningful choice and engagement for all.

CONCLUSION

Providing meaningful opportunities for demonstrating their choices, in relation to elements of research projects, is a critical component of facilitating a rights-based approach when conducting co-research and requires researchers to cede some level of control over the research process to co-researchers. This can be difficult to achieve in practice and researchers must continuously reflect on their own practice and be willing to change and adapt throughout the process.

Development and implementation of a continuing care program for patients with intellectual and developmental disabilities in family medicine

In the United States, individuals with intellectual and developmental disabilities (IDD) consistently experience health disparities. One factor is limited access to quality healthcare services equipped to meet the needs of those with IDD, particularly as they transition to adulthood. The purpose of this work is to describe the development and implementation of Jefferson's Continuing Care Program (JCCP), which was designed to address this care gap. We share how the idea, logistics, and support for the clinic were developed; how JCCP was designed to be uniquely accessible both via physical space and clinic flow; and how those challenges encountered have been crucial for fine-tuning optimal patient care. Since its inception in 2019, JCCP has made large strides towards educating the next generation of medical providers to care for patients with IDD. Looking to the future, JCCP plans to broaden its impact by serving more patients, continuing our advocacy and education work, and continuing to adapt to the needs of our community.

New Frontier: The First Year of an Adult Neurodevelopmental Disabilities Clinic

BACKGROUND

As patients with neurodevelopmental disorders (NDDs) transition from pediatric to adult health care systems, they often have difficulty finding physicians to address their NDD-related needs. In response to this care gap, we established a new consultation clinic within a behavioral neurology clinic in an adult neurology department to address the neurodevelopmental concerns of these adult patients.

OBJECTIVE

To characterize the population of adult patients with NDDs seen in the adult NDD clinic in its first year.

METHOD

Data were obtained by a retrospective chart review of all patients with NDDs seen in the adult NDD clinic from September 2020 through December 2021.

RESULTS

Of the 86 patients who were seen in the adult NDD clinic, the average age was 34 years (SD = 15, range = 18-74 years). Developmental diagnoses included intellectual disability (63%), autism spectrum disorder (47%), Down syndrome (15%), cerebral palsy (9%), and other genetic disorders (26%). Comorbidities addressed included behavioral concerns (34%), anxiety (29%), seizure disorders (22%), and depression (15%). Behavioral and/or mental health concerns prompted 65% of the initial clinic visits. The most common recommendation made was to begin or increase exercise (59%), followed by facilitating connection to community, social, and employment resources.

CONCLUSION

Adults with NDDs have diagnoses, comorbidities, and concerns that are similar to, but also distinct from, those addressed in other adult neurology clinics. This study addresses the need for, and feasibility of, caring for the diverse population of adults with NDDs in an adult neurology setting.

Lifestyle modification interventions for adults with intellectual disabilities: systematic review and meta-analysis at intervention and component levels

BACKGROUND

Adults with intellectual disabilities (IDs) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs.

METHODS

A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours and poor diet in adults (aged ≥ 18 years) with ID were included. Meta-analysis was conducted at the intervention level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie's 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Risk of Bias (ROB) Version 2 and Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I). The study involved a patient and public involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results and organising of dissemination events.

RESULTS

Our literature search identified 12 180 articles, of which 80 studies with 4805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only or multiple behaviours generated positive effects on various outcomes while some interventions led to no change or worsened outcomes, which could be attributed to the presence of a single core-component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared with treatment-as-usual and each other. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss [mean difference (MD) = -3.61, 95% credible interval (CrI) -9.68 to 1.95] and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the component network meta-analysis for which additional components were identified. Most studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation.

CONCLUSION

Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires and abilities of people with ID.

Appropriate inclusion of adult research participants with intellectual disability: an in-depth review of guidelines and policy statements

The history of human-subject experimentation has shown the need for safeguards to protect participants from abuse. Balancing participant protection with adequate representation of the adult intellectual disability population in research presents an important challenge. Our study aimed to analyze guidance on the appropriate inclusion of adults with intellectual disability who are or are not able to consent to biomedical research participation. Terminology, consent and type of ethically acceptable research provisions relevant to adult participants with intellectual disability were comprehensively reviewed in a selection of 17 international and national ethical research guidelines and statements. Most guidelines and statements recommend that adult participants with intellectual disability who are unable to consent be included when it is not possible to conduct the same research with adults capable of independent decision-making, or when there is therapeutic benefit and only minimal risk. Instead of naming specific requirements, the Australian statement stands out by asserting the "individual right" to participate. Assent requirements for incapacitated adults are not explicitly mentioned in most documents reviewed. There appears to be room for further description of the importance of careful capacity assessments and solid assent requirements in ethical research guidance documentation to promote meaningful participation of adults with intellectual disability.

Health and Well-Being at the Transition to Adulthood Among Individuals With Disabilities: An Analysis of the Panel Study of Income Dynamics

PURPOSE

To describe positive mental health, or "flourishing," and self-reported health trajectories among transition-aged young adults (TAYA) with developmental/learning and physical disabilities over a 12-year period, utilizing a population-based sample.

METHODS

This study features a secondary analysis of national data from the Panel Study of Income Dynamics Transition to Adulthood Supplement. The analytic sample included all TAYA with (n = 487) and without (n = 810) disabilities, including developmental/learning disabilities (DD/LD), attention deficit hyperactivity disorder (ADHD), and speech, hearing, and vision impairments who participated in 2017 Transition to Adulthood Supplement data collection (n = 1,297; M age = 24.5, standard deviation = 2.40). We utilized linear mixed modeling to retrospectively describe flourishing and self-reported health trajectories across 12 years among TAYA with and without disabilities between ages 18 to 28, adjusting for demographic and developmental characteristics.

