Physical access barriers to care for diagnosis and treatment of breast cancer among women with mobility impairments

The study of ableism in population health: a critical review

Over the past three decades, health equity has become a guiding framework for documenting, explaining, and informing the promotion of population health. With these developments, scholars have widened public health's aperture, bringing systems of oppression sharply into focus. Additionally, some researchers in disability and health have advocated for utilizing socially grounded frameworks to investigate the health of disabled people. Yet, naming ableism, much less operationalizing it for the empirical study of health, remains scant. This paper critically reviews the study of ableism as a social determinant of disabled people's health within population health research. First, we provide an orientation to the present state of this literature by looking to the past. We briefly trace a history of traditional approaches to studying disability and health and alternatives that have emerged from critiques of the individualized lens that has dominated this work. Next, we delineate the operation of ableism across social levels. We characterize how ableism has been studied in population health in terms of levels of analysis (intrapersonal, interpersonal, institutional, and structural) and measures of interest. To conclude, we discuss hinderances to and promising avenues toward population health research that advances health equity for disabled people.

Treatment of last resort? Psychological therapy seeking in chronic pain patients

OBJECTIVE

Our goal was to assess how many chronic pain patients seek psychological treatment for their condition and what psychological and demographic characteristics are associated with that decision.

METHODS

The association between pain intensity, quality of life and psychological treatment seeking was tested in two hypothetical models which differed according to beliefs about either external or internal control over pain.

RESULTS

A minority of patients had experience with psychological treatment of chronic pain. Patients who had that experience were younger, suffered from more intense pain, and applied many more coping strategies than patients who never tried this kind of treatment. Intense pain and low quality of life motivated chronic pain patients to seek psychological treatment only if they believed that doctors could control their pain.

DISCUSSION

The study results stress the importance of diversifying the methods used to treat chronic pain and educating patients about the benefits of psychological treatment. Low numbers of chronic pain patients who take advantage of psychological treatment indicate that encouragement from medical professionals might be necessary.

Twelve tips for including disability education in undergraduate medical education

Disability is a large and growing minority population worldwide. People with disabilities continue to experience health and healthcare disparities. Despite multiple calls to action to provide disability education within undergraduate medical education as a strategy to mitigate ongoing inequities, robust disability education is not routinely provided across medical schools. This article provides twelve tips that any medical school faculty can utilize to integrate meaningful disability education within existing core medical education.

[Oncologic Care of Breast Cancer Patients with Preexisting Disabilities: Results of a Qualitative Study on Perceived Barriers, Communication Difficulties, and Needs]

Up to now, people with disabilities have received little consideration in health care with regard to their individual needs. This study gathers information on the internal perspective of breast cancer patients with a pre-existing disability with regard to needs and barriers in oncological care. For this purpose, qualitative, guideline-based interviews were conducted and analysed using qualitative content analysis. Twenty-three patients with physical disabilities, chronic physical illnesses, sensory disabilities, mental illnesses and/or intellectual disabilities were included. Depending on the type of disability, patients faced different barriers. In order to reduce the barriers experienced by people with disabilities in care, it is necessary to promote cooperation between care providers from different care sectors and to train care providers in dealing with people with disabilities.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI

Despite significant advances in healthcare, many patients from medically underserved populations are impacted by existing healthcare disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge toolkit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, leveraging the four pillars provides a helpful framework to advance health equity efforts as a step towards social justice in health.

Development of Aerobic Exercise Equipment Using Universal Design: Treadmill and Arm Ergometer

Exercise products based on universal design, which reduce restrictions on the exercise environment and ensure convenience and safe use, are beneficial for people with a disability; however, the current universal design only considers the preferences of the general population, which is not suitable for the disabled population. This results in the exclusivity of the sports facilities and supplies for people with a disability. Consequently, we explored the components of universal design and product satisfaction by considering users with disabilities and proposed the direction for designing extended universal exercise equipment that is suitable for them. Specifically, this study focuses on developing exercise equipment for people with a disability. Based on the results from the evaluation of acceptance and satisfaction of universal sports products for people with a disability using design thinking, we suggest the following. First, it is necessary to consider safety devices for exercise products. Second, the user interface should be improved in terms of convenience. Third, the ergonomic instrument design should be improved. Finally, the instrument design should be centered on user convenience.

The Long-Term Impact of Childhood Disability on Mental Health Trajectories in Mid- to Late-Life

OBJECTIVES

We draw from the life course and stress process frameworks to examine how experiencing disability in early life influences mental health in adulthood.

METHODS

Data come from the Health and Retirement Study Cross-Wave Childhood Health and Family Aggregated Data file (2008-2018, n = 15,289). Childhood disability status is a retrospective self-report of whether respondents were disabled for six months or more because of a health problem before the age of 16 (n = 581). We used age-based growth curve models to construct trajectories of depressive symptoms by childhood disability status.

RESULTS

Respondents who experienced childhood disability exhibit more depressive symptoms at age 50 compared to those who did not experience this stressor. However, there is no difference in the growth of depressive symptoms with age between these groups, suggesting maintained inequality over the late adulthood life course.

DISCUSSION

Findings suggest that childhood disability has long-term implications for life course mental health.

Experiences of women with physical disabilities accessing prenatal care in low- and middle-income countries

INTRODUCTION

Women with physical disabilities experience barriers to accessing patient-centered and accommodative care during the prenatal and childbirth periods. While there is a growing body of work in high-income countries to address these needs, there is little research detailing specific challenges in low- and middle-income countries (LMICs) where a woman's' burden- and need-is greatest.

METHODS

We conducted an integrative review to synthesize the experiences of women with physical disabilities accessing prenatal care and childbirth services in LMICs. Five databases were searched for systematic reviews, retrospective cohort studies, cross-sectional studies, narrative literature reviews, as well as other evidence types. We used Ediom's EvidenceEngine™, a machine-assisted search engine that uses artificial intelligence to conduct this search using pertinent keywords to identify original research published between January 2009 - September 2018. These results were augmented by hand searching of reference lists. Forty articles were identified using this method and 11 retained after duplicates were removed and inclusion and exclusion criteria applied.

RESULTS

Four types of experiences are described in these 11 studies: (1) limited physical and material resources; (2) health care worker knowledge, attitudes, and skills; (3) pregnant people's knowledge; and (4) public stigma and ignorance.

DISCUSSION

People with physical disabilities face specific challenges during pregnancy and childbirth. Importantly, these findings offer targets for enhanced clinical training for nurses, midwives, traditional birth attendants and public health workers, as well as opportunities for the improved delivery of prenatal care and childbirth services to these vulnerable women.

