Health of community-dwelling adults with mobility limitations in the United States: prevalent health conditions. Part I

Resilience as a Moderator in the Relationship between Disability Related Stress and Community Participation in Individuals with Multiple Sclerosis

Resilience can be defined as one's ability to maintain or return to relatively stable psychological and physical functioning despite stressful life events and adversity. For people with multiple sclerosis (MS), building resilience has been shown to contribute to enhanced positive rehabilitation and mental health outcomes. However, there is no literature examining the role of resilience influencing the relationship between disability-related stress and community participation in individuals with MS. The present study aimed to examine the moderating role of resilience between disability-related stress and community participation among people with MS. Our findings suggested that the effect of disability-related stress on community participation was influenced by resilience. Interventions targeting resilience may help individuals effectively cope with MS and increase community participation in meaningful life situations.

Mobility Disability and Exercise: Health Outcomes of an Accessible Community-Based Center

Objective

The purpose of this study was to determine how support and guidance provided by trained professionals during a 12-week, community-based transition exercise program, impact health outcomes and continued engagement in physical activity for persons with a mobility disability (PwMD).

Design

A single arm pre-post design was used.

Setting

Accessible community-based health and wellness center.

Participants

The study included 244 PwMD using a mobility device.

Interventions

Participants completed a 12-week transition exercise program provided through an accessible community facility that provided education and support to complete endurance and strength related exercises as well as programming to encourage transition to self-directed engagement in exercise.

Main Outcome Measures

Bodyweight, BMI, pain, perceived exertion, speed, and distance during cardiovascular fitness testing, and strength were measured pre and post exercise program. The number of participants that signed up for a monthly membership after the program was also monitored.

Results

For the total group, average pain reported over previous 30 days decreased significantly (p < 0.01), current daily pain decreased significantly (p < 0.05), perceived exertion at the end of the 9-min endurance test decreased significantly (p < 0.05), and the four upper extremity strength exercises showed large, significant strength gains (p < 0.01) after the program. There was no significant change in bodyweight, BMI, or speed and distance completed during endurance testing. At the completion of the program, 76% of participants enrolled in a monthly membership at the facility with the intentions to continue to exercise regularly.

Conclusions

This study provides evidence that an accessible community-based exercise program, with a transitional component supported by trained professionals, can support the exercise goals of PwMD and improve strength, decrease pain, and may promote regular exercise adoption for PwMD.

Diabetes Self-Management Among Individuals With Diabetes and Physical Disabilities

PURPOSE

The purpose of this study was to examine diabetes self-management behavior among individuals who have diabetes living with and without physical limitations.

METHODS

Pooled cross-sectional data (2011-2016) from the Household Component of the Medical Expenditure Panel Survey was used. Dependent variables were utilization of dilated eye exams, foot checks, at least 1 dental checkup annually, treating diabetes with oral medication, treating diabetes with insulin injections, and engagement in moderate or vigorous physical exercise 5 times per week. The independent variable was diabetes with physical limitations compared with diabetes without physical limitations. The study controlled for predisposing, enabling, and need factors.

RESULTS

Findings indicate that individuals with diabetes and physical limitations were less likely to engage in moderate or vigorous physical exercise 5 times per week, have at least 1 annual dental checkup, and treat their diabetes orally with medication.

CONCLUSIONS

Self-management behavior was poor among individuals with diabetes and physical limitations. Environmental barriers may partially contribute to reasons why individuals with diabetes and physical limitations do not engage in diabetes self-management behaviors that would assist them in mitigating diabetes complications. Other reasons could be the lack of equipment accessibility or adaptability and cultural competence among providers treating/caring for individuals with physical limitations.

Developing Content for the Food Environment Assessment Survey Tool (FEAST): A Systematic Mixed Methods Study with People with Disabilities

Almost 1 in every 8 adults in the U.S. have a physical disability that impairs mobility. This participatory project aimed to identify and describe environmental and personal barriers to healthy eating among people with mobility impairments using a rigorous, structured mixed methodology. Community-dwelling adults with a self-reported mobility impairment (N = 20, M = 40.4 years old, 60% female) participated in nominal group technique focus groups. The Ecologic Model of Obesity grounded stimulus questions asked about barriers to obtaining and preparing healthy food. Participants emphasized common barriers across everyday settings—focusing, for example, on the ability to reach shelved food inside the home, navigating to and inside stores and restaurants, and using delivery services. Home environments often did not afford suitable spaces for food preparation and storage. Participants reported inadequate transportation and numerous additional barriers in many settings to be able to eat healthfully. Participants reported lack of accessible transportation and architectural barriers inside stores, restaurants, and their own homes, highlighting the need for efforts aimed at improving accessibility and usability. Findings support the use of the Ecologic Model of Obesity to guide research and suggest the need for improvement in assessment practices and policies that enhance access to healthy food.

Physical Mobility Impairment and Risk for Cardiovascular Disease

Background: People with disabilities (PWD) often self-report reduced access to preventive health services and poorer health than people without disability. Risk factors for chronic disease are more prevalent in PWD, increasing risk for secondary conditions including cardiovascular disease (CVD). Methods: Logistic regression was used to analyze data from the 2016 Behavioral Risk Factor Surveillance Survey to explore the relationship between disability with mobility impairment and CVD. Results: Difficulty walking and climbing stairs significantly predicted concomitant CVD and diabetes in logistic regression models. Conclusion: Information from this study may be useful in addressing CVD risk for adults with mobility impairments.