RESULTS

Relative to TAYA without disabilities, TAYA with speech [0.10, 0.85] and vision impairments [0.10, 0.92], DD/LD [0.38, 1.11], and ADHD [0.27, 0.97] demonstrated lower flourishing. TAYA with speech [0.07, 0.36] and vision impairments [0.08, 0.38], DD/LD [0.15, 0.411], and ADHD [0.14, 0.93] reported lower health. Relative to TAYA with other disabilities, TAYA with ADHD [0.14, 0.93] and DD/LD [0.01, 0.29] reported lower flourishing and health, respectively. Interaction effects and descriptive analyses revealed distinct patterns of change for TAYA with ADHD.

DISCUSSION

TAYA with disabilities report lower flourishing and health, relative to TAYA without disabilities. TAYA with specific disabilities differ in their flourishing and health trajectories. Findings can inform the development of interventions for TAYA with disabilities.

Equitable and accessible informed healthcare consent process for people with intellectual disability: a systematic literature review

OBJECTIVE

To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible.

DATA SOURCES

Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals.

ELIGIBILITY CRITERIA

Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability.

SYNTHESIS OF RESULTS

Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created.

RESULTS

Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals' attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3).

CONCLUSIONS

Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals' attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability.

PROSPERO REGISTRATION

CRD42021290548.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cognitive evaluation and rehabilitation in high- and low-income countries

Starting from her own personal experience, in the First Part of the article, the author reconstructs how the specialized sectors of cognitive evaluation and rehabilitation evolved in Western countries (Europe, the United States, Canada, and Australia, in particular) during the second half of the last century and the first decades of this century. In the Second Part, she describes her personal experience in setting up a rehabilitation centre dedicated to traumatic brain-injured subjects and her commitment to international cooperation (Bolivia, Rwanda, Myanmar, Tanzania) in the field of cognitive evaluation and rehabilitation in favour of people with congenital and acquired cerebral pathology, especially in the paediatric age, since there is an almost total lack of diagnostic, but above all, rehabilitative procedures for cognitive functions in low-middle income countries. In the Third Part of the article, the author carries out an extensive review of the international literature on the differences in access to cognitive diagnostic evaluation and cognitive rehabilitation in middle- and low-income countries - but not only - underlining the urgent need to launch a major international collaborative effort to reduce and eliminate these discrepancies.

Health support of people with intellectual disability and the crucial role of support workers

BACKGROUND

People with intellectual disability have a poorer health status than the general population. In The Netherlands, support workers play a key role in meeting health support needs of people with intellectual disability. Research on how people with intellectual disability and their support workers experience the support worker's role in preventing, identifying, and following up health needs of people with intellectual disability is scarce. To enhance health support of people with intellectual disability it is crucial that we understand how health support is delivered in everyday practice. Therefore, this study investigated experiences of people with intellectual disability and support workers with the health support of people with intellectual disability.

METHOD

Data collection consisted of six focus group (FG) discussions with between four and six participants (N = 27). The FGs consisted of three groups with support workers (n = 15), two groups with participants with mild to moderate intellectual disability (n = 8), and one group with family members as proxy informants who represented their relative with severe to profound intellectual disability (n = 4). The data was analysed thematically on aspects relating to health support.

RESULTS

We identified three main themes relevant to the health support of people with intellectual disability: 1) dependence on health support, 2) communication practices in health support, and 3) organizational context of health support. Dependence on health support adresses the way in which support workers meet a need that people with intellectual disability cannot meet themselves, and communication practices and organizational context are identified as systems in which health support takes place.

CONCLUSION

This study investigated experiences with the health support of people with intellectual disability from the perspectives of people with intellectual disability and support workers. We discuss the dependence of people with intellectual disability and the complexity of health support in everyday practice. We provide practical implications that can strengthen support workers in the provision of health support for people with intellectual disability in everyday practice. The findings of this study emphasize the need for intellectual disability care-provider organizations to establish policies around consistency in support staff to make it easier to identify and follow up health needs, and an environment where support staff can develop their expertise concerning communication practices, lifestyle choices, and identifying and following up health needs.

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

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

Health equity for people with intellectual and developmental disability requires vast improvements to data collection: Lessons from the COVID-19 pandemic

The COVID-19 pandemic drastically underscored the lack of proper health surveillance for people with intellectual and developmental disability (IDD) in the USA. This data equity failure resulted in researchers having to rely on nontraditional data sources to develop an understanding of how this population was faring during the pandemic. To begin addressing this data equity concern, in this commentary, we (1) discuss the difficulties in accessing data during the pandemic specifically related to people with IDD; (2) provide guidance regarding how existing data can be used to examine COVID-19 outcomes for people with IDD; and (3) provide recommendations for improving data collection for people with IDD in light of lessons learned during the pandemic. In sum, the data currently available to examine COVID-19 as well as other health outcomes among people with IDD are severely limited, compromising the ability to both understand and address health disparities among this population.

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability

BACKGROUND

Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access.

METHODS

Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N = 623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost.

RESULTS

The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years.

CONCLUSIONS

The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

The importance of cancer prevention policies to inform and guide preventative and screening measures for people with intellectual disabilities: The COST project "Cancer- Understanding Prevention in Intellectual Disabilities"

Cancer is a global public health problem, but its exact prevalence in people with intellectual disabilities is still uncertain. This population, with limited health skills and complex health needs, faces many challenges in cancer prevention, screening, timely diagnosis and treatment. Furthermore, they are often underrepresented in general cancer prevention and screening policies across Europe, leading to widened disparities in health outcomes and premature mortality. Thus, unified national and local policies are needed to reduce inequalities and promoting a pan-European inclusion of people with intellectual disabilities. Our goal is to raise public awareness of this issue, including the involvement of people with intellectual disabilities, and promote engagement from relevant stakeholders. The COST Action 'Cancer- Understanding Prevention in Intellectual Disabilities' (CUPID) project will address health inequalities faced by people with intellectual disabilities in relation to cancer, and support the development of policy recommendations specifically tailored to their unique cognitive and healthcare needs, having a positive long-term impact on quality of life.

Association of Intellectual Disability with Delayed Presentation and Worse Outcomes in Emergency General Surgery

OBJECTIVE

To examine the association between intellectual disability and both severity of disease and clinical outcomes among patients presenting with common emergency general surgery (EGS) conditions.

