BRFSS Health Behaviors and Outcomes Project

Principal Investigator: Charles Drum, JD, Ph.D.

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Introduction
Objectives
Methods
Results
Conclusions
Implications
References
Resources

INTRODUCTION

Health status is often viewed as the foundation for experiencing a quality life, being self-sufficient, and participating fully in society. The primary objectives of Healthy People 2010, the nation’s foremost public health document, are to increase the quantity and quality of life and to eliminate disparities in health among the American population, including disparities related to disability status.1 People with disabilities make up approximately 22% of the population or nearly 54 million Americans.2 People with disabilities experience a thinner margin of health3 and are at greater risk for specific medical complications and/or secondary conditions related to their disability than the general population.4,5,6 This increased risk has been coupled with an underlying assumption that disability is equivalent to illness, including all the associations of dependence, lack of physical activity and productivity that are incumbent to the notion of illness.7 Unfortunately, there are few national data collected that directly assess health status and health disparities of people with disabilities in the United States. Historically, research on the health of people with disabilities has primarily focused on health care utilization and secondary medical conditions. Only in the last decade or so has research begun to focus on life satisfaction, well-being, and health promotion among people with disabilities.

RESEARCH OBJECTIVE/RESEARCH QUESTIONS

As a foundation, the BRFSS: Health Status & Disability Project examined basic health status differences between people with and without disabilities. The project then assessed positive health among people with disabilities and identified factors related to positive health status. Part of this process involved understanding what respondents meant when they described their health status in certain ways, and whether this differed systematically for people with and without disabilities. The project was guided by the following research questions:

1. Are there significant differences in key demographic variables between people with and without disabilities?

2. Are there significant differences between people with disabilities and people without disabilities in general health status?

3. Are there significant differences between people with and without disabilities in physical health status?

4. Are there significant differences between people with and without disabilities in mental health status?

5. Are there significant differences between people with and without disabilities in health status affecting usual activities?

6. Is there a significant difference in the number of unhealthy days among people with and without disabilities who report the same level of health status?

METHODS

The project utilized data from the 1998 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS, designed and funded primarily by the federal Centers for Disease Control and Prevention (CDC), is an annual, random-digit telephone survey of non-institutionalized adults (>18 years) conducted by each state and territory in the United States. The BRFSS survey contains questions in ten core areas (including health status) and several supplemental areas, including disability status. For this analysis, data from the 1998 BRFSS were aggregated from people with and without disabilities across 14 states (Alabama, Arkansas, Arizona, Indiana, Iowa, Kansas, Massachusetts, Montana, New Mexico, New York, North Carolina, Oregon, Rhode Island, South Carolina) and the District of Columbia. The total sample size was 46,993. Disability was defined as an affirmative response to: “Are you limited in any way in any activities because of any impairment or health problem?” A total of 8,455 people met the definition of disability.

Health status was measured using the core healthy days measures described below.

Healthy Days Questions

In addition to analyzing the above questions individually, two of the questions were combined into a summary index of unhealthy days. Responses to the physical health and mental health questions were added together with a maximum range of 30 unhealthy days.8 Unhealthy days provides a simple and valid measure of a persons mental and physical health. It forms the basis for calculating positive health: healthy days were calculated by subtracting the number of unhealthy days from 30 days.9

Means and 95% confidence intervals (CIs) were calculated using SAS. SAS was used to account for the stratified survey sample methodology, and to weight the data to represent the entire sample population based on Census data. Samples were weighted for age, sex, and race.

RESULTS

Demographics

The total sample population consisted of 79.2% non-Hispanic whites, 10.5% non-Hispanic blacks, 3.4% other non-Hispanics, and 6.9% persons of Hispanic origin. The gender breakdown was 52.5% female, 47.5% male. The average age was 45.5 years.

Of the total sample population, 16% were people with disabilities. The racial/ethnic distribution was roughly the same, regardless of disability status. People with disabilities included a slightly higher proportion of women (55.5% compared to 51.8% for people without disabilities). People with disabilities were, on average, about 10 years older than people without disabilities. The average age of people with disabilities was 54 years, while the average age of people without disabilities was roughly 44 years.

