Disability and Health Research
2006-2009 Research and Outcomes
Disability and Health Research Projects are funded by the Disability and Health Branch, Division of Human Development and Disability, NCBDDD, CDC.
Pharmaceutical Case Management and Living Well with a Disability
Elizabeth A. Chrischilles, MS, PhD, U. of Iowa, College of Public Health,
Iowa City, IA
The United States state-specific age-adjusted disability prevalence ranges from 13.6% to 21.8%. A third to half of people with disability have drug therapy problems, 25 to 45% have an adverse drug effect each year, and virtually all regularly experience at least one secondary condition. The purpose of this randomized controlled trial is to test the effectiveness of the eight-week group-session health promotion program Living Well with a Disability (LW) augmented with a cooperative care model of medication management (Pharmaceutical Case Management; PCM). We theorize that the complementary mechanisms of the combined interventions will result in greater reduction in secondary conditions than the Living Well program alone. By reducing symptoms from secondary conditions our overall goal is to improve the health and quality of life of people with activity limitations. This research expands and replicates two promising evidence-based interventions in a broader population than they have previously been studied: we will test the interventions in a population-based sample of 252 adults with activity limitations who may or may not identify themselves as disabled. By combining the two interventions, this research also evaluates a new integrated intervention. Our primary specific aim is to compare the 6 and 12 month mean symptoms of secondary conditions among adults randomized to participate in the Living Well program augmented with PCM with those randomized to the traditional Living Well program and with those randomized to a no- intervention control group. Secondary aims are to compare the medication use quality, attitudes and adverse effects between the study groups. A population-based sample of adults with activity limitations will be identified by mailing a screening questionnaire to an age-stratified random sample of adults (18-44,45- 64, 65+) from the Iowa voters registration list living within 30 miles of the study facilities in three Iowa counties. To be eligible for our study, a person must report: (1) activity limitations according to the two BRFSS disability screening questions; (2) a physical impairment, including an anatomical loss or musculoskeletal, neurological, respiratory, or cardiovascular impairment which results from injury, disease, or congenital disorder; and (3) three or more symptoms from secondary conditions. Those randomized to traditional LW will participate in 8 weekly LW sessions. The augmented LW group will additionally receive four one-on-one in-person sessions with a study pharmacist to create a medication therapy action plan in cooperation with the subject's primary care physician. Questionnaires will be administered at baseline and 6 and 12 months and will be the source of the primary study outcome variable as well as measures of attitudes and adverse medication effects. Prescription dispensing records and medical records will be the data source for rating medication use quality using standardized guidelines.
Promoting Health of Youth with Disabilities through Violence Prevention Efforts
Terri Sullivan, PhD, Virginia Commonwealth University, Richmond, VA
The promotion of health and well-being among youth with disabilities is a significant public health concern. Almost 54 million Americans have disabilities that interfere with life activities, and research suggests that youth with disabilities are at higher risk that those in the general population for health-compromising behaviors including involvement in violence. Health promotion programs may benefit these youth greatly, and schools offer a practical and important social context for implementing such efforts. Unfortunately, most school-based violence prevention programs were developed for the general population and the effectiveness of these programs has not been evaluated among youth with disabilities, A key step in making progress is this area is to modify violence prevention efforts empirically demonstrated to be effective for the general population, such as Responding in Peaceful and Positive Ways (RIPP), to meet the needs of youth with disabilities and to determine the effectiveness of such interventions for this population. Youth with disabilities are at a high risk for violence perpetration and victimization, health-compromising behaviors that are strongly related to increased rtes of anti-social behavior, higher levels of depression and anxiety, and decreased life satisfaction. The goals of this research project include the following: (1) to increase community involvement in violence prevention efforts for youth with disabilities, (2) to work with youth with disabilities and their teachers to better understand the problem situations commonly faced by these youth that place them at risk for violence involvement, and identify supports and challenges in modifying the RIPP interventions for youth with disabilities, and (4) to evaluate the effectiveness of RIPP for youth with disabilities. Participation from youth with disabilities is included at each phase of this research project in hopes of creating a maximally effective program. Although this project focuses on a specific intervention, we anticipate that it will offer a practical template for the replication of health promotion efforts in other schools and school systems.