Introducing the Adults with Chronic Healthcare Needs (ACHCN) definition and screening instrument: Rationale, supporting evidence and testing

BACKGROUND

Among working age adults in the United States, there is a large, heterogeneous population that requires ongoing and elevated levels of healthcare and related services. At present, there are conflicting approaches to the definition and measurement of this population in health services research.

OBJECTIVE

An expert panel was convened by the National Institutes of Health with the objective of developing a population-level definition of Adults with Chronic Healthcare Needs (ACHCN). In addition, the panel developed a screening instrument and methods for its use in health surveys to identify and stratify the population consistently.

METHODS

The panel employed multiple methods over the course of the project, including scoping literature reviews, quantitative analyses from national data sources and cognitive testing.

RESULTS

The panel defined the ACHCN population as "Adults (age 18-65) with [1] ongoing physical, cognitive, or mental health conditions or difficulties functioning who [2] need health or related support services of a type or amount beyond that needed by adults of the same sex and similar age." The screener collects information on chronic health conditions, functional difficulties, and elevated use of or unmet need for healthcare services.

CONCLUSIONS

Adapted from the Maternal and Child Health Bureau definition that identifies Children with Special Healthcare Needs, aligned with the ACS-6 disability measure, and consistent with the HHS Multiple Chronic Condition Framework, this definition and screener provide the research community with a common denominator for the identification of ACHCN.

Reducing barriers to healthy weight: Planned and responsive adaptations to a lifestyle intervention to serve people with impaired mobility

BACKGROUND

People with impaired mobility (IM) disabilities have a higher prevalence of obesity and obesity-related chronic conditions; however, lifestyle interventions that address the unique needs of people with IM are lacking.

OBJECTIVE

This paper describes an adapted evidence-based lifestyle intervention developed through community-based participatory research (CBPR).

METHODS

Individuals with IM, health professionals, disability group representatives, and researchers formed an advisory board to guide the process of thoroughly adapting the Diabetes Prevention Program Group Lifestyle Balance (DPP GLB) intervention after a successful pilot in people with IM. The process involved two phases: 1) planned adaptations to DPP GLB content and delivery, and 2) responsive adaptations to address issues that emerged during intervention delivery.

RESULTS

Planned adaptations included combining in-person sessions with conference calls, providing arm-based activity trackers, and adding content on adaptive cooking, adaptive physical activity, injury prevention, unique health considerations, self-advocacy, and caregiver support. During the intervention, participants encountered numerous barriers, including health and mental health issues, transportation, caregivers, employment, adjusting to disability, and functional limitations. We addressed barriers with responsive adaptations, such as supporting electronic self-monitoring, offering make up sessions, and adding content and activities on goal setting, problem solving, planning, peer support, reflection, and motivation.

CONCLUSIONS

Given the lack of evidence on lifestyle change in people with disabilities, it is critical to involve the community in intervention planning and respond to real-time barriers as participants engage in change. A randomized controlled trial (RCT) is underway to examine the usability, feasibility, and preliminary effectiveness of the adapted intervention.

At the intersection of chronic disease, disability and health services research: A scoping literature review

BACKGROUND

There is a concerted effort underway to evaluate and reform our nation's approach to the health of people with ongoing or elevated needs for care, particularly persons with chronic conditions and/or disabilities.

OBJECTIVE

This literature review characterizes the current state of knowledge on the measurement of chronic disease and disability in population-based health services research on working age adults (age 18-64).

METHODS

Scoping review methods were used to scan the health services research literature published since the year 2000, including medline, psycINFO and manual searches. The guiding question was: "How are chronic conditions and disability defined and measured in studies of healthcare access, quality, utilization or cost?"

RESULTS

Fifty-five studies met the stated inclusion criteria. Chronic conditions were variously defined by brief lists of conditions, broader criteria-based lists, two or more (multiple) chronic conditions, or other constructs. Disability was generally assessed through ADLs/IADLs, functional limitations, activity limitations or program eligibility. A smaller subset of studies used information from both domains to identify a study population or to stratify it by subgroup.

CONCLUSIONS

There remains a divide in this literature between studies that rely upon diagnostically-oriented measures and studies that instead rely on functional, activity or other constructs of disability to identify the population of interest. This leads to wide ranging differences in population prevalence and outcome estimates. However, there is also a growing effort to develop methods that account for the overlap between chronic disease and disability and to "segment" this heterogeneous population into policy or practice relevant subgroups.

Accelerometer-assessed light-intensity physical activity and mortality among those with mobility limitations

BACKGROUND

Emerging research demonstrates that light-intensity physical activity is favorably associated with numerous health outcomes among the general population, even independent of high-intensity physical activity.

OBJECTIVE

To examine the association between accelerometer-assessed light-intensity physical activity and mortality in a national sample of American adults with mobility limitations.

METHODS

Data from the 2003-2006 National Health and Nutrition Examination Survey were utilized. Participants were followed through 2011. Based on self-report, analyzed participants included those with mobility limitations (N = 1369). Light-intensity physical activity was assessed via waist-mounted accelerometry.

RESULTS

For the sample, 108,010 person-months occurred with an all-cause mortality rate of 2.07 per 1000 person-months. After adjustments, for every 60 min/day increase in light-intensity physical activity, participants with mobility limitations had a 14% reduced risk of all-cause mortality (HR = 0.86; 95% CI: 0.75-0.98; P = 0.03).