BACKGROUND

Accurate and timely diagnosis of EGS conditions is crucial for optimal management and patient outcomes. Individuals with intellectual disabilities may be at increased risk of delayed presentation and worse outcomes for EGS; however, little is known about surgical outcomes in this population.

METHODS

Using the 2012-2017 Nationwide Inpatient Sample, we conducted a retrospective cohort analysis of adult patients admitted for 9 common EGS conditions. We performed multivariable logistic and linear regression to examine the association between intellectual disability and the following outcomes: EGS disease severity at presentation, any surgery, complications, mortality, length of stay, discharge disposition, and inpatient costs. Analyses were adjusted for patient demographics and facility traits.

RESULTS

Of 1,317,572 adult EGS admissions, 5,062 (0.38%) patients had a concurrent ICD-9/-10 code consistent with intellectual disability. EGS patients with intellectual disabilities had 31% higher odds of more severe disease at presentation compared with neurotypical patients (aOR 1.31; 95% CI 1.17-1.48). Intellectual disability was also associated with a higher rate of complications and mortality, longer lengths of stay, lower rate of discharge to home, and higher inpatient costs.

CONCLUSION

EGS patients with intellectual disabilities are at increased risk of more severe presentation and worse outcomes. The underlying causes of delayed presentation and worse outcomes must be better characterized to address the disparities in surgical care for this often under-recognized but highly vulnerable population.

A Randomized Controlled Trial using Brief Educational Messages Directed to Adults with Intellectual Disability and Hypertension or their Helpers Reduces Hospital Stays

PURPOSE

We assessed an educational intervention to reduce the number of emergency department (ED) and inpatient stays for cardiovascular diagnoses, among South Carolina adult Medicaid Members with intellectual and developmental disability and hypertension (Members).

DESIGN

This Randomized Controlled Trial (RCT) included Members or the person who helped them with their medications (Helpers). Participants, who included Members and/or their Helpers, were randomly assigned to an Intervention or Control group.

SETTING

South Carolina Department of Health and Human Services, which administers Medicaid, identified eligible Members.

SAMPLE

412 Medicaid Members - 214 Intervention (54 Members participating directly; 160 Helpers participating in lieu of Members) who received the messages about hypertension and surveys about knowledge and behavior and 198 Controls (62 Members; 136 Helpers) who only received surveys of knowledge and behavior.

INTERVENTION

Educational intervention about hypertension included a flyer and monthly text or phone messages for one year.

MEASURES

Input measures - characteristics of the Members; Outcome measures - hospital emergency department (ED) and inpatient visits for cardiovascular conditions.

ANALYSIS

Quantile regression tested the association of Intervention/Control group status with ED and inpatient visits. We also estimated models using Zero-inflated Poisson (ZIP) models for sensitivity analysis.

RESULTS

Participants in the Intervention group with highest baseline hospital use (top 20% ED; top 15% Inpatient) had significant reductions in Year 1 (.57 fewer ED and 2 fewer inpatient days) compared to the Control group. For ED visits, improvement continued in year two.

CONCLUSION

The intervention reduced the frequency of cardiovascular disease-related ED visits and Inpatient days for participants in the Intervention group in the highest quantiles of hospital use, and the improvement was better for those who had a Helper.

Healthcare experiences of patients with Down syndrome from primarily Spanish-speaking households

We report on the health care experiences of individuals with Down syndrome (DS) from families who are primarily Spanish-speaking. Data were collected through three methods: (1) a nationally distributed, 20-item survey, (2) two focus groups with seven family caregivers of individuals with DS who self-identified as living in primarily Spanish speaking households, and (3) 20 interviews with primary care providers (PCPs) who care for patients who are underrepresented minorities. Standard summary statistics were used to analyze the quantitative survey results. Focus group and interview transcripts, as well as an open-ended response question in the survey, were analyzed using qualitative coding methods to identify key themes. Both caregivers and PCPs described how language barriers make giving and receiving quality care difficult. Caregivers additionally described condescending, discriminatory treatment within the medical system and shared feelings of caregiver stress and social isolation. Challenges to care experienced by families of individuals with DS are compounded for Spanish-speaking families, where the ability to build trust with providers and in the health care system may be compromised by cultural and language differences, systemic issues (lack of time or inability to craft more nuanced schedules so that patients with higher needs are offered more time), mistrust, and sometimes, overt racism. Building this trust is critical to improve access to information, care options, and research opportunities, especially for this community that depends on their clinicians and nonprofit groups as trusted messengers. More study is needed to understand how to better reach out to these communities through primary care clinician networks and nonprofit organizations.

Updates to the Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda

INTRODUCTION

Autistic individuals, now representing one in 36 individuals in the U.S., experience disproportionate physical health challenges relative to non-autistic individuals. The Health Resources and Services Administration's (HRSA) Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multi-center Research Network that aims to increase the health, well-being, and quality of life of autistic individuals. The current paper builds on the initial AIR-P Research Agenda (proposed in Year 1) and provides an updated vision for the Network.

METHODS

Updates to the Research Agenda were made via the administration of a Qualtrics survey, and disseminated widely to all AIR-P entities, including the Research Node Leaders, Steering Committee, Autistic Researcher Review Board, and collaborating academic and non-academic entities. Network members were tasked with evaluating the Year 1 Research Agenda and proposing additional priorities.

RESULTS

Within each Research Node, all Year 1 priorities were endorsed as continued priorities for research on autism and physical health. Specific topics, including co-occurring conditions and self-determination, advocacy, and decision-making, were particularly endorsed. Opportunities for exploratory studies and intervention research were identified across Research Nodes. Qualitative responses providing feedback on additional research priorities were collected.

CONCLUSION

The updated AIR-P Research Agenda represents an important step toward enacting large-scale health promotion efforts for autistic individuals across the lifespan. This updated agenda builds on efforts to catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health promotion.

