The Contribution of Health Literacy to Disparities in Self-Rated Health Status and Preventive Health Behaviors in Older Adults

PURPOSE Health literacy is associated with a range of poor health-related outcomes. Evidence that health literacy contributes to disparities in health is minimal and based on brief screening instruments that have limited ability to assess health literacy. The purpose of this study was to assess whether health literacy contributes, through mediation, to racial/ethnic and education-related disparities in self-rated health status and preventive health behaviors among older adults.METHODS We undertook a cross-sectional study of a nationally representative sample of 2,668 US adults aged 65 years and older from the 2003 National Assessment of Adult Literacy. Multiple regression analysis was used to assess for evidence of mediation.RESULTS Of older adults in the United States, 29% reported fair or poor health status, and 27% to 39% reported not utilizing 3 recommended preventive health care services in the year preceding the assessment (influenza vaccination 27%, mammography 34%, dental checkup 39%). Health literacy and the 4 health outcomes (self-rated health status and utilization of the 3 preventive health care services) varied by race/ethnicity and educational attainment. Regression analyses indicated that, after controlling for potential confounders, health literacy significantly mediated both racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination, but only education-related disparities in receipt of mammography and dental care.CONCLUSIONS Health literacy contributes to disparities associated with race/ethnicity and educational attainment in self-rated health and some preventive health behaviors among older adults. Interventions addressing low health literacy may reduce these disparities.     

AIDS and palliative care in South Africa

As a result of limited access to antiretroviral treatment, many South Africans die yearly of AIDS. It is important that the end-of-life needs of these people be met. This article examines the major challenges involved in providing quality end-of-life care to people with AIDS in South Africa. Published reports are reviewed, as is the author's experience living and working in KwaZulu-Natal, South Africa. The issues discussed include the nature of the South African health care system, with emphasis on the scarcity of palliative care resources for AIDS patients, ineffective control of pain, models of care such as the integrated community-based home care model that relies heavily on community caregivers to meet the needs of people dying of AIDS, the living conditions of AIDS patients and their families, and AIDS-related stigma. Broad recommendations are presented for improving palliative care services for people with AIDS in the South African context.     

Food security and health in transition to adulthood for individuals with disabilities

BackgroundDue to a more stringent disability definition used for eligibility redetermination at age 18, individuals with disabilities may lose eligibility for the Supplement and Nutrition Assistance Program (SNAP).ObjectiveThis study examines how the transition to adulthood may affect the association between food security and self-rated health and healthcare needs for individuals with disabilities.MethodsThe study uses five years of data (2011–2015) from the National Health Interview Survey (NHIS). One health indicator, self-rated health status, and two indicators of unmet healthcare needs, delayed medical care and not receiving medical care due to cost, are analyzed as dependent variables. The effects of food security status on health and health-related outcomes are closely examined for the four groups: youth without disabilities, youth with disabilities, young adults without disabilities and young adults with disabilities.ResultsResults indicate a statistically significant association between food security status and self-rated health and unmet healthcare needs in late childhood and young adulthood. Such association is stronger for young adults than for youth. The association between low food security and self-rated health and health-related outcomes does not significantly differ between the two youth groups or the two young adult groups by disability status.ConclusionsSuggestions for improving accessibility of public food and nutrition programs are discussed. The study also suggests the importance of creating a healthcare system that benefits every member of the society.     

Impact of COVID-19: Nursing challenges to meeting the care needs of people with developmental disabilities

BackgroundPeople with developmental disabilities (DD) are a population at high-risk for poor outcomes related to COVID-19. COVID-19-specific risks, including greater comorbidities and congregate living situations in persons with DD compound existing health disparities. With their expertise in care of persons with DD and understanding of basic principles of infection control, DD nurses are well-prepared to advocate for the needs of people with DD during the COVID-19 pandemic.ObjectiveTo assess the challenges faced by nurses caring for persons with DD during the COVID-19 pandemic and how the challenges impact people with DD.MethodsWe surveyed 556 DD nurses, from April 6–20, 2020. The 35-item mixed-method survey asked nurses to rate the degree of challenges faced in meeting the care needs of people with DD. We analyzed responses based on presence of COVID-19 in the care setting and geographically. One open-ended question elicited challenges not included in the survey, which we analyzed using manifest content analysis.ResultsStartlingly, nurses reported being excluded from COVID-19 planning, and an absence of public health guidelines specific to persons with DD, despite their high-risk status. Obtaining PPE and sanitizers and meeting social-behavioral care needs were the most highly ranked challenges. COVID-19 impacted nurses’ ability to maintain adequate staffing and perform essential aspects of care. No significant geographic differences were noted.ConclusionsDD nurses must be involved in public health planning and policy development to ensure that basic care needs of persons with DD are met, and the disproportionate burden of COVID-19 in this vulnerable population is reduced.     

