Breast (female), colorectal, and lung cancer survival in people with intellectual or developmental disabilities: A population-based retrospective cohort study

OBJECTIVES

Cancer is a leading cause of death among people living with intellectual or developmental disabilities (IDD). There is little empirical evidence documenting survival or comparing outcomes to those without IDD. This study investigated the association between IDD and cancer survival among adults with breast (female), colorectal, or lung cancer.

METHODS

A population-based retrospective cohort study was conducted in Ontario, Canada, with routinely collected data. Patients with breast, colorectal, or lung cancer were included (2007‒2019). IDD status before cancer was determined using an established administrative data algorithm. The outcomes of interest included death from any cause and death from cancer. Cox proportional hazards models and competing events analyses using multivariable cause-specific hazards regression were completed. Analyses were stratified by cancer type. Interactions with age, sex, and stage at diagnosis, as well as sensitivity analyses, were completed.

RESULTS

The final cohorts included 123,695 breast, 98,809 colorectal, and 116,232 lung cancer patients. Individuals with IDD experienced significantly worse survival than those without IDD. The adjusted hazard ratios of all-cause death were 2.74 (95% CI 2.41‒3.12), 2.42 (95% CI 2.18‒2.68), and 1.49 (95% CI 1.34‒1.66) times higher for breast, colorectal, and lung cancer patients with IDD relative to those without. These findings were consistent for cancer-specific deaths. With few exceptions, worse survival for people with IDD persisted regardless of stage at diagnosis.

CONCLUSION

People with IDD experienced worse cancer survival than those without IDD. Identifying and intervening on the factors and structures responsible for survival disparities is imperative.

Stage IV breast, colorectal, and lung cancer at diagnosis in adults living with intellectual or developmental disabilities: A population-based cross-sectional study

BACKGROUND

Cancer is a leading cause of death among people living with intellectual or developmental disabilities (IDD). Although studies have documented lower cancer screening rates, there is limited epidemiological evidence quantifying potential diagnostic delays. This study explores the risk of metastatic cancer stage for people with IDD compared to those without IDD among breast (female), colorectal, and lung cancer patients in Canada.

METHODS

Separate population-based cross-sectional studies were conducted in Ontario and Manitoba by linking routinely collected data. Breast (female), colorectal, and lung cancer patients were included (Manitoba: 2004-2017; Ontario: 2007-2019). IDD status was identified using established administrative algorithms. Modified Poisson regression with robust error variance models estimated associations between IDD status and the likelihood of being diagnosed with metastatic cancer. Adjusted relative risks were pooled between provinces using random-effects meta-analyses. Potential effect modification was considered.

RESULTS

The final cohorts included 115,456, 89,815, and 101,811 breast (female), colorectal, and lung cancer patients, respectively. Breast (female) and colorectal cancer patients with IDD were 1.60 and 1.44 times more likely to have metastatic cancer (stage IV) at diagnosis compared to those without IDD (relative risk [RR], 1.60; 95% confidence interval [CI], 1.16-2.20; RR, 1.44; 95% CI, 1.24-1.67). This increased risk was not observed in lung cancer. Significant effect modification was not observed.

CONCLUSIONS

People with IDD were more likely to have stage IV breast and colorectal cancer identified at diagnosis compared to those without IDD. Identifying factors and processes contributing to stage disparities such as lower screening rates and developing strategies to address diagnostic delays is critical.

Exploring the complex cognitive, affective and behavioural processes of individuals with intellectual disabilities in financially abusive situations

BACKGROUND

Understanding the cognitive processes of individuals with intellectual disabilities in financially abusive situations is critical to develop effective prevention strategies.

AIMS

This study investigated how persons with intellectual disabilities define and analyse financially abusive situations, and how they would feel and act in situations that they consider abusive.

MATERIALS AND METHODS

Twelve participants with intellectual disabilities participated in a semi-structured interview where they were asked to reflect on three vignettes illustrating financial abuse. We analysed the interviews using thematic analysis.

FINDINGS

The findings revealed that individuals with intellectual disabilities considered the type of relationship between the victims and the perpetrators, the behavioural patterns of the perpetrators, and their own experiences when interpreting the situation. Furthermore, they discussed their emotional and behavioural reactions to the vignettes.

CONCLUSION

This study has important implications in supporting the autonomy and decision-making rights of persons with intellectual disabilities regarding their finances and developing effective preventions against financial abuse among this population.

Investigating inequalities in cancer staging and survival for adults with intellectual or developmental disabilities and cancer: A population-based study in Manitoba, Canada

BACKGROUND

Cancer is a leading cause of death among adults living with intellectual or developmental disabilities (IDD). However, few epidemiological studies exist worldwide quantifying inequalities in cancer stage at diagnosis and survival for people with IDD relative to those without IDD.

METHODS

A population-based, retrospective cohort study was conducted using provincial health and social administrative data in Manitoba, Canada. Adults (≥18 years) with a cancer diagnosis between 2004 and 2017 were included. Lifetime IDD was identified before the cancer diagnosis using an established algorithm. Modified Poisson regression with robust error variance was used to estimate the association between IDD status and metastatic cancer at diagnosis. Multivariable Cox proportional hazards analyses were used to the effect of IDD on overall survival following the cancer diagnosis.

RESULTS

The staging and prognosis cohorts included 62,886 (n = 473 with IDD) and 74,143 (n = 592 with IDD) cancer patients, respectively. People living with IDD were significantly more likely to be diagnosed with metastatic cancer and die following their cancer diagnosis compared to those without IDD (RR=1.20; 95 % CI 1.05-1.38; HR= 1.53; 95 % CI 1.38-1.71). Significant heterogeneity by sex was identified for cancer survival (p = 0.005).

