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

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

Promoting psychological health in women with SCI: Development of an online self-esteem intervention.

BACKGROUND: There are no known interventions addressing self-esteem in women following spinal cord injury (SCI). OBJECTIVES: To test the feasibility of an online self-esteem intervention for women with disabilities, as modified for women with SCI. METHOD: We conducted a randomized, controlled feasibility test of a self-esteem intervention (N = 21). Participants were randomly assigned to the intervention or control group that received intervention materials at the end of the study. Intervention participants met as avatars for 7 weekly real-time group sessions in Second Life (SL), a free online virtual world. Feasibility indicators were study engagement, acceptability of SL and the intervention, and improvements on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. RESULTS: Intervention participants (n = 10) were highly engaged, and most described the SL program as more enjoyable and more convenient than in-person programs. All rated the intervention as "good" (n = 4) or "very good" (n = 6), and all 10 rated themselves has having made positive life changes as a result of the program. Intervention participants experienced significantly greater change than controls on two measures of health-promoting behavior (Health Promoting Lifestyle Profile-II Spiritual Growth/Self-actualization; Interpersonal Relations). Examining change in the intervention group using regression analyses, we found medium-to-large effects of the intervention on these behaviors and measures of depression (CESD-10, PHQ-9). The intervention had small effects on remaining measures. CONCLUSION: We found preliminary support for the feasibility of this modified self-esteem intervention offered in SL. Such programming may help circumvent barriers to community-based psychological services and may improve psychological health.

A pilot test of the GoWoman weight management intervention for women with mobility impairments in the online virtual world of Second Life®.

Objective: Pilot test GoWoman, a small-group weight management intervention for mobility impaired women that was a disability- and gender-responsive adaptation of the Diabetes Prevention Program delivered in the online virtual world of Second Life®. Objectives were to (1) examine pre-/post-intervention differences in weight, waist circumference, diet, physical activity, self-efficacy for diet and physical activity, nutrition knowledge and social support for weight management, (2) determine intervention feasibility (fidelity, attrition, engagement, acceptability). Design: Single-group modified interrupted time series quasi-experimental design whereby participants served as their own controls. Results: Thirteen women attended ≥8 of 16 GoWoman weekly sessions and lost an average of 5.97 pounds (2.71 kg) (3.31%) body weight (Cohen's d = 0.74) and 1.44 inches (3.66 cm) (3.58%) waist circumference (Cohen's d = 0.83). There were significant improvements in physical activity, diet and self-efficacy for diet and physical activity. All benchmarks for feasibility were met. Ratings of intervention content, group interactions and support and virtual world experiences were highly positive. Conclusion: Findings suggest that a disability- and gender-responsive weight management intervention with peer group support delivered in an online virtual world is feasible, meaningful and may assist with weight management for mobility impaired women. Implications for Rehabilitation This study addresses a gap in the general and rehabilitation research literature by addressing the disproportionately high rates of obesity among women with mobility impairments, who are generally excluded from tests of weight management interventions if they have limited ability to engage in vigorous physical activity. The GoWoman program is an adaptation of the Diabetes Prevention Program Lifestyle Change curriculum that is tailored to meet the unique weight management needs of women with mobility impairments, and was created to become a publicly available, disability- and gender-responsive intervention that can be used in community and rehabilitation settings. More rehabilitation and health promotion program should be offered in the free, online, virtual world of Second Life® since participants in this pilot study offered many favorable comments about the new learning and social opportunities available to them there and they did not have to deal with the disability-related environmental and health challenges that often prevent them from participating in face-to-face workshops. Preliminary indications of improvements in body weight, waist circumference, diet and physical activity after attending the GoWoman weight management intervention offered in Second Life® tell us that these strategies are feasible for helping women with mobility impairments manage their weight and should undergo further testing.

An Internet-based virtual reality intervention for enhancing self-esteem in women with disabilities: Results of a feasibility study.

