Progress Review

Disability and Secondary Conditions

November 16 , 2006

In the sixth session in the second series of assessments of Healthy People 2010, ADM John O. Agwunobi, Assistant Secretary for Health, chaired a focus area Progress Review on Disability and Secondary Conditions. He was assisted by staff of the co-lead agencies for this Healthy People 2010 focus area, the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Education (ED), where programs related to disability are centered in the National Institute on Disability and Rehabilitation Research (NIDRR). Also participating in the review were representatives from other U.S. Department of Health and Human Services (HHS) offices and agencies and from the U.S. Access Board, an independent Federal Agency. In his introduction to Progress Review participants, ADM Agwunobi emphasized that people with disabilities deserve access to the same services, as well as to the same opportunities, as the rest of the population to be productive members of society. By addressing questions of employment and healthcare parity, among other subjects, the objectives for this focus area can quantify how far short of this ideal the Nation began the decade and how much progress, if any, has occurred in our efforts to close the gap between people with and without disabilities.

The complete text for the Disability and Secondary Conditions focus area of Healthy People 2010 is available online at www.healthypeople.gov/document/html/volume1/06disability.htm. More recent data used in the Progress Review for this focus area’s objectives and their operational definitions can be accessed at wonder.cdc.gov/data2010. For comparison, the report on the first-round Progress Review (held on January 15, 2003) is archived at www.healthypeople.gov/data/2010prog/focus06/2003fa06.htm. The meeting agenda, tabulated data for all focus area objectives, charts, and other materials used in the Progress Review can be found at a companion site maintained by the National Center for Health Statistics (NCHS)/CDC: www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa06-disability2.htm.

Data Trends

In his overview of data related to this focus area, Richard Klein of the NCHS Health Promotion Statistics Branch stated that 15 to 16 percent of the adult population in the United States report having some kind of disability. Compared with people without disabilities, people with disabilities are more likely to be in fair to poor health, to experience serious psychologic distress and more co-morbid health conditions, and to have a lower income and fewer resources. A slightly higher proportion of females have disabilities than males. The age-adjusted proportion of people aged 75 years and older who have disabilities approaches 50 percent. Among five racial and ethnic populations for which data are available, disabilities in adults are present at the highest proportion among non-Hispanic blacks (almost 20 percent), followed in descending order by American Indians/Alaska Natives, non-Hispanic whites, Hispanics, and Asians (less than 10 percent). Overall, this picture has not changed appreciably over the years. Mr. Klein then presented a more detailed examination of selected objectives that were highlighted during the Progress Review.

(Obj. 6-2): The proportion of children and youth with disabilities aged 4 to 17 years who report having feelings of sadness or depression decreased from 31 percent in 1997 to 27 percent in 2005. In 2005, 30 percent of females in that age group reported such feelings, compared with 26 percent of males. Among racial and ethnic groups, the proportions in 2005 were as follows: Hispanics, 30 percent; non-Hispanic blacks, 29 percent; and non-Hispanic whites, 25 percent. The 2010 target is 17 percent, which is parity with children and youth without disabilities.

(Obj. 6-3): In 2005, the age-adjusted proportion of adults with disabilities aged 18 years and older who reported having negative feelings that interfered with their activities was 32 percent, an increase from 28 percent in 1997. In 2005, 34 percent of females with disabilities reported having such feelings, compared with 29 percent of males. Among racial and ethnic groups for which data were available, the proportions in 2005 were as follows: Hispanics, 34 percent (a decrease from 40 percent in 1997); non-Hispanic blacks, 30 percent (31 percent in 1997); and non-Hispanic whites, 32 percent (an increase from 27 percent in 1997). The target is 7 percent, which is parity with adults without disabilities.

(Obj. 6-4): In 2001, the only year of the decade for which data are available, the age-adjusted proportion of adults with disabilities aged 18 years and older who participated in social activities was 61 percent overall (64 percent of females and 57 percent of males). Among racial and ethnic groups for which data were available, the proportions in 2001 were as follows: Asians, 54 percent; Hispanics, 56 percent; non-Hispanic blacks, 60 percent; non-Hispanic whites, 61 percent; and American Indians or Alaska Natives, 66 percent. The target is 79 percent, which is parity with adults without disabilities.

(Obj. 6-7a): In 2005, 65,575 adults with disabilities aged 22 years and older lived in congregate care facilities, compared with 93,362 in 1997. The continuation of this downward trend would be desirable provided the reduction is consistent with principles that seek permanent arrangements that enhance emotional and social growth and development. The target is 46,681 to reduce the number to half of what it was in 1997.

