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Inadequate Cardiovascular Disease Prevention in Women with Physical Disabilities
Health promotion and screening tests are important in persons with disability to avert secondary conditions that can lead to suboptimal functioning or premature death. Conversely, the existence of a primary disability can increase a person’s susceptibility to secondary conditions. Cardiovascular disease (CVD) is the major cause of death in the United States, and its prevalence has been underinvestigated in persons with disability. This descriptive study used survey research to compare the risk of CVD in samples of 100 physically disabled women with 50 nondisabled women in the community. Participants, recruited from health fairs, completed questionnaires that explored the participants’ knowledge of CVD risk factors, possession of specific CVD risk factors, and experience with CVD preventive screening procedures. Data revealed that compared with women without disability, women with disability were less knowledgeable about CVD risk factors and experienced marked deficiencies in CVD preventive screening. Body weight measurement, baseline electrocardiograms, family history, and smoking queries were performed less often in women with disabilities than in women without disabilities of similar age. Physical inactivity and postmenopausal status were specific CVD risk factors found to be more prevalent in the sample of women with disability. These findings suggest that risk of CVD is underrecognized and underassessed in women with a physical disability.
Prevalent Neglect of Basic Health Promotion Needs of the Disabled
People with disabilities face unique challenges accessing preventive health care in the United States. Extensive research demonstrates that persons with disability are not provided preventive health care services to the same extent as persons without disability. According to the National Institutes of Health (NIH), only 12% of persons with disability receive adequate preventive screening services in the United States (National Center for Health Statistics, 2000).
Investigators assert that basic health promotion needs of persons with disability are often overshadowed by a narrow focus on their disabling condition by health care providers. Studies have specifically shown that women with disability undergo less gynecologic and bone density screening tests compared with nondisabled women (Shabas & Weinreb, 2000; Iezzoni, McCarthy, Davis, & Siebens, 2000; Chan, MacLehose, Lawson, Rosenblatt, Baldwin, & Jha, 1999; Nosek & Howland, 1997; Becker, Stuifbergen, & Tinkle, 1997; Smeltzer, Zimmerman, Capriotti, & Fernandes, 2002).
Health promotion and screening tests are particularly important in persons with physical disability to prevent secondary conditions. Secondary conditions can hinder optimal functioning or lead to premature death in the disabled person. A primary disability can enhance susceptibility to secondary conditions. Persons with disability may experience the onset of certain secondary conditions earlier in life than persons without disability (Rimmer, 1999; Welner, Simon, & Welner, 2002).
Therefore, appropriate and timely preventive health care is crucial for persons with disability to avert secondary conditions that lead to ill health, functional decline, and premature death.
Prevalent Gender Bias in Cardiovascular Healthcare Provision
There are 27 million disabled women in the United States, and more than 16 million older than 50 (Americans with Disabilities Census Data, 1997). Women older than 50 are in the life phase of perimenopause, a stage in which the cardioprotective effects of estrogen begin to diminish. Studies show that health care providers often underestimate a woman’s risk of cardiovascular disease (CVD). Women undergo fewer CVD screening tests, diagnostic procedures, and treatments than men (Legato, Padua, & Slaughter, 1997; Tsang, Barnes, Gersh, & Hayes, 2000; Vaccarino, Parsons, Every, Barron, & Krumholz, 1999; Gan, Beaver, Houck, MacLehose, Lawson, & Chan, 2000). Yet, one-third of women older than 50 have CVD, which accounts for more than 50% of all deaths among women annually (American Heart Association [AHA], 2000).
For the population of 16 million women older than 50 who have a physical disability, CVD risk screening is an essential part of their health promotion. However, these women may face a dual disadvantage in terms of adequate CVD prevention. This female population may face the gender bias that exists in cardiovascular health care and be subjected to the health care provider’s focus on their primary disability. In view of these factors, women with disability may have a higher risk of CVD than nondisabled women. However, there is a dearth of research that specifically addresses CVD risk in women with disability.
The aim of this study was to compare CVD risk in two populations of women older than 30; women with a physical disability and women without physical disability. CVD risk was compared according to three different variables: frequency of CVD risk factors, general knowledge of CVD risk factors, and provision of preventive CVD healthcare services.
The following questions were addressed in this investigation:
This was a cross-sectional, descriptive study using survey research from two groups of women. Both groups completed the survey one time only.