Therapy use for U.S. school-aged children with developmental disabilities: State variation and determinants

BackgroundTherapy services can support developmental needs, improve social emotional outcomes, and reduce persistent health inequities for children with developmental disabilities (DD). Receipt of therapy services may be especially timely when children with DD are school-aged, once diagnosis has often occurred. Yet limited knowledge exists on geographic variability and determinants of therapy use among school-aged U.S. children with DD.ObjectivesWe aimed to (1) determine if therapy use varies significantly by state and (2) examine associations of health determinants with therapy use among U.S. school-aged children with DD.MethodsThis was a secondary analysis of 2016 and 2017 National Survey of Children's Health data. The sample included 9984 children with DD ages 6–17 years. We obtained odds ratios and predicted margins with 95% confidence intervals from multilevel logistic regression models to examine therapy use variation and determinants.ResultsOverall, 34.6% of children used therapy services. Therapy use varied significantly across states ($\sigma$² = 0.11, SE = 0.04). Younger age, public insurance, functional limitations, individualized education program, frustration accessing services, and care coordination need were associated with higher adjusted odds of therapy access. In states with Medicaid Home and Community-Based Services waivers, higher estimated annual waiver cost was associated with lower adjusted odds of therapy use.ConclusionsResults highlight geographic disparities in therapy use and multilevel targets to increase therapy use for school-aged children with DD.     

Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain

ObjectiveTo measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence.MethodWe analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage.ResultsThe probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities.ConclusionsDeveloping specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain.     

Disparities in Health Care Access and Receipt of Preventive Services by Disability Type: Analysis of the Medical Expenditure Panel Survey

ObjectiveTo examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities.ConclusionsThere are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups.     

Racial/ethnic health disparities among children with special health care needs in Boston,Massachusetts

BackgroundLittle is known about the factors that contribute to racial/ethnic disparities among children with special health care needs (CSHCN).ObjectiveTo quantify the contributions of determinants of racial/ethnic disparities in health and health care among CSHCN in Boston, Massachusetts.MethodsA sample of 326 Black, Latino, and white CSHCN was drawn from the Boston Survey of Children's Health, a city-wide representative sample of children. The study implemented Oaxaca–Blinder-style decomposition techniques to examine the relative contributions of health resources and child-, family-, and neighborhood-level factors to disparities in four outcomes: health status, barriers to medical care, oral health status, and utilization of preventive dental care.ResultsWhite CSHCN had a greater likelihood of having very good/excellent health and oral health and were less likely to experience barriers to care than Black CSHCN. Compositional differences on predictors explained 63%, 98%, and 80% of these gradients, respectively. Group variation in household income, family structure, neighborhood support, and exposure to adverse childhood experiences accounted for significant portions of the Black–white gaps in health and access. White CSHCN were also more likely to have very good/excellent health and oral health compared to Latino CSHCN. Differences on predictors accounted for about 86% and 80% of these gaps, respectively. Household income, adverse childhood experiences, and household language emerged as significant determinants of Latino–white disparities.ConclusionsRacial/ethnic health disparities among CSHCN are explained by relatively few determinants. Several of the contributing factors that emerged from the analysis and could be targeted by public health and policy interventions.     

Learning your ABDs: Variation in health care utilization across Kansas Medicaid disability groups

BackgroundState Medicaid programs provide critical health care access for persons with disabilities and older adults. Aged, Blind and Disabled (ABD) programs consist of important disability subgroups that Medicaid programs are not able to readily distinguish.Objective/hypothesisThe purpose of this project was to create an algorithm based principally on eligibility and claims data to distinguish disability subgroups and characterize differences in demographic characteristics, disease burden, and health care expenditures.MethodsWe created an algorithm to distinguish Kansas Medicaid enrollees as adults with intellectual or developmental delays (IDD), physical disabilities (PD), severe mental illness (SMI), and older age.ResultsFor fiscal year 2009, our algorithm separated 101,464 ABD enrollees into the following disability subgroups: persons with IDD (19.6%), persons with PD (21.0%), older adults (19.7%), persons with SMI (32.8%), and persons not otherwise classified (6.9%). The disease burden present in the IDD, PD, and SMI subgroups was higher than for older adults. Home- and community-based services expenditures were common and highest for persons with IDD and PD. Older adults and persons with SMI had their highest expenditures for long-term care. Mean Medicaid expenditures were consistently higher for adults with IDD followed by adults with PD.ConclusionsThere are substantial differences between disability subgroups in the Kansas Medicaid ABD population with respect to demographics, disease burden, and health care expenditures. Through this algorithm, state Medicaid programs have the opportunity to collaborate with the most closely aligned service providers reflecting needed services for each disability subgroup.     