(Obj. 6-8): In 2005, 40 percent of adults with disabilities aged 18 to 64 years were employed, a decrease from 43 percent in 1997. The 2005 employed proportions among adult males and females with disabilities were 44 percent and 36 percent, respectively. Among racial and ethnic groups for which data were available, the proportions in 2005 were as follows: non-Hispanic blacks, 28 percent; Hispanics, 36 percent; and non-Hispanic whites, 44 percent. The target is 80 percent, which is parity with people without disabilities.

(Obj. 6-9): In 2004–2005, 54 percent of children and youth with disabilities aged 6 to 21 years were included in regular education programs, an improvement over 1995–1996 when 45 percent were included. The target is 60 percent in accordance with the NIDRR long-range plan.

(Obj. 6-10): In 2002, the only year for which data are available, 48 percent (age-adjusted) of adults with disabilities aged 18 years and older reported having access to health and wellness programs. For adult females with disabilities, the proportion was 47 percent; for adult males with disabilities, it was 50 percent. Among racial and ethnic groups for which data were available, the proportions in 2005 were as follows: Hispanics, 27 percent; non-Hispanic blacks, 36 percent; and non-Hispanic whites, 54 percent. By education level attained, the proportions that had access among people with disabilities aged 25 years and older were as follows: less than high school, 30 percent; high school graduate, 46 percent; and at least some college, 59 percent. Reported access also increased as levels of family income increased. The target is 63 percent, which is parity with adults without disabilities.

(Obj. 6-11): In 2002, the only year of the decade for which data are available, the age-adjusted proportion of adults with disabilities aged 18 years and older who lacked needed assistive devices and technology was 10 percent (or 12 percent of females and 9 percent of males). Among racial and ethnic groups for which data were available, the proportions in 2002 were as follows: non-Hispanic blacks, 8 percent; non-Hispanic whites, 10 percent; and Hispanics, 11 percent. By education level attained, the proportions in need of assistive devices among people with disabilities aged 25 years and older were as follows: less than high school, 11 percent; high school graduate, 13 percent; and at least some college, 9 percent. The target is 7 percent.

Key Challenges and Current Strategies

In presentations that followed the data overview, the principal themes were introduced by Steven Tingus, Director of NIDRR, who discussed societal participation; Alison Johnson, Acting Director of the CDC National Center on Birth Defects and Developmental Disabilities (NCBDDD), who discussed public health surveillance, health promotion efforts, and health status measures; and Margaret Giannini, Director of the HHS Office on Disability, who discussed disability planning and policy efforts. These agency representatives set the stage for discussions among Progress Review participants, identified a number of barriers to achieving the objectives, and discussed activities under way to meet these challenges, including the following:

• People with disabilities are at higher risk for a number of adverse health behaviors and conditions than people without disabilities. In 2002, the proportions of adults with disabilities compared with adults without disabilities who were affected by or engaged in specific health conditions or behaviors were as follows: high cholesterol—19 percent as compared with 17 percent, high blood pressure—37 percent as compared with 29 percent, obesity—42 percent as compared with 28 percent, and smoking—31 percent as compared with 20 percent. Among high-school-aged youth, the incidence of suicide is highest among those who are cognitively or developmentally disabled; the next highest incidence occurs among those who have suffered spinal cord injuries.

• For many people with disabilities, personal assistance and caregivers are critical to health and well-being, community-based living, and societal participation, including education and employment. However, the demand for personal care and caregivers greatly exceeds the current capacity of care services.

• In fiscal year 2005, CDC/NCBDDD supported 16 state-level disability and health programs. These states are testing ways to implement health promotion interventions, such as Living Well with a Disability and Steps to Your Health.

• With funding support from CDC/NCBDDD, the National Center on Physical Activity and Disability (NCPAD) promotes fitness among people with disabilities. NCPAD provides guidance for communities and programs that want to make fitness and exercise facilities more accessible to all people. The Center also provides practical suggestions for individuals and groups that wish to pursue adapted recreational games, sports, and everyday activities.

• The target was met in 2003 for increasing the number of states with ongoing disability surveillance from 14 states in 1999 to 50 states and the District of Columbia in 2010 (Obj. 6-13a). As a result of funding from CDC/NCBDDD, the objective was achieved by adding questions that identify people with disabilities directly into a standard survey instrument. Beginning with 2003, all states and three U.S. Territories are able to assess the population of people with disabilities and their health and well-being.

• To help with this effort, CDC/NCBDDD produced Disability and Health State Chartbook—2006: Profiles of Health for Adults with Disabilities. This publication, the first in an annual series, gives the prevalence of disability in U.S. states and Territories and shows how health behaviors and access to health services differ between people with and without disabilities in each jurisdiction. (For more information, go to www.cdc.gov/ncbddd/dh.)