Implications of Physical Access Barriers for Breast Cancer Diagnosis and Treatment in Women with Mobility Disability

OBJECTIVE

More than 30 years since enactment of the Americans with Disabilities Act, people with disability continue to face physical access barriers, notably inaccessible medical diagnostic equipment, in clinical settings. Access barriers affect breast cancer screening and treatment for women with disability.

METHODS

We used standard diagnosis codes and natural language processing to screen electronic health records (EHRs) in a digital data repository from a large healthcare delivery system for patients with pre-existing mobility disability diagnosed with breast cancer between 2005-2017. We reviewed EHRs of 20 patients, using conventional content analysis to examine breast cancer diagnosis and treatment experiences.

RESULTS

Clinicians noted challenges positioning patients for routine procedures including manual breast exam, screening mammography, and breast biopsies. Given challenges accommodating disability for adjuvant therapies, mastectomy was favored over breast-conserving options despite early stages of diagnosis. Notations contained little information about proactive problem-solving for arranging accommodations.

CONCLUSIONS

Notations described physical access barriers for breast cancer detection and treatment, with limited planning for mitigating barriers. Despite 2017 promulgation of federal Standards for Accessible Medical Diagnostic Equipment, implementing these standards requires further rulemaking.

Identifying Accessibility Requests for Patients With Disabilities Through an Electronic Health Record-Based Questionnaire

IMPORTANCE

People with disabilities experience disparities in health care access and outcomes, and inaccessible health care facilities are major barriers to health care access. Methods to collect accessibility request information are needed to improve health care outcomes for patients with disabilities.

OBJECTIVE

To evaluate an electronic health record (EHR)-based questionnaire designed to identify accessibility requests for patients with disabilities at an eye clinic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional pilot study implemented an EHR questionnaire and prospectively collected data on accessibility requests at a university-based eye clinic. The study included 55 722 patients making appointments at the Johns Hopkins Wilmer Eye Institute from April 1, 2019, to March 31, 2020.

MAIN OUTCOMES AND MEASURES

The Wilmer Eye Institute staff were trained to assess accessibility requests of patients making appointments in-person or via telephone using a standardized script and entering patient responses into the EHR. Data were later extracted for analysis and used to determine the proportion of patients making eye appointments who reported a disability accessibility request (physical, sensory, or intellectual) during their clinic visit.

RESULTS

Accessibility request data were collected from 250 932 patient encounters. Patients had a mean (SD) age of 61.9 (20.6) years; most were women (146 846 [58.5%]) and were White individuals (162 720 [64.9%]). Of these, 23 510 (9.4%) encounters were associated with an accessibility request. The most reported accessibility request was mobility related (18 857 [7.5%]) (needing a cane, crutches, motorized scooter, walker, wheelchair, stretcher, assistance standing, or transport services), followed by sensory-related (2988 [1.2%]) (visual, hearing, or speech impairment), intellectual (353 [0.1%]), and other (1312 [0.5%]) (assistance with filling forms or service animal) requests. Patients with an accessibility request compared with those without, were older (72.6 vs 60.8 years), less likely to be White individuals (59.7% vs 65.4%), and more likely to be women (62.6% vs 58.1%), receiving Medicare (69.6% vs 41.5%), and have vision impairment (41.3% vs 13.6%) (P < .001 for all).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, a substantial proportion of patients making eye appointments reported having accessibility requests as captured using a new EHR-based questionnaire. Such standardization of data collection for disability-related accessibility requests in EHR is scalable, could be expanded to other clinical settings, and has the potential to improve accessibility of health care interactions for patients with disabilities.

US Physicians' Knowledge About The Americans With Disabilities Act And Accommodation Of Patients With Disability

More than thirty years since the enactment of the Americans with Disabilities Act (ADA), people with disability continue to experience health care disparities. The ADA mandates that patients with disability receive reasonable accommodations. In our survey of 714 US physicians in outpatient practices, 35.8 percent reported knowing little or nothing about their legal responsibilities under the ADA, 71.2 percent answered incorrectly about who determines reasonable accommodations, 20.5 percent did not correctly identify who pays for these accommodations, and 68.4 felt that they were at risk for ADA lawsuits. Physicians who felt that lack of formal education or training was a moderate or large barrier to caring for patients with disability were more likely to report little or no knowledge of their responsibilities under the law and were more likely to believe that they were at risk for an ADA lawsuit. To achieve equitable care and social justice for patients with disability, considerable improvements are needed to educate physicians and make health care delivery systems more accessible and accommodating.

A scoping review of public building accessibility

BACKGROUND

The built environment needs to be designed so that all people can participate in the activities they want and need to do. Yet, accessibility is difficult to put into practice, and accessibility issues tend to be overlooked in the building and planning processes.

OBJECTIVES

The aim of this scoping review was to summarize the research front in the area of accessibility to public buildings. Specific aims were to identify knowledge gaps, to identify access activities in relation to environmental features and to link to predominant activities in terms of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A literature search was performed in PubMed, PsycINFO, Inspec, Embase and Cochrane databases. Articles in English based on original empirical studies investigating accessibility of public buildings for adults aged ≥18 years with functional limitations were considered.

RESULTS

Of the 40 articles included, ten involved study participants, while 30 only examined buildings using instruments to assess accessibility. In addition, the psychometric properties were only tested for a few of them. All articles concerned mobility and several visual limitations, while few addressed cognitive or hearing limitations. Ten main access activities were identified, from using parking/drop-off area to exiting building.

CONCLUSIONS

By using the ICF and theoretically relating the accessibility problems to activities, the results revealed that there are large knowledge gaps about accessibility to public buildings for older people and people with functional limitations and that there is a need for more methodological considerations in this area of research.

Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide

BACKGROUND

Mobility limitations are the most common disability type among the 61 million Americans with disability. Studies of patients with mobility limitations suggest that inaccessible medical diagnostic equipment poses significant barriers to care.

METHODS

The study team surveyed randomly selected US physicians nationwide representing seven specialties about their reported use of accessible weight scales and exam tables/chairs when caring for patients with mobility limitations. A descriptive analysis of responses was performed, and multivariable logistic regression was used to examine associations between accessible equipment and participants' characteristics.

RESULTS

The 714 participants (survey response rate = 61.0%) were primarily male, White, and urban, and had practiced for 20 or more years. Among those reporting routinely recording patients' weights (n = 399), only 22.6% (standard error [SE] = 2.2) reported always or usually using accessible weight scales for patients with significant mobility limitations. To determine weights of patients with mobility limitations, 8.1% always, 24.3% usually, and 40.0% sometimes asked patients. Physicians practicing ≥ 20 years were much less likely than other physicians to use accessible weight scales: odds ratio (OR) = 0.51 (95% confidence interval [CI] = 0.26-0.99). Among participants seeing patients with significant mobility limitations (n = 584), only 40.3% (SE = 2.2) always or usually used accessible exam tables or chairs. Specialists were much more likely than primary care physicians to use accessible exam tables/chairs: OR = 1.96 (95% CI = 1.29-2.99).

