Cross-sectional and longitudinal risk of physical impairment in a cohort of postmenopausal women who experience physical and verbal abuse.

BACKGROUND: Exposure to interpersonal violence, namely verbal and physical abuse, is a highly prevalent threat to women's health and well-being. Among older, post-menopausal women, several researchers have characterized a possible bi-directional relationship of abuse exposure and diminished physical functioning. However, studies that prospectively examine the relationship between interpersonal abuse exposure and physical functioning across multiple years of observation are lacking. To address this literature gap, we prospectively evaluate the association between abuse exposure and physical functioning in a large, national cohort of post-menopausal women across 12 years of follow-up observation. METHODS: Multivariable logistic regression was used to measure the adjusted association between experiencing abuse and physical function score at baseline in 154,902 Women's Health Initiative (WHI) participants. Multilevel modeling, where the trajectories of decline in physical function were modeled as a function of time-varying abuse exposure, was used to evaluate the contribution of abuse to trajectories of physical function scores over time. RESULT: Abuse was prevalent among WHI participants, with 11 % of our study population reporting baseline exposure. Verbal abuse was the most commonly reported abuse type (10 %), followed by combined physical and verbal abuse (1 %), followed by physical abuse in the absence of verbal abuse (0.2 %). Abuse exposure (all types) was associated with diminished physical functioning, with women exposed to combined physical and verbal abuse presenting baseline physical functioning scores consistent with non-abused women 20 years senior. Results did not reveal a differential rate of decline over time in physical functioning based on abuse exposure. CONCLUSIONS: Taken together, our findings suggest a need for increased awareness of the prevalence of abuse exposure among postmenopausal women; they also underscore the importance of clinician's vigilance in their efforts toward the prevention, early detection and effective intervention with abuse exposure, including verbal abuse exposure, in post-menopausal women. Given our findings related to abuse exposure and women's diminished physical functioning at WHI baseline, our work illuminates a need for further study, particularly the investigation of this association in younger, pre-menopausal women so that the temporal ordering if this relationship may be better understood.

Food Insecurity, Hunger, and Obesity Among Informal Caregivers.

INTRODUCTION: Increasing numbers of US residents rely on informal caregiving from friends and family members. Caregiving can have substantial health and financial impacts on caregivers. This study addressed whether those impacts include adverse nutritional states. Specifically, we examined household food insecurity, individual hunger, and obesity among caregivers compared with noncaregivers. METHODS: We analyzed 2012 Behavioral Risk Factor Surveillance System data from Oregon. The Caregiving Module was administered to a random subset of 2,872 respondents. Module respondents included 2,278 noncaregivers and 594 caregivers providing care or assistance to a friend or family member with a health problem or disability. We used multivariable logistic regression to assess associations between caregiving status and each of our dependent variables. RESULTS: Caregivers had significantly greater odds of reporting household food insecurity (odds ratio [OR] = 2.10, P = .003) and personal hunger (OR = 2.89, P = .002), even after controlling for income and other correlates of food insecurity. There were no significant differences in obesity between caregivers and noncaregivers. CONCLUSION: Caregiving is associated with increased risk of food insecurity and hunger in Oregon, suggesting that careful attention to the nutritional profile of households with family caregivers is needed in this population.

U.S. population estimates and correlates of sexual abuse of community-dwelling older adults.

We describe the annual prevalence of sexual abuse among community-dwelling older adults in the United States. We also describe factors associated with experiencing sexual abuse. We used data from 24,343 older adults from the 2005 Behavioral Risk Factor Surveillance System pooled across 18 states. We estimated prevalence of sexual abuse, bivariate distributions, and odds ratio associations across demographic, health, and contextual factors. Our results show that 0.9% of older adults reported experiencing sexual abuse in the previous year. This represents approximately 90,289 community-dwelling older adults. We also report on factors associated with experiencing recent sexual abuse. There was a significant gender by binge drinking interaction, with a stronger association among women. There is a need for health promotion efforts targeted specifically toward older adults, encouraging them to seek services, if possible, after exposure to sexual abuse.

Doubly robust testing and estimation of model-adjusted effect-measure modification with complex survey data.

