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

Cross-sectional analysis of disability education in American Medical Schools

Greater than 25% of the American population has a disability. The demand for disability-informed physicians underscores the need to better prepare physicians to care for patients with disabilities. This study presents findings from three Qualtrics survey studies that investigated (1) medical students' exposure to patients with disabilities while on clinical rotations at Western University of Health Sciences, (2) students' perceived preparedness to care for patients with disabilities nationwide, and (3) the effectiveness of Special Olympics online modules to teach students about caring for patients with disabilities. Descriptive analysis from these studies together indicated that medical students did not feel prepared to care for patients with disabilities. To remedy this, Special Olympics online modules for healthcare professionals were found to effectively enhance student physician training. These findings highlight a critical need for improved medical training to prepare the next generation of physicians to care for patients with disabilities, while outlining a possible educational tool that could be incorporated into medical school curriculum.

A Study of Disability Severity, Barriers, and Facilitating Factors in Accessing Healthcare Among Differently Abled Adults

BACKGROUND

Disability impacts many individuals, thus restricting access to necessary healthcare. Barriers that affect health equity among people with disabilities include physical inaccessibility, financial constraints, and stigma in society. This study aims to report on the level of disability and factors determining healthcare access among adult differently abled persons in Chennai, Tamil Nadu, focusing on the WHO Disability Assessment Schedule (WHODAS 2.0).

METHODS

In this cross-sectional study, 300 differently abled adults affiliated with the Tamil Nadu Udavikkaram Association participated. The severity of disability was assessed using WHODAS 2.0, while a structured questionnaire elicited details on socio-demographic characteristics, barriers to healthcare utilization, and facilitating factors. Data was analyzed using SPSS version 16 (IBM Corp., Armonk, New York, USA), with descriptive statistics and odds ratios calculated for key variables.

RESULTS

Most participants (N=286, 93%) had mild levels of disability with problems mainly in self-care and mobility. The main barriers reported were healthcare expenses, distance to facilities, and lack of family support. Key facilitators were government schemes and assistive devices. Socio-economic factors like income and education showed marked correlations with the severity of disability.

CONCLUSION

Healthcare access varies with disability severity, revealing a need for targeted financial, familial, and accessibility interventions to reduce disparity. Future longitudinal studies may provide insights into the development of policies and programs to support individuals living with disabilities.

Top Ten Tips Palliative Care Clinicians Should Know About Providing Care for People With Disabilities

Palliative care (PC) clinicians are well poised to help people with disabilities (PWD) live well in the context of serious illness. PC prioritizes person-centered care with a focus on function, autonomy, and quality of life. This approach aligns with principles of high-quality care for PWD. An understanding of the unique experiences and needs of PWD can advance the delivery of comprehensive, equitable PC for this population. In this article, we provide 10 tips to help PC clinicians develop an informed disability lens in their approach to care.

Come Roll with Me: An Interprofessional Experience to Promote Disability Awareness

Problem: One in four American adults have a disability, which makes people with disabilities the largest minority group in the United States (U.S.). Chronic diseases are prevalent within this population, which faces myriad barriers that limit access to healthcare and create significant health care disparities. Yet, disability awareness programs are limited in U.S. medical schools and graduates report a sense of unpreparedness to care for this population. Intervention: Come Roll with Me (CRWM) was implemented as an interprofessional, preclinical experience to provide medical and Doctor of Physical Therapy (DPT) students an opportunity to engage with wheelchair users and one another. Students rotated through four stations with a licensed physical therapist and wheelchair user facilitator. Stations included (1) manual wheelchair self-propulsion, (2) accessible parking, (3) transfers, and (4) open dialog on barriers to healthcare led by the wheelchair user. Context: This study sought to assess the impact of CRWM on students' understanding of the barriers and health disparities faced by individuals with disabilities. Assessment was conducted using course evaluations, thematic analysis of student reflection essays and a focus group with the wheelchair user facilitators to determine if CRWM met pre-implementation program goals and objectives, including the Interprofessional Educational Collaborative (IPEC) core competencies. Impact: Student reflections from both disciplines indicated that learners were able to identify a variety of barriers faced by people with disabilities and prioritize methods to mitigate these factors. Approximately 91% of medical students agreed or strongly agreed that CRWM was effective in their learning on course evaluations. Wheelchair user facilitators noted three important outcomes of CRWM: educating, teaming, and impact on students. Lesson Learned: Come Roll with Me is a robust educational activity, as evidenced by the program meeting all goals and objectives as well as (IPEC) core competencies. It provides students a unique opportunity to learn about disability from another profession and wheelchair users. People with disabilities and DPT students are a unique and underutilized pool of educators in undergraduate medical education.