CONCLUSION

More than 30 years after enactment of the Americans with Disabilities Act, most physicians surveyed do not use accessible equipment for routine care of patients with chronic significant mobility limitations.

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.

Marginalized patient identities and the patient-physician relationship in the cancer care context: a systematic scoping review

PURPOSE

We sought to examine and categorize the current evidence on patient-physician relationships among marginalized patient populations within the context of cancer care using a systemic scoping review approach.

METHODS

Web-based discovery services (e.g., Google Scholar) and discipline-specific databases (e.g., PubMed) were queried for articles on the patient-physician relationship among marginalized cancer patients. The marginalized populations of interest included (1) race and ethnicity, (2) gender, (3) sexual orientation and gender identity, (4) age, (5) disability, (6) socioeconomic status, and (7) geography (rural/urban). Study screening and data extraction were facilitated through the Covidence software platform.

RESULTS

Of the 397 screened studies, 37 met study criteria-most articles utilized quantitative methodologies (n = 28). The majority of studies focused on racial and ethnic cancer disparities (n = 27) with breast cancer (n = 20) as the most common cancer site. Trust and satisfaction with the provider were the most prevalent issues cited in the patient-physician relationship. Differences in patient-physician communication practices and quality were also frequently discussed. Overall, studies highlighted the need for increased culturally congruent care among providers.

CONCLUSION

Results from this review suggest marginalized cancer patients face significant barriers in establishing culturally and linguistically congruent patient-physician relationships. Future studies should focus on the intersectionality of multiple marginalized identities and optimization of the patient-physician relationship.

A perspective on adverse health outcomes after breast cancer treatment in women with spinal cord injury

Aging women face increased risks of both breast cancer and spinal cord injury (SCI). Unique treatment challenges for this population warrant consideration. Despite advances in breast cancer treatments, significant adverse health outcomes continue to occur. Cancer treatments can be detrimental to the quality of life of able-bodied women, but more so for women living with pre-existing SCI. The goal of this Perspective Paper is to inform rehabilitation professionals about the needs of women with SCI treated for breast cancer. Specific objectives were: (1) give an overview of breast cancer treatment-related adverse outcomes that need special attention in women with SCI; and (2) inspire researchers to study the consequences of breast cancer-related health conditions in women with SCI. We identified SCI-specific considerations for undergoing breast cancer surgery, chemotherapy, radiation and endocrine therapy. This paper attempts to raise awareness regarding these issues due to the lack of research attention they have received.

Perspectives of Patients with Pre-existing Mobility Disability on the Process of Diagnosing Their Cancer

BACKGROUND

Mobility disability is the most common disability among adult Americans, estimated at 13.7% of the US population. Cancer prevalence is higher among people with mobility disability compared with the general population, yet people with disability experience disparities in cancer screening and treatment.

OBJECTIVE

We explored experiences of patients with mobility disability with the process of cancer diagnosis.

DESIGN

Open-ended individual interviews, which reached data saturation. Interviews were transcribed verbatim for conventional content analysis.

PARTICIPANTS

We interviewed 20 participants with pre-existing mobility disability that required the use of an assistive device or assistance with performance of activities of daily living and who were subsequently diagnosed with cancer (excluding melanoma).

KEY RESULTS

Concerns coalesced around five broad categories: inaccessibility of medical diagnostic equipment affecting the process of cancer diagnosis, attitudes of clinical staff about accommodating disability, dismissal of cancer signs/symptoms as emotional responses to chronic health conditions, misattributing cancer signs/symptoms to underlying disability, and attitudes about pursuing legal action for substandard care. Participants provided examples of how erroneous assumptions and potentially biased attitudes among clinicians interfered with the process of their cancer diagnosis, sometimes contributing to an insufficient workup and diagnostic delays.

CONCLUSIONS

Physical and attitudinal barriers affect the process of cancer diagnosis in people with mobility disability. Though people with mobility disability may be clinically complex, clinicians should be aware of the risks of diagnostic overshadowing (i.e., the misattribution of cancer signs/symptoms to underlying disability) and other erroneous assumptions that may affect timeliness of cancer diagnosis and quality of care. Further efforts, including educating clinicians about challenges in caring for persons with disability, should be considered to improve the process of cancer diagnosis for this population.

TRIAL REGISTRATION

N/A.

Disparities in Liver Cancer Surveillance Among People With Disabilities: A National Database Study in Korea

GOAL

The goal of this study was to determine disparities in liver cancer surveillance among people with disabilities is the goal of this study.

BACKGROUND

Using the linked administrative database in Korea, we sought to investigate (1) whether there are disparities in liver cancer surveillance according to degree and type of disability and (2) temporal trends in liver cancer surveillance among people with disabilities.

MATERIALS AND METHODS

We linked national disability registration data with national cancer surveillance data. We analyzed age-standardized participation rates for each year during the 2006-2015 period according to presence, type, and severity of the disability. We also examined factors associated with liver cancer surveillance by multivariate logistic regression using the most current data (2014-2015).

RESULTS

The age-adjusted and sex-adjusted surveillance rate for liver cancer in people with disabilities increased from 25.7% in 2006 to 49.6% in 2015; however, during the same period, surveillance rate among people without disabilities increased from 24.9% to 54.5%. As a result, disparities in surveillance for liver cancer increased over time. The surveillance participation rate among people with disabilities was 12% lower than among people without disabilities. Surveillance rates were markedly lower among people with severe disabilities [adjusted odds ratio (aOR)=0.71] and people with renal disease (aOR=0.43), brain injuries (aOR=0.60), ostomy problems (aOR=0.60), and intellectual disabilities (aOR=0.69).

CONCLUSIONS

Despite the availability of a national liver cancer surveillance program, a marked disparity was found in liver cancer surveillance participation, especially among people with severe disabilities, renal disease, or brain-related or mental disabilities.

Exploring Cancer Treatment Experiences for Patients With Preexisting Mobility Disability

OBJECTIVE

We explored the process of cancer care for patients with preexisting mobility disability, focusing on treatment decisions and experiences.

DESIGN

We recruited 20 participants with preexisting mobility disability, requiring use of an assistive device or assistance with activities of daily living, subsequently diagnosed with cancer (excluding skin cancers). We conducted open-ended individual interviews, which reached data saturation and were transcribed verbatim for conventional content analysis.

