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. Author manuscript; available in PMC: 2025 Aug 27.
Published in final edited form as: J Adv Nurs. 2024 Jul 5;81(4):2136–2147. doi: 10.1111/jan.16304

An evaluation of conceptual frameworks to improve reproductive health outcomes among women with physical disabilities

Sarah E Harkins 1, Veronica Barcelona 1
PMCID: PMC12379760  NIHMSID: NIHMS2105805  PMID: 38969486

Abstract

Aim(s):

To identify and evaluate conceptual frameworks intended to guide reproductive health research among women with physical disabilities.

Design:

Discussion paper.

Methods:

We identified and evaluated frameworks related to the reproductive health of women with physical disabilities using modified criteria by Fawcett and DeSanto-Madeya with constructs from the International Classification of Functioning, Disability, and Health.

Data Sources:

We conducted a systematic review of literature published from 2001 to 2024 in four databases.

Results:

Our review revealed two frameworks: (1) A perinatal health framework for women with physical disabilities is applicable to studies that consider multiple socioecological determinants in pregnancy; (2) A conceptual framework of reproductive health in the context of physical disabilities can guide the development of patient-reported outcome measures for a range of reproductive health outcomes.

Conclusion:

The identified frameworks have high potential to guide studies that can improve the reproductive health of women with physical disabilities. However, they have low social congruence among racially and ethnically minoritized women.

Implications for Nursing:

Future frameworks must take an intersectional approach and consider the compounding injustices of ableism, racism, classism and ageism on reproductive health. A holistic approach that is inherent to the discipline of nursing is essential to address these knowledge gaps.

Impact:

The reproductive health of women with disabilities is a research priority. Nurses and other researchers can select the framework most applicable to their research questions to guide study designs and should incorporate multi-level determinants to eliminate reproductive health disparities.

Keywords: conceptual frameworks, framework evaluation, health inequities, nursing/nurses, perinatal health, physical disability, reproductive health, social determinants of health, theoretical models

1 |. INTRODUCTION

Approximately, one in six women of reproductive age (18–44 years) in the United States has a disability (Okoro et al., 2018). Of these, about 31% have a physical disability, defined as mobility-limiting conditions that impede participation in daily activities (e.g. cerebral palsy and stroke) (Okoro et al., 2018). Women with physical disabilities experience worse reproductive health outcomes compared to women without physical disabilities (Deierlein et al., 2021). Broadly, reproductive health includes a range of outcomes and health states that relate to the reproductive health system, including pregnancy, contraception and abortion care, infertility, sexually transmitted infections and gynaecological cancers (Centers for Disease Control and Prevention, 2022). For example, women with physical disabilities are less likely to receive cervical cancer screening tests and are more likely to be diagnosed with late-stage cancers compared to women without disabilities (Horner-Johnson et al., 2014; Hughes et al., 2022). Pregnancy-related reproductive health outcomes are similarly inequitable by disability status (Signore et al., 2021). Women with physical disabilities are at higher risk of having a preterm birth, a low-birthweight baby, and undergoing caesarean birth without indication, resulting in longer maternal and infant hospital stays after birth (Horner-Johnson et al., 2020; Tarasoff et al., 2020). Further, women with physical disabilities are three times more likely to experience venous thromboembolism during pregnancy and are 11 times more likely to experience severe maternal morbidity and death compared to women without disabilities (Gleason et al., 2021; Vainder et al., 2023).

Structural ableism and the continued history of violence and discrimination towards women with disabilities underlie these persistent reproductive health disparities (Fletcher et al., 2023). Structural ableism refers to policies, practices and socially accepted standards that advantages the able-bodied and marginalizes people with disabilities (Lundberg & Chen, 2024). Inadequate transportation systems and inaccessible gynaecological care centres are examples of structural ableism that inhibit access to reproductive health services for women with physical disabilities (Biggs et al., 2023). Provider bias and stigmatization are downstream effects of structural ableism and a eugenic history embedded in obstetric medicine, which also contributes to reproductive health inequities (Fletcher et al., 2023). Women with physical disabilities have experienced judgement from their providers for becoming pregnant and have reported encounters with providers who assume they are not sexually active (Mitra et al., 2016). Qualitative studies have also reported that a lack of provider education regarding the reproductive health needs of women with disabilities has resulted in poor care experiences and may contribute to these negative health outcomes (Mitra et al., 2017; Smeltzer et al., 2016).

Published research has clearly identified women with physical disabilities as a vulnerable population at high risk of poor reproductive health outcomes. However, few studies have explored the role of the social determinants of health and structural ableism as factors in the causal pathway leading to reproductive health disparities. Addressing these multiple health determinants is essential to develop effective interventions that improve reproductive healthcare access and outcomes for women with physical disabilities.

2 |. BACKGROUND

Improving the reproductive health of women with disabilities has recently become a national priority (National Institutes of Health (NIH), 2023). On 26 September 2023, the NIH formally designated people with disabilities as a health disparity population (NIH, 2023). As a result, the NIH has launched a new programme of research focused on understanding and addressing the health needs of people with disabilities, including women with disabilities (NIH, 2023). In their report, the Working Group on Persons Living with Disabilities found little research to support intervention development or clinical practice guidelines to improve the health of pregnant people with disabilities (2023). Therefore, this NIH designation is both timely and critical to support high-quality research studies that include the complex determinants of disability and reproductive health to ultimately eliminate growing disparities (Signore et al., 2021).

One method to support these research efforts involves identifying and employing conceptual frameworks applicable to the reproductive health of women with physical disabilities. Conceptual frameworks consist of several inter-related concepts that impact a central phenomenon of interest, and they are key to ensuring research questions are theoretically-justified (Fawcett & DeSanto-Madeya, 2013). Given the paucity of robust research questions in this area, an evaluation of conceptual frameworks focused on the reproductive health of women with physical disabilities is urgently needed to inform comprehensive research questions and to guide high-quality study designs (Cohen & Shang, 2015). Therefore, the purpose of this paper was to: (1) conduct a systematic review of conceptual frameworks intended to guide reproductive health research among women with physical disabilities; (2) describe and evaluate the conceptual frameworks according to Fawcett and DeSanto-Madeya (2013); and (3) identify gaps in existing conceptual frameworks that should be considered in future frameworks to improve the reproductive health of women with physical disabilities.

