More than just a mammogram: breast cancer screening perspectives of relatives of women with intellectual disability

Optimizing the Patient Experience for Women With Disabilities in the Breast Imaging Clinic

While there are varying opinions on what age to begin and at what interval to perform breast cancer screening, screening mammography is recommended for all women irrespective of disability. Unfortunately, women with disabilities are more likely to present with later-stage disease and higher mortality owing to the barriers for more widespread screening in this population. Women with disabilities may experience challenges accessing breast imaging services, and imaging centers may have suboptimal facilities and staff who are inexperienced in caring for this population. Efforts to increase accessibility by employing universal design to increase ease of access and provide training to improve the patient experience will go far to improve outcomes for patients with disabilities. To date, there exists no comprehensive guidance on how to improve breast cancer screening programs for women with disabilities. The purpose of this paper is to review barriers to screening faced by patients with disabilities, describe strategies to overcome these barriers, and provide guidance for radiologists and referring providers in selecting the best exam for the individual patient.

Cancer risk-factor and symptom awareness among adults with intellectual disabilities, paid and unpaid carers, and healthcare practitioners: a scoping review

BACKGROUND

The physical health of people with intellectual disabilities (ID) has been identified as an area of ongoing concern and priority. Research has increasingly focused on cancer, with studies indicating that people with ID are at an increased risk of cancer and of mortality, compared with the general population. This review aims to systematically identify and synthesise the published academic literature exploring cancer risk-factor and symptom awareness among people with IDs, carers and healthcare professionals.

METHODS

In line with Arksey and O'Malley's (2005) framework for scoping reviews, five incremental stages were followed: (1) identifying research question, (2) identifying relevant studies, (3) study selection, (4) extracting and charting of data, and (5) collating, summarising and reporting results. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-Scr).

RESULTS

The search strategy identified 352 records, 16 records met all eligibility criteria and were included for review. The studies address a range of areas including knowledge and awareness of cancer risk-factors and symptoms and interventions to promote awareness of cancer.

CONCLUSIONS

Cancer risk-factor and symptom awareness is low among adults with ID, paid and unpaid carers and healthcare practitioners (HCPs). Theoretically underpinned, co-designed tools and interventions to improve awareness are lacking. There is uncertainty surrounding how to best support people with ID in raising cancer awareness, even within the professional healthcare environment. There is a predominance of research on breast cancer awareness. Future studies focusing on other cancers are needed to build a complete picture of awareness among adults with IDs, paid and unpaid carers, and HCPs.

Preventive Healthcare Screening Completion Among Midlife and Older Adults With Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) face several barriers to healthcare, making them less likely to receive numerous routine preventive health screenings. Preventive healthcare is a critical aspect to maintaining health and wellness, particularly for people with complex health needs. This study examines individual- and state-level factors associated with mammogram and colonoscopy screenings in mid- and later-life foradults with IDD receiving state services. Multilevel logistic regression models analyzed data from the 2012-2013 and 2018-2019 waves of the National Core Indicators In-Person Survey (NCI-IPS). Results indicated that factors such as age, living situation, transportation access, and community involvement were associated with completion of both preventive screenings. Medicaid expansion was associated with a significantly greater likelihood of completing a colonoscopy screening only among younger persons in the sample (i.e., in their 50s). These findings may have implications for completion of preventive health screenings for adults with IDD.

Disparities in breast cancer among patients with disabilities: care gaps, accessibility, and best practices

Pronounced disparities exist in detecting and treating breast cancer in women with disabilities, leading to cancer detection at advanced stages. This paper provides an overview of disparities for women with disabilities related to breast cancer screening and care, primarily focusing on clinically significant mobility disabilities. Current care gaps include screening barriers related to accessibility and inequitable treatment options, with race and ethnicity, socioeconomic status, geographic location, and disability severity factors mediating the disparities for this population. The reasons for these disparities are myriad and stem from both system-level deficiencies and individual-level clinician bias. Although structural changes are warranted, individual healthcare professionals must also be incorporated into the requisite change. Intersectionality is critical to disparities and inequities and should be central to any discussion of strategies for improving care for people with disabilities, many of whom have intersectional identities. Efforts to reduce screening rate disparities for breast cancer in women with mobility-related disabilities should start with improving accessibility through removing structural barriers, establishing comprehensive accessibility standards, and addressing healthcare professional bias. Future interventional studies are needed to implement and assess the value of programs to improve breast cancer screening rates in women with disabilities. Increasing the representation of women with disabilities in clinical trials may provide another avenue for reducing treatment disparities because these trials often provide breakthrough treatment to women with cancer diagnosed at later stages. Ultimately, attention to the specific needs of patients with disabilities should be improved across the United States to promote inclusive and effective cancer screening and treatment.

