Environmental Modifications for People With Intellectual and Developmental Disabilities: A Policy Analysis of Medicaid Home- and Community-Based Services.

IMPORTANCE: Environmental modifications are targets for occupational therapy intervention because they support activities of daily living, self-efficacy, personal control, independence, and community living for people with intellectual and developmental disabilities (IDDs). OBJECTIVE: To examine how environmental modifications were provided to people with IDDs through Medicaid home- and community-based services (HCBS) waivers across the United States in fiscal year (FY) 2021. DESIGN: Using a mixed-methods policy analysis, we examined FY 2021 Medicaid HCBS 1915(c) waivers from across the United States to examine whether, and how, states provided environmental modifications to people with IDDs. RESULTS: In FY 2021, 35 states projected spending $68.8 million on environmental modifications for 12,671 people with IDDs. The purpose of environmental modifications was most often to promote the health, welfare, and safety of people with IDDs (82.68%), and to promote their independence (69.29%). The most common examples of environmental modifications included ramps and/or lifts (70.08%), widening doorways and/or hallways (61.42%), bathroom modifications (58.27%), specialized electrical and/or plumbing for medical equipment (54.33%), and grab bars and/or handrails (53.54%). CONCLUSIONS AND RELEVANCE: HCBS waiver data on environmental modifications for people with IDDs enhances an understanding of this funding source and provides a foundation of advocacy for occupational therapy practitioners to support people with IDDs with living, as well as aging, in the community rather than in institutions. An expansion of environmental modifications in HCBS for people with IDDs aligns with the aim of Medicaid HCBS waivers to promote community integration, self-determination, and independence, which are all benefits of environmental modifications. Plain-Language Summary: This study can help occupational therapy practitioners determine what funding sources are available in their state to help their clients with intellectual and developmental disabilities access environmental modifications. The findings can also help guide advocacy and lobbying efforts to expand access to environmental modifications.

Developing Client Self-Advocacy in Occupational Therapy: Are We Practicing What We Preach?

Background: Developing client self-advocacy is in occupational therapy's (OT) scope of practice; however, there is limited understanding of if, or how, occupational therapists learn about self-advocacy interventions as well as implement self-advocacy into clinical practice. Objective: This study sought to identify if and how therapists learn about self-advocacy intervention approaches and identify if and how therapists implement self-advocacy into their work with clients. Method: A survey was distributed via email to academic and professional listservs in the United States, and data were collected using REDCap survey software. Descriptive statistics were analyzed data using REDCap/SPSS. Comparative statistics, Kruskal-Wallis's tests, Chi-square tests for independence, and Pearson's correlation tests analyzed differences across groups of respondents. Results: Practicing and licensed occupational therapists (n = 138) across the United States completed the survey. Findings indicate a majority (59.5%) of occupational therapists not learning strategies for addressing or developing client self-advocacy. Of significance, 21.7% of participants had never been exposed to concepts of client self-advocacy in academic or clinical education. Practitioners who did address self-advocacy did so indirectly through teaching-related skills (76.6%). Conclusion: Many clients of OT will need self-advocacy skills in order to address issues of exclusion and discrimination that prohibit full participation in society. Occupational therapists must prioritize incorporating client self-advocacy into curricula and clinical practice.

'Not seeing people as capable': Disability professionals' mis/understandings of ableism.

BACKGROUND: Knowledge about how disability professionals understand ableism may provide insight into the production of inequalities. The aim of this study was to examine how disability professionals understand ableism. METHODS: We asked 347 disability professionals, all of whom worked with people with intellectual and developmental disabilities, among other populations, to define ableism and then analysed those definitions using content analysis. RESULTS: The themes about how participants understood ableism were: discrimination; differential treatment; individualization; norms and othering; ableist language; microaggressions; and systems and environments. It was also not uncommon for participants to say ableist things, and express misconceptions in their definitions. This included these themes: avoiding disability; using ableist language; framing disability as in/ability; centring people without disabilities; ignoring invisible disabilities; believing only people without disabilities have bias; and believing ableism does not exist. CONCLUSIONS: Knowing disability professionals' understandings of ableism is necessary to intervene biased attitudes and reduce ableism.