3 |. DATA SOURCES

3.1 |. Search strategy

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to conduct a systematic review of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase and PsycInfo to identify original literature describing the development of conceptual frameworks (Page et al., 2021). We included search terms related to physical disability (e.g. ‘functional limitation’), reproductive health (e.g. ‘reproductive health services’) and conceptual frameworks (e.g. ‘theoretical model’). Our search strings were informed by recommended search strategies for identifying individuals with disabilities in the literature (Walsh et al., 2014). The search was initially conducted and screened by one author (SEH) in October 2023. Two authors (SEH and VB) then conducted an updated search in February 2024 and independently screened studies at both the title and abstract and full-text level in Covidence. Both authors noted reasons for exclusion, and disagreements were resolved through weekly discussions. A full list of search terms and a PRISMA diagram describing reasons for exclusion of articles at the full-text level are presented in the Data S1.

3.2 |. Inclusion and exclusion criteria

Conceptual frameworks were considered for inclusion based on the following criteria: (1) a focus on women with physical disabilities; (2) targeting reproductive health and pregnancy outcomes; (3) a sufficient description of its development and purpose in a peer-reviewed publication; and (4) the inclusion of a figure or diagram of the conceptual framework. We recognize that some conceptual frameworks may not have a diagram and are instead summarized entirely through text. However, a diagram was part of our inclusion criteria to facilitate the comparison of constructs and their relational propositions across included frameworks. This approach is consistent with prior framework evaluations (Kang & Barcelona, 2023). This criterion also supports the implementation of the frameworks by future nurse researchers who may easily operationalize constructs and clearly communicate hypothesized relationships in grant applications, which is an intended implication of this paper. We further limited inclusion to conceptual frameworks published since 2001 to fairly appraise their use of disability constructs represented in the International Classification of Functioning, Disability, and Health (ICF) framework, a key component of our evaluation criteria.

In addition, we excluded conceptual frameworks that focused on people with cognitive disabilities, as this population may require additional interpersonal and institutional factors that are not shared with women with physical disabilities (Brown & Mitra, 2023). We also excluded conceptual frameworks that were specific to one type of physical disability (e.g. spina bifida), as single disability frameworks may not be inclusive of the full spectrum of stigmas experienced by women with physical disabilities and may limit applicability to the larger population. Finally, conceptual frameworks that were unrelated to reproductive health, not published in a peer-reviewed journal, or not published in English were also excluded.

3.3 |. Analysis and evaluation criteria

Following extraction methods from prior conceptual framework evaluations (Cohen & Shang, 2015), SEH and VB extracted the purpose, constructs and number of PubMed citations for each included framework. We then followed criteria developed by Fawcett and DeSanto-Madeya (2013) to rigorously analyse and evaluate the conceptual frameworks. Many of the Fawcett and DeSanto-Madeya (2013) guiding questions are specific to nursing conceptual frameworks. Kang and Barcelona (2023) modified these questions with a more appropriate framework to reflect the content of their unique research question. We followed similar methodology by modifying Fawcett and DeSanto-Madeya (2013) criteria with content from the ICF. The ICF was developed in 2001 by the World Health Organization (WHO) and is widely used to guide disability research, clinical care and policy (WHO, 2001;Figure 1). We present the modified evaluation criteria in Table 1.

FIGURE 1.

FIGURE 1

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The International Classification of Functioning, Disability, and Health (ICF). Source: From WHO (2001) (https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pdf).

Table 1.

Fawcett and DeSanto-Madeya (2013) Analysis and Evaluation of Conceptual Frameworks Modified by the International Classification of Functioning, Disability, and Health (ICF)

Questions for analysis of a conceptual framework
Step 1. Origins of the conceptual framework

  • What is the historical evolution of the conceptual framework?

  • What motivated the development of the conceptual framework?

  • On what philosophical beliefs and values about disability is the conceptual framework based?

  • What strategies for knowledge development were used to formulate the conceptual framework?

  • What scholars influenced the conceptual framework authors’ thinking?

  • What world view is reflected in the conceptual framework?

Step 2. Unique focus of the conceptual framework

  • What is the unique focus of the conceptual framework?

Step 3. Content of the conceptual framework in the International Classification of Functioning, Disability, and Health framework

  • How are disability and functioning defined and described?

  • How are environmental factors defined and described?

  • How are personal factors defined and described?

  • How is reproductive health defined and described? a

  • What is the goal of the conceptual framework?

  • What statements are made about the relations among disability and functioning, environmental factors, personal factors, and reproductive health?

Questions for evaluation of a conceptual framework
Step 1. Explication of origins

  • Are the philosophical claims on which the conceptual framework is based explicit?

  • Are the scholars who influenced the thinking of the conceptual framework author acknowledged, and are bibliographical citations given?

Step 2. Comprehensiveness of contents in the International Classification of Functioning, Disability, and Health framework

  • Does the conceptual framework provide adequate descriptions of disability and functioning, environmental factors, personal factors, and reproductive health?

  • Do the relational propositions of the conceptual framework completely link disability and functioning, environmental factors, personal factors, and reproductive health?

  • Is the practitioner given sufficient direction to be able to make pertinent observations and prescribe and execute a course of action or interventions that achieves the goal specified in a variety of practice situations?

  • Is the researcher given sufficient direction about what questions to ask and what methodology to use?

  • Does the educator have sufficient guidelines to construct a curriculum?

  • Does the administrator have sufficient guidelines to organize and deliver reproductive healthcare to women with physical disabilities? a

Step 3. Logical congruence

  • Does the conceptual framework reflect more than one world view or category of knowledge?

  • Do the components of the conceptual framework consistently reflect logical translation or reformulation of diverse perspectives?