DISCUSSION

People with IDD had more advanced cancer stage at diagnosis and worse survival relative to those without IDD. Identifying and developing strategies to address the factors responsible that contribute to these disparities is required for improving patient-centred cancer care for adults with IDD.

Including people with intellectual and other cognitive disabilities in research and evaluation teams: A scoping review of the empirical knowledge base

We conducted a rapid scoping review of empirical studies to identify how persons with intellectual and other cognitive disabilities have been engaged as active members of research and evaluation teams. We conducted a literature search using a systematic method that accessed peer reviewed studies in relevant library databases and all major evaluation journals. The search resulted in 6,624 potential articles, of which 32 met the inclusion criteria for this study. The findings address three categories of interest: 1) methodological underpinnings and practical justifications for using inclusive approaches, 2) different inclusion processes, and 3) reflections by researchers with and without intellectual and other cognitive disabilities. Findings provide conceptual and practical insights for researchers and evaluators when designing inclusive methods involving persons with intellectual and other cognitive disabilities. Gaps in inclusive research and evaluation are discussed and suggestions for future research are proposed.

Accessibility of child protection investigations during pandemic: A qualitative analysis of court proceedings

BACKGROUND

Qualitative research using published court records to examine contextual factors that contribute to child protection decisions in cases involving parents with intellectual disabilities is limited, particularly during the COVID-19 pandemic.

METHOD

The present study conducted qualitative content analysis on 10 published Ontario court cases to study child protection decision-making between 2019 and 2021.

RESULTS

The findings corroborated previous literature with nine out of 10 cases resulting in loss of child custody. Four major themes emerged from content analysis: (1) Impact of COVID-19 pandemic on cases; (2) Systemic barriers to accessibility; (3) Attitudes and bias toward parents with intellectual disabilities; and (4) Ultimate reliance on intellectual disability status for final custody decision.

CONCLUSIONS

Conducting content analysis on published court cases is useful in learning about accessibility barriers for parents with intellectual disabilities and may help in understanding the impact of the COVID-19 pandemic on the child protection system.

Measuring social isolation in older adults: A rapid review informing evidence-based research and practice

OBJECTIVES

Older adults account for 18.5% of the Canadian population and are at risk of experiencing social isolation, compared to other age groups. Researchers define social isolation as a lack of social contact and relationships, but many social isolation measures do not reflect this definition. The aim of our study is to review the existing measures of social isolation with older adults to recommend evidence-based measures to researchers and practitioners.

METHODS

We conducted a rapid review on PsycInfo and PsycTests. We included articles that were written in English or French, were peer-reviewed, used an older adult sample, included a self-report social isolation measure, and reported psychometric information.

RESULTS

Following exclusion of ineligible articles, 12 measures were available for analysis. We further categorized the measures into: five most recommended measures, five measures that require further research, and two measures not recommended for use with older adults.

CONCLUSIONS

We observed a range of measures with varying suitability to be used with older adults; some were empirically driven but did not have strong psychometric properties, or vice-versa.

CLINICAL IMPLICATIONS

It is imperative that interventions aimed to address social isolation in older adults use evidence-based measures to assess progress and report treatment effectiveness.

Service Use Patterns by Children With Down Syndrome in a Canadian Region

Children with Down syndrome require services from different sectors over time to optimize health and development, however, there is little information on longitudinal, cross-sector service use. Parents of children with Down syndrome attending a Canadian children's hospital participated in semistructured interviews covering life-time multiple sector service use. Five key service patterns were identified: (1) primary care physicians playing a circumscribed role; (2) a marked shift in public habilitative service receipt from development agencies in the preschool years to exclusive school delivery after school entry; (3) families obtaining private services to address gaps from public sector services; (4) a prominent role for parents to identify additional services; and (5) service variability as a function of timing and severity of medical comorbidity.

Caregivers' Role in Cybersecurity for Aging Information Technology Users with Intellectual Disability

Information technology (IT) users with intellectual disability (ID) are likely to experience online privacy violations without adequate support from their caregivers. Given that aging users face additional challenges when using IT than their younger counterparts, the goal of this exploratory study is to investigate caregivers' strategies and barriers for helping to protect the privacy of aging IT users with ID. Six caregivers (four paid caregivers, two family members) of aging users with ID completed a series of six focus groups about their experiences assisting the people they support with using IT, including their strategies and barriers for helping to protect these users' privacy. Participants were also asked about their own attitudes and experiences related to online privacy and information security. Based on our inductive thematic analysis of the qualitative data, participants used three main strategies to help protect the privacy of aging users with ID: (1) restricting access to personal information, (2) limiting disclosure of personal details, and (3) providing just-in-time instruction and feedback. We also identified four key barriers to privacy protection: (1) limited awareness and knowledge about information security, (2) balancing privacy and autonomy, (3) maintaining professional boundaries, and (4) residential care services' policies. Inclusive and transdisciplinary research is needed to address the elevated privacy and security risks for aging IT users with ID, and provide caregivers with training on how to support this population to use IT safely. Technology developers should create solutions to decrease aging users with ID's dependence on caregivers for privacy protection.

Cross-sector service use patterns among children with developmental disabilities in a district in Canada

BACKGROUND

There is a lack of information about cross-sector service use by children with developmental disabilities despite their need for services from multiple sectors.

