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      Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults — United States, 2016

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          Abstract

          Persons with disabilities face greater barriers to health care than do those without disabilities ( 1 ). To identify characteristics of noninstitutionalized adults with six specific disability types (hearing, vision, cognition, mobility, self-care, and independent living), * and to assess disability-specific disparities in health care access, CDC analyzed 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalences of disability overall and by disability type, and access to health care by disability type, were estimated. Analyses were stratified by three age groups: 18–44 years (young adults), 45–64 years (middle-aged adults), and ≥65 years (older adults). Among young adults, cognitive disability (10.6%) was the most prevalent type. Mobility disability was most prevalent among middle-aged (18.1%) and older adults (26.9%). Generally, disability prevalences were higher among women, American Indians/Alaska Natives (AI/AN), adults with income below the federal poverty level (FPL), and persons in the South U.S. Census region. Disability-specific disparities in health care access were prevalent, particularly among young and middle-aged adults. These data might inform public health programs of the sociodemographic characteristics and disparities in health care access associated with age and specific disability types and guide efforts to improve access to care for persons with disabilities.

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          Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016

          Objectives: This study describes key population health concepts and examines major empirical trends in US health and healthcare inequalities from 1935 to 2016 according to important social determinants such as race/ethnicity, education, income, poverty, area deprivation, unemployment, housing, rural-urban residence, and geographic location. Methods: Long-term trend data from the National Vital Statistics System, National Health Interview Survey, National Survey of Children’s Health, American Community Survey, and Behavioral Risk Factor Surveillance System were used to examine racial/ethnic, socioeconomic, rural-urban, and geographic inequalities in health and health care. Life tables, age-adjusted rates, prevalence, and risk ratios were used to examine health differentials, which were tested for statistical significance at the 0.05 level. Results: Life expectancy of Americans increased from 69.7 years in 1950 to 78.8 years in 2015. However, despite the overall improvement, substantial gender and racial/ethnic disparities remained. In 2015, life expectancy was highest for Asian/Pacific Islanders (87.7 years) and lowest for African-Americans (75.7 years). Life expectancy was lower in rural areas and varied from 74.5 years for men in rural areas to 82.4 years for women in large metro areas, with rural-urban disparities increasing during the 1990-2014 time period. Infant mortality rates declined dramatically during the past eight decades. However, racial disparities widened over time; in 2015, black infants had 2.3 times higher mortality than white infants (11.4 vs. 4.9 per 1,000 live births). Infant and child mortality was markedly higher in rural areas and poor communities. Black infants and children in poor, rural communities had nearly three times higher mortality rate compared to those in affluent, rural areas. Racial/ethnic, socioeconomic, and geographic disparities were particularly marked in mortality and/or morbidity from cardiovascular disease, cancer, diabetes, COPD, HIV/AIDS, homicide, psychological distress, hypertension, smoking, obesity, and access to quality health care. Conclusions and Global Health Implications: Despite the overall health improvement, significant social disparities remain in a number of health indicators, most notably in life expectancy and infant mortality. Marked disparities in various health outcomes indicate the underlying significance of social determinants in disease prevention and health promotion and necessitate systematic and continued monitoring of health inequalities according to social factors. A multi-sectoral approach is needed to tackle persistent and widening health inequalities among Americans.
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            Declining Prevalence of Hearing Loss in US Adults Aged 20 to 69 Years