CONCLUSION

These findings underscore the importance of promoting light-intensity physical activity to those with mobility limitations.

Association between muscle strengthening physical activities and mortality among American adults with mobility limitations

Compared to aerobic-based physical activity, less research has evaluated the effects of muscle-strengthening physical activity (MSPA) on mortality. Additionally, limited research has evaluated this among adults with mobility limitations, which was this study's purpose. Data from the 2003-2006 NHANES, with follow-up through 2011, were used (analyzed in 2016). MSPA was assessed via self-report, with all-cause, CVD-specific, and cancer-specific mortality assessed as the outcome variables. Analyses were limited to adults with mobility limitations (N=1411), assessed via a validated questionnaire. After adjustments, those meeting MSPA guidelines (vs. not) had a 38% reduced hazard of all-cause death (HR=0.62; 95% CI: 0.41-0.95). Results were similar for CVD-specific mortality (HR=0.46; 95% CI: 0.23-0.97) and cancer-specific mortality (HR=0.27; 95% CI: 0.06-1.20). Meeting MSPA guidelines is associated with reduced all-cause and cause-specific mortality among adults with mobility limitations. This is an encouraging observation as adults with mobility limitations may be unable to engage in sufficient amounts of aerobic-based physical activity. Thus, promotion of MSPA among this population may be of critical importance.

Preventing health problems that disrupt community living: A health promotion needs assessment

People with physical disabilities experience health disparities and poor health outcomes that endanger community living and participation, and sometimes contribute to institutionalization. Centers for Independent Living (CILs) provide vital services to assist consumers with disabilities in achieving and maintaining community living; these organizations could be trusted sources in providing targeted health information. As first steps in devising a Health Promotion Assistance Tool for CIL staff to use with consumers, this project conducted a Needs Assessment study to collect feedback on what information would be most useful. First, researchers interviewed key informants from a sample of CIL staff members to gain input for a survey on the content of the proposed tool. Then, they disseminated the survey by e-mail to 426 CILs listed in a national data bank, and received responses from one or more staff members from 93 CILs. CIL staff reported that their consumers experienced a variety of chronic conditions (e.g., diabetes, high blood pressure) in addition to their physical disability, and that they also experienced secondary health conditions such as chronic pain and depression. CIL staff also reported that they believed their consumers were in need of supports to enable them to engage in preventive health care. We discuss implications for these findings to our further research.

Femoral muscle mass relates to physical frailty components in community-dwelling older people

AIM

To examine the relationship between lower limb muscle (femoral muscle, calf muscle) mass and exercise capacity, and frailty components in community-dwelling older people.

METHODS

Participants included 121 community-dwelling individuals. There were 42 men and 79 women, and the mean age was 77.7 years (range 56-97 years). Appendicular skeletal muscle mass was determined using dual-energy X-ray absorptiometry, and the skeletal muscle index was calculated using the following formula: appendicular skeletal muscle / body height² . Femoral muscle mass and calf muscle mass were determined, respectively, by dividing the femoral bone and tibial bone at the knee joint space. A symptom-limited cardiopulmonary exercise testing was carried out and peak oxygen uptake was measured. Functional exercise performance was evaluated using the handgrip strength measurement, comfortable walking speed, and the Timed Up and Go test. All patients gave written, informed consent before data collection.

RESULTS

Peak oxygen uptake correlated positively with the skeletal muscle index (r = 0.491). Only femoral muscle mass that was corrected with the whole body muscle mass was positively correlated with peak oxygen uptake (r = 0.473), handgrip strength (r = 0.382), comfortable walking speed (r = 0.427), and the Timed Up and Go test (r = 0.379). Calf muscle mass that was corrected with the whole-body muscle mass showed no correlation with exercise capacity and frailty components. A similar tendency was observed in both men and women.

CONCLUSIONS

Femoral muscle mass influenced exercise capacity and physical frail components compared with calf muscle mass. These results suggest the importance of the femoral muscle in physical frailty. Geriatr Gerontol Int 2017; 17: 1636-1641.

Experiences of violence across life course and its effects on mobility among participants in the International Mobility in Aging Study

BACKGROUND

Life course exposure to violence may lead to disability in old age. We examine associations and pathways between life course violence and mobility disability in older participants of the International Mobility in Aging Study (IMIAS).

METHODS

A cross-sectional study using IMIAS 2012 baseline. Men and women aged 65-74 years were recruited at 5 cities (n=1995): Kingston and Saint-Hyacinthe (Canada), Tirana (Albania), Manizales (Colombia) and Natal (Brazil). Mobility was assessed by the Short Physical Performance Battery (SPPB) and by 2 questions on difficulty in walking and climbing stairs. Childhood physical abuse history and the HITS instrument were used to gather information on childhood exposure to violence and violence by intimate partners or family members. Multivariate logistic regression and mediation analysis models were constructed to explore the significance of direct and indirect effects of violence on mobility. Interaction effects of gender on violence and on each of the mediators were tested.

RESULTS

Experiences of physical violence at any point of life were associated with mobility disability (defined as SPPB<8 or limitation in walking/climbing stairs) while psychological violence was not. Chronic conditions, C reactive protein, physical activity and depression mediated the effect of childhood exposure to violence on both mobility outcomes. Chronic conditions and depression were pathways between family and partner violence and both mobility outcomes. Physical activity was a significant pathway linking family violence to mobility. Gender interactions were not significant.