The Needle Anxiety Program: A Patient-Centered Initiative for Individuals With Developmental Disabilities

Objective To describe the development process of a patient-centered initiative focused on improving primary care health outcomes of patients with intellectual and developmental disabilities (IDD) and needle-related anxiety using evidence-based practices and novel approaches that can be implemented in outpatient settings. The overall outcome of the program is to increase vaccine uptake and accessibility in the IDD population as well as improve needle-related procedures in primary care settings to be more humane and effective. Methods The development process occurred in the context of a large healthcare system serving a diverse patient population in the U.S. and was led by an expert committee made of an multidisciplinary team of physicians, psychologists, ambulatory and clinic nurses, pharmacists, and anesthesiologists committed to promoting quality healthcare for the IDD population. Committee members were recruited within the healthcare system based on their relevant expertise. The methodology included an iterative and collaborative process that took place over three development phases: ideation and design, literature review and synthesis, and expert engagement. The ideation and design phase included a series of planning meetings among the expert committee, in which committee members identified preliminary concerns based on their expertise in the field and background knowledge on the current procedures related to improving routine care for individuals with IDD and/or needle-related anxiety. The literature review and synthesis phase led to the development of an annotated bibliography of research and clinical guidelines that synthesized findings on needle anxiety in clinical care. The expert engagement phase included all Committee members meeting for a final discussion to establish a tiered approach to utilizing evidence-based strategies that could be implemented across clinics within the healthcare system.  Results The multidisciplinary team of experts developed a three-tier system, deployed sequentially as needed. The first tier focuses on training nurses in evidence-based behavioral modification strategies to implement as standard of care. The second tier uses the addition of a distraction device and topical analgesic to reduce anxiety in patients with slightly elevated procedural anxiety. The third tier involves a novel minimal sedation protocol using intranasal midazolam for patients with needle phobia that can be administered in an outpatient setting. Conclusion The Needle Anxiety Program eases the administration of needle-related medical procedures in the primary care setting for patients with IDD and needle-related anxiety. The use of evidence-based practices and a novel minimal sedation protocol for individuals with needle phobia assists in the completion of routine healthcare procedures, such as vaccinations and phlebotomy, in a patient-preferred setting. The purpose of delineating needle-related processes and procedures through the Needle Anxiety Program is to reduce health disparities for patients with IDD and promote uptake of the Needle Anxiety Program in similar healthcare settings.

Developing and implementing a public health co-research program for Special Olympics athletes

Individuals with intellectual and developmental disabilities are often the subject of research while rarely being included in formulating research questions, planning studies, and making decisions related to protocols and analyses. In turn, most research regarding people with intellectual and developmental disabilities is not carried out by researchers with disabilities themselves. We developed a co-research training program where individuals with intellectual and developmental disabilities were taught about research. The program was designed using best practices and existing materials resources. We recruited four participants from Special Olympics Massachusetts and conducted the training in the Fall of 2021. We evaluated the program with surveys, qualitative interviews, and tracking continued involvement of co-researchers in research projects. Participants were partners in the evaluation process. The training program was six sessions and included lessons about why research is important, how to conduct research, and an experiential learning project where co-researchers conducted a study of their coaches. The program was well received by participants, and one year later they were still involved with research projects. A co-researcher training focused on public health for Special Olympics athletes is feasible and beneficial for athletes, researchers, and Special Olympics programs. However, there are still barriers like a lack of funding and time, that need to be addressed to ensure wide program success.

Developing "Adulting for Health": Investigating the Health Needs of Neurodivergent Emerging Adults

INTRODUCTION

Neurodivergent emerging adults - defined as individuals between the ages of 18 and 30 with intellectual and/or developmental disabilities (e.g., attention-deficit hyperactivity disorder (ADHD), autism, cerebral palsy, learning disabilities, seizures, developmental delays, with or without intellectual impairment) and physical and/or sensory disabilities (e.g., blindness or hearing impairment) - experience poor mental and physical health outcomes. Existing interventions are insufficient because they are not based on the self-reported and developmental needs of this population.

METHODS

The current study is an exploratory pilot study that features a multidimensional health-based needs assessment of self-identified neurodivergent emerging adults with ADHD, learning disabilities, autism, and other conditions, mean (M) age = 22.8; standard deviation (SD) = 3.4; n = 26). This research used validated measures. The assessment - administered via Qualtrics to the participants in two sites - included the Mental Health Continuum-Short Form, Kessler-6 Psychological Distress Scale, Project EAT (Eating and Activity over Time)-IV (with the intuitive eating, weight-related control, emotional eating, and physical activity subscales), and an original health-focused needs assessment developed by interdisciplinary healthcare professionals and neurodivergent individuals.

RESULTS

The sample reported low positive mental health, with only 3% reportedly "flourishing." The sample also reported high psychological distress according to clinical and psychometric cut-off scores; varied intuitive eating and weight-control behaviors and attitudes; and distinct needs related to integrating the principles of health promotion into daily life, navigating the healthcare system, and learning from healthcare professionals. Based on these findings, we present an initial conceptualization of "Adulting for Health," a potential virtual education program to promote health-related knowledge and capacities for this population.

CONCLUSIONS

The results from this exploratory pilot study can be incorporated into existing programs and spur efforts to develop and test new interventions that can ameliorate health disparities for neurodivergent emerging adults.

A new measure of physicians' erroneous assumptions towards adults with intellectual disability: A first study

BACKGROUND

Incomplete knowledge and unfamiliarity with intellectual disability (ID) contribute to erroneous assumptions of physicians towards ID, which negatively impact the health equity of people with ID. This study aimed to identify the erroneous assumptions that, based on the ID stakeholders' perceptions, were the most prevalent in physicians and damaging for the healthcare of adults with ID, verify their unidimensionality and that no personal characteristics of ID stakeholders were associated with their ratings of erroneous assumptions' prevalence and damage.

METHODS

Seventy-four possible physician erroneous assumptions were developed concerning health, daily living skills and quality of life of individuals with ID. ID stakeholders rated each one for perceived prevalence in physicians and damage for the healthcare of adults with ID. Frequency analysis, exploratory factor analysis and correlations were run separately for participants' prevalence and damage ratings.

RESULTS

Twenty-seven erroneous assumptions were identified as those perceived most prevalent and damaging. Their unidimensionality was ascertained and participants' characteristics were not associated with their prevalence and damage ratings.