Association between Perceived Activity Restriction Due to People's Perception of Aging and Unmet Medical Needs among Middle-Aged and Elderly People: A Population-Based Study

Background and Objectives: The older members of a population might experience unmet medical needs, despite desiring medical care due to activity limitations driven by their perception of aging. This study conducted a cross-sectional analysis of the association between perceived activity restriction (PAR) due to people's own perception of aging and unmet medical needs (UMN) in late middle-aged and older Koreans based on the Korean National Health and Nutrition Examination Survey (KNHANES). Materials and Methods: The 2016-2020 KNHANES was used to analyze a total of 2008 participants among groups aged 45 years or older by applying individual weights imposed from the raw data. The independent variable of PAR was assessed using self-reported questionnaires based on the global activity limitation indicator. Also, the dependent variable of UMN, referring to the state in which a patient's medical care or service was insufficient, inadequate, or lacking, was assessed using a single question. After excluding missing values, the data on 2008 individuals were analyzed using a chi-square test, weighted logistic regression, and a stratified analysis of gender, age, and the presence of chronic illnesses. Results: The group that experienced PAR had an OR 2.13 higher (odds ratio [OR]: 2.13; 95% confidence interval [CI]: 1.27-3.56) to present UMN than the group that did not experience PAR. Furthermore, the results of the stratified analysis indicated that, in the group of female participants with chronic illness and in the group of elderly people, experiencing PAR was associated with a higher experience of UMN. Conclusions: There was a close association between PAR and UMN. In particular, when PAR occurred in the group of female participants with chronic illness and in the group of elderly people, the incidence rate of UMN was also found to be high. This finding highlights the need for policies and institutional measures to reduce UMN within vulnerable groups with an increased risk of medical inaccessibility due to activity restriction.

Spinal cord injury and prescribed opioids for pain: a scoping review

OBJECTIVE

Spinal cord injury (SCI) is a life-altering neurological condition affecting physical and psycho-social functioning and associated high rates of pain. Thus, individuals with SCI may be more likely to be exposed to prescription opioids. A scoping review was conducted to synthesize published research findings on post-acute SCI and prescription opioid use for pain, identify literature gaps, and propose recommendations for future research.

METHODS

We searched 6 electronic bibliographic databases (PubMed [MEDLINE], Ovid [MEDLINE], EMBASE, Cochrane Library, CINAHL, PsychNET) for articles published from 2014 through 2021. Terms for "spinal cord injury" and "prescription opioid use" were used. Included articles were in English and peer reviewed. Data were extracted using an electronic database by 2 independent reviewers. Opioid use risk factors for chronic SCI were identified and a gap analysis was performed.

RESULTS

Of the 16 articles included in the scoping review, a majority were conducted in the United States (n = 9). Most articles lacked information on income (87.5%), ethnicity (87.5%), and race (75%). Prescription opioid use ranged from 35% to 64% in articles reporting this information (n = 7 articles, n = 3675 participants). Identified risk factors for opioid use included middle age, lower income, osteoarthritis diagnosis, prior opioid use, and lower-level spinal injury. Limited reporting of diversity in study populations, absence of risk of polypharmacy, and limited high quality methodology were identified gaps.

CONCLUSIONS

Future research should report data on prescription opioid use in SCI populations, with additional demographics such as race, ethnicity, and income, given their importance to risk outcomes.

From inequity to access: Evidence-based institutional practices to enhance care for individuals with disabilities

People with disabilities experience barriers to care in all facets of health care, from engaging with the provider in a clinical setting (attitudinal and communication barriers) to navigating a large institution in a complex health care environment (organizational and environmental barriers), culminating in significant health care disparities. Institutional policy, culture, and physical layout may be inadvertently fostering ableism, which can perpetuate health care inaccessibility and health disparities in the disability community. Here, we present evidence-based interventions at the provider and institutional levels to accommodate patients with hearing, vision, and intellectual disabilities. Institutional barriers can be met with strategies of universal design (i.e., accessible exam rooms and emergency alerts), maximizing electronic medical record accessibility/visibility, and institutional policy development to recognize and reduce discrimination. Barriers at the provider level can be met with dedicated training on care of patients with disabilities and implicit bias training specific to the surrounding patient demographics. Such efforts are crucial to ensuring equitable access to quality care for these patients.

Unmet health care needs: factors predicting satisfaction with health care services among community-dwelling Canadians living with neurological conditions

Background

Neurological conditions (NCs) can lead to long-term challenges including functional impairments and limitations to activities of daily living. People with neurological conditions often report unmet health care needs and experience barriers to care. This study aimed to (1) explore the factors predicting patient satisfaction with general health care, hospital, and physician services among Canadians with NCs, (2) examine the association between unmet health care needs and satisfaction with health care services among neurological patients in Canada, and (3) contrast patient satisfaction between physician care and hospital care among Canadians with NCs.