People with Disabilities' Access to Medical Care During the COVID-19 Pandemic.

Delaying and forgoing medical care intensifies the health disparities and unmet needs people with disabilities already face. While many people with disabilities were at high risk for COVID-19, less is known about their access to medical care during the pandemic. This study explored people with disabilities' access to medical care during the COVID-19 pandemic. We analyzed United States Census Bureau COVID-19 Household Pulse Survey data from the second year of the pandemic (April-July 2021) from people with (n = 38,512) and without (n = 296,260) disabilities. During the second year of the pandemic, 30.8% of people with disabilities delayed getting medical care and 28.9% forwent needed care. People with disabilities were also significantly more likely to delay and forgo medical care than people without disabilities. Attention must be drawn to the unmet needs of people with disabilities and efforts must be made to expand their access to health care.

Early Career Occupational Therapists' Experiences during the COVID-19 Pandemic.

Occupational therapists entering the clinical workforce during the COVID-19 pandemic experienced levels of uncertainty and stress. This study's aim was to explore the clinical experiences and concerns of early-career occupational therapists entering the workforce during the COVID-19 pandemic (n = 27). We administered an open-ended online survey and analyzed the data using inductive thematic analysis. Resulting themes included: safety, exposure, and transmission; implementation and enforcement of safety protocols; quality of care; and impact of the pandemic on overall health highlighting the issues that need to be addressed to be more prepared for future practice in an evolving environment.

Anti-Fat Biases of Occupational and Physical Therapy Assistants.

Fat people are highly stigmatized, and anti-fat bias is pervasive resulting in stigma, prejudice, and discrimination, including in health care. The aim of this study was to explore occupational and physical therapy assistants' anti-fat biases. We analyzed secondary weight implicit association tests from 5,671 occupational/physical therapy assistants. The overwhelming majority (82%) of occupational/physical therapy assistants were implicitly prejudiced against fat people. Interventions for occupational/physical therapy assistants' anti-fat biases are critical, especially with increasing prevalence and responsibilities of occupational/physical therapy assistants in the provision of rehabilitation services.

Explicit and implicit disability attitudes of occupational and physical therapy assistants.

BACKGROUND: Reduction of explicit and implicit bias in healthcare providers is a critical issue faced by our society in moving toward more equitable and culturally appropriate health and rehabilitation care. Because resources for OT and PT services are limited and shortages in these professions exist, direct care provision by occupational and physical therapist assistants (OTA/PTA) is on the rise and valued in comprehensive rehabilitation practice. It is important to consider attitudes and biases of OTA/PTA, as they are directly involved in provision of rehabilitation services for people with disabilities. OBJECTIVE: This study examined the explicit and implicit disability attitudes of a large cross-section of OTA/PTA. METHODS: Secondary data analysis was completed using data from 6113 OTA/PTA from the Project Implicit Disability Attitudes Implicit Association Test. Implicit attitudes were calculated and OTA/PTA explicit and implicit disability attitudes were compared. Results were further categorized using an adapted version of Son Hing et al.'s two-dimensional model of prejudice. RESULTS: Findings revealed the majority of OTA/PTA reported having no explicit preference for people with disabilities or nondisabled people. However, the majority of OTA/PTA were aversive ableists, indicating low explicit and high implicit bias. CONCLUSIONS: Though explicit bias is lower in OTA/PTA, implicit bias is strong, indicating that people with disabilities face bias that may influence clinical interactions, and may be reproduced in professional education, practice, and policy. Concrete action must be taken to recognize and address disability bias to reduce health disparities in people with disabilities.

Impact of Occupational Therapy Education on Students' Disability Attitudes: A Longitudinal Study.