Underserved Farmers With Disabilities: Designing an AgrAbility Program to Address Health Disparities

ABSTRACT

Awareness of health disparities is crucial for individuals with disabilities to minimize additional health-related challenges. Adding rural residence and age to disability creates a triple threat in terms of potential health disparities. Kentucky AgrAbility is developing innovative new partnerships with the goal of expanding service provision to underserved populations with disabilities in Kentucky: women, minority, and Appalachian small farmers. Kentucky AgrAbility is evolving to include a more focused approach to the needs of underresourced and underserved regions and populations of farmers in Kentucky. Through new partnerships and a commitment to addressing potential health disparities, farmers and families who can benefit from AgrAbility services will be broadly identified. It is concluded that health disparities need to be recognized and addressed in all health care service provision and education. Kentucky AgrAbility is attempting to develop and implement an innovative, multidisciplinary team of partners with a goal of providing one of a kind service and education to all Kentucky farmers with disabilities. This includes underserved farmers who are at risk of not receiving the appropriate services due to limited resources and lack of awareness.     

Health disparities among adults with developmental disabilities, adults with other disabilities, and adults not reporting disability in North Carolina

OBJECTIVES: The purposes of this study were (1) to identify disparities between adults with developmental disabilities and non-disabled adults in health and medical care, and (2) to compare this pattern of disparities to the pattern of disparities between adults with other disabilities and adults without disabilities. METHODS: The authors compared data on health status, health risk behaviors, chronic health conditions, and utilization of medical care across three groups of adults: No Disability, Disability, and Developmental Disability. Data sources were the 2001 North Carolina Behavioral Risk Factor Surveillance System and the North Carolina National Core Indicators survey. RESULTS: Adults with developmental disabilities were more likely to lead sedentary lifestyles and seven times as likely to report inadequate emotional support, compared with adults without disabilities. Adults with disabilities and developmental disabilities were significantly more likely to report being in fair or poor health than adults without disabilities. Similar rates of tobacco use and overweight/obesity were reported. Adults with developmental disabilities had a similar or greater risk of having four of five chronic health conditions compared with non-disabled adults. Significant medical care utilization disparities were found for breast and cervical cancer screening as well as for oral health care. Adults with developmental disabilities presented a unique risk for inadequate emotional support and low utilization of breast and cervical cancer screenings. CONCLUSIONS: Significant disparities in health and medical care utilization were found for adults with developmental disabilities relative to non-disabled adults. The National Core Indicators protocol offers a sound methodology to gather much-needed surveillance information on the health status, health risk behaviors, and medical care utilization of adults with developmental disabilities. Health promotion efforts must be specifically designed for this population.     

Environmental barriers and supports to the health, function, and participation of people with developmental and intellectual disabilities: report from the State of the Science in Aging with Developmental Disabilities Conference

BackgroundThis article summarizes the proceedings of the Environmental Barriers and Supports to Health, Function and Participation Work Group that was part of the “State of the Science in Aging with Developmental Disabilities: Charting Lifespan Trajectories and Supportive Environments for Healthy Living” symposium. The aim was to provide a research and policy agenda targeting the assessment and evaluation of environmental factors influencing the health, function, and participation of people with developmental and intellectual disabilities (I/DD).MethodsKey environmental areas addressed were (1) the built environment including homes and communities; (2) assistive and information technology design and use; (3) social environment factors and interventions; and (4) environmental access and participation policies, legislation, and system change implications.ResultsThe group identified gaps in knowledge and priorities for future research, including (1) multivariate analyses of attributes of the built environment; (2) large-scale intervention trials of assistive and information technology use with people with cognitive disabilities; (3) development and testing of social, peer-mentoring, and self-management interventions as applied to people with I/DD; (4) incorporation of environmental health research methodologies, such as GIS mapping into I/DD research; (5) participatory action approaches that actively include people with I/DD in the research process; and (6) rigorous examination of the impact of legislative and policy initiatives related to least restrictive community living and participation with people with I/DD.ConclusionFuture research and policy initiatives should focus on examining how the environment (build, technological, social, and system level) influence community living and participation of people with intellectual disabilities.     

Do Children with Developmental Disabilities and Mental Health Conditions have Greater Difficulty Using Health Services than Children with Physical Disorders?