Methods

We conducted a secondary analysis on a subsample of the 2010 Canadian Community Health Survey - Annual Component data (N = 6335) of respondents with neurological conditions, who received general health care services, hospital services, and physician services within twelve months. Multivariate logistic regression fitted the models and odds ratios and 95% confidence intervals were reported using STATA version 14.

Results

Excellent quality care predicts higher odds of patient satisfaction with general health care services (OR, 95%CI–237.6, 70.4–801.5), hospital services (OR, 95%CI–166.9, 67.9–410.6), and physician services (OR, 95%CI–176.5, 63.89–487.3). In contrast, self-perceived unmet health care needs negatively predict patient satisfaction across all health care services: general health care services (OR, 95%CI–0.59, 0.37–0.93), hospital services (OR, 95%CI–0.41, 0.21–0.77), and physician services (OR, 95%CI–0.29, 0.13–0.69). Other negative predictors of patient satisfaction include some post-secondary education (OR, 95%CI–0.36, 0.18–0.72) for general health services and (OR, 95%CI–0.26, 0.09–0.80) for physician services. Those with secondary (OR, 95% CI–0.32, 0.13–0.76) and post-secondary graduation (OR, 95%CI– 0.28, 0.11–0.67) negatively predicted patient satisfaction among users of physician services while being an emergency room patient most recently (OR, 95%CI– 0.39, 0.20–0.77) was also negatively associated with patients satisfaction among hospital services users.

Conclusion

This study found self-perceived unmet health care needs as a significant negative predictor of neurological patients’ satisfaction across health care services and emphasizes the importance of ensuring coordinated efforts to provide appropriate and accessible care of the highest quality for Canadians with neurological conditions.

The Cross-Country Comparison Model for Labor Participation (CCC Model for LP) of Persons with Chronic Diseases

Purpose To design a model based on the three pillars of new institutional theory (NIT), that facilitates cross-country comparison of labor participation (LP) of people with chronic diseases. This model should support getting a comprehensive overview of factors representing country differences, understanding these differences and should support estimating cross-country transferability of policies and interventions in the context of Work Disability Prevention. Methods Based on NIT, a draft model was designed by means of (1) a literature review of empirical studies; (2) theoretical books and articles; (3) a focus group with six expert researchers. This draft model was (4) adapted in the context of academic education. Literature was searched on Web of Science and EBSCO host. Feedback on (use of) the model was received from the focus group, four different academic courses at 28 occasions and two international conferences. Results The cross-country comparison model for labor participation (CCC model for LP) of persons with chronic diseases is proposed consisting of five factors: (1) Legislation; (2) Norms & values in practice; (3) Culture; (4) Organization of WDP in practice; (5) Labor market characteristics. Within these factors and based on (in)direct empirical evidence, subfactors are distinguished. The feedback received led to renaming (sub) factors, improved visual representation and a tool for estimating transferability. Conclusions The CCC model for LP of persons with chronic diseases allows for a comprehensive understanding of country differences and cross-country transferability of policies and interventions. The CCC model can be used for other populations when population-specific subfactors are included.

Team-based primary care program for disabled people and changes in rate of unmet health care needs

BACKGROUND

Few studies have been conducted on the application of specific and practical methods, such as interventions, for reducing the unmet health care needs (UHCN) of disabled people.

OBJECTIVES

The study aims to evaluate the impact of the team-based primary care program (TPCP) for disabled people on UHCN.

METHOD

In 2017, we surveyed 696 disabled people who were enrolled in the TPCP at one of the 11 institutions belonging to the Korea Health Welfare Social Cooperative Federation from 2015 to 2017 to assess their unmet needs before and after enrolment. We conducted a logistic regression analysis before and after the program to evaluate the relationship between participation period and unmet needs after adjusting for physician type, gender, age, drinking, monthly income, disability type, personal assistance services and living alone.

RESULT

After using the service, the proportion of disabled people with unmet needs decreased from 42.9% to 20.4% for a medical doctor and 43.6% to 18.6% for a Korean medical (KM) doctor. After adjusting for related factors and stratifying with type of physician, the proportion of disabled people with unmet needs decreased significantly in response to the participation period for the medical doctor-involved program (P-trend < 0.001); this was not observed in the KM counterpart (P-trend = 0.6).

CONCLUSION

The TPCP for disabled people provides disease prevention, health care and health promotion activities and is crucial for solving the unmet needs.