  • Is the conceptual framework logically congruent?

Step 4. Generation of theory

  • What theories have been generated from the conceptual framework?

Step 5. Legitimacy of the conceptual framework

  • Is the conceptual framework a useful guide for examining reproductive health outcomes among women with physical disabilities?

  • Does evaluation of the use of the conceptual framework reveal that the content of the conceptual framework is sound and believable?

 Social utility

  • Are education and special skill training required before applying the conceptual framework?

  • Is it feasible to implement practice protocols derived from the conceptual framework and related theories?

  • To what extent is the conceptual framework actually used to guide reproductive care practices, research, education, and administration for women with physical disabilities?

 Social congruence

  • Does the conceptual framework meet the expectations of women with physical disabilities and reproductive care providers of various cultures and in diverse geographic regions?

 Social significance

  • Does application of the conceptual framework, when linked with relevant theories and appropriate empirical indicators, make important and positive differences in the reproductive health of women with physical disabilities?

Step 6. Contributions to the discipline

  • What is the overall contribution of the conceptual framework to the advancement of reproductive health among women with physical disabilities?
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Note. Guiding questions were adapted from Contemporary Nursing Knowledge: Analysis of and Evaluation of Nursing Models (3rd ed., p. 47–54), by J. Fawcett & S. DeSanto-Madeya, 2013, F. A. Davis Company. Bolded items reflect guiding questions that were modified with content from the ICF from The ICF: An Overview, by World Health Organization, n.d. (https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pdf)

a

Reproductive health is not a construct within the ICF framework. However, it is necessary to consider when evaluating the applicability of the conceptual frameworks to the reproductive health of women with physical disabilities.

4 |. CONCEPTUAL FRAMEWORK ANALYSIS AND EVALUATION

After duplicates were removed, the authors (SEH, VB) screened 2273 articles identified from the electronic databases at the title and abstract level (Data S1). Of these, five articles were read in full to determine eligibility. Two articles did not focus on reproductive health (Lawler et al., 2015; Nery-Hurwit et al., 2022) and one did not provide a figure of the conceptual framework (Barbera et al., 2024), resulting in two conceptual frameworks included in our analysis: (1) A Perinatal Health Framework for Women with Physical Disabilities (Mitra et al., 2015); and (2) A Conceptual Framework of Reproductive Health in the Context of Physical Disabilities (Kalpakjian et al., 2020). In Table 2, we describe the purpose of each conceptual framework, their defining characteristics, and the number of PubMed citations as an indicator of their influence. A summary of the evaluation results is presented in Table 3.

Table 2.

Characteristics of Conceptual Frameworks Applicable to the Reproductive Health of Women People with Physical Disabilities

Conceptual framework Source Purpose Constructs included PubMed citations
A Perinatal Health Framework for Women with Physical Disabilities Mitra et al. (2015) To address perinatal health disparities among women with physical disabilities by employing a life-span approach that takes into consideration individual, environmental, and health-care system factors on maternal and infant health outcomes

  • Individual factors

  • Mediating factors

  • Environmental context

  • Short/long-term maternal and child outcomes

 22
A Conceptual Framework of Reproductive Health in the Context of Physical Disabilities Kalpakjian et al. (2020) To address reproductive health disparities among women with physical disabilities by supporting the development of theoretically-based patient-reported outcome measures

  • Knowledge about reproductive health

  • Communication about reproductive health

  • Self-advocacy & identity

  • Reproductive health environment

  • Relationships

  • Reproductive health issues

 10
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Table 3.

Fawcett and DeSanto-Madeya (2013) Evaluation of Conceptual Frameworks Modified by the International Classification of Functioning, Disability, and Health Framework

Evaluation criteria Mitra et al. (2015) Kalpakjian et al. (2020)
Explication of origins Yes. Philosophical assumptions about disability and perinatal health are explicitly stated. Influential conceptual frameworks are referenced (Misra et al., 2003; Nosek et al., 1995). No. Philosophical assumptions about disability and reproductive health are not explicitly stated. “Prior work” is mentioned as informing the conceptual framework, but no references are provided.
Comprehensiveness of content Moderate to high. All ICF constructs are sufficiently incorporated in the conceptual framework. Researchers are provided sufficient information to ask questions. Providers are not given sufficient guidance to make practice changes. Low to moderate. Disability and functioning are not included in the conceptual framework. Most of the environmental and personal concepts recommended by the ICF are also omitted. The narrow focus of the conceptual framework on reproductive care settings supports feasible practice changes. Researchers are provided sufficient direction to create patient-reported outcome measures.
Logical congruence Yes. The outcomes category of knowledge is ontologically consistent with the reciprocal interaction worldview (Fawcett & DeSanto-Madeya, 2013). Yes. The outcomes and interactions categories of knowledge are ontologically consistent with the reciprocal interaction worldview (Fawcett & DeSanto-Madeya, 2013).
Generation of theory Moderate. No theories were originated from the conceptual framework. It has contributed to the development of a conceptual framework for perinatal health outcomes among women with cognitive disabilities. Moderate. No theories were originated from the conceptual framework. It has contributed to the development of a conceptual framework for sexual well-being among women with physical disabilities.
Legitimacy Mixed. The conceptual framework was used to guide multiple qualitative studies to explore barriers to perinatal care among women with physical and sensory disabilities (Long-Bellil et al., 2017a; Long-Bellil et al., 2017b; Mitra et al., 2016; Powell et al., 2018; Smeltzer et al., 2016). Only one quantitative study employed the conceptual framework and outcomes were specific to women with cognitive disabilities (Kassee et al., 2023). Mixed. Few studies used the conceptual framework to interpret their qualitative findings (Alhusen et al., 2021; Horner-Johnson et al., 2022). Only one study developed patient-reported outcome measures from the conceptual framework (Kalpakjian et al., 2023).
Social utility Moderate to High. Some knowledge of the ICF is required to understand how disability and functioning are defined in the conceptual framework. Practice protocols may not feasibly integrate all environmental concepts (e.g., societal attitudes). Moderate to High. An understanding of instrument development is needed for researchers that utilize the conceptual framework to develop patient-reported outcome measures. Practice protocols may be more readily implemented due to the narrow scope of the conceptual framework on reproductive care settings and providers.
Social congruence Low. The conceptual framework has generated research among predominantly White women with physical disabilities in the United States and Canada. Low. The conceptual framework was developed based on qualitative interviews with mostly White women with physical disabilities living in urban areas in the United States. Demographic factors are not included in the conceptual framework.
Social significance High. The focus on individual, environmental, and healthcare system determinants in combination with a life-span approach to perinatal health outcomes has the potential to reduce perinatal disparities among women with physical disabilities. High. By supporting the development of patient-reported outcome measures, the conceptual framework has the potential to guide intervention development and reduce reproductive disparities among women with physical disabilities. The focus on interactions with providers can also support qualitative research study designs.
Contributions to the discipline Moderate. First conceptual framework to adopt ICF definitions of disability and functioning to support perinatal health research for women with physical disabilities. Future quantitative research studies are needed to support the relational propositions of the conceptual framework. Moderate. First conceptual framework to support patient-reported outcome measures for the reproductive health of women with physical disabilities. More research is needed to evaluate its utility to support patient-reported outcome measures.
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Note. Adapted from Contemporary Nursing Knowledge: Analysis of and Evaluation of Nursing Models (3rd ed., p. 47–54), by J. Fawcett & S. DeSanto-Madeya, 2013, F. A. Davis Company. with content from the ICF from The ICF: An Overview, by World Health Organization, n.d. (https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pdf)

