Disability and Health Journal 9 (2016) 600e608
www.disabilityandhealthjnl.com
Research Paper
Impact of disability and chronic conditions on health
Katherine Froehlich-Grobe, Ph.D.a,*, Denton Jones, M.P.H.b, Michael S. Businelle, Ph.D.c,
Darla E. Kendzor, Ph.D.c, and Bjial A. Balasubramanian, M.B.B.S., Ph.D.d
a
Baylor Institute for Rehabilitation, Dallas, TX 75246, USA
Pepperdine University, Campus Recreation, Malibu, CA 90263-4490, USA
c
University of Oklahoma Health Science Center, Department of Family and Preventive Medicine, Oklahoma City, OK 73104, USA
d
University of Texas, School of Public Health, Dallas Regional Campus, Epidemiology, Genetics, Environmental Health, Dallas, TX 75390-9128, USA
b
Abstract
Background: Today one in five Americans have a disability and nearly half of Americans experiences a chronic condition. Whether
disability results from or is a risk factor for chronic conditions, the combined effects of disability and chronic conditions warrants further
investigation.
Objectives: Examine the added impact of chronic conditions among those with and without disability on self-reported health status and
behaviors.
Methods: 2009 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to examine the association of disability with
unhealthy behaviors and poor health stratified by number of self-reported chronic conditions (0, 1, or 2þ). Linear and logistic regression
models accounting for the complex survey weights were used.
Results: Participants with disability were 6 times more likely to report fair/poor self-rated health, reported 9 more unhealthy days in a
month and 6 more days in a month when poor health kept them from usual activities, were 4 times more likely to be dissatisfied with life,
had greater odds of being a current smoker, and were less likely to be physically active. Presence of chronic conditions in addition to
disability was associated, in a doseeresponse manner, with poor health status and unhealthy behaviors.
Conclusions: People living with both chronic diseases and disability are at substantially increased risks for poor health status and unhealthy behaviors, further affecting effective management of their chronic conditions. Multi-level interventions in primary care and in the
community that address social and environmental barriers that hinder adults with disability from adopting more healthy lifestyles and
improving health are needed. Ó 2016 Elsevier Inc. All rights reserved.
Keywords: Disability; Health status; Health behaviors
About one in five Americans, 56.7 million people, experiences a disability.1,2 Total disability-related health care costs
were estimated at nearly $400 billion in 2006.3 These costs
account for more than a quarter (27%) of all health care expenditures and are predominantly covered by the public
sector, with $280 billion paid by Medicare and Medicaid.
Public health perceptions of disability have slowly shifted
over the past two decades. Previously, public health viewed
disability exclusively as an outcome to prevent, but today
public health encompasses the view that people living with
Funding: Funding was not received for this study.
Financial disclosure: The authors of this paper have no financial disclosures to report.
This study received no external or internal funding.
* Corresponding author. Tel.: þ1 214 818 2584.
E-mail address: kfgrobe@bir-rehab.com (K. Froehlich-Grobe).
1936-6574/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.dhjo.2016.04.007
disabilities are a population for whom promoting health
and preventing disease should be addressed.4
In 1980, the federal Healthy People Initiative began
setting broad health goals for the nation to work toward
achieving over the following decade and each decade since,
the federal initiative has issued new health goals. After two
decades of progress, the Healthy People initiative included
people with disabilities as a population of interest in both
the 2010 and 20205,6 objectives. Among the disabilityrelated national objectives are targets for improving surveillance for people with disabilities, including developing a
standardized set of questions to identify people with disabilities. Historically federal surveillance systems either
have not included items to identify disability or not used
consistent definitions of disability, which has led various
methods to identify disability. While some sources such
as the National Health Interview Survey have included
many items to characterize the type and severity of
K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
limitations respondents’ experience, others such as the
Behavioral Risk Factor Surveillance System for a more
than a decade (2001e2012) used only two items to identify
disability. Nevertheless, the current evidence base derived
from extant published data from different data sources using various disability identifiers consistently reveals that individuals with disabilities report significantly poorer
health,7 are less likely to be physically active,8,9 are more
likely to be overweight or obese,10,11 and are more likely
to smoke.12,13 People with disabilities are also more likely
to experience chronic health conditions, such as arthritis,
hypertension, and diabetes among others.9,11,14,15,16
Notably, future evidence may be better able to illuminate
these relationships between disability and health following
progress of an interagency working group in developing a
standardized set of items to identify disability using questions that ask people whether they experience serious limitations in six domains of function: hearing, vision,
cognitive, ambulatory, self-care, or independent living.