CONCLUSIONS

The identified assumptions are appropriate to represent the items of a new instrument that can be used in medical education to guide the development of curricula to change erroneous assumptions.

Population level administrative data evidence of visits to the emergency department by youth with intellectual/developmental disabilities in BC, Canada

INTRODUCTION

The literature indicates that youth with intellectual/developmental disabilities (IDD) have poor health and that access to health services decreases as they transition from pediatric to adult services. At the same time their use of emergency department services increases. The objective of this study was to compare use of emergency department services by youth with IDD to youth without IDD, with particular emphasis on the transition period from pediatric to adult health care services.

METHODS

This research used a population level administrative health data base for the province of British Columbia Canada for 2010-2019 to examine the use of emergency departments by youth with IDD (N = 20,591) compared to a population group of youth without IDD (N = 1,293,791). Using the ten years of data, odds ratios for visits to the emergency department were calculated adjusting for sex, income and geographical area within the Province. In addition, difference-in-differences analyses were calculated for age matched subsets of the two cohorts.

RESULTS

Over the ten year period, 40.60% of youth with IDD visited an emergency department at least once, compared to 29.10% of youth without IDD. Youth with IDD had an odds ratio of visiting an emergency department 1.697 (1.649, 1.747) times that of youth without IDD. However, when odds were adjusted for a diagnosis of either psychotic illness or anxiety/depression, the odds for youth with IDD visiting emergency compared to youth without IDD were reduced to 1.063 (1.031, 1.096). Use of emergency services increased as youth aged. Type of IDD also affected use of emergency services. Youth with Fetal Alcohol Syndrome had the greatest odds of using emergency services compared to youth with other types of IDD.

DISCUSSION

The findings from this study indicate that youth with IDD have higher odds of using emergency services than youth without IDD although these increased odds appear to be largely driven by mental illness. In addition, use of emergency services increases as the youth age and transition from pediatric to adult health services. Better treatment of mental health issues within this population may reduce their use of emergency services.

Developing self-report disability questions for a voluntary patient registration form for general practice in Australia

OBJECTIVE

This article reports on research undertaken to develop self-report disability questions for a patient registration form that may be implemented in general practices across Australia as part of a voluntary patient registration program.

METHODS

There were four research components: rapid review of approaches for capturing disability information; expert informant interviews (n=19); stakeholder consultation via virtual focus groups (n=65); and online survey (n=35). Findings from each component informed development of materials for subsequent components in an iterative research process.

RESULTS

Three disability questions were developed: two alternative questions for identifying disability, conceptually aligned with the operational definition of disability in Australia's national disability survey; one question to determine the patient's disability group/s.

CONCLUSIONS

Knowledge and perspectives from a variety of sources informed the development of self-report questions to identify patients with disability. Implementing these questions represents an opportunity to test new ways of capturing disability information suited to mainstream service provision contexts. It will be essential to evaluate the quality of the data produced during the initial period of implementation.

IMPLICATIONS FOR PUBLIC HEALTH

The collection of self-report patient disability information within general practice, using standard and conceptually-sound questions, has the potential to support improved provision of health care to patients with disability.

ADAPTATION AND TESTING OF THE DEVELOPMENTAL DISABILITY ATTITUDES IN NURSING CARE INSTRUMENT

Background and Purpose: Individuals with developmental disability (DD) often experience poor health outcomes, potentiated by healthcare inequities. Nurses have the potential to reduce these inequities through the quality of care provided. The quality of care provided by nursing students, the future generation of nurses, is affected by the attitudes of their clinical nursing faculty. The purpose of this study was to adapt and test an instrument to specifically measure the attitudes of clinical nursing faculty toward providing care to people with DD. Methods: The Disability Attitudes in Health Care (DAHC) instrument was adapted to create the new Developmental Disability Attitudes in Nursing Care (DDANC) instrument. Results: Content experts reviewed the DDANC for content validity (CVI = 0.88), followed by testing for internal consistency reliability (Cronbach's alpha = 0.7). The study respondents had overall positive attitudes toward the care of people with DD. Conclusions: The DDANC is an acceptably valid and reliable instrument to assess attitudes of clinical nursing faculty toward providing care to people with DD.

Reporting Down syndrome on the death certificate for Alzheimer disease/unspecified dementia deaths

BACKGROUND

Death certificates are crucial for understanding population health trends including the burden of disease mortality. Accurate reporting of causes of death on these records is necessary in order to implement adequate public health policies and fund disease research. While there is evidence that Alzheimer disease and unspecified dementia are prevalent among people with Down syndrome, a 2014 Centers for Disease Control and Prevention (CDC) rule change instructing that Down syndrome should be reported as the underlying cause of death in instances when death occurred from Alzheimer disease or unspecified dementia threatens the accuracy and the utility of death certificates for this population.

METHODS

This study used 15 years (2005-2019) of US death certificate data for adults with and without Down syndrome. We compare the mortality burden due to Alzheimer disease and unspecified dementia prior to and after amending death certificates that report Down syndrome as the underlying cause of death.

RESULTS

When analyzing death certificates without addressing the reporting of Down syndrome as the underlying cause of death, rates of death due to Alzheimer disease and dementia ranked as the third leading cause of death for both adults with and without Down syndrome. After amending death certificates that reported Down syndrome as the underlying cause of death, Alzheimer disease and dementia were the leading cause of death among those with Down syndrome, occurring 2.7 times more in adults with compared to without Down syndrome.

CONCLUSION

The findings of this study highlight the importance of accurate mortality data for studying and addressing population health trends. The current practice of reporting Down syndrome as the underlying cause of death rather than the disease responsible for death needs to be reconsidered and modified. If not, people with Down syndrome may be further marginalized within dementia related support and research.