IMPORTANCE: Discrimination based on disability-ableism-is pervasive and affects the opportunities of people with disabilities to fully engage in society. OBJECTIVE: The aim of this study was to explore the impact of occupational therapy graduate education on students' explicit and implicit disability attitudes throughout their graduate education. DESIGN: Longitudinal observational study, measuring occupational therapy students' attitudes on an annual basis. SETTING: Three Midwestern graduate occupational therapy programs. PARTICIPANTS: Occupational therapy students (N = 67). Outcomes and Measures: Participants completed the Symbolic Ableism Scale (to measure their explicit disability attitudes) and the Disability Attitude Implicit Association Test (to measure their implicit disability attitudes) on an annual basis, from when they entered their occupational therapy program to when they graduated. RESULTS: The students' explicit attitudes decreased (i.e., became more favorable) throughout their education; however, their implicit attitudes did not change. In fact, most students (68%) were implicitly ableist at graduation. CONCLUSIONS AND RELEVANCE: Occupational therapy education programs have an important role to play in terms of intervening with students' beliefs and preconceived assumptions about disability. Our finding suggests that occupational therapy programs may fail to intervene with students' ableist attitudes. What This Article Adds: Little longitudinal research has examined how students' implicit disability bias may be affected by their academic experience. Our findings about ableism among occupational therapy students should open the door for further dialogue on the existence of ableism in program content, its potential impact on future client interactions, and the development of approaches to address it.

Recognizing Inequity: A Critical Step of Health Literacy for People With Disability.

IMPORTANCE: Receiving accommodations may require a person with physical disability (PWPD) to recognize and address disparate care when it occurs. OBJECTIVE: To explore whether PWPDs recognize disparate health care and how their experiences contribute to the development of strategies to access care. DESIGN: In this qualitative study, we used grounded theory methods to explore perceptions of PWPDs regarding access to health care. Ten PWPDs participated in three semistructured focus group interviews. The analysis used multiple phases of analysis and methods to ensure rigor. SETTING: Focus groups were held at an urban university campus. PARTICIPANTS: Four male and six female English speakers who identified as a PWPD in need of a mobility aid and who attended a primary health care visit in the past year. RESULTS: Seven thematic categories emerged, representing a continuum of stages for recognizing health care as disparate and strategies to receiving equitable health care for PWPDs: (1) unrecognized experiences of normalization of disability discrimination (NODD), with a subtheme of medicalization; (2) knowing what you need; (3) noticing differences; (4) emerging understanding; (5) learning to take personal action; (6) NODD is systemic; and (7) taking control. CONCLUSIONS AND RELEVANCE: The findings of this study can be used on micro, meso, and macro levels to work toward equitable health care access and outcomes for clients. What This Article Adds: Occupational therapy practitioners can use these findings to understand the health literacy demands of PWPDs in efforts to access equitable health care and, when necessary, educate clients on their potential need for accommodation, rights to care, and development of strategies for requesting accommodations.

"A Legitimate Place in the Profession": Author Reflections on the 2005 Disability Studies Special Issue.

IMPORTANCE: In 2005, the American Journal of Occupational Therapy published a special issue focused on disability studies. Contributing authors challenged readers to reflect on their practices and recommended ways to change the field, yet literature on the current state of the integration of disability studies into occupational therapy is scarce. OBJECTIVE: To engage the original authors of the 2005 special issue in an examination of perspectives on how disability studies perspectives have contributed to changes within occupational therapy and what work remains. DESIGN: The research team conducted semistructured interviews with 11 authors who published an article in the special issue. Interview transcripts were analyzed using thematic analysis. Triangulation of coders, multiple phases of data analysis, and member checking were used to establish trustworthiness. RESULTS: Five themes emerged from the data: (1) exposure to disability and disability studies, (2) impact of the special issue on occupational therapy, (3) changes observed in occupational therapy beyond the special issue, (4) challenges integrating disability studies into occupational therapy, and (5) disability studies-informed recommendations for occupational therapy. CONCLUSIONS AND RELEVANCE: Although the original contributing authors acknowledged the transformative impact of disability studies on their own practice and scholarship, the results suggest that disability studies remains outside mainstream occupational therapy scholarship. Exploring the connections and divergence between disability studies and fields such as occupational science could improve understanding of how disability studies concepts are defined and used in theory and practice. What This Article Adds: Since the publication of the original special issue in 2005, the field of disability studies has continued to influence occupational therapy, although more often in individual than in systemic ways. Work is needed to embrace a disability studies-informed critical and intersectional foundation for the profession and explore the ways in which occupational therapy can better partner with populations through a disability studies lens.

