Authors
- Smeltzer, Suzanne C. EdD, RN, FAAN
Abstract
Although the Americans With Disabilities Act was enacted 15 years ago in an effort to improve access of people with disabilities to a broad range of services, women with physical disabilities continue to receive less preventive health screening than women without disabilities and less than is recommended. Furthermore, women with more severe disabilities undergo less screening than those with mild or moderate severity of disability. This article reviews findings of studies on health screening for breast and cervical cancer and osteoporosis in women with physical disabilities and identifies practice and research implications on the basis of those findings to improve the health status of women with physical disabilities.
Article Content
SEVERAL objectives in Healthy People 2010 specifically address the need for increasing health screening in women with disabilities,1 who have been identified as one of the most disadvantaged groups in terms of primary healthcare and support.2 Women have traditionally received healthcare that is different from, less aggressive than, and inferior to care provided to men,3 and this is particularly true for women with disabilities. Although efforts have been made recently to address the health disparities and lack of quality healthcare that women with disabilities face, there is strong evidence that they continue to encounter barriers to obtaining preventive healthcare.1,4-8 A major barrier is the inaccessibility of health screenings, which are an important first step in using healthcare resources, including medical care, social support groups, and health promotion interventions.
Some lack of access arises from obstacles in the physical environment. While the 1990 Americans With Disabilities Act (ADA)9 has led to increased access to public facilities and improvements in equipment, and many clinical facilities have made it easier for some women with physical disabilities to access preventive healthcare, women with more severe disabilities remain unable to enter these facilities. Other inaccessibility arises from healthcare providers' own lack of knowledge about issues facing women with disabilities. These women continue to report their providers' failures to address screening and health promotion issues even when women themselves raise the issues.4 As a result, many women with disabilities lack basic information about pertinent health issues and are often ill equipped to insist on attention to them; thus, they are unlikely to receive recommended primary healthcare, including preventive health screening.
This article summarizes what is known about health screening of women with disabilities for breast cancer, cervical cancer, and low bone density. For the purposes of this review, "health screening" refers to provision of or recommendation and referral by a primary healthcare provider (physician, nurse practitioner, nurse midwife, or physician's assistant) for screening or diagnostic testing to detect increased risk for primary health disorders as well as secondary conditions related to the primary disabling condition. Although this review is limited to screening for breast and cervical cancer and osteoporosis, it is important to note that healthcare for women with disabilities includes a number of other primary healthcare issues (eg, immunizations, smoking, contraception, obesity, risk for abuse) as well as management of their primary disabling conditions.
The literature on primary healthcare and health screening for persons with physical disabilities was reviewed. Extensive searches were conducted of MEDLINE (1966-2005), CINAHL (1982-2005), and PsychInfo (1980-2005) databases. The initial searches used "disabilities" as one search term in combination with "health screening" and "primary healthcare" as key search terms. Subsequent searches were conducted using specific physical disabilities (eg, multiple sclerosis, spinal cord injury, spina bifida, cerebral palsy, polio, and arthritis) in combination with "health screening" and "primary healthcare" as key search terms. Reference lists in retrieved studies were also reviewed to identify additional articles. To be included in the review, articles had to be reports of research written in English that addressed breast and cervical cancer screening or osteoporosis screening in women with disabilities. If studies included both men and women with disabilities, they were included if they addressed the relevant health issues. Limiting this review to women with these specific physical disabilities does not imply that other physically disabling disorders, visual and hearing loss, or disorders that are psychologically, cognitively, or emotionally disabling (eg, severe persistent mental illness, intellectual disabilities, and learning disabilities) are unimportant or that women with such disorders do not encounter barriers to healthcare. However, their issues and barriers may differ from those of women with physical disabilities. Although essential to the health status and well-being of all women, including those with disabilities, assessment of abuse and depression were not included in this review; again, this does not imply that these issues are or should be considered less important than those identified and discussed in this review.