PURPOSE: To examine the feasibility of an online self-esteem enhancement group program for women with disabilities. METHOD: A sample of 19 racially and ethnically diverse, community-living women with physical disabilities, 22 to 61 years old, participated in a 7-session interactive group intervention (extending Hughes et al., 2004) in the 3-D, immersive, virtual environment of SecondLife.com, using avatars with voice and text communication. Baseline and postintervention questionnaires were administered online. Criteria for determining feasibility were (a) enrollment, (b) engagement, (c) acceptability, and (d) improvement on measures of self-esteem, depression, self-efficacy, and social support. RESULTS: We attained our enrollment goal and engagement exceeded expectations. Acceptability was positive; participants gave "helpful" and "enjoyable" ratings of 3.21 and 3.27, respectively, (mean on a 1 to 4 Likert scale, where 4 = high) to 5 intervention components-session materials, group sharing and discussion, relaxation exercises, action planning, and group excursions. Significant increases from baseline to postintervention were found on the Rosenberg Self-Esteem Scale (p = .02; Cohen's d = .60) and the Center for Epidemiologic Studies Depression Scale-10 (p = .005; Cohen's d = .74), with a trend toward significance on the Generalized Self-Efficacy Scale (p = .08; Cohen's d = .42). The intervention did not significantly affect the measure of social support. IMPLICATIONS: An intervention to enhance self-esteem may have a corollary benefit on depressive symptomatology. Offering psycho-educational, small group interventions using online virtual worlds shows promise for circumventing disability-related and environmental barriers to accessing mental health services experienced by women with mobility limitations, and should undergo further development and testing. (PsycINFO Database Record

Depression and depression treatment in women with spinal cord injury.

BACKGROUND: Research has documented high rates of depression in people with spinal cord injury (SCI); however, most SCI research is conducted with predominantly male study participants. Additional research is needed on depression and depression treatment among women with SCI. OBJECTIVE: Study objectives were to examine depression, correlates of depression, and depression treatment in a sample of women with SCI. METHODS: The sample included 51 ethnically and racially diverse women with SCI who participated in a larger study on secondary conditions of women with diverse physical disabilities. Recruited through health clinics and community organizations in a large metropolitan area, participants completed structured interviews that included demographic and disability characteristics and measures of health and health care utilization. RESULTS: Scores on the Beck Depression Inventory-II (BDI-II) indicated that 41% of the women had depressive symptomatology in the mild to severe range. BDI-II scores were significantly related to more severe secondary conditions, greater pain, and poorer health perceptions but not to demographic or disability variables. Nearly a third (n = 16) of the women had scores exceeding the standard cutoff for significant clinical depressive symptomatology, yet only 5 of those had received any treatment for depression in the past 3 months and only 1 had received counseling or psychotherapy. Lifelong depression treatment showed a similar pattern of predominantly pharmacologic treatment. CONCLUSION: Depression is a common problem for women with SCI, and many do not receive treatment, particularly psychological treatment. Disability-sensitive and affordable depression treatment must be made available to women with SCI.

Development and psychometric assessment of the function-neutral health-related quality of life measure.

OBJECTIVE: The aim of this study was to determine the conceptual framework, item pool, and psychometric properties of a new function-neutral measure of health-related quality-of-life (HRQOL). DESIGN: This is an expert panel review of existing measures of HRQOL and development of a conceptual model, core constructs, and item pool and a validation by experts in specific disabilities and in cultural competence. Items were cognitively tested, pilot tested for functional bias, field tested with a national sample of adults with various limitations, and reliability tested via repeat administration. Final item selection was based on analyses of factor structure, demographic bias, variance in likelihood of endorsement, and item-total correlation. Psychometric properties were demonstrated through differential item functioning analyses, factor analyses, correlations, and item response theory analyses. RESULTS: The results supported a four-domain conceptual model of HRQOL (physical health, mental health, social health, and life satisfaction and beliefs) for a 42-item HRQOL measure with an ancillary 15-item environment scale. The measure has strong internal consistency (α = 0.88-0.97), known-groups validity, and test-retest reliability (r = 0.83-0.91). Tests of convergent and divergent validity confirmed the ability of the Function-Neutral Health-Related Quality of Life to measure health while being relatively free of content assessing function. CONCLUSIONS: A conceptually grounded four-domain, function-neutral measure of HRQOL that is appropriate for use with persons with and without various functional limitations was developed.