RESULTS

Concerns coalesced around 4 themes: disability-related healthcare experiences affect cancer treatment decisions; concerns about cancer treatment worsening functional impairments; access barriers; and limited provider awareness and biases about treating people with disability. Residual fear from previous medical interventions and concerns about exacerbating functional impairments influenced cancer treatment preferences. Participants also raised concerns that their underlying disability may be used to justify less aggressive treatment. Nevertheless, cancer treatment did exacerbate mobility difficulties for some participants. Inaccessible hospital rooms, lack of accessible medical equipment, and attitudinal barriers complicated treatments.

CONCLUSIONS

People with preexisting mobility disability experience barriers to cancer treatment, compromising quality of care and potentially outcomes. Further training and proactive planning for accommodating disability during cancer treatment and rehabilitation are warranted.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of the article, the reader should be able to: (1) Recognize inadequate accommodations that compromise the diagnosis and treatment of a new cancer in patients with preexisting disability; (2) Recommend involving rehabilitation specialists in the process of care and clinical decision making from the time of cancer diagnosis for patients with preexisting disability newly diagnosed with malignancy; and (3) In the setting of accessibility barriers, facilitate efforts to accommodate patients with preexisting disability to improve quality of care in diagnosing and treating cancer.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Barriers in access to healthcare for women with disabilities: a systematic review in qualitative studies

Background

Studies show that different socio-economic and structural factors can limit access to healthcare for women with disabilities. The aim of the current study was to review barriers in access to healthcare services for women with disabilities (WWD) internationally.

Methods

We conducted a systematic review of relevant qualitative articles in PubMed, Web of Science and Scopus databases from January 2009 to December 2017. The search strategy was based on two main topics: (1) access to healthcare; and (2) disability. In this review, women (older than 18) with different kinds of disabilities (physical, sensory and intellectual disabilities) were included. Studies were excluded if they were not peer-reviewed, and had a focus on men with disabilities.

Results

Twenty four articles met the inclusion criteria for the final review. In each study, participants noted various barriers to accessing healthcare. Findings revealed that WWD faced different sociocultural (erroneous assumptions, negative attitudes, being ignored, being judged, violence, abuse, insult, impoliteness, and low health literacy), financial (poverty, unemployment, high transportation costs) and structural (lack of insurance coverage, inaccessible equipment and transportation facilities, lack of knowledge, lack of information, lack of transparency, and communicative problems) factors which impacted their access healthcare.

Conclusions

Healthcare systems need to train the healthcare workforce to respect WWD, pay attention to their preferences and choices, provide non-discriminatory and respectful treatment, and address stigmatizing attitudinal towards WWD. In addition, families and communities need to participate in advocacy efforts to promote WWD’s access to health care.

Breast cancer, screening and diagnostic tools: All you need to know

Breast cancer is one of the most frequent malignancies among women worldwide. Methods for screening and diagnosis allow health care professionals to provide personalized treatments that improve the outcome and survival. Scientists and physicians are working side-by-side to develop evidence-based guidelines and equipment to detect cancer earlier. However, the lack of comprehensive interdisciplinary information and understanding between biomedical, medical, and technology professionals makes innovation of new screening and diagnosis tools difficult. This critical review gathers, for the first time, information concerning normal breast and cancer biology, established and emerging methods for screening and diagnosis, staging and grading, molecular and genetic biomarkers. Our purpose is to address key interdisciplinary information about these methods for physicians and scientists. Only the multidisciplinary interaction and communication between scientists, health care professionals, technical experts and patients will lead to the development of better detection tools and methods for an improved screening and early diagnosis.

Reproductive Health in Women with Physical Disability: A Conceptual Framework for the Development of New Patient-Reported Outcome Measures

Background: Barriers in the built environment, enduring stereotypes and biases, and limited disability competency of health care providers compromise access to and quality of reproductive health care for women with physical disabilities. One way to improve our understanding of critical factors that drive reproductive health inequity and its impact on access to care is to use patient-reported outcome measures (PROMs) that capture relevant and meaningful information about experience. In this study, we developed a conceptual framework as the foundation for relevant and clinically meaningful patient-reported outcome measures targeting the interface of disability and reproductive health. Materials and Methods: We conducted semistructured focus groups and interviews to assess women's experiences around their reproductive health and contextual factors related to disability. We used deductive and inductive qualitative coding approaches to develop the conceptual framework. Results: Eighty-one women between the ages of 16 and 50 with a self-reported physical disability, defined by an impairment of mobility, participated in 13 focus groups (N = 64) and 17 individual interviews. Five major themes characterized the conceptual framework that emerged-knowledge about reproductive health, communication about reproductive health, relationships, the reproductive health care environment, and self-advocacy/identity-all of which had some relationship with five major reproductive health issues-pregnancy and labor/delivery, periods and menstrual management, contraception, sexuality and sexual functioning, and pelvic examinations. Conclusions: This conceptual framework will serve as a foundation for PROM and guide intervention development to reduce reproductive health inequity and improve reproductive health outcomes of women with physical disabilities.

Exploring attitudes about developing cancer among patients with pre-existing mobility disability

OBJECTIVE

Mobility disability affects approximately 13.7% of the United States population, representing the most common disability type. People with mobility disability experience disparities in cancer screening and higher prevalence of some cancers compared to the general population. We sought to explore the attitudes of people with pre-existing mobility disability about their cancer diagnosis.

METHODS

We conducted open-ended individual interviews with 20 participants who had pre-existing mobility disability requiring use of an assistive device or assistance with performance of activities of daily living (ADLs), subsequently diagnosed with cancer (excluding skin cancers). Interviews reached data saturation and were transcribed verbatim for conventional content analysis.

RESULTS

Concerns coalesced around three major themes: sense of control over health conditions, seeking support, and recommendations for other people with disability seeking cancer care. Some participants described feeling a loss of control over their cancer diagnosis that they did not have regarding disability, while others suggested that disability presented greater challenges than their cancer diagnosis. Participants described seeking various forms of support, including emotional support (e.g., from friends and family), informational support (e.g., recommendations for seeking care), instrumental support (e.g., ADLs), and appraisal (e.g., self-reflection of personal qualities for fighting cancer). They provided recommendations, highlighting importance of self-advocacy and being attuned to changes in health status.

CONCLUSIONS

We found that people with pre-existing mobility disability and cancer express complex attitudes towards their cancer diagnosis. Findings may inform efforts to improve quality of relevant supports to meet the psychosocial needs of this population.