A myriad of conditions have been defined as ‘‘chronic
conditions.’’ This paper follows the conceptual model outlined by Goodman and colleagues17 that guided the multiple chronic conditions (MCC) working group through the
process of developing a standardized approach to defining
and identifying chronic conditions in the U.S. The working
group’s goal was to develop of list of conditions that met
three characteristics: chronicity (lasting a year or more
and require ongoing medical attention and/or limit activities of daily living), prevalent (commonly occur), and
amenable to public health or clinical intervention. The 20
conditions Goodman and colleagues identified include hypertension, heart disease, high cholesterol, stroke, arthritis,
asthma, cancer, diabetes, depression, HIV, autism, among
others. Evidence consistently demonstrates that individuals
who live with disability are significantly more likely to
experience these chronic conditions.15,16,18,19
A bidirectional relationship exists between disability and
chronic conditions.20 National estimates indicate that
arthritis, heart trouble, and diabetes are among the top six
causes of disability.21 Thus, while chronic conditions can
cause disability, primary conditions like spinal cord injury
are also known to increase risk for chronic conditions such
as high blood pressure or diabetes.22 Dixon-Ibarra and
Horner-Johnson15 explored this issue by examining
whether those who had a lifelong disability experienced a
greater risk for developing chronic conditions than those
without a disability. The results demonstrated that even after controlling for relevant factors (e.g., age, sex, race/
ethnicity, marital status, and working status) individuals
living with lifelong disabilities experienced a significantly
increased odds of having each of the five chronic conditions
compared to those with no limitations, with adjusted odds
rates that ranged from as high as 2.92 (CI 2.33e3.66) for
congestive heart disease to 1.61 (CI 1.34e1.94) for cancer.
National efforts have targeted preventing chronic diseases,17 with greater attention paid over the past 15 years
601
toward addressing the preventive health needs of individuals living with one or more chronic conditions.23,24 While
emerging evidence points to higher rates of chronic conditions among those living with disabilities,15,16,18,19 the individual and combined effects of disability and chronic
conditions on overall health status have not been characterized in a population-based study. The purpose of this study
is to compare self-reported health status and health behaviors among those with and without disabilities and by number of chronic conditions using the nationally representative
Behavioral Risk Factor Surveillance System (BRFSS). We
hypothesized that the overall health status of those with
disability and with co-occurring chronic conditions would
be significantly poorer than those without co-occurring
chronic conditions. Notably, there are a myriad ways to
define disability, including based on work limitations; experiencing limitations in major life activities of walking,
seeing, hearing, or speaking; experiencing limitations in activities of daily living such as toileting, bathing, dressing,
eating, walking or limitations in instrumental activities of
daily living such as cleaning, shopping, paying bills; or being perceived as having an physical or mental impairment
that substantially impairs functioning as within the federal
legislation of the Americans with Disabilities Act. This paper uses a broad definition of disability that is consistent
with the taxonomy of the International Classification of
Functioning, where the terms functioning and disability
are characterized by impairments of body functions and
structures that can result in activity limitations and participation restrictions. Thus, in this paper disability status is
based on respondents endorsing that they experience either
(1) any activity limitation due to physical, mental, or
emotional problems or (2) special equipment use because
of a health problem.
Methods
Data for this cross-sectional study were collected as part
of the 2009 Behavioral Risk Factor Surveillance System
(BRFSS), which is an ongoing state-based random digit
dial telephone survey that collects data about the health risk
factors of non-institutionalized adults in the U.S. BRFSS
sampling design and weighting strategy have been
described in detail elsewhere.25,26 In 2009, the median
response rate was 52.48% and the median cooperation rate
was 72.04%, yielding a sample of 432,607 respondents.27,28
Data for this study were analyzed in the fall of 2014.
Independent variables
The main independent variable was disability status, assessed using participant responses to the following questions: 1) Are you limited in any way in any activities
because of physical, mental, or emotional problems? and
2) Do you now have any health problem that requires you
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K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
to use special equipment, such as a cane, a wheelchair, a
special bed, or a special telephone? Participants who reported ‘‘yes’’ to one or both of these questions were classified as having a disability, and those who answered no to
both questions were classified as not having a disability.
In addition to disability status, participants were asked if
they were diagnosed with any of the following eight
chronic medical conditions by a health care provider:
arthritis, high cholesterol, high blood pressure, asthma, diabetes, heart disease, stroke, and cancer. Similar to previous
studies,29,30 the number of conditions was summed and participants were categorized as having 0, 1, or 2 or more
chronic conditions. The list of conditions defined as chronic
conditions for this study represent 8 of the 20 identified by
the US Department of Health and Human Services
(USDHHS) in their efforts to foster a standardized
approach to measuring chronic conditions.17
Dependent variables
Health status
Three indicators of health status were used: (1) Healthy
Days Core Module (CDC HRQOL-4), (2) self-reported
health status, and (3) life satisfaction. Four questions from
the CDC Health Related Quality of Life-4 questionnaire,
known as the Healthy Days Core Module (CDC HRQOL4)31 assessed the number of days, out of the last 30, that
participants experienced poor (a) physical health, (b)
mental health, or (c) poor physical or mental health that
kept them from performing usual activities. Also included
was a calculated variable, based on the CDC-HRQOL provides a summary index of self-reported unhealthy days that
reflects an estimate of the overall number of days, over the
past 30 days, when respondents felt their physical or mental
health was not good. Self-reported health status was dichotomized to reflect those who did and did not rate their current health as fair or poor. Life satisfaction was
dichotomized to identify those who reported being either
dissatisfied/very dissatisfied or satisfied/very satisfied with
life.