An Efficacy Trial of Steps to Your Health for Adults with Learning Domain Disabilities
Suzanne McDermott, PhD, University of South Carolina, School of Medicine,
Columbia, SC
The overall aim of this project is to determine the efficacy of Steps to Your Health (STYH), a health promotion program, in adults with mental retardation, autism, or traumatic brain injury. STYH is an eight session participatory and didactic intervention that has been utilized for over ten years in these population groups in South Carolina. It emphasizes physical activity, good nutrition, and stress reduction as key aspects of a healthy lifestyle. Ongoing program evaluations indicate that STYH participants significantly improve in their knowledge, physical activity, and diet in addition to losing weight. Previous evaluations, while promising do not provide definitive proof of a program impact, as they did not utilize experimental study designs. Given the need for demonstrably effective health promotion interventions for persons with cognitive disabilities, the promising evaluation results call for a well-controlled study of program efficacy. The proposed study is a randomized trial of the STYH program community-dwelling adults in South Carolina with mild to moderate cognitive impairment due to mental retardation, autism, or traumatic brain injury. Participants will be recruited through local disability service agencies and randomized to participate in the STYH program or serve as controls. While randomization will be at the individual level, all adults living in the same household with an intervention participant will be encouraged to participate in the program as well, though they will not be included in the analyses. Participants and controls will be assessed at baseline and one week, six months, and twelve months following program completion. The key study outcomes are levels of physical activity as measured by self report and accelerometers, dietary composition as measured by self report and direct observation, and weight loss. Knowledge about diet, exercise, and stress reduction will also be assessed. We hypothesize that STYH participants will exhibit increased physical activity, healthier diets, and greater weight loss in comparison with controls. We further hypothesize, based on previous analyses that increased knowledge will be the primary intermediate variable that accounts for the program impact in each of these areas. This research will provide important information on an existing health promotion program for adults with cognitive disabilities and will inform future efforts at designing effective interventions for this population.
Personalized Physical Activity & Nutrition Intervention for Overweight/Obese
James Rimmer, PhD, University of Illinois at Chicago, IL
Developing effective and sustainable interventions to increase key health behaviors remains a critical issue in health promotion for people with disabilities. Our current research uses a personalized intervention approach with telephone coaching support to achieve increases in physical activity participation, lowering of body mass index (BMI), and reduced healthcare utilization. The proposed project will expand the scope of this promising research by (1) training multiple wellness coaches in the implementation of the intervention; (2) using a computer-assisted system to conduct baseline assessment, facilitate goal development, identify local resources, and monitor progress; (3) adding a nutrition component to examine the additive effects on health outcomes; and (4) recruiting a more diverse sample of persons with mobility disabilities from multiple sites. 228 obese individuals with mobility disabilities (spinal cord injury, multiple sclerosis, cerebral palsy, spina bifida) will be randomized into one of three conditions: (1) PEP-II, Personalized Physical Activity Program involving physical activity telephone coaching only; (2) PEP Plus, Personalized Physical Activity and Nutrition coaching; and (3) control group. Eligibility criteria include (a) permission from physician to participate in the study; (b) BMI of 30-40; (c) have the ability to converse in English; (d) not enrolled in another health promotion program; and (e) sedentary lifestyle over the previous six months. Primary outcomes include physical activity, nutrition, self-efficacy, blood pressure, blood lipids, and healthcare utilization costs. Intervention group participants will receive wellness telephone coaching in the following phases: (a) 0-6 months (Adoption) - weekly coaching; (b) 7-12 months (Maintenance) - bimonthly to monthly coaching; (c) 12-18 months (Follow up) - no coaching. We hypothesize that relative to controls, the intervention groups will evidence significant gains on measures of physical activity, nutrition intake, and self- efficacy, as well as significant reduction in healthcare utilization, BMI, blood pressure and blood lipids. On these same outcome measures, participants in the PEP Plus group are hypothesized to evidence significant gains relative to their PEP-II counterparts. Intention-to-treat analysis will be conducted using a series of mixed models that will compare the three treatment groups over time (pre-test and six, 12 and 18-month post-test).