Accessibility to people with motor, visual, or hearing disabilities during delivery and childbirth: the structure of SUS facilities linked to Rede Cegonha

There are no nationwide studies characterizing accessibility for people with disabilities during delivery. This study aimed to describe the physical structure of hospital units regarding accessibility for pregnant and puerperae with motor (MD), visual (VD), or hearing (HD) disabilities in Brazil. This is an ecological, descriptive study conducted in all 606 health facilities linked to the "Rede Cegonha" where deliveries occurred, according to 2015 databases. We performed the descriptive and geospatial analysis and considered the presence of motor accessibility when the establishment had a handrail or elevator ramp, wheelchair-sized doors, and accessible bathroom with bars. We assumed visual accessibility when there was tactile signage on the floor (Braille system or embossed figures) and hearing accessibility when there was signage by texts, pictures, signs, posters, or symbols in the environments. In Brazil, only 26 (4.3%) of the facilities had accessibility for people with MD, 20 (3.3%) for people with VD, and none for HD. Motor accessibility was worse in the North and Northeast of Brazil, and hearing accessibility in the North region. Despite advances in the implementation of the "Rede Cegonha" in Brazil, the facilities' structure is not adapted for women with MD, VD, or HD.

Disparities in gastric cancer screening among people with disabilities: a national registry-linkage study in South Korea

BACKGROUND AND AIM

Using the national disability registration linked to the cancer screening database in Korea, we examined (1) trends in the gastric cancer screening rate among people with disabilities over time, and (2) whether gastric cancer screening participation and modalities differed according to presence, severity, and type of disability.

METHODS

We examined gastric cancer screening participation rates among individuals with registered disability, from 2006 to 2015.

RESULTS

The age- and sex-adjusted rate for gastric cancer screening in people with disabilities increased from 25.9% in 2006 to 51.9% in 2015 (change: + 26.0%). During the same period, screening rates among people without disability improved from 24.7 to 56.5% (change: + 31.8%). Disability was associated with a screening rate [adjusted odds ratio (aOR) 0.89, 95% confidence interval (CI), 0.88-0.89]. Screening rates were markedly lower among people with severe disabilities (aOR 0.58, 95% CI 0.57-0.58) and people with autism (aOR 0.36, 95% CI 0.25-0.52), renal failure (aOR 0.39, 95% CI 0.38-0.39), brain injury (aOR 0.41, 95% CI 0.40-0.41), ostomy problems (aOR 0.53, 95% CI 0.51-0.55), intellectual disabilities (aOR 0.54, 95% CI 0.53-0.54), or mental disorders (aOR 0.55, 95% CI 0.54-0.56). The use of gastroscopy as the initial screening modality in people with disabilities was lower than in people without a disability.

CONCLUSIONS

In spite of the availability of national gastric cancer screening program, we found significant disparities in gastric cancer screening participation, especially among people with severe disabilities and those with renal failure or brain-related/mental disabilities.

Reducing Barriers to Breast Imaging in Patients with Mobility Limitations

Over 1 billion people worldwide live with a disability. Patients living with disability are often challenged by many barriers to healthcare access, especially preventive and screening services. The Americans with Disabilities Act of 1990 mandated that access to public accommodations related to medical care in the United States be available to all; however, many healthcare facilities fall short of meeting this requirement. Research studies suggest that women with chronic disabilities are less likely to undergo breast cancer screening due to financial, environmental, and physical limitations, as well as psychological barriers. There is scarcity of research on the needs of individuals with mobility impairments and the features of the barriers they face when accessing healthcare services, especially breast imaging services. The objective of this article is to illustrate the existing barriers to breast imaging services that individuals with mobility impairments face and to provide a list of guidelines to be used in clinical practice for breast care practices and medical staff working with patients who have mobility impairments.

Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.

COVID-19 and the need for disability conscious medical education, training, and practice

The COVID-19 era exposes what was already a crisis in the medical profession: structural racism, ageism, sexism, classism, and ableism resulting in healthcare disparities for Persons with Disabilities (PWD). Early research highlights these disparities, but we do not yet know the full impact of this pandemic on PWD. Over the last 20 years, many medical schools have attempted to develop disability competency trainings, but discrimination and inequities remain, resulting in a pervasive distrust of medicine by the disability community at large. In this commentary, we suggest that disability competency is insufficient because the healthcare disparities experienced by PWD are not simply a matter of individual biases, but structural and systemic factors requiring a culture shift in the healthcare professions. Recognizing that disability is a form of diversity that is experienced alongside other systemic disadvantages like social class, race, age, sex, gender identity, and geographic location, we explore the transformative potential of disability conscious medical education, training, and practice that draws on insights from intersectional disability justice activism. Disability conscious medicine is a novel approach, which improves upon competency programs by utilizing disability studies and the principles of disability justice to guide us in the critique of norms, traditions, and institutions to more fully promote the respect, beneficence, and justice that patients deserve.

Ensuring the Reproductive Rights of Women with Intellectual Disability

BACKGROUND

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

METHODS

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

RESULT

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

CONCLUSIONS

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

Health disparities among breast cancer patients with/without disabilities in Germany

BACKGROUND

Prevalence and incidence of cancer are increasing in people with disability. Nevertheless, little is known about cancer care for people with disabilities.

OBJECTIVE

The goal of this study was to examine the quality of care of breast cancer patients with pre-existing disabilities regarding diagnosis and type of breast surgery in Germany.

METHODS

Within the framework of quality assurance of breast cancer centers, a patient survey was conducted by the University of Cologne. Survey data from 4626 newly-diagnosed breast cancer patients treated in 86 hospitals were analyzed using multilevel modeling. Data about socio-demographics, disability specific data as well as data about diagnosis and type of surgery were collected.

RESULTS

About 13% (n = 568) of the patients indicated they had a pre-existing disability prior to their breast cancer. The majority of patients with disabilities have physical impairments (PI n = 385; 68.0%) or sensory impairments (SI n = 131; 23.1%). 16.7% of the patients indicated they have a mental illness (MI n = 95; 16.7%) and 8 patients indicated to have an intellectual disability (ID n = 8; 1.4%). Patients with PI and SI are less often diagnosed for cancer through a mammography screening (OR PI = 0.70; p < 0.05; OR SI = 0.58; p < 0.05). Patients with PI are less likely to receive breast conserving treatment (OR = 0.58; p < 0.00) and more likely to have a mastectomy without reconstruction (OR = 1.96; p < 0.00) compared to patients without disabilities.

CONCLUSION

Our data show that there are differences in the frequency of cancer diagnosis through mammography screening and in surgery applied between breast cancer patients with and without disabilities.

Barriers to, and facilitators of, access to cancer services and experiences of cancer care for adults with a physical disability: A mixed methods systematic review

BACKGROUND

Cancer services need to be inclusive and accessible to everybody, including people with disabilities. However, there is evidence suggesting that people with disabilities experience poorer access to cancer services, compared to people without disabilities.

OBJECTIVES

To investigate the barriers and facilitators of access to cancer services for people with physical disabilities and their experiences of cancer care.