Health behaviors
Measures of health behavior included heavy drinking
(O2 drinks per day for men or O1 drink per day for
women), current smoking status (smoker, nonsmoker),
eating 5þ servings of fruits and vegetables per day (yes,
no), and meeting the current minimum weekly physical activity recommendations (accumulated 150 min of moderate
physical activity in the past week, 75 min of vigorous physical activity in the past week, or an equivalent combination
of moderate and vigorous activity).
Covariates
Demographic variables included sex, age, health insurance coverage (yes, no), race/ethnicity (Non-Hispanic
White, Non-Hispanic Black, Hispanic, or Other), education
level (less than high school, high school graduate, some
college, or college graduate), employment status (employed
at least part time or not employed), and income category
(!$15,000, $15,000e!$24,999, $25,000e!$34,999,
$35,000e!$49,999, or >$50,000). Body mass index
(BMI) was also included and calculated based on respondents’ self-reported height and weight (weight in kg/height
in meters squared).
Analysis
Data were analyzed using SAS 9.3 and accounted for the
complex survey design of the 2009 BRFSS. All analyses
included BRFSS computed weighted variables to adjust
for the probability of selection bias due to the sampling
design (ststr) and adjustment based on demographic factors
(finalwt). First, we compared demographic characteristics,
self-reported health status, and health behaviors among
those with and without disabilities using simple descriptive
statistics, mean, and standard deviation for continuous variables and proportions for categorical variables. Next, t-tests
and chi-square tests were used to assess whether differences
between those with and without disability were statistically
significant. Finally, we conducted multivariable linear and
logistic regressions to evaluate the association of disability
and number of chronic conditions on individuals’ selfreported health status and health behaviors. All regression
analyses were adjusted for the effects of age, sex, race/
ethnicity, income, education, health insurance coverage,
and body mass index.
Results
In 2009, 9435 of the 432,607 respondents (2.18%) had
missing responses on disability-identifying questions,
yielding a sample of 423,172 individuals. Among these,
113,603 were classified as having a disability. After weighting,
disability prevalence of the US adult non-institutionalized
population was estimated at 20.63% (Table 1). Those with a
disability were more likely to be older, female, and NonHispanic White. They also had a higher BMI and more chronic
conditions than those without a disability. Notably, those with
a disability were more likely to experience all 8 chronic conditions, and about half reported arthritis, high cholesterol, or
high blood pressure whereas prevalence among those without
a disability was significantly lower at 18%, 35%, and 25%
respectively. Those with a disability were more likely to have
health insurance coverage and less likely to be employed, and
they had less education and lower incomes than those without
a disability.
Table 2 shows the weighted means, weighted prevalence,
adjusted means, and adjusted odds ratios for health status
and engaging in specific health behaviors for those with
and without a disability. People with disabilities reported
significantly worse health on all indices. Notably, people
K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
Table 1
Weighted estimates of socio-demographic characteristics of people with and without disabilities: US BRFSS, 2009
Has a disability n 5 113,603 weighted %
No disability n 5 309,569 weighted %
Variables
(SEa) 5 20.63 (0.12)
(SEa) 5 79.37 (0.12)
Age
BMI
Chronic conditions, mean
Arthritis
High cholesterol
High blood pressure
Asthma
Diabetes
Heart disease
Stroke
Cancer
Chronic condition categories
0 chronic conditions
1 chronic condition
2þ chronic conditions
Sex
Male
Female
Race/ethnicity
White
Black
Hispanic
Other
Employed
Has health care coverage
Education level
!High school
High school graduate
Some college
College graduate
Income
!$15,000
$15,000e!$25000
$25,000e!$35,000
$35,000e!$50,000
$50,000þ
603
Significance
(0.07)
(0.02)
(0.00)
(0.12)
(0.18)
(0.15)
(0.13)
(0.08)
(0.04)
(0.03)
(0.08)
!0.0001
!0.0001
!0.0001
c2 5 54068.74***
c2 5 6937.08***
c2 5 18775.73***
c2 5 6250.81***
c2 5 12500.26***
c2 5 11925.86***
c2 5 10717.41***
c2 5 7047.32***
15.37 (0.28)
23.52 (0.29)
61.11 (0.31)
47.06 (0.20)
28.08 (0.17)
24.86 (0.15)
c2 5 28860.26***
c2 5 729.68***
c2 5 41603.68***
Weighted % (SEa)
Weighted % (SEa)
45.51 (0.33)
54.49 (0.33)
49.42 (0.19)
50.58 (0.19)
54.36
29.20
2.15
56.82
50.63
48.24
21.60
18.76
10.51
7.45
17.12
(0.13)
(0.05)
(0.10)
(0.33)
(0.32)
(0.32)
(0.28)
(0.23)
(0.17)
(0.14)
(0.20)
44.43
27.05
1.21
17.80
34.58
24.50
11.33
6.55
2.32
1.26
7.57
c2 5 424.14***
c2 5 1362.08***
72.00
10.80
11.05
6.16
32.91
86.69
(0.34)
(0.23)
(0.29)
(0.17)
(0.31)
(0.27)
67.24
10.06
15.79
6.91
63.70
84.24
(0.20)
(0.13)
(0.18)
(0.12)
(0.19)
(0.17)
14.43
31.32
28.34
25.92
(0.24)
(0.30)
(0.28)
(0.27)
9.70
27.30
26.17
36.83
(0.13)
(0.17)
(0.17)
(0.18)
c2 5 26,772.87***
c2 5 320.88***
c2 5 4351.06***
c2 5 15,256.73***
19.52
22.55
12.06
13.71
32.17
(0.27)
(0.29)
(0.21)
(0.26)
(0.32)
8.23
14.24
10.23
14.52
52.78
(0.13)
(0.15)
(0.12)
(0.14)
(0.20)