The objective of this study is to determine whether achievement of the Maternal and Child Health Bureau core outcome ease of use of health services differs between children with developmental disabilities, mental health conditions and physical disorders. We analyzed data from the 2005 National Survey of Children with Special Health Care Needs. Children with special health care needs were classified into 4 health condition groups: developmental disabilities (DD), mental health conditions (MH), physical disorders (PD) and multiple conditions. The outcome measure was ‘difficulty using services’. We conducted bivariate and multivariate analyses to determine the associations between the health condition groups and the outcome. Of the CSHCN included in the study, 2.6% had DD, 12.9% had MH, 49.9% had PD and 34.6% belonged to multiple conditions group. Four percent of CSHCN with PD, 17% of those with DD, 13% of those with MH and 20% of those in the multiple conditions group had difficulty using services. In multivariate analyses, CSHCN with DD had 2.3 times and MH conditions had 2.6 times the odds of having difficulty using services compared to those with PD. Existing programs for CSHCN should be evaluated for the adequacy of services provided to children with DD and MH. Future studies should evaluate how developmental disabilities and mental health policies affect navigating the health care system for this population.     

Report of the state of the science in aging with developmental disabilities: charting lifespan trajectories and supportive environments for healthy community living symposium

BackgroundThis paper is an introduction to four papers that present the findings of the 2007 “State of the Science in Aging with Developmental Disabilities: Charting Lifespan Trajectories and Supportive Environments for Healthy Community Living” symposium. The overall goal of this symposium was to increase our understanding and improve the health, psychosocial well-being, and community participation of adults with intellectual and developmental disabilities over their life course.MethodsThe symposium consisted of four main tracks: (1) neurodevelopmental conditions; (2) health care services, health promotion needs, and health literacy; (3) family support and intergenerational caregiving; and (4) environmental barriers and supports to community living.Results/ConclusionsRecommendations offer a research agenda that would increase our knowledge on the life span trajectory for individuals with intellectual and developmental disabilities and on methods for developing and assessing effectiveness of practices and policies on individuals with intellectual and developmental disabilities, their families, and their other service providers.     

Health care needs of community-dwelling older adults

OBJECTIVE: To identify, assess, and rank the importance of health care needs of community-dwelling older adults. METHOD: A structured telephone interview with 107 respondents (physicians, direct service providers and administrators) about the importance of a list of 31 health care needs of older adults. Respondents also identified the single most important health issue facing local older adults now and in the next 5 to 10 years. RESULTS: The five most important health care needs, in descending order, are: care-giver support services, community long-term care services, services for people with dementia/Alzheimer's disease, palliative/end-of-life care, and services for cancer patients and their families. Community long-term care services were identified as the single most important health issue both now and in the next 5 to 10 years. CONCLUSION: The study findings should be of value to health and social service researchers, planners, providers and administrators regarding the needs of community-dwelling older adults.     

Changes in health insurance coverage and health care access as teens with disabilities transition to adulthood

BackgroundPre-ACA, less than 6% of children with disabilities were uninsured, compared with more than 42% of young adults with disabilities ages 19–25. Individuals with disabilities face greater barriers to health care access upon transition into adulthood.ObjectivesWe examined whether the ACA dependent coverage provision and Medicaid expansion improved the transition from pediatric to adult healthcare systems by reducing the gap in insurance coverage and access to care between teens and young adults with disabilities.MethodsUsing cross-sectional data from the 2006–2009 and 2011–2015 National Health Interview Survey (n = 10,136), we estimate the change in insurance coverage and access to care from pre-to post-ACA time periods for teens (ages 13–18) and young adults (ages 19–25) with disabilities in a difference-in-differences model. We completed the same analyses for these groups in Medicaid expansion and non-expansion states.ResultsBoth teens and young adults with disabilities made significant gains in insurance coverage (4.55 and 8.96% point gains respectively, p < .001) and access to care (4.01 and 3.14% points decline in delayed care due to cost, p < .05) under the dependent coverage provision and Medicaid expansion.ConclusionsMedicaid expansion had a greater impact on both insurance coverage and on access to care than did the dependent coverage provision. The benefits of these changes flowed primarily to young adults with disabilities, reducing the gaps in insurance coverage between teens and young adults, and expanding access to care for both groups, providing a more seamless transition from pediatric to adult health care systems, post-ACA.     