CONCLUSIONS

Our results provide evidence for the detrimental effects of life course exposure to violence on mobility in later life.

Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

Accessible weight loss: Adapting a lifestyle intervention for adults with impaired mobility

BACKGROUND

Despite disparities in obesity between those with and without disability, there is limited evidence to guide weight loss intervention in people with impaired mobility (IM), particularly those with severe impairments.

OBJECTIVE

Examine the usability, feasibility, and effectiveness of adapting an existing evidence-based weight loss program for people with IM.

METHODS

In this single-group pre-test post-test pilot study, 10 overweight or obese individuals with permanent IM (e.g. spinal cord injury, spina bifida, osteoarthritis) participated in a 20-week modification of the DPP Group Lifestyle Balance™ (DPP GLB) program, a group-based adaptation of the Diabetes Prevention Program (DPP). Fifteen conference calls encouraged reducing calorie and fat intake and increasing exercise through self-monitoring and problem solving. We defined feasibility as retention and engagement, usability as participants' program satisfaction ratings, and effectiveness as physiological and psychosocial change measured on three occasions over 20 weeks. Analytic methods included basic descriptive statistics (feasibility and usability) and repeated measures ANOVA (effectiveness).

RESULTS

The program retained 70% of participants. These individuals attended an average of 79.3% of conference calls and self-monitored more than half of the weeks. Participants rated the program highly, with mean overall scores of 6.3 ± 0.3 and 6.2 ± 0.6 out of 7 on helpfulness and satisfaction scales, respectively. Program completers experienced a significant mean weight loss of 8.86 ± 8.37 kg (p = 0.024), or 7.4% of their start weight, and significantly reduced their BMI.

CONCLUSIONS

An adapted version of the DPP GLB is a feasible, usable, and potentially effective intervention for promoting weight loss among persons with IM.

Health Disparities by Type of Disability: Health Examination Results of Adults (18-64 Years) with Disabilities in Shanghai, China

AIMS

There have been few studies on the disparities within the population with disabilities, especially in China. The aim of this study was to evaluate the differences in some health conditions among people with different types of disabilities in Shanghai.

METHODS

This study was conducted using data from the Shanghai Disabled Persons' Rehabilitation Comprehensive Information Platform. The records of 31,082 persons with disabilities who had undergone professional health examination were analyzed, and the prevalence and number of five diseases and five risk factors were examined. Logistic regression was used to explore disparities from two perspectives: 1) basic differences, unadjusted for other factors, and 2) differences after adjusting for key demographic covariates. A p-value < 0.05 was considered significant.

RESULTS

Individuals with visual disability had a high rate of refractive error (60.0%), and averaged 1.75 diseases of interest, which was the highest value among all disability types. The mean number of risk factors we measured was greatest (1.96) in the population with mental disability. There were significant differences (p < 0.05) between the hearing and speech impairment group and the other groups with respect to most health outcomes, except chronic pharyngitis, hepatic cysts, and high blood pressure.

CONCLUSION

Significant differences of selected health outcomes between groups with different types of disabilities remained after controlling for key demographic indicators. Further research is needed to explore the relationships between health conditions and disability types.

Asthma and asthma-related health care utilization among people without disabilities and people with physical disabilities

BACKGROUND

Previous research has shown that people with disabilities have higher rates of some chronic diseases and receive poorer disease-specific care than their counterparts without disabilities. Yet, little is known about the relationship between asthma and disability.

OBJECTIVE

This study examines whether differences in the prevalence of asthma, asthma flare, and asthma-related measures of health care quality, utilization and cost exist among people with physical limitations (PL) and without any limitations.

METHODS

Data from the 2004-2010 Medical Expenditure Panel Survey were pooled to compare outcomes for working-age adults (18-64) with PL to those with no limitations.

RESULTS

People with PL had higher rates of asthma (13.8% vs. 5.9%, p < 0.001) and recent asthma flare (52.6% vs. 39.6%, p < 0.001) than people without limitations. There were no differences in health care quality, utilization or cost between people with PL and people without limitations in multivariate analyses.

CONCLUSIONS

Although there are no differences in asthma-related quality or utilization of health care, people with PL have poorer asthma control than people without limitations. Research is needed to determine what factors (e.g., focus on other acute ailments, perceptions that asthma control cannot improve) are related to this outcome. Future research must also examine differences in asthma severity, and its impact on asthma control and health care-related outcomes, among people with and without disabilities.

Impact of disability and chronic conditions on health

BACKGROUND

Today one in five Americans have a disability and nearly half of Americans experiences a chronic condition. Whether disability results from or is a risk factor for chronic conditions, the combined effects of disability and chronic conditions warrants further investigation.

OBJECTIVES

Examine the added impact of chronic conditions among those with and without disability on self-reported health status and behaviors.

METHODS

2009 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to examine the association of disability with unhealthy behaviors and poor health stratified by number of self-reported chronic conditions (0, 1, or 2+). Linear and logistic regression models accounting for the complex survey weights were used.

RESULTS

Participants with disability were 6 times more likely to report fair/poor self-rated health, reported 9 more unhealthy days in a month and 6 more days in a month when poor health kept them from usual activities, were 4 times more likely to be dissatisfied with life, had greater odds of being a current smoker, and were less likely to be physically active. Presence of chronic conditions in addition to disability was associated, in a dose-response manner, with poor health status and unhealthy behaviors.