Model-based standardization enables adjustment for confounding of a population-averaged exposure effect on an outcome. It requires either a model for the probability of the exposure conditional on the confounders (an exposure model) or a model for the expectation of the outcome conditional on the exposure and the confounders (an outcome model). The methodology can also be applied to estimate averaged exposure effects within categories of an effect modifier and to test whether these effects differ or not. Recently, we extended that methodology for use with complex survey data, to estimate the effects of disability status on cost barriers to health care within three age categories and to test for differences. We applied the methodology to data from the 2007 Florida Behavioral Risk Factor Surveillance System Survey (BRFSS). The exposure modeling and outcome modeling approaches yielded two contrasting sets of results. In the present paper, we develop and apply to the BRFSS example two doubly robust approaches to testing and estimating effect modification with complex survey data; these approaches require that only one of these two models be correctly specified. Furthermore, assuming that at least one of the models is correctly specified, we can use the doubly robust approaches to develop and apply goodness-of-fit tests for the exposure and outcome models. We compare the exposure modeling, outcome modeling, and doubly robust approaches in terms of a simulation study and the BRFSS example.

Association of blood cotinine level with cognitive and physical performance in non-smoking older adults.

UNLABELLED: Background Studies show that active smoking may be associated with cognitive decline. However, the consequence of secondhand smoke on cognitive and physical performance remains unclear. The purpose of this study was to assess the association of secondhand smoke with cognitive performance and physical function using a population-based sample. METHODS: Data of 2,542 non-smoking participants from the 1999-2002 National Health and Nutrition Examination Survey were analyzed. Secondhand smoke exposure level was estimated using blood cotinine concentrations. Cognitive performance was assessed with the Digit Symbol Substitution Test and self-reported confusion/memory problems. Physical performance was analyzed using visual gait speed (m/s) and self-reported physical function. Multivariate linear and logistic regression models were used to assess the association. RESULTS: In never smokers, cognitive performance score decreased by 2.03 points (95% confidence interval (CI): -3.00, -1.05) per one unit increase in log-transformed blood cotinine level. After adjusting for potential confounders, including diabetes, hypertension, body mass index, alcohol, and blood lead level, change in cognitive performance score was still statistically significant (-1.17 95% CI: -2.32, -0.02). Similar trends were observed in former smokers. Gait speed decreased by 0.02m/s for one unit increase in log-transformed blood cotinine level. This was evident in both never and former smokers. The relationship remained significant after adjusting for potential confounders in former smokers. CONCLUSIONS: Our study suggests that secondhand smoke may contribute to cognitive decline in never and former smokers. Considering the cross-sectional design and the limitations of this study, the relationship warrants further assessment.

Observer ratings of neighborhoods: comparison of two methods.

BACKGROUND: Although neighborhood characteristics have important relationships with health outcomes, direct observation involves imperfect measurement. The African American Health (AAH) study included two observer neighborhood rating systems (5-item Krause and 18-item AAH Neighborhood Assessment Scale [NAS]), initially fielded at two different waves. Good measurement characteristics were previously shown for both, but there was more rater variability than desired. In 2010 both measures were re-fielded together, with enhanced training and field methods implemented to decrease rater variability while maintaining psychometric properties. METHODS: AAH included a poor inner city and more heterogeneous suburban areas. Four interviewers rated 483 blocks, with 120 randomly-selected blocks rated by two interviewers. We conducted confirmatory factor analysis of scales and tested the Krause (5-20 points), AAH 18-item NAS (0-28 points), and a previous 7-item and new 5-item versions of the NAS (0-17 points, 0-11 points). Retest reliability for items (kappa) and scales (Intraclass Correlation Coefficient [ICC]) were calculated overall and among pre-specified subgroups. Linear regression assessed interviewer effects on total scale scores and assessed concurrent validity on lung and lower body functions. Mismeasurement effects on self-rated health were also assessed. RESULTS: Scale scores were better in the suburbs than in the inner city. ICC was poor for the Krause scale (ICC=0.19), but improved if the retests occurred within 10 days (ICC=0.49). The 7- and 5-item NAS scales had better ICCs (0.56 and 0.62, respectively), and were higher (0.71 and 0.73) within 10 days. Rater variability for the Kraus and 5- and 7-item NAS scales was 1-3 points (compared to the supervising rater). Concurrent validity was modest, with residents living in worse neighborhood conditions having worse function. Unadjusted estimates were biased towards the null compared with measurement-error corrected estimates. CONCLUSIONS: Enhanced field protocols and rater training did not improve measurement quality. Specifically, retest reliability and interviewer variability remained problematic. Measurement error partially reduced, but did not eliminate concurrent validity, suggesting there are robust associations between neighborhood characteristics and health outcomes. We conclude that the 5-item AAH NAS has sufficient reliability and validity for further use. Additional research on the measurement properties of environmental rating methods is encouraged.