The Role of Information and Knowledge in COVID-19 Vaccination Among People With Intellectual and Developmental Disabilities and Their Families

People with intellectual and developmental disabilities (IDD) may be at an increased risk of severe illness and death from COVID-19. This article examines the role of information and knowledge in COVID-19 vaccine uptake for people with IDD and their families. We developed a survey about COVID-19 vaccine uptake, confidence, and knowledge for people with IDD and their families. COVID-19 vaccine uptake was associated with higher self-reported knowledge about the vaccine, learning about the vaccine from one's doctor, and social media use. Qualitative results reflected the importance of trusted relationships with medical providers in vaccination.

The delivery of healthy lifestyle interventions for people with disability living in supported accommodation: a scoping review of intervention efficacy and consumer involvement

BACKGROUND

People with disability living in supported accommodation experience health disparities that may be partly attributed to sedentary lifestyle behaviors and poor dietary quality. Healthy lifestyle interventions have been suggested as a method of health promotion for this population; however, a synthesis of their efficacy has not yet been conducted.

OBJECTIVE

The primary aims were to (1) identify healthy lifestyle interventions delivered to people with disability living in supported accommodation and (2) examine their efficacy in supporting health and well-being. A secondary aim was to explore whether people with disability have been involved in the codesign of these interventions.

METHODS

A scoping review was conducted following the Joanna Briggs Institute's guidance for conducting scoping reviews, and six databases were searched from January 2011 to November 2021.

RESULTS

Thirty-two studies were included. Identified intervention types included training and education, exercise programs, and multicomponent interventions. A broad range of outcomes were examined; however, findings regarding efficacy were overall mixed and limited due to significant heterogeneity and the underreporting of consistently measured outcomes. The codesign of interventions in consultation with people with disability was underexplored.

CONCLUSIONS

Health promotion training for staff and tailored education for people with disability hold promise in creating a care environment that supports a healthy lifestyle. The paucity of interventions developed in consultation with people with disability is concerning and highlights the importance of meaningful co-design. The development of a theoretically informed intervention that is codesigned and addresses the broader social determinants that influence health behavior is recommended.

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

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

A Scoping Review of Health Research with Racially/Ethnically Minoritized Adults with Intellectual and Developmental Disabilities

Living with intersectional identities, having a disability, and being a member of a racial or ethnic minoritized group in the U.S., contributes to marginalization that may result in health disparities and health inequities. The purpose of this scoping review is to describe health research regarding adult racial/ethnic minoritized individuals in the U.S with intellectual and developmental disabilities (I/DD). Eight electronic databases were searched to identify literature on the topic published since 2000. Of the 5,229 records, 35 articles were included in the review. Eligible studies included research conducted in the U.S., published in English, and research focused on adults with I/DD with race and/or ethnicity information. The 35 articles included racial/ethnic minoritized individuals who were Black, Latinx/Hispanic, American Indian, and Asian. Twenty-nine of the 35 articles identified health disparities experienced by adults with I/DD from racial/ethnic minoritized groups. Many health disparities were demonstrated in the articles, where adult racial/ethnic minoritized individuals with I/DD fared worse compared to White adults with I/DD. Additionally, four articles describe differences in health experiences by those from racial or ethnic minoritized backgrounds. Results of this scoping review highlight the need for research that incorporates intentional inclusion of racial/ethnic minoritized people with I/DD and include novel methodologies that allow for the contributions of historically marginalized voices. Future research with an intersectionality approach is recommended to promote equity.

Impact of the COVID-19 Pandemic on the Behavioral Health of People With Intellectual and Developmental Disabilities

OBJECTIVE

The authors examined how the COVID-19 pandemic affected the behavioral health of people with intellectual and developmental disabilities (IDD).

METHODS

A modified version of the Coronavirus Health Impact Survey-Adapted for Autism and Related Neurodevelopmental Conditions was sent to the authors' clinical networks and IDD-affiliated organizations from March to June 2021.

RESULTS

In total, 437 people with IDD or their caregivers responded to the survey. Diagnoses included intellectual disability (51%) and autism spectrum disorder (48%). More than half (52%) of respondents reported worsened mental health. Losing access to services correlated with declining mental health. Interventions suggested to improve behavioral health included more time with friends and family (68%), more time outdoors (61%), and access to community activities (59%).

CONCLUSIONS

COVID-19 affected the behavioral health of individuals with IDD. Survey results highlight the opportunity to leverage physical activity and pandemic-safe social supports as accessible means to mitigate gaps in services.

Bilateral posterior scleritis due to giant cell arteritis

A woman aged mid 70s with mild learning difficulty presented with eye symptoms, headache and shoulder pains. She was found to have bilateral posterior scleritis secondary to giant cell arteritis. Posterior scleritis is a potentially blinding condition, with ambiguous symptoms and signs, therefore diagnosis is commonly delayed. This patient was seen in General Practice as well as in Accident and Emergency, where diagnoses of acute angle closure glaucoma as well as iritis were rightfully considered. Her symptoms persisted for 11 days before ophthalmic opinion was sought. Thorough assessment of a painful red eye as well as knowledge of these red-flag signs may allow early treatment and a better outcome for patients. The Royal College of Ophthalmologists has published guidance on how to assess and manage visual loss in people with learning difficulties, including recognising 'symptoms' such as hesitancy on steps, eye rubbing and loss of interest in activities.

Establishing childhood disability clinics may help reduce the prevalence of disability among children in Africa: A viewpoint

Globally, there are about a billion people comprising of about 95 million children who experience disability. The number of people in Africa living with disability is about 80 million people; out of which 10%-15% are children of school age. The causes of disability among these children include epilepsy, vision loss, or hearing loss, cerebral palsy, poliomyelitis, tetanus, cerebrospinal meningitis and malaria. However, these causes of disability are preventable and can be managed with proper care. The aim of this article is to propose the establishment of childhood disability clinics in Africa in order to help prevent or reduce the incidence/ prevalence of disability among children. Some of the mandates of the clinics will be to carry out routine assessment of children for disability, to provide education on disability and strategies for disability prevention to parents and caregivers, to promptly prevent and manage disability or its causes. However, establishing these clinics requires shared commitment of all the stakeholders.