METHODS

Responses to service use questions from a parent-completed survey on school-aged children who attended clinics specific for those with developmental disabilities at a Canadian children's hospital were examined.

RESULTS

School meetings were the most common of three professional meeting types attended in the last 12 months (64.9%) for the sample of 205 children. Recreational services were the most common of five service types received in the same time period (79.0%). Using ordinal logistic regression models, a higher number of behavioural difficulties was the only variable consistently related to indices of more meeting types (school, physician, other) attended and more service types received (recreation, respite, etc.).

CONCLUSIONS

The service relationship with behavioural problems, and not socio-demographic variables, is consistent with a needs-based oriented delivery system.

Protecting the privacy of technology users who have cognitive disabilities: Identifying areas for improvement and targets for change

Introduction

Information Technologies (IT) may serve assistive roles that facilitate the interaction of people living with cognitive disabilities (CD) within their environments. However, there are some notable concerns related to privacy threats associated with the use of IT. The purpose of this study was to examine how assistive technology developers may best adapt over time to develop their IT to be resilient against threats to privacy. We therefore focused on the following areas: (1) developers' knowledge and practices related to privacy protection; (2) challenges when applying recommended practices, and; (3) preferred channels to acquire knowledge.

Method

We conducted semi-structured interviews with ten technology developers who are members of the AGE-WELL network undertaking research and development of assistive technologies to be used by people who have cognitive disabilities. We used an inductive-deductive method for the analysis of qualitative data to examine participant responses and generate themes related to the study goals.

Results

Principal themes that emerged from the data include practices specific to populations with CD, challenges to obtaining consent to use of information, and preferred channels to acquire knowledge.

Conclusion

We identify areas of focus for developing a knowledge mobilization strategy to improve relevant policies and practices.

Antipsychotic initiation among adults with intellectual and developmental disabilities in Ontario: a population-based cohort study

OBJECTIVES

To describe factors associated with initiating antipsychotics and patterns of persistence to antipsychotic therapy in a large cohort of adults with intellectual and developmental disabilities.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Adults with intellectual and developmental disabilities (IDD) in Ontario.

OUTCOME MEASURES

We used multivariable logistic regression to investigate patient characteristics associated with antipsychotic initiation. Patient characteristics studied included sociodemographic characteristics, measures of clinical comorbidity and health service use.

RESULTS

Among 39 244 individuals eligible for this study, 6924 (17.6%) initiated an antipsychotic over the accrual window, of whom 1863 (26.9%) had no psychiatric diagnosis in the prior 2 years. A number of factors were significantly associated with antipsychotic initiation, including male gender, residence in a group home, prior use of benzodiazepines, antidepressants or cognitive enhancers, a recent emergency department visit or mental health hospitalisation and a visit to a psychiatrist or family physician in the prior 90 days. In a secondary analysis, the association between antipsychotic initiation and age, prior diagnosis of diabetes or myocardial infarction and polypharmacy differed slightly on the basis of whether an individual had a previously diagnosed psychiatric disorder.

CONCLUSIONS

Factors associated with the initiation of an antipsychotic differ according to the presence of a psychiatric diagnosis. Given the long duration of antipsychotic use in this population, future research is needed to understand the appropriateness of antipsychotic initiation among adults with IDD and the safety implications of long-term use of these products.

Reproductive Health in Women with Intellectual and Developmental Disabilities in Ontario: Implications for Policy and Practice

Reproductive healthcare needs of women with intellectual and developmental disabilities (IDD) have received little attention. Using health and social services administrative data in Ontario, Canada, we comprehensively documented the reproductive health of women with IDD, including their fertility rates, pregnancy outcomes and reproductive health after pregnancy. Our findings showed high rates of adverse health outcomes for these women and their babies, supporting the development of reproductive healthcare programs tailored to their unique needs.

A family systems perspective on supporting self-determination in young adults with intellectual and developmental disabilities

BACKGROUND

This study explored the way families support self-determination in young adults with intellectual and developmental disabilities (IDD) during life transitions.

METHOD

Qualitative case studies were conducted with two Canadian families who participated in semi-structured interviews and ethnographic observations every quarter for one year. Analyses were informed by family systems theory and self-determination theory.

FINDINGS

Families considered the needs and preferences of the young adults with IDD, suggesting individualized approaches for balancing independence and protection. Families set short-term and long-term goals for increased independence, scaffolded the learning of new skills and collaborated on important choices. Collaboration occurred to the extent that all family members perceived agency in planning and implementing transitions.

CONCLUSIONS

Families supported the young adults with IDD in their psychological needs for competence, relatedness and autonomy, which allowed them to experience self-determination. Findings have implications for supporting self-determination and transition planning in the family system.

What adults with intellectual and developmental disabilities say they need to access annual health examinations: System navigation support and person-centred care

OBJECTIVE

To gain an understanding of the support needs of adults with intellectual and developmental disabilities (IDD) when scheduling, traveling to, and attending annual health examinations (AHEs).

DESIGN

Qualitative study that is part of a large population-level intervention aiming to increase uptake of AHEs among adults with IDD.

SETTING

Ontario.

PARTICIPANTS

A total of 8 men and 5 women with IDD took part in semistructured interviews about their personal experiences related to AHEs.

METHODS

Thematic analysis was used to examine experiences relating to scheduling, traveling to, and attending AHEs.

MAIN FINDINGS

Support emerged as the overarching theme. Support included assistance navigating the health care system (assistance scheduling AHEs, reminders to book AHEs, financial assistance, transportation) and person-centred care (respect of privacy and autonomy, communication style, kindness, compassion, rapport with physician, health advocacy, and collaboration). Barriers to this support were also identified (lack of rapport, perception of unfriendliness, perception that the physician is too busy to tend to needs, and perception that the physician did not want to perform AHEs).

