Mobility impairments and use of preventive services in women with multiple sclerosis: observational study

Participants, methods, and results

In 1996, we sent questionnaires to 1164 adults with multiple sclerosis who had received outpatient care in 1993 or 1994 from one of three systems of health care (two forms of managed care and fee for service insurance) in two regions of the United States.2 The overall response rate was 80% (930/1164). We report here survey analyses from the 713 women respondents.

We collected self reported rates of cervical smear testing, mammography, and breast examination (if over age 50), blood pressure checks, cholesterol screening, and physician assessment of health habits. We assessed these rates according to the patient's mobility level (fully ambulatory, ambulatory with help, and not ambulatory) and compared them with Healthy People 2000 recommendations.3 For each preventive service, we used logistic regression to model the relation between that service, mobility, patient demographics, comorbidity,2 system of health care, indicators for having a primary care physician and a multiple sclerosis physician, and specialty of these physicians.

The mean age of the women was 47 years; 86% were white and 40% had a four year college degree. Overall rates for cervical smear tests, breast examinations, and mammography exceeded Healthy People 2000 recommendations, but rates were highest for the ambulatory group and lowest for the non-ambulatory group (P≥0.05, table). Cervical smear testing was below Healthy People 2000 goals for the ambulatory with help and non-ambulatory groups. In contrast, rates for general preventive services did not differ by mobility.

In the multivariable models, ambulatory patients had 5.32 times the odds of having a cervical smear test, 3.62 times the odds of having a breast examination, and 3.24 times the odds of having mammography relative to non-ambulatory patients (all P<0.05). Older age was associated with a lower rate of cervical smear tests; however, no other variables were related to receipt of women's preventive services. Except for an increased odds of assessing eating habits in the non-ambulatory group, mobility status did not affect the odds of receiving general preventive services.

Comment

Use of women's preventive health services was lower in non-ambulatory women than in fully or partially ambulatory women with multiple sclerosis. These results are the same as those in a previous population based US study of women with and without mobility impairments due to various conditions,4 even though women in our study had a single chronic condition, were younger, were more educated, and all had health insurance and a regular source of care in health systems that met broad national screening goals.

There are several possible explanations for these findings. Doctors may believe that such patients do not have an adequate life expectancy to warrant women's preventive screening. However, such attitudes would be incompatible with the high rates of blood pressure and cholesterol checks. Alternatively, patients may be reluctant to undergo screening services that are potentially uncomfortable or embarrassing.5 A third possibility is that the medical systems cannot easily accommodate patients with mobility impairments, who may require access to specialised equipment and extra time.

Women with impaired mobility should be considered a vulnerable population for receipt of breast examinations, mammography, and cervical smear tests. Studies are needed to identify factors causing this and to evaluate interventions to reduce the variation across mobility levels.