To be eligible for the study, women needed to be older than 30 and able to understand and respond to items on a questionnaire. Women recruited for the disabled group were health fair attendees with an apparent physical disability who reported a diagnosis associated with a physical disability. Women recruited for the nondisabled group had to report no physical disability. The study was approved by the institutional review board, and all subjects gave written informed consent.
The assessment tool was a 39-item self-report questionnaire that explored general knowledge of CVD risk factors, the subject’s possession of specific CVD risk factors, and CVD screening tests or assessments provided to the individual within the last 2 years. The American Heart Association (AHA) Heart Health Quiz (2000) provided the basis for assessment of knowledge of CVD risk factors. Personal data were also surveyed, such as ambulatory status, demographic characteristics, and diagnoses related to physical disability. Survey completion required 5–10 minutes, and all items could be answered by circling yes or no responses. The internal consistency reliability of the AHA Heart Health Quiz (2000) was calculated using data from both groups. The statistical analysis of split-half reliability yielded a coefficient of .874, indicating an acceptable internal consistency (Polit & Beck, 2004).
A convenience sample of 100 community-dwelling women older than 30 with various self-reported physical disabilities were recruited as volunteers for the study. Subjects were attendees at a health fair specifically for disabled persons that was held at a convention center in a suburb of a major northeastern U.S. city in April 2000. The women ranged in age from 33 to 85 years (N = 100, mean age = 55.6, SD = 9.7).
A convenience sample of 50 community-dwelling women without disabilities older than 30 were recruited as volunteers for the study. Participants were attendees at a university health fair and employee benefits fair in a suburb of a major northeastern U.S. city in April 2002. The group comprised women aged 35 to 82 years (N = 50, mean age = 56, SD = 8.8).
The demographic characteristics, ambulatory status, and diagnoses related to physical disabilities of both study groups are summarized in Table 1.
Comparison of Mean Numbers of CVD Risk Factors
To assess number of CVD risk factors, subjects answered yes or no to nine simple statements derived from the AHA/American College of Cardiology (ACC) Global Coronary Heart Disease Risk Assessment Scoring Tool (Grundy, Pasternak, Greenlund, Smith & Fuster, 1999). Examples of statements included: “I am 55 years old or older,” “I have been told I have high cholesterol,” “I smoke.” The following CVD risk factors were assessed: age, smoking behavior, exposure to passive smoke, high blood cholesterol, high blood pressure, family history of CVD, diabetes, postmenopausal status, and lack of physical activity. Each CVD risk factor was allotted one point with a possible total of nine points. Numbers of risk factors were tallied for each subject as a point score. Mean point scores were calculated for each group and the differences in the means were analyzed using unpaired t tests.
Sixteen percent of the disabled women did not answer all the questions with a yes or no response. Disabled women (n = 84) had a mean of 4.2 out of 9 possible CVD risk factors, compared with a mean of 4.1 out of 9 for women without disabilities (n = 49). Unpaired t tests revealed no statistically significant difference in the means (p = .6222). These results are summarized in Table 2.
All 16% of women with disabilities (n = 100), who did not complete the risk factor checklist, did not respond to the statement: “I have been told I have high cholesterol.” In contrast, only 1% of the women without disabilities (n = 50) did not answer this question.
One additional question asked postmenopausal participants whether they took hormone replacement therapy (HRT), because this was thought to be a cardio-protective measure until 2002. During this study, research emerged that demonstrated an association between HRT and increased CVD risk (Grady et al., 2002). Responses to this question were not included in CVD risk factor tallies. Frequency distributions were calculated and compared for the two groups with regard to use of HRT. Chi-square statistical analysis revealed no significant difference in frequency of HRT use between two groups; see Table 3.
Comparison of Frequency of CVD Risk
Chi square statistical analysis revealed a significant difference in the frequency of specific CVD risk factors for the two groups. Lack of physical activity was more prevalent among disabled women. Participants were considered lacking in physical activity if they answered yes to the statement “I spend most of my day sitting.” Eighty seven percent of disabled women (n = 100) versus 14 % of nondisabled women (n = 50), answered yes to this statement. These were statistically significant differences (χ2 = 75.926, df = 1, p < .01).