Cost disparities in lung cancer treatment by disability status,sex, and race

BackgroundThe recent literature contains numerous reports of disparities in the diagnosis, treatment, and outcomes of lung cancer across a growing list of population subgroups, including disability status. A common assumption is that disparities stem mainly from variations in the level and type of treatment resources available to specific subgroups. Few studies, however, have directly measured resource differentials. Since policy makers identify reducing health disparities as a critical priority, this study examined whether cumulative Medicare costs (resource consumption) for lung cancer treatment differ across eight patient subgroups defined by disability status, sex, and race.HypothesisTreatment disparities across the eight subgroups will be reflected in variations in the cumulative cost profiles of those subgroups, controlling for other plausible cost drivers. Failure to detect statistically significant differentials in these cost profiles implies that treatment disparities stem from factors other than access to, and utilization of, health care services.MethodsLinked SEER-Medicare data were used to construct cost profiles by service type and treatment phase for roughly 80,000 incident lung cancer cases in patients aged 45 to 85 years at diagnosis. Multiple regression models then tested for cost differentials across the eight subgroups, controlling for various patient and disease characteristics.ResultsSignificant cost differentials were detected, some unanticipated. Women tended to have higher treatment costs than men; they also had more favorable survivals. Nonwhites also tended to have higher treatment costs than whites, although they had significantly shorter survivals. On average, men with disabilities consumed the fewest treatment resources and had the shortest survivals. Mixed results were obtained for women with disabilities.ConclusionsAmong others, the findings suggest that reducing disparities will take more than just improving access to health care. Special attention must be paid to lung cancer patients with disabilities by both policy makers and clinicians.     

Disparities in service utilization and expenditures for individuals with developmental disabilities

BackgroundThe factors that affect access to services for individuals with developmental disabilities (DD) have not received much attention.MethodsThis study examined service utilization and expenditures provided by regional centers to individuals with DD living at home and in residential settings in California in 2004–2005. Logistic regressions of secondary data were used to predict the receipt of services, and ordinary least squares regressions were used to examine the predictors of service expenditures.ResultsOf the 175,595 individuals assessed with DD, 21% did not receive any purchased services from regional centers in 2004–2005. Controlling for client needs, individuals aged 3–21 years were less likely than other age groups to receive services. All racial and ethnic minority groups were less likely to receive any services than were whites. The supply of intermediate care facilities for habilitation and residential care reduced the likelihood of receiving regional center services. Of those who received services, younger individuals and all racial and ethnic minority groups had significantly lower expenditures. Provider supply, area population characteristics, and regional centers also predicted variation in service use and expenditures.ConclusionThe disparities by age, race/ethnicity, and geographic area require further study, and specific approaches are needed to ensure equity in access to services.     

Caregiving in the shadows: National analysis of health outcomes and intensity and duration of care among those who care for people with mental illness and for people with developmental disabilities

BackgroundThe health impacts of caring for people with mental illness (MI) and developmental disabilities (DD) are not well understood.ObjectiveThe present study explored whether health outcomes differed between MI and DD caregivers, and if intensity and duration of care moderated health outcomes.MethodsNationally representative 2016 Behavioral Risk Factor Surveillance System survey data were used to explore how caring for people with MI (n = 1071) and DD (n = 888) impacted general health status and physical and mental health days, and whether intensity and duration of care moderated health outcomes. Logistic regression models and cumulative logistic regression models were used to model health outcomes.ResultsCaregivers had worse health (p = 0.0001) and more poor physical (p < 0.0001) and mental health days (p < 0.0001) than non-caregivers. Relative to DD caregivers, MI caregivers had worse health status (p = 0.02) and more poor physical (p = 0.02) and mental (p = 0.003) health days. As intensity of care increased, MI caregivers had more poor physical health days (p = 0.04) than DD caregivers and as duration of care increased, MI caregivers had worse health status (p = 0.03) than DD caregivers.ConclusionsAlthough the care provided to adults with DD was more intense and for a longer duration, MI caregivers had poorer health outcomes and were more impacted by intensity and duration of care. Implications for supporting MI and DD caregivers are discussed.     

Disparities in health care access for women with disabilities in the United States from the 2006 National Health Interview Survey

BackgroundThe objective of this study was to determine the relationship between disability, gender and access to health care, especially for women with disabilities compared to women without disabilities and men with disabilities.MethodsData from the 2006 NHIS were examined using chi square, linear regression, and logistic analysis to determine the relationship between health care access, severity of disability, and gender. Responses regarding functional limitations from adults aged 18 and over or their proxies were used to determine placement for analysis. The dependent variable was access to health care. The independent variables were disability and gender.ResultsWomen with disabilities had less access to health care than women without disabilities and men with disabilities. Disability and gender were predictive of lack of access to health care. Those who are disabled are 2.26 to 3.78 times more likely to not to have access to health care, and women were 1.26 times more likely not to have access to health care.ConclusionHealth care professionals should advocate for more parity in health care access, removal of barriers and policies to provide needed funding for health care.