Survey of Physician Wellness Practices with Persons with Disabilities
Presenter Name: Gloria Krahn, PhD, MPH;
Institution: RRTC: Health & Wellness Consortium, Oregon Health & Science University
Health status is critically important to experiencing a quality life, maintaining independence, and participating fully in society. For the more than 52 million Americans with disabilities (Pope & Tarlov, 1991; Brandt & Pope, 1997), maintaining health and wellness is essential to reduce the impact of impairment on functioning and to foster positive development. Additionally, as persons with disabilities live longer, long-term health promotion and quality of life issues must receive greater attention.
The role of primary health care providers is important because they are frequently the first point of contact for people seeking health promotion information. This is particularly true for person with disabilities or chronic health conditions. When individuals seek medical care, they are usually open to accepting guidance from the physician with whom they have entrusted their future well-being (National Center for Health Statistics, 2000). There is evidence that when health care professionals counsel their patients about risk reduction and illness management, those patients are more likely to change poor health habits (Center for the Advancement of Health, 2001). Since physicians are in a unique position to influence the behavior of patients, attaining the national goals for health promotion requires their active participation (Wechsler, Schor, Coakley, 1996). Previous studies have examined the extent to which primary health care providers in general have engaged in health promotion practices with their general patient population (Wechsler, Levine, Idelson, Rohman & Taylor, 1983; Wechsler, Levine, Idelson, Schor, & Coakley, 1996). However, there remains a paucity of research advancing the understanding of issues related to health care providers’ wellness promotion activities with adults and children with disabilities.
The purpose of the present study was to examine the wellness promotion practices of primary care physicians as they relate to adults and children with physical disabilities.
Study I examines:
- differences in wellness promotion practices of primary care physicians for adults living with physical disabilities compared to those without disabilities
- predictors of physician wellness attitudes and practices
- physician perceived barriers and incentives to providing wellness promotion care
Study II examines:
- differences in wellness promotion practices of primary care pediatricians for children living with physical disabilities compared to those without disabilities
- comparison of adult care physician practices with those of pediatricians
A 20-item questionnaire was developed that represents a modified version of the Wechsler et al. (1983 and 1996) questionnaire that provided data from the early 1980’s and the mid 1990’s for primary care providers around wellness practices. Specifically, the survey asks respondents to provide information about the following: (a) their attitudes about the importance of wellness promotion activities (e.g., decreasing cigarette smoking, or drug/alcohol intake, promoting healthy eating habits, and decreasing sexual risk taking), (b) their knowledge and professional practice of wellness promotion activities, (c) barriers and incentives for engaging in health and wellness promotion activities, and (d) demographic characteristics. The questionnaire was modified in two ways: topics specifically relevant to persons with disabilities (e.g., pain management) were added, and practices were queried regarding “typical patients” and then repeated querying about patients with physical disabilities. Patients with disabilities were defined as “adults (age 18-65) with physical and functional limitations that may or may not include cognitive and/or sensory impairments and does include conditions such as: spinal cord injury, head injury (including TBI and CVA), cerebral palsy, multiple sclerosis, spina bifida and post-polio.” Similarly, children with physical disabilities were defined as “children (age 0-17) with physical limitations that may have a cognitive component such as muscular dystrophy, cerebral palsy, spina bifida, spinal cord injury, traumatic brain injury, and Down syndrome.”
Following the format of Wechsler et al. (1983, 1996), Likert rating scales were used of 1-4 (1= Very Unimportant, 4 = Very Important) for attitude and 1-3 (1 = No, 2 = Sometimes, 3 = Yes, Almost Always) for physician professional practice and personal behaviors. Barriers and incentives were either endorsed as “Yes” or “No.” Copies of the survey are available by request to the authors.
Physician names and addresses were obtained from the medical marketing services list representing the American Academy of Family Physicians, the American Society of Internal Medicine, and the American Pediatric Association. For study one, a national stratified random sample of 600 internal medicine and 600 family practice physicians were selected as these two groups constitute the majority of adult primary care providers across the country. For study two, a nationally representative sample of 1200 pediatricians was recruited.
For study one, the responses of 417 physicians were used (34.8% response rate). Of those responding, 51% reported family practice as their specialty and 37% reported internal medicine. 275 of the respondents were male and 126 female. Year of graduation from medical school ranged from 1927 to 1999 (mean year was 1983). Work settings varied with the most common being private office (38%), partnership/group practice (23%), clinic (13%), hospital (7%), HMO facility (4%), and university (4%). 32% of respondents reported practicing in a metropolitan area of 500,000 people or more, and 75% indicated that they spend more than 75% of their time in direct patient care. Most respondents (61%) reported that only 0-10% of their patients were living with disabilities, while 29% reported that 11-29% of their patients were living with a disability.