Depressive symptoms in women with physical disabilities: identifying correlates to inform practice.

OBJECTIVE: To examine correlates of depressive symptomatology in a sample of women with diverse physical disabilities to inform practice of modifiable risk factors that warrant attention and intervention. DESIGN: Interview survey. SETTING: Outpatient chronic care clinics. PARTICIPANTS: Racially and ethnically diverse women (N=415) aged 18 to 64 years living with physical disabilities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Center for Epidemiologic Studies Depression Scale. RESULTS: Depressive symptoms were high with more than half the women exceeding an established cutoff for clinically significant depressive symptomatology. In hierarchical multiple regression analyses, demographic, disability, and health variables explained significant variance in depressive symptoms; however, modifiable variables (pain interference, social support, abuse) contributed significantly to depression scores over and above demographic, disability, and health variables. Analyses examining predictors of depression classification revealed similar findings. CONCLUSIONS: Depression is a significant problem for many women with physical disabilities. Modifiable contributors to depressive symptoms may provide intervention opportunities for researchers and clinicians. Clinicians need to attend closely to pain, particularly perceptions of pain interference; social support and social isolation; and abuse among women with physical disabilities. It may be valuable to include pain self-management, social networking and social skill development, and safety and abuse prevention training when designing depression intervention programs for this population.

The dilemma of measuring perceived health status in the context of disability.

BACKGROUND: Advances in the conceptual differentiation of health from disability have not been incorporated in popular measures of perceived health status. The inclusion of function in the measurement of health presents a dilemma for researchers assessing the perceived health of people with functional limitations. OBJECTIVES: The purposes of the present paper are to identify this problem in health measurement, describe its implications for disability and health researchers, and outline potential strategies for future measure development of perceived health status. METHODS: Reflecting the International Classification of Function, Disability, and Health, distinctions among the concepts of health, function, and disability are reviewed. Implications of confounded health measurement are discussed in terms of monitoring health status, assessing health disparities, using health as a mediator or moderator of other outcomes, and assessing effectiveness of interventions. The problem of function confounded with health measurement is illustrated with findings using the SF-36 with persons with spinal cord injury. RESULTS: Recommendations are provided for developing function-neutral measures of perceived health status. CONCLUSION: New measures of perceived health status are needed that do not confound function with health.

Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities?

OBJECTIVE: To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association. DESIGN: A time series of 7 interviews over a 1-year period. SETTING: Large, southern metropolitan area. PARTICIPANTS: Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory-Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs. RESULTS: Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models. CONCLUSIONS: Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs.

Overweight and obesity in women with physical disabilities: associations with demographic and disability characteristics and secondary conditions.

BACKGROUND: This cross-sectional study was designed to examine weight in association with demographic and disability characteristics and secondary conditions in a sample of community living women with physical disabilities. METHODS: 443 predominantly ethnic minority women with physical disabilities were recruited through public and private health clinics and community organizations. They completed questionnaires including measures of body mass index and a health conditions checklist. RESULTS: Data showed that nearly three-quarters of the sample were overweight (26.6%) or obese (47.6%) with 14% extremely obese. Obesity was highest among middle aged women (aged 45-54, 52.7%; aged 55-64, 52.5%; compared to aged 18-44, 37.8%; or aged ≥65, 39.1%). Black (84.0%) and Hispanic women (83.8%) were more likely to be overweight or obese compared to non-Hispanic white women (56.7%). Women with joint and connective tissue diseases and women with more extensive functional limitations were more likely to have excess weight. Disability factors were more strongly associated with excess weight than demographic factors other than age. Weight classification was significantly related to whether or not the women had ever had diabetes or blood pressure problems. Diabetes was reported 4 times as often as among women in general (36.3% versus 8.9%), and hypertension nearly twice as often (56.2% versus 30.9%). CONCLUSIONS: These findings indicate extremely high rates of overweight and obesity in women with physical disabilities, a growing population greatly in need of effective weight management interventions. Overweight and obesity in combination with disability in women was associated with disproportionately high rates of diabetes and hypertension.