GENERAL HEALTH SCREENING AND PREVENTIVE SERVICES IN WOMEN WITH DISABILITIES
The multiple searches uncovered 22 articles that fit the inclusion criteria. Because many women with disabilities have normal or near-normal life spans,10 they need routine health screening, preventive services, and information about health-promoting strategies. However, many do not receive such healthcare.10 Recommendations for health screening have been developed by a number of agencies and organizations, primarily to detect risk for disease or the presence of disease, including breast and cervical cancer, early in its course.11,12 Bone mineral density (BMD) screening can detect low bone density and increased risk for fractures in the presence of falls or other forms of low-intensity trauma13,14 that may be common in women with disabilities.15,16
A number of authors discussed the need for screening and preventive services for individuals with disabilities,1,2,17-20 the role of various healthcare providers and medical specialists in providing these services,21-23 and the modifications needed in clinical facilities and insurance systems to improve care for persons with disabilities.6,9,20,24-26 Despite the recognition of the benefits of early detection and prevention strategies and the need for health screening in women with disabilities, obtaining pelvic examinations, Pap tests, mammograms, and screening for low BMD remain problematic. Researchers also examined these women's ability to obtain the general healthcare and screenings that are recommended and routinely provided to other women.
Health screening for cervical and breast cancer in women with disabilities
Several studies have examined health screening for detection of cervical and breast cancer in women with disabilities. With few exceptions,27,28 most studies revealed that women with disabilities are significantly less likely to have regular pelvic examinations and mammograms than women without disabilities.2,4-6,8,28-32 In particular, women with major lower-extremity mobility limitations and with severe disabilities are much less likely to have these examinations.2,6,8,29,30,34 Seeing a healthcare provider frequently has been shown to be no guarantee that women with disabilities will receive recommended health screening. In one study,35 although 96% of the study participants (N = 170) with physical disabilities had seen a primary healthcare provider within the past 6 months, with 60% reporting such visits 3 or more times in this time frame, many of the women had not received routine preventive gynecologic cancer screening services in the past 5 years. Some women have reported being refused medical care because of their disability.33,36 Physical barriers (eg, lack of transportation; inaccessible offices, examination tables, mammography equipment, and restrooms; and difficulty transferring to the examination table or standing for a mammogram) were identified as major factors responsible for inadequate care. These barriers were reported by women themselves as well as by healthcare providers.37
These physical barriers were also consistently reported in qualitative studies that examined barriers that reduce the frequency of pelvic examinations and other health screenings.29,33,38,39 Other explanations for lack of screening included inadequate time allotted to them for healthcare visits, the healthcare community's lack of knowledge about disability, and the modifications needed if women with disabilities are to receive thorough examinations and screening.33,34,36,40 Family physicians and their staffs have been described as either insensitive or overly sensitive about the disability32,33; many women with disabilities described negative attitudes from healthcare providers.36 One report suggested that women with disabilities, in this case those with multiple sclerosis, may be perceived as having a life expectancy that is so shortened by the disease that health screening is not warranted.28
In addition, being viewed as asexual by healthcare providers was consistently identified as an issue33,36,39; some women identified this as a possible explanation for not being offered gynecologic care, including pelvic examinations. Because of these and other negative experiences in obtaining healthcare,36 women have reported that they forego regular gynecologic visits despite their awareness of the recommendations for regular healthcare screening and its importance. As a result, they seek gynecologic care only when problems occur.33 Other women lack knowledge about the importance of health screening and fear having pelvic examinations because they do not understand how they are done.36
While not the focus of most of the research that has been conducted on this topic, financial considerations have also caused women to not undergo screenings or to postpone care.8,34,41 This is an issue for women with disabilities with limited financial resources.
Screening for osteoporosis in women with disabilities
Although data on breast and cervical cancer screening for women with disabilities have been described as limited,2 even less data are available on screening of women with disabilities for low BMD and osteoporosis risk. Low bone density and osteoporosis are major health issues more common in all groups of women than previously recognized.13,14,42,43 Although recent efforts have targeted specific groups (postmenopausal women, women receiving chemotherapy for breast cancer), osteoporosis in women with physical disabilities has largely been overlooked.4,7,15,44 Because osteoporosis has been identified as one of the most commonly reported1 yet frequently ignored secondary conditions in women with disabilities, the remainder of this review focuses on screening for osteoporosis.