General Health Status

Overall, people with disabilities reported lower rates of general health status than people without disabilities. The percentage of people with disabilities who described their health as excellent/very good/good was 56.1% (95% CI=54.24--57.97). In comparison, 91.5% of people without disabilities described their health as excellent/very good/good (95% CI=91.01—91.98). The percentage of people with disabilities who described their health as fair/poor was 43.9% (95% CI=42.03--45.76). In comparison, 8.5% of people without disabilities described their health as fair/poor (95% CI=8.02--8.99).

Number of unhealthy days by health status

Among people who described their health as excellent, people with disabilities reported an average of 4.8 days physical health not good (95% CI=3.0--6.6), 2.8 days mental health not good (95% CI=1.8--3.7), and 5.8 days health prevented usual activities (95% CI=3.3--8.2). People without disabilities reported an average of 0.8 days physical health not good (95% CI=0.7--0.9), 1.4 days mental health not good (95% CI=1.3--1.5), and 1.0 days health prevented usual activities (95% CI=0.8--1.2).

Among people who described their health as very good, people with disabilities reported an average of 4.2 days physical health not good (95% CI=3.6--4.9), 3.7 days mental health not good (95% CI=3.0--4.4), and 3.9 days health prevented usual activities (95% CI=3.1--4.9). People without disabilities reported an average of 1.2 days physical health not good (95% CI=1.1--1.3), 2.2 days mental health not good (95% CI=2.0--2.3), and 1.3 days health prevented usual activities (95% CI=1.1--1.5).

Among people who described their health as good, people with disabilities reported an average of 6.5 days physical health not good (95% CI=5.9--7.2), 4.0 days mental health not good (95%CI=3.4--4.5), and 6.2 days health prevented usual activities (95% CI=5.3--7.1). People without disabilities reported an average of, 2.0 days physical health not good (95% CI=1.8--2.1), 2.9 days mental health not good (95% CI=2.6--3.1), and 2.2 days health prevented usual activities (95% CI=2.0--2.5).

Among people who described their health as fair, people with disabilities reported an average of 12.6 days physical health not good (95% CI=11.7--13.5), 6.4 days mental health not good (95% CI=5.6--7.1), and 10.8 days health prevented usual activities (95% CI=9.9--11.8). People without disabilities reported an average of 5.1 days physical health not good (95% CI=4.5--5.7), 4.5 days mental health not good (95% CI=3.9--5.1), and 3.6 days health prevented usual activities (95% CI=3.1--4.1).

Among people who described their health as poor, people with disabilities reported an average of 23.7 days physical health not good (95% CI=22.6--24.8), 11.1 days mental health not good (95% CI=10.0--12.3), and 18.3 days health prevented usual activities (95% CI=17.2--19.5). People without disabilities reported an average of 15.3 days physical health not good (95% CI=13.0--17.6), 6.3 days mental health not good (95% CI=4.5--8.1), and 9.6 days health prevented usual activities (95% CI=7.4--11.8).

Healthy Days Summary Index

A healthy days summary index was calculated by subtracting the summary index of unhealthy days (combined responses to the physical health and mental health questions with a maximum range of 30 unhealthy days) from a total of 30 days. People with disabilities reported fewer healthy days overall than people without disabilities. The mean number of healthy days for people with disabilities was 16.71 (95% CI=16.22—17.21). In comparison, the mean number of healthy days for people without disabilities was 26.14 (95% CI=26.01--26.27).

Among people who described their health as excellent, people with disabilities reported an average of 22.78 healthy days (95% CI=20.74--24.82). People without disabilities reported an average of 27.87 healthy days (95% CI=27.68--28.06). Among people who described their health as very good, people with disabilities reported an average of 22.77 healthy days (95% CI=21.94--23.60). People without disabilities reported an average of 26.70 healthy days (95% CI=26.51--26.89). Among people who described their health as good, people with disabilities reported an average of 20.45 healthy days (95% CI=19.64--21.25). People without disabilities reported an average of 25.39 healthy days (95% CI=25.13--25.66).

Among people who described their health as fair, people with disabilities reported an average of 14.26 healthy days (95% CI=13.36--15.17). People without disabilities reported an average of 21.47 healthy days (95% CI=20.76--22.18). Among people who described their health as poor, people with disabilities reported an average of 4.45 healthy days (95% CI=3.42--5.48). People without disabilities reported an average of 12.70 healthy days (95% CI=10.28--15.12).