The complex array of antecedents of depression in women with physical disabilities: implications for clinicians.

PURPOSE: This article discusses the complex interrelation of elements of the physical, psychological, social, and environmental life context of women with physical disabilities and the association of these elements with significant disparities in rates of depression and access to mental health care for this population. METHODS: Literature and concept review. RESULTS: High rates of depression in women with physical disabilities are well documented in the literature. Many elements that are disproportionately common in the lives of women with physical disabilities, including socio-economic disadvantage, functional limitations, pain and other chronic health conditions, poor diet, physical inactivity, smoking, violence, low self-esteem, sexuality problems, chronic stress, environmental barriers, and barriers to health care, have also been linked with higher rates of depression and depressive symptomatology. Depression self-management interventions tailored for women with disabilities have been developed and proven effective. CONCLUSIONS: Many women who must deal with the stresses surrounding an array of health problems may experience symptoms of depression without necessarily meeting the criteria for clinical depression. Psychologists, counselors, primary care physicians, specialists, and other medical and rehabilitation professionals are challenged to recognize the symptoms of depression in women with physical disabilities and assist them in obtaining appropriate psychological and pharmacological interventions.

Response shift theory: important implications for measuring quality of life in people with disability.

Measurement of health-related quality of life (HRQOL) in people with disability can be problematic. Ambiguous or paradoxical findings can occur because of differences among people or changes within people regarding internal standards, values, or conceptualization of HRQOL. These "response shifts" can affect standard psychometric indices, such as reliability and validity. Attending to appraisal processes and response shift theory can inform development of HRQOL measures for people with disability that do not confound function and health and that consider important causal indicators such as environment. By design, most HRQOL measures equate function with health, necessarily leading to a lower measured HRQOL in people with functional impairments regardless of their level of self-perceived health. In this article, we present theoretical and conceptual distinctions building on response shift theory and other current developments in HRQOL research. We then submit a set of suggested directions for future measurement development in populations with disabilities that consider these distinctions and extend their use in future measurement developments.

Correlates of depression in rural women with physical disabilities.

OBJECTIVE: To describe demographic and disability-related characteristics, to examine the patterns of treatment for depression, and to investigate correlates of depression severity and predictors of who receives treatment among a sample of depressed rural women with physical disabilities. DESIGN: A correlational analysis of data gathered from women recruited for a depression intervention study. SETTING: Rural centers for independent living located in nine different states across the United States. PARTICIPANTS: Women (N=134) who reported at least mild depression and expressed interest in participating in a depression intervention study. MAIN OUTCOME MEASURES: Depressive symptomatology based on the Beck Depression Inventory-II; treatment for depression in the past 3 months. RESULTS: The majority of participants reported moderate to severe depression (n=101, 75.4%), with nearly 20% reporting thoughts of suicide. At risk of severe depression were women who were younger, had greater problems with pain, had more limited mobility, and were less satisfied with their social network. Despite the high levels of depressive symptomatology in the sample, more than one third of the women had not received recent treatment for depression. CONCLUSIONS: This study suggests that depression and access to treatment are critical issues for women with physical disabilities living in rural areas.

Mammography use may partially mediate disparities in tumor size at diagnosis in women with social security disabilities.

OBJECTIVE: This study determined the association between screening mammography and tumor size at diagnosis in older women whose original reason for entitlement to Medicare benefits was disability (SSDI). METHODS: A retrospective study of female Medicare beneficiaries older than 69 years diagnosed with breast cancer using Surveillance Epidemiological End Results (SEER)-Medicare linked database. Multiple linear regression techniques were used to determine the effect of screening mammography use on tumor size. MAIN FINDINGS: The total number of women was 413 with SSDI and 8,989 without. Bivariate analysis showed that significantly fewer women with SSDI used screening mammography (45% vs. 38%, P = 0.0006) during the two years prior to diagnosis. Mean tumor size at diagnosis was 2.91 mm (95%, CI = 1.10, 4.73) larger in the group with SSDI. CONCLUSION: This study found that older women whose original reason for Medicare benefits was disability present with larger tumors at breast cancer diagnosis compared to those who were not. Screening mammography may partially mediate the disparity.