For the pediatric sample, a total of 384 usable responses were received (32% response rate), with 51% males. Of those who responded, 75% reported that less than 10% of their patient population met criteria for disability with another 11% reporting 11-29% meeting criteria.
Adult Care Physicians
Figure 1 depicts those practices of adult care physicians in which significant differences in practice were reported for patients with compared to without physical impairments.
Child and Adolescent Care Pediatricians:
Figure 2 portrays pediatrician practices for their patients with and without physical impairments.
These survey results indicate that pediatricians considered across the US gather more information on children with disabilities on behavior problems, accidental injuries, sleep, parenting, abuse/neglect, social support, depression, and stress. They gather less information on adolescents with disabilities on smoking, alcohol/drug use and sexual activity.
Comparison of Adult and Child/Adolescent Care Physicians:
Only preliminary results are currently available. As depicted in Table 1 below, pediatricians providing care to children and adolescents generally report attitudes that endorse the importance of health promoting behaviors more than adult care physicians. The only exception relates to smoking behavior, where adult care providers report more concern than pediatricians.
|Attitude about Behavior||Typical Pediatric||Typical Adult||Disability Pediatric||Disability Adult|
|Have a regular physical exam||3.39||2.74||3.82||3.33|
|Have a regular dental exam||3.50||3.26||3.50||3.32|
|Get sufficient rest||3.54||3.34||3.68||3.50|
|Use sunscreen when outside||3.48||3.30||3.63||3.31|
|Practice safe sex||3.75||3.61||3.84||3.44|
In terms of actual practices, pediatricians again report gathering information about health promotion behaviors more often than adult care providers, but these differences are only significant for their care of typical patients and not for children/adolescents and adults with disabilities.
|Practice||Typical Pediatric||Typical Adult||Disability Pediatric||Disability Adult|
|Gathered information on diet/nutrition||2.84||2.48||2.85||2.49|
|Gathered information on school or work performance||2.82||2.07||2.80||2.21|
|Gathered information on family and social relationship||2.50||2.25||2.61||2.31|
|Gathered information on sexual activity||2.70||2.14||2.52||2.10|
|Gathered information on smoking||2.78||2.95||2.66||2.92|
The findings of this survey of adult care physicians corroborates what surveys of people with disabilities have reported regarding referrals for preventive and early detection tests—that they are referred at lower rates than their non-disabled counterparts. The study represents one of the first studies of physician practices on health promotion for children with disabilities. Implications are outlined below.
- Refine measurement of physician /health care provider practices to determine what influences increased likelihood of questioning about and supporting healthy lifestyle behaviors
- Expand the exploration of incentives and barriers to physician practices to promote health and research effectiveness of interventions.
- Explore differences in practices toward patients with disabilities compared to patients without disabilities.
- Examine and address public and private health insurance reimbursement rates and mechanisms to support health promotion efforts by health care providers
- Promote inclusion of health promotion knowledge and practices in credentialing of health care providers
- Infuse awareness and competency training in promoting healthy behaviors by health care providers into the education of physicians and nurses.
- Provide information and training to persons with disabilities and their support systems to support planning with their health care providers for achieving and maintaining health/wellness goals
Brandt, N., Pope, A. M., Institute of Medicine, & Committee on Assessing Rehabilitation Science and Engineering (1997). Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, DC: National Academy Press.
Center for the Advancement of Health (2001). Integration of Health Behavior Counseling in Routine Medical Care Washington, DC: Center for the Advancement of Health.
Pope, A. M., Tarlov, A. R., Institute of Medicine, & Committee on a National Agenda for the Prevention of Disabilities (1991). Disability in America: Toward a national agenda for prevention. Washington, DC: National Academy Press.
Wechsler, H., Levine, S., Idelson, R. K., Rohman, M., & Taylor, J. O. (1983). The physician's role in health promotion--a survey of primary-care practitioners. N.Engl.J.Med., 308, 97-100.
Wechsler, H., Levine, S., Idelson, R. K., Schor, E. L., & Coakley, E. (1996). The physician's role in health promotion revisited--a survey of primary care practitioners. N.Engl.J.Med., 334, 996-998.