Physical and mental health of older people with disabilities in residential homes in Switzerland

Objectives:

People with disabilities are underserved in terms of health care and prevention, and special health conditions exist among older people with intellectual disabilities. The Swiss Health Survey only covers people over the age of 15 years living in private households. Therefore, this study aims to assess the health status of older persons living in residential facilities for adults with disabilities.

Methods:

A cross-sectional survey with written questionnaires was conducted in six cantons in Switzerland to capture context factors and the physical health status of persons aged between 50 and 65 years in residential homes in Switzerland. The survey collected data on physical and mental health from 241 persons aged 50–65 years living in residential homes for people with disabilities. This was compared with data from the 2012 Swiss Health Survey comprising a sample of 2261 persons of the same age with chronic morbidities living in their own apartments.

Results:

Regarding their health, 94.1% of the survey respondents rated it as being very good, good or moderate. Although higher limitations on activities of daily living, higher levels of psychological distress and lower energy and vitality were reported by all respondents, a lower level of health issues was assessed than in the sample of persons with chronic morbidities living in their own apartment.

Conclusion:

Low energy and vitality, high limitations on activities of daily living, high psychological distress, high obesity rates and the assessment of health issues and pain should be specifically addressed in residential homes for people with disabilities.

Emergency Medicine Resident Education on Caring for Patients With Disabilities: A Call to Action

People with disabilities constitute a marginalized population who experience significant health care disparities resulting from structural, socioeconomic, and attitudinal barriers to accessing health care. It has been reported that education on the care of marginalized groups helps to improve awareness, patient-provider rapport, and patient satisfaction. Yet, emergency medicine (EM) residency education on care for people with disabilities may be lacking. The goal of this paper is to review the current state of health care for patients with disabilities, review the current state of undergraduate and graduate medical education on the care of patients with disabilities, and provide suggestions for an improved EM residency curriculum that includes education on the care for patients with disabilities.

Health and Disability Among Young Black Men

BACKGROUND

Black men experience the highest rate of disability compared to White, Asian, and Hispanic men. Yet, we know little about how Black men with disabilities experience the embodiment of their gender, race, social class, and disability positionalities and how they draw from their cultural backgrounds as they engage in health-seeking behaviors.

OBJECTIVES

The purpose of this study was to explore how young Black men experienced the onset of chronic disabling conditions while negotiating health-promoting activities in the context of gender, race, social class, disability positionalities, and culture.

METHODS

This descriptive study used hermeneutic phenomenology to achieve study objectives. This study's research questions were answered using audiotaped, one-on-one qualitative interviews, along with detailed field notes. Each participant was interviewed twice at a mutually decided upon location to ensure their privacy and comfort.

RESULTS

In relation to their embodied interactions of self in the context of disability, these men described their health-related decisions using four themes: maintaining manhood, economic constraints, the "risk" of healthcare, and health promotion.

CONCLUSIONS

By examining the experiences of young adult Black men living with disabilities, knowledge of their perspectives and experiences at earlier stages in their life course contributes to the understanding of their personal challenges, health needs, and their perspectives of health-promoting strategies.

Financial Catastrophism Inherent with Out-of-Pocket Payments in Long Term Care for Households: A Latent Impoverishment

Background: Out-of-pocket (OOP) payments are configured as an important source of financing long-term care (LTC). However, very few studies have analyzed the risk of impoverishment and catastrophic effects of OOP in LTC. To estimate the contribution of users to the financing of LTC and to analyze the economic consequences for households in terms of impoverishment and catastrophism after financial crisis in Spain.

METHODS

The database that was used is the 2008 Spanish Disability and Dependency Survey, projected to 2012. We analyze the OOP payments effect associated to the impoverishment of households comparing volume and financial situation before and after OOP payment. At the same time, the extent to which OOP payment had led to catastrophism was analyzed using different thresholds.

RESULTS

The results show that contribution of dependent people to the financing of the services they receive exceeds by 50% the costs of these services. This expenditure entails an increase in the number of households that live below the poverty. In terms of catastrophism, more than 80% of households dedicate more than 10% of their income to dependency OOP payments. In annual terms, the catastrophe gap generated by devoting more than 10% of the household income to dependent care OOP payment reached €3955, 1 million (0.38% of GDP).

CONCLUSION

This article informs about consequences of OOP in LCT and supplements previous research that focus on health. Our results should serve to develop strategic for protection against the financial risk resulting from facing the costs of a situation of dependence.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.

Access to primary care for persons with spinal cord injuries in the greater Gaborone area, Botswana

Background

People with spinal cord injury (SCI) often have great need for healthcare services, but they report access challenges. Primary care access to people with SCI has not been explored in Botswana.