Disability Studies and Occupational Therapy: Renewing the Call for Change.

Disability studies (DS) is an interdisciplinary field grounded in a minority studies philosophy that approaches disability as a socially constructed phenomenon. The first special issue of the American Journal of Occupational Therapy on DS was published in 2005. The present issue serves as a follow-up to highlight opportunities for and examples of DS integration into occupational therapy education, research, and practice. Studies in this special issue reflect a DS approach to research that prioritizes lived experiences, critical approaches, and participatory methodologies. Reported interventions focus on changing societal barriers rather than remediating individual impairments and acknowledge instrumental activities of daily living often neglected by traditional research. Studies on educational practices in occupational therapy have found persistent issues around negative attitudes toward disability and many opportunities to better infuse disabilities studies into curricula. Revisiting DS as it applies to occupational therapy has shown that many of the issues and considerations raised in 2005 remain in the field today. Recommendations across articles in this special issue highlight that advocacy and working for broader social change are essential for occupational therapy practitioners, given ongoing occupational injustices for people with disabilities. Infusing DS ideas into occupational therapy can promote greater alignment with priorities of disability communities and spur professional change to dismantle oppressive structures and ideologies.

Telehealth Use By Persons with Disabilities During the COVID-19 Pandemic.

Telehealth use rapidly expanded during the COVID-19 pandemic. Understanding if, and how, persons with disabilities (PWDS) used telehealth during the pandemic is vital to assuring that this evolving and increasingly common form of health care is equitably developed and delivered to avoid reproducing the health disparities PWDS already face. Our aim was to explore the use of telehealth among PWDS during the pandemic. We conducted a weighted secondary analysis of United States Census Bureau data (April-July 2021) from 38,512 (unweighted) PWDS. Our findings revealed 39.8% of PWDS used telehealth during the second year of the pandemic, ranging from 34.5% of persons with hearing disabilities to 43.3% of persons with mobility disabilities. There were also differences in telehealth use based on sociodemographics. Telehealth promises to open doors to more equitable health care access for many PWDS, but only if access barriers are removed.

Explicit and implicit disability attitudes of healthcare providers.

PURPOSE/OBJECTIVE: Health care providers' attitudes of marginalized groups can be key factors that contribute to health care access and outcome disparities because of their influence on patient encounters as well as clinical decision-making. Despite a growing body of knowledge linking disparate health outcomes to providers' clinical decision making, less research has focused on providers' attitudes about disability. The aim of this study was to examine providers' explicit and implicit disability attitudes, interactions between their attitudes, and correlates of explicit and implicit bias. Research Method/Design: We analyzed secondary data from 25,006 health care providers about their disability attitudes. In addition to analyzing people's explicit and implicit attitudes (Disability Attitudes Implicit Association Test), we used Son Hing, Chung-Yan, Hamilton, & Zanna's (2008) model of two-dimensional prejudice to compare provider's explicit and implicit attitudes. Finally, we used linear regression models to examine correlates of providers' explicit and implicit attitudes. RESULTS: While on average, provider's explicit attitudes (M = 4.41) indicated little prejudice, their implicit attitudes (M = 0.54) revealed they moderately preferred nondisabled people-they were aversive ableists. Correlates of providers' explicit and implicit attitudes also included age, gender, political orientation, and having relationships with disability (friends, family, and being a person with disability). CONCLUSIONS/IMPLICATIONS: This study revealed that despite a majority of providers self-reporting not being biased against people with disabilities, implicitly, the overwhelming majority were biased. This study's findings can be used to better understand how provider disability bias can contribute to inequitable health care access and health outcomes for people with disabilities. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Relationships between occupational therapy students' understandings of disability and disability attitudes.

