HD420 Unit 7 Health Equity Paper on Disability Example

Same Insurance, Fewer Mammograms: A Unit 7 Health Equity Paper on Women Who Use Wheelchairs

[Student Name]

Purdue University Global

HD420: Social Determinants of Health and Health Behavior

Unit 7 Health Equity Paper

[Instructor Name]

[Date]

The health system, its patients and every figure are composite; the studies of disability and health care, the social determinants review and the ecological model cited are real.

The Gap

In the composite health system's records, among women aged 50 to 74, [72] percent of those without a recorded mobility disability were screened within the last two years, compared with [51] percent of women who use a wheelchair. Disability is a recognized dimension of health equity, and national survey analyses have found lower receipt of some preventive services among people with certain types of disability (Horner-Johnson et al., 2014).

Holding Insurance Constant

Insurance is the first explanation most readers reach for, since women with disabilities are more likely to have Medicaid or Medicare and less likely to have employer coverage. The paper therefore compares the two groups within each insurance type.

Commercial insurance: [76] percent without disability screened, [56] percent of wheelchair users. Medicare: [70] percent and [50] percent. Medicaid: [64] percent and [44] percent.

The gap is about twenty percentage points in every insurance group.

Insurance changes how often everyone is screened, but within each type of coverage, a woman who uses a wheelchair is still about twenty points less likely to have had a mammogram, so coverage cannot be the main explanation.

Explanation 1: Equipment

Standard mammography machines require the patient to stand, or to sit on a stool and lean in. A woman who cannot stand or transfer easily may not be positioned well, or may be told the exam cannot be done. In the composite system, three of its five imaging sites have machines that can be lowered for a seated patient, but scheduling does not ask about mobility, so women are booked at the wrong site and turned away. Evidence: strong. Staff report repeated turned-away visits, and the site records support it.

Explanation 2: Transportation

Many wheelchair users rely on paratransit, which must be booked a day or more ahead and has long pickup windows. A mammogram that takes twenty minutes can take half a day. Evidence: moderate. Women who drive their own adapted vehicles are screened more often than those who use paratransit, but the difference is smaller than the overall gap.

Explanation 3: Time

Appointments are booked in fifteen-minute slots. A woman who needs help undressing and transferring may need thirty. When a visit runs over, she may be asked to reschedule. Evidence: moderate. Schedulers have no field to request a longer slot.

Explanation 4: Clinicians' Assumptions

A national survey of physicians found that many held negative views of the quality of life of people with significant disability, and many were not confident in their ability to provide equal care (Iezzoni et al., 2021). If a clinician assumes screening matters less or is too difficult for a woman in a wheelchair, the referral may never be made. Evidence: moderate. In the composite system, wheelchair users were less likely to have a mammogram order in their records at all, not just less likely to complete one.

Weighing the Explanations

The explanations are not alternatives; they compound. A woman whose clinician does not order the test never meets the scheduling problem. One whose clinician does may meet a fifteen-minute slot at a site without the right machine, after a paratransit ride that takes three hours. Each barrier sits at a different level of the ecological model: the clinician's beliefs at the interpersonal level, the scheduling system and equipment at the organizational level, and paratransit rules at the community and policy level (McLeroy et al., 1988).

What This Means

The gap is a question of fairness, not of individual preference, because it follows from how services are designed rather than from what women want. The social determinants literature describes this as attention to the conditions that shape opportunities for health (Braveman & Gottlieb, 2014). Federal disability law requires reasonable access to health care, which makes some of these barriers not only unfair but avoidable under existing obligations.

Recommendations

1. Add a mobility question to scheduling and route women to sites with accessible machines.

2. Allow double appointment slots on request.

3. Prompt clinicians when a woman due for screening has no order, regardless of disability status.

4. Coordinate with paratransit to allow standing rides for screening appointments, booked by the imaging scheduler at the same time as the exam.

5. Train imaging staff in safe transfer and positioning, with lift equipment available at every site that offers the accessible machines, so that a transfer is never the reason an exam is stopped.

Measuring Progress

The health system already reports screening rates to its quality committee, but not by disability status. The first change would be to add a mobility field to the screening report so the gap can be tracked each quarter. A second measure would count turned-away imaging visits, which the scheduling system can flag when an appointment ends without an exam. A third would track how many eligible women with a mobility disability have an active mammogram order, which would show whether clinicians' referral patterns are changing. Each measure should be reported by insurance type as well, so the stratified picture in this paper can be repeated over time. Targets should aim to halve the gap within two years, a realistic goal given that equipment already exists at three sites and the largest single barrier is routing.

Why This Matters Beyond Mammography

The same barriers, inaccessible equipment, short appointment slots, transport and clinicians' assumptions, are likely to affect other screenings and exams that require positioning or transfer, such as cervical cancer screening, bone density scans and weight measurement. Fixing mammography access by building the mobility question into scheduling would improve all of them at once. In that sense, the mammography gap is a visible marker of a broader design problem, one that the health system can address with changes to routing, scheduling and training rather than new money. It also signals to patients with disabilities that the system expects them, which may matter as much as any single fix.

Limits

Disability status in records is incomplete, so some wheelchair users may be counted in the comparison group. The comparison controls for insurance but not for other health conditions that may affect screening decisions. And the explanations were tested with system records and staff reports gathered over a single year at one health system, not with interviews of the women themselves, which would be the next step.

References

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Horner-Johnson, W., Dobbertin, K., Lee, J. C., & Andresen, E. M. (2014). Disparities in health care access and receipt of preventive services by disability type: Analysis of the medical expenditure panel survey. Health Services Research, 49(6), 1980-1999. https://doi.org/10.1111/1475-6773.12195

Iezzoni, L. I., Rao, S. R., Ressalam, J., Bolcic-Jankovic, D., Agaronnik, N. D., Donelan, K., Lagu, T., & Campbell, E. G. (2021). Physicians' perceptions of people with disability and their health care. Health Affairs, 40(2), 297-306. https://doi.org/10.1377/hlthaff.2020.01452

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-377. https://doi.org/10.1177/109019818801500401