Objective

This study aimed to identify barriers and facilitators that users with spinal cord injuries experience in accessing primary care services in the greater Gaborone area, Botswana.

Methods

A quantitative, cross-sectional, observational study was conducted. Data were collected with a structured questionnaire from 57 participants with traumatic and non-traumatic SCI. Descriptive and inferential analysis was performed.

Results

The male to female ratio was 2.8:1. The mean age of participants was 40 years (standard deviation 9.59). Road traffic crashes caused 85% of the injuries. Most participants visited primary care facilities between 2 and 10 times in the 6 months before the study. Participants were satisfied with the services (63%) and felt that facilities were clean (95%) and well maintained (73.5%). Preferential treatment, respect, short waiting times and convenient hours facilitated satisfaction with services. Availability was hampered by insufficient provider knowledge on SCI as indicated by 71.9% of participants, and shortage of consumables (80.7%). Structural challenges (42.1% could not enter the facility by themselves and 56.5% could not use the bathroom) and lack of height-adjustable examining couches (66.7%) impeded accessibility. Cost was incurred when participants (64.9%) utilised private health services where public services failed to address their needs.

Conclusion

Primary care services were mostly affordable and adequate. Availability, acceptability and accessibility aspects created barriers.

Competency-Based Curriculum Development to Meet the Needs of People With Disabilities: A Call to Action

People with disabilities constitute 22.2% of the population in the United States, and virtually all physicians have people with disabilities in their clinical practice across a wide range of diagnostic groups. However, studies demonstrate that people with disabilities are inadequately served by the health care system, leading to high costs and poor outcomes. The authors argue that one cause of this discrepancy is that medical students receive limited training in the care of people with disabilities and may therefore not be able to adequately meet the competencies that underlie the Core Entrustable Professional Activities for Entering Residency. To address these gaps, the authors present practical examples of integrating concepts of disability into the curriculum with minimal additional time requirements. A comprehensive disability curriculum is suggested to include active classroom learning, clinical, and community-based experiences. At institutions that do not have a comprehensive curriculum, the authors recommend adding disability-related knowledge and skill acquisition to existing curricula through modifications to current case-based learning, simulated patients, and objective structured clinical examinations. To facilitate curriculum development, they recommend that the World Health Organization International Classification of Functioning, Disability, and Health be used as a tool to build disability concepts into active learning. The goal of these recommended curricular changes is to enhance student performance in the clinical management of people with disabilities and to better train all future physicians in the care of this population.

Challenges in Accessing Health Care for People with Disability in the South Asian Context: A Review

South Asia is a unique geopolitical region covering 3.4% of the world’s surface area and supporting 25% of the world’s population (1.75 billion). Available evidence from South Asia shows variable estimates of the magnitude of disability. The projected magnitude depends on whether an impairment focus is highlighted (approximately 1.6–2.1%) or functionality is given precedence (3.6–15.6%). People with disability (PWD) face significant challenges to accessing health care in the region. Studies show that adults with disability reported a four times higher incidence of a serious health problem in a year’s recall period. Evidence shows a significantly higher rate (17.8%) of hospitalization among PWD compared to others (5%). Chronic conditions like diabetes were also significantly higher. Women with disability had significantly more concerns on reproductive health issues. Studies from the South Asia region reveal that not only did PWD have a higher load of adverse health outcomes but they also faced significantly more barriers in accessing health services.

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.

Effect modification of social-context changes on mental disability in China from 1987 to 2006: a multi-level study of 1.9 million people

BACKGROUND

Very little literature has explored how mental disability in China is connected with inequalities in social and environmental contexts. In the study described herein, we determine whether social-context inequalities were associated with mental disability in China from 1987 to 2006.

METHODS

Data were derived from national representative population-based data from the 1987 and 2006 China National Sample Survey on Disability. Both surveys used multistage, stratified random cluster sampling, with a probability proportionate to size, to derive nationally representative samples. A multilevel logistic regression model was applied to estimate the effects of province-specific contextual characteristics on men and women. We also examined the association with mental disability risk stratified by selected covariates. Study populations were (N = 698,810) in 1987 and (N = 1,260,947) in 2006.

RESULT

Most of the province-level variables in the 1987 and 2006 surveys were unrelated to mental disability risks in either men or women after controlling for individual characteristics. The age-adjusted prevalence of mental disability nearly doubled among men and women from 1987 to 2006. The effects of the province-specific prevalence of agricultural, forestry, animal husbandry and fishery activities and the percentage of the population age 65 and over significantly lowered the risk of mental disability among women in 1987, by 48 and 32%, respectively. Moreover, the number of health professionals modified the association with per capita gross domestic product (GDP) among women but only in 1987.