CONCLUSION

For adults with IDD, system navigation support and person-centred care were central to accessing AHEs. In collaboration with informal caregivers, physicians have an important role in reducing barriers to patients accessing this valuable preventive care opportunity. Physicians can fulfil some of the needs disclosed by adults with IDD related to attending AHEs by offering support for scheduling appointments, by linking patients with IDD to resources that facilitate appointment attendance, and by increasing consultation duration.

"I Didn't Need People's Negative Thoughts": Women With Intellectual and Developmental Disabilities Reporting Attitudes Toward Their Pregnancy

Background

Since the illegalization of involuntary sterilization of persons with intellectual and developmental disabilities, there has been an increase in childbearing in this population. However, women with intellectual and developmental disabilities continue to experience prejudicial attitudes toward their pregnancies.

Objective

To analyze the experiences of women with intellectual and developmental disabilities regarding their perceptions of support persons’ attitudes toward their pregnancies.

Methods

Three case studies derived from grounded theory research exploring perinatal social support received by women with intellectual and developmental disabilities. Using inductive content analysis, we further analyzed the perceptions of women with intellectual and developmental disabilities regarding support persons’ attitudes toward their pregnancies. Findings: The nature of interactions with support persons and women’s characteristics, such as help-seeking behaviors, disability, mental illness, and age, influenced support persons’ attitudes toward childbearing. Women preferred support from caregivers perceived as nonjudgmental and tended to restrict contact with persons perceived as prejudicial. However, some attitudes improved following positive interactions with the women. The relationship between support persons’ attitudes and the women’s help-seeking behaviors is thus complex.

Conclusions

Education of families and medical and social services practitioners and opportunities for positive contact should be further explored. Caseworkers of women with intellectual and developmental disabilities may have invaluable roles in facilitating positive interactions between women with intellectual and developmental disabilities and caregivers.

The Association Between Continuity of Primary Care and Preventive Cancer Screening in Women With Intellectual Disability

Women with intellectual disability have low screening rates for breast and cervical cancer. This population-based cohort study examined the association between the level of primary care continuity and breast and cervical cancer screening rates in women with intellectual disability. Data were obtained from the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Community and Social Services. Neither high (adjusted OR [aOR] = 1.06; 95% CI: 0.88-1.29) nor moderate (aOR = 1.11; 95% CI: 0.91-1.36) continuity of care were associated with mammography screening. Women were less likely to receive a Pap test with high (aOR = 0.70; 95% CI: 0.64-0.77) and moderate (aOR = 0.81, 95% CI 0.74-0.89) versus low continuity of care. Improving continuity of care may not be sufficient for increasing preventive screening rates.

Are we making a difference in primary care for adults with intellectual and developmental disabilities?

OBJECTIVES

To examine the impact of the dissemination of guidelines to physicians and of a population-level health communication intervention on the percentage of adults with intellectual and developmental disabilities (IDD) receiving preventive care through primary care.

METHODS

Noninstitutionalized adults with IDD in the province of Ontario, Canada, aged 40 to 64 years were matched to Ontarians without such disabilities each fiscal year (FY) from 2003 to 2016. Health administrative data were used to create a composite measure of receipt of recommended preventive primary care. Age-adjusted rates were used to assess trends, and average two-year rate ratios (RRs) and confidence intervals (CIs) were used to evaluate the effectiveness of the interventions.

RESULTS

The number of adults with IDD identified ranged from 20 030 in FY 2003 to 28 080 in FY 2016. The percentage of adults with IDD receiving recommended preventive primary care ranged from 43.4% in 2003 to 55.7% in 2015. Men with IDD had a 53.7% increase across the 13 years, while women with IDD only had a 30.9% increase. When evaluating the impact of the interventions, men with IDD were 4% more likely (RR: 1.04; 95% CI: 1.02-1.05) to receive recommended primary care in FY 2015 and FY 2016 as compared to FY 2009 and FY 2010; in contrast, women with IDD were 5% less likely (RR: 0.95; 95% CI: 0.93-0.98). A comparable drop was observed among women without IDD.

CONCLUSIONS

Nearly 45% of adults with IDD in Ontario still do not receive recommended preventive care through primary care. Long-term impacts of the interventions introduced in the province may still occur over time, so ongoing monitoring is warranted. Special attention should be given to the preventive care needs of women with IDD.

Contraceptive Provision to Postpartum Women With Intellectual and Developmental Disabilities: A Population-Based Cohort Study

CONTEXT

Women with intellectual and developmental disabilities who experience pregnancy, like all women, require postpartum care that supports their contraceptive knowledge and decision making. Yet, little is known about the postpartum contraceptive care these women receive, or how it compares with care given to other women.

METHODS

A population-based study using linked health and social services administrative data examined provision of postpartum contraceptive care to women who had a live birth in Ontario, Canada, in 2002-2014 and were beneficiaries of Ontario's publicly funded drug plan. Modified Poisson regression was used to compare care between 1,181 women with and 36,259 women without intellectual and developmental disabilities. Outcomes were provision of any nonbarrier contraceptive in the year following the birth and type of method provided.

RESULTS

In the first year postpartum, women with intellectual and developmental disabilities were provided with contraceptives at a higher rate than were other women (relative risk 1.3); the difference was significant for both nonsurgical and surgical methods (1.2 and 1.8, respectively). The higher rate of nonsurgical contraceptive provision was explained by provision of injectables (1.9); there were no differences for pills or IUDs.

