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

Background

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

Methods

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

Results

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

Conclusion

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

The Association of Cervical Cancer Screening With Disability Type Among U.S. Women (Aged 25-64 Years)

INTRODUCTION

Despite a gradual decline in cervical cancer mortality because of greater use of screening, including Pap and human papillomavirus (HPV) tests, disparities in screening among adult women by disability type have not been examined. This study aims to assess the odds of cervical cancer screening using HPV tests by disability type among U.S. women aged 25-64 years.

METHODS

This study was analyzed in 2022 using pooled data from 2018 and the 2020 Behavioral Risk Factor and Surveillance System. The analytic sample included 189,795 women aged 25-64 years. Disability was defined as having any sensory disability, cognitive disability, physical disability, ≥2 disabilities, or no disability adapted from a standardized questionnaire. Descriptive analyses were used to estimate the proportion of HPV tests on the basis of 2020 American Cancer Society guidelines, which recommend testing within five years for all women aged 25-65 years. Multivariable analyses were conducted to estimate AORs of cervical cancer screening by disability type.

RESULTS

Overall, 53.8% of women met recommended 2020 American Cancer Society guidelines for cervical cancer screening using HPV tests. The proportion of HPV tests was higher in women with a cognitive disability (55.9%) and lower in those with sensory (49.7%), physical (48.2%), and ≥2 disabilities (47.8%) than in those without disabilities (54.8%). In adjusted analyses, women with any disability (AOR=0.95, 95% CI=0.88, 0.97), physical disability (AOR=0.96, 95% CI=0.80, 0.98), and ≥2 disabilities (AOR=0.88, 95% CI=0.78, 0.97) had lower odds of receiving cervical cancer screening with HPV testing than women without disabilities.

CONCLUSIONS

Disparities in screening with HPV tests among women with physical and ≥2 disabilities suggest the need for a targeted approach to improve prevention screening awareness, access, and availability in this population.

Have Almost Fifty Years Of Disability Civil Rights Laws Achieved Equitable Care?

For almost fifty years, federal civil rights laws such as Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act of 2008, and Section 1557 and other provisions of the 2010 Patient Protection and Affordable Care Act have prohibited discrimination against Americans with disabilities, including in health care. Despite these laws, disabled Americans continue to experience disparities in health and health care, from preventive care to home and community-based services. In its 2022 Health Equity Framework for People with Disabilities, the National Council on Disability highlighted some of these disparities and recommended remedies. To explore these concerns, this article examines disability inequities and potential solutions within six areas. It concludes by recommending the ratification of the 2006 United Nations Convention on the Rights of Persons with Disabilities to reinvigorate US efforts to maximize the health and dignity of disabled Americans and support their full participation in the community.

Cervical Cancer Screening Among Patients with Physical Disability

Background:

Pap smear has a central role in cervical cancer screening. Previous studies have found that female patients with disabilities are less likely to receive a Pap smear as recommended by guidelines. The aim of our study was to examine the association between physical disability and Pap smear receipt in Israel.

Methods:

This cross-sectional study was conducted using the electronic medical records of the second largest health care maintenance organization in Israel. All female patients during 2012–2017 aged 25–65 were identified. The exposure variable was physical disability, and the outcome variable was Pap smear receipt. We used logistic regression to control for covariates.

Results:

A total of 391,259 patients were eligible for this study, 6,720 (1.7%) with physical disability. 56.7% of patients with disabilities had received Pap smear compared to 63.3% of patients without disabilities, odds ratio (OR) 0.76, 95% confidence interval [CI] 0.72–0.80. When adjusting to sociodemographic and clinical covariates, patients with disabilities were less likely to receive Pap smear, adjusted OR 0.83, 95% CI 0.79–0.88. For all patients, older age, lower socioeconomic status, religious minorities, cardiovascular disease, type-2 diabetes mellitus, hypertension, smoking, and obesity were associated with lower odds of receipt of Pap smear. A history of nongynecologic oncologic disease was associated with increased odds of Pap smear receipt.