CONCLUSIONS

People living with both chronic diseases and disability are at substantially increased risks for poor health status and unhealthy behaviors, further affecting effective management of their chronic conditions. Multi-level interventions in primary care and in the community that address social and environmental barriers that hinder adults with disability from adopting more healthy lifestyles and improving health are needed.

Self-Management Interventions to Prevent the Secondary Condition of Pain in People with Disability Due to Mobility Limitations

Introduction

This focused review examines the use and effectiveness of self-management strategies in preventing or managing pain, which is among the most common secondary conditions faced by individuals with a mobility disability.

Methods

This focused review was part of a two-phase comprehensive scoping review. Phase I was a comprehensive scoping review of the literature targeting multiple outcomes of self-management interventions for those with mobility impairment, and Phase II was a focused review of the literature on self-management interventions that target pain as a primary or secondary outcome. Two authors searched CINAHL, PubMed, and PsyclNFO for papers published from January 1988 through August 2014 using specified search terms. Following the scoping review, the authors independently screened and selected the studies and reviewed the eligible studies, and the first author extracted data from the included studies.

Results

The scoping review yielded 40 studies that addressed pain self-management interventions for those living with mobility impairment. These 40 accumulated papers revealed a heterogeneous evidence base in terms of setting (clinic, community, and online), target populations, intervention duration (3 weeks to 24 months), and mode (health-care providers and lay leaders). Most of the reviewed studies reported that the self-management intervention led to significant reduction of pain over time, suggesting that self-management may be a promising approach for addressing pain experienced by people who live with mobility limitations.

Discussion

This review also reveals moderate-to-high bias across studies, and findings indicate that future research should enhance the methodological quality to provide stronger evidence about the effectiveness of self-management strategies for reducing pain among those with mobility impairments.

Diagnosis isn't enough: Understanding the connections between high health care utilization, chronic conditions and disabilities among U.S. working age adults

BACKGROUND

Under the ACA, new programs are being developed to enhance care coordination and reduce health care costs among people with chronic conditions, disabilities, and high utilization of health care. However, the relationships between these groups are not well understood.

OBJECTIVES

Our aims were to (1) identify high utilizers of health care in the U.S. working age (18-64) population, (2) examine the overlap between this group and people with chronic conditions and/or disabilities, (3) identify predictors of high service use or cost among these subpopulations, and (4) recommend approaches for stratification of individuals with high health care utilization.

METHODS

Using pooled national data from the Medical Expenditure Panel Survey (2006-2008), we created indices to identify elevated or high utilization and cost groups. We performed descriptive analyses, bivariate comparisons and multivariate analyses to examine the relations between these populations and individuals with chronic conditions and/or disabilities.

RESULTS

While the large majority of persons with high use/cost had chronic conditions, the minority of persons with chronic conditions had high health care utilization. However, among persons with chronic conditions, disability was a significant predictor of high utilization. Annual expenditures were significantly elevated among people with disabilities, particularly when activities of daily living were limited.

CONCLUSIONS

We conclude that medical diagnosis alone is insufficient for the development of eligibility criteria for, or the evaluation of, programs intended to better the delivery or coordination of services for high utilizers of health care services. New approaches are needed to assess functional limitations and identify ongoing needs for services and supports.

The effects of obesity and mobility disability in access to breast and cervical cancer screening in france: results from the national health and disability survey

Objectives

We aimed to disentangle the effects of obesity and mobility limitation on cervical and breast cancer screening among community dwelling women.

Methods

The data source was the French national Health and Disability Survey - Household Section, 2008. The Body Mass Index (BMI) was used to categorize obesity status. We constructed a continuous score of mobility limitations to assess the severity of disability (Cronbach's alpha = 0.84). Logistic regressions were performed to examine the association between obesity, mobility limitations and the use of Pap test (n = 8 133) and the use of mammography (n = 7 561). Adjusted odds ratios were calculated (AOR). Interaction terms between obesity and the disability score were included in models testing for effect modifications.

Results

Compared with non-obese women, the odds of having a Pap test in the past 3 years was 24% lower in obese women (AOR = 0.76; 95% CI: 0.65 to 0.89), the odds of having a mammogram in the past 2 years was 23% lower (AOR = 0.77; 95% CI: 0.66 to 0.91). Each time the disability score was 5 points higher, the odds of having a Pap test decreases by 20% (AOR = 0.96; 95% CI: 0.94 to 0.98), the odds of having a mammogram decreases by 25% (AOR = 0.95; 95% CI: 0.94 to 0.97). There was no significant interaction between obesity and disability score.

Conclusion

Obesity and mobility limitation are independently associated with a lower likelihood of cervical and breast cancer screening. Protective outreach and follow-up are necessary to reduce inequalities and thus to reduce health disparities in these vulnerable and high-risk populations of obese women with disabilities.

Heart age differentials and general cardiovascular risk profiles for persons with varying disabilities: NHANES 2001-2010

BACKGROUND

Persons with disabilities are at risk for secondary conditions, including allostatic load contributing to cardiovascular disease. The General Cardiovascular Risk Profile (GCRP) estimates cardiovascular disease risk for individuals. The GCRP variables are present in the National Health and Nutrition Examination Survey (NHANES) for the Healthy People 2010 decade.

OBJECTIVE/HYPOTHESIS

The objective of this study was to compare persons with varying disabilities versus persons without disabilities on GCRP cardiovascular disease risk estimates across the Healthy People 2010 decade.