An Adapted Cancer Screening Education Program for Native American Women With Intellectual and Developmental Disabilities and Their Caregivers: Protocol for Feasibility and Acceptability Testing

BACKGROUND

Women with intellectual and developmental disabilities (IDD) do not undergo breast and cervical cancer screening at the same rate as women without IDD. IDDs are diagnosed in childhood, are lifelong, and involve difficulties in adaptive behaviors and intellectual functioning. Native American women also experience disparities in breast and cervical cancer screenings. Despite known disparities, women with IDD are often not included in health promotion programs, and there is a need for evidence-based programming for those with intersectional identities, such as Native American women with IDD.

OBJECTIVE

This study aims to assess the feasibility and acceptability of My Health My Choice (MHMC), an adaptation of the Women Be Healthy 2 program. There are 2 parts to the study: adaptation of the Women Be Healthy 2 program and feasibility and acceptability testing of MHMC.

METHODS

Individuals aged over 18 years who identify as Native American females with IDD and their caregivers (N=30 women-caregiver dyads) are eligible for the study. Participants, who are affiliated with 2 partnering sites in Arizona (1 rural and 1 urban), complete pre- and postsurveys assessing knowledge, self-efficacy, and screening expectations before and immediately after completing the program. In addition, all participants complete brief satisfaction surveys after each of the 6 educational sessions. A subsample of Native American women with an IDD (n=12), caregivers (n=12), and community health educators (n=2) who participate in the MHMC program will provide semistructured qualitative input regarding the content, delivery, and cultural relevance of the program.

RESULTS

The adaptation of the culturally responsive MHMC program was completed in August 2021. In November 2021, the project team began recruitment for feasibility and acceptability studies. Feasibility will be examined using participation metrics, and acceptability will be measured using satisfaction measures. Pre- and postmeasures in cancer screening knowledge, self-efficacy, and screening expectations will examine improvements among participants.

CONCLUSIONS

The results of feasibility and acceptability testing of MHMC will guide future implementation studies of the program.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37801.

Access to general practice for people with intellectual disability in Australia: a systematic scoping review

BACKGROUND

People with intellectual disability experience inadequate access to general practice and poorer health outcomes than the general population. While some access barriers have been identified for this population, these studies have often used narrow definitions of access, which may not encompass the multiple dimensions that influence access to general practice. To address this gap, we conducted a scoping review to identify factors impacting access to general practice for people with intellectual disability in Australia, using a holistic framework of access conceptualised by Levesque and colleagues.

METHODS

This scoping review followed Joanna Briggs Institute methodology and was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Medline (Ovid), Scopus, CINAHL, Informit and PsycINFO databases were searched. Screening, full-text review and data extraction were completed by two independent reviewers, with consensus reached at each stage of the study. Data were extracted, coded and synthesised through deductive qualitative analysis - using the five corresponding conceptual dimensions within Levesque and colleagues' theoretical framework of access, which incorporate both supply-side features of health systems and services, and demand-side characteristics of consumers and populations.

RESULTS

The search identified 1364 publications. After duplicate removal, title and abstract screening and full-text review, 44 publications were included. Supply-side factors were more commonly reported than demand-side factors, with the following issues frequently identified as impacting access to general practice: limited general practitioner education about, and/or experience of, people with intellectual disability; communication difficulties; and inadequate continuity of care. Less frequently included were factors such as the health literacy levels, promotion of general practice services and availability of complete medical records.

CONCLUSIONS

This is the first scoping review to assess access barriers for people with intellectual disability using a comprehensive conceptualisation of access. The findings highlight the need for increased efforts to address demand-side dimensions of access to general practice and offer a basis for a balanced portfolio of strategies that can support recent policy initiatives to enhance access to care for people with intellectual disability.