CONCLUSION

To face the challenges of mental disability and interprovincial inequality, the Chinese government should adjust its strategies not only for health-care systems but also to correct for inequalities in interprovincial development; this action may help prevent mental disability.

Prevalence and reasons for delaying and foregoing necessary care by the presence and type of disability among working-age adults

BACKGROUND

While it is commonly accepted that disparities in unmet need for care vary by age, race/ethnicity, income, education, and access to care, literature documenting unmet needs experienced by adults with different types of disabilities is developing.

OBJECTIVE

The main objective was to determine whether subgroups of people with disabilities are more likely than people without disabilities to delay/forgo necessary care, in general and among the insured.

METHODS

We used pooled Medical Expenditure Panel Survey data (2004-2010) to examine delaying or forgoing medical, dental, and pharmacy care among five disability subgroups (physical, cognitive, visual, hearing, multiple) and the non-disabled population. Logistic regression was conducted to examine delayed/forgone care, controlling for sociodemographic, health, and health care factors.

RESULTS

Over 13% of all working-age adults delayed/forwent necessary care; lack of insurance was the strongest predictor of unmet needs. Among the insured, disability subgroups were greater than two times more likely to report delayed/forgone care than adults without disabilities. Insured working-age adults with multiple chronic conditions and those with ADL/IADL assistance needs had higher odds of delayed or forgone care than their peers without these characteristics. Reasons related to affordability were most often listed as leading to unmet needs, regardless of disability.

CONCLUSION

Although insurance status most strongly predicted unmet needs for care, many people with insurance delayed/forewent necessary care. Even among the insured, all disability subgroups had significantly greater likelihood of having to delay/forgo care than those without disabilities. Differences also existed between the disability subgroups. Cost was most frequently cited reason for unmet needs.

The impact of health service variables on healthcare access in a low resourced urban setting in the Western Cape, South Africa

Background

Health care access is complex and multi-faceted and, as a basic right, equitable access and services should be available to all user groups.

Objectives

The aim of this article is to explore how service delivery impacts on access to healthcare for vulnerable groups in an urban primary health care setting in South Africa.

Methods

A descriptive qualitative study design was used. Data were collected through semi-structured interviews with purposively sampled participants and analysed through thematic content analysis.

Results

Service delivery factors are presented against five dimensions of access according to the ACCESS Framework. From a supplier perspective, the organisation of care in the study setting resulted in available, accessible, affordable and adequate services as measured against the District Health System policies and guidelines. However, service providers experienced significant barriers in provision of services, which impacted on the quality of care, resulting in poor client and provider satisfaction and ultimately compromising acceptability of service delivery. Although users found services to be accessible, the organisation of services presented them with challenges in the domains of availability, affordability and adequacy, resulting in unmet needs, low levels of satisfaction and loss of trust. These challenges fuelled perceptions of unacceptable services.

Conclusion

Well developed systems and organisation of services can create accessible, affordable and available primary healthcare services, but do not automatically translate into adequate and acceptable services. Focussing attention on how services are delivered might restore the balance between supply (services) and demand (user needs) and promote universal and equitable access.

Disparities in receipt of breast and cervical cancer screening for rural women age 18 to 64 with disabilities

BACKGROUND

Previous research has found breast and cervical cancer screening disparities between women with and without disabilities, and between women living in rural versus urban areas. Living in a rural area may add to the barriers women with disabilities experience when attempting to obtain screening for breast and cervical cancer. The purpose of this study was to examine the combination of disability status and rurality in association with receipt of breast and cervical cancer screening among women age 18 to 64 in the United States.

METHODS

We conducted cross-sectional analyses of data from the Medical Expenditure Panel Survey, using pooled annual data files from 2002 through 2008. We compared recent receipt of breast and cervical cancer screening among four groups: 1) urban women without disabilities, 2) urban women with disabilities, 3) rural women without disabilities, and 4) rural women with disabilities.

FINDINGS

Overall, women with disabilities were less likely to be up to date with mammograms and Pap tests compared with women with no disabilities. Similarly, women in rural areas were less likely to have received breast or cervical cancer screening within recommended timeframes. Women who both had a disability and lived in a rural area were the least likely to be current with screening.

CONCLUSIONS

Our findings suggest that living in rural regions compounds disparities in receipt of cancer screening among women with disabilities. Increased attention is needed to improve receipt of cancer screening among rural women with disabilities.