Sixty-eight percent of disabled women (n = 100), versus 88 % of nondisabled women (n = 50), reported a family history of CVD. This difference was statistically significant at a p < .05 (χ2 = 7.049, df = 1, p = .0079).
Seventy percent of disabled women (n = 100), reported they were postmenopausal, whereas 42% of the nondisabled women (n = 50) reported this status. According to chi-square analysis, the difference in menopausal status between the two groups was statistically significant (χ2 = 12.596, df =1, p = .0004). For a summary of the data on all CVD risk factors for the two groups, see Table 2.
Comparison of Knowledge Level of CVD Risk Factors
To compare knowledge levels of CVD risk factors, the AHA Heart Health Quiz (2000) was administered to each subject as part of the survey. Disabled women were less knowledgeable about CVD risk than nondisabled women. The quizzes were scored and a mean score was calculated for the nondisabled and disabled groups. Women with a disability (n = 100) had a mean score of 11.49 out of 14 points versus 12.86 out of 14 points for women without a disability (n = 50). According to unpaired t tests, this was a statistically significant difference (p < .01).
Comparison of Cardiovascular Preventive Health Care
The frequency distributions of the yes or no responses to questions regarding CVD preventive health care provision experienced by each group were determined and analyzed using the chi-square statistic. Chi-square analysis revealed significant differences for the two groups using a p > .05. See Table 3 for a summary of the responses to all questions. The specific CVD preventive health care measures which were significantly different for both study groups are described below.
Forty-three percent of disabled women (N = 100) answered yes, whereas 99% of nondisabled women (n = 50) answered yes to the question, “Has your healthcare provider weighed you within the last 2 years?” This result was statistically significant (χ2 = 42.518, df = 1, p < .01).
Seventy-five percent of disabled women (n = 100) answered yes, but 94% of nondisabled women (n = 50) answered yes, to the “Has your healthcare provider asked if anyone in your family has or had high blood pressure, heart attack, or stroke?” These differences were statistically significant (χ2 = 7.926, df = 1, p < .01).
To the question “Has your health care provider asked if you smoke?” 91% of disabled women (n = 100) answered yes, whereas 100% of nondisabled women (n = 50) answered yes. This was a statistically significant difference between the groups (χ2 = 4.270, df = 1, p = .0388).
When participants were asked, “Has your healthcare provider performed a cardiogram (ECG) on you or referred you for a cardiogram?” 28% of disabled women (n = 100) responded yes versus 70% of nondisabled women (n = 50). These differences were statistically significant according to chi-square analysis (χ2 = 24.138, df = 1, p < .01).
In this study, women with a physical disability were at higher risk for CVD than nondisabled women of similar age in the community. Disabled women experienced deficiencies in CVD risk preventive screening, possessed distinct CVD risk factors, and had less general knowledge of CVD risk factors.
With regard to CVD preventive health screening, disabled women were weighed far less frequently by healthcare providers than nondisabled women. This is significant since obesity, a modifiable CVD risk factor, is prevalent in adults with physical disability (Weil et al., 2002). Recent studies show that obesity is a predictor of CVD, particularly for women (Bender, Jockel, Richter, Spraul, & Berger, 2002; Hubert, Feinlieb, McNamara, & Castelli, 1983). Approximately 14% of cases of heart failure among women in the community are attributable to obesity (Kenchaiah, Evans, Levy, Wilson, Benjamin, Larson, Kannel & Vasan, 2002). Because obesity increases risk of hypertension, left ventricular hypertrophy, heart failure, diabetes, and dyslipidemia, weight measurement is integral to CVD risk assessment and screening. Disabled women also reported that health care settings lack adequate equipment to weigh them, particularly those who cannot assume a standing posture. Adaptations to standard medical scales are necessary for those patients who cannot stand.
Many disabled women reported inadequate queries related to CVD risk during the health history taken by health care providers. More disabled women were not asked about family history of CVD or smoking behavior than nondisabled women. There is a known predisposition to CVD among members of the same family (Granger, 2000; Singer,1991; Odawara, Matsunuma, & Yamashita, 1997). Health care providers fail to assess a highly significant CVD risk factor when they neglect to ask questions about family history of CVD. Smoking behavior, a known CVD risk factor, needs to be assessed during the health history as well. If the health care provider does not ask the patient about smoking, then it can be assumed that smoking cessation advice is not provided.