            IMPORTANCE As the American population ages, effective healthcare planning requires understanding changes in hearing loss prevalence. OBJECTIVE Determine if age- and sex-specific prevalence of adult hearing loss changed during the past decade. DESIGN Analysis of 2011–2012 National Health and Nutrition Examination Survey (NHANES) audiometric data compared to NHANES 1999–2004. NHANES is a cross-sectional, nationally-representative interview and examination survey of the civilian, non-institutionalized population. PARTICIPANTS A stratified random sample of 3,831 adults aged 20–69 years INTERVENTIONS Audiometry and questionnaires MAIN OUTCOMES AND MEASURES Speech-frequency hearing impairment (HI) defined by pure-tone average (PTA) of thresholds across 0.5–1–2–4 kHz greater than 25 dB hearing level (HL); high-frequency HI defined by PTA across 3–4–6 kHz >25 dB HL. Logistic regression was used to examine unadjusted, age- and sex-adjusted, and multivariable-adjusted associations with demographic, noise exposure, and cardiovascular risk factors. RESULTS The 2011–2012 unadjusted adult prevalence of unilateral and bilateral speech-frequency HI was 14.1%, compared to 16% for 1999–2004; after age- and sex-adjustment, the difference was significant, odds ratio (OR)=0.70 (95% confidence interval [95% CI]: 0.56–0.86). Men had nearly twice the prevalence of speech-frequency HI, 18.6% (17.8 million), compared to women, 9.6% (9.7 million). For 60–69 year-olds, speech-frequency HI prevalence was 39.3% (95% CI: 30.7%–48.7%). In multivariable analyses for bilateral speech-frequency HI, age was the major risk factor; however, men, non-Hispanic (NH) white and NH Asian race, lower educational attainment, and heavy use of firearms all had significant associations. Additional associations for high-frequency HI were Mexican-American and Other Hispanic race/ethnicity and the combination of loud and very loud noise exposure occupationally and outside of work, OR=2.4 (95% CI: 1.4–4.2). CONCLUSIONS AND RELEVANCE Adult hearing loss is common and strongly associated with age and other demographic factors (sex, race/ethnicity, education). Noise exposure, which is preventable, was less strongly associated. Cardiovascular risk factors – heavy smoking, hypertension, and diabetes – were significant only in unadjusted analyses. Age- and sex-specific HI prevalence continues to decline. Despite the benefit of delayed onset of HI, hearing healthcare needs will increase as the U.S. population grows and ages.
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              Prevalence of Disability and Disability Type Among Adults — United States, 2013