The relationship between subjective socioeconomic status and health in adults with and without intellectual disability

BACKGROUND

This study investigated if subjective socioeconomic status (SSS) is related to self-rated health (SRH) and objective indicators of health in people with and without intellectual disability.

METHODS

Participants were 217 adults with, and 2350 adults without intellectual disability in Jersey. In the intellectual disability sample, 85 (39.2%) participants consented independently, while 132 (60.8%) participants consented through proxy procedures. The MacArthur Scale of Subjective Social Status was used to measure SSS. The Euro-Qol EQ-5D-5L and a five-point scale ranging from poor to excellent health were used to measure SRH.

RESULTS

Higher SSS and younger age were predictors of better SRH for the proxy-report intellectual disability group. Being employed was associated with higher EQ-5D-5L index values for all intellectual disability groups.

CONCLUSION

As SSS was only related to SRH in the proxy intellectual disability group, further research with a larger intellectual disability sample is needed to explore its utility further.

COVID-19 mortality burden and comorbidity patterns among decedents with and without intellectual and developmental disability in the US

BACKGROUND

While there is ample evidence of increased COVID-19 mortality risk among people with intellectual and developmental disability (IDD), research has not documented whether this higher risk resulted in increased COVID-19 mortality burden in the US or whether comorbidity patterns among COVID-19 deaths are similar or distinct for people with IDD.

OBJECTIVE

To determine the differences in COVID-19 mortality burden between decedents with and without IDD during the first year of the pandemic.

METHODS

This study uses 2020 US death certificate data to compare COVID-19 mortality burden and comorbidity patterns among decedents with and without IDD.

RESULTS

COVID-19 was the leading cause of death among decedents with IDD in 2020, compared with the 3rd leading cause among decedents without IDD. The proportion of deaths from COVID-19 was also higher for decedents with compared to without IDD. Comorbidities resulting from COVID-19 were similar among decedents with and without IDD, but there were some differences among reported pre-existing conditions, notably higher rates of hypothyroidism and seizures among decedents with IDD.

CONCLUSION

The COVID-19 mortality burden was greater for people with than without IDD during the first year of the pandemic. The continued practice of postmortem diagnostic overshadowing prevents analyzing whether this difference continues through today. Action is needed by the Centers for Disease Control and Prevention to mitigate this data inequity. Out of an abundance of caution, medical providers should carefully monitor symptoms among COVID-19 patients with IDD diagnosed with hypothyroidism and/or seizures.

Pregnancy recommendations from women with intellectual and developmental disabilities to their peers

BACKGROUND

As recent as the mid-twentieth century, eugenics practices on women with intellectual and developmental disabilities were commonplace. Deinstitutionalization has led to an increasing proportion of women with intellectual and developmental disabilities living in the community and becoming pregnant. Previous research has reported barriers to maternal health care (i.e., perceived provider stigma, inadequate communication, stress surrounding child protective services involvement, and financial strain). Research shows that this population is at increased risk of adverse outcomes including preterm delivery, low birth weight babies, and maternal mortality.

OBJECTIVE/HYPOTHESIS

This study aimed to explore recommendations from mothers with intellectual and developmental disabilities for other women to potentially improve pregnancy experiences for this population.

METHODS

We conducted semi-structured individual interviews among 16 women with intellectual and developmental disabilities. Data were coded using a content analysis process and iteratively analyzed using inductive and deductive techniques to determine emergent themes.

RESULTS

Participants offered recommendations for navigating pregnancy to their peers who are pregnant, or thinking about becoming pregnant. Themes included: (1) planning for birth; (2) advocating at the point-of-care; (3) seeking supports and services; (4) interacting with child protective services; (5) communicating with providers; and (6) exhibiting resilience.

CONCLUSION

Our study highlights recommendations for improving pregnancy experiences of women with intellectual and developmental disabilities. Informed by the lived pregnancy experiences of our participants, these recommendations can inform clinician training, new guidelines, and services to support and improve pregnancy experiences for women with intellectual and developmental disabilities.

Opening the door to university health research: recommendations for increasing accessibility for individuals with intellectual disability

BACKGROUND

Advances in health equity rely on representation of diverse groups in population health research samples. Despite progress in the diversification of research samples, continued expansion to include systematically excluded groups is needed to address health inequities. One such group that is infrequently represented in population health research are adults with intellectual disability. Individuals with intellectual disability experience pervasive health disparities. Representation in population health research is crucial to determine the root causes of inequity, understand the health of diverse populations, and address health disparities. The purpose of this paper was to develop recommendations for researchers to increase the accessibility of university health research and to support the inclusion of adults with intellectual disability as participants in health research.

METHODS

A comprehensive literature review, consultation with the university ethics review board, and review of United States federal regulations was completed to identify barriers to research participation for individuals with intellectual disability. A collaborative stakeholder working group developed recommendations and products to increase the accessibility of university research for participants with intellectual disability.

RESULTS

Eleven key barriers to research participation were identified including gaps in researchers' knowledge, lack of trust, accessibility and communication challenges, and systematic exclusion among others. Together the stakeholder working group compiled seven general recommendations for university health researchers to guide inclusion efforts. Recommendations included: 1) address the knowledge gap, 2) build community partnerships, 3) use plain language, 4) simplify consent and assent processes, 5) establish research capacity to consent, 6) offer universal supports and accommodations, and 7) practice accessible dissemination. In addition, four products were created as part of the stakeholder working group to be shared with researchers to support the inclusion of participants with intellectual disability. 1) Supports I Need Checklist, 2) Plain language glossary of health and research terms, 3) Understanding Consent and Assent in Plain Language, 4) Easy-Read Paper Template.

CONCLUSION

Community members and individuals with intellectual disability want to be included in research and are eager to engage as research participants. It is the responsibility of the researcher to open the door to university health research. The recommendations discussed in this paper could increase accessibility for a broader range of research participants and, in particular, promote the inclusion of individuals with intellectual disability to advance health equity in population health research.