Conclusion:

Our study highlights the disparities between patients with and without physical disability with regard to screening for cervical cancer by receipt of Pap smear. Creating an appropriate practice with adequate access to patients with disability should be a focus for health care providers and policy makers.

Comparison of colorectal cancer screening between people with and without disability: a nationwide matched cohort study

Background

The World Health Organization has recognized that people with disability are among the most marginalized in the world. This study’s objective was to investigate the differences in the probability of colorectal cancer (CRC) screening with faecal immunochemical testing (FIT) between people with disability and without disability in Taiwan.

Methods

The study participants included people with and without disability from the Disability Registration Database (2012) and the National Health Insurance Research Database (2009–2012). The study included 50- to 69-year-olds with and without disability who were screened from 2011 to 2012 and were alive in 2012. There were 16 categories of disability. After propensity score matching (PSM) between the two groups, conditional logistic regression analysis with control variables was used to investigate the odds ratio (OR) that people with or without disability would undergo CRC screening.

Results

The percentage of people with disability receiving CRC screening was 21.84%, and the highest rate of those receiving CRC screening (38.72%) was found in people with intractable epilepsy, whose OR was 1.47 times that of people with moving functional limitation (95% confidence interval (CI) = 1.17–1.85). The results showed that the probability of CRC screening in people with disability was lower than that in people without disability (OR = 0.88, 95%CI = 0.87–0.89). The probability of receiving CRC screening differed between people with different categories of disability.

Conclusions

Although the probability of CRC screening in the four categories of disability was higher than that in the general population, overall, people with disability were less likely than people without disability to undergo CRC screening. Health inequalities still exist under National Health Insurance in Taiwan.

The Disability and Wellbeing Monitoring Framework: data, data gaps, and policy implications

OBJECTIVE

To develop a framework and indicators to monitor inequalities in health and the social determinants of health for Australians with disability.

METHODS

The development drew on existing frameworks and input from people with lived experience of disability.

RESULTS

The Disability and Wellbeing Monitoring Framework has 19 domains. Australian national data are available for 73% of the 128 indicators in these domains. Data gaps and limitations include the absence of national data and the absence of disability identifiers in some data sources.

CONCLUSIONS

The framework will be used to report baseline data for people with and without disability and to monitor inequalities over time in Australia. It will also be used to locate policy priorities and focus efforts to address data gaps. Implications for public health: Inequality between people with and without disability in relation to health and the social determinants of health is a public health issue that warrants greater attention than it has received to date. The framework provides a robust, evidence-informed tool to address the health inequalities of people with disability, inform the development of effective policy and practice responses, and monitor change over time.

Breast and cervical cancer screening for women with physical disabilities: A qualitative study of experiences and barriers

AIM

To determine the experiences of women with physical disabilities regarding the barriers to their participation in breast and cervical cancer screening.

DESIGN

Qualitative descriptive study.

METHOD

Sixteen women who use wheelchairs were recruited. Data were collected via semi-structured face-to-face interviews between January - March 2017. Interviews were transcribed and data were analysed thematically.

RESULTS

Three main themes were uncovered: (a) Personal factors; such as lack of knowledge, fear and embarrassment, feeling anxious about the examination process and dependency on others; (b) Environmental and structural factors; and (c) expectations and suggestions of women with disabilities to enable their participation in screening.

CONCLUSION

The participation rate of women with physical disabilities in screening is low. The participation of women with disabilities in breast and cervical cancer screening may increase if physical barriers to accessing healthcare services are removed, appropriate and less time-consuming examination conditions are met, and healthcare personnel are informed about the needs of persons with disabilities.

IMPACT

Knowing the barriers for women with physical disabilities to participate in cancer screening can help health professionals develop new procedures to increase their participation to cancer screening. Women with physical disabilities encountered various barriers such as; lack of knowledge, fear and embarrassment, feeling anxious about the examination process and dependency on others, access to the healthcare services, environmental, physical limitations, and inadequate knowledge of healthcare professional about their disability. This study will guide healthcare professionals in developing strategies to increase the participation of women with physical disabilities in screening.