4.1 |. A perinatal health framework for women with physical disabilities

4.1.1 |. Description

Mitra et al. (2015) developed a perinatal health framework for women with physical disabilities to generate research focused on understanding the multiple factors that influence the perinatal health outcomes and experiences of women with physical disabilities and their infants. The conceptual framework includes four constructs: (1) individual factors, (2) mediating factors, (3) short/long-term maternal and child outcomes and (4) the environmental context. Mitra et al. (2015) posited that mediating factors, including access to information and resources (e.g. preconception counselling), healthcare-related factors (e.g. health insurance), psychosocial factors (e.g. self-efficacy) and social support (e.g. family support) influence the relationship between individual factors (e.g. disability) and the environmental context (e.g. policies) to impact maternal outcomes (e.g. caesarean delivery) and infant outcomes (e.g. preterm birth). A figure of the conceptual framework is presented in Figure 2.

FIGURE 2.

FIGURE 2

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A perinatal health framework for women with physical disabilities. Source: From Mitra et al. (2015).

4.1.2 |. Analysis

Origins

Mitra et al. (2015) found that existing reproductive health frameworks lacked an inclusion of healthcare system and environmental factors specific to women with physical disabilities. They built upon the work of several scholars and organizations including the ICF, the Perinatal Health Framework, which applies a life-span approach to pregnancy outcomes (Misra et al., 2003), and the Reproductive Health Maintenance Framework, which added important healthcare system constructs, such as provider knowledge (Nosek et al., 1995). This integration of constructs from other frameworks constitutes deductive reasoning, or the process by which knowledge is derived from established assumptions (Aggleton, 1986). Mitra et al. (2012). They also employed inductive reasoning, the process by which knowledge is derived from identifying patterns across observations (Aggleton, 1986) by integrating new constructs that were informed from their prior research.

Fawcett and DeSanto-Madeya (2013) describe three worldviews in accordance with the ontological claims supporting a conceptual framework: (1) reaction; (2) reciprocal; and (3) simultaneous action. The reaction worldview assumes change is causal while the reciprocal interaction worldview assumes that change is probable. The simultaneous action worldview posits that change is unpredictable. Reciprocal interaction is the worldview most reflected in Mitra’s conceptual framework, as disability is viewed as an interaction between individuals and their environment in which pregnancy outcomes are the probable result of individual, environmental and mediating factors.

Unique focus

A perinatal health framework for women with physical disabilities focuses on pregnancy outcomes for women with physical disabilities and their children. Specifically, the authors consider individual, environmental and mediating determinants that impact perinatal health outcomes. This focus is consistent with the outcomes category of knowledge (Fawcett & DeSanto-Madeya, 2013).

Content

The Mitra et al. (2015) framework includes several concepts within the individual factors construct to describe disability that are congruent with the ICF (WHO, 2001). Genetic factors are also included as a disability concept, which is important to consider in the context of pregnancy. The environmental context incorporates physical, social, attitudinal and legal and political factors in accordance with the ICF. The framework identifies several demographic variables that should be considered, such as age, race, ethnicity and sexual orientation. While the ICF does not classify the personal factors construct, a scoping review of 226 articles found that most studies also conceptualized personal factors as demographic variables (Karhula et al., 2021). The reproductive health outcomes of interest are clearly defined as short- and long-term maternal and infant health and well-being. In addition to the ICF constructs, the conceptual framework includes mediating factors that are specific to the perinatal healthcare context, such as access to pregnancy information, that interact with individual and environmental factors to influence outcomes (Mitra et al., 2015). Overall, the goal of the conceptual framework is to promote research that improves our understanding of the perinatal health risks and needs of women with physical disabilities.

4.1.3 |. Evaluation

The Mitra et al. (2015) conceptual framework is logically congruent and their definitions of disability, environmental factors and personal factors are consistent with the ICF (WHO, 2001). While the researcher is provided with sufficient guidance regarding the types of questions to ask (e.g. identify needs, barriers and outcomes of pregnancy), the framework lacks specific, actionable recommendations for providers to improve their clinical care of women with physical disabilities. However, the framework has contributed to the development of a second framework specific to the reproductive health of women with cognitive disabilities (Brown & Mitra, 2023). Qualitative studies have utilized Mitra’s framework to explore barriers to perinatal healthcare among women with physical and sensory disabilities (Long-Bellil et al., 2017; Mitra et al., 2016; Panko et al., 2023; Smeltzer et al., 2016). One quantitative study referenced the framework as a guide for their latent class analysis to describe perinatal health risks among women with cognitive disabilities (Kassee et al., 2023). More quantitative studies are needed to support or refute the hypothesized relational propositions to improve the legitimacy of the conceptual framework.