METHODS

Weighted cross-sectional one-way Analyses of Variance (ANOVA) and non-parametric Kruskal-Wallis analyses compared persons with each of eight disability types versus persons without disabilities for point estimate GCRP heart vascular age differential and Cox regression model ten-year risk estimate in each NHANES survey year for 2001-2010.

RESULTS

Persons with mobility or vision disabilities had significantly (p < .025) greater ten-year percent risks for cardiovascular disease and negative heart vascular age differentials (with respect to actual age, therefore "older" hearts) than persons without disabilities. The GCRP dual models conflict for certain disabilities (e.g., hearing, physical/mental/emotional) but are consistently reliable measures of GCRP for persons with mobility limitations and vision disabilities.

CONCLUSIONS

With higher CVD risk among persons with disabilities, there is a clear need for increased interventions to benefit the health of persons with disabilities. The GCRP represents a valuable, simple measurement that uses routinely collected examination data. Physicians and nurses can use the GCRP to make immediate CVD assessments and to provide point-of-contact counseling to patients with and without disabilities.

Health outcome disparities among subgroups of people with disabilities: a scoping review

BACKGROUND

A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences.

OBJECTIVES

To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities.

METHODS

We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article.

RESULTS

For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender.

CONCLUSIONS

There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

Exercise for everyone: a randomized controlled trial of project workout on wheels in promoting exercise among wheelchair users

OBJECTIVE

To compare the effectiveness of 2 home-based behavioral interventions for wheelchair users to promote exercise adoption and maintenance over 12 months.

DESIGN

Randomized controlled trial, with participants stratified into groups based on disability type (stable, episodic, progressive) and support partner availability.

SETTING

Exercise occurred in participant-preferred locations (eg, home, recreation center), with physiological data collected at a university-based exercise laboratory.

PARTICIPANTS

Inactive wheelchair users (N=128; 64 women) with sufficient upper arm mobility for arm-based exercise were enrolled. Participants on average were 45 years of age and lived with their impairment for 22 years, with spinal cord injury (46.1%) most commonly reported as causing mobility impairment.

INTERVENTIONS

Both groups received home-based exercise interventions. The staff-supported group (n=69) received intensive exercise support, while the self-guided group (n=59) received minimal support. Both received exercise information, resistance bands, instructions to self-monitor exercise, regularly scheduled phone calls, and handwritten cards.

MAIN OUTCOME MEASURES

The primary outcome derived from weekly self-reported exercise. Secondary outcomes included physical fitness (aerobic/muscular) and predictors of exercise participation.

RESULTS

The staff-supported group reported significantly greater exercise (∼17min/wk) than the self-guided group over the year (t=10.6, P=.00), with no significant between-group difference in aerobic capacity (t=.76, P=.45) and strength (t=1.5, P=.14).

CONCLUSIONS

Although the staff-supported group reported only moderately more exercise, the difference is potentially clinically significant because they also exercised more frequently. The staff-supported approach holds promise for encouraging exercise among wheelchair users, yet additional support may be necessary to achieve more exercise to meet national recommendations.

Disparities in obesity and related conditions among Americans with disabilities

BACKGROUND

Despite representing nearly 20% of the U.S. population, individuals with disabilities are invisible in obesity surveillance and intervention efforts.

PURPOSE

The current study (1) compares obesity and extreme obesity prevalence between Americans with and without disabilities and (2) examines the association between BMI category and weight-related chronic disease risk factors in both groups.

METHODS

In 2012, six waves of data from the National Health and Nutrition Examination Survey (NHANES, 1999-2010) were pooled to compare the prevalence of obesity and extreme obesity between adults (aged ≥20 years, N=31,990) with disabilities (n=11,556) versus without disabilities (n= 20,434). Chronic disease risk factors (blood pressure, lipids, C-reactive protein [CRP], glucose) were compared across weight categories, by disability severity, and disability status.

RESULTS

Obesity (41.6%) and extreme obesity (9.3%) prevalence among those with disabilities were significantly higher than they were among those without disabilities (29.2% and 3.9%, respectively). Disability severity and disability status negatively affected nearly all chronic disease risk factors. Additionally, there was a disability-by-weight interaction: people with disabilities at all weight categories were significantly more likely to report being told they had hypertension, high cholesterol, or diabetes and to have been prescribed antihypertensive and lipid-lowering medications.

CONCLUSIONS

The prevalence of obesity (41.6%) and extreme obesity (9.3%) found in individuals with disabilities is high. When compared to obese adults without disabilities, obese adults with disabilities are more likely to have diabetes, high cholesterol, hypertension, and higher CRP. Thus, the study provides convincing evidence of obesity-related health disparities between Americans with and without disabilities.

Assessing stress in disability: developing and piloting the Disability Related Stress Scale

BACKGROUND

Stress negatively influences health, but few scales capture unique stressors encountered by people with physical disability.

OBJECTIVE/HYPOTHESIS

Conduct a pilot study to develop and evaluate the factor structure of a stress measure targeting unique stressors facing people with physical limitations due to impaired movement of the upper and lower extremities.