***p ! 0.001.
a
Standard Error.
with disabilities reported having 9.4 more unhealthy days in
the last 30 days than those without disabilities, and reported
about 6.5 more days when their health kept them from
completing usual activities. People with disabilities were
also 6.4 times more likely to report fair to poor health status
and 4.3 times more likely to report dissatisfaction with life
as compared to those without a disability. Additionally,
people with disabilities reported being less likely to meet
physical activity recommendations and being more likely
to smoke than those without a disability.
Within each chronic condition category (0, 1, or 2þ),
people with a disability reported significantly more unhealthy days in the last 30 days than people without a
disability (Table 3). Even among people with no chronic
diseases, disability was associated with poor health status
and health behaviors. A pattern emerged from the
difference scores, which reflects absolute differences in
poor health days. People with disabilities reported nearly
4 more days of poor mental health and this difference remained constant across each chronic condition category.
They also reported increasingly greater numbers of days
of poor physical health than those without a disability e
5, 6, and 8 more days of poor health respectively for those
with a disability and who experienced 0, 1, or 2þ chronic
conditions. Further, people with disabilities who had 2þ
chronic conditions reported almost 16 days out of the last
30 days of poor healthdnearly 9 more days than those
without disabilities who had 2þ chronic conditions. People
with disabilities and 2þ chronic conditions also reported 7
more days when poor health prevented them from doing
their usual activities than people without disability and
2þ chronic conditions.
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K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
Table 2
Weighted means and weighted prevalence of health status and health Behavior of people with and without disabilities: aUS BRFSS, 2009
Has a disability
No disability
Weighted mean (SEb)
Days in the last 30 experienced poor mental health
Days in the last 30 experienced poor physical health
Unhealthy days reported in the last 30
Days in the last 30 that poor physical or mental health
kept you from usual activity
9.68
9.60
15.92
6.76
(0.25)
(0.22)
(0.29)
(0.29)
5.28
1.68
6.45
0.27
Weighted % (SEa)
Health status
Fair/poor self-reported health
Dissatisfied/very dissatisfied with life
Health behaviors
Heavy drinker (men O2 drinks/day, women O1 drink/day)
Current smoker
Consumes 5+ fruit & vegetable servings per day
Meets recommended amount of weekly physical activity
44.23 (0.32)
14.77 (0.25)
4.32
24.38
22.92
36.28
(0.16)
(0.29)
(0.26)
(0.32)
Weighted mean (SEb)
(0.22)
(0.18)
(0.26)
(0.25)
Weighted % (SEa)
8.67 (0.11)
3.51 (0.08)
5.32
16.32
23.94
52.49
(0.09)
(0.15)
(0.16)
(0.20)
Difference (adjusted means) p values
4.40,
7.92,
9.47,
6.49,
!0.0001
!0.0001
!0.0001
!0.0001
AOR (95% CI)a
6.43*** (6.14, 6.74)
4.29*** (3.99, 4.65)
0.96
1.74***
0.98
0.66***
(0.87, 1.05)
(1.7, 1.82)
(0.95, 1.03)
(0.65, 0.69)
***p ! 0.001.
a
Adjusted for age, race/ethnicity, income, education, health insurance, and body mass index.
b
Standard error.
Regardless of the number of chronic conditions, people
with disabilities had five-fold increased odds of reporting
fair/poor health and about four times increased odds of being dissatisfied with life than those without disabilities.
Additionally, for both those with and without disability,
as the number of chronic conditions increased the prevalence of meeting physical activity recommendations
decreased as did heavy drinking and current smoking. Stratified by chronic conditions, those with disability were more
than 1.6 times more likely to smoke, but less likely to meet
physical activity recommendations than those without a
disability. Interestingly, among those with 2þ chronic conditions, people with disability were less likely to drink
heavily than those without disability.