Most population-based studies that have examined bone density in women have excluded women with chronic illnesses and disability because of concern that they will confound the studies' results. Those few studies that have addressed osteoporosis in women with disabilities have revealed a high incidence of low BMD across the spectrum of age and menopausal status,16,45 and the failure of clinicians to address osteoporosis in disabilities has been reported by a variety of researchers.4,7,15,16,30,44-47 Despite the high incidence of low BMD in women with disabilities reported in these studies,4,16,45 screening for low bone density and osteoporosis is not considered standard or routine care for women with spinal cord injury, spina bifida, multiple sclerosis, or cerebral palsy,48 even though many women with disabilities have a number of risk factors for bone loss, osteoporosis, and fractures. Healthcare providers rarely ask about these risk factors or recommend screening, prevention, or treatment.7,16,46,49
While the healthcare community's lack of attention to osteoporosis does extend to nondisabled groups,50-53 the risk for osteoporosis, falls, and fracture is greater in persons with disabilities. Their increased risk for falls and fractures is not merely a theoretical risk. Studies of nonelderly persons with disabilities have revealed an increased incidence of falls and fractures. The rate of falls and injuries, including fracture of the femur, in people with disabilities has been reported to range from 4 to 10 times that of the general population.54,55 While a higher incidence of fall-related fractures has been reported in persons with disabilities who are able to ambulate compared to those who are unable to do so, both groups have a higher risk for fracture than nondisabled populations. Limited ambulation has been identified as a strong indicator of fracture.55 Of concern is the fact that fracture, especially of the femur, can make individuals with disabilities who use assistive mobility devices dependent on wheelchairs.15
Although a number of osteoporosis risk factors has been reported in women with disabilities,16,45,56 several studies have suggested that osteoporosis may be overlooked because healthcare providers and women themselves focus on the primary disabling condition at the expense of other health issues.4,6,44 Physical barriers may also make women with disabilities and their healthcare providers reluctant to consider BMD screening or to refer women for such screening. They may see no strong justification for referral for BMD testing.
The failure to consider BMD screening may be due, in part, to the absence of studies that identify specific clinical indicators of osteoporosis in women with disabilities. A number of clinical indices have been developed to identify individuals who are likely to have low BMD and likely to benefit from screening and early treatment, but these studies have consistently excluded women with physical disabilities or factors common in individuals with disabilities: the presence of concurrent serious illness, being immobilized or confined to bed or wheelchair, or a history of prolonged steroid use and anticonvulsant agents.57-59
As a result, despite the increased number of risk factors in this population, no recommendations about BMD screening for women with disabilities have been developed, and no clinical index to identify those likely to have low BMD currently exists.60 Similarly, studies that have tested osteoporosis prevention and treatment strategies have largely been conducted in nondisabled populations. Strategies that might be effective in nondisabled populations (eg, promotion of weight-bearing exercise) may be difficult or impossible for many women with disabilities. To date, the effect of lifestyle changes and other prevention and treatment strategies, including pharmacologic treatment options, has not been examined in women with disabilities.
It is not known if screening, diagnostic testing, treatment and prevention strategies differ for women across disabilities. Although the 2004 Surgeon General's Report on Bone Health and Osteoporosis14 outlines the standard of care for people at risk for osteoporosis, no guidelines exist for screening for or treating osteoporosis in women with disabilities.
The recent US Surgeon General's Call to Action to Improve the Health and Wellness of Persons With Disabilities of 200510 identified osteoporosis as a secondary condition in disability that can often be mitigated or prevented with early and adequate treatment. However, the 2004 US Surgeon General's Report on bone health14 identified healthcare providers' lack of awareness about low bone density as a major obstacle to its detection and treatment. Furthermore, women who have brought the issue of osteoporosis risk to the attention of their healthcare providers have often had their concerns ignored. Even women who have undergone bone density screening on their own and received screening results strongly suggestive of osteoporosis and shared those results with their physicians, and women who have experienced fractures, have had their concerns about osteoporosis dismissed.46,47
DISCUSSION
Four overarching conclusions can be identified from the results of the studies included in this review. First, women with disabilities receive health screening for breast and cervical cancer and for osteoporosis less frequently than women without disabilities. Second, considerably less empirical data are available about screening for osteoporosis in women with disabilities than about screening for breast and cervical cancer. Third, barriers to health screening for women with disabilities include physical barriers and a host of nonphysical barriers encountered in healthcare. Fourth, women with severe disabilities are less likely than women with mild or moderate severity of disability to receive screening for breast cancer, cervical cancer, and osteoporosis.