METHODS

Development of the Disability Related Stress Scale (DRSS) included: (1) obtaining input regarding content and items from focus groups and outside experts and (2) piloting the instrument. Participants recruited from an independent living center attended a focus group or completed the pilot survey. The piloted measure was a 107 item two-part survey. Part 1 assessed stressors encountered over the past week and Part 2 assessed stressors encountered over the past six months. Participants included a convenience sample of 143 adults who experienced a physical limitation; 26 attended focus groups and 117 completed the instrument. Respondents were predominantly women (60%), Caucasian (58%), and unemployed (92%). Respondents were 50.51 ± 14.46 years old and had lived with their disability for 15.64 ± 13.04 years.

RESULTS

Exploratory factor analyses revealed a 4-factor solution for Part 1 and a 2-factor solution for Part 2 of the DRSS. Estimates of internal consistency (Part 1 Cronbach's α = .78-84; Part 2 Cronbach's α = .72) and factor loadings (.40-1.00 for Part 1; .43-.87 for Part 2) indicate adequate reliability for all subscales.

CONCLUSIONS

Preliminary results provide initial support for the instrument's reliability and factor structure although further validation studies are warranted.

Nutrition initiatives in the context of population aging: where does the United States stand?

In 2011, the earliest segment of the baby boom generation turned 65 years of age. This event marks the beginning of a new phase of growth of the older adult population in the United States and is in line with what is referred to worldwide as "population aging." By 2030, older adults will comprise 20% of the U.S. population. With the impending increase in the older adult population, the United States is unprepared to handle the accompanying social and economic impact of growing rates of age-related diseases such as diabetes, hypertension, and cardiovascular disease. These diseases have nutritional determinants and, as such, they signify the need for effective preventive nutrition initiatives to address population aging in the United States. Comparatively, the European Union (EU) is projected to reach an older adult population of 24% by 2030. In this special article we evaluate nutrition initiatives for older adults in the United States and also examine nutrition initiatives in the European Union in search of an ideal model. However, we found that available data for EU initiatives targeted at population aging were limited. We conclude by offering the proposal of a physician-based model that establishes the primary care physician as the initiator of nutrition screening, education, referrals, and follow-up for the older adult population in the United States as a long-term goal. Apropos of the immediate future, we consider barriers that underscore the establishment of a physician-based model and suggest objectives that are attainable. Although the data are limited for the European Union, this model may serve to guide management of chronic diseases with a nutritional component in economies similar to the United States worldwide.

Truth be told: evidence of wheelchair users' accuracy in reporting their height and weight

OBJECTIVES

To examine whether wheelchair users' self-reports of height and weight differed significantly from direct measurements and whether weight category classifications differed substantially when based on self-reported or measured values.

DESIGN

Single group, cross-sectional analysis. Analyses included paired t tests, chi-square test, analysis of variance, and Bland-Altman agreement analyses.

SETTING

A university-based exercise lab.

PARTICIPANTS

Community-dwelling wheelchair users (N=125).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Participants' self-reported and measured height, weight, and body mass index.

RESULTS

Paired t tests revealed that there were significant differences between wheelchair users' self-reported and measured values for height (difference of 3.1±7.6cm [1.2±3.0in]), weight (-1.7±6.5kg [-3.6±14.2lb]), and BMI (-1.6±3.3). These discrepancies also led to substantial misclassification into weight categories, with reliance on self-reported BMI underestimating the weight status of 20% of the sample.

CONCLUSIONS

Our findings suggest that similar to the general population, wheelchair users are prone to errors when reporting their height and weight and that these errors may exceed those noted in the general population.

An exercise trial for wheelchair users: project workout on wheels

There is growing interest in promoting health for people with disabilities, yet evidence regarding community-based interventions is sparse. This paper describes the design details of a randomized controlled trial (RCT) that will test the effectiveness of a multi-component behaviorally based, intervention to promote exercise adoption (over 6 months) and maintenance (up to one year) among wheelchair users and includes descriptive data on participant characteristics at baseline. Participants were randomly assigned to either a staff-supported intervention group or a self-guided comparison group. The primary study aim is to assess the effectiveness of the multi-component behaviorally based intervention for promoting physical activity adoption and maintenance. The RCT will also assess the physical and psychosocial effects of the intervention and the complex interplay of factors that influence the effectiveness of the intervention. Therefore, the primary outcome derives from participant reports of weekly exercise (type, frequency, duration) over 52 weeks. Secondary outcomes collected on four occasions (baseline, 3 months, 6 months, 12 months) included physiological outcomes (VO(2) peak, strength), disability-related outcomes (pain, fatigue, participation), and psychosocial outcomes (exercise self-efficacy, exercise barriers, quality of life, depression, mood). This study will provide evidence regarding the effectiveness of a multi-component behaviorally based intervention for promoting exercise adoption among people with mobility impairments that necessitate wheelchair use.

Diabetes among adults with cognitive limitations compared to individuals with no cognitive disabilities

Using a retrospective analysis of data from the 2006 Medical Expenditures Panel Survey (MEPS), we assessed the health status of working-age adults with cognitive limitations in comparison to adults with no disability (unweighted N  =  27,116; weighted N  =  240,343,457). Adults with cognitive limitations had a significantly higher prevalence of diabetes than did adults with no disability (19.4% vs. 3.8%, respectively) and a significantly higher prevalence of six other major chronic conditions. In addition, individuals with cognitive limitations and diabetes were significantly more likely to have multiple (four or more) chronic illnesses. The health disparities we found in this study demonstrate the need to improve disease prevention and education efforts for individuals with cognitive limitations and their health care providers.

