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March 2004, Vol 94, No. 3 | American Journal of Public Health 443-445
© 2004 American Public Health Association

RESEARCH AND PRACTICE

Prevalence of Secondary Conditions Among People With Disabilities

Susan Kinne, PhD, Donald L. Patrick, PhD, MSPH and Debra Lochner Doyle, MS, CGC

Susan Kinne and Donald L. Patrick are with the Center for Disability Policy and Research, University of Washington, Seattle. Debra Lochner Doyle is with the Genetics Services Section, Community and Family Health, Washington State Department of Health, Kent.

Correspondence: Requests for reprints should be sent to Susan Kinne, Center for Disability Policy and Research, 146 N Canal St, #313, Seattle, WA 98103 (e-mail: susaki{at}u.washington.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

We analyzed data from 2075 respondents to the disability supplement of the 2001 Washington State Behavior Risk Factor Surveillance Survey to describe population prevalence of secondary conditions among adults with disabilities. Eighty-seven percent of respondents with disabilities and 49% without disabilities reported at least 1 secondary condition. Adjusted odds ratios for disability for 14 of 16 conditions were positive and significant. The association of disability with substantial disparities in common conditions shows a need for increased access to general and targeted prevention interventions to improve health.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
One in 5 Americans reports disability or limitation in major life activities because of physical, mental, or emotional conditions lasting 6 or more months.1 Disability is increasing as the population ages with chronic conditions and more young people survive birth- and injuryrelated limitations.2 People with disabilities are at risk for "secondary conditions," preventable physical, mental, and social disorders resulting directly or indirectly from an initial disabling condition.3–5 There is agreement that prevention of secondary conditions should be a major component of health promotion for people with disabilities.3,5 What is known about the prevalence of these conditions comes from clinical studies of patients and convenience samples.6,7 This article reports the first effort to collect data on population prevalence and impact of common secondary conditions.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Sixteen telephone survey questions about common secondary conditions were adapted from an existing instrument8 and were piloted in interviews with 98 adults with disabilities. These questions were included in the disability supplement to the 2001 Washington State Behavior Risk Factor Surveillance Survey (BRFSS). The BRFSS is a random-digit–dialed annual telephone survey of the noninstitutionalized population aged 18 years and older.9 The survey interviewed 1 adult in 2075 households using BRFSS methods that gave a 43% response rate.

Persons who met the BRFSS disability criteria were asked whether they had experienced each of 16 secondary conditions in the past 12 months as a result of their primary impairment and, if so, how big of a problem it had been. Persons without disabilities were asked whether they had experienced each of the 16 conditions in the past 12 months and its impact using the same wording without reference to an underlying cause. The sample was weighted by age, gender, and race to represent the state population. Chi-square and logistic regression analyses were run in SUDAAN 75 (Research Triangle Institute, Research Triangle Park, NC) to account for the survey’s multistage stratified sampling.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
One-quarter of sample adults (25.7%; n = 545) met BRFSS criteria for disability, reporting limitations in daily activities or use of special equipment (mobility aids, adapted telephones, etc.). Respondents with disabilities were more likely to be female (56.3% vs 49.3% for no disability; P = .0064), to be older (mean age 52.9 vs 42.1 years), to have incomes below $25 000 (39.0% vs 18.4%), to be divorced or widowed (29.0% vs 13.5%), and to report fair or poor health (38.5% vs 4.9%) (all P < .0000). Respondents were representative of the Washington adult disability population10 in terms of age, gender, ethnicity, and employment but had more education than that population (per the 2000 census).

Eighty-seven percent of those with disabilities reported at least 1 condition they said was a result of their disability, and 49% of persons without limitations reported at least 1 condition (P < .0001). People with disabilities reported more conditions than did those without limitations (mean of 4.02 vs 1.28 conditions per respondent; P < .0001) (data not shown). Only persons responding that a condition posed a "moderate or very big problem" in the last 12 months were counted as reporting that condition (Table 1Go).


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  		TABLE 1—— Rates of Conditions That Are a "Very Big" or "Moderate" Problem in Total Sample and in People With and Without Disabilities
 
The prevalence (12% to 56%) of each of the 16 secondary conditions in the disability group (56% to 12%) was 2 to 3 times higher than among adults without disabilities. Crude odds ratios for disability for each secondary condition were large and uniformly significant (Table 2Go). When adjusted for age, gender, education, income, and health status in a multivariate logistic regression, 14 of 16 odds ratios for disability were significant, ranging from 4.94 for chronic pain to 1.67 for difficulty making and keeping friends. For the 8 most prevalent conditions (pain, weight problems, fatigue, difficulty getting out into the community, falls and injuries, sleep problems, muscle spasms, bowel and bladder problems), having a disability was the strongest predictor of the condition. Age and health status contributed more to having anxiety, depression, social isolation, and asthma than did disability, but disability remained a significant predictor.