Access to the US Department of Veterans Affairs health system: self-reported barriers to care among returnees of Operations Enduring Freedom and Iraqi Freedom.

BACKGROUND: The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. METHODS: We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. RESULTS: Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. CONCLUSIONS: This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Adult caregivers in the United States: characteristics and differences in well-being, by caregiver age and caregiving status.

We examined the characteristics of adults providing regular care or assistance to friends or family members who have health problems, long-term illnesses, or disabilities (ie, caregivers). We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to examine caregiver characteristics, by age and caregiving status, and compare these characteristics with those of noncaregivers. Approximately 24.7% (95% confidence interval, 24.4%-25.0%) of respondents were caregivers. Compared with younger caregivers, older caregivers reported more fair or poor health and physical distress but more satisfaction with life and lower mental distress. Understanding the characteristics of caregivers can help enhance strategies that support their role in providing long-term care.

Does a standard measure of self-reported physical disability correlate with clinician perception of impairment related to cancer screening?

BACKGROUND: Adults with physical disabilities are less likely than others to receive cancer screening. It is not known, however, whether commonly used measures assess elements of physical ability necessary for successful screening. The objective of this exploratory study was to determine whether patients who reported limitations in activities of daily living (ADLs) or instrumental ADLs (IADLs) are perceived by their primary care clinicians to have physical limitations that may impede cancer screening. METHODS: Patients at 2 rural primary care clinics were surveyed about ADLs and IADLs and about their up-to-date status for breast, cervical, and/or colorectal cancer screening. Clinicians and office staff were asked whether they believed each patient had a physical limitation that might impede screening. The agreement between patient and clinician assessments was evaluated. RESULTS: Clinicians believed that 43% of patients with severe disability (ADLs) and 30% of patients with moderate disability (IADLs) had limitations that might affect screening. Agreement between patient and clinician assessments was low according to the kappa statistic (κ = 0.355), but had a high percentage of negative agreement (92.3%) and a low percentage of positive agreement (42.7%). Patients with ADL/IADL-related disability were less likely than nondisabled patients to be current for cervical and breast cancer screening. Patients who were viewed by clinicians as having limitations relevant for screening were less likely to be current for cervical cancer screening. CONCLUSIONS: These results indicate that a common measure of general disability may not capture all factors relevant for cancer screening. An instrument designed to include these factors may help identify and accommodate patients who have disabilities that may impede screening.

Health-related quality of life among older adults with and without functional limitations.

OBJECTIVES: We examined factors that influence health-related quality of life (HRQOL) among individuals aged 50 years and older with and without functional limitations. METHODS: We analyzed data from the 2009 Behavioral Risk Factor Surveillance System to assess associations among demographic characteristics, health care access and utilization indicators, modifiable health behaviors, and HRQOL characterized by recent physically and mentally unhealthy days in those with and those without functional limitations. We defined functional limitations as activity limitations owing to physical, mental, or emotional health or as the need for special equipment because of health. RESULTS: Age, medical care costs, leisure-time physical activity, and smoking were strongly associated with both physically and mentally unhealthy days among those with functional limitations. Among those without functional limitations, the direction of the effects was similar, but the size of the effects was substantially smaller. CONCLUSIONS: The availability of lower cost medical care, increasing leisure-time physical activity, and reducing rates of cigarette smoking will improve population HRQOL among older adults with and without functional limitations. These factors provide valuable information for determining future public health priorities.

Childhood school segregation and later life sense of control and physical performance in the African American Health cohort.

