Abstract
We examined the effect of mobility on health screening for people with multiple sclerosis. General practice records were searched for blood pressure and cholesterol measurements, lifestyle advice, cervical smears, and mammograms. Blood pressure measurement decreased with decreasing mobility (P<0.001). Lifestyle advice was also related to mobility (P<0.01), with those with a moderate disability most likely to receive lifestyle advice. Overall, wheelchair users received fewer preventative services. Findings were similar for men and women.
Introduction
THERE is a perception that patients with a disability are inhibited from participation in health screening.1 It has been shown that mobility is related to use of preventative services by women in the United States (US).1,2 People with multiple sclerosis have almost normal life spans and therefore need access to preventative services in the hope of preventing premature mortality.2 Multiple sclerosis is the most common cause of chronic neurological disability in young adults, with a local prevalence of almost 1 in 600.3 The aim of this study was to audit how a representative, community-based sample of patients with multiple sclerosis complies with a range of National Health Service screening standards.
Method
Approval was obtained from the Queen's University of Belfast Ethics Committee. General practitioners (GPs) in a representative network of practices across Northern Ireland were asked to identify all of their patients with multiple sclerosis. Consent to their general practice records being examined was obtained from participants. The diagnosis of multiple sclerosis was verified using Poser et al's criteria.4 Notes for the 5 years before January 2002 were examined for evidence of blood pressure measurement and advice on smoking, alcohol, diet, and exercise. As 45 years is the youngest age at which cholesterol measurement alone appears to be relevant on the coronary risk prediction charts, records of participants over 45 years of age were searched for evidence of this. Records of women under 65 years of age were searched for cervical smear results, and those of women aged 50–65 years were searched for mammogram results. Patients' assessment of their mobility was recorded.
Results were analysed by dividing the sample into three groups, depending on mobility:
patients with no mobility problems — able to walk 100 metres without aid or rest;
patients with a moderate disability — needing a cane, crutch or brace, and;
patients confined to a wheelchair — unable to walk beyond 5 metres, even with aids.
Once this had been done, χ2 statistics were calculated and referred to standard probability tables.
Results
The results are shown in Table 1. From a population of approximately 190 000 patients, the GPs identified 178 people with multiple sclerosis. Of these, 170 agreed to have their general practice records examined. Two-thirds were women, 38% had no mobility problems, 33% had a moderate disability, and 29% were confined to a wheelchair.
Table 1 Uptake of screening in people with multiple sclerosis.
HOW THIS FITS IN
What do we know?
Many people with multiple sclerosis have virtually normal life spans and therefore require appropriate preventative services. Participation in health screening has been shown to be related to mobility in women with multiple sclerosis in the United States.
What does this paper add?
Wheelchair users of both sexes are significantly disadvantaged by the current provision of preventative services. People with a moderate disability were most likely to receive lifestyle advice.
General preventative health services
Participants who were confined to a wheelchair were less likely to receive preventative services. We found recent blood pressure measurements in 82% of records and a significant relationship (χ2 = 21.98, degrees of freedom [df] = 2, P<0.001) between blood pressure measurement and the mobility group.
Those with moderate mobility problems were the most likely to receive lifestyle advice or have their cholesterol measured. There was a statistically significant difference between the three groups with regard to advice on smoking (χ2 = 9.68, df = 2, P<0.01), alcohol (χ2 = 9.67, df = 2, P<0.01), or diet and exercise (χ2 = 9.99, df = 2, P<0.01).
Women's health screening
Uptake of cervical screening in eligible women decreased with decreasing mobility, but failed to reach statistical significance. Only 23% of the female participants were eligible for mammography.
Discussion
Overall, our findings reflect a good uptake of health screening. Of participants, 82% had had recent blood pressure measurements, and 84% of eligible women had had recent cervical screening. People with multiple sclerosis sometimes feel that doctors focus on their multiple sclerosis to the detriment of wider issues, but these results provide evidence against that.
In this study, mobility is related to participation in health screening. However, despite the perception that women in wheelchairs are unable or unwilling to participate in health screening,1,2 67% had had an up-to-date cervical smear result. The finding that those with moderate mobility problems were most likely to receive lifestyle advice fits with reports that GPs prefer to offer such advice opportunistically5 and that it may be seen as a package. Those with moderate mobility problems attend their general practice more often than people with no mobility problems. GPs may feel that lifestyle advice is inappropriate in some consultations with wheelchair users.
The practices participating in this study aim to reflect the population profile and are organised; for example, they all met their higher targets (80% for cervical screening). Record keeping is unlikely to vary with disability; however, these practices may also have addressed access issues.
There are gaps in the provision of preventative services for patients confined to a wheelchair. Awareness of the need for people with mobility problems to access preventative services and to know about the accessible services already in place could improve uptake. Services might also be improved by a shared approach from the primary healthcare team. Further research could explore the differences between actual and perceived barriers to preventative services and the priority given to health screening by doctors and patients.
Although we could have expected up to 300 patients from these practices, as our participants had similar characteristics to those in other studies3 we feel they are representative of such patients. This study is limited by its small size and possible under-representation of wheelchair users. As blood pressure recording is done more frequently with increasing age, it is of note that in the group of those with the most disability, whose average age is higher, the percentage of people with recent blood pressure measurements is unexpectedly lower. A larger sample could explore trends that did not reach statistical significance but could be clinically important for people with mobility problems accessing health services.
We have shown that wheelchair users are disadvantaged by the current provision of preventative services, which was found in previous studies of American women.1,2 This study suggests that men and women in wheelchairs have equal difficulty in accessing health screening within the current provision of services.
Acknowledgments
The authors would like to thank the patients and GPs involved for their help in completing this study, and the Multiple Sclerosis Society (Great Britain and Northern Ireland) for funding.
- Received September 11, 2003.
- Revision received January 9, 2004.
- Accepted April 5, 2004.
- © British Journal of General Practice, 2004.