The results of these studies indicate that women with disabilities receive less breast and cervical cancer screening than recommended. Furthermore, they undergo osteoporosis screening less often than seems warranted, even though they have a number of risk factors for osteoporosis. Lack of empirical data extends beyond bone density screening. For example, few studies to date have examined factors associated with osteoporosis that could be used to predict high risk for osteoporosis, or have examined the effectiveness of prevention and treatment strategies.
Although physical barriers that limit women's access to healthcare have been identified as major impediments to screening among women with disabilities, other factors also serve as barriers. These include lack of knowledge on the part of healthcare providers about the disability, a focus of healthcare providers and women themselves on the disability itself to the exclusion of other health issues, inadequate amounts of time allotted to women with disabilities for healthcare appointments, negative attitudes on the part of healthcare providers and office staff, previous negative experiences during healthcare visits, and the perception among healthcare providers that women with disabilities are asexual and not in need of gynecologic care or that their life spans are shortened and as a result such care is not warranted.
The findings of this review also strongly suggest that the more severe the disability, the less likely women are to undergo health screening. Severe disability not only makes it more difficult for women to obtain health screening; it also makes it less likely that they will receive treatment for these disorders. Thus, the presence of severe disability makes them hard to reach for purposes of health screening and for treatment. As a result, most of what we know about breast and cervical cancer and osteoporosis is based on data obtained from women who are mobile enough to obtain screening and treatment. Sparse evidence suggests that rates of breast and cervical cancer of women with severe disability differ significantly from those of women with less severe disability, but some data do suggest that women with more severe disability and mobility limitations are more likely to have low bone density. However, the severity of their disability makes it more difficult for them to undergo testing for low bone density and thus less likely that they will be offered treatment for it.
IMPLICATIONS
Although the Americans With Disabilities Act was enacted more than 15 years ago, barriers to healthcare of women with disabilities remain. Modifications are needed in primary healthcare offices, gynecological services, mammography facilities, sites for bone density screening, and equipment used in these settings, if women with disabilities are to receive preventive health screening. Research is needed to examine the effect of a variety of incentives to encourage implementation of the modifications mandated by the Americans With Disabilities Act. Special efforts are also needed to ensure that women whose severity of disability limits their participation in preventive health screening receive recommended screening and healthcare. Disability should not be considered an acceptable reason to defer examinations and health screening.
Additional research related to screening women with disabilities is needed. At a symposium sponsored by the Center for Research on Women With Disabilities61 in 2003 to establish a research agenda to improve the health and wellness of women with disabilities, the effect of the presence of a disability on testing and health screening was identified as an area requiring research. In the area of osteoporosis detection and diagnosis, research on osteoporosis screening was identified as warranted because of the putative effects of preexisting disability on bone density screening methods. Specific issues requiring study include the reliability and validity of screening measures as well as the appropriateness of current criteria for the diagnosis of osteoporosis. Although norms for low BMD by screening currently exist, they were established with nondisabled young Caucasian women.56,62 Thus, criteria for a diagnosis of osteopenia and osteoporosis in women with disabilities need to be identified. Valid, reliable, and clinically useful indices to predict osteoporosis risk in women with disabilities are also needed to identify those women with disabilities most in need of osteoporosis screening. In the absence of these criteria, the diagnosis of osteoporosis in women with disabilities will continue to be delayed until fracture-often the first sign of osteoporosis-occurs.63
Treatment options to prevent or reduce bone loss and treat established osteoporosis in women with disabilities require study to determine which strategies are most effective. Research is also needed to develop and test strategies to prevent falls and osteoporotic fractures in this population because of the major consequences of fractures in women with preexisting disabilities.
Strategies are needed to reach women with severe disabilities for health screening and treatment. Special, creative efforts may be needed to ensure that they receive recommended screening and healthcare, as are rigorous studies to determine what works and what does not, particularly in those with severe disabilities. Severe disability should not be considered an acceptable reason to defer screening and treatment.
Education of healthcare providers about the need for primary healthcare, including health screening, in women with disabilities is essential.4,10,64,65 Information about health issues of women with disabilities in general and health issues related to specific disabilities is needed if healthcare for women with disabilities is to improve. While healthcare providers and women with disabilities themselves may be aware of the need for screening for breast and cervical cancer, there is less evidence that this is the case for screening for osteoporosis. No matter how effective screening, diagnostic testing, prevention, and treatment strategies are, if these strategies are not made available to women with disabilities, including those with severe disabilities, knowledge about osteoporosis in this population will not make a difference in their lives. Efforts are needed to develop and test a variety of strategies designed to improve education to healthcare professionals about health issues of women with disabilities, primary healthcare and screening, and prevention of secondary conditions. Without such efforts, women with disabilities will continue to receive inadequate health screening and the national objectives to improve the healthcare and health status of women with disabilities3,10 will go unheeded.