CONCLUSION

Nonbarrier contraceptives may be the most appropriate methods for some women with intellectual and developmental disabilities. However, future research should investigate why women with such disabilities are more likely than others to receive injectable contraceptives, which have possible negative side effects, and surgical contraception, which is irreversible. Research also should investigate how these women perceive their participation in contraceptive decision making.

Antipsychotic Use With and Without Comorbid Psychiatric Diagnosis Among Adults with Intellectual and Developmental Disabilities

OBJECTIVE

Antipsychotic use is controversial in the management of adults with intellectual and developmental disabilities (IDD) because of inconclusive evidence for efficacy in the absence of a comorbid psychiatric condition, and substantial concerns about adverse effects. We aimed to characterize antipsychotic use among Ontario adults with IDD and compare profiles of those with and without a documented psychiatric diagnosis.

METHOD

This population-based study included 51,881 adults with IDD under 65 y as of April 2010 receiving provincial drug benefits in Ontario who were followed until March 2016 to identify those dispensed at least one antipsychotic medication. Profiles of those with and without a psychiatric diagnosis were compared.

RESULTS

Overall, 39.2% of adults ( n = 20,316) were dispensed an antipsychotic medication, which increased to 56.4% in a subcohort residing in group homes. Almost one-third (28.91%) of people prescribed an antipsychotic medication did not have a documented psychiatric diagnosis. Those without a psychiatric diagnosis differed considerably from those with a diagnosis. In particular, those without a psychiatric diagnosis were older, less likely to have used antidepressants or benzodiazepines in the year before, and less likely to have used ambulatory and acute care.

CONCLUSIONS

Antipsychotic use in IDD is common, and occurs frequently without a psychiatric diagnosis. Attention toward how antipsychotics are prescribed and monitored for people with IDD in Canada is warranted to ensure appropriate prescribing.

Ethical Issues Related to IT Adoption by Elderly Persons with Cognitive Impairments

Ethical issues arise when the risks and benefits of technology use are unclear or controversial, or their access inequitable. This paper presents a preliminary framework for understanding ethical issues related to IT development and adoption by elderly persons with cognitive impairments and their caregivers. The development of the framework relied on a hybrid qualitative approach that draws on several data sources: 1) systematic literature review, 2) focus groups with IT users, and 3) a reflexive researcher-learning diary.Preliminary findings were synthesized into a coherent model that views IT adoption as the outcome of complex interactions between different factors: 1) Personal factors that include the cognitive abilities of the users, as well as their physical and sensory limitations, and 2) Environmental factors that are related to the technology, the caregivers, and the support networks of the user with cognitive impairment. Findings from this project will help better understand, balance, and responsibly address the competing ethical issues at play in technology development and adoption by elderly persons with cognitive impairments and their caregivers.

Perinatal Health of Women with Intellectual and Developmental Disabilities and Comorbid Mental Illness

OBJECTIVE

Women with intellectual and developmental disabilities (IDD) have high rates of adverse perinatal outcomes. However, the perinatal health of women with co-occurring IDD and mental illness (dual diagnosis) is largely unknown. Our objectives were to 1) describe a cohort of women with dual diagnosis in terms of their social and health characteristics and 2) compare their risks for adverse maternal and neonatal outcomes to those of women with IDD only.

METHOD

We conducted a population-based study using linked Ontario (Canada) health and social services administrative data to identify singleton obstetric deliveries to women with dual diagnosis (n = 2080) and women with IDD only (n = 1852; 2002-2012). Primary maternal outcomes were gestational diabetes, gestational hypertension, preeclampsia/eclampsia, and venous thromboembolism. Primary neonatal outcomes were preterm birth, small for gestational age, and large for gestational age. We also examined several secondary outcomes.

RESULTS

Women with dual diagnosis were more likely than women with IDD only to live in poor neighborhoods and to have prepregnancy health conditions; however, they had more frequent prenatal care. Infants born to women with dual diagnosis had increased risks for preterm birth (adjusted relative risk [aRR] 1.31, 95% confidence interval [CI] 1.08 to 1.59) and neonatal morbidity (aRR 1.35, 95% CI 1.03 to 1.76) compared with infants born to women with IDD only. All other primary and secondary outcomes were nonsignificant.

CONCLUSIONS

Comorbid mental illness contributes little additional risk for adverse perinatal outcomes among women with IDD. Women with dual diagnosis and women with IDD alone require increased surveillance for maternal and neonatal complications.

Inclusion Through Work and Productivity for Persons with Intellectual and Developmental Disabilities

BACKGROUND

Employment provides an important avenue to social inclusion for most adults. A range of productivity options exist for persons with intellectual and developmental disabilities (IDD) who wish to work, each offering unique challenges relative to inclusion.

METHODS

This qualitative study examined the productivity experiences of people with intellectual and developmental disabilities in Ontario, Canada. A purposive sample of 74 individuals with productivity experiences spanning the spectrum of no employment to community-based jobs was selected from a pool of volunteers recruited through a mailed survey. Semi-structured interviews were conducted with individuals and family members. Interview transcripts were subjected to a team-based analysis using grounded theory methods.

RESULTS

Varying needs and interests exist in regard to work. Participants revealed a multitude of factors contributing to inclusion and exclusion through productivity.

CONCLUSIONS

Productivity, whether paid or unpaid, can be an avenue to social inclusion. The experience of inclusion, particularly of belonging, depends on a successfully negotiated congruence between worker attributes and the social features and demands of the work environment.