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  		TABLE 2—— Crude and Adjusted Odds Ratios of Disability When the Dependent Variable Is "Moderate or Very Big Problem" for Each Condition
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
This is the first population-based prevalence study to show that secondary conditions are common among adults with disabilities. These findings converge with those from the BRFSS Quality of Life module, wherein adults with disabilities are consistently more likely than the nondisabled to report unattributed conditions such as experiencing pain that interferes with activities, feeling sad or depressed, being worried or anxious, or sleeping poorly.11

As with other health promotion, prevention of secondary conditions requires intervening in the complex relationship between individual risk factors and environmental determinants of health and quality of life.12,13 For people with disabilities, access to services and opportunity for equal participation may be as important to their health as medical interventions.4 Population-based health promotion addressing common issues such as obesity, physical activity, and falls should be augmented with targeted approaches to ensure that people with disabilities are reached, have access to services, and can benefit from them.14 Older adults with disabilities—who are particularly vulnerable to secondary depression, anxiety, asthma, and social isolation—are a particular focus of concern.

These findings must be treated with caution. They are self-reported cross-sectional data, subject to the usual limitations on attribution of causality. The survey questions have not been validated in a nondisabled population. The introductions to the questions differed for people with and without disabilities, as respondents with disabilities were asked to attribute conditions to their primary impairment. People may report more limitation when they are asked to attribute it to a specific cause (e.g., injured arm).15 This might contribute to higher rates among people with disabilities, although the BRFSS Quality of Life data suggest that the findings are not an artifact of this attribution. Finally, although there is broad agreement on the importance of secondary conditions to people with disabilities, there is no consensus on definition, or on how to distinguish, for example, whether chronic joint pain is secondary to or the primary cause of a person’s disability. However, the precision of the "secondary" label is less important than the clear health promotion challenge that these data pose: addressing and reducing these substantial disability-related disparities in common and preventable health conditions.14


   Acknowledgments
 
This research was supported by the Centers for Disease Control and Prevention (cooperative agreement U59/CCU006992-06-01).

Human Participant Protection
This study was approved by the institutional review board of the Washington State Department of Health.


   Footnotes
 
Contributors
D. Lochner Doyle conceived the study. S. Kinne conducted the analyses and wrote the paper with D. L. Patrick.

Peer Reviewed

Accepted for publication April 21, 2003.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults—United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50(7):120–125.[Medline]

2. Kaye HS, LaPlante MP, Carlson D, Wenger BL. Trends in Disability Rates in the United States, 1970–1994. San Francisco: University of California, San Francisco, Disability Statistics Rehabilitation Research and Training Center; 1996. Disability Statistics Abstract 17.

3. Simeonsson RJ, Bailey DB, Scandlin D, Huntington GS, Roth M. Disability, health, secondary conditions and quality of life: emerging issues in public health. In: Simeonsson RJ, McDevitt LN, eds. Issues in Disability and Health: The Role of Secondary Conditions and Quality of Life. Chapel Hill: University of North Carolina Press; 1999:51–72.

4. Lollar D. Public Health and disability: emerging trends. Public Health Rep. 2002;117:131–136.[ISI][Medline]

5. Wilber N, Mitra M, Walker DK, Allen D, Meyers AR, Tupper P. Disability as a public health issue: findings and reflections from the Massachusetts Survey of Secondary Conditions. Milbank Q. 2002;80:393–421.[Medline]

6. Seekins T, Clay J, Ravesloot CH. A descriptive study of secondary conditions reported by a population of adults with physical disabilities served by three independent living centers in a rural state. J Rehabil. 1994;60(2):47–51.

7. Arkansas Spinal Cord Commission. Identifying Secondary Conditions in Arkansans With Spinal Cord Injuries: A Final Report. Little Rock: Arkansas Spinal Cord Commission; 1996.

8. Risk Assessment for Secondary Conditions (RASC) [instrument]. Missoula: The University of Montana Rural Institute, Research and Training Center on Disability in Rural Communities.

9. Centers for Disease Control and Prevention. State-specific prevalence of disability among adults—11 states and the District of Columbia, 1998. MMWR Morb Mortal Wkly Rep. 2000;49(31):711–714.[Medline]

10. US Bureau of the Census. Census of Population and Housing, 2000: Summary Tape File 3 (STF 3). Supplementary Survey. Washington, DC: US Bureau of the Census.

11. Centers for Disease Control and Prevention. Measuring Healthy Days: Population Assessment of Health-Related Quality of Life. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 2000.

12. Patrick DL. Rethinking prevention for people with disabilities. Part I: A conceptual model for promoting health. Am J Health Promot. 1997;11:257–260.[ISI][Medline]

13. Patrick DL, Richardson ML, Starks HE, Rose MA, Kinne S. Rethinking prevention for people with disabilities. Part II: A framework for designing interventions. Am J Health Promot. 1997;11:261–263.[ISI][Medline]

14. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Department of Health and Human Services; 2001.

15. Marx RG, Hogg-Johnson S, Hudak P, Beaton D, Shields S, Bombardier C, et al. A comparison of patients’ responses about their disability with and without attribution to the affected area. J Clin Epidemiol. 2001;54:580–586.[Medline]




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This Article
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