BACKGROUND: The association between childhood school desegregation and later life sense of control and physical performance among African Americans is not clear. We hypothesized that childhood school desegregation adversely affected the sense of control of in later life, and that this reduced sense of control accounts in part for reduced physical performance. METHODS: In-home follow-up assessments were completed in 2010 with 582 of the 58-74 year old men and women participating in the on-going African American Health cohort. We used these data to examine the relationship between (a) retrospective self-reports of attending segregated schools during one's 1st-to-12th grade education and one's current sense of control, as well as (b) the association between current sense of control and physical performance. Multiple linear regression analysis with propensity score re-weighting was used. RESULTS: Attending segregated schools for at least half of one's 1st-to-12th grade education was significantly associated with higher scores on the sense of control. Adjusting for all covariates and potential confounders, those receiving half or more of their 1st-to-12th grade education in segregated schools had sense of control scores that were .886 points higher (p ≤ .01; standardized effect size = .22). Sense of control scores were independently (all p < .01) associated with better systolic blood pressure, grip strength, peak expiratory flow, chair stands, balance tests, and the Short Portable Physical Battery even after adjusting for all covariates and potential confounders. Moreover, sense of control scores either partially or fully mediated the statistically significant beneficial associations between childhood school segregation and physical performance. CONCLUSIONS: Childhood school desegregation was adversely associated with the sense of control of African Americans in later life, and this reduced sense of control appears, in part, to account for their poorer physical performance. The etiologic mechanism through which childhood school segregation at the time that this cohort experienced it improved the sense of control in later life, which subsequently led to better physical performance, has not been identified. We suspect, however, that the pathway involves greater exposure to racial solidarity, same-race students as peer role models and same-race teachers and principals as authority role models, the reduced likelihood of exposure to race-based discrimination or antagonism during their formative early lives, and greater exposure to encouragement and support for academic and life success.

Testing and estimating model-adjusted effect-measure modification using marginal structural models and complex survey data.

Recently, it has been shown how to estimate model-adjusted risks, risk differences, and risk ratios from complex survey data based on risk averaging and SUDAAN (Research Triangle Institute, Research Triangle Park, North Carolina). The authors present an alternative approach based on marginal structural models (MSMs) and SAS (SAS Institute, Inc., Cary, North Carolina). The authors estimate the parameters of the MSM using inverse weights that are the product of 2 terms. The first term is a survey weight that adjusts the sample to represent the unstandardized population. The second term is an inverse-probability-of-exposure weight that standardizes the population in order to adjust for confounding; it must be estimated using the survey weights. The authors show how to use the MSM parameter estimates and contrasts to test and estimate effect-measure modification; SAS code is provided. They also explain how to program the previous risk-averaging approach in SAS. The 2 methods are applied and compared using data from the 2007 Florida Behavioral Risk Factor Surveillance System Survey to assess effect modification by age of the difference in risk of cost barriers to health care between persons with disability and persons without disability.

Adverse housing and neighborhood conditions and inflammatory markers among middle-aged African Americans.

Adverse housing and neighborhood conditions are independently associated with an increased risk of various diseases and conditions. One possible explanation relates to systemic inflammation, which is associated with these adverse health outcomes. The authors investigated the association between housing and neighborhood conditions with inflammatory markers using data about 352 persons aged 49-65 years from the African American Health study. Participants were identified by a multistage random selection process in 2000 to 2001(response rate, 76%). Blood was analyzed for soluble cytokine receptors (interleukin-6, tumor necrosis factor alpha), C-reactive protein, and adiponectin. Neighborhood and housing characteristics consisted of five observed block face conditions (external appearance of the block on which the subject lived), four perceived neighborhood conditions, four observed housing conditions (home assessment by the interviewers rating the interior and exterior of the subject's building), and census-tract level poverty rate from the 2000 census. Differences in some inflammatory markers were found by age, gender, chronic conditions, and body mass index (all Bonferroni-adjusted p < 0.0034). There was no association between any of the housing/neighborhood conditions and the pro-inflammatory markers and potential associations between some housing/neighborhood conditions and adiponectin (p < 0.05, Bonferroni-adjusted p > 0.0034). Inflammation does not appear to be a mediator of the association between poor housing/neighborhood conditions and adverse health outcomes in middle-aged African Americans.

Structure of health-related quality of life among people with and without functional limitations.