Most study samples that employed Mitra’s framework included predominantly White women in the United States, limiting its social congruence. Therefore, more research is needed to evaluate its applicability among women with disabilities who identify with other minoritized identities due to their race, ethnicity, age, gender identity or socioeconomic status. Considering this important limitation, the conceptual framework has still contributed to the literature by illuminating physical and attitudinal barriers to perinatal healthcare among women with disabilities in qualitative studies (Mitra et al., 2016). The focus on individual, environmental and healthcare system determinants in combination with a life-span approach to perinatal health has the potential to effectively guide research to reduce reproductive disparities.

4.2 |. A conceptual framework of reproductive health in the context of physical disabilities

4.2.1 |. Description

A conceptual framework of reproductive health in the context of physical disabilities was developed by Kalpakjian et al. (2020) to support the development of patient-reported outcome measures that are specific to the reproductive health concerns of women with physical disabilities. Patient-reported outcome measures are instruments that measure patient-reported outcomes, such as quality of life (Weldring & Smith, 2013). The conceptual framework includes six constructs: (1) knowledge about reproductive health; (2) communication about reproductive health; (3) relationships; (4) reproductive health environment; and (5) self-advocacy & identity, which interact with each other to impact (6) reproductive health issues among women with physical disabilities. The conceptual framework is outlined in Figure 3.

FIGURE 3.

FIGURE 3

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A conceptual framework of reproductive health in the context of physical disabilities. Source: From Kalpakjian et al. (2020).

4.2.2 |. Analysis

Origins

Kalpakjian et al. (2020) developed their conceptual framework in response to a dearth of literature on reproductive patient-reported outcome measures specific to women with physical disabilities. To develop the framework, the authors conducted individual interviews and focus groups with women with physical disabilities throughout Michigan, New Jersey, and New York to elicit their reproductive healthcare experiences. They report using inductive reasoning by identifying novel concepts from coding the focus group and interview data (Kalpakjian et al., 2020). They also state that their deductive strategy was based on prior work, though it is unclear if this is referring to prior patient-reported outcomes for disability or prior studies conducted by the authors. In addition, the authors employed phenomenology and grounded theory approaches to analyse their data, supporting a reciprocal interaction worldview in which reality is considered a multi-dimensional and relative phenomenon (Fawcett & DeSanto-Madeya, 2013).

Unique focus

The conceptual framework provides researchers with theoretically based domains to generate patient-reported outcomes and patient-reported outcome measures for the reproductive health of women with physical disabilities (Kalpakjian et al., 2020). Therefore, the framework reflects the outcomes and interactions categories of knowledge due to its particular focus on interpersonal relationships between women with physical disabilities and their reproductive care providers, partners and families (Fawcett & DeSanto-Madeya, 2013).

Content

Kalpakjian et al. (2020) do not include a specific disability construct within their conceptual framework. Rather, all of the constructs are meant to be considered in the context of disability. The framework considers environmental factors that are specific to the reproductive healthcare setting, including the built environment (e.g. inaccessible exam rooms) and attitudinal environments (e.g. provider attitudes). While personal factors are not explicitly included, the constructs of self-advocacy & identity and relationships can include individual characteristics, such as partner status (Kalpakjian et al., 2020). In addition, the authors include constructs to describe the interpersonal relationships between women with physical disabilities and their reproductive care providers. The outcomes of interest are sufficiently broad and relate to pregnancy and reproductive health management. The framework hypothesizes that reproductive health outcomes among women with physical disabilities are influenced by provider knowledge and communication, access to reproductive care environments, relationships with peers, partners, families and self-advocacy, which in turn influence each other (Kalpakjian et al., 2020). Overall, the goal of the framework is to provide researchers with a guide to develop patient-reported outcome measures that will support intervention development to eliminate reproductive health disparities among women with physical disabilities.

4.2.3 |. Evaluation

While the framework is logically congruent, many of the ICF constructs are not fully considered, most notably the lack of a specific disability construct (Kalpakjian et al., 2020). Similarly, the environmental factors are specific to the reproductive care environment which excludes the influence of structural ableism factors that stem from policies and contribute to inequities (Lundberg & Chen, 2024). However, the authors adequately define their reproductive health concepts and include a range of outcomes applicable to women of reproductive age. They also provide sufficient direction for researchers to construct patient-reported outcome measures and recommend that future qualitative work further refine this preliminary framework. The narrow focus of the conceptual framework on interpersonal relationships and reproductive care settings also supports the development of feasible interventions and practice changes for providers.

The Kalpakjian et al. (2020) framework has contributed to the development of a second conceptual framework focused on the sexual well-being of women with physical disabilities (Nery-Hurwit et al., 2022) and provided the theoretical basis for a pregnancy informational and decisional needs instrument developed for women with physical disabilities (Kalpakjian et al., 2023). In addition, qualitative studies focused on contraceptive conversations between women with physical disabilities and their providers have interpreted their findings within the framework (Alhusen et al., 2021; Horner-Johnson et al., 2022). Of note, Kalpakjian et al. (2020) developed their conceptual framework among a sample of predominantly White women, limiting its social congruence. However, by contributing to the development of patient-reported outcome measures, the conceptual framework has significant potential to guide intervention development and improve reproductive health outcomes among women with physical disabilities.

5 |. DISCUSSION

5.1 |. Comparison

Based on our review of published articles, we identified two conceptual frameworks to guide reproductive health research among women with physical disabilities: (1) A Perinatal Health Framework for Women with Physical Disabilities (Mitra et al., 2015) and (2) A Conceptual Framework of Reproductive Health in the Context of Physical Disabilities (Kalpakjian et al., 2020). The conceptual frameworks were both developed in response to a need for theoretically supported research to reduce reproductive health disparities among women with physical disabilities. Similarly, both conceptual frameworks have been employed in qualitative research studies to explore reproductive care experiences for women with physical disabilities, and have also influenced the development of additional frameworks for specific populations of women with disabilities.