[Barriers to breast cancer screening for people with disabilities]

A significant increase in breast cancer is expected in the coming decades among people with disabilities. However, their participation rate in screening programs is significantly lower than women without disabilities. Our objective was therefore to analyse the barriers to breast cancer screening in people with disabilities based on a recent review of the international literature. The articles analysed were retrieved from the PUBMED database from 2014 to 2020 using the following keywords "breast cancer", "screening" and "disability". A total of 37 studies were included, including 30 original articles and 7 meta-analyses. The main barriers to performing breast cancer screening for women with disabilities were environmental factors such as lack of adapted transportation means or difficult access to medical facilities and mammography. To a lesser extent, the unsupportive views of family caregivers and health care staff about screening were also barriers to screening acceptance by people with disabilities. In general, breast cancer screening is a useful public health measure that reduces the burden of treatment and breast cancer-related mortality. Screening is useful for women over 50 years of age who have a sufficiently long-life expectancy, generally estimated at more than 10 years. Educational measures are needed to reduce the barriers to screening for PH who meet these criteria, their caregivers, and their providers so that they can actively participate in health care, rather than being marginalized because of their disability.

A scoping review documenting cancer outcomes and inequities for adults living with intellectual and/or developmental disabilities

INTRODUCTION

Emerging evidence suggests adults with intellectual and/or developmental disabilities (IDD) may be at risk of inequities in cancer experiences and outcomes. Individuals with IDD may experience multiple barriers that could worsen outcomes and experience. These barriers may be connected to features of IDD or the healthcare system overall. Future research and program planning to support adults with IDD and cancer must be informed by evidence that acknowledges potential disparities, underlying determinants, and knowledge deficits.

OBJECTIVE

We conducted a scoping review to systematically map the evidence describing and comparing cancer-related outcomes along the cancer continuum from risk to mortality for adults with IDD. We identified specific factors observed to influence those outcomes.

METHODS

We followed the expanded Arksey & O'Malley framework for conducting the scoping review. We searched for literature in PubMed and Embase databases. We abstracted cancer-related data, IDD-related data, and data related to physical and social determinants of health.

RESULTS

Of the 2796 studies retrieved, 38 were included for review. Most studies focused on screening outcomes and experiences. Studies reported that adults with IDD experienced inequities at various points along the cancer continuum. Numerous social and physical determinants of health influenced the experiences and outcomes of adults with IDD.

CONCLUSION

This scoping review identified significant gaps in the literature. Of note was the focus on cancer screening and lack of attention to larger systems of oppression that may influence poor cancer experiences and outcomes for adults with IDD. There is strong need to improve both quality and quantity of research in this area.

Barriers and facilitators to primary health care for people with intellectual disabilities and/or autism: an integrative review

Background

Globally, people with intellectual disabilities and/or autism experience health inequalities. Death occurs at a younger age and the prevalence of long-term morbidities is higher than in the general population. Despite this, their primary healthcare access rates are lower than the general population, their health needs are often unmet, and their views and experiences are frequently overlooked in research, policy, and practice.

Aim

To investigate the barriers and facilitators reported by individuals with intellectual disabilities, autism, or both, and/or their carers, to accessing and utilising primary health care for their physical and mental health needs.

Design & setting

An integrative review was undertaken, which used systematic review methodology.

Method

Electronic databases MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane were searched for relevant studies (all languages) using a search strategy. Two researchers independently screened the results and assessed the quality of the studies.

Results

Sixty-three international studies were identified. Six main themes relating to barriers and facilitators emerged from an analysis of these studies. The main themes were: training; knowledge and awareness; communication; fear and embarrassment; involvement in healthcare decision-making; and time. All the themes were underpinned by the need for greater care, dignity, respect, collaborative relationships, and reasonable adjustments. Opposing barriers and facilitators were identified within each of the main themes.

Conclusion

Adolescents and adults with intellectual disabilities and/or autism experience several barriers to accessing and utilising primary health care. The findings highlight the reasonable adjustments and facilitators that can be implemented to ensure that these individuals are not excluded from primary health care.