REFERENCES
1. US Department of Health and Human Services. Healthy People 2010. Washington, DC: US Public Health Services; 2000. [Context Link]
2. Thierry JM. Increasing breast and cervical cancer screening among women with disabilities. Journal of Women's Health and Gender Based Medicine. 2000;9(1):9-12. [Context Link]
3. Thierry JM. Promoting the health and wellness of women with disabilities. Journal of Women's Health. 1998;7(5):505-507. [Context Link]
4. Nosek MA, Howland CA, Rintala DH, Young ME, Chanpong GF. National Study of Women With Physical Disabilities. Final Report. Houston, TX: Center for Research on Women With Disabilities; 1997. [Context Link]
5. Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and use of screening and preventive services. American Journal of Public Health. 2000;90(6):955-961. [Context Link]
6. Iezzoni LI, McCarthy EP, Davis RB, Harris-David L, O'Day B. Use of screening and preventive services among women with disabilities. American Journal of Medical Quality. 2001;16(4):135-144. [Context Link]
7. Shabas D, Weinreb H. Preventive health care in women with multiple sclerosis. Journal of Women's Health and Gender Based Medicine. 2000;9(4):389-395. [Context Link]
8. Chan L, Doctor JN, MacLehose RF, et al. Do Medicare patients with disabilities receive preventive services? A population-based study. Archives of Physical Medicine and Rehabilitation. 1999;80(6):642-646. [Context Link]
9. Grabois E. Guide to getting reproductive health care services for women with disabilities under the Americans with Disabilities Act of 1990. Sexuality and Disability. 2001;19(3):191-208. [Context Link]
10. US Department of Health and Human Services. The Surgeon General's Call to Action to Improve the Health and Wellness of Persons With Disabilities. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2005. [Context Link]
11. American Cancer Society. American Cancer Society's Guidelines for the Early Detection of Cancer. Atlanta, GA: American Cancer Society Inc; 2004. [Context Link]
12. US Preventive Services Task Force. Put Prevention Into Practice. January 2004. Rockville MD: Agency for Healthcare Research and Quality; 2004. Available at: http://ahrq.gov/ppip/adulttm.htm. Accessed December 11, 2005. [Context Link]
13. National Osteoporosis Foundation. America's Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation; 2002. [Context Link]
14. National Institutes of Health Consensus Development Panel on Osteoporosis, Prevention, Diagnosis and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285(6):785-795. [Context Link]
15. Herndon RM, Mohandas N. Osteoporosis in multiple sclerosis: a frequent, serious, and under-recognized problem. International Journal of Multiple Sclerosis Care. 2000;2(2):1-5. [Context Link]
16. Smeltzer SC, Zimmerman V, Capriotti T. Osteoporosis risk and low bone mineral density in women with physical disabilities. Archives of Physical Medicine and Rehabilitation. 2005;86(3):582-586. [Context Link]
17. DeJong G. Primary care for persons with disabilities: an overview of the problem. American Journal of Physical Medicine and Rehabilitation. 1997;76(suppl 3):S2-S8. [Context Link]
18. Marge M. Health promotion for persons with disabilities: moving beyond rehabilitation. American Journal of Health Promotion. 1998;2(4):29-35. [Context Link]
19. Welner SL, Foley CC, Nosek MA, Holmes A. Practical considerations in the performance of physical examinations on women with disabilities. Obstetrical and Gynecological Survey. 1999;54(7):457-462. [Context Link]
20. Welner SL, Temple B. General health concerns and the physical examination. In: Welner SL, Haseltine F, eds. Welner's Guide to the Care of Women With Disabilities. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. [Context Link]
21. Gans BM. Primary care for persons with disabilities. The rehabilitation hospital perspective. American Journal of Medicine and Rehabilitation. 1997;76(suppl):S35-S36. [Context Link]
22. Werner P. Primary care for persons with disabilities. The family practice perspective. American Journal of Medicine and Rehabilitation. 1997;76(suppl): S21-S24. [Context Link]