However, the unique foci of the conceptual frameworks are quite different. Mitra et al. (2015) focus on pregnancy, and include individual, environmental and mediating factors that interact to influence short and long-term maternal and infant health outcomes. While Kalpakjian et al. (2020) also include pregnancy outcomes, their general focus on reproductive health supports a range of potential study outcomes that can occur from menarche through menopause.

Each conceptual framework has its advantages and limitations that should be carefully considered before using it to guide study designs. A perinatal health framework for women with physical disabilities has many strengths, particularly due to its philosophical inspirations by the ICF. The authors incorporate all disability and functioning constructs from the ICF into their conceptual framework. In doing so, they recognize the unique interactions that specific physical disability conditions may have on perinatal health. Further, the authors incorporate the breadth of environmental factors that are outlined in the ICF. This approach supports the framework’s potential to guide research examining the impact of structural ableism factors on maternal and infant health outcomes. The main limitation of this conceptual framework is its explicit focus on perinatal health. Though it adopts a life-span approach after pregnancy, it is still limited to the event of pregnancy, thus limiting its applicability to all other reproductive health outcomes and stages.

Kalpakjian et al. (2020) also have several strengths and weaknesses in their conceptual framework. The most critical weakness is the exclusion of disability and functioning as an individual construct within the conceptual framework. This assumption can result in missed reproductive care needs for specific populations of women with physical disabilities. In addition, the environmental construct does not consider societal and political factors, which are essential health determinants in the context of reproductive health and disability (Addlakha et al., 2017). However, this specific focus on the clinical setting allows for more direct, actionable change for reproductive care providers and administrators to follow, and is ideal for generating patient-reported outcomes. Further, its broad inclusion of reproductive health outcomes allows researchers to address disparities not just in the event of pregnancy, but throughout the reproductive lifespan.

We recommend that the research question should drive the choice of conceptual framework. Researchers should first determine the focus of their study outcome. The Kalpakjian et al. (2020) framework should be used to guide study designs when the research question is unrelated to pregnancy or if the goal of the study is to develop patient-reported outcome measures. The Mitra et al. (2015) conceptual framework may best reflect research questions that consider a range of individual and structural ableism factors on pregnancy outcomes. Both conceptual frameworks may be used to support qualitative research studies, while the Mitra et al. (2015) framework has clear relational propositions to test hypotheses in quantitative study designs. Ultimately, researchers should first develop their definitions of disability and the reproductive health outcomes of interest to choose the most applicable conceptual framework to guide their study.

5.2 |. Implications for nursing

Perhaps the most significant finding of this paper was the very small number of conceptual frameworks that met our search criteria and were directly applicable to the reproductive health of women with physical disabilities. There is a critical need to develop conceptual frameworks that integrate the ICF constructs of disability, functioning, environment and personal factors, as seen in the Mitra et al. (2015) conceptual framework, with an expanded scope of reproductive health outcomes, akin to Kalpakjian et al. (2020). In addition, the identified conceptual frameworks have been studied among largely White women with physical disabilities. Future conceptual frameworks should take an intersectional approach and consider the compounding injustices of ableism, racism, classism, and ageism, along with the systems that propagate these, when conducting research and recommending policy and practice changes for women with disabilities (Bailey & Mobley, 2019). Finally, reproductive health disparities have been well-established among women with physical disabilities. Future research efforts should focus on the underlying mechanisms and mediators of these adverse health outcomes, and support a shift in the science towards intervention development to eliminate disparities. Nurses are uniquely positioned to address these knowledge gaps by incorporating a holistic approach to research and clinical practice that is essential to improve the reproductive health of women with physical disabilities.

5.3 |. Limitations

One limitation of the present analysis is that Fawcett and DeSanto-Madeya (2013) developed their evaluation criteria specifically for nursing conceptual frameworks. Modifying the evaluation criteria with constructs from the ICF was necessary to maintain the rigour of the technique and applicability to the conceptual frameworks of interest. In addition, publication bias could have impacted the legitimacy of the conceptual frameworks. Studies that utilized the conceptual frameworks but were not published in a peer-reviewed journal were not considered. Further, we excluded conceptual frameworks focusing on the reproductive health of women with cognitive disabilities. Women with cognitive disabilities may have additional factors that should be considered when examining reproductive health outcomes (e.g. guardianship) that may not be applicable to women with physical disabilities (Brown & Mitra, 2023). Future studies should conduct similar evaluations of conceptual frameworks for the reproductive health of women with cognitive disabilities to ensure that their unique needs are identified and addressed.

6 |. CONCLUSION

Conceptual frameworks applicable to the study of reproductive health among women with physical disabilities can inform high-quality study designs to reduce growing disparities. In our analysis, we identified and evaluated two conceptual frameworks using Fawcett and DeSanto-Madeya (2013) criteria modified by content from the ICF (WHO, 2001). A perinatal health framework for women with physical disabilities by Mitra et al. (2015) is recommended to support hypothesis-driven research questions for pregnancy outcomes that include individual, environmental and mediating healthcare system factors. A conceptual framework of reproductive health in the context of physical disabilities by Kalpakjian et al. (2020) is recommended to support the development of patient-reported outcome measures and guide qualitative research focused on interpersonal experiences between women with physical disabilities and their reproductive care providers. Ultimately, the development of a conceptual framework that: (1) incorporates all ICF constructs; (2) employs an intersectional focus; and (3) considers outcomes across the reproductive lifespan is needed to guide future research that addresses inequities among women with physical disabilities.

Supplementary Material

Supplemental

Key points.

  • The identified frameworks have the potential to generate reproductive health research among women with physical disabilities.

  • Future frameworks should: (1) incorporate all constructs of the International Classification of Functioning, Disability, and Health, (2) employ an intersectional focus, and (3) consider outcomes across the reproductive lifespan.