METHODS

A mixed-method systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach. We used the Mixed Methods Appraisal Tool (MMAT -Version 11) to assess the quality of the included studies. We employed thematic synthesis to bring together data from across both qualitative and quantitative studies and we assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach.

RESULTS

Seven quantitative studies and 10 qualitative studies (across 18 publications) were included. The findings highlighted a dearth of research on the experiences of men with disabilities. Furthermore, only one study explored experiences of cancer treatment, with all other studies focusing on cancer screening. Five synthesised findings were identified that reflected barriers and facilitators, highlighting both what makes access to services difficult and what are the strategies that could improve it.

CONCLUSIONS

Knowing what works for people with disabilities can enable the delivery of appropriate services. The findings of this review suggest that the mere existence of services does not guarantee their usability. Services need to be relevant, flexible, and accessible, and offered in a respectful manner.

WeCanConnect: Development of a Community-Informed mHealth Tool for People with Disabilities and Cancer

BACKGROUND

Cancer care for people with disabilities (PWD) is rife with uncertainty and obstacles. Not only do PWD have to contend with cancer and treatment-related sequelae, but also its impact on disabling conditions and functional capacity, as well as a health care system lacking accessibility and disability competence. Peer support can address important needs for emotional and informational support. mHealth tools for smart phones, tablets, or laptops hold promise to deliver such support in an accessible and scalable manner. This concept is unexplored for use among PWD with cancer.

OBJECTIVES

To describe a community-based participatory study that 1) identifies consumer-reported support needs and priorities among PWD and cancer and 2) integrates consumer perspectives into the design of an mHealth cancer support tool to address these needs and priorities.

METHODS

Part 1 is a thematic analysis of semistructured, qualitative interviews with a purposive sample of experts in health and cancer care for PWD (n = 7) and a convenience sample of cancer survivors with preexisting disabilities (n = 9). In part 2, results were integrated to develop an mHealth peer support tool to addresses identified needs.

RESULTS

Themes included 1) barriers across the cancer care continuum, 2) strengths within the disability community, and 3) recommendations for mHealth and peer support. Based on the qualitative findings, we designed a mHealth tool for peer support and information sharing among PWD with cancer.

CONCLUSION

Consumer-informed mHealth tools hold great potential to leverage strengths in the disability community to address emotional and informational needs created by a lack of disability competence across the cancer care continuum.

Development of Patient-Centered Disability Status Questions to Address Equity in Care

BACKGROUND

Patients with disabilities experience disparities in accessing and receiving high-quality health care services as compared to patients without disabilities. To address the disparities, health care organizations need to identify which of their patients have disabilities to track quality of care and provide appropriate health care accommodations. To date, no evidence-based sets of disability questions exist that serve these purposes. A study was conducted to identify patient-centered disability questions for health care organizations to determine which patients require health care accommodations and to track the quality of care experienced by patients with disabilities.

METHODS

In the first of three phases, a focus group with patients and caregivers (N = 54) and interviews with providers (N = 15) were conducted to explore the disability questions that they believed were important. In the second phase, nationally recognized experts (N = 17) participated in a modified Delphi panel to develop a set of disability questions. The third phase entailed cognitive interviews (N = 46) with patients with and without disabilities to refine the wording of the disability questions identified through the previous rounds.

RESULTS

Through the three phases, six essential questions and three additional recommended questions were identified. Questions addressed hearing, visual, motor, cognitive, communication, and learning disabilities, and the ability to conduct activities of daily living. An overall question for disabilities not included in the previous questions was also identified.

CONCLUSION

Through a rigorous, three-stage process that engaged multiple stakeholders, patient-centered disability questions were identified for health care organizations to use to identify disparities within their organizations and accommodations that address these disparities.

Barriers to accessing cancer services for adults with physical disabilities in England and Wales: an interview-based study

OBJECTIVES

The aim of this study was to explore the barriers to accessing cancer services faced by adults with pre-existing physical disabilities.

DESIGN

Cross-sectional, exploratory qualitative study. Data were collected by semistructured interviews and analysed thematically.

SETTING

Participants were recruited through statutory and third sector organisations in England and Wales between October 2017 and October 2018.

PARTICIPANTS

18 people with a diagnosis of cancer and a pre-existing physical disability.

RESULTS

The findings illustrate that people with physical disabilities in England and Wales face a variety of barriers to accessing cancer services. The overall theme that emerged was that participants experienced a lack of attitudinal and institutional preparation both from healthcare professionals and healthcare facilities. This overall theme is illustrated through three subthemes: lack of acknowledgment of disability, unseeing disability and physical inaccessibility.

CONCLUSIONS

As the population ages and increasing numbers of people live with cancer and disability, it is important to develop knowledge to respond to the needs of this population. The mere existence of services does not guarantee their usability. Services need to be relevant, flexible, and accessible and offered in a respectful manner. It is important that healthcare professionals work towards inclusive healthcare provision, enabling the utilisation of services by all. Necessary steps to be taken include better communication between the various professionals and across the different teams involved in patients' care, raising awareness of how physical disability can affect or interact with cancer-related treatment and creating more accessible physical environments.

Sex/gender disparities in health outcomes of individuals with long-term disabling conditions

BACKGROUND

Women with disabling conditions experience health disparities relative to nondisabled women, but few studies have compared women and men with disabling conditions.

OBJECTIVES

To investigate gender differences in physical functioning and emotional health among individuals with long-term disabling conditions, that is, neuromuscular disease, multiple sclerosis, postpolio syndrome, or spinal cord injury.

METHOD

From a mailed survey of 1,862 adults with long-term disabling conditions, we used the 12-item Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning to assess physical limitations in activities and Patient Health Questionnaire-9 (PHQ-9) for emotional health and severity of secondary conditions (rated 0-10). Least square means models were used to estimate marginal mean PHQ-9 scores and severity of secondary conditions by age and sex adjusted for diagnosis. Generalized linear models were performed to determine the association between sex/gender and PROMIS physical function t score, controlling for age and diagnostic group with potential Age × Sex interaction.

RESULTS

Women reported more fatigue than men (5.48 ± .08 vs. 5.13 ± .11, p = .01) and more pain (3.99 ± .08 vs. 3.67 ± .11, p = .03). Women aged 45-54 had higher average PHQ-9 scores than men aged 45-54 (M = 8.05, SE = .33 vs. M = 6.35, SE = .42, p < .007) adjusted for diagnosis. Younger women had higher physical functioning than younger men while older women had lower physical functioning than older men adjusted for diagnostic group (p = .0003 for the interaction term).

CONCLUSION

Middle-aged and older women with long-term disabling conditions experience considerable health disparities in physical functioning and emotional health compared with middle-aged and older men with similar conditions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Accessibility of Medical Diagnostic Equipment for Patients With Disability: Observations From Physicians

OBJECTIVE

To explore attitudes and practices of physicians relating to accessible medical diagnostic equipment in serving patients with mobility disability.