              Understanding the prevalence of disability is important for public health programs to be able to address the needs of persons with disabilities. Beginning in 2013, to measure disability prevalence by functional type, the Behavioral Risk Factor Surveillance System (BRFSS), added five questions* to identify disability in vision, cognition, mobility, self-care, and independent living.† CDC analyzed data from the 2013 BRFSS to assess overall prevalence of any disability, as well as specific types of disability among noninstitutionalized U.S. adults. Across all states, disabilities in mobility and cognition were the most frequently reported types. State-level prevalence of each disability type ranged from 2.7% to 8.1% (vision); 6.9% to 16.8% (cognition); 8.5% to 20.7% (mobility); 1.9% to 6.2% (self-care) and 4.2% to 10.8% (independent living). A higher prevalence of any disability was generally seen among adults living in states in the South and among women (24.4%) compared with men (19.8%). Prevalences of any disability and disability in mobility were higher among older age groups. These are the first data on functional disability types available in a state-based health survey. This information can help public health programs identify the prevalence of and demographic characteristics associated with different disability types among U.S. adults and better target appropriate interventions to reduce health disparities. BRFSS is an annual state-based random-digit–dialed telephone (landline and cell phone) survey of the U.S. noninstitutionalized civilian population aged ≥18 years. During 2013, the median response rate among the 50 states and District of Columbia (DC) was 45.9% and ranged from 29.0% (Alabama) to 59.2% (North Dakota).§ The 2013 survey included, for the first time, questions about five disability types (vision, cognition, mobility, self-care, and independent living).¶ Respondents were identified as having one of the five disability types if they answered “yes” to the relevant question. Respondents who responded “yes” to at least one of the disability questions were identified as having any disability. Responses of “don’t know” or “refused” were excluded from analyses. Prevalences of any disability and disability type (with 95% confidence intervals) were calculated by state, sex, age group, race/ethnicity, veteran status, annual household income, employment status, and education level. All estimates were age-adjusted to the 2000 U.S. population. Data were weighted and analyzed to account for the complex sampling design of BRFSS. Two-sided chi-square tests were used to compare prevalence estimates between demographic subgroups. Overall, 22.2% of U.S. adults (53,316,677 persons) reported any disability. Disability in mobility was the most frequently reported type (13.0%), followed by disability in cognition (10.6%), independent living (6.5%), vision (4.6%), and self-care (3.6%) (Table 1). Prevalence of any disability differed across states, ranging from 16.4% (Minnesota) to 31.5% (Alabama). Prevalences of each disability type also varied across states. Disability in vision ranged from 2.7% in Idaho and New Hampshire to 8.1% in Mississippi; disability in cognition ranged from 6.9% in North Dakota and South Dakota to 16.8% in Arkansas; disability in mobility ranged from 8.5% in Minnesota to 20.7% in Mississippi; self-care disability ranged from 1.9% in Hawaii to 6.2% in Mississippi; and disability in independent living ranged from 4.2% in Nebraska and Utah to 10.8% in Mississippi. Generally, states with higher disability prevalences were located in the South and those with lower prevalences were in the Midwest or West (Table 1; Figure). Women reported a higher prevalence of any disability (24.4%) than did men (19.8%), and also reported higher prevalences of each disability type. Prevalences of any disability and of each type were highest in either the oldest age group (≥65 years) or both the middle (45–64 years) and oldest age groups, with the exception of cognition, where the reported prevalence was highest among persons aged 45–64 years (12.0% versus 10.1% [18–44 years] and 9.9% [≥65 years]). Black, non-Hispanic adults reported the highest prevalences of any disability and of each disability type; the highest prevalence of disability in vision (7.4%) was the same among black, non-Hispanic adults and Hispanic adults. Compared with veterans, non-veterans reported a higher prevalence of disability in vision (4.7% versus 3.9%) and independent living (6.7% versus 5.9%). Respondents with higher household income levels and higher levels of education had lower prevalences of any disability and of each disability type. Nearly 50% of adults with a household income of <$15,000 and 40% of adults who did not graduate from high school had any disability compared with only 10.8% of adults with a household income of ≥$50,000 and 11.8% of college graduates, respectively. Prevalence of any disability among unemployed adults was more than twice as high as it was among those who were employed. (33.5% versus 12.6%) (Table 2). Discussion In 2000, in the first report of state-based data on disability that was generated from the 1998 BRFSS data (1),** CDC described a median state-level disability prevalence of 17.1% in 11 states and DC. Since 2003, BRFSS has assessed disability†† in all participating states and territories using two questions regarding activity limitation and special equipment use. These questions, however, did not address the type of functional limitation or condition associated with the disability. In 2011, pursuant to Section 4302 of the Affordable Care Act,§§ the Department of Health and Human Services issued guidance for defining and collecting data on disability status using a standard set of questions. On the basis of this guidance,† BRFSS added five additional disability questions to the survey in 2013.