Health, preventive health care, and health care access among women with disabilities in the 1994-1995 National Health Interview Survey, Supplement on Disability.

OBJECTIVES: This study presents national estimates on the health, preventive health care, and health care access of adult women with disabilities. We compared women with 1 or 2 functional limitations (FLs) and > or =3 FLs with women with no FLs. Topics covered included demographic characteristics, selected reported health measures, selected clinical preventive services, and selected access to care indicators and health care coverage. METHODS: Estimates in this report were based on data from the 1994-1995 National Health Interview Survey, Supplement on Disability (NHIS-D). The sample size for women > or =18 years of age used in producing the estimates from the combined 1994 and 1995 NHIS-D was 77,762. RESULTS: An estimated 16% of women > or =18 years of age had difficulty with at least 1 FL. Women with FLs were less likely to rate their health as excellent or very good and more likely to report their health as fair or poor when compared with women with no FLs. Women with FLs were also more likely to report being a current smoker, having hypertension, being overweight, and experiencing mental health problems. Among women > or =65 years of age, those with FLs were also less likely to have received Pap smear tests within the past year and those with > or =3 FLs were less likely to have received mammograms within the past year than women with no FLs. Women with > or =3 FLs were more likely to report being unable to get general medical care, dental care, prescription medicines, or eyeglasses, regardless of age group, compared with women with no FLs. The main reasons reported for being unable to receive general care were financial problems or limitations in insurance. These findings suggest that increased attention to the health care needs of women with disabilities from researchers, clinicians, and public health professionals is warranted.

Physical activity and nutritional behaviors of women with physical disabilities: physical, psychological, social, and environmental influences.

INTRODUCTION: We examined predictors of 2 important health behaviors, namely, physical activity and nutritional behaviors, in a sample of community-living women with physical disabilities (N = 386). METHOD: We conducted a cross-sectional survey with regression analysis. RESULTS: Our regression model accounted for 33.5% of the variance in physical activity. Women with joint problems or multiple sclerosis tended to engage in less physical activity than those with stroke-related disabilities. Those who had lived with their disability longer and those experiencing greater pain tended to report less physical activity. Consistent with the literature, women with greater self-efficacy for physical activity tended to engage in more physical activity. The regression model for nutritional behaviors accounted for 37.9% of the variance. Women with better mobility, greater self-efficacy for nutrition, and more vitality had better nutritional behaviors while those who needed assistance with activities of daily living, had lower social functioning scores, and were engaged in more productive activities reported poorer nutritional behaviors. CONCLUSIONS: Our findings highlight the importance of self-efficacy for improving health behaviors. Further research is needed to develop a new paradigm for the measurement of health behaviors, one that focuses on individual improvement rather than comparison to a norm, and health promoting interventions that are responsive to the needs and life circumstances of women with physical disabilities.

Improving the health and health behaviors of women aging with physical disabilities: A peer-led health promotion program.

OBJECTIVE: To examine the efficacy of a health promotion program for women aging with physical disabilities. METHOD: A sample of 137 middle-aged and older women with physical disabilities was randomly assigned to either an 8-week health promotion program or to a wait-list control group. Both groups completed questionnaires before, immediately after, and 3 months after the intervention. RESULTS: Relative to women in the control group, women in the health-promotion program demonstrated improvements in health behaviors, most of which were maintained at follow-up. The intervention group showed some improvements on measures of physical health, but there was little evidence of improvement in psychological health outcomes. Testing our theoretical model, self-efficacy was supported as a mediator of the effect of the intervention on health behaviors, and health behaviors combined with self-efficacy were supported as mediators of the effect of the intervention on physical health outcomes. Contrary to our hypotheses, our measures of social support and social connectedness were not affected by the intervention. CONCLUSIONS: A brief, peer-led, group health promotion program resulted in improved scores on measures of self-efficacy, increased health behavior, and physical health. Self-efficacy, which was supported as a mediator in the effect of the intervention on behaviors and health outcomes, should remain an important focus of future interventions with this population.