Background: Entering occupational therapy (OT) students have established beliefs, informed by sociocultural backgrounds. Understanding how students define and understand disability, and the relationships these understandings have to disability bias, can guide curriculum design decisions to integrate meso and macro level perspectives of disability into clinical reasoning.Aim/Objective: This study's aim was to explore incoming occupational therapy students' (n = 67) understandings of disability and their attitudes towards it.Material and method: An online survey was used to collect data on students' attitudes and definitions of disability. Mixed research methods were used to analyze students' definitions of disability (content analysis) in relation to disability attitudes (Disability Attitudes Implicit Association Test).Results/Finding: Findings reveal students enter curriculums with vast differences in understandings of people with disabilities and these may provide a basis for and contribute to differences in attitudes of disability.Conclusions: OT students have established beliefs of disability as individualized or more socially constructed and these influence disability biases.Significance: Students' education has considerable influence in shaping attitudes and ways of interacting with people with disability. Understanding students' assumptions as they enter a program is a first step to evaluate how curriculum design may influence development of student clinical reasoning strategies.

ScreenABLE: Breast Cancer Screening among Women with Disabilities from Community Identified Challenges to Community-Based Programs.

BACKGROUND: Women with disabilities are an unrecognized cancer disparities population who experience well-documented barriers to breast cancer screening. There is a critical need for targeted, community-directed programing to address these disparities. OBJECTIVES: To describe the trajectory of a long-term community-academic partnership aimed at understanding and addressing breast cancer screening disparities among women with disabilities. METHODS: Phase 1 was a thematic qualitative focus group study (n = 40) with women with physical disabilities to understand their breast cancer screening experiences. Phase 2 was the application of an equity-focused knowledge translation (KT) process that brought together breast cancer survivors with disabilities and graduate applied health students in KT collaboratives to create innovative, evidence-informed knowledge products. Phase 3 included the development of community-based programming. RESULTS: In phase 1, women with disabilities identified provider and patient barriers to breast cancer screening, including a lack of provider knowledge and respect for individuals with disabilities, lack of accessibility, the history of stigma and mistreatment within the health care setting, and treatment fatigue. In phase 2, KT collaboratives created the short film "ScreenABLE" to educate providers and community members about physical and attitudinal barriers to cancer screening. In phase 3, community, academic, and clinical partners collaborated to create ScreenABLE Saturday, a wellness fair and free accessible mammograms, for women with disabilities with programming developed to directly address cancer screening barriers identified from the phase 1 research. CONCLUSIONS: Long-term sustained partnerships between academic, disability, and clinical partners are needed to address the complex issues that perpetuate breast cancer screening disparities among women with disabilities.

The relationship between disability prejudice and medicaid home and community-based services spending.