Discussion
In a nationally representative sample, our findings indicated that disability was strongly associated with several indicators of poor health status, including number of
unhealthy days, life dissatisfaction, self-reported health status, and health behaviors. Even among people with no
chronic diseases, presence of a disability was associated
with poorer health status and poorer health behaviors
(i.e., more likely to smoke and less likely to be physically
active) than those without disabilities. Additionally, presence of chronic diseases increased the odds of having more
unhealthy days for people with disability compared to those
without disability.
The results offer evidence of substantial health disparities between Americans with and without disability. Study
findings indicating that Americans with disabilities have
poorer health status and health behaviors corroborate and
extend previous research.9,10,13,25,32 Specifically, worse
health reported by those with disabilities in this study
(i.e., 44% reported poor/fair health) are similar to other
studies where 39%e45% of those with disabilities reported
fair/poor health compared to about 10% of those without
disabilities.10,12,33,34 Drum, Horner-Johnson, and Krahn34
reported similar findings to ours regarding the number of
poor mental and physical health days in the previous 30
days for those with disabilities. Additionally, our findings
regarding disparities in physical activity9,10,33 and smoking12,13 are similar to those reported by other studies. Yet,
data pooled over 2009e2012 from the National Health
Interview Survey reported a higher smoking prevalence of
39%13 among individuals with disabilities compared to a
prevalence of 24% reported by BRFSS respondents from
2009. It is unclear whether the difference reflects increasing
smoking prevalence over the last several years among those
with disabilities or differences between survey methodology and/or disability definitions.
The novel contributions of this study derive from analyses of differences in health status and health behaviors
between those with and without disability who live with
chronic conditions. Given the recent focus on preventing
chronic disease and reducing disability that may result from
chronic conditions,35 it is critical to recognize that many
people living with disabilities commonly have chronic conditions.36 In our study, 61% of those who had a disability
had 2 or more chronic conditions and 84% had at least 1
chronic condition. Those with a disability, but no chronic
diseases reported 8 more unhealthy days and nearly 6 more
days that prevented them from doing their usual activities
than those without a disability or chronic conditions.
Findings from this nationally representative study suggest that health care providers must continue to focus on
0 CC
1 CC
2+ CC
Healthy days items
Days in the last 30 experienced poor mental health
5.61 (0.41) 8.30 (0.45) 11.45 (0.41)
Days in the last 30 experienced poor physical health 6.07 (0.33) 7.81 (0.38) 9.23 (0.43)
Unhealthy days reported in the last 30
10.52 (0.49) 13.60 (0.52) 15.75 (0.50)
Days in the last 30 that poor physical or mental
6.10 (0.55) 6.73 (0.66) 9.89 (0.53)
health kept you from usual activity
Weighted % (SEb)
Health status
Fair/poor self-reported health
Dissatisfied/very dissatisfied with life
Health behaviors
Heavy drinker (men O2 drinks/day, women
O1 drink/day)
Current smoker
Consumes 5+ fruit & vegetable servings per day
Meets recommended amount of weekly
physical activity
25.17 (0.94) 32.03 (0.68) 53.73 (0.36)
14.81 (0.86) 13.99 (0.57) 15.06 (0.27)
6.04 (0.65)
5.44 (0.41)
3.46 (0.13)
0 CC
1.64
0.27
2.40
0.27
1 CC
(0.33)
(0.21)
(0.39)
(0.44)
4.35
1.62
5.58
0.64
(0.39)
(0.32)
(0.46)
(0.62)
2+ CC
7.46
0.80
6.50
2.48
(0.38)
(0.38)
(0.45)
(0.48)
0 CC
3.97,
5.80,
8.12,
5.83,
!0.0001
!0.0001
!0.0001
!0.0001
Weighted % (SEb)
1 CC
3.95,
6.19,
8.02,
6.09,
!0.0001
!0.0001
!0.0001
!0.0001
2+ CC
3.99,
8.43,
9.25,
7.41,
!0.0001
!0.0001
!0.0001
!0.0001
AOR (95% CI)c
4.78 (0.15)
3.30 (0.13)
7.83 (0.21) 17.00 (0.25) 6.10*** (5.27, 7.05) 5.09*** (4.59, 5.64) 5.05*** (4.78, 5.34)
3.71 (0.15) 3.67 (0.13) 4.21*** (3.54, 5.00) 3.53*** (3.08, 4.06) 4.03*** (3.67, 4.43)
5.19 (0.14)
5.87 (0.18)
4.92 (0.14)
1.10 (0.87, 1.40)
0.99 (0.84, 1.16)
0.85** (0.76, 0.95)
28.36 (0.94) 27.20 (0.72) 22.30 (0.31) 17.03 (0.24) 16.80 (0.28) 14.42 (0.23) 1.58*** (1.41, 1.76) 1.69*** (1.54, 1.86) 1.69*** (1.58, 1.80)
21.86 (0.80) 23.24 (0.58) 23.07 (0.29) 24.16 (0.27) 23.62 (0.30) 23.88 (0.26)
0.95 (0.86, 1.05)
1.01 (0.94, 1.10)
1.01 (0.96, 1.06)
46.00 (1.05) 42.55 (0.75) 31.42 (0.34) 54.99 (0.32) 52.84 (0.36) 47.36 (0.32) 0.77*** (0.70, .85) 0.76*** (0.71, 0.82) 0.61*** (0.58, 0.64)
**p ! 0.01, ***p ! 0.001.
a
Adjusted for age, race/ethnicity, income, education, health insurance, and body mass index.
b
Standard error.
c
Confidence interval.