PURPOSE: The objective of this study was to assess the factor structure of nine health-related quality of life (HRQOL) survey items among people with and without disabilities or functional limitations (FL) and determine whether factor loadings were similar for the two groups. METHODS: Data were from US states and territories in the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). Confirmatory factor analyses assessed fit of the data to a previously found factor structure. RESULTS: A two-factor structure was confirmed, conceptually representing physical and mental health. Although this structure fit data for both people with and without FL, factor loadings were significantly different for the two groups. In all but one instance, factor loadings were higher for people with FL than for people without FL. CONCLUSIONS: Results suggest that people with and without FL conceptualize physical and mental HRQOL similarly. However, the nine items analyzed appear to be a better reflection of the latent constructs of physical and mental HRQOL in the population of people with FL than those without FL.

Neighborhood conditions, diabetes, and risk of lower-body functional limitations among middle-aged African Americans: a cohort study.

BACKGROUND: The relationship between presence of diabetes and adverse neighborhood and housing conditions and their effect on functional decline is unclear. We examined the association of adverse neighborhood (block face) and housing conditions with incidence of lower-body functional limitations among persons with and those without diabetes using a prospective population-based cohort study of 563 African Americans 49-65 years of age at their 2000-2001 baseline interviews. METHODS: Participants were randomly sampled African Americans living in the St. Louis area (response rate: 76%). Physician-diagnosed diabetes was self reported at baseline interview. Lower-body functional limitations were self reported based on the Nagi physical performance scale at baseline and the three-year follow-up interviews. The external appearance of the block the respondent lived on and five housing conditions were rated by study interviewers. All analyses were done using propensity score methods to control for confounders. RESULTS: 109 (19.4%) of subjects experienced incident lower-body functional limitations at three-year follow-up. In adjusted analysis, persons with diabetes who lived on block faces rated as fair-poor on each of the five conditions had higher odds (7.79 [95% confidence interval: 1.36-37.55] to 144.6 [95% confidence interval: 4.45-775.53]) of developing lower-body functional limitations than the referent group of persons without diabetes who lived on block faces rated as good-excellent. At least 80 percent of incident lower-body functional limitations was attributable to the interaction between block face conditions and diabetes status. CONCLUSIONS: Adverse neighborhood conditions appear to exacerbate the detrimental effects on lower-body functioning associated with diabetes.

Lack of choice in caregiving decision and caregiver risk of stress, North Carolina, 2005.

INTRODUCTION: An aspect of caregiving that has received little attention is the degree to which the choice to provide care affects a caregiver's emotional well-being. We compared a population-based sample of informal caregivers who reported having a choice in caring with caregivers who did not have a choice in caring to determine the extent to which choice affects caregivers' self-reported stress. METHODS: We identified 341 informal caregivers who completed a caregiving module appended to the 2005 North Carolina Behavioral Risk Factor Surveillance System survey. We determined participants' self-reported stress by using a 5-point scale that was dichotomized and used adjusted binomial logistic regression to assess the risk of stress given lack of choice in caregiving. RESULTS: In the fully adjusted model, caregivers without a choice in caring were more than 3 times as likely to report stress as caregivers with a choice in caring. High level of burden also increased stress. Caregivers with no choice in caring were most commonly the primary caregiver of a parent. CONCLUSION: Caregivers who do not have a choice in caregiving were at increased risk of stress, which may predispose them to poor health outcomes. Further investigation is needed to determine whether interventions that target caregivers without a choice in caring can reduce their levels of stress.

Caregivers of older adults with cognitive impairment.

INTRODUCTION: Because of the growing number of caregivers and the awareness of related health and quality-of-life issues, caregiving has emerged as an important public health issue. We examined the characteristics and caregiving experiences of caregivers of people with and without cognitive impairment. METHODS: Participants (n = 668) were adults who responded to the 2005 North Carolina Behavioral Risk Factor Surveillance System. Caregivers were people who provided regular care to a family member or friend aged 60 years or older either with or without cognitive impairment (ie, memory loss, confusion, or Alzheimer's disease). RESULTS: Demographic characteristics of caregivers of people with cognitive impairment were similar to those of caregivers of people without cognitive impairment. However, compared with caregivers of people without cognitive impairment, caregivers of people with cognitive impairment reported higher levels of disability, were more likely to be paid, and provided care for a longer duration. Care recipients with cognitive impairment were more likely than care recipients without cognitive impairment to be older, have dementia or confusion, and need assistance with memory and learning. CONCLUSION: State-level caregiving surveillance is vital in assessing and responding to the needs of the growing number of caregivers.