Pregnancy in Women With Intellectual and Developmental Disabilities

OBJECTIVE

Our objectives were to describe the general fertility rate (GFR) and age-specific fertility rates (ASFRs) of women with intellectual and developmental disabilities (IDD) and the social and health characteristics of those with a singleton live birth, and to compare these to women without IDD.

METHODS

In this population-based retrospective cohort study using linked Ontario health and social services administrative data, we identified 18- to 49-year-old women with IDD (N = 21 181) and without IDD (N = 990 776). The GFR and ASFRs (2009) were calculated for both groups and compared using rate ratios (RR) and 95% confidence intervals (CI). Among women with a singleton live birth (N = 423 with, N = 42 439 without IDD), social and health characteristics were compared using Pearson's Chi square tests.

RESULTS

The GFR in women with IDD (20.3 per 1000) was lower than that in women without IDD (43.4 per 1000) (RR 0.47; 95% CI 0.43 to 0.51). ASFRs in 18- to 24-year-olds were similar in both groups. Among women with a singleton live birth, those with IDD were younger and had higher rates of poverty, epilepsy, obesity, and mental health issues. They also had high rates of medication use during pregnancy.

CONCLUSION

In the largest study of fertility in women with IDD to date, we found that ASFRs are similar in young women with and without IDD. Women with IDD with a singleton live birth experience significant social and health disparities during pregnancy. These findings suggest the need to develop services to support the reproductive health of this vulnerable group.

Social support received by women with intellectual and developmental disabilities during pregnancy and childbirth: An exploratory qualitative study

OBJECTIVE

this study aims to contribute to the development of a conceptual framework that will inform maternity care improvements for expectant mothers with intellectual and developmental disabilities (IDD) by exploring the structure, functions, and perceived quality of social support received by women with IDD during pregnancy and childbirth.

DESIGN/SETTING

using a grounded theory approach, we conducted an exploratory study set in Ontario, Canada in 2015.

PARTICIPANTS

the sample included four adult women with IDD who had given birth in the last five years.

MEASUREMENTS

data were collected using semi-structured interviews.

FINDINGS

the structure of social support received by women with IDD consisted of both formal and informal sources, but few or no friendships. Women with IDD reported high levels of informational and instrumental support and low levels of emotional support and social companionship. However, a high level of available support was not always perceived as beneficial. Emergent core categories suggest that social support is perceived as most effective when three conditions are met: (1) support is accessible, (2) support is provided by individuals expressing positive attitudes towards the pregnancy, and (3) autonomy is valued.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

our study confirms and identifies important gaps in the social support received by expectant mothers with IDD. Women with IDD currently lack accessible informational support, emotional support, and social companionship during pregnancy and childbirth. Additional findings regarding the structure and functions of social support are presented, and a preliminary conceptual framework of effective social support during pregnancy and childbirth, as perceived by women with IDD is also proposed. Findings suggest that increasing support accessibility should be a social and clinical priority; however, maternity care providers should be aware of stigmatizing attitudes and respect the autonomy of pregnant women with IDD as they prepare for motherhood.

Morbidity and mortality of women and men with intellectual and developmental disabilities newly initiating antipsychotic drugs

BACKGROUND

While up to 45% of individuals with intellectual and developmental disabilities (IDD) have a comorbid psychiatric disorder, and antipsychotics are commonly prescribed, gender differences in the safety of antipsychotics have rarely been studied in this population.

AIMS

To compare men and women with IDD on medical outcomes after antipsychotic initiation.

METHOD

Our population-based study in Ontario, Canada, compared 1457 women and 1951 men with IDD newly initiating antipsychotic medication on risk for diabetes mellitus, hypertension, venous thromboembolism, myocardial infarction, stroke and death, with up to 4 years of follow-up.

RESULTS

Women were older and more medically complex at baseline. Women had higher risks for venous thromboembolism (HR 1.72, 95% CI 1.15-2.59) and death (HR 1.46, 95% CI 1.02-2.10) in crude analyses; but only thromboembolism risk was greater for women after covariate adjustment (aHR 1.58, 95% CI 1.05-2.38).

CONCLUSIONS

Gender should be considered in decision-making around antipsychotic medications for individuals with IDD.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Contextual factors associated with uptake of breast and cervical cancer screening: A systematic review of the literature

Existing research on barriers to breast and cervical cancer screening uptake has focused primarily on socio-demographic characteristics of individuals. However, contextual factors, such as service organization, as well as healthcare providers' training and practices, are more feasibly altered to increase health service use. The objective of the authors in this study was to perform a critical systematic review of the literature to identify contextual factors at the provider- and system-level that were associated with breast and cervical cancer screening uptake. Studies published from 2000 to 2013 were identified through PubMed and PsycInfo. Methodologic quality was assessed, and studies were examined for themes related to provider- and system-level factors associated with screening uptake. Thirteen studies met the inclusion criteria. Findings revealed a positive association between patients' receipt of provider recommendation and uptake of breast and cervical cancer screening. Uptake was also higher among patients of female providers. Facilities with flexible appointment times and reminders had higher mammography and Pap test uptake. Similarly, greater organizational commitment to quality and performance had higher breast and cervical cancer screening rates. Knowledge provided in this review could be used in future research to inform the development of public health policy and clinical programs to improve screening uptake.