Evolving views of disability and public health: the roles of advocacy and public health

Promoting health, quality of life, and participation of persons with disabilities is a relatively recent development in public health. Its brief history reflects three distinct public health perspectives toward disability-a traditional approach that focuses on preventing disability, a contemporary approach that regards disability as a minority group experiencing disparities relative to people without disabilities, and an emerging perspective where disability status is considered one of multiple determinants of health. The field of disability and health has been influenced by the interaction of disability advocacy with the public health process of surveillance, epidemiology research, and intervention. Advocacy draws on political and legal arguments to press for action on issues such as health care access, control of services, and choice of residence. Public health uses surveillance to document magnitude of problems; epidemiology to identify specific groups, develop measures, and apply rigorous research methods; and intervention to improve health behaviors and health outcomes. The field of disability and public health, however, has lagged in addressing the role of environmental factors in the disabling process, in moving to societal participation as an outcome, and in implementing population scale interventions.

Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities

BACKGROUND

An overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?

METHODS

Cross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.

RESULTS

In covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.

CONCLUSION

Based on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.

Physical and mental health-related correlates of physical function in community dwelling older adults: a cross sectional study

BACKGROUND

Physical function is the ability to perform both basic and instrumental activities of daily living, and the ability of older adults to reside in the community depends to a large extent on their level of physical function. Multiple physical and health-related variables may differentially affect physical function, but they have not been well characterized. The purpose of this investigation was to identify and examine physical and mental health-related correlates of physical function in a sample of community-dwelling older adults.

METHODS

Nine hundred and four community dwelling older men (n = 263) and women (n = 641) with a mean (95% Confidence Interval) age of 76.6 (76.1, 77.1) years underwent tests of physical function (Timed Up and Go; TUG), Body Mass Index (BMI) was calculated from measured height and weight, and data were collected on self-reported health quality of life (SF-36), falls during the past 6 months, number of medications per day, depression (Geriatric Depression Scale; GDS), social support, and sociodemographic variables.

RESULTS

Subjects completed the TUG in 8.7 (8.2, 9.2) seconds and expended 6,976 (6,669, 7,284) Kcal.wk-1 in physical activity. The older persons had a mean BMI of 27. 6 (27.2, 28.0), 62% took 3 or more medications per day, and 14.4% had fallen one or more times over the last 6 months. Mean scores on the Mental Component Summary (MCS) was 50.6 (50.2, 51,0) and the Physical Component Summary (PCS) was 41.3 (40.8, 41.8).Multiple sequential regression analysis showed that, after adjustment for TUG floor surface correlates of physical function included age, sex, education, physical activity (weekly energy expenditure), general health, bodily pain, number of medications taken per day, depression and Body Mass Index. Further, there is a dose response relationship such that greater degree of physical function impairment is associated with poorer scores on physical health-related variables.

CONCLUSIONS

Physical function in community-dwelling older adults is associated with several physical and mental health-related factors. Further study examining the nature of the relationships between these variables is needed.

Lower extremity muscle mass predicts functional performance in mobility-limited elders

OBJECTIVES

This study examined the influence of lower extremity body composition and muscle strength on the severity of mobility-disability in community-dwelling older adults.

METHODS

Fifty-seven older males and females (age 74.2 +/- 7 yrs; BMI 28.9 +/- 6 kg/m2) underwent an objective assessment of lower extremity functional performance, the Short Physical Performance Battery test (SPPB). Participants were subsequently classified as having moderate (SPPB score 7: n = 38) or severe mobility impairments (SPPB score

RESULTS

TLM was a strong independent predictor of the level of functional impairment, after accounting for chronic medical conditions, BMD, body fat, body weight and habitual physical activity. In a separate predictive model, reduced muscle strength was also a significant predictor of severe functional impairment. The severity of mobility-disability was not influenced by gender (p = 0.71). A strong association was elicited between TLM and muscle strength (r = 0.78, p < 0.01).

CONCLUSIONS

These data suggest that lower extremity muscle mass is an important determinant of physical performance among functionally-limited elders. Such findings may have important implications for the design of suitable strategies to maintain independence in older adults with compromised physical functioning. Additional studies are warranted to assess the efficacy of lifestyle, exercise or therapeutic interventions for increasing lean body mass in this population.

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Key Words

• aging
• sarcopenia
• mobility
• muscle mass
• strength

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MESH Headings

• Absorptiometry, Photon
• Activities of Daily Living
• Aged
• Body Composition/physiology
• Bone Density/physiology
• Cross-Sectional Studies
• Exercise Test
• Female
• Health Status
• Humans
• Logistic Models
• Lower Extremity/physiology
• Male
• Mobility Limitation
• Muscle Strength/physiology
• Muscle Strength Dynamometer
• Muscle, Skeletal/anatomy & histology
• Muscle, Skeletal/physiology
• Physical Fitness/physiology
• Randomized Controlled Trials as Topic

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Grants

• AG18844 NIA NIH HHS
• R01 AG018844 NIA NIH HHS
• M01 RR000533 NCRR NIH HHS
• R01 AG018844-06 NIA NIH HHS
• M01 RR00533 NCRR NIH HHS

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Affiliation(s)

Kieran F. Reid Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA Department of Public Health and Family Medicine, Tufts University School of Medicine, Boston, MA
Elena N. Naumova Department of Public Health and Family Medicine, Tufts University School of Medicine, Boston, MA
Robert J. Carabello Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA
Edward M. Phillips Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA
Roger A. Fielding Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA Department of Health Sciences, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA

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