K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
Table 3
Weighted mean and weighted prevalence of health status and health behavior of people with and without disabilities by chronic conditions: aUS BRFSS, 2009
Has a Disability
No Disability
Difference (adjusted means), p values
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K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
preventing chronic diseases and improving chronic disease
self-management for those who live with them, yet additional efforts should encompass intentionally addressing
the health issues, needs, and concerns of individuals living
with disabilities who are at increased risk for incurring
these chronic conditions20,36 and poorer health outcomes
due to a myriad of biologic, personal, social, and environmental factors.36 These findings offer clear targets for
improving health for people living with disabilities through
promoting healthy lifestyle change; specifically to exercise
more, lose weight, eat more fruits and vegetables, and quit
smoking. Sustained healthy behaviors can reduce people’s
risk for developing chronic conditions, improve the health
of those living with them, contribute to people being and
feeling healthier, and potentially reduce the number of days
when health problems interfere with participation in daily
activities. Evidence suggests that people with disabilities
are both receptive to physician counseling and are willing
to take action. People with disabilities are equally likely
as those without a disability to attempt weight loss37 and individuals with a disability whose physician recommended
physical activity were 1.8 times more likely to be active.9
Yet, research has indicated that less than half of people with
a disability receive a physician recommendation to be
active.9
Approaches to address improving the health status of
people with disabilities should derive from ecological
models of health38 to assure that interventions address not
only individual-level behavior change strategies, but also
environmental influences that include physical, social, and
policy environments. People with disabilities need greater
access to health promotion programs that are adapted to
deliver behavior change strategies they can feasibly adopt.
Physicians should counsel their patients with disabilities
about healthy lifestyles, including following a healthy diet,
engaging in regular physical activity, and stopping smoking
among patients who smoke. Programs need to develop inclusive programming for events and classes to actively
target people with disabilities in promotional materials
and activities.20,39,40 Environments need to offer accessible
and affordable opportunities to be active; have affordable
healthy food options; and assure smoking cessation programs are available and accessible to individuals who
disabilities.
Research in this area of health promotion for people with
disabilities is nascent and the evidence base to date predominantly focuses on promoting physical activity for specific diagnostic groups, such as those with spinal cord
injury41,42 or multiple sclerosis43,44 or those with various
diagnosis that result in mobility impairment45e48 with
mixed results. To date there are not clearly established
evidence-based programs that can be suggested to explicitly address increasing physical activity or weight loss.
Yet, several publications offer investigators a roadmap to
guide efforts in building a stronger evidence base to address
developing health promotion programs for people with
disabilities.39,49,50 Common threads across these approaches include adapting existing evidence-based programs, guided by input from individuals with disabilities
and experts in the field to target components that should
be adapted to address the unique concerns and needs of
those living with disabilities. Future research should follow
these suggested approaches to build a robust evidence base
to guide efforts to improve the health behaviors of those
living with disabilities.
Limitations
The study has some limitations that warrant mention.
First, BRFSS data are cross-sectional, therefore causality
cannot be established between disability and chronic conditions. Second, disability is broadly defined in the BRFSS
based on respondents’ report of experiencing activity limitations due to physical, mental, emotional problems, or
need for assistive devices. Thus, it is impossible to identify
from this dataset either the type of disability or limitations
experienced by respondents. Notably, the causes of
disability are numerous and chronic conditions represent
one pathway to disability. Other causes of disability include
genetic abnormalities, premature birth and birth defects,
and childhood or adult onset diseases and traumatic injuries. Third, the BRFSS disability questions do not allow
for distinguishing between acute, temporary impairments
and chronic, permanent impairments. Some individuals reporting limitations or using special equipment may be
experiencing a short-term period of poor health and function that will resolve within days, weeks, or months. Yet
the dataset does not allow for identifying or differentiating
between these groups. A fourth limitation is that among individuals with similar types of chronic conditions and functioning some may report having activity limitations, while
others who do not.
Conclusions
Promoting health for people living with disabilities is a
public health concern5,51 of growing proportions. Nearly
20% of the US population now lives with a disability and
disability prevalence is projected to increase due to an aging population with an increased prevalence of chronic conditions.52 While national evidence indicates substantial
disparities between individuals with and without
disability,5,10 action to address and reverse these disparities
has been slow, yet is urgently needed.15,51 Efforts should be
focus on increasing access to existing community-based
health promotion programs such as to county recreation
programs. Notably, efforts that target improving access
need to consider physical (e.g., the built environment), programmatic (e.g., time of classes), and attitudinal (e.g., staff
speak and act with respect toward those with disability) access so that the program welcomes and materials are
K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
relevant to those with disabilities. Additionally, innovative
interventions addressing social and environmental barriers
that hinder adults with disability from adopting more
healthy lifestyles and improving health are needed in primary care practices and in the community. Although closing these gaps may be challenging, the identified
disparities are staggering and warrant immediate attention
and intervention.