• Access to transportation is an ongoing problem for people with disabilities, especially in rural environments. The U.S. Department of Transportation’s Interagency Transportation Coordinating Council on Access and Mobility (www.unitedweride.gov) is working to ensure that all transportation services are seamless, comprehensive, and accessible.

• Under a wide range of Federal laws and regulations, the U.S. Access Board develops accessibility guidelines for buildings and facilities, transit vehicles, telecommunications, electronic and information technology, and voting machines. These guidelines are used as the basis of both enforceable and voluntary standards that serve as measures of accessibility.

• The U.S. Department of Labor’s Office of Disability Employment Policy funds the Employer Assistance and Recruiting Network to assist employers in preparation, awareness, education, and candidate recruitment among people with disabilities.

• In addition, ED’s Rehabilitation Services Administration, through its Title 1 formula grants program, offers funds to state vocational rehabilitation agencies to provide employment-related services for individuals with disabilities, giving priority to individuals who are significantly disabled.

• Through its Family Support 360 Program, the Administration on Developmental Disabilities within the HHS Administration for Children and Families provides grants to One-Stop Centers for supporting unserved and underserved families with a member who has a developmental disability. These Centers assist in reducing family stress by serving as a resource and guide to various services, including health-related services.

• Since 1991, NIDRR has supported regional Disability and Business Technical Assistance Centers (DBTAC), which have provided technical assistance and training and disseminated information on the requirements of the Americans with Disabilities Act (ADA) to entities covered by the law and individuals with disabilities. NIDRR is seeking to expand the focus of the DBTAC program beyond compliance with the ADA to include assistance in identifying and implementing a variety of more effective intervention approaches and more cost-effective strategies to help individuals with a variety of disabilities reach their full potential on the job.

• To help reduce the unmet need for assistive technologies, NIDRR underwrites technology demonstration, testing, validation, and market assessment to meet the specific needs of small businesses so they can better serve people with disabilities.

• President Bush’s New Freedom Initiative directs the Interagency Committee on Disability Research (ICDR) to improve the coordination of Federal assistive technology research and development programs. Furthermore, ICDR is prioritizing assistive technology needs in the disability community and fostering collaborative projects between Federal laboratories and the private sector.

• The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities (2005) highlights disability as a major public health issue. In the words of then Surgeon General Richard H. Carmona, “This Call to Action encourages healthcare providers to see and treat the whole person, not just the disability; educators to teach about disability; a public to see an individual’s abilities, not just his or her disability; and a community to ensure accessible healthcare and wellness services for persons with disabilities.”

Approaches for Consideration

Progress Review participants made the following suggestions for public health professionals and policymakers to consider as steps to enable further progress toward achievement of the objectives for Disability and Secondary Conditions:

• Broaden efforts to identify and implement evidence-based practices that include people with disabilities in public health promotion programs. In conjunction with these efforts, encourage states that do not have them already to institute dedicated health promotion programs for people with disabilities.

• In planning for data collection efforts in the future, seek to ensure that people with and without disabilities will be included as a distinct category, to the extent possible, in all healthcare databases and surveys concerned with factors affecting health and well-being.

• In research on challenges to the employment of people with disabilities, shift the focus more toward an examination of policies and practices of potential industrial and other employers and less on the circumstances of individuals seeking employment.

• In accordance with the July 26, 2004, Executive Order 13347 Individuals with Disabilities in Emergency Preparedness, expand the inclusion of people with disabilities in disaster management processes, training for first responders, county-level data to locate and evacuate such people, and planning to ensure the supply of resources will meet specific disability needs during a disaster.

• Increase research to identify risk factors for depression in people with disabilities and on interventions to reduce the risk, with special attention to the roles of social support and physical activity and exercise to increase fitness.

• Explore ways to increase the labor pool and job competence of caregivers for people with disabilities, giving consideration to credentialing, higher pay levels, health insurance coverage and other associated benefits, enhanced social standing, and other factors that might make this employment sector more attractive to potential recruits.

• Strengthen education efforts to persuade physicians and other healthcare providers to make their facilities, practices, communication, and exam equipment (for example, mammography setups) adaptable to the special needs of people with disabilities.

• Explore strategies for reducing the excessive dropout rate that occurs among high school youth with disabilities.

• Endeavor to standardize the lexicon of terms and definitions that pertain to disability and health, for example, through greater use of the World Health Organization’s International Classification of Functioning, Disability and Health.

[Signed April 4, 2007]
ADM John O. Agwunobi , M.D., M.B.A., M.P.H.
Assistant Secretary for Health

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