Brief report: cervical cancer screening in women with intellectual and developmental disabilities who have had a pregnancy

BACKGROUND

Women with intellectual and developmental disabilities (IDD) have lower cervical cancer screening rates than women without IDD. Key barriers to screening uptake include physician or caregiver assumptions that screening is unnecessary because women with IDD are not sexually active. Our objective was to compare cervical cancer screening rates in women with and without IDD who had had a pregnancy.

METHOD

We conducted a population-based retrospective cohort study using linked Ontario (Canada) health and social services administrative data. We identified 20- to 64-year-old women with (N = 5033) and without (N = 527 437) IDD who had had a pregnancy. We examined the occurrence of cervical cancer screening between April 1, 2007 and March 31, 2010. We compared screening rates in women with and without IDD using logistic regression, controlling for age, region of residence, neighbourhood income quintile and morbidity level.

RESULTS

Women with IDD who had had a pregnancy were more likely than those without IDD to be young, to live in the lowest neighbourhood income quintile, to live in rural areas and to have high or very high morbidity. Even after controlling for these factors, women with IDD were less likely than women without IDD to be screened (67.7% vs. 77.0%; adjusted odds ratio 0.61; 95% confidence interval 0.58-0.65).

CONCLUSIONS

Even among women who have had a pregnancy and are therefore known to have been sexually active, women with IDD face significant disparities in cervical cancer screening. Strategies to promote equitable uptake of cervical cancer screening for women with IDD need to be implemented.

Primary care of adults with developmental disabilities in Ontario

The health status and healthcare of adults with developmental disabilities have not been well-studied in Ontario, due to the absence of population-based data. To address this deficit, the Health Care Access Research and Developmental Disabilities (H-CARDD) program - a provincial partnership of scientists, policymakers and clinicians - has used existing provincial-level administrative data to provide descriptive information on the health of adults with developmental disabilities and the quality of their primary care relative to other adults. H-CARDD's findings have revealed many gaps in the care of adults with developmental disabilities. While primary care providers are critical to achieving needed changes, the broader healthcare context and infrastructure also need to be considered.

Labour and delivery interventions in women with intellectual and developmental disabilities: a population-based cohort study

BACKGROUND

Our objectives were to: (1) examine the occurrence of labour induction, caesarean section, and operative vaginal delivery in women with intellectual and developmental disabilities compared to those without and (2) determine whether pre-pregnancy health conditions and pregnancy complications explain any elevated occurrence of these interventions.

METHODS

We conducted a population-based study using linked Ontario (Canada) administrative data. We identified deliveries to women with (N=3932) and without (N=382,774) intellectual and developmental disabilities (2002-2011). Modified Poisson regression was used to estimate adjusted relative risks (aRR) and 95% CIs for interventions, controlling for sociodemographic characteristics. We used generalised estimating equations to determine whether pre-pregnancy health conditions and pregnancy complications explained any statistically significantly elevated aRRs.

RESULTS

After controlling for socio-demographic characteristics, women with intellectual and developmental disabilities were more likely to have labour inductions (aRR, 1.13; 95% CI 1.06 to 1.20) and caesarean sections (aRR, 1.09; 95% CI 1.03 to 1.16) but not operative vaginal deliveries, compared to the referent group. Pre-pregnancy health conditions explained 12.9% of their elevated aRR for labour induction. Pre-pregnancy health conditions and maternal complications explained 27.8% and 13.3%, respectively, of their elevated aRR for caesarean section.

CONCLUSIONS

Women with intellectual and developmental disabilities are slightly more likely to have labour inductions and caesarean sections than women without intellectual and developmental disabilities. The elevated occurrence of these interventions is not fully explained by their pre-pregnancy health conditions or pregnancy complications. Non-medical issues should be evaluated for their influence on the timing of labour and delivery in this population.

Uptake of colorectal cancer screening among Ontarians with intellectual and developmental disabilities

Under-screening for cancer may contribute to a greater disease burden in individuals with intellectual and developmental disabilities (IDD) as their life expectancy increases. In 2008, the province of Ontario launched Canada’s first population-based colorectal cancer screening program. Our objectives were to compare the proportions of Ontarians with and without IDD who have undergone colorectal cancer screening and to examine factors associated with screening uptake among Ontarians with IDD. Records for Ontario residents 50–64 years of age were linked across various administrative health and social services datasets to identify individuals with IDD and to select a random sample of the age-equivalent Ontario population without IDD as a comparison group. Logistic regression models were fit to examine the odds of screening uptake among individuals with IDD while controlling for age, sex, urban or rural residence, neighbourhood income quintile, expected use of health care resources, and being enrolled with or seeing a physician in a patient enrolment model (any of several primary care practice models designed to improve patient access and quality of care in Ontario), and to examine the association between these variables and colorectal cancer screening in the IDD population. The odds of having had a fecal occult blood test in the previous two years and being up-to-date with colorectal tests were 32% and 46% lower, respectively, for Ontarians with IDD compared to those without IDD. Being older, female, having a greater expected use of health care resources, and being enrolled with or seeing a physician in a primary care patient enrolment model were all significantly associated with higher odds of having been screened for colorectal cancer in the IDD population. These findings underscore the need for targeted interventions aimed at making colorectal cancer screening more equitable.