References
1. Brault MW. Americans With Disabilities: 2010. Current Population
Reports; 2012:P70eP131.
2. Courtney-Long EA, Carroll DD, Zhang QC, Stevens AC, GriffinBlake S, Armour BS. Prevalence of disability and disability types
among adults e United States, 2013. Morb Mortal Wkly Rep
(MMWR). 2015;64(29):777e783.
3. Anderson B, Armour BS, Finkelstein EA, Wiener JM. Estimates of
state-level health-care expenditures associated with disability. Public
Health Rep. 2010;125:44e51.
4. Krahn G, Walker DK, Correa-De-Araujo R. Persons with disabilities
as an unrecognized health disparity population. Am J Public Health;
2015:e1ee19.
5. U.S. Department of Health and Human Services. Chapter 6:
disability and secondary conditions. In: Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: USDHHS.
US Government Printing Office; 2000.
6. Services UDoHaH. Healthy People 2020: Disability and Health
[cited July 17 2012]; Available from: http://www.healthypeople.
gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId59; 2010.
7. Drum DE, Krahn G, Culley C, Hammond L. Recognizing and responding to the health disparities of people with disabilities. Calif
J Health Promot. 2005;3(3):29e42.
8. Rimmer JH, Armour BS, Sinclair LB. Physical activity among adults
with a disability-United States, 2005. Morb Mortal Wkly Rep.
2007;56(39):1021e1024.
9. Carroll DD, Courtney-Long EA, Stevens AC, et al. Vital signs:
disability and physical activityeUnited States, 2009e2012. Morb
Mortal Wkly Rep. 2014;63(18):407e413.
10. Altman BM, Bernstein A. Disability and health in the United States,
2001e2005. In: National Center for Health Statistics. Hyattsville,
MD: U.S. Department of Health and Human Services; 2008.
11. Froehlich-Grobe K, Lee J, Washburn RA. Disparities in obesity and
related conditions among Americans with disabilities. Am J Prev
Med. 2013;45(1):83e90.
12. Armour BS, Campbell VA, Crews JE, Malarcher A, Maurice E,
Richard RA. State-level prevalence of cigarette smoking and treatment advice, by disability status, United States, 2004. Prev Chronic
Dis. 2007;4(4):1e11.
13. Courtney-Long EA, Stevens AC, Caraballo R, Ramon I, Armour BS.
Disparities in current cigarette smoking prevalence by type of
disability, 2009e2011. Public Health Rep. 2014;129:252e260.
14. Rasch EK, Hochberg MC, Magder L, Magaziner J, Altman BM.
Health of community-dwelling adults with mobility limitations in
the United States: prevalent health conditions. Arch Phys Med Rehabil. 2008;89:210e218.
15. Dixon-Ibarra A, Horner-Johnson W. Disability status as an antecedent to chronic conditions: national health interview survey,
2006e2012. Prev Chronic Dis. 2014;11.
16. Reichard A, Stolzle H, Fox MH. Health disparities among adults with
physical disabilities or cognitive limitations compared to individuals
with no disabilities in the United States. Disabil Health J. 2011;4:
59e67.
607
17. Goodman RA, Posner SF, Huang ES, Parekh AK, Koh HK. Defining
and measuring chronic conditions: imperatives for research, policy,
program, and practice. Prev Chronic Dis. 2013;10:120239.
18. Khoury AJ, Hall A, Andreson EM, Zhang J, Ward RC, Jarjoura C.
The association between chronic disease and physical disability
among female Medicaid beneficiaries 18-64 years of age. Disabil
Health J. 2013;6:141e148.
19. Gulley SP, Rasch EK, Chan L. The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep. 2011;126(4):495e507.
20. Krahn G, Reyes M, Fox M. Commentary: chronic conditions and
disability; toward a conceptual model for national policy and practice
considerations. Disabil Health J. 2014;7:13e18.
21. Brault MW, Hootman J, Helmick CG, Theis KA. Prevalence and
most common causes of disability among adults e United States,
2005. Morb Mortal Wkly Rep. 2009;58(16):421e426.
22. Bauman WA, Spungen AM. Carbohydrate and lipid metabolism in
chronic spinal cord injury. J Spinal Cord Med. 2001;24(4):266e277.
23. Parekh AK, Goodman RA, Gordon C, Koh HK. Managing multiple
chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126:460e571.
24. Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions
among US adults: a 2012 update. Prev Chronic Dis. 2014;11:130389.
25. Chen HY, Baumgardner DJ, Rice JP. Health-related quality of life
among adults with multiple chronic conditions in the United States,
Behavioral Risk Factor Surveillance System, 2007. Prev Chronic
Dis. 2011;8(1):A09.
26. Centers for Disease Control and Prevention. 2009 BRFSS Overview;
2009.