DESIGN

Open-ended individual telephone interviews, which reached data saturation. Interview recordings were transcribed verbatim for qualitative conventional content analysis.

SETTING

Massachusetts, the United States, October 2017-January 2018.

PARTICIPANTS

Practicing physicians from 5 clinical specialties (N=20).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Common themes concerning physical accessibility.

RESULTS

Mean ± SD time in practice was 27.5±12.5 years; 14 practices had height-adjustable examination tables; and 7 had wheelchair-accessible weight scales. The analysis identified 6 broad themes: height-adjustable examination tables have advantages; height-adjustable examination tables have drawbacks; transferring patients onto examination tables is challenging; rationale for examining patients in their wheelchairs; perceptions of wheelchair-accessible weight scales; and barriers and facilitators to improving physical accessibility. Major barriers identified by participants included costs of equipment, limited space, and inadequate payment for extra time required to care for persons with disability. Even physicians with accessible examination tables sometimes examined patients seated in their wheelchairs.

CONCLUSIONS

Even if physicians have accessible equipment, they do not always use it in examining patients with disability. Future efforts will need to consider ways to eliminate these access barriers in clinical practice. Given small sample size, results are not generalizable to physicians nationwide and globally.

Utilisation of mammography by women with mobility impairment in the UK: secondary analysis of cross-sectional data

OBJECTIVES

Research has shown that people with physical impairment report lower utilisation of preventive services. The aim of this study was to examine whether women with mobility impairments have lower odds of using mammography compared with women with no such impairment, and explore the factors that are associated with lower utilisation.

SAMPLE AND DESIGN

We performed secondary analysis, using logistic regressions, of deidentified cross-sectional data from the European Health Interview Survey, Wave 2. The sample included 9491 women from across the UK, 2697 of whom had mobility impairment. The survey method involved face-to-face and telephone interviews.

OUTCOME MEASURES

Self-report of the last time a mammogram was undertaken.

RESULTS

Adjusting for various demographic and socioeconomic variables, women with mobility impairment had 1.3 times (95% CI 0.70 to 0.92) lower odds of having a mammogram than women without mobility impairment. Concerning women with mobility impairment, married women had more than twice the odds of having a mammogram than women that had never been married (OR 2.07, 95% CI 1.49 to 2.88). Women in Scotland had 1.5 times (95% CI 1.08 to 2.10) higher odds of undertaking the test than women in England. Women with upper secondary education had 1.4 times (95% CI 1.10 to 1.67) higher odds of undergoing the test than women with primary or lower secondary education. Also, women from higher quintiles (third and fifth quintiles) had higher odds of using mammography, with the women in the fifth quintile having 1.5 times (95% CI 1.02 to 2.15) higher odds than women from the first quintile.

CONCLUSIONS

In order to achieve equitable access to mammography for all women, it is important to acknowledge the barriers that impede women with mobility impairment from using the service. These barriers can refer to structural disadvantage, such as lower income and employment rate, transportation barriers, or previous negative experiences, among others.

Disparities in Cervical Cancer Screening Among Women With Disabilities: A National Database Study in South Korea

Purpose

Using the linked administrative database in Korea, we investigated (1) whether cervical cancer screening participation differed by the presence of varying degrees and types of disability; (2) trends in the cervical cancer screening rate relative to disabilities over time; and (3) factors associated with cervical cancer screening.

Methods

We linked national disability registration data with national cancer screening program data. Age-standardized participation rates were analyzed for each year during the period 2006 to 2015, according to the presence, type, and severity of disabilities. Factors associated with undergoing cervical cancer screening were examined by multivariate logistic regression with the most current data (ie, 2014 to 2015).

Results

The age-adjusted screening rate for cervical cancer screening in women with disabilities increased from 20.8% in 2006% to 42.1% in 2015 (change, +21.3%); however, among women without disabilities, it increased from 21.6% to 53.5% (change: +31.9%) during that time. Disability was associated with a lower screening rate (adjusted odds ratio [aOR], 0.71; 95% CI, 0.71 to 0.72). Screening rates were markedly lower in women with severe disabilities (aOR, 0.42; 95% CI, 0.42 to 0.42) and women with autism (aOR, 0.06; 95% CI 0.03 to 0.11), intellectual disability (aOR, 0.25; 95% CI, 0.25 to 0.26), brain injury (aOR, 0.311; 95% CI, 0.31 to 0.32), ostomy (aOR, 0.36; 95% CI, 0.33 to 0.38), or mental disorder (aOR, 0.43; 95% CI, 0.42 to 0.44).

Conclusion

Despite the availability of free screening, a significant disparity was found in cervical cancer screening participation, especially in women with severe disabilities and those with mental disabilities. The identification of barriers associated with decreased screening rates in women with disabilities has important implications for the design of tailored interventions and health care policies to improve cervical cancer screening and outcomes in this vulnerable population.

A 5-step framework to promote nursing community inclusivity: The example of nurses with disabilities

AIMS AND OBJECTIVES

To provide a five-step conceptual framework to promote community inclusivity among nurses and nursing students, using the example of nursing student with a disability.

BACKGROUND

The value of cultural diversity, including characteristics such as socioeconomic status, ability/disability, sexual affection and ethnicity and/or race, is integrated into bachelor's nursing programmes. Yet, often the focus centres on patient care rather than to fellow nursing students or registered nurses.

DESIGN

Discursive paper describing a five-step health promotion course framework to promote inclusion for students with disabilities into the nursing community.

METHODS

Using the health promotion course platform, this framework demonstrates the integration of important issues such as well-being to those of cultural diversity, inclusivity and feeling belonging to a community, which are essential prerequisites towards achieving cultural competence.

FINDINGS

Health promotion courses provide an optimal platform to teach students about the social environment, well-being and inclusivity, and gives students the opportunity to reflect on the impact of their attitudes and behaviours on social inclusivity in their student community, and later, on their nursing community.

CONCLUSIONS

Using the example of nursing students with disabilities, the five-step framework incorporates the concepts of social well-being, health and community inclusivity. Nursing students belong to a culturally diverse community including individuals with disabilities. A single course on community inclusivity is insufficient; the approach of inclusivity must be woven throughout the nursing curriculum.

RELEVANCE TO CLINICAL PRACTICE

As approximately 15% of the world's population has a disability, nurses must possess an understanding of individuals with a disability as an aspect of cultural diversity. It is the responsibility of programmes to instil in nursing students, the ability to appreciate and work with culturally diverse student and registered nurses. Such goals not only reflect nursing goals, but also strengthen the cohesion and inclusivity of the nursing community.