FUNDING INFORMATION

SEH is supported by the (NINR) National Institute of Nursing Research (T32NR007969).

Funding information

National Institute of Nursing Research (NINR), Grant/Award Number: T32NR007969 (SEH)

Footnotes

CONFLICT OF INTEREST STATEMENT

There are no conflicts of interest.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were analysed.

REFERENCES

  1. Addlakha R, Price J, & Heidari S (2017). Disability and sexuality: Claiming sexual and reproductive rights. Reproductive Health Matters, 25(50), 4–9. 10.1080/09688080.2017.1336375 [DOI] [PubMed] [Google Scholar]
  2. Aggleton P (1986). Nursing research, nursing theory and the nursing process. Journal of Advanced Nursing, 11(2), 197–202. 10.1111/j.1365-2648.1986.tb01237.x [DOI] [PubMed] [Google Scholar]
  3. Alhusen JL, Bloom T, Laughon K, Behan L, & Hughes RB (2021). Perceptions of barriers to effective family planning services among women with disabilities. Disability and Health Journal, 14(3), 101055. 10.1016/j.dhjo.2020.101055 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bailey M, & Mobley IA (2019). Work in the intersections: A black feminist disability framework. Gender & Society, 33(1), 19–40. 10.1177/0891243218801523 [DOI] [Google Scholar]
  5. Barbera JP, Cichon B, Ankam N, & Schwartz BI (2024). Equitable Care for Patients with Disabilities: Considerations for the gynecologic health care professional. Obstetrics and Gynecology, 143, 475–483. 10.1097/aog.0000000000005493 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Biggs MA, Schroeder R, Casebolt MT, Laureano BI, Wilson-Beattie RL, Ralph LJ, Kaller S, Adler A, & Gichane MW (2023). Access to reproductive health services among people with disabilities. JAMA Network Open, 6(11), e2344877. 10.1001/jamanetworkopen.2023.44877 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brown HK, & Mitra M (2023). Perinatal health framework for people with intellectual disability. Disability and Health Journal, 17, 101576. 10.1016/j.dhjo.2023.101576 [DOI] [PubMed] [Google Scholar]
  8. Centers for Disease Control and Prevention. (2022). Reproductive Health. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/reproductivehealth/womensrh/index.htm [Google Scholar]
  9. Cohen CC, & Shang J (2015). Evaluation of conceptual frameworks applicable to the study of isolation precautions effectiveness. Journal of Advanced Nursing, 71(10), 2279–2292. 10.1111/jan.12718 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Deierlein AL, Antoniak K, Chan M, Sassano C, & Stein CR (2021). Pregnancy-related outcomes among women with physical disabilities: A systematic review. Paediatric and Perinatal Epidemiology, 35(6), 758–778. 10.1111/ppe.12781 [DOI] [PubMed] [Google Scholar]
  11. Fawcett J, & DeSanto-Madeya S (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). F. A. Davis Company. [Google Scholar]
  12. Fletcher J, Yee H, Ong B, & Roden RC (2023). Centering disability visibility in reproductive health care: Dismantling barriers to achieve reproductive equity. Women’s Health, 19, 17455057231197166. 10.1177/17455057231197166 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Gleason JL, Grewal J, Chen Z, Cernich AN, & Grantz KL (2021). Risk of adverse maternal outcomes in pregnant women with disabilities. JAMA Network Open, 4(12), e2138414. 10.1001/jamanetworkopen.2021.38414 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Horner-Johnson W, Darney BG, Biel FM, & Caughey AB (2020). Prolonged postpartum length of hospital stay among women with disabilities. Disability and Health Journal, 13(4), 100934. 10.1016/j.dhjo.2020.100934 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Horner-Johnson W, Dobbertin K, Andresen EM, & Iezzoni LI (2014). Breast and cervical cancer screening disparities associated with disability severity. Women’s Health Issues, 24(1), e147–e153. 10.1016/j.whi.2013.10.009 [DOI] [PubMed] [Google Scholar]
  16. Horner-Johnson W, Klein KA, Campbell J, & Guise JM (2022). “It would have been Nice to have a choice”: Barriers to contraceptive decision-making among women with disabilities. Women’s Health Issues, 32(3), 261–267. 10.1016/j.whi.2022.01.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Hughes RB, Robinson-Whelen S, & Knudson C (2022). Cancer disparities experienced by people with disabilities. International Journal of Environmental Research and Public Health, 19(15), 9187. 10.3390/ijerph19159187 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kalpakjian CZ, Haapala HJ, Ernst SD, Orians BR, Barber ML, Mulenga L, Bolde S, Kreschmer JM, Parten R, Carlson S, Rosenblum S, & Jay GM (2023). Development and pilot test of a pregnancy decision making tool for women with physical disabilities. Health Services Research, 58(1), 223–233. 10.1111/1475-6773.14103 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Kalpakjian CZ, Kreschmer JM, Slavin MD, Kisala PA, Quint EH, Chiaravalloti ND, Jenkins N, Bushnik T, Amtmann D, Tulsky DS, Madrid R, Parten R, Evitts M, & Grawi CL (2020). Reproductive health in women with physical disability: A conceptual framework for the development of new patient-reported outcome measures. Journal of Women’s Health, 29(11), 1427–1436. 10.1089/jwh.2019.8174 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Kang JA, & Barcelona V (2023). A comparison of conceptual frameworks to examine health inequities in end-of-life care. Journal of Advanced Nursing, 79(5), 2025–2041. 10.1111/jan.15393 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Karhula M, Saukkonen S, Xiong E, Kinnunen A, Heiskanen T, & Anttila H (2021). ICF personal factors strengthen commitment to person-centered rehabilitation—A scoping review. Frontiers in Rehabilitation Sciences, 2, 709682. 10.3389/fresc.2021.709682 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Kassee C, Lunsky Y, Patrikar A, & Brown HK (2023). Impact of social-, health-, and disability-related factors on pregnancy outcomes in women with intellectual and developmental disabilities: A population-based latent class analysis. Disability and Health Journal, 16(2), 101426. 10.1016/j.dhjo.2022.101426 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Lawler D, Begley C, & Lalor J (2015). (Re)constructing myself: The process of transition to motherhood for women with a disability. Journal of Advanced Nursing, 71(7), 1672–1683. 10.1111/jan.12635 [DOI] [PubMed] [Google Scholar]