27. Centers for Disease Control and Prevention. BRFSS Annual Survey
Data; 2009.
28. Centers for Disease Control and Prevention. 2009 Summary Data
Quality Report; 2009.
29. Ralph NL, Mielenz TJ, Parton H, Flately AM. Multiple chronic conditions and limitations in activities of daily living in a communitybased sample of older adults in New York City, 2009. Prev Chronic
Dis. 2013;10:130159.
30. Ward BW, Schiller JS. Prevalence of multiple chronic conditions
among US adults: estimates from the national health Interview survey, 2010. Prev Chronic Dis. 2013;10:120203.
31. Centers for Disease Control and Prevention. Measuring Healthy
Days: Population Assessment of Health-related Quality of Life;
2000. Atlanta, GA.
32. Thompson WW, Zack MM, Krahn GL, Andresen EM, Barile JP.
Health-related quality of life among older adults with and without
functional limitations. Am J Public Health. 2012;102(3):496e502.
33. Centers for Disease Control and Prevention (CDC). Physical activity
among adults with a disability-United States, 2005. Morb Mortal
Wkly Rep. 2007;56(39):1021e1024.
34. Drum CE, Horner-Johnson W, Krahn GL. Self-rated health and
healthy days: examining the ‘‘disability paradox’’. Disabil Health
J. 2008;1:71e81.
35. IOM (Institute of Medicine). Living Well with Chronic Illness: A Call
for Public Health Action. Washington, DC: The National Academies
Press; 2012.
36. Reichard A, Nary DE, Simpson J. Commentary: chronic conditions
and disability; research contributions and implications. Disabil
Health J. 2014;7:6e12.
37. Weil E, Wachterman M, McCarthy EP, et al. Obesity among adults with
disabling conditions. J Am Med Assoc. 2002;288(10):1265e1268.
38. Sallis JF, Owen N, Fisher EB. Ecological models of health behavior.
In: Glanz K, Rimer BK, Viswanath K, eds. Health Beahvior and
Health Education. San Francisco, CA: Jossey-Bass; 2008:465e485.
39. Drum CE, Peterson JJ, Culley C, et al. Guidelines and criteria for the
implementation of community-based health promotion programs for
individuals with disabilities. Am J Health Promot. 2009;24(2):
93e101. ii.
608
K. Froehlich-Grobe et al. / Disability and Health Journal 9 (2016) 600e608
40. Traci M, Seekins T. Integration of chronic disease and disability and
health state programs in Montana. Disabil Health J. 2014;7:19e25.
41. Arbour-Nicitopoulos KP, Ginis KAM, Latimer AE. Planning, leisuretime physical activity, and coping self-efficacy in persons with spinal
cord injury: a randomized controlled trial. Arch Phys Med Rehabil.
2009;90(12):2003e2011.
42. Block P, Vanner EA, Keys CB, Rimmer JH, Skeels SE. Project
Shake-It-Up: using health promotion, capacity building and a
disability studies framework to increase self efficacy. Disabil Rehabil. 2010;32(9):741e754.
43. McAuley E, Motl RW, Morris KS, et al. Enhancing physical activity
adherence and well being in mutliple sclerosis: a randomized
controlled trial. Mult Scler. 2007;13(5):652e659.
44. Stuifbergen AK, Becker HA, Blozis S, Timmerman G, Kullberg V. A
randomized clinical trial of a wellness intervention for women with
multiple sclerosis. Arch Phys Med Rehabil. 2003;84:467e476.
45. Froehlich-Grobe K, Lee J, Aaronson LS, Nary DE, Washburn RA,
Little TD. Exercise for everyone: a randomized controlled trial of
project workout on wheels in promoting exercise among wheelchair
users. Arch Phys Med Rehabil. 2014;95:20e28.
46. Froehlich-Grobe K, White GW. Promoting physical activity among
women with mobility impairments: a randomized controlled trial to
47.
48.
49.
50.
51.
52.
assess a home- and community-based intervention. Arch Phys Med
Rehabil. 2004;85(4):640e648.
Rowland JL, Rimmer JH. Feasibility of using active video gaming as a
means for increasing energy expenditure in three nonambulatory
young adults with disabilities. Phys Med Rehabil. 2012;4(8):569e573.
Rimmer JH, Hsieh K, Graham BC, Gerber BS, Gray-Stanley JA. Barrier removal in increasing physical activity levels in obese African
American women with disabilities. J Womens Health. 2010;19(10):
1869e1876.
Stuifbergen AK. Building health promotion interventions for persons
with chronic disabling conditions. Fam Community Health.
2006;29(1):28Se34S.
Rimmer J, Vanderbom KA, Badini LG, et al. GRAIDs: a framework
for closing the gap in the availability of health promotion programs
and interventions for people with disabilities. Implement Sci.
2014;9(1):100.
U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons
with Disabilities. In: USDHHS, ed. Office of the Surgeon General;
2005.
Institute of Medicine (IOM). The Future of Disability in America.
Washington, DC: National Academies Press; 2007.