Barriers and facilitators to mammography among women with intellectual disabilities: a qualitative approach

Although women with intellectual disabilities have the same breast cancer incidence rate as women without intellectual disabilities, they have fewer mammograms and higher mortality rates. Qualitative inquiry was employed to explore barriers and facilitators to mammography among this population. In-depth qualitative interviews were conducted with 30 women with intellectual disabilities and their caregivers in Philadelphia during 2015-2016. Thematic analysis was conducted using inductive and deductive coding. While results provide further evidence for prior research on barriers to mammography among women with intellectual disabilities (e.g. being unprepared, fear of the exam), this study generated novel barriers such as lack of breast ultrasound awareness, sedation failing to work, and lack of mammogram education in adult day programs, and novel facilitators such as extended family support and positive attitudes. Results support the need to address barriers and promote facilitators to improve the breast cancer screening experience among women with intellectual disabilities.

Exploring the impact of mental capacity on breast screening for women with intellectual disabilities

This study explores the impact of mental capacity in relation to breast screening for women with intellectual disabilities in the UK. Participation in breast screening is considerably lower for women with intellectual disabilities compared to the general population. Barriers to screening include poor mobility and behavioural difficulties. There is currently no research which primarily explores the relationship between mental capacity and breast screening for this group of individuals. This paper presents the results of a cross-sectional survey of 131 women with intellectual disabilities supported by eight Social Care Providers within England and Wales. The data were collected between January 2017 and July 2017. The current research explores the decision-making process surrounding breast screening, considering the impact of associated risk factors during this process. Participants completed a specifically created survey addressing the aforementioned issues. The results indicated that women who lacked capacity, were less likely to engage in breast screening. It was also demonstrated that the process outlined in the Mental Capacity Act (MCA; 2005) was not always followed; women were not routinely assessed if there were doubts regarding their decision-making ability around breast screening and best interest meetings (BIM) were not always held if the person lacked capacity. In order to be able to generalise the current findings, further research is needed to gain a broader understanding of how professionals make decisions around breast screening for women with intellectual disabilities in case the individuals are unable to decide this independently.

Racial/Ethnic Disparities in Mammogram Frequency Among Women With Intellectual Disability

Little information exists on the associations between intellectual disability (ID) and race/ethnicity on mammogram frequency. This study collected survey and medical record data to examine this relationship. Results indicated that Hispanic and Black women with ID were more likely than White women with ID to have mammograms every 2 years. Participants who live in a state-funded residence, were aged 50+, and had a mild or moderate level of ID impairment were more likely to undergo mammography compared to participants living with family or alone, were <50, and had severe ID impairment. Further research is needed to understand the mechanisms explaining disparities in mammograms between these racial/ethnic groups.

Long-term condition management in adults with intellectual disability in primary care: a systematic review

BACKGROUND

Adults with intellectual disabilities have higher morbidity and earlier mortality than the general population. Access to primary health care is lower, despite a higher prevalence of many long-term conditions.

AIM

To synthesise the evidence for the management of long-term conditions in adults with intellectual disabilities and identify barriers and facilitators to management in primary care.

DESIGN & SETTING

Mixed-methods systematic review.

METHOD

Seven electronic databases were searched to identify both quantitative and qualitative studies concerning identification and management of long-term conditions in adults with intellectual disability in primary care. Both the screening of titles, abstracts, and full texts, and the quality assessment were carried out in duplicate. Findings were combined in a narrative synthesis.

RESULTS

Fifty-two studies were identified. Adults with intellectual disabilities are less likely than the general population to receive screening and health promotion interventions. Annual health checks may improve screening, identification of health needs, and management of long-term conditions. Health checks have been implemented in various primary care contexts, but the long-term impact on outcomes has not been investigated. Qualitative findings highlighted barriers and facilitators to primary care access, communication, and disease management. Accounts of experiences of adults with intellectual disabilities reveal a dilemma between promoting self-care and ensuring access to services, while avoiding paternalistic care.

CONCLUSION

Adults with intellectual disabilities face numerous barriers to managing long-term conditions. Reasonable adjustments, based on the experience of adults with intellectual disability, in addition to intervention such as health checks, may improve access and management, but longer-term evaluation of their effectiveness is required.

