Americans with disabilities are an often overlooked population experiencing health disparities, with women facing greater disability-related health disparities than men [1-3]. Although the presence of disparities between individuals with disability and those without disability is clear, inconsistent definitions of disability across research studies and government agencies have hampered progress towards a fuller understanding of the factors underlying these disparities, and how to best address them to promote health equality in this population .
In 2003 the Interagency Committee on Disability Research found the United States government had 67 different definitions of disability . Most disability definitions fall into one of three conceptual categories: medical (based on medical diagnoses), social (defines disability as a predominantly social construct arising from environmental barriers) and functional (defines disability as the inability to complete certain life tasks . Each of the definitions has utility for specific research projects, but the lack of a standard definition makes it impossible to compare data across studies.
Additionally, studies which use the functional definition are often too broad to identify health issues unique to groups with specific medical diagnoses, whereas medical definitions may miss individuals with significant impairments who lack a medical diagnosis. The Centers for Disease Control and Prevention (CDC), as well as the World Health Organization, have adopted the functional definition of disability. The CDC utilizes the Behavioral Risk Surveillance System (BRFSS) as their primary source of data on disability, estimating that 1 in 5 Americans experience disability, with mobility and cognitive disabilities as the most common .
Racial and ethnic minorities, as well as those unemployed or living in poverty, have higher rates of disability . Nationwide women are more likely than men to experience disability at all ages, with 24.4% of women reporting a functional disability compared to 19.8% of men .
Among women, those with disabilities are less likely to receive routine preventive health care such as cervical cancer screening, mammography and dental care [1, 6]. While women with and without disability are equally likely to desire pregnancy, once pregnant, women with disabilities may experience barriers to accessing health care, may be less likely to receive adequate prenatal care, and may face criticism and judgement from those who dis-approve of their pregnancy [7, 8]. Pregnant women with disability may be at risk for stillbirth, preterm birth, low birthweight babies, fetal growth restriction, and cesarean delivery, although risks vary by type of disability .
Three national surveys include questions about disabilities: BRFSS, the American Community Survey, and the National Health Interview Survey. All three surveys use a functional definition; however, the methodology and number of questions vary by survey. Despite standardized questions in each of the three surveys, disability prevalence in 2013 varied by survey . The 2013-2015 BRFSS survey, which we utilized in this data snapshot, contained questions on five categories of disability: cognitive, mobility, vision, self-care and independent living (see appendix for the list of questions). BRFSS data was utilized because information about health care utilization and outcomes were also available in this dataset. The statistics reported below are compiled from BRFSS data using the Disability and Health Data System.
Utah has lower rates of overall disability compared to the United States (19.0% vs 22.5%), as well as lower levels of disability in each of the five categories . County-level data for Utah shows the highest rates of disability (for people of all ages and genders) in Carbon, Emery, San Juan and Piute counties . According to 2006 data (the most current year of publicly-available expenditures data) Utah spent less on disability-associated health-care than any other state; the per person expenditure for Utah was estimated at $1,443 com-pared to $2,190 for the nation .
As in the rest of the United States, mobility disabilities were the most common type in Utah, with a prevalence of 10.1% (compared to 13.1% nationally). Disability rates for all reported racial and ethnic minorities in Utah were higher than for whites. Most strikingly, disability was 17.9% among whites compared to 32.2% among American Indian/Alaskan Natives. Utah veterans also had higher rates of disabilities than non-veterans (22.8% vs. 18.8%) .
Women in Utah have higher rates of disability overall (21.8%) compared to men (16.0%).
Figure one shows the breakdown of disability by category for Utah women and men.
There are pronounced disparities in health care utilization and health outcomes for women with disabilities in Utah (Figure Two). The largest difference is in the proportion of women with Self-Reported Fair or Poor Health; only 6.5% of women without disabilities fit this category compared to 36.8% percent of women with disabilities.
Between 2013 and 2014, most of the factors displayed in Figure Two were stable. However, although there were minimal changes in the proportion of women without disability who were obese between 2013 and 2014, the percentage of women with disability who were obese increased from 33.5% in 2013 to 41.4% in 2014. This increase highlights a unique risk factor for Utah women with disabilities, and presents a possible key point for future public health interventions.
Seven Domains of Health
Creating an environment in the state of Utah which is supportive of women with disabilities is a crucial aspect of addressing the multi-faceted model of wellness. As showing in Figure Two, Utah women with disabilities are experiencing markedly lower levels of physical wellness than their counterparts, but the disparities do not end with their physical well-being. Studies have shown that people with any type of disability are 1.7 times as likely to report inadequate emotional support than those without a disability  and as borne out in the Utah data, women with disabilities are almost five times as likely to have 14+ days of poor mental health than women without disabilities. Some women with disabilities may face discrimination and stigma because of their impairment , which leads to difficulties in creating the robust social network needed for optimal health and can also impact a woman’s spiritual health.
The financial well-being of women with disabilities is another area of concern for overall health, as people with disabilities are much more likely to live in poverty and be unemployed . People with disabilities are less than half as likely to attend college, which can impact their intellectual heath . Many of the disparities in these domains of health are not the consequence of the person’s impairment alone, but are exacerbated by deficiencies in the individual’s environment. Despite government actions to require physical accommodations, many areas of public life are still not accessible to those with physical limitations.