23. Mann NR. Primary care for persons with disabilities. The Rehabilitation Institute of Michigan Model Program. American Journal of Medicine and Rehabilitation. 1997;76(suppl):S47-S49. [Context Link]
24. Schopp LH, Sanford TC, Hagglund KJ, Gay JW, Coatney MA. Removing service barriers for women with physical disabilities: promoting accessibility in the gynecologic care setting. Journal of Midwifery and Women's Health. 2002;47(2):74-79. [Context Link]
25. Smith V. Primary care for persons with disabilities. The public policy perspective. American Journal of Medicine and Rehabilitation. 1997;76(suppl):S14-S16. [Context Link]
26. Jones KE, Tamari IE. Making our offices universally accessible: guidelines for physicians. Journal of the Canadian Medical Association. 1997;156(5):647-655. [Context Link]
27. Bechmann CRB, Gittler M, Barzansky BM, Bechmann CA. Gynecologic health care of women with disabilities. Obstetrics and Gynecology. 1989;74(1):75-79. [Context Link]
28. Cheng E, Myers E, Wolf L, et al. Mobility impairments and use of preventive services in women with multiple sclerosis: observational study. BMJ. 2001;323(7319):986-989. [Context Link]
29. Nosek MA, Howland CA. Breast and cervical cancer screening among women with physical disabilities. Archives of Physical Medicine and Rehabilitation. 1997;78(suppl 12, pt 5):S39-S44. [Context Link]
30. Thierry JM, Cyril JK. Health of women with disabilities: From data to action. In: Welner SL, Haseltine F, eds. Welner's Guide to the Care of Women With Disabilities. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. [Context Link]
31. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Archives of Physical Medicine and Rehabilitation. 2004;85(5):749-757. [Context Link]
32. Veltman A, Stewart DE, Tardif GS, Branigan M. Perceptions of primary health care services among people with physical disabilities, I: access issues. Medscape General Medicine. 2001;3(2):18. [Context Link]
33. Becker H, Stuifbergen A, Tinkle M. Reproductive health care experiences of women with physical disabilities: a qualitative study. Archives of Physical Medicine and Rehabilitation. 1997;78(suppl 12, pt 5):S26-S33. [Context Link]
34. Henry J. Kaiser Foundation. Understanding the Health-care Needs and Experiences of People With Disabilities: Findings From a 2003 Survey. Menlo Park, CA: Henry J. Kaiser Foundation; 2003. [Context Link]
36. Coyle CP, Santiago MC. Health care utilization among women with physical disabilities. Medscape Women's Health. 2002;7(4):2. [Context Link]
36. Nosek MA, Young ME, Rintala DH, Howland BA, Foley CC, Bennett JL. Barriers to reproductive health maintenance among women with physical disabilities. Journal of Women's Health. 1995;4(5):505-518. [Context Link]
37. Grabois EW, Nosek MA, Rossi CD. Accessibility of primary care physicians' offices for people with disabilities: an analysis of compliance with the Americans With Disabilities Act. Archives of Family Medicine. 1999;8(1):44-51. [Context Link]
38. Persaud D. Barriers to preventive health practices in women with spinal cord impairments. SCI Nursing. 2000;17(4):168-179. [Context Link]
39. North Carolina Office on Disability and Health. Women. Women With Disabilities in North Carolina: Their Views on Health Care. Raleigh, NC: North Carolina Office on Disability and Health; 1999. Available at: http://fgp.unc.edu/~ncodh/pubs.htm. [Context Link]
40. Branigan M, Stewart DE, Tardif GS, Veltman A. Perceptions of primary healthcare services among persons with physical disabilities, II: quality issues. Medscape General Medicine. 2001;3(2):19. [Context Link]
41. Robert Wood Johnson Foundation. Survey finds US health care system not meeting needs of people with disabilities. Advances. 1994;7(1):10. [Context Link]
42. Siris ES, Miller PD, Barrett-Connor E, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA. 2001;286(22):2815-2822. [Context Link]
43. National Osteoporosis Foundation. Physician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2003. [Context Link]
44. Vandenakker CB, Glass DD. Menopause and aging with disability. Physical and Medical Rehabilitation Clinics of North America. 2001;12(1):133-151. [Context Link]