Lessons learned from our elders: how to study polypharmacy in populations with intellectual and developmental disabilities

Polypharmacy is the concurrent use of multiple medications, including both psychotropic and non-psychotropic drugs. Although it may sometimes be clinically indicated, polypharmacy can have a number of negative consequences, including medication nonadherence, adverse drug reactions, and undesirable drug-drug interactions. The objective of this paper was to gain a better understanding of how to study polypharmacy among people with intellectual and developmental disabilities (IDD). To do this, we reviewed literature on polypharmacy among the elderly and people with IDD to inform future research approaches and methods on polypharmacy in people with IDD. Results identified significant variability in methods used to study polypharmacy, including definitions of polypharmacy, samples studied, analytic strategies, and variables included in the analyses. Four valuable methodological lessons to strengthen future polypharmacy research in individuals with IDD emerged. These included the use of consistent definitions of polypharmacy, the implementation of population-based sampling strategies, the development of clinical guidelines, and the importance of studying associated variables.

Are cervical and breast cancer screening programmes equitable? The case of women with intellectual and developmental disabilities

BACKGROUND

Effective cancer screening must be available for all eligible individuals without discrimination. Lower rates of cervical and breast cancer screening have been reported in certain groups compared with women from the general population, such as women with intellectual and developmental disabilities (IDD). Research on the factors explaining those observed differences is crucial to determine whether practices are unfair and could be improved. The aim of this population-based study was to describe cancer screening utilisation by women with IDD in Ontario, Canada compared with other women in Ontario. The specific objectives were (1) to estimate the rates of cervical and breast cancer screening among eligible women with IDD in Ontario; (2) to compare the rates of cervical and breast cancer screening between eligible women with and without IDD; and (3) to examine if any observed differences between women with and without IDD persist after factors such as age, socio-economic status, rurality and healthcare utilisation are accounted for.

METHOD

This study draws women with IDD from an entire population, and draws a randomly selected comparison group from the same population. It controls for important confounders in cancer screening within the limitations of the data sources. The study was conducted using health administrative databases and registries in Ontario, Canada. Two cohorts were created: a cohort of all women identified as having an IDD and a cohort consisting of a random sample of 20% of the women without IDD.

RESULTS

The proportion of women with IDD who are not screened for cervical cancer is nearly twice what it is in the women without IDD, and 1.5 times what it is for mammography.

CONCLUSIONS

Findings suggest that women with IDD experience inequities in their access to cancer screening. Public health interventions targeting this population should be implemented.

Using administrative health data to identify individuals with intellectual and developmental disabilities: a comparison of algorithms

BACKGROUND

Individuals with intellectual and developmental disabilities (IDD) experience high rates of physical and mental health problems; yet their health care is often inadequate. Information about their characteristics and health services needs is critical for planning efficient and equitable services. A logical source of such information is administrative health data; however, it can be difficult to identify cases with IDD in these data. The purpose of this study is to evaluate three algorithms for case finding of IDD in health administrative data.

METHODS

The three algorithms were created following existing approaches in the literature which ranged between maximising sensitivity versus balancing sensitivity and specificity. The broad algorithm required only one IDD service contact across all available data and time periods, the intermediate algorithm added the restriction of a minimum of two physician visits while the narrow algorithm added a further restriction that the time period be limited to 2006 onward. The resulting three cohorts were compared according to socio-demographic and clinical characteristics. Comparisons on different subgroups for a hypothetical population of 50,000 individuals with IDD were also carried out: this information may be relevant for planning specialised treatment or support programmes.

RESULTS

The prevalence rates of IDD per 100 were 0.80, 0.52 and 0.18 for the broad, intermediate and narrow algorithms, respectively. Except for 'percentage with psychiatric co-morbidity', the three cohorts had similar characteristics (standardised differences < 0.1). More stringent thresholds increased the percentage of psychiatric co-morbidity and decreased the percentages of women and urban residents in the identified cohorts (standardised differences = 0.12 to 0.46). More concretely, using the narrow algorithm to indirectly estimate the number of individuals with IDD, a practice not uncommon in planning and policy development, classified nearly 7000 more individuals with psychiatric co-morbidities than using the intermediate algorithm.

CONCLUSIONS

The prevalence rate produced by the intermediate algorithm most closely approximated the reported literature rate suggesting the value of imposing a two-physician visit minimum but not restricting the time period covered. While the statistical differences among the algorithms were generally minor, differences in the numbers of individuals in specific population subgroups may be important particularly if they have specific service needs. Health administrative data can be useful for broad-based service planning for individuals with IDD and for population level comparisons around their access and quality of care.

Beyond an autism diagnosis: children's functional independence and parents' unmet needs

High demand has resulted in gaps in autism service provision. Our objective was to explore the association between children's functioning and parents' perceived unmet needs. We conducted a cross-sectional study of 97 families of school-aged children with an autism spectrum disorder. Log binomial regression was used to examine the relative risk for unmet need. Families of children with high functional independence had lower unmet need than families of children with moderate functional independence (RR = 0.81, 95% CI = 0.67-0.99). Those who experienced greater impact of the child's disability had greater unmet need (RR = 1.22, 95% CI = 1.03-1.45). The child's functioning and its impact on the family provide insight into unmet need which may inform service planning.

Reliability of the Supports Intensity Scale (French version)

The definition of intellectual disability, according to the American Association on Intellectual and Developmental Disabilities, includes the assumption that adequate supports should improve a person's functioning. Consequently, support needs have to be assessed to plan services for persons with intellectual disability. The Supports Intensity Scale (SIS; J. R. Thompson et al., 2004) is a standardized instrument for assessing support needs and their intensity. This study was designed to estimate the interrespondent, interinterviewer coefficients of the French version of the SIS. Approximately 40 persons with intellectual disabilities from Quebec, a Canadian province, participated in this study. For each participant, 2 respondents and 2 interviewers were identified and 3 French SIS questionnaires were filled out. Results are presented and discussed compared with those obtained with the original, English-based SIS.