A large disparity was evident in the frequency of ECGs performed in disabled women compared to nondisabled women. A small proportion of disabled participants (28%) reported that they had had a cardiogram or referral for an ECG within the last 2 years. In contrast, a very large proportion of nondisabled women (70%) reported that they did have an ECG or referral in the past 2 years. Review of the literature demonstrates that there is no established practice guideline regarding ECG as a preventive screening test in persons without suspected heart disease. However, a baseline ECG is recommended for patients with CVD risk factors (ACC/AHA Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures, 1992). Studies show that a significant proportion of myocardial infarctions in men older than 30 and women older than 40 are asymptomatic, but can be diagnosed by ECG (Kannel & Abbott, 1984; Kannel, 1986). The disabled women in this study reported that they were unable to maneuver onto a standard table for an ECG. Inaccessible equipment may have impeded ECG monitoring of this population, which demonstrates the need for adaptations to facilitate CVD screening tests. Further investigation into this issue is warranted.
Physical inactivity is a prevalent, modifiable CVD risk factor among women with physical disability. A recent study demonstrated that physically inactive adults with chronic disease had a three-times higher risk of death than those who were physically active. As little as 30 minutes of physical activity per week decreased risk of mortality (Martinson, O’Connor, & Pronk, 2001). Exercise reduces coronary artery disease, diabetes, high blood pressure, and osteoporosis (Glassberg & Balady,1999). Physical disability does not preclude persons from performing modified aerobic exercise regimens. Studies show that a prescribed aerobic exercise program for women with multiple sclerosis can improve lipid profiles, decrease obesity, and increase insulin sensitivity (Slawta, McCubbin, Wilcox, Fox, Nalle, & Anderson, 2002). Exercise specialists need to devise various exercise regimens which enable disabled persons to achieve a level of “cardio-fitness” despite ambulatory limitations. Further research into this issue is warranted.
Lack of awareness of CVD risk factors can significantly increase susceptibility to CVD. Compared to nondisabled women, women with physical disability were less knowledgeable about CVD risk factors, particularly their own total blood cholesterol level. Lack of awareness of cholesterol level is important in light of this study’s findings that disabled women are far less physically active and are weighed far less frequently. Inadequate exercise, lack of body weight measurement, and lack of awareness of blood cholesterol level markedly increase risk of unrecognized CVD in women with disability. In sum, health care providers need to be vigilant in screening this population for an important triad of risk factors: obesity, physical inactivity, and hypercholesterolemia.
In addition, there was a prevalent lack of awareness regarding the meaning of homocysteine in both study populations of women. Homocysteine level has recently been recommended as a preventive screening test for CVD risk. Increasing evidence shows that hyperhomocysteinemia can cause endothelial damage and is related to folic acid deficiency (Wald, Watt, Law, Weir, McPartlin, & Scott, 1998). This study revealed that many women are unaware of this CVD risk factor. Patient education is needed to increase awareness of the relationship between homocysteine, CVD risk, and folic acid.
Despite the comparable chronological age of the subjects in both samples, there was a greater proportion of women with disability who described themselves as postmenopausal. Postmenopausal status increases CVD risk in this group of women. The causes of this disparity in menopausal status between these two populations of women are worthy of future study.
This study highlights the CVD risk factors in women with physical disability and the prevalence of inadequate primary care CVD preventive screening for this population. Note that specialist physicians, such as neurologists, may be consulted by women with a physical disability more often than primary care providers. Specialist health care providers may overlook the primary care needs of this population and fail to make appropriate referrals. Since CVD is the most common cause of death in women, CVD risk factors are as significant as disability-related problems in this population. It seems futile to narrowly focus on the interventions related to the specific disabilities of these women, if the fatal threat of CVD goes unrecognized.
Generalizability of this study’s findings to the population of women with disability has limitations. The study lacked random selection, and both study groups consisted of a small number of women. The sample of disabled women in this study comprised those who attended a health fair which inherently self-selects for women who have heightened interest in their health. The disabled attendees at this health fair had the mobile capacity and resources to travel to the event. Women with physical disability without mobile capability and limited resources to travel were not represented in this study. The group of nondisabled women were those who were employed and attended a university health fair and employee benefits fair. These women also had a keen interest in their health by attending these events.