Working Well with a Disability: Health Promotion as a Means to Employment
Tom Seekins, PhD, University of Montana, Missoula, MT
Healthy People 2010 establishes the national goal of eliminating participation disparities in employment between people with disabilities and the general population. Indeed, only about 52% of people with disabilities report being employed, while 82% of the general population report having a job (DHHS, 2001). While there are many factors that affect the employment rate of people with disabilities, health status appears to be one of them. In a longitudinal study of 264 consumers of VR services in ten states preliminary data show higher ratings of secondary conditions at baseline were associated with lower employment outcomes at the 6-month follow-up measure (F = 8.448, p = .00). Further, results from a logistic regression (n=164) show that reported secondary conditions at baseline predict employment outcomes at 6-months (p=.021), after controlling for demographic characteristics, severity of disability, life satisfaction, and health promoting lifestyle behaviors. Efforts to increase the employment and economic independence of people with disabilities should analyze the impact of secondary health conditions on employment. Although health promotion activities prevent or ameliorate many secondary conditions (Lorig, et al., 1999; Ravesloot, Seekins, & Walsh, 1997; Ravesloot, Seekins, & White, 2005), VR agencies currently cover only acute care services (Rehabilitation Services Administration, 2001). Treating acute episodes is costly to VR (Hoffman, Rice, & Sung, 1996). Integrating interventions designed to help consumers prevent and manage secondary conditions may reduce the need for medical services and improve employment outcome. Accordingly, the GOAL of this project is to develop and evaluate the effectiveness of a new health promotion intervention, Working Well with a Disability, on increasing health status, health promoting activities, and successful employment outcomes of people with disabilities served by the national network of Vocation Rehabilitation programs.
Promoting Health and Functioning in Person with Serious Mental Illness
Stephen J. Bartels, MD, MS, Dartmouth Medical School, Department of
Psychiatry, Hanover, VT
Serious mental illness (SMI) is a leading cause of worldwide disability and is associated with impaired community functioning and increased rates of medical comorbidity and mortality. People with SMI have a lifespan that is 10-12 years shorter than the general population and have high rates of obesity, sedentary lifestyle, poor dietary habits and inadequate preventive health care. Findings from a pilot study conducted by our group evaluating a novel program, "In Shape Lifestyles" (ISL), suggest that significant health benefits can be achieved by persons with SMI through a health promotion program consisting of a personal fitness assessment, diet and exercise programs supported by weekly meetings with a health mentor, nurse facilitated preventive care, access to fitness facilities through a YMCA membership, dietary education and consultation, an incentive program, and group motivational sessions. The ISL intervention is guided by the ICF Model of Functioning, Disability, and Health by addressing mental and physical functioning and impairments, activity limitations and participation restrictions, environmental factors, and personal factors. In the proposed randomized, controlled study, 130 adults age 21+ with SMI and poor physical fitness (BMI > 25, or < 10 minutes of exercise 2x over the past month) will be randomized to either: a) ISL or b) Health Club Membership and Education (HCME): consisting of a YMCA membership, educational materials on exercise and healthy diet, and an on-site introduction to the health club. The following three specific aims will be addressed: (1) To compare ISL and HCME with respect to: (a) participation in regular exercise and dietary change; (b) participation in preventive health care; and (c) improved fitness and health; (2) to compare ISL and HCME with respect to: (a) indicators of mental health and (b) personal self-efficacy; and (3) to explore differences in ISL and HCME with respect to (a) selected physical, metabolic, dietary, and community functioning secondary outcomes; and (b) the relationship of demographic variables and readiness to change to outcomes. ISL participants will receive a six-month intensive program of one-to-one health mentoring, followed by a 3-month period of transitioning to self-directed individual and group programming, with assessments conducted at baseline, 3, 6, 9 and 12 months. If found to be effective, ISL will provide a practical approach to improving health, independent functioning, and longevity in disabled persons with SMI.
Improving Activity and Participation After Limb Loss: PALS Plus
Stephen T. Wegener, PhD, John Hopkins University, Baltimore, MD
Limb loss can result from a variety of etiologies including diabetes, trauma and cancer. Following limb loss, individuals are at elevated risk for activity limitations and participation restrictions with significant impact on health and quality of life. Intervention: Working with the Amputee Coalition of America we have developed, evaluated, and established the effectiveness of a self-management program (PALS) to improve health and outcomes following limb loss. Literature suggests that the access to, and effectiveness and utilization of, this class of interventions may be enhanced by the concerted use of early intervention, peer mentorship, motivational interviewing and provider training. Objectives: Our goal is to evaluate the effectiveness of an enhanced, early self-management intervention- PALS Plus. The specific aims are: 1) evaluate the effectiveness of the PALS Plus intervention in improving outcomes for persons with limb loss; (2) evaluate the effectiveness of the PALS Plus intervention in maximizing utilization of self-management interventions for persons with limb loss. Study Design and Participants: The prospective clinical trial will use a two group, lagged-control design to evaluate the intervention at five health care facilities. A cohort of 200 patients will be enrolled prior to implementation of the intervention and will serve as the control group. Subsequently, a second cohort of 200 patients will be enrolled and receive the PALS Plus intervention and will serve as the intervention group. Assessment will be at baseline, treatment completion and six month follow-up. Outcomes: Primary outcome measures are: pain, depressed mood, and positive mood. Secondary outcome measures are: function, participation and bothersomeness of limitations. Improvements in primary and secondary outcomes will result through the impact on self efficacy, patient activation, catastrophizing and social support. The investigation will also provide unique and valuable information regarding patients' acceptance and use of peer visitation and self-management following limb loss. Relevance: By establishing the utility and effectiveness of the enhanced self-management intervention, there is the potential to improve the health, activity, participation and quality of life for individuals with disabilities. The intervention addresses he areas of activity and participation in such a way that it can be implemented in local health care facilities working in combination with a national consumer based organization - the Amputee Coalition of America.