Opening the door to university health research: recommendations for increasing accessibility for individuals with intellectual disability

BACKGROUND

Advances in health equity rely on representation of diverse groups in population health research samples. Despite progress in the diversification of research samples, continued expansion to include systematically excluded groups is needed to address health inequities. One such group that is infrequently represented in population health research are adults with intellectual disability. Individuals with intellectual disability experience pervasive health disparities. Representation in population health research is crucial to determine the root causes of inequity, understand the health of diverse populations, and address health disparities. The purpose of this paper was to develop recommendations for researchers to increase the accessibility of university health research and to support the inclusion of adults with intellectual disability as participants in health research.

METHODS

A comprehensive literature review, consultation with the university ethics review board, and review of United States federal regulations was completed to identify barriers to research participation for individuals with intellectual disability. A collaborative stakeholder working group developed recommendations and products to increase the accessibility of university research for participants with intellectual disability.

RESULTS

Eleven key barriers to research participation were identified including gaps in researchers' knowledge, lack of trust, accessibility and communication challenges, and systematic exclusion among others. Together the stakeholder working group compiled seven general recommendations for university health researchers to guide inclusion efforts. Recommendations included: 1) address the knowledge gap, 2) build community partnerships, 3) use plain language, 4) simplify consent and assent processes, 5) establish research capacity to consent, 6) offer universal supports and accommodations, and 7) practice accessible dissemination. In addition, four products were created as part of the stakeholder working group to be shared with researchers to support the inclusion of participants with intellectual disability. 1) Supports I Need Checklist, 2) Plain language glossary of health and research terms, 3) Understanding Consent and Assent in Plain Language, 4) Easy-Read Paper Template.

CONCLUSION

Community members and individuals with intellectual disability want to be included in research and are eager to engage as research participants. It is the responsibility of the researcher to open the door to university health research. The recommendations discussed in this paper could increase accessibility for a broader range of research participants and, in particular, promote the inclusion of individuals with intellectual disability to advance health equity in population health research.

Inequities in Receipt of the North Carolina Medicaid Waiver Among Individuals with Intellectual Disability or Autism Spectrum Disorder

OBJECTIVE

We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization.

METHOD

Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017.

RESULTS

Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED.

CONCLUSION

Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Understanding mental health outcomes related to compassion fatigue in parents of children diagnosed with intellectual disability

BACKGROUND

Parenting a child diagnosed with intellectual disability includes a variety of stressors. The degree to which stress affects these parents has been given little emphasis. Compassion fatigue includes experiencing an emotional response to being unable to relieve the suffering of a loved one, burnout, strain and stress on the caregiver. Compassion fatigue develops in parents of children diagnosed with intellectual disability due to their caregiving roles.

METHOD

A phenomenological qualitative study was conducted using 25 semi-structured interviews to understand the mental health outcomes of parents caring for a child diagnosed with intellectual disability.

RESULTS

The results showed that initial emotional reactions after receiving their child's diagnosis was a combination of anxiety, depression and compassion satisfaction. This study's findings suggest that parents of children diagnosed with intellectual disability experience moderate levels of compassion fatigue in the caring of their child.

CONCLUSIONS

This research provides evidence that the caregiving of a child diagnosed with intellectual disability comes with a myriad of stressors that can lead to compassion fatigue.

A picture is worth a thousand words: A proposal to incorporate video into the evaluation of adults with intellectual or developmental disability living outside the home

Adults with intellectual or developmental disability (IDD) comprise 1-2% of the population worldwide. IDD is a significant risk factor for premature morbidity or mortality. This is likely due in part to preventable health conditions, which are modifiable with the intervention of direct care providers in areas including nutrition, promotion of an active lifestyle and effective identification of health or functional deterioration. Adults with IDD are also at increased risk for neglect or mistreatment, a finding that has been documented across multiple countries and in a variety of care settings. Contributing factors include resource availability, lack of person-centered care, management culture and care worker training. Practical and economical interventions may address the known disparities and challenges facing the large community of adults with IDD. To promote person-centered care, improve record-keeping/documentation, and aid in protecting the health and safety of this vulnerable population, we propose incorporation of a video into the evaluation of adults with IDD living outside the home.

Perspectives on delivering health promotion for the intellectual disability population

The qualitative study reported in this article set out to develop an understanding of how staff supporting individuals with intellectual disabilities deliver health promotion in their practice. The aim was to determine how social care managers working within an intellectual disability care setting in Ireland perceived health promotion and their role within it. Semi-structured interviews were conducted to collect the data. Participants perceived health promotion to be a priority for this population group that should be tailored to meet individual needs. Study participants recognised that they have a role in supporting and providing health promotion for this population, but also that they themselves required more training and education on the issue. Health promotion enablers identified in the study for this client group need to be enhanced and ways to reduce the barriers to access identified. The results reflect observations reported in the literature and indicate a need to prioritise health promotion with this population by establishing policies and practices in the organisation to promote it. A requirement for relevant training and education for social care managers-and other staff, as appropriate-was identified, as were areas for further research.

Factors associated with the reporting of Down syndrome as the underlying cause of death on US death certificates

BACKGROUND

Efforts aimed at preventing premature mortality for people with Down syndrome are hindered by the practice of reporting disability as the underlying cause of death. Prior research suggests this form of diagnostic overshadowing may be the result of increased uncertainty surrounding the death.

METHODS

This study uses bivariable analysis and multivariable logistic regression models to investigate associations between sociodemographic characteristics, comorbidities, and death context and processing characteristics with the reporting of Down syndrome as the underlying cause of death in 2005-2017 US Multiple Cause of Death data files.

RESULTS

The reporting of Down syndrome as the underlying cause of death was associated with characteristics indicative of an increased amount of uncertainty surrounding the death. Results also suggest other mechanisms may inform inaccurate reporting, such as racial bias, and the continued conflation of disability and health.

CONCLUSIONS

Medical personnel certifying death certificates should strive for accuracy when reporting the causes of death. To ensure this outcome, even in the midst of increased uncertainty, Down syndrome should not be reported as the underlying cause of death unless the decedent was diagnosed with Alzheimer's disease or unspecified dementia. Future research should further explore the possibility that increased death certification errors for adults with Down syndrome, or other developmental disabilities, are associated with racial bias.