Both sites of data collection were suburbs of major metropolitan areas. The participants were urban- and suburban-dwelling women with access to major healthcare centers. Therefore, results cannot be generalized to women who reside in rural areas or those who are institutionalized. Women in this study also had a high level of literacy and concern for their own health because they demonstrated an understanding of a CVD poster presentation. Therefore, women with low literacy or cognitive impairment are not represented in this study.
The assessment tool used to gather data required self-report of information by subjects. This self- reported information is subject to error in recall. Participants were asked to assess their level of physical activity in a gross manner, defining themselves as sedentary “if they sit for most of their day.” Participants’ determination of their level of physical activity was open to interpretation and is another limitation of this study. Part 2 of AHA Heart Health Quiz (2000) was retrieved from the organization’s Web site: (www.americanheart.org/risk/quiz.html). The AHA has not published any information regarding the reliability or validity of this instrument for assessing an individual’s knowledge of CVD risk factors.
Untreated and treated CVD risk factors experienced by the participants at the time of their survey were assessed. Only CVD screening procedures furnished by the participant s’ healthcare providers, not treatments related to CVD, were reported in this study.
Healthcare providers often neglect the cardiovascular health promotion needs of persons with a disability. Historically, CVD risk in women has been underestimated and less aggressively assessed by healthcare providers as well. This study demonstrated that women with a physical disability had greater risk for unrecognized cardiovascular disease than nondisabled women of comparable age and ethnicity. A large proportion of disabled women in this investigation were inadequately assessed for CVD by their healthcare providers; specifically body weight measurement, family history queries, and smoking queries were neglected in this population of women. Although the ECG is not a basic CVD screening test, there was also a marked deficiency in the performance of this diagnostic test for disabled women compared to nondisabled women.
This study also demonstrated that lack of exercise is a highly prevalent, modifiable CVD risk factor among physically disabled women. Lack of physical activity and lack of weight measurement are significant in light of the prevalence of obesity among disabled persons. Modified aerobic exercise regimens need to be devised and recommended for persons with limited mobility. Compared with women without disabilities, women with physical disabilities have less knowledge of CVD risk factors, particularly their own total blood cholesterol level. Lack of knowledge, lack of physical activity, and inadequate CVD risk screening contribute to an increased risk of CVD in this population of women.
Nurses in rehabilitation clinical settings are in a unique position to assess and educate women with physical disabilities about CVD. Although the primary disability is usually the focus of the specialist physician (e.g., neurologist or physiatrist), rehabilitation nurses often counsel the patient about broader issues. Rehabilitation nurses in the setting come to understand the patient’s lifestyle, sociocultural influences, family dynamics, emotional needs, body image concerns, and role issues. The rehabilitation nurse educates the patient about health maintenance needs with all these factors in mind. Therefore, rehabilitation nurses should attend to the preventive healthcare needs of the patient to ward off secondary disability.
Rehabilitation nurses are suited to educate disabled women about their specific risks of CVD, such as lack of physical activity. Nurses can consult with physiatrists about prescription of customized cardio-protective aerobic exercises for those who are disabled. Nurses can weigh patients to calculate cardiovascular risk and counsel them about weight management. By asking questions about the patient’s family history of CVD, blood cholesterol testing, cardiogram procedures, and smoking behavior, nurses can assess cardiovascular risk. With the knowledge gained from this investigation, rehabilitation nurses should not narrowly focus on solely their female patients’ primary disability. The nurses should assess cardiac risk, education, counsel, and refer patients for cardiovascular screening. Despite the fact that heart disease is the number one cause of death among women, this study revealed that CVD risk is particularly underrecognized and underassessed in women with physical disabilities. Rehabilitation nurses can be instrumental in raising awareness and preventing cardiac disease in this group of underassessed patients—women with a physical disability. It seems futile to focus all efforts on the female patient’s primary disability, if the most common cause of death among women is CVD.
This research study was funded by the Research Seed Fund of the Health Promotion for Women with Disabilities Project through support of the Bristol-Myers Squibb Foundation.
Special acknowledgment goes to Suzanne C. Smeltzer, EdD, for her expertise in research.
About the Author
Theresa Capriotti, DO MSN RN CRNP, is a clinical associate professor at Villanova University College of Nursing, Villanova, PA. Address correspondence to her at 800 Lancaster Avenue, Villanova, PA 19085, or email@example.com.
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