One recent survey of 2400 health care facilities in California found only a small fraction of offices were accessible— only 3.6% of offices had a scale that could accommodate those with physical disabilities, and only 8.4% had exam tables with adjustable heights . For individuals with intellectual disabilities, they can find themselves in a healthcare environment where their provider excludes them from decisions on their care, or does not properly understand how to share health information with them .
Actions, Resources and Recommendations
There are many changes Utah could make to improve the health of people with disabilities. Two key areas, which are promoted by Healthy People 2020, are: 1) Increase the quality of disability health data, and 2) increase the use of evidence-based health/wellness programs for people with disabilities .
In addition to continuing to collect population-level data on functional disability, Utah should promote the exploration of how functional disability and medical conditions overlap to produce disparities, particularly for women and racial/ethnic minorities. The Utah Population Database (UPDB) is uniquely suited to fill this research gap. The UPDB condition-specific data would be particularly useful to women’s health providers in Utah, as pregnancy in women with disability is understudied.
Utah could also expand the use of evidence-based health and wellness programs for women with disabilities, particularly those suffering from obesity. Utah currently has a wide-range of services available for people with disabilities available through the Utah Department of Human Services. Unfortunately, these services only reach a small proportion of those who need them. In 2016, 5,559 people with disabilities received services, with an additional 2,510 individuals on a wait list due to limited state funding. On average, those who received services waited 5.73 years . Despite having a higher prevalence of disability, women were less likely to receive services than men, with only 38.6% of state-funded services going to women. Attention to the unique needs of women, as well as additional state funding, are needed to promote health equality for Utah women with disability.
- Iezzoni, L.I., Stigma and Persons with Disabilities, in Stigma and Prejudice. 2016, Springer. p. 3-21.
- McDermott, S. and M.A. Turk, The myth and reality of disability prevalence: measuring disability for research and service. Disabil Health J, 2011. 4(1): p. 1-5.
- Krahn, G.L., L. Hammond, and A. Turner, A cascade of disparities: Health and health care access for people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 2006. 12(1): p. 70-82.
- Krahn, G.L., D.K. Walker, and R. Correa-De-Araujo, Persons with disabilities as an unrecognized health disparity population. American journal of public health, 2015. 105 Suppl 2: p. S198.
- Courtney-Long, E.A., et al., Prevalence of Disability and Disability Type Among Adults–United States, 2013. MMWR Morb Mortal Wkly Rep, 2015. 64(29): p. 777-83.
- Mitra, M., et al., Maternal Characteristics, Pregnancy Complications, and Adverse Birth Outcomes Among Women With Disabilities. Med Care, 2015. 53(12): p. 1027-32.
- Iezzoni, L.I., et al., Physical Accessibility of Routine Prenatal Care for Women with Mobility Disability. J Womens Health (Larchmt), 2015. 24(12): p. 1006-12.
- Iezzoni, L.I., et al., “How did that happen?” Public responses to women with mobility disability during pregnancy. Disabil Health J, 2015. 8(3): p. 380-7.
- Morton, C., et al., Pregnancy outcomes of women with physical disabilities: a matched cohort study. PM&R, 2013. 5(2): p. 90-8.
- Courtney-Long, E.A., et al. A Comparison of Disability Prevalence Estimates Across Three Federal Population-Based Surveys 2015; Available from: https://ww2.amstat.org/meetings/jsm/2015/onlinepro gram/AbstractDetails.cfm?abstractid=316947.
- Centers for Disease Control and Prevention. Disability and Health Data System (DHDS). June 1 2016 [cited 2017 May 5]; Available from: http://dhds.cdc.gov/.
- Community Commons. Community Health Needs Assessment: Utah Statewide Disability Report. [cited 2017 May 9]; Available from: http://www.communitycommons.org/.
- Anderson, W.L., et al., Estimates of State-Level Health-Care Expenditures Associated with Disability. Public Health Reports, 2010. 125(1): p. 44-51.
- Havercamp, S.M. and H.M. Scott, National health surveillance of adults with disabilities, adults with intellectual and developmental disabilities, and adults with no disabilities. Disabil Health J, 2015. 8(2): p. 165-72
- Mudrick, N.R., et al., Physical accessibility in primary health care settings: Results from California on-site reviews. Disability and Health journal, 2012. 5(3): p. 159-167.
- Healthy People2020. Disability and Health. [cited 2017 5/30/2017]; Available from: https://www.healthy people.gov/2020/topics-objectives/topic/disability-and-health?topicid=9https://www.healthypeople.gov/2020/topics-objectives/topic/disability-and-health?topicid=9.
- DSPD. Annual Report 2016 Division of Services for People With Disabilities. 2016; Available from: https://dspd.utah.gov/pdf/AR_Final_Draft2016.pdf.
The five BRFSS questions on disability which were included in the 2013, 2014 and 2015 surveys are as follows:
- Cogitive: Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
- Mobility: Do you have serious difficulty walking or climbing stairs?
- Vision: Are you blind, or do you have serious difficulty seeing, even when wearing glasses?
- Self-care: Do you have difficulty dressing or bathing?
- Independent living: Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
Baayd J, Clark L, Willis S, & Simonsen SE. (2019). Women with Disabilities: An Important Health Disparity Population. Utah Women’s Health Review. doi: 10.26054/0K5ME66CA2.