BACKGROUND: Medicaid is one of the most important health care safety nets for people with disabilities in the United States. Yet, from the beginning Medicaid only covered long-term services and supports (LTSS) through institutional care. In 1981 changes to Medicaid allowed states to provide home and community-based services (HCBS) instead so people with disabilities could receive LTSS in their own homes or in the community. As a result of these changes, there has been a significant decline in institutionalization of people with disabilities in favor of HCBS in the United States. However, the priority of HCBS can be impacted by ideas about community living and disability attitudes, among others. How these attitudes may trickle down to impact Medicaid funding decisions is unknown. OBJECTIVE: The aim of this study was to examine the relationship between HCBS and disability prejudice in the United States. METHODS: We used secondary data about state LTSS expenditures from across the nation in fiscal year (FY) 2015, as well as disability prejudice data (Disability Attitudes Implicit Association Test) from 325,000 people residing in all 50 states and the District of Columbia. RESULTS: Findings revealed regardless of the state size or wealth, states with more disability prejudice direct less of their LTSS funding towards HCBS. CONCLUSIONS: Biases and prejudice in disability policy decision-making are obstacles to equality of opportunity and full participation in society, as promised by civil rights.

"The Bigger Picture": Occupational Therapy Practitioners' Perspectives on Disability Studies.

OBJECTIVE: This qualitative study explored occupational therapy practitioners' perspectives about integrating principles from the field of disability studies (DS) into clinical education and practice. METHODS: After a conference presentation about DS, three simultaneous focus groups were conducted with 27 occupational therapy practitioners. A constant comparative, grounded-theory approach was used to identify themes across groups. RESULTS: Identified themes included convergences and divergences between the profession of occupational therapy and the field of disability studies, influence of perspectives of disability on service delivery, clinician navigation of systemic barriers, and incorporation of DS-aligned intervention strategies into practice. CONCLUSION: Despite points of alignment, occupational therapy has not fully addressed DS critiques. Practitioners recognized professional, systemic, and societal barriers and the need for more educational experiences, resources, and professional reflexivity and dialogue to inform the integration of DS concepts into practice.

Our Peers-Empowerment and Navigational Support (OP-ENS): Development of a Peer Health Navigator Intervention to Support Medicaid Beneficiaries With Physical Disabilities.

People with disabilities (PWD) are a health disparities population who experience well-documented physical, structural, attitudinal, and financial barriers to health care. The disability rights community is deeply engaged in advocacy to promote health care justice for all PWD. As the community continues to work toward systems change, there is a critical need for community-directed interventions that ensure individuals with disabilities are able to access the health care services they need and are entitled to. Peer health navigator (PHN) programs have been shown to help people from diverse underserved communities break down barriers to health care. The PHN model has not been systematically adapted to meet the needs of PWD. In this article, we describe the collaborative process of developing Our Peers-Empowerment and Navigational Supports (OP-ENS), an evidence-informed PHN intervention for Medicaid beneficiaries with physical disabilities in Chicago, IL, USA. Our Peers-Empowerment and Navigational Supports is a 12-month community-based PHN intervention that pairs Medicaid beneficiaries with physical disabilities (peers) with disability PHNs who use a structured recursive process of barrier identification and asset mapping, goal setting, and action planning to help peers meet their health care needs. Our Peers-Empowerment and Navigational Supports was developed by a collaborative team that included disability rights leaders, representatives from a Medicaid managed care organization, and academic disability health care justice researchers. We highlight both the conceptual and empirical evidence that informed OP-ENS as well as the lessons learned that can assist future developers.

The impact of people with disabilities choosing their services on quality of life outcomes.

BACKGROUND: In recognition of the importance of services and supports that are defined and chosen by the recipient with disabilities, there has been a shift toward person-centered services. Quality person-centered services not only aim to ensure people have control over their own lives, but also to improve individually defined outcomes. OBJECTIVE: The aim of this study was to explore the relationships between people with disabilities (PWD) choosing their services and their quality of life (QOL). METHODS: We had two main research questions: 1) what factors predict PWD choosing their services - who was most/least likely to choose their services?; and, 2) how does choosing their services impact the QOL of PWD? To examine these questions, we analyzed Personal Outcome Measures® interviews from approximately 1100 PWD. RESULTS: Our findings have revealed that when PWD are able to choose their services, the impact can be widespread. CONCLUSIONS: By ensuring PWD are able to choose their services, organizations are not only facilitating self-determination, but, ultimately, improving PWD's QOL.