45. Smeltzer SC, Zimmerman V, Capriotti T, Fernandes L. Osteoporosis risk factors and bone mineral density in women with MS. International Journal of Multiple Sclerosis Care. 2002;4(1):17-23, 29. [Context Link]
46. Sharts-Hopko NC, Sullivan MP. Beliefs, perceptions, and practices related to osteoporosis risk reduction among women with multiple sclerosis. Rehabilitation Nursing. 2002;27(6):232-236. [Context Link]
47. Sharts-Hopko NC, Smeltzer S. Perceptions of women with multiple sclerosis about osteoporosis follow-up. Journal of Neuroscience Nursing. 2004;36(4):189-194, 199. [Context Link]
48. Turk MA, Scandale J, Rosenbaum PF, Weber RJ. The health of women with cerebral palsy. Physical Medicine and Rehabilitation Clinics of North America. 2001;12(1):153-168. [Context Link]
49. Schrager S. Osteoporosis in women with disabilities. Journal of Women's Health. 2004;13(4):431-437. [Context Link]
50. Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. Journal of the Canadian Medical Association. 2000;163(7):819-822. [Context Link]
51. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. American Journal of Medicine. 2000;109(4):326-328. [Context Link]
52. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? Journal of Bone and Joint Surgery. 2000;82-A(8):1063-1070. [Context Link]
53. Gehlbach SH, Fournier M, Bigelow C. Recognition of osteoporosis by primary care physicians. American Journal of Public Health. 2002;92(2):271-273. [Context Link]
54. Kinne S, Patrick DL, Doyle DL. Prevalence of secondary conditions among people with disabilities. American Journal of Public Health. 2004;94(3): 443-445. [Context Link]
55. Peabody TD, Stasikelis PJ. Fractures in adults at an institution for the developmentally disabled. Clinical Orthopaedics and Related Research. 1999;366:217-220. [Context Link]
56. Jackson RD, Ryan LE, Mysiw WJ. Osteoporosis: unique aspects of pathophysiology, evaluation and treatment. In: Welner SL, Haseltine F, eds. Welner's Guide to the Care of Women With Disabilities. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. [Context Link]
57. Dargent-Molina P, Douchin MN, Cormier C, Meunier PJ, Breart G, for the EPIDOS Study Group. Use of clinical risk factors in elderly women with low bone mineral density to identify women at higher risk of hip fracture: The EPIDOS prospective study. Osteoporosis International. 2002;13(7):593-599. [Context Link]
58. Versluis RG, Papapoulos SE, de Bock GH, et al. Clinical risk factors as predictors of postmenopausal osteoporosis in general practice. British Journal of General Practice. 2001;51(471):806-810. [Context Link]
59. Cadarette SM, Jaglal SB, Kreiger N, McIsaac WJ, Darlington GA, Tu JV. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. Journal of the Canadian Medical Association. 2000;162(9):1289-1294. [Context Link]
60. Smeltzer SC, Zimmerman VL. Usefulness of the SCORE index as a predictor of osteoporosis in women with disabilities. Orthopedic Nursing. 2005;24(1):33-39. [Context Link]
61. Nosek M, and the Center for Research on Women With Disabilities (CROWD). Improving the Health and Wellness of Women With Disabilities: A Symposium to Establish a Research Agenda (Executive Summary). Houston, TX: Center for Research on Women With Disabilities; 2004. [Context Link]
62. WHO Study Group. Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis: Report of a WHO Study Group. Geneva: World Health Organization; 1994. WHO Technical Report Series 843. [Context Link]
63. Coyle CP, Santiago MC, Shank JW, Ma GX, Boyd R. Secondary conditions and women with physical disabilities: a descriptive study. Archives of Physical Medicine and Rehabilitation. 2000;81(10):1380-1387. [Context Link]
64. Oshima S, Kirschner KL, Heinemann A, Semik P. Assessing the knowledge of future internists and gynecologists in caring for a woman with tetraplegia. Archives of Physical Medicine and Rehabilitation. 1998;79(10):1270-1276. [Context Link]
65. Smeltzer SC, Dolen MA, Robinson-Smith G, Zimmerman V. Integration of disability-related content in nursing curricula. Nursing Education Perspectives. 2005;26(4):210-216. [Context Link]