Health care utilization by people with disabilities: A longitudinal analysis of the Korea Welfare Panel Study (KoWePS)

BACKGROUND

Health care is important for people with disabilities in terms of maintaining basic functional status and promoting health. However, empirical studies on health care utilization by this population in South Korea are rare.

OBJECTIVE

The purpose of this study was to examine the characteristics of people with disabilities and to evaluate the relationship between the presence and severity of disabilities and health care utilization.

METHODS

We analyzed the 2005-2011 Korea Welfare Panel Study data, and the final sample included 38,598 observations over seven years. Health care utilization was measured by health screening attendance, number of outpatient physician visits, and inpatient days. To examine the impact of disabilities on health care utilization, random-effects logistic regression and negative binomial regression models were adopted.

RESULTS

About 3.3% of the sample had physical disabilities, as defined by the Korean disability registration system. In the sample, the prevalence of chronic diseases and percentage of poor self-rated health were higher in people with disabilities than in people without disabilities. The results of the regression analyses showed that people with severe disabilities had a lower probability of health screening attendance, and they also had significantly longer inpatient stays for health care services.

CONCLUSIONS

These findings imply poor accessibility of preventive or outpatient health care services for people with severe disabilities in Korea, and suggest that barriers should be removed. Further studies are necessary for effective health care provision to meet the complex needs of people with disabilities.

Promoting a new research agenda: health disparities research at the intersection of disability, race, and ethnicity

BACKGROUND

Differences in access to and receipt of health care have been extensively documented across racial and ethnic groups. Similarly, a growing body of research has documented disparities between people with and without disabilities in obtaining needed health care. However, our understanding of the intersection of disability with race and ethnicity in health care is very limited.

OBJECTIVES

The purpose of this supplement is to begin to bridge the gap between research on racial and ethnic health disparities and research on disability-related health disparities.

RESULTS

The papers in this supplement examine evidence of racial and ethnic disparities within various populations of people with disabilities, and explore unique issues at the intersection of disability, race, and ethnicity.

CONCLUSIONS

The studies in this issue provide a starting point, and are intended to serve as an impetus for building a more robust literature on health care issues impacting the expanding segment of United States population that both experience disability and belong to racial and ethnic groups other than non-Hispanic white.

[Disability and use of health services by the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based study]

This study focused on the association between disability and use of health services among elderly individuals in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil. The study included 1,624 elderly patients (≥ 60 years) selected by representative sampling. The dependent variable was use of health services, based on three descriptors: number of physician visits, home consultations, and hospitalizations. The target independent variable was disability, including difficulty in performing activities of daily living (ADL) and instrumental activities of daily living (IADL). IADL was only associated with hospitalization (PR = 1.62; 95%CI: 1.16-2.26), while ADL was associated with hospitalization (PR = 1.73; 95%CI: 1.24-2.42) and home consultations (PR = 8.54; 95%CI: 4.22-17.27). The findings show increased use of health services (especially more costly ones) among older adults with disabilities, and that functional health dimensions have not oriented health services, still largely conditioned on the presence of diseases.

Subgroup differences in having a usual source of health care among working-age adults with and without disabilities

BACKGROUND

Having a usual source of health care is positively associated with regular health maintenance visits and receipt of preventive services. People with disabilities are, overall, more likely than those without disabilities to have a usual source of care (USC). However, the population of people with disabilities is quite heterogenous, and some segments of the population may have less access to a USC than others.

OBJECTIVE

To determine whether there are significant subgroup differences in having a USC within the U.S. population of working-age adults with disabilities, and to compare adults with and without disabilities while controlling for other subgroup differences.

METHODS

We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We performed both bivariate and multivariate logistic regression analyses to examine the relationship of sociodemographic and disability subgroup variables with having a USC.

RESULTS

Within the disability population, individuals who were younger; male; Black, Hispanic, or other (non-White) race; less educated; of lower income; or uninsured for part or all of the year were significantly less likely to have a USC. These differences mirrored those among adults without disabilities. When controlling for these differences, people with physical, hearing, or multiple disabilities had greater odds of having a USC than people without disabilities, but those with vision or cognitive limitations did not differ significantly from the non-disabled referent group.

CONCLUSIONS

Disparities among people with and without disabilities are similar, underscoring the need for attention to disparities within the disability population.

Disparities in health care access and receipt of preventive services by disability type: analysis of the medical expenditure panel survey

OBJECTIVE

To examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities.

DATA SOURCE

Secondary analysis of Medical Expenditure Panel Survey (MEPS) data from 2002 to 2008.

STUDY DESIGN

We conducted cross-sectional logistic regression analyses comparing people with different types of disabilities on health insurance status and type; presence of a usual source of health care; delayed or forgone care; and receipt of dental checkups and cancer screening.

