> Identifying Barriers to Health Care

Slide 1 -- Title

In recent years, women's health has emerged as a prominent public health
priority. Research focused on women's health has led to valuable
information about how and why certain diseases affect women
disproportionately, predominantly, or differently than men. It has also
led to a better understanding of the differential health risks faced by
particular subpopulations of women, such as those who are members of
racial and ethnic minority groups*.* Yet despite the increased awareness
of women's health, research to date has not adequately addressed the
health concerns of women with disabilities (Thierry & Cyril, 2004).

Although there is a growing interest in women's health, research
addressing the health of women with disabilities is a new and emerging
field. Only within the past decade has an increasing number of
researchers begun to examine the health of women with disabilities and
address topics such as access to care, health care utilization, and the
prevention of secondary conditions (Vines & Shackelford, 1996; Turk,
Geremski, Rosenbaum. 1997; Stuifbergen & Roberts, 1997; Iezzoni,
McCarthy, Davis, & Siebans, 2000; Turk, Rosenbaum, Scandale, 2001;
Rimmer & Liu, 2001; White, Figoni, Froehlich, Marquis, 2001; Coyle &
Santiago, 2002). And for the first time objectives on the public health
needs of people with disabilities, including disabled women, are
reflected in *Healthy People 2010* (U.S. Department of Health and Human
Services (HHS), 2000).

Slide 2 -- Definition of Disability

In general terms, disability refers to "limitations in physical or
mental function, caused by one or more health conditions, in carrying
out socially defined tasks or roles" (IOM).^8^ Commonly accepted
measures of disability have focused on functional limitations, activity
limitations, and work limitations. These definitions allow for the
inclusion of people with many disabling conditions including sensory,
cognitive, emotional, or physical impairments, and various chronic
health conditions. However, use of these multiple definitions has
resulted in varying prevalence estimates of disability in women.

Slide 3 -- Prevalence of Disability Among Women with FLs

For example, estimates from the National Health Interview
Survey-Disability Supplement indicate that 16% of women 18 years of age
or older have at least one functional limitation.^2^ The prevalence of
having at least one functional limitation increases with age from 6% for
women 18-44 years to 40% for women 65 years or older. In comparison,
state-based estimates from the Behavioral Risk Factor Surveillance
System suggest the overall prevalence of disability among women is 18%.
^9^

Slide 4 -- Activity Limiting Conditions with Highest Prevalence Rates

Depending on the definition used, overall estimates of disability among
women in the United States range from 19.9 to 28.6 million.^10-11^
Disorders of the back and spine are the most prevalent conditions
associated with disability among women followed by arthritis and heart
disease. ^12^ Together, these conditions represent approximately 38
percent of all conditions causing limitations among women. Conditions
generally thought to have a high risk for causing severe disability
among women, such as multiple sclerosis, spinal cord injury, and mental
retardation, have small prevalence rates, yet are often associated with
greater severity of disability and increased need for specialized
services. ^6^

Slide 5 -- Perceived Health Status

Recent studies suggest that women with disabilities encounter many of
the same health problems as women who are not disabled, yet they
consistently report poorer health (Iezzoni, McCarthy, Davis, & Siebans,
2000; Chevarley, Thierry, Gill, Nosek, & Ryerson, unpublished data).

Data from the National Health Interview Survey -- Disability Supplement
suggest a strong inverse relationship between self-reported heath status
and the number of Fls; women with Fls are less likely than women with no
Fls to rate their health as excellent or very good, and more likely to
report their health as fair or poor. As seen in this slide,
Approximately 14% of women with 3 or more Fls rated their health as
excellent or very good, compared to 65% of women with no Fls. Women with
disabilities between the ages of 45-64 were the most likely to rate
their health as poor. **(Sixty-three percent rated their health to be
fair or poor, compared to only 8% of women with no Fls.)**

Slide 6 -- Barriers to Healthcare

All members of the disability community should have access to health
promotion, disease prevention, and the direct medical services they need
to optimize good health. Yet women with disabilities continue to face
substantial barriers that limit their access to healthcare services.
These include physical, attitudinal, and policy barriers; lack of
information about how disability affects health; limited finances; and
insufficient personal assistance.

Slide 7 -- Inability to Access Health Care

In an analysis by Chevarley et al., women with FLs were more likely to
report being unable to get medical care, mental health care, dental
care, prescription medications, and eyeglasses than women without FLs.

Slide 8 -- Delayed Care due to Cost

In addition, many of these women reported delaying care because of cost.
Women with three or more Fls most often reported delaying care, 26%
compared with 9% of women with no FLs.