CONCLUSIONS

BRFSS limitations include bias introduced by relying on telephone interviews (excluding households without telephones, individuals with hearing, speech, cognitive, or other communication impairments or who are institutionalized)10 and the exclusion of persons <18 years. Since the sampling frame is only 14 states and DC, caution should be used in generalizing the results to the U.S. population.

These preliminary results indicate that people with disabilities report an overall lower health status compared to people without disabilities. People with disabilities also report more days of poor physical and mental health and more days when poor health prevented usual activities than people without disabilities. Using the healthy days summary index, people with disabilities had fewer healthy days compared to people without disabilities. Interestingly, people with disabilities report more unhealthy days and fewer healthy days than people without disabilities in the same health status category. The differences between people with and without disabilities in the same health status categories suggests that people with disabilities consider additional factors in evaluating their health status. Additional research is needed to determine the factors and assess their impact on health status.

IMPLICATIONS

Research:

1. Additional research is needed to determine the factors that contribute to people with disabilities’ alternative definitions of health.

2. Research needs to be extended using all fifty states and territories as the sample.

3. Comparisons by minority status and different definitions of disability need to be conducted.

Policy:

1. CDC may wish to develop a disability module with a number of questions, rather than just having disability identifiers in the core BRFSS, to provide sufficient data regarding the health of people with disabilities.

2. The concepts of burden of disease and, or burden of disability may need to be reevaluated given the prospect that people with disabilities may be defining quality of health more broadly than typical public health approaches.

Training/Intervention:

1. If people with disabilities define health differently than people without disabilities, generic health promotion programs may not be applicable to people with disabilities.

2. Alternatively, if people with disabilities define health differently than people without disabilities, health promotion programs will need to account for these differences.

3. What implications do your research or training project findings have for changes in concepts of health and disability?

4. The concept of health appears to be interpreted more broadly among people with disabilities. Therefore, concepts of health and disability may need to consider other factors besides issues of poor physical or mental health.

References

U.S. Department of Health and Human Services. (2000). Healthy people 2010: With understanding and improving health and objectives for improving health (2nd ed., Vols 1 - 2). Washington, DC: U.S. Government Printing Office.

U.S. Census Bureau. (2000). Statistical abstract of the United States: 2000 (120th ed.). Washington, DC: U.S. Government Printing Office.

Pitetti, K.H. & Campbell, K.D. (1991). Mentally retarded individuals: A population at risk? Medicine and Science in Sports and Exercise, 23(5). 586 – 593.

Center, J., Beange, H., & McElduff, A. (1998). People with mental retardation have an increased prevalence of osteoporosis: A population study. American Journal on Mental Retardation, 103(1). 19 – 28.

Gleeson, J. (1999). On the right road: Public health in Sweden. Nursing Times, 95(3). 20 – 26.
Marrone, J. & Golowka, E. (1999). Speaking out: If work makes people with mental illness sick, what do unemployment, poverty, and social isolation cause? Psychiatric Rehabilitation Journal, 23(2). 187 – 193.

McGinnis, J.M., Williams-Russo, P., & Knickman, J.R. (2002). The case for more active policy attention to health promotion. Health Affairs, 21(2).

Centers for Disease Control and Prevention. Meassuring Helathy Days. Atlanta, Georgia: CDC, November 2000.

Ibid.

Hough, J. B. (1999) Surveillance and outcome measurement systems for monitoring disabilities. In R.J. Simeonsson and D.B. Bailey (Eds.), Issues in disability and health: The role of secondary conditions and quality of life. Chapel Hill, NC: University of North Carolina, Frank Porter Graham Child Development Center, pp. 95-128.

Resources:

Behavioral Risk Factor Surveillance System Project- Health Status & Disability, a presentation by Charles Drum, PhD and Willi Horner-Johnson, PhD at the "Changing Concepts of Health and Disability" Science Conference in 2003

BRFSS Health Behaviors and Outcomes Project, a presentation by Willi Horner-Johnson, PhD and Charles Drum, JD, PhD.

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