  24. Long-Bellil L, Mitra M, Iezzoni LI, Smeltzer SC, & Smith L (2017). The impact of physical disability on pregnancy and childbirth. Journal of Women’s Health, 26(8), 878–885. 10.1089/jwh.2016.6157 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Lundberg DJ, & Chen JA (2024). Structural ableism in public health and healthcare: A definition and conceptual framework. The Lancet Regional Health—The Americas, 30, 100650. 10.1016/j.lana.2023.100650 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Misra DP, Guyer B, & Allston A (2003). Integrated perinatal health framework. A multiple determinants model with a life span approach. American Journal of Preventive Medicine, 25(1), 65–75. 10.1016/s0749-3797(03)00090-4 [DOI] [PubMed] [Google Scholar]
  27. Mitra M, Akobirshoev I, Moring NS, Long-Bellil L, Smeltzer SC, Smith LD, & Iezzoni LI (2017). Access to and satisfaction with prenatal care among pregnant women with physical disabilities: Findings from a National Survey. Journal of Women’s Health, 26(12), 1356–1363. 10.1089/jwh.2016.6297 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Mitra M, Long-Bellil LM, Iezzoni LI, Smeltzer SC, & Smith LD (2016). Pregnancy among women with physical disabilities: Unmet needs and recommendations on navigating pregnancy. Disability and Health Journal, 9(3), 457–463. 10.1016/j.dhjo.2015.12.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Mitra M, Long-Bellil LM, Smeltzer SC, & Iezzoni LI (2015). A perinatal health framework for women with physical disabilities. Disability and Health Journal, 8(4), 499–506. 10.1016/j.dhjo.2015.05.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Mitra M, Manning SE, & Lu E (2012). Physical abuse around the time of pregnancy among women with disabilities. Maternal and Child Health Journal, 16(4), 802–806. 10.1007/s10995-011-0784-y [DOI] [PubMed] [Google Scholar]
  31. National Institutes of Health. (2023). NIH designates people with disabilities as a population with health disparities. U.S. Department of Health and Human Services, National Institutes of Health. https://www.nih.gov/news-events/news-releases/nih-designates-people-disabilities-population-health-disparities [Google Scholar]
  32. Nery-Hurwit MB, Kalpakjian CZ, Kreschmer JM, Quint EH, & Ernst S (2022). Development of a conceptual framework of sexual well-being for women with physical disability. Women’s Health Issues, 32(4), 376–387. 10.1016/j.whi.2022.02.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Nosek MA, Young ME, Rintala DH, Howland CA, Foley CC, & Bennett JL (1995). Barriers to reproductive health maintenance among women with physical disabilities. Journal of Women’s Health, 4(5), 505–518. 10.1089/jwh.1995.4.505 [DOI] [Google Scholar]
  34. Okoro CA, Hollis ND, Cyrus C, & Griffin-Blake S (2018). Prevalence of disabilities and health care access by disability status and type among adults-United States, 2016. Morbidity and Mortality Weekly Report, 67(32), 882–887. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, … Moher D (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ (Clinical research ed.), 372, n71. 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Panko TL, Cuculick J, Albert S, Smith LD, Cooley MM, Herschel M, Mitra M, & McKee M (2023). Experiences of pregnancy and perinatal healthcare access of women who are deaf: A qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology, 130(5), 514–521. 10.1111/1471-0528.17300 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Powell RM, Mitra M, Smeltzer SC, Long-Bellil LM, Smith LD, & Iezzoni LI (2017). Family Attitudes and Reactions toward Pregnancy among Women with Physical Disabilities. Women’s Health Issues, 27(3), 345–350. 10.1016/j.whi.2017.01.003. [DOI] [PubMed] [Google Scholar]
  38. Signore C, Davis M, Tingen CM, & Cernich AN (2021). The intersection of disability and pregnancy: Risks for maternal morbidity and mortality. Journal of Women’s Health (2002), 30(2), 147–153. 10.1089/jwh.2020.8864 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Smeltzer SC, Mitra M, Iezzoni LI, Long-Bellil L, & Smith LD (2016). Perinatal experiences of women with physical disabilities and their recommendations for clinicians. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(6), 781–789. 10.1016/j.jogn.2016.07.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Tarasoff LA, Murtaza F, Carty A, Salaeva D, Hamilton AD, & Brown HK (2020). Health of newborns and infants born to women with disabilities: A meta-analysis. Pediatrics, 146(6), e20201635. 10.1542/peds.2020-1635 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Vainder M, Ray JG, Lunsky Y, Fung K, Vigod SN, Havercamp SM, Parish SL, & Brown HK (2023). Physical disability and venous thromboembolism during pregnancy and the postpartum period: A population-based cohort study. Journal of Thrombosis and Haemostasis, 21(7), 1882–1890. 10.1016/j.jtha.2023.03.035 [DOI] [PubMed] [Google Scholar]
  42. Walsh ES, Peterson JJ, & Judkins DZ (2014). Searching for disability in electronic databases of published literature. Disability and Health Journal, 7(1), 114–118. 10.1016/j.dhjo.2013.10.005 [DOI] [PubMed] [Google Scholar]
  43. Weldring T, & Smith SM (2013). Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs). Health Services Insights, 6, 61–68. 10.4137/hsi.S11093 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. World Health Organization (WHO). (2001). International Classification of Functioning, Disability, and Health.

Associated Data

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Supplementary Materials

Supplemental
NIHMS2105805-supplement-Supplemental.docx (39KB, docx)

Data Availability Statement

Data sharing not applicable to this article as no datasets were analysed.

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