Breast cancer screening in women with cerebral palsy: Could care delivery be improved?

BACKGROUND

Women with disabilities (WWD) have reported lower mammography rates than the general population, however rates for women with cerebral palsy (CP) have not been specifically studied.

OBJECTIVE

To evaluate mammography rates in women with CP and to identify strengths and barriers with their screening experience.

METHODS

Women with CP 40 years or older (n = 118) participating in a prospective cross-sectional survey were queried regarding screening status, imaging modality, and accommodation needs and availability. Categorical variables were summarized and Chi-square testing used to assess factors contributing to screening compliance. The effect of functional factors on screening was evaluated using logistic regression.

RESULTS

77 women (65.3%) had mammograms within the past two years; 56 (47.5%) were screening mammograms. Severity of fine motor deficits was associated with lack of screening (OR 0.559, p = 0.019). 85 (72.0%) experienced positive staff attitudes. Facilities most often met needs for ramps, elevators, and/or wide doorways (92.9%), exam explanations (84.4%), and accessible parking (82.5%). Needs least often met included accommodations for standing (59.3%) or for difficulties with arm/shoulder positioning (57.1%), and wheelchair-accessible mammogram machines (59.1%).

CONCLUSIONS

The screening compliance rate for women with CP is low, although the 2-year mammography rate is comparable to that reported for WWD and the general female U.S.

POPULATION

Women were usually offered respectful care. Adequate physical accommodations during the procedure were reported less often than overall facility environmental accommodations. These findings demonstrate the need for improved screening rates in women with CP, and highlight areas for improving their screening experience.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Labor, delivery, and anesthesia experiences of women with physical disability

BACKGROUND

Although many women with physical disabilities report poor quality reproductive health care, little research has addressed labor, delivery, and anesthesia experiences of these women. This study was conducted to explore these experiences in women with significant mobility disabilities.

METHODS

A qualitative descriptive study was conducted with 22 women from the United States who had delivered newborns within the prior 10 years. All had significant mobility disabilities. Two-hour, in-depth telephone interviews were conducted using a semistructured, open-ended interview protocol, which addressed many topics, including labor, delivery, and anesthesia experiences. We recruited most participants through social networks, interviewing women from 17 states. Conventional content analysis, facilitated by NVivo software, was used to identify major themes.

RESULTS

The mean age of women was 34.8 ± 5.3 years. Most women were white, college educated, and used wheeled mobility aids. Four key themes emerged from participants' narratives of laboring and giving birth with a disability. These included women's preferences for type of delivery, clinicians and some women expected no labor pain, fears prompting active advocacy, and positive experiences. As participants discussed their experiences with anesthesia, four additional themes were identified: importance of consultation with the anesthesia team, decisions about epidural/spinal vs general anesthesia, failed epidural with repeated efforts, and fear of injury related to anesthesia.

CONCLUSIONS

The responses of women in this study suggest that there is need to make intrapartum care better for women with physical disabilities and to improve their experiences with labor, birth, and obstetric anesthesia care.

The Guide to Community Preventive Services and Disability Inclusion

INTRODUCTION

Approximately 40 million people in the U.S. identify as having a serious disability, and people with disabilities experience many health disparities compared with the general population. The Guide to Community Preventive Services (The Community Guide) identifies evidence-based programs and policies recommended by the Community Preventive Services Task Force (Task Force) to promote health and prevent disease. The Community Guide was assessed to answer the questions: are Community Guide public health intervention recommendations applicable to people with disabilities, and are adaptations required?

METHODS

An assessment of 91 recommendations from The Community Guide was conducted for 15 health topics by qualitative analysis involving three data approaches: an integrative literature review (years 1980-2011), key informant interviews, and focus group discussion during 2011.

RESULTS

Twenty-six recommended interventions would not need any adaptation to be of benefit to people with disabilities. Forty-one recommended interventions could benefit from adaptations in communication and technology; 33 could benefit from training adaptations; 31 from physical accessibility adaptations; and 16 could benefit from other adaptations, such as written policy changes and creation of peer support networks. Thirty-eight recommended interventions could benefit from one or more adaptations to enhance disability inclusion.

CONCLUSIONS

As public health and healthcare systems implement Task Force recommendations, identifying and addressing barriers to full participation for people with disabilities is important so that interventions reach the entire population. With appropriate adaptations, implementation of recommendations from The Community Guide could be successfully expanded to address the needs of people with disabilities.

Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey

BACKGROUND

Previous qualitative studies suggest that women with physical disabilities face disability-specific barriers and challenges related to prenatal care accessibility and quality. This study aims to examine the pregnancy and prenatal care experiences and needs of U.S. mothers with physical disabilities and their perceptions of their interactions with their maternity care clinicians.

MATERIALS AND METHODS

We conducted the first survey of maternity care access and experiences of women with physical disabilities from 37 states. The survey was disseminated in partnership with disability community agencies and via social media and targeted U.S. women with a range of physical disabilities who had given birth in the past 10 years. The survey included questions regarding prenatal care quality and childbirth and labor experiences.

RESULTS

A total of 126 women with various physical disability types from 37 states completed the survey. Almost half of the respondents (53.2%) reported that their physical disability was a big factor in their selection of a maternity care provider and 40.3% of women reported that their prenatal care provider knew little or nothing about the impact of their physical disability on their pregnancy. Controlling for maternal demographic characteristics and use of mobility equipment, women who reported that their prenatal care provider lacked knowledge of disability and those who felt they were not given adequate information were more likely to report unmet needs for prenatal care.

CONCLUSIONS

The findings from this study suggest the need for training and education for clinicians regarding the prenatal care needs of women with physical disabilities.

The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries

BACKGROUND

Studies suggest nurse practitioners are heavily represented among primary care providers for vulnerable Medicare beneficiaries.

PURPOSE

The purpose of this study was to compare quality indicators among three groups of vulnerable beneficiaries managed by MDs and nurse practitioners (NPs).

METHODS

The methods include retrospective cohort design examining 2012 and 2013 Medicare claims for three beneficiary groups: (a) initially qualified for the program due to disability, (b) dually eligible for Medicare and Medicaid, and (c) both disabled and dually eligible. Validated quality indicators in four domains were analyzed.

DISCUSSION

Gaps in outcomes suggest better performance for primary care nurse practitioners (PCNPs) in preventable hospitalizations and adverse outcomes. Outcome gaps suggesting better performance for primary care physicians in chronic disease management were diminished for beneficiaries who were both disabled and dually eligible suggesting improved performance for PCNPs within this subpopulation.

CONCLUSION

These findings add new evidence indicating the quality of primary care provided to vulnerable Medicare beneficiaries by PCNPs is generally consistent with clinical guidelines and the less intensive use of costly health care services.