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).

Sociodemographic characteristics and health-related factors affecting the use of Pap smear screening among women with mental disabilities in Taiwan

This study examined the use of the Pap cervical cancer screening test among women with mental disabilities in Taiwan and analyzed factors related thereto. Data were obtained from three national databases in Taiwan: the 2008 database of physically and mentally disabled persons from the Ministry of the Interior, 2007-2008 Pap smear test data from the Health Promotion Administration, and claims data from the National Health Insurance Research Database. The study subjects included 49,642 Taiwanese women aged ≥30 years with mental disabilities. Besides descriptive and bivariate analyses, logistic regression analysis was also performed to examine factors affecting Pap smear use. In 2007-2008, Taiwanese women with mental disabilities had a Pap screening rate of 11.05%. Age, income, education, marital status, catastrophic illness/injury, relevant chronic illnesses, and severity of disability were identified as factors affecting their Pap smear use. Age and severity of disability were negatively correlated with Pap screening, with the odds of screening being 0.37 times as high in ≥70-year-olds as in 30-39-year-olds and 0.49 times as high for very severe disability as for mild disability. Income was positively correlated with Pap screening. Being married (OR=2.55) or divorced or widowed (OR=2.40) relative to being unmarried, and having a catastrophic illness/injury (OR=1.13), cancer (OR=1.47), or diabetes (OR=1.25), were associated with greater odds of screening. In Taiwan, women with mental disabilities receive Pap smears at a far lower rate than women in general.

Cervical cancer screening: a prospective cohort study of the effects of historical patient compliance and a population-based informatics prompted reminder on screening rates

AIMS AND OBJECTIVES

The aim of this study was to assess the impact of historical screening compliance with the effectiveness of patient reminder letters on cervical cancer screening rates.

METHOD

Using population-based informatics systems, women with no cervical cancer screening in the prior 3 years were identified in two primary care clinics, Mayo Family Clinic Northeast (NE; n = 1613) and Northwest (NW; n = 1088). Patients were divided into two compliance groups: overdue/unknown screening status at study start or previously compliant. The NE Clinic sent reminder letters over a 6 months window to patients eligible for screening at the study start or during the study that were also identified as employees/dependents (E/D). There were 795 intervention (NE Clinic E/D patients) and 1906 control subjects. Using an intent-to-treat analysis, differences in screening rates were assessed.

RESULTS

A higher unadjusted screening rate was observed for the E/D group than the non-E/D group at both sites (32.7 versus 18.2% at NW, P < 0.001; 39.0 versus 14.7% at NE, P < 0.001). For the historically compliant group, unadjusted screening rates were higher for those who received letters (E/D subjects at NE) versus those who did not (E/D subjects at NW; 56.1 versus 44.5%, P = 0.01). No difference was observed between E/D subjects at NE (received letters) and NW (no letters) for the overdue/unknown group (27.4 versus 25.9%, P = 0.62). There was no difference in screening rates for non-E/D subjects at NE versus at NW (none of whom received letters) for both the compliant (24.2 versus 30.6%, P = 0.18) and the overdue/unknown groups (11.9 versus 13.0%, P = 0.59). Multivariate logistic regression models showed a significant overall effect of E/D status (P = 0.006), compliance group (P < 0.001), and the interaction between clinic site and E/D status (P = 0.04).

CONCLUSION

Among insured women, reminder letters appear to improve cervical cancer screening rates for those with a history of screening compliance. Reminder letters appear insufficient to motivate women if screening is overdue. Further investigation of the cohort of women overdue for screening is needed to develop interventions to successfully target this group.