Telehealth: Automated Phone Follow Up for People with Mobility Impairments
Steve Williams, MD, Boston University Medical Center, Boston, MA
The goal of the Telehealth for Health study is the development and initial evaluation of an automated, telephone-based screening, referral, and educational behavioral intervention system with the long-term objective of promoting health by preventing secondary conditions and decreasing their severity among adult patients with mobility impairments (Ml) who are wheelchair users. This study forwards the goals of Healthy People 2010 Chapter 6 on Disability and Secondary Conditions. The target population will consist of people with spinal cord dysfunction, including people with spinal cord injury and people with multiple sclerosis at Boston Medical Center and affiliated institutions. The specific aims of the proposed study are: 1) To design and develop TLC-SCD that consists of: (a) a Pressure Ulcer Module which screens for new ulcers, promotes healthy prevention behaviors, and detects and monitors existing ulcers; (b) a Depression and Substance Use Module that will detect depressive symptoms and substance use problems and measure their severity; (c) a Health Care Utilization Module that inquires about individualized mental and physical health care utilization and misconceptions for targeted behavior change; and (d) a Community Integration Resource Module that provides referrals and resources. 2) To conduct a preliminary qualitative evaluation of the acceptability and usability of TLC-SCD by patients with SCO and to modify, improve, and refine TLC-SCD accordingly. 3) To conduct an initial randomized clinical trial (RCT) comparing TLC-SCD to a control condition (standard care) to evaluate its preliminary efficacy to promote the health of patients with SCO through prevention and detection of secondary conditions for treatment referral and behavioral intervention. Alerts to the nurse coordinator will occur whenever TLC-SCD detects a clinically significant event. A randomized clinical trial will be conducted to compare the TLC-SCD intervention to a control (no-intervention standard care) group. Participants in the intervention group will be called weekly for 3 months, followed by an observation period of 3 months, and will interact with the system through voice recognition technology. Such rigorous results will contribute greatly to developing and implementing low-cost, effective interventions for people with mobility impairments.
Workshop and Internet Wellness Interventions for Women Aging with Disabilities
Margaret Nosek, PhD, Baylor College of Medicine, Houston, TX
Health promotion research conducted by the
Center for Research on Women with Disabilities strongly suggests that our traditional, face-to-face workshop format shows great promise for helping women aging with physical disabilities improve their health. A larger, national sample with more diverse characteristics is now needed to demonstrate its wider applicability. We propose (1) to refine and further test our health promotion workshop intervention for women aging with disabilities. To address the needs of women who lack access to traditional formats due to multiple barriers such as transportation problems, mobility limitations, and secondary conditions such as pain and fatigue, we propose (2) to develop and establish the feasibility and efficacy of an online health promotion program designed to offer the same content and behavior change strategies using the technique of serious gaming. To fulfill Aim 1, we will collaborate with 12 centers for independent living around the US to conduct a randomized, controlled trial of our workshop intervention. To fulfill Aim 2, we will collaborate with researchers at Case Western Reserve University to develop an online intervention based on their self-paced, web-based health promotion course. We will test three hypotheses: (1) Participants in the workshop intervention group will report significantly higher scores on measures of self- efficacy, health behavior, and health status at the completion of the 8-session intervention and at 6 and 12 months after baseline compared to participants in a wait-list control group; (2) The effect of the workshop intervention on physical and psychological health status will be mediated by self-efficacy and health behavior; (3) Participants in the Internet group will report significantly higher scores on measures of self- efficacy, health behavior, and health status compared to participants in a wait-list control group. To test the first two hypotheses, a sample of 312 women with physical disabilities will be recruited and randomly assigned to the workshop group or a wait-list control group. To test the third hypothesis, an additional 100 women will be randomly assigned to the internet group or a wait-list control group. These interventions are designed for use in clinical and social service settings and to advise public health policy governing the delivery of health services to people with physical disabilities.