* In 2013, approximately one in five U.S. adults reported any disability, with state-level prevalence of any disability ranging from 16.4% in Minnesota to 31.5% in Alabama. Reasons behind state-level differences in disability are unclear; however, disability prevalence was generally higher in the South, a region noted to have one of the higher prevalences of social determinants of poor health (2,3), which are also associated with disability (2–4). The higher overall prevalence of disability in this report compared with the 2000 report might be explained, in part, by the use of different operational definitions of disability, a true increase in prevalence in the 15 years since the 1998 survey, or the inclusion of all states and DC in this report. Many findings in this study are consistent with earlier reports. Previous research found lower education levels among adults with a disability compared with those without (5); in this study, approximately 40% of those who did not complete high school reported any disability. Public health programs for persons with one or more disabilities might need to account for this, as lower health literacy has been associated with lower education levels (6). The most frequently reported disability type was mobility, which is consistent with other findings (7): the top two causes of disability are associated with physical or mobility limitations (arthritis, back and spine problems) and account for over 35% of all disability (8). Disability prevalence has been shown to increase with age (5). Although the prevalences of any disability and disabilities in mobility and independent living increased with age, this was not the case for disabilities in vision, cognition and self-care. This observed association of any disability with increasing age might be because of disability in mobility; at 13%, this was the most frequently reported disability type, and disability in mobility increases with age. Prevalences of vision and self-care disability were similar for adults aged 45–64 years and adults aged ≥65 years. In contrast, the highest prevalence of disability in cognition was among adults aged 45–64 years. This could be accounted for, in part, by the exclusion from the survey of adults living in institutional settings, as older adults may be more likely to live in such settings (e.g., nursing homes) than younger adults. In addition, although underlying medical conditions are not ascertained in BRFSS, many middle-aged adults who indicated a limitation in cognition during development and testing of that question also reported having mental illness (9). Furthermore, among all disability types, the largest increases in prevalence occurred between persons aged 18–44 years and those aged 45–64 years (e.g., the prevalence of mobility disability was more than three times higher among persons aged 45–64 years compared with those aged 18–44 years). Understanding the age profiles of different disability types can enhance the development of age- and disability-inclusive public health programs. Summary What is already known on this topic? Disability has been measured in numerous ways in national health surveys. CDC previously used 1998 BRFSS data to report disability prevalence in 11 states and the District of Columbia (DC). The median disability prevalence, using a nonspecific definition of disability, was 17.1%. What is added by this report? Five questions added to the 2013 BRFSS were used to measure functional disability type in the 50 states and DC. Overall prevalence of any disability was 22.2%; the most frequently reported disability types were mobility (mean = 13.0%) and cognition (mean = 10.6%). In general, disability prevalences were higher among women, adults ≥65 years of age, racial/ethnic minorities, persons with annual household incomes <$15,000 per year, and those who had less than a high school education. What are the implications for public health practice? More than 53 million U.S. adults reported a disability in 2013. Since disability among adults is associated with disparities in behavioral risk factors for health (e.g., smoking and physical inactivity), more specific information on disability and disability types will inform public health researchers and program planners to better understand the relationships between disability, demographic factors, and health status to identify and address barriers to more effective interventions. The findings in this report are subject to at least four limitations. First, all BRFSS data are self-reported and, therefore, might be subject to recall and social desirability bias. However, self-reporting is the most commonly used method for assessing disability for surveillance purposes. Second, nonresponse bias is possible because response rates among the states and DC ranged from 29.0% to 59.2% (median: 45.9%). Third, because three of the disability questions include the modifier “serious,” they might not identify respondents with more moderate limitations or who do not perceive their disabilities to be serious. Finally, BRFSS does not include adults living in institutional settings or group homes, which might systematically exclude persons with disabilities, since persons residing in these settings might be more likely to have a disability. Because these last two limitations can result in an underestimation of the disability prevalence and profile among all U.S. adults, the estimates reported here are likely to be conservative. Disability has been associated with health disparities in behavioral risk factors (e.g., smoking and physical inactivity) and preventive health measures (e.g., mammography) (4). Maintaining health among people with disabilities is important, as annual disability-associated health care expenditures were estimated at nearly $400 billion in 2006, with over half attributable to costs related to non-independent living (e.g., institutional care, personal care services) (10). The ability of state programs to address these and other important public health needs among adults with disabilities has possibly been hindered by a lack of information on specific disability types. Having information about disability types, the demographic profiles of persons with different disability types, and health disparities associated with disabilities¶¶ will better enable researchers and program planners to make more focused, data-driven decisions and modify existing interventions to more effectively improve the health of persons with disabilities.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                17 August 2018
                17 August 2018
                : 67
                : 32
                : 882-887
                Affiliations
                [1 ]Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC.
                Author notes
                Corresponding author: Catherine A. Okoro, cokoro@ 123456cdc.gov , 770-488-5220.
                Article
                mm6732a3
                10.15585/mmwr.mm6732a3
                6095650
                30114005
                1884e286-5c60-4e69-a936-f6c79a24e917

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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