Slide 9 -- MMWR

An important aspect of improving the health status of women and
achieving the HP 2010 objectives is the provision of clinical preventive
services. Although only a few studies have examined the use of
preventive health services for women with disabilities, results indicate
that these women do not consistently receive preventive health services.

A 1998 report on cervical and breast cancer screening among women with
functional limitations (FLs) found that older women with FLs were less
likely to have received a Pap test or mammogram within the recommended
guidelines.^16^ A recent study of health care utilization by Coyle &
Santiago found that while most women with disabilities had seen a
general practitioner within the past six months, a substantial
proportion of these women had not received routine gynecological care in
the preceding five years. ^15^

Slide 10 - Iezzoni Slide?

Researchers in Boston found that women with major mobility problems were
significantly less likely to receive pap tests and mammograms than women
with no mobility impairments.^1^ The same study reported that people
with mobility impairments were as likely as others to receive
(pneumococcal and ) influenza immunizations but were less likely to
receive additional services such as tetanus immunization.

Slide 11 -- Procedures performed

In a study by Tamaskar et. al., Deaf and hard of hearing persons were
less likely than hearing persons to report being asked about alcohol
consumption and smoking, or to have been examined for hypertension,
cancer, height, and weight. Similarly, data from the NHIS-D suggest that
women with FLs are less likely to be asked about diet/eating habits,
physical activity, smoking, drinking, drug use, Sexually Transmitted
Diseases, and contraceptive use than women with no FLs.

Slide 12 -- Barriers /Picture

These studies confirm that more attention should be given to screening
and preventive services for women with disabilities. Health care
providers must be careful not to overlook the preventive health needs of
women with disabilities. Efforts to improve provider training should
include techniques for examinations that can accommodate women with
disabilities including any disability-related symptom that may interfere
with their examinations.^17^ To increase the likelihood that women
receive appropriate preventive care, accessible equipment such as
adjustable height examination tables and accessible mammography machines
must be widely available. In addition, health information must be made
available in alternative formats. As women with disabilities live longer
lives, it is important that clinicians recognize that these women can
benefit from the full range of preventive services.

Slide 13 -- Overweight & Obesity

Overweight and obesity are major contributors to morbidity and mortality
in the United States. Obesity is a well-established risk factor for
hypertension, type 2 diabetes, cardiovascular disease, osteoarthritis,
sleep apnea, gallstones, and certain types of cancer. ^12,\ 17^ Obesity
has reached epidemic proportions in our society, particularly among
women. Previous studies have shown that 35% of women in the U.S. are
overweight. ^17^ Despite this increased interest in obesity, few studies
have addressed the prevalence of obesity among women with disabilities.

Estimates from the National Health Interview Survey-Disability
Supplement, indicate that obesity is more prevalent among adults with
physical, sensory, and mental health conditions.^18^ These researchers
found that nearly 26% of adults with disabilities were obese, compared
to approximately 15% of those without disabilities.^18^ Adults with
mobility difficulties were the most likely to be obese.

Slide 14 -- BRFSS/Obesity

State based estimates from CDC's BRFSS indicate that 27% of adults with
disabilities are obese. Compared to women without disabilities, a
substantially larger percentage of women with disabilities are obese
(15% and 29% respectively). Effective interventions must address
obstacles to weight control and exercise, including barriers such as
inaccessible fitness facilities, lack of recreational opportunities, and
limited transportation. In addition, guidelines should be developed to
improve providers' counseling skills in this area.

Slide 15 -- Physical Activity

Physical activity plays an important role in improving and maintaining
health. The 1996 Surgeon General's report on Physical Activity concluded
that moderate physical activity can decrease considerably the risk of
developing or dying from heart disease, diabetes, colon cancer, and high
blood pressure.^20^ Despite the numerous benefits of physical activity,
few individuals, including people with disabilities, engage in regular
physical activity. Data show that people with disabilities are more
likely to report no leisure time physical activity and are less likely
to participate in regular physical activity than people without
disabilities.^11^ Similar to overweight and obesity, intervention
strategies that improve access and facilitate participation should be
used to increase physical activity among women with disabilities. Health
care providers can obtain additional information on physical activity
for people with disabilities by contacting the National Center on
Physical Activity and Disability (NCPAD) at www.ncpad.org.

Slide 16 -- Conclusion

One in every five women living in the United States has a disability
(Jans & Stoddard, 1999; McNeil, 2001). Everyone knows someone with a
disability. Nevertheless, the health needs of women with disabilities
are not fully acknowledged by our current healthcare system. ADD
CONCLUDING STATEMENT.

Slide 17 - Questions