Knowledge and attitudes regarding cervical cancer screening among women with physical disabilities living in the community

The study aims to explore knowledge and attitudes regarding cervical cancer screening and to examine its determinants based on the perspectives of Taiwanese women with physical disabilities living in the community. A cross-sectional survey was employed in the study, and we recruited 498 women aged more than 15 years who were officially registered as having physical disabilities in Taipei County, Taiwan, in March 2009. A mail-out structured questionnaire designed to collect data concerning the participants' demographics, reported use, health experience and perception (understanding and attitudes) of cervical cancer screening among women with physical disabilities. We used a scoring system (range 0-10) to categorize the study subjects' awareness of screening (low vs. high). The results showed that 77.3% of subjects reported a low level of awareness (score < [double bond] 7), whereas 22.7% were in the high awareness level group (score > 7). The logistic regression model revealed that married women (OR = 3.30, 95%CI = 1.25-8.71), those with a higher educational level (OR = 2.88, 95%CI=1.51-5.53), and those with a high familiarity with Pap smear resources (OR = 5.31, 95%CI = 2.82-9.98) had a significantly higher perception level of cervical cancer screening among women with physical disabilities. This study highlights the necessity of increasing the knowledge and awareness of cervical cancer screening and reducing the barriers to cervical cancer screening experienced by women with disabilities.

The use of Pap smear and its influencing factors among women with disabilities in Taiwan

Cervical cancer is a prevalent cancer among Taiwanese women, and can be effectively cured if diagnosed early. Therefore, cervical cancer is worthy of preventive health screening. Due to physical and psychological barriers, patients with disability may be unable to express their physical complaints accurately, thus reducing their access to health care; some may not even receive proper preventive health care or medical treatment. This study investigates the utilization of Pap smear among women with disability in Taiwan and its influencing factors. With women aged 30 and over as the study subjects, this retrospective cohort study is conducted based on the database of the Ministry of the Interior, Taiwan, 2008, combined with information gathered between 2006 and 2008 regarding preventive health care and health insurance medical claims data from the Bureau f Health Promotion and the National Health Research Institutes, respectively. The frequency of Pap smears and the percentage differences of each variable are examined using the 2× tests to check for statistical significance. Finally, logistic regression analysis is used to examine the factors influencing the use of Pap smears. The results revealed that among disabled women aged 30 and over, the use of Pap smears was 7.71% in 2008. Disabled women with the following characteristics had lower use levels regarding Pap smears: greater age, residing in areas of higher urbanization, lower income, lower education levels, unmarried, not diagnosed with cancer, diagnosed with diabetes, and with severe disability levels. Disabled women with hearing impairments or mental retardation were possessed of the highest and lowest probabilities of using Pap smear, respectively. The recommendations of this study include: (1) provide physicians with a varying pricing scheme and incentives for Pap smear based on the type or severity of disability; (2) proactively encourage gynecologist and obstetricians to conduct regular and convenient Pap smear on disabled women; and (3) target disabled women in low usage groups, and improve their knowledge of Pap smear.

Comparison of the perforation rate for acute appendicitis between nationals and migrants in Taiwan, 1996-2001

OBJECTIVE

Immigrant populations have grown rapidly in recent years in many countries. Immigrant-related healthcare issues have thus become more and more important. The aim of this study was to assess any possible disparity in access to care between migrants and nationals under the national health insurance (NHI) system in Taiwan.

STUDY DESIGN

Retrospective population-based observational study.

METHODS

National population-based data on patients aged ≥20 years in Taiwan under the NHI programme were studied. The frequency of use and expenditure on ambulatory care, inpatient care and emergency care were analysed separately. Ruptured appendicitis was also analysed as an outcome indicator for access to care. Logistic regression and two-part models were applied.

RESULTS

Overall, migrants had a lower rate of healthcare utilization than nationals, and this gap remained consistent from 1996 to 2001. However, using ruptured appendicitis as the outcome indicator, no significant overall difference in access to care was found between nationals and migrants under the NHI programme in Taiwan (odds ratio 1.01, 95% confidence interval 0.93∼1.11).

CONCLUSION

This study found that although migrants had a lower rate of healthcare utilization than nationals, their rate of adverse outcome was similar to nationals when they faced an acute, non-selective emergency condition such as appendicitis. The findings suggest that the use of more dimensional indicators may help to avoid possible misleading inferences on the variation in access to health care in Taiwan.