Defining Information Quality Into Health Websites: A Conceptual Framework of Health Website Information Quality for Educated Young Adults

Background

Today’s health care environment encourages health care consumers to take an active role in managing their health. As digital natives, young educated adults do much of their health information management through the Internet and consider it a valid source of health advice. However, the quality of information on health websites is highly variable and dynamic. Little is known about the understandings and perceptions that young educated adults have garnered on the quality of information on health websites used for health care–related purposes.

Objective

To fill this gap, the aim of this study was to develop a conceptual framework of health website information quality with quality dimensions (ie, criteria) and associated quality drivers (ie, attributes) specified in the context of young educated adults’ use of health websites for health care–related purposes. This aim was achieved by (1) identifying information quality dimensions of health websites from the perspective of young educated adults; (2) identifying the importance ratings of these quality dimensions; and (3) constructing a framework of health website information quality with quality dimensions and associated drivers specified in the context of young educated adults’ use of health websites for health care–related purposes.

Methods

The study employed both qualitative and quantitative methods. Methods included semistructured group interviews and an individual quality assessment exercise grounded in visiting various websites and responding to Likert scale questions regarding the importance ratings of information quality dimensions and open-ended questions with specifying website quality drivers. Study participants included junior and senior undergraduate and graduate students in business, allied health, and public health majors. Qualitative, open-coding procedures were used to develop the conceptual framework reflecting the participants’ means of assessing information quality on health websites.

Results

Five dimensions of information quality for health websites were identified: Completeness of information, Understandability of information, Relevance of information, Depth of information, and Accuracy of information. Completeness of information and Understandability of information were rated as the two most important quality dimensions by the study participants. Results indicated that these five information quality dimensions for health websites were supported by the following main driver themes: Content, Design, Links, Consumer resources, Search functionality, Supporting references, User focus, Content FAQ, Open access, Policy statements, and Site performance.

Conclusions

This study contributes to the literature by developing a health website information quality conceptual framework with quality dimensions and associated drivers specified for a young educated adult population. The detailed quality drivers supporting the corresponding quality dimensions provide a rich picture of young educated adults’ perceptions on health website information quality. This framework can be used to guide the development of health websites, as well as the foundation for a means to evaluate health information from existing health websites with young educated adults as the target audience.

Health Care Access for Adults With Intellectual and Developmental Disabilities: A Scoping Review

Adults with intellectual and/or developmental disabilities (IDD) often experience health disparities. To address disparities, Healthy People 2020 includes specific disability and health goals focused on improving health care access. The study's purpose was to review the literature exploring health care access for adults with IDD to identify opportunities for occupational therapy research and practice. A scoping review was completed of articles discussing health care access among adults with IDD in the United States. Thirty-seven articles met the inclusion criteria. Results are framed using the ecology of human performance theory identifying person and environmental issues affecting health care access of adults with IDD. Opportunities exist for occupational therapy to improve participation and health of adults with IDD through engaging in research and practice efforts addressing health care access. Occupational therapy could develop interventions to establish skills and abilities and recommend changes to the health care environment.

A longitudinal assessment of adherence to breast and cervical cancer screening recommendations among women with and without intellectual disability

Each year in the United States, about 4000 deaths are attributed to cervical cancer, and over 40,000 deaths are attributed to breast cancer (U.S. Cancer Statistics Working Group, 2015). The purpose of this study was to identify predictors of full, partial, and no screening for breast and cervical cancer among women with and without intellectual disability (ID) who are within the age group for screening recommended by the U.S. Preventive Service Task Force (USPSTF), while accounting for changes in recommendations over the study period. Women with ID and an age matched comparison group of women without ID were identified using merged South Carolina Medicaid and Medicare files from 2000 to 2010. The sample consisted of 9406 and 16,806 women for mammography screening and Papanicolaou (Pap) testing adherence, respectively. We estimated multinomial logistic regression models and determined that women with ID were significantly less likely than women without ID to be fully adherent compared to no screening with mammography recommendations (adjusted odds ratio [AOR]: 0.63, 95% confidence interval [CI] 0.55-0.72), and Pap testing recommendations (AOR: 0.17, 95% CI 0.16-0.19). For the 70% of women with ID for whom we had residential information, those who lived in a group home, medical facility, or supervised community living setting were more likely to be fully adherent with both preventive services than those living alone or with family members. For both outcomes, women residing in a supervised nonmedical community living setting had the highest odds of full adherence, adjusting for other covariates.