DATA COLLECTION

We pooled annualized MEPS data files across years. Our analytic sample consisted of adults (18-64 years) with physical, sensory, or cognitive disabilities and nonmissing data for all variables of interest.

PRINCIPAL FINDINGS

Individuals with hearing impairment had better health care access and receipt than people with other disability types. People with multiple types of limitations were especially likely to have health care access problems and unmet health care needs.

CONCLUSIONS

There are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups.

Rural disparities in receipt of colorectal cancer screening among adults ages 50-64 with disabilities

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths in the United States. Early detection can reduce mortality; however, only 59% of U.S. adults age 50 and over meet recommended colorectal cancer screening guidelines. Studies in the general population have observed that rural residents are less likely to have received colorectal cancer screening than residents of urban areas.

OBJECTIVE

To determine whether urban/rural disparities in colorectal cancer screening exist among people with disabilities, similar to the disparities found in the general population.

METHODS

We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We conducted logistic regression analyses to examine the relationship between urban/rural residence and ever having received screening for colorectal cancer (via colonoscopy, sigmoidoscopy, or fecal occult blood test).

RESULTS

Among U.S. adults ages 50-64 with disabilities, those living in rural areas were significantly less likely to have ever received any type of screening for colorectal cancer. The urban/rural difference was statistically significant regardless of whether or not we controlled for demographic, socioeconomic, health, and health care access variables.

CONCLUSIONS

Disparity in screening for colorectal cancer places rural residents with disabilities at greater risk for late stage diagnosis and mortality relative to people with disabilities in urban areas. Thus, there is a need for strategies to improve screening among people with disabilities in rural areas.

[Factors associated with difficulty of access of the elderly with disabilities to the health services]

This study seeks to analyze which are the variables associated with the difficulty of elderly people with disabilities gaining access to the health services. This is an observational study of an analytical cross-sectional nature, with a sample of 244 elderly people with disabilities. Data relating to socio-economic profile, the nature of the disability, and the conditions of access to health services were gathered. Version 11.0 of the Statistical Package for the Social Sciences software was used for descriptive, statistical and analytical assessment of the data. The protection variables for difficulties in being treated in the health services were: the lack of drains, culverts, trash, bags of refuse, or irregular floor surfaces; the absence of ramps on sidewalks and pavements; the availability of transport; ease in scheduling appointments; and the length of the waiting period to be attended. The number of factors listed shows that the architectonic barriers and the current situation of healthcare need to be adequate in order to ensure full access and use by the elderly with disabilities to the health services.

The complex web of health: relationships among chronic conditions, disability, and health services

OBJECTIVES

A critical issue in health-care reform concerns how to realign health-care delivery systems to manage medical care services for people with ongoing and costly needs for care. We examined the overlapping health-care needs of two such population groups among the U.S. working-age population (those aged 18-64 years): people with chronic medical conditions and people with disabilities.

METHODS

Using the Medical Expenditure Panel Survey (2002-2004), we examined differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. We also analyzed people with three key chronic conditions: arthritis, diabetes, and depression.

RESULTS

More than half of working-age people with disabilities reported having more than one chronic condition. Among those with activities of daily living or instrumental activities of daily living limitations, 35% reported four or more chronic conditions at a time. We found considerable variability in access problems and service use depending on how we accounted for the overlap of multiple conditions among people with arthritis, diabetes, and depression. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.

CONCLUSIONS

The overall prevalence of chronic conditions among the U.S. working-age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health-care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diagnosis are required to track the ongoing needs for health services that these populations present.

Ongoing coverage for ongoing care: access, utilization, and out-of-pocket spending among uninsured working-aged adults with chronic health care needs

OBJECTIVES

We sought to determine how part-year and full-year gaps in health insurance coverage affected working-aged persons with chronic health care needs.

METHODS

We conducted multivariate analyses of the 2002-2004 Medical Expenditure Panel Survey to compare access, utilization, and out-of-pocket spending burden among key groups of persons with chronic conditions and disabilities. The results are generalizable to the US community-dwelling population aged 18 to 64 years.

RESULTS

Among 92 million adults with chronic conditions, 21% experienced at least 1 month uninsured during the average year (2002-2004). Among the 25 million persons reporting both chronic conditions and disabilities, 23% were uninsured during the average year. These gaps in coverage were associated with significantly higher levels of access problems, lower rates of ambulatory visits and prescription drug use, and higher levels of out-of-pocket spending.

CONCLUSIONS

Implementation of health care reform must focus not only on the prevention of chronic conditions and the expansion of insurance coverage but also on the long-term stability of the coverage to be offered.