Three-year measured weight change in the African American health study.

OBJECTIVE: This study examines 3-year weight change in African Americans. METHOD: Nine hundred and ninety-eight participants 49 to 65 years old were assessed at baseline and 3 years later. Weight was measured, and weight change was defined as clinically meaningful increases or decreases (+/- 5 kg). Potential risk factors were investigated using multinomial logistic regression. RESULTS: In-home measured weights were available for 752 participants (75%): 504 (67%) had stable weights, 131 (17%) gained more than 5 kg, and 117 (16%) lost more than 5 kg. Among all participants, the risks for weight gains were cancer, chronic obstructive pulmonary disease, lower income, and Medicaid status; the risks for weight losses were angina, cancer, high measured systolic blood pressure, asthma, and physical inactivity. Sex-stratified analyses reveal differences involving age, socioeconomic status, cancer, blood pressure, and lower body function. DISCUSSION: Three-year weight changes in middle-aged African Americans were frequent and significantly associated with several risk factors.

Application of an intersectional framework to understanding the association of disability and sexual orientation with suicidal ideation among Oregon Teens.

BACKGROUND: Suicide is the second leading cause of death among U.S. youth. Prior research has found that disability and sexual orientation are each independently associated with suicide risk. However, most analyses regarding sexual orientation or disability in relation to teenagers' health have isolated the effects of these identities via multiple regression models. That approach assumes there is no multiplicative or synergistic effect between the two identities. OBJECTIVE: To examine the association between suicidal ideation and the intersection of disability and sexual orientation. METHODS: Cross-sectional data from the 2015 Oregon Healthy Teens Survey were analyzed using Poisson regression analysis with robust variance to estimate the relationship between the intersection of disability and sexual orientation and youth reports of suicidal ideation. We calculated three measures of interaction: 1) the excess risk due to interaction (RERI); 2) the proportion attributable to interaction (AP); and 3) the synergy index (SI). RESULTS: Sexual minority teenagers with disabilities had higher risk of suicidal ideation (adjusted relative risk [ARR] = 2.82, 95% CI: 2.47-3.21) with respect to heterosexual teenagers without disabilities. The risk was also elevated, to a lesser degree, for heterosexual youth with disabilities (ARR = 1.97, 95% CI: 1.78-2.19) and LGB youth without disabilities (ARR = 2.17, 95% CI: 1.95-2.42) with respect to the reference group. Our measures of interaction were indicative of a synergistic effect between disability and sexual orientation. CONCLUSIONS: Our findings suggest the combination of disability and minority sexual orientation may be associated with compounded negative experiences that could exacerbate the risk of suicide.

Contraceptive knowledge and use among women with intellectual, physical, or sensory disabilities: A systematic review.

BACKGROUND: Women spend most of their reproductive years avoiding pregnancy. However, we know little about contraceptive knowledge and use among women with disabilities, or about strategies to improve contraceptive knowledge and decision-making in this population. OBJECTIVE: To systematically review published literature on women with disabilities and: 1) contraceptive knowledge; 2) attitudes and preferences regarding contraception; 3) contraceptive use; 4) barriers and facilitators to informed contraceptive use; and 5) effectiveness of interventions to improve informed contraceptive decision-making and use. METHODS: We searched MEDLINE, PsychINFO, the Cochrane Library, CINAHL, and ERIC databases from inception through December 2017. Two reviewers independently reviewed studies for eligibility, abstracted study data, and assessed risk of bias following PRISMA guidance. RESULTS: We reviewed 11,659 citations to identify 62 publications of 54 unique studies (total n of women with disabilities = 21,246). No standard definition of disability existed across studies. The majority of studies focused on women with intellectual disabilities (ID). Women with ID and those who were deaf or hard-of-hearing had lower knowledge of contraceptive methods than women without disabilities. Estimates of contraceptive use varied widely, with some evidence that women with disabilities may use a narrower range of methods. Five of six studies evaluating educational interventions to increase contraceptive knowledge or use reported post-intervention improvements. CONCLUSIONS: Women with disabilities may use a more narrow mix of contraceptive methods and are often less knowledgeable about contraceptives than women without disabilities. Interventions to improve knowledge show some promise. A lack of data exists on contraceptive preferences among women with disabilities.